D455 Professional Nursing Role Transition - Set 2 - Part 3

Correct Answer: Venturi mask set to sixty percent

Option d is correct because the Venturi mask delivers precise and controlled oxygen concentrations through calibrated entrainment ports, making it the ideal device when a specific percentage of inspired oxygen is required for accurate titration of respiratory support. Option a is incorrect because a simple face mask delivers variable oxygen concentrations between approximately thirty-five to fifty percent depending on the client's respiratory pattern, and it cannot reliably provide the precise sixty percent concentration this client requires. Option b is incorrect because a nasal cannula at four liters per minute delivers only approximately thirty-six percent oxygen concentration, which is significantly below the sixty percent target needed, and nasal cannulas cannot deliver precise high-concentration oxygen therapy. Option c is incorrect because a non-rebreather mask with a full reservoir delivers very high oxygen concentrations between eighty and ninety-five percent, which excee

Correct Answer: Continuous bubbling suggests an air leak

Option b is correct because continuous vigorous bubbling in the water-seal chamber that persists regardless of respiratory phase indicates an air leak in the system, requiring the nurse to systematically check all connections, tubing, and the insertion site for the source. Option a is incorrect because normal chest tube function shows intermittent tidaling in the water-seal chamber that fluctuates with respiration, and continuous vigorous bubbling that does not correlate with breathing indicates a system malfunction requiring immediate investigation. Option c is incorrect because the water level in the water-seal chamber is typically maintained at two centimeters and continuous bubbling is not resolved by adding more sterile water, as the bubbling indicates air entering the system rather than insufficient water volume. Option d is incorrect because continuous vigorous bubbling in the water-seal chamber is not an indicator of appropriate suction settings, and the suction control chamber

Correct Answer: Remove and clean the inner cannula

Option a is correct because the thick secretions obstructing the inner cannula are the direct cause of the breathing difficulty, and removing the inner cannula for cleaning immediately restores airway patency through the outer cannula while the obstruction is cleared. Option b is incorrect because waiting for respiratory therapy introduces an unnecessary delay when the nurse can immediately resolve the airway obstruction by removing the inner cannula, as this is within the registered nurse's scope of practice and training for tracheostomy management. Option c is incorrect because increasing oxygen flow rate does not address the physical obstruction caused by thick secretions in the inner cannula, and the client needs airway clearance rather than increased oxygen delivery to resolve the immediate breathing difficulty. Option d is incorrect because the client's anxiety is a direct response to the breathing difficulty caused by the obstructed cannula, and treating the anxiety ph

Correct Answer: Hyperoxygenate the client before suctioning

Option c is correct because suctioning removes air along with secretions causing transient hypoxemia, and hyperoxygenating with one hundred percent oxygen before the procedure creates an oxygen reserve that protects against dangerous desaturation during the suctioning pass. Option a is incorrect because deflating the endotracheal tube cuff before suctioning is not standard practice, as this would allow secretions pooled above the cuff to enter the lower airway, increasing aspiration risk and potential ventilator-associated pneumonia development. Option b is incorrect because disconnecting the ventilator for two minutes before suctioning deprives the client of both oxygen delivery and positive pressure ventilation support, creating unnecessary hypoxemia risk rather than the controlled brief disconnection used during actual suctioning. Option d is incorrect because applying continuous suction during catheter insertion is contraindicated as it causes mucosal trauma and excessive oxygen re

Correct Answer: Educate about expected medication side effects

Option d is correct because tachycardia, tremors, and shakiness are well-documented pharmacological effects of albuterol's beta-2 agonist action, and educating the client that these are expected side effects reduces anxiety while the therapeutic bronchodilation benefit continues. Option a is incorrect because stopping the albuterol treatment is unnecessary since tachycardia and tremors are expected pharmacological effects rather than adverse reactions, and discontinuing the bronchodilator could worsen the underlying respiratory condition being treated. Option b is incorrect because nebulizer flow rate controls aerosol delivery rather than drug dosage, and adjusting the flow does not meaningfully reduce the pharmacological side effects that result from albuterol's systemic beta-adrenergic stimulation of cardiac and skeletal muscle receptors. Option c is incorrect because administering a beta-blocker to counteract albuterol's cardiac effects would antagonize the therapeuti

