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 B
Explanation
b. Methylergonovine.
Explanation:
Postpartum hemorrhage is a significant complication that can occur after childbirth. Methylergonovine is a medication commonly used to manage postpartum hemorrhage. It is an ergot alkaloid that helps to contract the uterus, reducing bleeding. It is typically administered either intramuscularly or orally.
Option a, Terbutaline, is a medication used for the management of preterm labor by relaxing the uterine smooth muscles. It is not indicated for postpartum hemorrhage.
Option c, Magnesium sulfate, is a medication used for the prevention and treatment of seizures in patients with preeclampsia or eclampsia. It is not specifically indicated for postpartum hemorrhage.
Option d, Nifedipine, is a calcium channel blocker commonly used to manage hypertension. It is not indicated for postpartum hemorrhage.
It's important to note that the specific management of postpartum hemorrhage may vary depending on the underlying cause, severity of bleeding, and individual patient factors. The healthcare provider will determine the most appropriate interventions and medications for each case.
Correct Answer is C
Explanation
The nurse should inform the family that the client has the right to refuse medication. It is important to
respect the client's autonomy and right to make decisions about their own care.
a) Scheduling the medication at meal times does not address the issue of the client refusing their medication.
b) Requesting that the family talk to the provider about administering the medication by injection may be an option, but it does not address the issue of informed consent.
d) Asking the family what foods the client likes does not address the issue of informed consent and could be seen as a way to deceive the client into taking their medication.
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