Airway clearance techniques are critical for patients with cystic fibrosis and should take priority over the other activities. Although allowing more independent decision making is important for adolescents, the physiologic need for improved respiratory function takes precedence at this time. A private room may be desirable for the patient but is not necessary. With increased shortness of breath, it will be more important that the patient have frequent respiratory treatments than 8 hours of sleep.
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While a patient is receiving anticoagulation therapy, it is important to avoid trauma to the rectal tissue, which could cause bleeding (e.g., avoid rectal thermometers and enemas). All of the other instructions are appropriate to the care of a patient receiving anticoagulants.
A non-rebreather mask can deliver nearly 100% oxygen. When the patient’s oxygenation status does not improve adequately in response to delivery of oxygen at this high concentration, refractory hypoxemia is present. Usually at this stage, the patient is working very hard to breathe and may go into respiratory arrest unless health care providers intervene by providing intubation and mechanical ventilation to decrease the patient’s work of breathing.
Assisting patients with positioning and activities of daily living is within the educational preparation and scope of practice of a nursing assistant. Teaching, instructing, and assessing patients all require additional education and skills and are more appropriate for a licensed nurse.
The nursing assistant can remind patients about actions that have already been taught by the nurse and are part of the patient’s plan of care. Discussing and teaching require additional education and training. These actions are within the scope of practice of the RN. The RN can delegate administration of medication to an LPN/LVN.
The patient with asthma did not achieve relief from shortness of breath after using the bronchodilator and is at risk for respiratory complications. This patient’s needs are urgent. The other patients need to be assessed as soon as possible, but none of their situations are urgent. in COPD patients pulse oximetry oxygen saturations of more than 90% are acceptable.
Infections are always a threat for the patient receiving mechanical ventilation. The endotracheal tube bypasses the body’s normal air-filtering mechanisms and provides a direct access route for bacteria or viruses to the lower part of the respiratory system.
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The experienced LPN is capable of gathering data and making observations, including noting breath sounds and performing pulse oximetry. Administering medications, such as those delivered via MDIs, is within the scope of practice of the LPN. Independently completing the admission assessment, initiating the nursing care plan, and evaluating a patient’s abilities require additional education and skills. These actions are within the scope of practice of the professional RN.
Many surgical patients are taught about coughing, deep breathing, and use of incentive spirometry preoperatively. To care for the patient with TB in isolation, the nurse must be fitted for a high-efficiency particulate air (HEPA) respirator mask. The bronchoscopy patient needs specialized procedure, and the ventilator-dependent patient needs a nurse who is familiar with ventilator care. Both of these patients need experienced nurses.
You can give the patient 100% FiO2 by manually ventilating them while you try to figure out what's causing the high-pressure alarm. Safe ventilation parameters for each patient and their conditions should be taken into account while using proper ventilation strategies with the BVM.
The mucous membranes may dry out if the oxygen flow rate exceeds 4 L/min. The best course of action is to upgrade the oxygen delivery system with humidification. For patients who need high-flow oxygen systems for longer than 24 hours or who complain of upper airway irritation owing to dryness, it is permissible to utilize humidified oxygen. It can also be beneficial to apply a water-soluble jelly to the nares to lessen mucosal irritation. None of the alternative solutions will address the issue.
Patients must take isoniazid for a minimum of six months. The other three assertions are true and demonstrate knowledge about TB. The preferred drug is isoniazid. Usually, it is taken along with pyridoxine, or vitamin B6 (to prevent nerve damage). For people who test positive for Mantoux or Quantiferon, isoniazid should be continued for 6 or 9 months.
A type of artificial surfactant is called exosurf neonatal. Two to four doses may be administered to a newborn with RDS within the first 24 to 48 hours of birth. It promotes respiratory health, and studies have shown that giving it reduces the risk of pneumothorax significantly.
Supervision and delegation. Potassium levels should be between 3.5 and 5 mEq/L. The client has a high potassium level. With the help of kayexalate, potassium is expelled from the body through the digestive tract. The appropriate person must be given the appropriate tasks and responsibilities under the appropriate conditions. Following that, the nurse who assigned the tasks and jobs must interact with and supervise the person performing them.
Experienced LPNs/LVNs can collect information on how well patients perform interventions that have already been taught by observing patients. The legal ability for the licensed practical or vocational nurse to gather data, plan, implement, and evaluate care while working under the direct supervision and direction of the registered nurse would most likely be included in the scope of practice for this nurse.
The patient's medical history and current symptoms point to the possibility of developing ARDS, which calls for intubation and mechanical ventilation. Until signs of improvement are seen, patients are mechanically ventilated, protected from fluid excess with diuretics, and given nutritional support.
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NCLEX Nursing Prioritization Test #2
