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 A
Explanation
The nurse should identify that caring for a client who has a new onset of chest pain is outside the scope of practice for an LPN. This is a complex and potentially life-threatening situation that requires the assessment and intervention of a registered nurse (RN) or other advanced practice provider.
b) Caring for a client who has a tracheostomy is within the scope of practice for an LPN.
c) Caring for a client who is receiving enteral feedings is within the scope of practice for an LPN.
d) Caring for a client who has urinary retention is within the scope of practice for an LPN.
Correct Answer is A
Explanation
a. "Many people have colostomies and they live full lives."
Explanation:
The correct answer is a. "Many people have colostomies and they live full lives."
When a client expresses concerns or distress regarding their colostomy and not wanting others to see the colostomy bag, it is essential for the nurse to provide support and reassurance. Responding by acknowledging that many people live full lives with colostomies helps normalize the experience and offers hope to the client.
Option b, "Would it help to speak to someone else who has a colostomy?" may be a helpful suggestion, but it should not be the initial response. First, it is important to provide immediate reassurance and support to the client before exploring additional resources or contacts.
Option c, "Why don't you want people to see the colostomy bag?" may be seen as invasive and may put the client on the spot, potentially making them feel uncomfortable or defensive. It is important to create a safe and non-judgmental environment for the client.
Option d, "The colostomy is probably only temporary," assumes information about the client's specific situation that may not be accurate. It is important to avoid making assumptions about the duration or permanence of the colostomy unless the client has shared that information. Providing false reassurances can negatively impact the client's trust and emotional well-being.
By responding with the statement that many people live full lives with colostomies, the nurse offers support, normalizes the client's experience, and promotes a positive outlook for the client's future.
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