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.

Follow ventilator-weaning protocols.

Provide frequent mouth care.

Suction the patient every hour.

Place the patient in a prone position.

Refrain from suctioning the patient.

Answer and Explanation

Correct Answer : A,B,D

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.

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

Explanation

Choice A rationale
Thoracentesis may be performed to remove air from the pleural space in a client with a pneumothorax.
Choice B rationale
Obtaining arterial blood gases (ABGs) can help assess the client’s respiratory status and the severity of the pneumothorax.
Choice C rationale
A computed tomography (CT) scan of the chest can provide detailed images of the lungs and can help confirm the diagnosis of a pneumothorax.
Choice D rationale
Preparation for the insertion of a chest tube may be necessary to remove air from the pleural space and allow the lung to re-expand in a client with a pneumothorax.
Choice E rationale
Obtaining intravenous access is often necessary for administering medications and fluids.

A. “As your appetite returns, your sense of smell will also return.”. B. “Your body will slowly develop an ability to smell through your stoma.”. C. “Your sense of smell will gradually return after several months.”. D. “Breathing through a stoma has altered your sense of smell.”.

Correct Answer is D

Explanation

Choice A rationale
While it’s true that appetite and sense of smell are closely linked, the return of appetite does not necessarily mean the return of the sense of smell, especially after a total laryngectomy.
Choice B rationale
The body does not develop an ability to smell through the stoma. The sense of smell is primarily mediated by the olfactory nerve (Cranial Nerve I), which is located in the upper part of the nasal cavity.
Choice C rationale
The sense of smell does not typically return after several months following a total laryngectomy. This is because the surgery involves removal of the larynx and separation of the airway from the mouth, nose and throat.
Choice D rationale
Breathing through a stoma after a total laryngectomy does alter the sense of smell. This is because the nose and mouth are bypassed during breathing, and these are the primary routes for smell.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a pneumothorax. The nurse is reviewing the client’s medical record. What prescriptions should the nurse anticipate for a client who has a pneumothorax?

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

Explanation

A nurse is caring for a patient who reports experiencing an alteration in sense of smell following surgery for a total laryngectomy. The nurse should address the patient’s concern through which of the following responses?

Correct Answer is D

Explanation

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A nurse is educating a client after surgery for laryngeal cancer about a full liquid diet. What selection made by a client indicates to a nurse that the teaching was effective?

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