A nurse is caring for a patient who has just returned to the unit following a bronchoscopy and requests coffee.

The nurse assesses that it is safe for the patient to resume oral liquids when which of the following behaviors is demonstrated?

The patient can drink water through a straw without choking.

The patient has intact cough and swallowing reflexes.

The patient has clear breath sounds upon auscultation.

The patient reports that they are not experiencing a sore throat.

Answer and Explanation

The Correct Answer is B

Choice A rationale
While being able to drink water through a straw without choking is a positive sign, it is not the primary indicator that a patient can safely resume oral liquids after a bronchoscopy. The primary indicator is the return of the patient’s cough and swallowing reflexes.
Choice B rationale
The patient has intact cough and swallowing reflexes is the primary indicator that a patient can safely resume oral liquids after a bronchoscopy. These reflexes are essential for preventing aspiration, which can lead to pneumonia.
Choice C rationale
While clear breath sounds upon auscultation are a positive sign, they are not the primary indicator that a patient can safely resume oral liquids after a bronchoscopy. The primary indicator is the return of the patient’s cough and swallowing reflexes.
Choice D rationale
The absence of a sore throat is not the primary indicator that a patient can safely resume oral liquids after a bronchoscopy. The primary indicator is the return of the patient’s cough and swallowing reflexes.

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Correct Answer is ["A","B","D"]

Explanation

Choice A rationale
Following ventilator-weaning protocols is an important intervention to prevent ventilator-associated pneumonia. Weaning protocols help to reduce the duration of mechanical ventilation, which is a risk factor for developing ventilator-associated pneumonia.
Choice B rationale
Providing frequent mouth care is a key intervention in preventing ventilator-associated pneumonia. Good oral hygiene can help to reduce the amount of bacteria in the mouth that can potentially be aspirated into the lungs.
Choice C rationale
Suctioning the patient every hour is not typically recommended as a method to prevent ventilator-associated pneumonia. Over-suctioning can potentially damage the lung tissue and mucous membranes, and it can also increase the risk of introducing bacteria into the lungs.
Choice D rationale
Placing the patient in a prone position can help to improve oxygenation and reduce the risk of ventilator-associated pneumonia. The prone position can help to drain secretions from the lungs, reducing the risk of bacteria growth and infection.
Choice E rationale
Refraining from suctioning the patient is not a recommended intervention to prevent ventilator-associated pneumonia. Suctioning is necessary to remove secretions from the airway, which can help to prevent infection.

A. Potential Condition: Bleeding, Actions to Take: Observe surgical dressing, obtain blood cultures, Parameters to Monitor: Blood pressure, Patient’s performance of lung expansion exercises. B. Potential Condition: Air leak, Actions to Take: Check the drainage system, Parameters to Monitor: Respiratory status, Chest tube drainage. C. Potential Condition: Pulmonary edema. D. Potential Condition: Pneumonia.

Correct Answer is B

Explanation

Choice A rationale
While bleeding is a potential complication following a thoracotomy, the actions and parameters listed do not align with the care of a patient with a chest tube.
Choice B rationale
An air leak is a potential complication following a thoracotomy with chest tube insertion. The nurse should check the drainage system and monitor the patient’s respiratory status and chest tube drainage.
Choice C rationale
Pulmonary edema is a potential complication following a thoracotomy, but the actions and parameters listed do not align with the care of a patient with a chest tube.
Choice D rationale
Pneumonia is a potential complication following a thoracotomy, but the actions and parameters listed do not align with the care of a patient with a chest tube.

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A nurse is caring for a patient who has just returned to the unit following a bronchoscopy and requests coffee. The nurse assesses that it is safe for the patient to resume oral liquids when which of the following behaviors is demonstrated?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a plan of care for a patient on a ventilator, to prevent ventilator-associated pneumonia. The nurse recognizes that which of the following interventions should be included? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

What condition is the patient most likely experiencing, what two actions should the nurse take to address that condition, and what two parameters should the nurse monitor to assess the patient’s progress?

Correct Answer is B

Explanation

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A nurse is caring for a patient who has just returned to the unit following a bronchoscopy and requests coffee.

The nurse assesses that it is safe for the patient to resume oral liquids when which of the following behaviors is demonstrated?