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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
c. Instruct the client to use abdominal breathing.
When a client is experiencing a panic atack, the nurse's first priority is to help the client manage their symptoms and provide immediate relief. Instructing the client to use abdominal breathing is the most appropriate initial intervention.
Explanation for the other options:
a. Discuss the client's feelings prior to the panic atack. While discussing the client's feelings can be beneficial in addressing the underlying causes of anxiety, it may not be the most effective immediate intervention during a panic atack. The client's focus during a panic atack is typically on managing the physical symptoms and regaining control.
b. Encourage the use of positive self-talk strategies. Positive self-talk can be helpful in managing anxiety in general, but during a panic atack, the individual may have difficulty engaging in positive self-talk due to the intensity of symptoms. Addressing the immediate physical symptoms is a priority before exploring coping strategies.
d. Administer an anti-anxiety medication. Medication administration may be necessary in some cases, but it is not the first-line intervention for managing a panic atack. Non-pharmacological interventions, such as breathing techniques, should be implemented first. If the panic atack persists or worsens despite these interventions, medication may be considered.
In summary, during a panic atack, the immediate focus should be on helping the client manage their symptoms. Instructing the client to use abdominal breathing can help promote relaxation and reduce the intensity of the panic atack.
Correct Answer is C
Explanation
Yogurt is a beneficial food for individuals with IBS for several reasons: Yogurt contains live beneficial bacteria, known as probiotics, which can help regulate the balance of gut bacteria. Probiotics may improve digestive health and reduce symptoms such as bloating, gas, and diarrhea in some individuals with IBS. Yogurt is a good source of calcium, which is an essential nutrient for overall health and plays a role in maintaining normal digestive function.
Ice cream is not typically recommended for individuals with IBS. It contains high amounts of fat and lactose, which can worsen symptoms such as bloating, gas, and diarrhea in some individuals with IBS. Moreover, some people with IBS may be sensitive to dairy products.
Honey is generally well-tolerated by individuals with IBS. However, it does not offer specific benefits for managing IBS symptoms. Its inclusion in the diet would depend on individual preferences and tolerances.
Watermelon is a low-FODMAP fruit, which means it is generally well-tolerated by individuals with IBS. It can be a refreshing and hydrating option. However, its inclusion in the diet would depend on individual preferences and tolerances.
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