While caring for a client who is being mechanically ventilated, the nurse responds to a high-pressure alarm on the ventilator. Which assessment finding warrants immediate intervention by the nurse?

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Adult Health 2 Exam 1 Questions

Question 1 of 5

While caring for a client who is being mechanically ventilated, the nurse responds to a high-pressure alarm on the ventilator. Which assessment finding warrants immediate intervention by the nurse?

Correct Answer: D

Rationale: A restless client biting the endotracheal tube can increase airway resistance, triggering the high-pressure alarm and indicating a need for immediate intervention. This behavior can lead to complications such as dislodgement of the tube or airway obstruction. Endotracheal cuff pressure greater than 25 cm H2O, decreased lung compliance, and bilateral crackles with increased secretions are important assessments but do not directly address the urgent need to intervene when a high-pressure alarm is triggered.

Question 2 of 5

The nurse is caring for a client who underwent a total knee replacement yesterday. What activity level should the nurse encourage today?

Correct Answer: B

Rationale: After a total knee replacement, early ambulation is crucial for promoting circulation and preventing complications like thrombosis. Bed rest should be avoided as it can increase the risk of complications. Range of motion exercises are important but should be performed gradually and not excessively. Leg elevation is beneficial for reducing swelling but should not be the primary activity level encouraged immediately after surgery.

Question 3 of 5

The nurse is caring for a postoperative client who is reluctant to ambulate. What strategy should the nurse use to encourage the client?

Correct Answer: A

Rationale: Corrected Rationale: The correct strategy for the nurse to encourage the postoperative client to ambulate is to explain the benefits of ambulation for recovery. Educating the client on how ambulation aids in preventing complications and promotes faster recovery can motivate their participation. Choice B is incorrect because waiting for the client to request to walk may lead to delays in mobilization. Choice C is incorrect as it may induce unnecessary fear in the client. Choice D is incorrect as offering pain medication before walking does not address the client's reluctance to ambulate.

Question 4 of 5

A client with a urinary tract infection is prescribed antibiotics. What should the nurse inform the client about antibiotic therapy?

Correct Answer: D

Rationale: Completing the full course of antibiotics is crucial to fully eradicate the infection and prevent the development of antibiotic resistance. Informing the client about the importance of finishing the prescribed course helps in ensuring the effectiveness of the treatment and reduces the risk of recurrence. Choice A is incorrect because antibiotics do not generally interfere with oral contraceptive effectiveness. Choice B is incorrect because drowsiness is not a common side effect of antibiotics. Choice C is incorrect because while some antibiotics may need to be taken with meals, it is not a universal rule for all antibiotics.

Question 5 of 5

A client with a diagnosis of heart failure is receiving furosemide (Lasix). Which electrolyte imbalance should the nurse monitor for?

Correct Answer: D

Rationale: The correct answer is D: Hypokalemia. Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Therefore, the nurse should monitor the client for low potassium levels. Choice A, Hyperkalemia, is incorrect as furosemide does not typically cause high potassium levels. Choice B, Hyponatremia, is incorrect as furosemide primarily affects potassium levels, not sodium. Choice C, Hypocalcemia, is incorrect as furosemide does not directly impact calcium levels.

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