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","C","D"]

Explanation

Choice A rationale
Dyspnea, or difficulty breathing, is a common symptom of Obstructive Sleep Apnea (OSA). This occurs due to the repeated episodes of upper airway obstruction and resultant intermittent hypoxia.
Choice B rationale
Insomnia is not a typical symptom of OSA. While individuals with OSA may experience disrupted sleep, it is usually characterized by excessive daytime sleepiness rather than an inability to sleep.
Choice C rationale
Snoring is a hallmark symptom of OSA. It occurs due to the partial obstruction of the upper airway, which causes vibration of the tissues and results in the sound of snoring.
Choice D rationale
Daytime sleepiness is a common symptom of OSA. This is due to the repeated awakenings throughout the night to resume breathing, which disrupts the sleep cycle and leads to excessive sleepiness during the day.
Choice E rationale
Dyspnea on exertion is not a typical symptom of OSA. While it can occur in severe cases, it is more commonly associated with conditions that affect the heart or lungs, such as heart failure or chronic obstructive pulmonary disease.

A. Skin breakdown. B. Pneumonia. C. Thrombosis. D. Atelectasis.

Correct Answer is D

Explanation

Choice A rationale
While skin breakdown can occur due to prolonged bed rest, it is not directly related to shallow respirations and refusal to cough or get out of bed.
Choice B rationale
Pneumonia is a possible complication due to immobility and shallow breathing. However, it is not the most immediate risk for a postoperative client who is refusing to cough or get out of bed.
Choice C rationale
Thrombosis is a risk associated with immobility, but it is not directly related to shallow respirations.
Choice D rationale
Atelectasis, or the collapse of alveoli in the lungs, is a common complication after surgery due to shallow breathing and lack of movement. This condition leads to reduced or absent gas exchange, which can further complicate the client’s recovery.

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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 providing education to a client diagnosed with Obstructive Sleep Apnea (OSA). Which of the following signs and symptoms of OSA should the nurse include in the education? Select all that apply.

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

Explanation

A nurse is caring for a postoperative client experiencing shallow respirations and refusing to cough or get out of bed to the chair. The nurse should educate the client about the increased risk of which complication?

Correct Answer is D

Explanation

A nurse is caring for a client diagnosed with pneumonia who has labored breathing and copious tracheobronchial secretions. What priority action should the nurse encourage with the client?

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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?

During a central IV line insertion at the bedside, a client reports shortness of breath and becomes tachypneic. Which finding should a nurse suspect indicates the client developed a pneumothorax?

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 clinic nurse is planning to teach a group of clients about laryngeal cancer. The nurse should include which of the following risk factors associated with the development of laryngeal cancer? Select all that apply.

A nurse is caring for a patient at risk for atelectasis. Which independent nursing measure should the nurse prioritize to prevent the development of atelectasis?

A nurse is reviewing incident reports submitted during the previous month. The nurse should identify which of the following as a problem that should be reported to the risk manager?