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

Answer and Explanation

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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Correct Answer is B

Explanation

The nurse should include maintaining elbow restraints on the infant in the plan of care following cleft palate repair. This helps to prevent the infant from touching their surgical site and disrupting the healing process.

a) Allowing the infant to have soft foods may be appropriate, but it is not the highest priority. The infant's diet should be determined by the provider and based on the infant's individual needs.

c) Instructing the parents to feed the infant with a spoon may be appropriate, but it is not the highest priority. The infant's feeding method should be determined by the provider and based on the infant's individual needs.

d) Telling the parents to avoid brushing the infant's teeth for two weeks may be appropriate, but it is not the highest priority. The infant's oral care should be determined by the provider and based on the infant's individual needs.

A. Celiac disease B. Lactose intolerance C. Acute renal failure D. Iron-deficiency anemia

Correct Answer is D

No explanation

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a 12-month-old infant following cleft palate repair. Which of the following actions should the nurse include?

Correct Answer is B

Explanation

Correct Answer is D

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