Extract:

Question 1 of 5

A client admitted to the intensive care unit (ICU) with acute respiratory distress syndrome (ARDS) is intubated and placed on assist-control mechanical ventilation. When suctioning pulmonary secretions from the endotracheal tube (ETT) using a closed suction system, which action should the nurse implement to ensure that the client receives adequate oxygenation?

Correct Answer: B

Rationale: Pre-oxygenating by delivering additional breaths via the ventilator prevents hypoxia during suctioning, ensuring adequate oxygenation.

Question 2 of 5

A pH level of ________ and bicarbonate (HCO3-) level of ________ indicate a resolution of ketoacidosis.

A. pH 7.25 and HCOâ‚- 18 mEq/L. B. pH 7.30 and HCOâ‚- 20 mEq/L. C. pH 7.38 and HCOâ‚- 24 mEq/L. D. pH 7.20 and HCOâ‚- 15 mEq/L.

Correct Answer: C

Rationale: A pH of 7.38 and bicarbonate of 24 mEq/L are within normal ranges, indicating resolution of ketoacidosis.

Question 3 of 5

Twelve hours following orthopedic surgery on the right leg, the client begins to have acute chest pain and difficulty breathing. Which action should the nurse take first?

A. Notify healthcare provider (HCP) of the symptoms and administer a PRN pain medication. B. Increase the client's IV flow rate and start low flow oxygen. C. Position the client on the left side while immobilizing the affected leg. D. Take the client's vital signs and auscultate all lung sounds.

Correct Answer: B

Rationale: Acute chest pain and difficulty breathing suggest a pulmonary embolism. Providing oxygen and increasing IV flow rate support vital functions immediately.

Extract:

Medical History
Vital Signs
Physical Examination
Chronic use of hydrocortisone and fludrocortisone
History of hypertension
Recent viral illness with vomiting and diarrhea
A 55-year-old male client is brought to the emergency department by his spouse due to sudden weakness, dizziness, and confusion. The spouse states that the client has had persistent fatigue and nausea for the past few days but suddenly became disoriented and lethargic this morning. The client also reports severe abdominal pain and muscle cramps

Question 4 of 5

Complete the diagram by specifying which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Actions to Take Choices A. Hold hydrocortisone dose B. Collect urine for a urinalysis C. Check blood glucose D. Bolus intravenous fluids E. Change intravenous fluids to 0.45%

Potential Conditions Choices A. Ketoacidosis B. Diabetes insipidus C. Myxedema D. Acute adrenal crisis

Parameters to Monitor Choices A. Blood pressure B. Urine output C. Thyroid stimulating hormone D. Electrolytes E. Heart rate

Correct Answer: D,E,F,A,D

Rationale: The client's symptoms and history of steroid use suggest acute adrenal crisis. Fluid resuscitation and glucose monitoring are critical actions, while blood pressure and electrolytes are key parameters to monitor.

Extract:

Question 5 of 5

The vital signs for a client with heart failure (HF), who is admitted to the intensive care unit (ICU), are a temperature of 98.6Â° F (37Â°C), heart rate 125 beats/minute, respirations 22 breaths/minute, and blood pressure 140/50 mm Hg. The nurse determines the client's central venous pressure (CVP) and pulmonary artery wedge pressure (PAWP) are elevated. Which intervention should the nurse implement?

A. Initiate an IV bolus of 0.9% normal saline 500 mL. B. Titrate IV dopamine at 8 mcg/kg/minute. C. Administer furosemide 40 mg IV push (IVP). D. Encourage a liberal PO fluid intake.

Correct Answer: C

Rationale: Elevated CVP and PAWP indicate fluid overload. Furosemide reduces preload and promotes diuresis, improving symptoms.