a nurse is planning care for a client who is receiving mechanical ventilation which of the following modes of ventilation that increase the effort of

ATI RN

ATI Fundamentals

1. When planning care for a client on mechanical ventilation, which mode of ventilation that increases the effort of the client's respiratory muscles should NOT be included in the plan of care?

A. Assist-control
B. Synchronized intermittent mandatory ventilation
C. Continuous positive airway pressure
D. Pressure support ventilation

Correct answer: A

Rationale: Assist-control ventilation mode delivers a preset tidal volume at a set rate; however, it may not be suitable for clients who need to maintain some level of respiratory muscle activity. This mode provides full support for each breath, potentially leading to decreased respiratory muscle strength over time. Therefore, it is important to avoid using assist-control mode for clients who require increased effort of respiratory muscles to prevent muscle atrophy and promote optimal respiratory function.

2. A charge nurse is recommending postpartum client discharge following a local disaster. Which of the following should the nurse recommend for discharge?

A. A 42-year-old client who has preeclampsia and a BP of 166/110 mm Hg
B. A 15-year-old client who delivered via emergency cesarean birth 1 day ago
C. A client who received 2 units of packed RBCs 6 hr ago for a postpartum hemorrhage
D. A client who delivered precipitously 36 hr ago and has a second-degree perineal laceration

Correct answer: D

Rationale: The most appropriate client to recommend for discharge following a local disaster in the postpartum unit is the one who delivered precipitously 36 hours ago and has a second-degree perineal laceration. This client's condition is stable enough for discharge, and the timing and extent of the perineal laceration are within expectations for a safe discharge. Clients with conditions such as preeclampsia, recent emergency cesarean birth, or recent administration of packed RBCs for postpartum hemorrhage require further monitoring and care before being considered for discharge.

3. When providing mouth care to an unconscious client, what is the best position for the client?

A. Fowler’s position
B. Side-lying
C. Supine
D. Trendelenburg

Correct answer: B

Rationale: The best position for an unconscious client when providing mouth care is the side-lying position. This position helps prevent aspiration by allowing fluids to drain out of the mouth easily, reducing the risk of choking or aspiration pneumonia. Placing the client in a side-lying position also promotes comfort and safety during the procedure. The other options are not ideal for mouth care in an unconscious client: Fowler’s position may increase the risk of aspiration, the supine position can lead to aspiration as well, and Trendelenburg position is not recommended due to potential adverse effects on blood circulation and increased intracranial pressure.

4. Palpating the midclavicular line is the correct technique for assessing

A. Baseline vital signs
B. Systolic blood pressure
C. Respiratory rate
D. Apical pulse

Correct answer: D

Rationale: Palpating the midclavicular line is the correct technique for assessing the apical pulse. The apical pulse is located at the point of maximal impulse (PMI), which is typically at the fifth intercostal space at the midclavicular line. This technique allows healthcare providers to accurately assess the heart rate and rhythm by listening to the heart sounds directly at this point.

5. How many drops are equivalent to 1 tsp?

A. 15
B. 60
C. 10
D. 30

Correct answer: B

Rationale: 1 teaspoon (tsp) is equivalent to approximately 60 drops. Drops and teaspoons vary in volume and size, affecting the conversion ratio. Choice A (15 drops) is incorrect as it's a common misconception. Choice C (10 drops) and Choice D (30 drops) do not align with the standard conversion of 1 tsp to 60 drops.