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    Ngu Hesi Rn Compass Exit Proctored Exam
    Select All That Apply

    Patient Data Exhibits The nurse notifies the healthcare provider of the client's status. The healthcare provider comes to the bedside to evaluate the client. Which should the nurse do? Select all that apply.

    Explanation & Rationale

    Rationale: A. Increase the fraction of inspired oxygen: Increasing FiO₂ is only necessary if the client shows signs of hypoxemia or respiratory distress. Since oxygen saturation and respiratory status are not reported as compromised, this is not the immediate intervention. B. Gather supplies for extubation: The client has been weaned to 0 cm H₂O pressure support, indicating readiness for spontaneous breathing. Preparing extubation supplies ensures the nurse is ready for safe removal of the endotracheal tube when the healthcare provider decides it is appropriate. C. Set up supplemental oxygen delivery: After extubation, the client may require supplemental oxygen to maintain adequate oxygenation. Setting up oxygen delivery devices in advance promotes a smooth transition from mechanical ventilation to spontaneous breathing. D. Offer the client ice chips: Ice chips are inappropriate for an intubated client or a client being evaluated for extubation, as swallowing may be impaired and aspiration risk is high. Oral intake should only be introduced after a swallow assessment. E. Set the ventilator to give mandatory breaths: Providing mandatory breaths may be necessary if the client shows signs of respiratory fatigue or inadequate ventilation. This intervention supports the client temporarily until extubation is safely performed. F. Suggest a different ventilator mode to the provider: While input may be valuable, the healthcare provider evaluates ventilator management and decides on mode adjustments. The nurse should focus on preparing for extubation and supporting spontaneous breathing. G. Place a nasogastric tube: NG tube insertion is not indicated solely because the client is being weaned from the ventilator. This intervention is unrelated unless there are concerns about gastric distention or feeding tolerance post-extubation.

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