Nokea
The nurse is caring for a client who is receiving mechanical ventilation. The ventilator alarms are sounding, and the nurse notes high-pressure alarms. Which of the following actions should the nurse take FIRST?
- A. Suction the client’s airway.
- B. Notify the respiratory therapist.
- C. Check the ventilator tubing for kinks.
- D. Administer a bronchodilator.
Correct Answer: C
Rationale: checking for kinks in the tubing is the first step, as it is a common cause of high-pressure alarms
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Following procurement of organs from a standard criteria donor (donor younger than 50 years who suffered brain death), within what time period should the heart and lungs be transplanted?
- A. 4-6 hours
- B. 8-12 hours
- C. 24 hours
- D. 36 hours
Correct Answer: A
Rationale: Heart and lungs have a short ischemic tolerance, requiring transplantation within 4-6 hours (A) to ensure viability. Longer periods (B, C, D) risk organ failure.
The nurse is making initial rounds on a client with a C5 fracture and crutchfield tongs. Which equipment should be kept at the bedside?
- A. A pair of forceps
- B. A torque wrench
- C. A pair of wire cutters
- D. A screwdriver
Correct Answer: B
Rationale: A torque wrench is needed to adjust and maintain the tension of crutchfield tongs for cervical stabilization.
The client is receiving peritoneal dialysis. If the dialysate returns cloudy, the nurse should:
- A. Document the finding
- B. Send a specimen to the lab
- C. Strain the urine
- D. Obtain a complete blood count
Correct Answer: B
Rationale: Cloudy dialysate suggests peritonitis, requiring lab analysis.
The client with preeclampsia is admitted to the unit with an order for magnesium sulfate IV. Which action by the nurse indicates a lack of understanding of magnesium sulfate?
- A. The nurse places a sign over the bed not to check blood pressures in the left arm.
- B. The nurse obtains an IV controller.
- C. The nurse inserts a Foley catheter.
- D. The nurse darkens the room.
Correct Answer: A
Rationale: Avoiding blood pressure checks in one arm is unrelated to magnesium sulfate; the other actions align with monitoring and managing side effects.
The nurse is caring for a client with a head injury who has increased ICP. The physician plans to reduce the cerebral edema by constricting cerebral blood vessels. Which physician order would serve this purpose?
- A. Hyperventilation per mechanical ventilation
- B. Insertion of a ventricular shunt
- C. Furosemide (Lasix)
- D. Solu medrol
Correct Answer: A
Rationale: Hyperventilation reduces PaCO2, causing cerebral vasoconstriction, which decreases cerebral blood flow and edema. The other options address pressure or fluid but not vasoconstriction.