Questions 42

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Female Reproductive System NCLEX RN Questions Questions

Extract:

The following scenario applies to the next 1 items
The nurse is caring for a 72-year-old client in the emergency department (ED)
Item 1 of 1
Nurses' Notes
1430: 72-year-old male was brought to the ED with reports of dyspnea, chest pain, diaphoresis, and restlessness. The client's daughter reports that he recently took a long drive across several states and that the symptoms started abruptly. The client's oxygen saturation was 80% on room air and improved to 86% on 100% FiO2 via a nonrebreather mask. The physician was immediately notified at this time of the client's condition and came to the bedside for evaluation.
1442: The physician ordered rapid sequence intubation medications for immediate endotracheal intubation (ETT). The physician intubated the client using a #8 ETT and connected the client to mechanical ventilation using assist-control at a tidal volume of 500 mL, rate of 12/minute, 100% FiO2, PEEP 5 cm H2O. Post-intubation vital signs: T 99° F (37° C), P110, RR 12, BP 90/62, pulse oximetry reading 98%.


Question 1 of 5

The nurse has reviewed both of the Nurses' Note entries and is planning care for the client. For each potential nursing intervention, click to specify whether the intervention is indicated or contraindicated for the care of the client.

Potential Intervention Indicated Contraindicated
Request an order for a chest radiograph (x-ray)
Obtain an order for an arterial blood gas (ABG)
Collaborate with respiratory therapy to assist in the client's care
Place the client in low-Fowler's position
Request an order to administer an 0.45% saline intravenous fluid bolus
Turn the client every four hours
Suction the endotracheal tube (ETT) every two hours

Correct Answer: A, B, C, F (indicated); D, E, G (contraindicated)

Rationale: Indicated: Chest x-ray confirms tube placement, ABG assesses ventilation, respiratory therapy collaboration optimizes care, and turning prevents complications. Contraindicated: Low-Fowler€™s position worsens respiratory distress, 0.45% saline is inadequate for hypovolemia, and routine ETT suctioning is unnecessary.

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Question 2 of 5

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