A patient who is receiving positive pressure ventilation is scheduled for a spontaneous breathing trial (SBT). Which finding by the nurse is most important to discuss with the health care provider before starting the SBT?

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Question 1 of 5

A patient who is receiving positive pressure ventilation is scheduled for a spontaneous breathing trial (SBT). Which finding by the nurse is most important to discuss with the health care provider before starting the SBT?

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 2 of 5

Which action will the nurse include in the plan of care for a patient who has had a total right knee arthroplasty?

Correct Answer: D

Rationale: Choice D as progressive exercises target 90-degree flexion post-arthroplasty for function. Extension aims for 180 degrees (choice A), bandages maintain extension (choice B), and weight bearing starts early (choice C). This aligns with NCLEX Physiological Integrity, planning rehabilitation for knee recovery.

Question 3 of 5

The day after a 60-year-old patient has an open reduction and internal fixation (ORIF) for an open, displaced tibial fracture, the priority nursing diagnosis is

Correct Answer: D

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 4 of 5

A 78-kg patient with septic shock has a urine output of 30 mL/hr for the past 3 hours. The pulse rate is 120/minute and the central venous pressure and pulmonary artery wedge pressure are low. Which order by the health care provider will the nurse question?

Correct Answer: A

Rationale: Choice A as furosemide, a diuretic, would further reduce low filling pressures and renal perfusion in septic shock, where fluid resuscitation and vasopressors are needed. Increasing saline (choice B) addresses hypovolemia, hydrocortisone (choice C) supports refractory shock, and norepinephrine (choice D) maintains BP, all appropriate. This aligns with NCLEX Physiological Integrity, emphasizing the nurse's role in questioning orders that exacerbate hypoperfusion in a critically ill patient with low preload and oliguria.

Question 5 of 5

Which assessment information is most important for the nurse to obtain to evaluate whether treatment of a patient with anaphylactic shock has been effective?

Correct Answer: D

Rationale: Choice D as oxygen saturation is critical in anaphylactic shock, reflecting airway and breathing improvement. Heart rate (choice A), orientation (choice B), and BP (choice C) improve secondarily. This aligns with NCLEX Physiological Integrity, prioritizing respiratory status in allergic emergencies.

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