The nurse is caring for a mechanically ventilated patient and responds to a high inspiratory pressure alarm. Recognizing possible causes for the alarm, the nurse assesses for which of the following? (Select all that apply.)
a. Coughing or attempting to talk
b. Disconnection from the ventilator
c. Kinks in the ventilator tubing
d. Need for suctioning
A, C, D
Coughing, kinks, and mucus in the airway can cause the inspiratory pressure to increase; ventilator disconnects result in low-volume alarms. A disconnection from the ventilator would result in a low exhaled volume alarm, not a high-pressure alarm.
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For which of the following behaviors would limit setting be most essential? The client
a. clings to the nurse and asks for advice about inconsequential matters. b. is flirtatious and provocative toward staff members of the opposite sex. c. displays hypervigilance and refuses to attend unit activities. d. urges a suspicious client to hit anyone who stares at him.
When taking care of a patient with inflammatory bowel disease, you would expect the physician's orders to include what?
A) Anticholinergic medications 30 minutes before a meal B) Antidiarrheal medications 30 minutes before a meal C) Antibiotic medications 30 minutes before a meal D) Narcotic pain medications 30 minutes before a meal
What activities are performed by the public health nurse engaged in the process surveillance?
A) Providing direct care to patients in a clinic B) Administering vaccinations in an elementary school C) Collecting data from occupational health records D) Providing community education on dangers of lead poisoning in children
A major wildfire has struck a town in California. The firefighters have finally put the fire out, but there are large sections of several communities that have been destroyed. How should the nurse intervene during the immediate recovery phase?
A. Revise the emergency preparedness plans to reflect the problems that have emerged. B. Go into the community to assess the needs of the displaced residents. C. Allow the first responders to take control of the situation. D. None of the above