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The nurse is caring for a client on mechanical ventilation via an oral endotracheal tube. What are the possible causes of the high-pressure alarm sounding?
- A. A kink in the tube
- B. The client fighting the ventilator
- C. Increased secretions in the airway
- D. A cuff leak in the endotracheal tube
- E. The client biting on the endotracheal tube
- F. The ventilator tubing disconnecting from the endotracheal tube
Correct Answer: A,B,C,E
Rationale: The high-pressure alarm sounds when the peak inspiratory pressure reaches the set alarm limit. Causes include obstruction of the endotracheal tube because of the client lying on the tube or water or a kink in the tubing; the client being anxious or fighting the ventilator; an increased amount of secretions in the airways or a mucous plug; the client coughing, gagging, or biting on the oral endotracheal tube; decreased airway size related to wheezing or bronchospasm; pneumothorax; and displacement of the artificial airway and the endotracheal tube slipping into the right main stem bronchus. The low-pressure alarm sounds when there is a leak or disconnection in the ventilator circuit or a leak in the client's artificial airway cuff.
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The nurse has created a plan of care to include interventions focused on reassuming self-care for a client who is in traction. The nurse evaluates the plan of care and determines that which observation indicates a successful outcome?
- A. The client denies a need for assistance with care.
- B. The client allows the family to assist in the care.
- C. The client assists in self-care as much as possible.
- D. The client allows the nurse to complete the care on a daily basis.
Correct Answer: C
Rationale: A successful outcome for reassuming self-care is for the client to do as much of the self-care as possible. The nurse should promote independence in the client and allow the client to perform as much self-care as is optimal considering the client's condition. The nurse would determine that the outcome is unsuccessful if the client refuses care or allows others to perform the care.
The nurse reviews the nursing care plan of a hospitalized preschool child who is immobilized as a result of skeletal traction. The nurse notes concerns related to the child's development because of immobilization and hospitalization. Which evaluative statement indicates a positive outcome for the child?
- A. The fracture heals without complications.
- B. The caregivers verbalize safe and effective home care.
- C. The child maintains normal joint and muscle integrity.
- D. The child displays age-appropriate developmental behaviors.
Correct Answer: D
Rationale: Regression and inappropriate developmental behaviors may be displayed in response to immobilization and hospitalization. With individualized care planning, a positive outcome of age-appropriate behavior can be achieved. The remaining options are appropriate evaluative statements for an immobilized child, but they do not directly address the child's development.
The nurse is assigned to care for a client diagnosed with acquired immunodeficiency syndrome (AIDS) who is receiving amphotericin B for a fungal respiratory infection. Which would indicate an adverse effect of the medication?
- A. Hypokalemia
- B. Hypernatremia
- C. Hypochloremia
- D. Hypercalcemia
Correct Answer: A
Rationale: Clients receiving amphotericin B may develop hypokalemia, which can be severe and lead to extreme muscle weakness and electrocardiogram changes. Distal renal tubular acidosis commonly occurs, and this contributes to the development of hypokalemia. High potassium levels do not occur. The medication does not cause sodium, chloride, or calcium levels to fluctuate.
The nurse has taught a client who is prescribed a xanthine bronchodilator about beverages to avoid. The nurse determines that the client understands the information if the client chooses which beverage from the dietary menu?
- A. Cola
- B. Coffee
- C. Chocolate milk
- D. Cranberry juice
Correct Answer: D
Rationale: Cola, coffee, and chocolate contain xanthine and should be avoided by the client who is taking a xanthine bronchodilator. This could lead to an increased incidence of cardiovascular and central nervous system side effects that can occur with the use of these types of bronchodilators.
A client has been taking nadolol for the past month. Which finding would indicate a therapeutic effect of the medication?
- A. The client is afebrile.
- B. The client has clear breath sounds.
- C. The client reports no episodes of headache.
- D. The client has a blood pressure of 118 / 72mmHg .
Correct Answer: D
Rationale: Nadolol is a beta-adrenergic blocking agent that is used to treat hypertension. Therefore, a blood pressure within the normal range would indicate an effective response to the medication. Based on this information the remaining options are unrelated to the action of this medication.