Nokea
The client diagnosed with ARDS is transferred to the intensive care department and placed on a ventilator. Which intervention should the nurse implement first?
- A. Confirm that the ventilator settings are correct.
- B. Verify that the ventilator alarms are functioning properly.
- C. Assess the respiratory status and pulse oximeter reading.
- D. Monitor the client's arterial blood gas results.
Correct Answer: C
Rationale: Assessing respiratory status and SpO2 (C) ensures immediate patient stability. Ventilator settings (A), alarms (B), and ABGs (D) follow.
You may also like to solve these questions
An adult man has a tracheostomy tube in place. Which of the following actions is most appropriate for the nurse to take when suctioning the tracheostomy?
- A. Use a sterile tube each time and suction for 30 seconds
- B. Use sterile technique and turn the suction off as the catheter is introduced
- C. Use clean technique and suction for 10 seconds
- D. Discard the catheter at the end of every shift
Correct Answer: B
Rationale: Suctioning should use sterile technique, with suction off during insertion and applied intermittently for no more than 10 seconds to prevent hypoxia and trauma.
Which statement indicates to the nurse the client diagnosed with asthma understands the teaching regarding mast cell stabilizer medications?
- A. I should take two (2) puffs when I begin to have an asthma attack.
- B. I must taper off the medications and not stop taking them abruptly.
- C. These drugs will be most effective if taken at bedtime.
- D. These drugs are not good at the time of an attack.
Correct Answer: D
Rationale: Mast cell stabilizers (D) prevent asthma by stabilizing mast cells, not treating acute attacks. Puffs during attack (A), tapering (B), and bedtime use (C) are incorrect.
What information does the nurse need to know first before recommending further action?
- A. What is the victim's age?
- B. Can the victim cough?
- C. How is the victim positioned?
- D. Can the victim still swallow?
Correct Answer: B
Rationale: Determining if the victim can cough assesses whether the airway is partially or completely obstructed, guiding the next steps.
Which nursing action is essential before suctioning the client with a tracheostomy tube?
- A. Preoxygenating the client
- B. Maintaining the head in a flexed position
- C. Cleaning around the stoma
- D. Removing the inner cannula
Correct Answer: A
Rationale: Preoxygenating the client prevents hypoxia during suctioning, which can temporarily reduce oxygen intake.
The nurse is caring for a client on a ventilator and the alarm goes off. Which action should the nurse implement first?
- A. Notify the respiratory therapist immediately.
- B. Check the ventilator to determine the cause.
- C. Elevate the head of the client's bed.
- D. Assess the client's oxygen saturation.
Correct Answer: B
Rationale: Checking the ventilator (B) is the first action to identify the alarm’s cause (e.g., disconnection, obstruction), per the ABCs. Notifying the therapist (A) delays intervention. Elevating the bed (C) is irrelevant. Assessing oxygen saturation (D) is secondary to addressing the ventilator issue.