The low-exhaled volume alarm sounds on a mechanical ventilator of a client with an endotracheal tube. Disconnect the client from the ventilator and manually ventilate the client with a resuscitation device. Call the health care provider (HCP) for further instructions.Ĥ. Call the respiratory therapy department to fix the problem.ģ. Which initial nursing action would be appropriate if the nurse is unable to determine the cause of ventilator alarm?Ģ. The nurse assesses the client and attempts to determine the cause of the alarm. The nurse is caring for a client on a mechanical ventilator. Aspiration of gastric contents occurs during suctioning. Excessive secretions are suctioned from the tube and stoma. Aspiration of gastric contents occurs during suctioning.Ĥ. The client's skin and mucous membranes are light pink.ģ. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs?Ģ. "I should use diluted alcohol on the stoma to clean it." The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. "I should apply a non-oil-based ointment to the skin surrounding the stoma." 3. "I should use diluted alcohol on the stoma to clean it."Ĥ. "Soaps should be avoided near the stoma."ģ. "I need to protect the stoma from water."Ģ. Which statement by the client indicates a need for further instruction?ġ. The nurse provides instructions to a client after a total laryngectomy. Assist the client to a sitting position with the head tilted forward. Instruct the client to swallow the blood until the bleeding can be controlled. Assist the client to a sitting position with the head tilted forward.Ĥ. Apply an ice collar around the client's neck.ģ. A client arrives in the hospital emergency department with a bloody nose. The nurse provides which instruction to the client?Ĥ. Monitoring the respiratory status frequently as prescribed The clinic nurse is providing instructions to a client with a diagnosis of pharyngitis. Monitoring the respiratory status frequently as prescribed 1. Supporting the neck incision when the client coughsĥ. Placing the bed in low Fowler's positionĤ. To promote adequate respiratory function in this client, the nurse should implement which activities? Select all that apply.ģ. 48 to 72 hours A client who has undergone radical neck dissection for a tumor has a potential problem of obstruction related to postoperative edema, drainage, and secretions. The nurse tells the client to return to the clinic for reading the results in how long?Ĥ. Hyperoxygenating the client before, during, and after suctioning The clinic nurse administers a tuberculin (Mantoux) skin test to a client. Keeping a supply of suction catheters at the bedsideģ. Placing suction on the catheter for at least 30 seconds to ensure that all secretions are removed 1. Intermittently suctioning during insertion of the suction catheterĥ. Hyperoxygenating the client before, during, and after suctioningĤ. Auscultating breath sounds to determine the need for suctioningģ. Keeping a supply of suction catheters at the bedsideĢ. The nurse should perform which actions when performing this procedure? Select all that apply.ġ. Several weeks to months The nurse is suctioning an unconscious client who has a tracheostomy. The nurse should expect the client to report having fatigue and cough that have been present for how long?Ĥ. The nurse is assessing a client with the typical clinical manifestations of tuberculosis. This is expected, and the client should gradually increase activity as tolerated. This is a short-lived problem that should be gone within 1 week after beginning drug therapy. This is an unexpected finding with tuberculosis, but it should resolve within 1 month or so.Ĥ. This is expected, and the client should gradually increase activity as tolerated.ģ. This is expected and will last for at least 1 year.Ģ. A client diagnosed with tuberculosis is distressed over fatigue and the loss of physical stamina.
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