1-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?
Endotracheal cuff pressure greater than 25 cm H20. Decreased lung compliance during ventilation.
Bilateral crackles with increased secretions. Restless client who is biting the endotracheal tube.
2-While making rounds, the charge nurse notices that a young adult client with asthma who was admitted yesterday is sitting on the side of the bed and leaning over the bed-side table. The client is currently receiving oxygen at 2 liters/minute via nasal cannula. The client is wheezing and is using pursed-lip breathing. Which intervention should the nurse implement?
Administer a nebulizer treatment. Increase oxygen to 6 liters/minute. Assist the client to lie back in bed. Call for an Ambu resuscitating bag.
3-After placement of a left subclavian central venous catheter (CVC), the nurse receives report of the X- ray findings that indicate the CVC tip is in the client's superior vena cava. Which action should the nurse implement?
Remove the catheter and apply direct pressure for 5 minutes. Initiate intravenous fluids as prescribed.
Secure the catheter using aseptic technique.
Notify the healthcare provider of the need to reposition the catheter.
4-While caring for a client's postoperative dressing, the nurse observes purulent wound drainage. Previously, the wound was inflamed and tender but without drainage. Which is the most important action for the nurse to take?
Determine if the drainage has an unpleasant odor. Monitor the client's white blood cell count (WBC). Request
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