Free NCLEX-RN Exam Braindumps (page: 251)

Page 251 of 431

Endotracheal tube cuff pressure should never exceed:

  1. 10 mm Hg
  2. 20 mm Hg
  3. 45 mm Hg
  4. 60 mm Hg

Answer(s): B

Explanation:

(A) Pressure<10 mm Hg places the client at risk for aspiration. (B) Pressure in the endotracheal tube cuff should never exceed 20 mm Hg, because higher pressure places the client at risk for tracheal erosion. (C) A pressure of 45 mm Hg is an extremely high pressure in the endotracheal tube cuff. This places the client at great risk for tracheal erosion. (D) A pressure of 60 mm Hg is an extremely high pressure in the endotracheal tube cuff. This places the client at great risk for tracheal erosion.



Endotracheal tube cuff pressure should never exceed:

  1. 10 mm Hg
  2. 20 mm Hg
  3. 45 mm Hg
  4. 60 mm Hg

Answer(s): B

Explanation:

(A) Pressure<10 mm Hg places the client at risk for aspiration. (B) Pressure in the endotracheal tube cuff should never exceed 20 mm Hg, because higher pressure places the client at risk for tracheal erosion. (C) A pressure of 45 mm Hg is an extremely high pressure in the endotracheal tube cuff. This places the client at great risk for tracheal erosion. (D) A pressure of 60 mm Hg is an extremely high pressure in the endotracheal tube cuff. This places the client at great risk for tracheal erosion.



In working with a manipulative client, which of the following nursing interventions would be most appropriate?

  1. Bargaining with the client as a strategy to control the behavior
  2. Redirecting the client
  3. Providing a consistent set of guidelines and rules
  4. Assigning the client to different staff persons each day

Answer(s): C

Explanation:

(A) This answer is incorrect. Bargaining is a manipulative act, which the nurse could expect from the client. (B) This answer is incorrect. Confrontation is an effective nursing strategy with manipulative behavior. Redirection is appropriate for the client who is out of touch with reality. (C) This answer is correct. Manipulative clients must abide by consistent rules. (D) This answer is incorrect. Manipulation is kept at a minimum if the same staff person is assigned to the client. Often the client will attempt to play staff persons against each other.



In working with a manipulative client, which of the following nursing interventions would be most appropriate?

  1. Bargaining with the client as a strategy to control the behavior
  2. Redirecting the client
  3. Providing a consistent set of guidelines and rules
  4. Assigning the client to different staff persons each day

Answer(s): C

Explanation:

(A) This answer is incorrect. Bargaining is a manipulative act, which the nurse could expect from the client. (B) This answer is incorrect. Confrontation is an effective nursing strategy with manipulative behavior. Redirection is appropriate for the client who is out of touch with reality. (C) This answer is correct. Manipulative clients must abide by consistent rules. (D) This answer is incorrect. Manipulation is kept at a minimum if the same staff person is assigned to the client. Often the client will attempt to play staff persons against each other.



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