Nokea
The following scenario applies to the next 1 items
The intensive care unit nurse has completed the assessment of a client
Item 1 of 1
Nurses' Notes
Progress Notes Orders
Day 2
1445: Physician at the bedside. The client is sedated, receiving mechanical ventilation via the #8 endotracheal tube. Current ventilator settings: assist control; rate 12/minute; tidal volume 450 mL; FiO 2 100%; positive end-expiratory pressure (PEEP) 5 cm H20. Intraventricular catheter present and zeroed and calibrated. No purposeful movement, and pupils were 3 mm equally round and sluggish to light. No abnormal posturing. + gag reflex; + corneal reflex. Lung sounds clear bilaterally, and the chest rises and falls synchronously with the ventilator. Peripheral pulses 2+ and S1 and S2 heart tones. Normoactive bowel sounds in all quadrants, no abdominal distention. Skin warm and dry. Indwelling urinary catheter patent and draining clear, concentrated urine. The client is currently positioned in a semi-Fowler position.
The nurse reviews the physician's orders
Click to specify if the order is indicated or requires follow-up with the physician:
Correct Answer: B,B,B,A,A,A
Rationale: Hypotonic saline (0.45%) may worsen cerebral edema in brain injury; isotonic saline is preferred.