The nurse is assessing the client who is on a mechanical ...

[craiczarry]

The nurse is assessing the client who is on a mechanical ventilator. A priority assessment for this client is:
 
  1. assessing pedal pulses.
  2. providing dehumidified oxygen.
  3. using hand signals to communicate with the client.
  4. ensuring that the endotracheal tube is secured.

Question 2

The nurse is working with a client who is beginning weaning from a mechanical ventilator. The nurse explains to the family that which lab result would indicate a need to alter the wean settings?
 
  1. pH is 7.30.
  2. PCO2 is 30.
  3. O2 is 75.
  4. HCO3 is 25.

[Smiles0805]

Answer to Question 1

Answer: 4

1. Pedal pulses are a priority for the client who has peripheral vascular disease.
2. When on a ventilator, the client is placed on humidified oxygen to help thin secretions.
3. Using hand signals is communication and implementation, not assessment.
4. It is critical for the client who needs mechanical ventilation that the endotracheal tube is secure, and the nurse assesses this frequently as a priority.

Answer to Question 2

Answer: 2

1. A pH of 7.30 indicates acidosis. The nurse determines whether the reason for the acidosis is metabolic or respiratory. If respiratory, weaning would not be recommended.
2. The client with a carbon dioxide of 30 would have the rate weaned down, because 30 is low.
3. The oxygen of 75 might be acceptable but not enough to wean.
4. Weaning is not determined on the bicarbonate content.