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 B

Explanation

Choice A rationale
Establishing a benchmark to identify a standard of performance is a crucial step in any quality improvement process. It provides a reference point against which progress can be measured. However, it does not directly evaluate the effectiveness of the implemented measures.
Choice B rationale
Comparing the number of medication errors before and after the implementation of the measures is the most direct and effective method to evaluate the success of the changes. This method provides quantitative data that can clearly show whether the measures have led to a reduction in medication errors.
Choice C rationale
Conducting a study on the time and cost implications of implementing the change can provide valuable information about the efficiency of the measures. However, it does not directly assess their effectiveness in reducing medication errors.
Choice D rationale
Providing a questionnaire to the staff to quantify their satisfaction with the changes can help to assess the acceptance of the measures among the staff. However, staff satisfaction does not necessarily correlate with the effectiveness of the measures in reducing medication errors.

A. Implement ventilator-weaning protocols. B. Provide frequent oral care. C. Suction the patient every hour. D. Position the patient in a prone position. E. Avoid suctioning the patient.

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

Explanation

Choice A rationale
Implementing ventilator-weaning protocols is a crucial intervention in the care plan for a patient on a ventilator to prevent ventilator-associated pneumonia. These protocols aim to minimize the patient’s exposure to mechanical ventilation, which is a significant risk factor for developing ventilator-associated pneumonia. By systematically reducing the level of ventilatory support, these protocols facilitate the earliest possible liberation from mechanical ventilation, thereby reducing the risk of ventilator-associated pneumonia.
Choice B rationale
Providing frequent oral care is another essential intervention in preventing ventilator- associated pneumonia. Oral health can quickly deteriorate in mechanically ventilated patients, leading to an increased risk of ventilator-associated pneumonia. Regular oral care, including the use of antiseptics, can help reduce the number of potential respiratory pathogens in the oral cavity and prevent their aspiration into the lower respiratory tract.
Choice C rationale
Suctioning the patient every hour is not typically recommended as a standard intervention to prevent ventilator-associated pneumonia. Over-suctioning can lead to trauma and inflammation in the airway, potentially increasing the risk of infection. Suctioning should be performed based on the patient’s needs and clinical signs, rather than on a fixed schedule.
Choice D rationale
Positioning the patient in a semi-upright position (30 to 45 degrees), rather than a prone position, is recommended to prevent ventilator-associated pneumonia. This position helps to reduce the risk of aspiration, which is a major risk factor for ventilator-associated pneumonia.
Choice E rationale
Avoiding suctioning the patient is not a recommended strategy for preventing ventilator- associated pneumonia. Suctioning is necessary to clear secretions from the airway, and its omission could potentially increase the risk of infection. However, as mentioned earlier, suctioning should be performed based on the patient’s needs and clinical signs, rather than on a fixed schedule.

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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 on a quality control committee is evaluating the effectiveness of recently implemented measures aimed at reducing medication errors. Which methods should the nurse use to evaluate the success of the changes?

Correct Answer is B

Explanation

In the context of developing a care plan for a patient on a ventilator to prevent ventilator-associated pneumonia, which interventions should be included? Select all that apply.

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

Explanation

A nurse is part of a Continuous Quality Improvement (CQI) committee tasked with developing a program to decrease medication administration errors following a sentinel event. Which strategy should the committee consider implementing first?

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?

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A nurse is preparing to discharge a patient who is post-operative following a laryngectomy. The nurse should recognize which of the following discharge teaching as the highest priority?

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A nurse is caring for a client newly diagnosed with active tuberculosis (TB) and prescribed triple antibiotic therapy. The nurse should recognize that which clinical sign indicates inadequate drug therapy after 2 months of treatment?

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?