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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

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

Explanation

A. Confusion and restlessness: Confusion and restlessness can indicate changes in cerebral perfusion as the body begins to shut down. These signs may occur as death approaches.

B. Increased appetite and thirst: Increased appetite and thirst are less likely as death approaches.

In fact, clients often have decreased appetite and thirst as the body's systems slow down.

C. Increase in urinary and bowel output: As death approaches, urinary and bowel output typically decrease as the body's metabolic processes slow down.

D. Increased fatigue and sleep: Increased fatigue and sleepiness are common as death approaches. The body's energy levels decrease, leading to increased periods of sleep and rest.

E. Excess secretions in the throat and decrease swallow reflex: Excess secretions in the throat and a decrease in the swallow reflex can occur as the body's ability to manage secretions diminishes. This can lead to a gurgling sound in the throat known as the death rattle.

A. Freshly squeezed orange juice. B. Milk. C. Black Coffee. D. Sweetened iced tea.

Correct Answer is D

Explanation

A. Freshly squeezed orange juice: Orange juice is generally not considered a trigger for gout attacks. However, it is high in fructose, which may contribute to gout if consumed excessively.

B. Milk: Milk is not typically associated with triggering gout attacks and is often recommended as part of a healthy diet for gout.

C. Black Coffee: Coffee, especially black coffee, is generally considered safe for individuals with gout and may even have some protective effects against gout attacks.

D. Sweetened iced tea: Sweetened iced tea is often made with high-fructose corn syrup, which can increase uric acid levels and potentially trigger gout attacks. Therefore, it is important for individuals with gout to limit their intake of sweetened beverages like iced tea.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving hospice care in the home. The family asks, "how will we know when death is near?" The nurse should inform the family that which of the following signs indicates that death is approaching? (Select all that apply.)

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

Explanation

A nurse is teaching a client who has gout about dietary recommendations. The nurse should teach the client that which of the following beverages can trigger an attack?

Correct Answer is D

Explanation

A nurse is caring for a client diagnosed with rheumatoid arthritis (RA). The nurse is assessing the client to determine the effectiveness of the current treatment regimen. Which finding would be the best indicator that the client's RA management is effective?

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.)

A nurse is assessing a client with a chest tube and observes the water level in the water seal bubbling as the client breathes. How should the nurse best respond to this assessment finding?

A nurse is caring for a client diagnosed with chronic renal disease. The nurse should recognize that which of the following medications is contraindicated for clients with chronic renal disease?

The nurse manager is negotiating a conflict between the staff nurses and nursing assistants. The nurse manager talked to everyone involved and created a list of the main issues. Which step in the negotiation process does this best describe?

A nurse suspects impending respiratory failure in a client diagnosed with chronic obstructive pulmonary disease (COPD). The nurse should recognize that which assessment finding supports the presence of hypoxemia?

A nurse is planning care for a client who has malnutrition due to cancer. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

A nurse is teaching a client diagnosed with hypertension and is prescribed Atenolol. Which of the following findings should the nurse include as adverse effects of Atenolol?