ATI RN Comprehensive Online Practice 2019 B with NGN

ATI RN Comprehensive Online Practice 2019 B with NGN A nurse is caring for a client who is receiving positive end-expiratory pressure (PEEP) via mechanical ventilation. The nurse should monitor the client for which of the following adverse effects of PEEP? Hypoxemia Tension pneumothorax Malignant hypertension Atelectasis - ANSWER Tension pneumothorax The nurse should identify that tension pneumothorax is a possible adverse effect of PEEP. The nurse should monitor the client's lung sounds hourly for indications of a tension pneumothorax, such as tracheal deviation, absent breath sounds, and distended neck veins. A nurse is providing information to a client immediately before his scheduled Romberg test. Which of the following statements should the nurse make? "You will be standing with your feet 1 foot apart." "You will place and hold your hands on your hips." "I will be standing across the room from you to evaluate your sense of balance." "I will be checking you once with your eyes open and once with them closed." - ANSWER "I will be checking you once with your eyes open and once with them closed." The nurse should inform the client that the Romberg test will be performed once with eyes open and once with eyes closed. A Romberg test is performed to assess balance and motor function. A nurse is caring for a client who is postoperative following administration of general anesthesia. - ANSWER Upon recognizing and analyzing the client cues of tachycardia, tachypnea, hypotension, and irregular heart rhythm, the nurse's priority hypothesis should be that this client is most likely experiencing malignant hyperthermia and that it is important to generate solutions and take actions that will correct dysrhythmias, provide oxygen to tissues, correct electrolyte imbalances, and reverse metabolic and respiratory acidosis. Therefore, the nurse should prepare to administer dantrolene and administer oxygen. The nurse should monitor the PCO2 level on the client's ABGs for hypercapnia and observe the client for muscle rigidity of the jaw and chest muscles.