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NurseDive Free Nursing Practice Question
A nurse is caring for a client who is receiving mechanical ventilation and has an ideal weight of 60 kg. The nurse should expect the tidal volume to be set at which of the following?
A. 800 mL
B. 480 mL
This is because the recommended tidal volume for mechanical ventilation is 6 to 8 mL/kg of ideal body weight. Therefore, for a client who has an ideal weight of 60 kg, the tidal volume should be between 360 and 480 mL. A tidal volume that is too high or too low can cause lung injury or hypoventilation.
C. 950 mL
D. 300 mL
This question is an excerpt from Nurse Dive's nursing test bank - ATI SP 250 Exam 3 Med Surg Proctored Exam. Take the full exam now
Full Explanation
This is because the recommended tidal volume for mechanical ventilation is 6 to 8 mL/kg of ideal body weight. Therefore, for a client who has an ideal weight of 60 kg, the tidal volume should be between 360 and 480 mL. A tidal volume that is too high or too low can cause lung injury or hypoventilation.
Similar Questions
A nurse is caring for a client who is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select all that apply.)
A. Administer pantoprazole as prescribed.
Stress ulcer prophylaxis (e.g., a PPI) is indicated for critically ill, ventilated patients to prevent GI bleeding from stress-related mucosal damage.
B. Reposition the endotracheal tube to the opposite side of the mouth daily.
Rotating the tube and tape from side to side prevents pressure necrosis of the lips and oral mucosa.
C. Verify the prescribed ventilator settings daily.
Verifying vent settings only once a day isn’t adequate-settings must be checked each shift or whenever the patient’s status changes.
D. Elevate the head of the bed to at least 30°.
Semi-Fowler’s positioning (≥30°) reduces aspiration risk and helps prevent ventilator-associated pneumonia.
E. Apply restraints if the client becomes agitated.
Physical restraints are a last-resort to prevent self-extubation after all less-restrictive measures (sedation, reorientation, sitter) have failed-not a routine “complication-prevention” bundle item.
Full Explanation
Correct answers: A, B ,D
A. Stress ulcer prophylaxis (e.g., a PPI) is indicated for critically ill, ventilated patients to prevent GI bleeding from stress-related mucosal damage.
B. Rotating the tube and tape from side to side prevents pressure necrosis of the lips and oral mucosa.
D. Semi-Fowler’s positioning (≥30°) reduces aspiration risk and helps prevent ventilator-associated pneumonia.
A nurse is teaching a client who has hepatitis A about preventing transmission of the disease. Which is included in the teaching?
A. Practice effective hand hygiene.
B. Avoid serving raw foods.
C. Avoid eating at fast food restaurants
D. Wear barrier protection during vaginal intercourse.
Full Explanation
Hepatitis A is an acute viral infection that affects the liver and is transmitted by fecal-oral route. It can be spread by contaminated food or water, or by close contact with an infected person. Practicing effective hand hygiene can reduce the risk of ingesting or spreading the virus. Avoiding serving raw foods, especially shellfish, can prevent exposure to contaminated food sources.
A nurse is caring for a client who has COPD.
Nurses' Notes
Vital Signs
Medication
Home health nurse admission note:
Client discharged from healthcare facility yesterday following a 4-day stay for exacerbation of COPD. Lives alone; alert and oriented to person, place, and time. Lung fields with scattered rhonchi throughout, cough productive for thick white sputum, dyspnea with minimal exertion.
Clubbing is noted on fingers, chest is barrel-shaped. Supplemental oxygen at 2L/min via nasal cannula.
Home Health Nurse Note 3 days following discharge from health care facility: Client sleeping in recliner with nasal canula on their lap; awakens easily and is oriented to person but disoriented to place and time.
Lung sounds with scattered rhonchi, cough productive for thick, yellow secretions. 2+pitting edema bilateral in ankles and feet.
Re-oriented client. Client states "I don't remember if I did that breathing machine thing you told me about."
Instructed client on oxygen use, safety, and nebulizer treatments. Elevated lower extremities.
Select the 5 findings that require follow-up.
A. Disorientation
B. Barrel-shaped chest
C. Yellow sputum
D. Nebulizer use
E. Ankle edema SaO2 92% Clubbing of fingers
F. Lives alone
Full Explanation
- Disorientation may indicate hypoxia, infection, or medication side effects. - Yellow sputum may indicate a bacterial infection that requires antibiotics. - Nebulizer use may indicate that the client is not using it correctly or regularly as prescribed, which can affect their lung function and oxygenation. - Ankle edema may indicate fluid overload or heart failure, which can worsen COPD symptoms and increase the risk of complications.
- Living alone may pose safety risks for the client, especially if they are disoriented or have difficulty managing their oxygen and nebulizer treatments. The nurse should assess the client's support system and refer them to community resources if needed.