Nokea
The client with ARDS is on a mechanical ventilator. Which intervention should be included in the nursing care plan addressing the endotracheal tube (ET) care?
- A. Do not move or touch the ET tube.
- B. Obtain a chest x-ray daily.
- C. Determine if the ET cuff is deflated.
- D. Ensure that the ET tube is secure.
Correct Answer: D
Rationale: Securing the ET tube (D) prevents dislodgement, critical for ventilation. Avoiding movement (A), daily CXR (B), and cuff deflation (C) are incorrect or secondary.
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During suctioning of a tracheostomy tube, the catheter appears to attach to the tracheal wall and creates a pulling sensation. What is the best action for the nurse to take?
- A. Release the suction by opening the vent
- B. Continue suctioning to remove the obstruction
- C. Increase the pressure
- D. Suction deeper
Correct Answer: A
Rationale: Releasing suction by opening the vent prevents trauma to the tracheal mucosa when the catheter adheres to the wall.
Before suctioning, the nurse attaches a pulse oximeter to the client's finger. Which nursing actions are appropriate at this time? Select all that apply.
- A. Remove the client's fingernail polish.
- B. Place the sensor and receiver opposite to each other on the client's finger.
- C. Connect the cable to the oximeter.
- D. Set the SpO2 alarms between 95% and 100%.
- E. Notify the physician each time an alarm sounds.
- F. Relocate the spring-loaded sensor periodically.
Correct Answer: A, B, C, F
Rationale: Removing nail polish, positioning the sensor correctly, connecting the cable, and relocating the sensor periodically ensure accurate pulse oximetry readings.
A patient is ordered at 1400 to take Theophylline. You're assessing the patient's morning lab results and note that the Theophylline level drawn this morning reads: $15 \mathrm{mcg} / \mathrm{mL}$. You're next nursing action is to?
- A. Administer the dose at 1400 as ordered
- B. Notify the physician for further orders
- C. Hold the 1400 dose
- D. Collect another blood sample to confirm the level
Correct Answer: A
Rationale: A Theophylline level of 15 mcg/mL is within the therapeutic range (10-20 mcg/mL), so the dose should be administered as ordered . No further action is needed.
Which side effect can the nurse expect when the client receives aminophylline (Truphylline)?
- A. Bronchospasm
- B. Hypotension
- C. Drowsiness
- D. Tachycardia
Correct Answer: D
Rationale: Aminophylline, a xanthine derivative, commonly causes tachycardia as a side effect due to its stimulatory effects.
You note your patient's sweat and urine is orange. You reassure the patient and educate him that which medication below is causing this finding?
- A. Ethambutol
- B. Streptomycin
- C. Isoniazid
- D. Rifampin
Correct Answer: D
Rationale: This medication will cause body fluids to turn orange.