A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following actions should the nurse take?
Monitor the client's vital signs every 8 hours
Reposition the endotracheal tube every 12 hours.
Place the client in a supine position.
Perform oral care every 2 hours
The Correct Answer is D
Performing oral care every 2 hours is an important nursing intervention for a client receiving mechanical ventilation via an endotracheal tube. This helps to reduce the risk of ventilator-associated pneumonia.
a) Monitoring the client's vital signs is important, but it should be done more frequently than every 8 hours.
b) Repositioning the endotracheal tube is not necessary unless there is a specific indication.
c) Placing the client in a supine position is not recommended as it increases the risk of aspiration.
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Related Questions
Correct Answer is D
Explanation
d. Corn tortillas with black beans.
Explanation:
Celiac disease is an autoimmune disorder that requires strict adherence to a gluten-free diet. Gluten is a protein found in wheat, barley, and rye. Therefore, options a, b, and c should be avoided as they contain wheat or barley.
Option d, corn tortillas with black beans, is a suitable choice because corn is a gluten-free grain and black beans are also gluten-free. This option provides a balanced and nutritious meal for a child with celiac disease. It is important for individuals with celiac disease to carefully read food labels and choose gluten- free alternatives to ensure their diet is free of gluten-containing ingredients.
Correct Answer is A
Explanation
a . Provide a tour of the perioperative area prior to surgery.
The correct answer is a. Provide a tour of the perioperative area prior to surgery.
Explanation:
When caring for an adolescent scheduled for surgery, providing a tour of the perioperative area prior to the procedure is an important action for the nurse to take. Adolescents may experience fear and anxiety related to the unfamiliar environment and procedures associated with surgery. Providing a tour allows the adolescent to become familiar with the surroundings, equipment, and healthcare team, which can help alleviate anxiety and promote a sense of control.
Explanation for the other options:
b. Explain that anesthesia is a special type of sleep: While it is important to provide information about anesthesia to the adolescent, describing it as a "special type of sleep" may be misleading. Anesthesia is a medical procedure that involves more than just being asleep, and it is important to provide accurate information to the adolescent.
c. Keep medical equipment out of the client's sight: While it is important to create a comfortable and non- threatening environment for the adolescent, completely hiding medical equipment may not be feasible or necessary. Instead, the nurse should address any specific fears or concerns the adolescent may have and provide age-appropriate explanations and reassurance.
d. Wait until after surgery to explain the importance of coughing and deep breathing: It is important to provide preoperative education to the adolescent to promote their understanding and cooperation. Explaining the importance of coughing and deep breathing before surgery helps the adolescent prepare and participate in their own recovery. Waiting until after surgery may result in missed opportunities for early postoperative interventions.
In summary, providing a tour of the perioperative area prior to surgery helps familiarize the adolescent with the environment, reducing anxiety and promoting a sense of control.
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