A nurse is caring for a client on a ventilator. The nurse should include which of the following interventions in the plan of care to prevent ventilator associated pneumonia? (Select all that apply.)

Elevate the head of the bed 30 to 45 degrees.

Perform hand hygiene before touching the ventilator tubing.

Refrain from suctioning the client.

Provide mouth care every 2-4 hours.

Perform hand hygiene before touching the client.

Answer and Explanation

Correct Answer : A,B,D,E

A.   Elevating the head of the bed 30 to 45 degrees helps prevent aspiration, which is a risk factor for ventilator-associated pneumonia.
B.   Performing hand hygiene before touching the ventilator tubing is crucial to prevent the introduction of pathogens into the ventilator system.
C.   Refraining from suctioning the client is incorrect; suctioning should be performed as needed to keep the airway clear.
D.   Providing mouth care every 2-4 hours can reduce the risk of pathogens entering the lower respiratory tract.
E.   Performing hand hygiene before touching the client reduces the risk of transmitting infectious agents to the client.

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Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"A"},"G":{"answers":"A"}}

Explanation

Client calm not agitated. Grimaces with movement.
No change: While the client is calm and not agitated, grimacing with movement indicates continued discomfort or pain, which remains unchanged.
Oral mucous membranes dry.

No change: Dry oral mucous membranes persist, suggesting ongoing dehydration or inadequate oral hydration.
Axillary temp 102 F (38.9 C), client shivering.

Declined: The axillary temperature has increased from 100.8 F (38.22 C) to 102 F (38.9 C), indicating a worsening of the client's fever. Shivering suggests the body's attempt to generate heat in response to the fever.
Productive cough.

No change: The client continues to have a productive cough, indicating ongoing respiratory congestion or infection.
Coarse rhonchi bilaterally. Crackles in bases.

Declined: The presence of coarse rhonchi bilaterally and crackles in the bases suggests worsening respiratory status, possibly indicating progression of underlying lung disease or development of complications such as pneumonia.
Respirations irregular with periods of apnea.

Improved: The client's respirations, previously irregular with periods of apnea, are now regular, indicating an improvement in respiratory function.
Client resting in recliner. RR 12, regular.

Improved: The client's respiratory rate has decreased from 18 to 12 breaths per minute, and respirations are now regular, suggesting improved respiratory status and possibly reduced distress.

A. Allergic rhinitis B. Cough C. Hypotension D. Wheezing E. Urticaria

Correct Answer is ["A","B","C","D","E"]

Explanation

A. Allergic rhinitis: This is a common manifestation of a type I hypersensitivity reaction, often involving nasal congestion, sneezing, and itching.

B. Cough: While a cough can occur, it is not as specific or common in the context of systemic type I hypersensitivity reactions as the other options.

C. Hypotension: Hypotension can occur due to vasodilation and increased vascular permeability, which are hallmarks of systemic anaphylaxis.

D. Wheezing: Wheezing results from bronchoconstriction, a common feature in systemic type I hypersensitivity reactions, such as anaphylaxis.

E. Urticaria: Urticaria (hives) is a common skin manifestation of a type I hypersensitivity reaction, characterized by itchy, raised welts on the skin.

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A nurse is caring for a client on a ventilator. The nurse should include which of the following interventions in the plan of care to prevent ventilator associated pneumonia? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

A nurse caring for a client who is at home on hospice care. Exhibits At the end of the visit, the nurse reevaluates the client. Indicate if the assessment findings are improved, show no change, or show that the client has declined.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"A"},"G":{"answers":"A"}}

Explanation

A client is noted to have type I hypersensitivity reaction with a systemic response. Which clinical manifestations should the nurse anticipate? (Select all that apply).

Correct Answer is ["A","B","C","D","E"]

Explanation

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