Correct Answer: Heart failure with crackles and low saturation

Option b is correct because new bilateral crackles with oxygen saturation of eighty-six percent in a heart failure client indicates acute pulmonary congestion with significant hypoxemia requiring immediate assessment, oxygen support, and potential emergent diuretic therapy to prevent respiratory failure. Option a is incorrect because a strong pedal pulse following cardiac catheterization is actually a reassuring finding indicating adequate peripheral circulation to the catheterized extremity, and this client does not require immediate nursing intervention. Option c is incorrect because a stable angina client requesting a medication refill represents a routine pharmacological need that can be safely addressed after managing the client with acute respiratory compromise and dangerously low oxygen saturation levels. Option d is incorrect because dietary education about low-sodium choices is an important but non-urgent teaching need that can be appropriately scheduled after addressing the c

Correct Answer: Begin chest compressions immediately

Option a is correct because high-quality chest compressions must begin immediately upon recognizing cardiac arrest to maintain cerebral and coronary perfusion, as delays in compression initiation significantly reduce survival rates even when defibrillation equipment is nearby. Option b is incorrect because intravenous epinephrine is administered during the resuscitation sequence after compressions and defibrillation have been initiated, and it requires either existing intravenous access or placement during the code rather than being the first action. Option c is incorrect because while early defibrillation is critical for ventricular fibrillation, current resuscitation guidelines emphasize initiating high-quality chest compressions immediately and minimizing interruptions while the defibrillator is being prepared by additional team members. Option d is incorrect because obtaining a twelve-lead electrocardiogram during active ventricular fibrillation delays life-saving interventions, an

Correct Answer: Monitor continuous cardiac rhythm closely

Option d is correct because post-cardiac arrest clients are at extremely high risk for recurrent lethal dysrhythmias during the immediate recovery period, and continuous cardiac monitoring allows the nurse to detect and respond to rhythm changes before hemodynamic collapse recurs. Option a is incorrect because while family support is important for holistic care, assessing family coping is a psychosocial intervention that does not take priority over the immediate physiological monitoring needed to prevent recurrent cardiac arrest in the unstable post-resuscitation period. Option b is incorrect because while chest compression-related pain is expected and should be managed, pain evaluation does not take priority over continuous cardiac rhythm monitoring during the critical post-resuscitation stabilization period when lethal dysrhythmias are most likely. Option c is incorrect because reviewing the pre-arrest medication history provides useful background information but does not address the

Correct Answer: Acute respiratory failure with acidosis

Option c is correct because the combination of severe hypoxemia, significant hypercapnia with uncompensated respiratory acidosis, accessory muscle use, paradoxical breathing, and confusion collectively indicate acute respiratory failure requiring immediate intervention including possible intubation. Option a is incorrect because the arterial blood gas values show an acidotic pH with elevated carbon dioxide levels, which is the opposite of metabolic alkalosis, and the respiratory distress signs point to a primary ventilatory failure rather than a metabolic acid-base disorder. Option b is incorrect because compensated chronic respiratory acidosis would show a near-normal pH with elevated bicarbonate levels reflecting renal compensation, whereas this client has an acutely acidotic pH indicating the body has not had time to compensate for the rising carbon dioxide. Option d is incorrect because while COPD clients may have mildly abnormal baseline blood gases, the severity of hypoxemia, deg

Correct Answer: Chest tightness with diaphoresis and arm pain

Option b is correct because sudden chest tightness with diaphoresis and left arm pain represents classic acute coronary syndrome presentation that is immediately life-threatening, requiring emergent assessment, electrocardiogram, and potential cardiac catheterization to prevent myocardial death. Option a is incorrect because a twisted ankle with mild swelling is a musculoskeletal injury that is painful but not life-threatening, and this client can safely wait for assessment while the nurse addresses the client presenting with acute cardiac symptoms first. Option c is incorrect because a laceration requiring three stitches is a minor wound that does not pose an immediate threat to life, and this client can safely wait with appropriate wound coverage while the nurse prioritizes the potentially life-threatening cardiac presentation. Option d is incorrect because heartburn after a large meal typically represents gastroesophageal reflux rather than a cardiac emergency, and while cardiac cau