A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following actions should the nurse include in the plan of care?
Assess the need for oral suction every 4 hr.
Check the ventilator settings every 12 hr.
Keep the head of the client's bed elevated at 30°.
Perform oral hygiene using an alcohol-based oral rinse.
The Correct Answer is C
Choice A rationale:
Assessing the need for oral suction every 4 hours is essential in maintaining airway patency and preventing complications associated with excessive secretions. This is an appropriate action and does not require clarification.
Choice B rationale:
Checking the ventilator settings every 12 hours is necessary to ensure that the mechanical ventilation is providing adequate support for the client's respiratory needs. This prescription is appropriate and does not need clarification.
Choice C rationale:
Keeping the head of the client's bed elevated at 30° is important in preventing aspiration and ventilator-associated pneumonia. This position helps promote optimal lung expansion and improves oxygenation in ventilated clients.
Choice D rationale:
Performing oral hygiene using an alcohol-based oral rinse is not recommended for clients receiving mechanical ventilation. Alcohol-based products can be harmful if aspirated and may disrupt the normal oral flora, leading to complications. The nurse should use a non-alcohol-based oral rinse or foam swabs instead.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
Choice A rationale:
Lurasidone does not necessarily need to be taken on an empty stomach. It can be taken with or without food.
Choice B rationale:
Avoiding grapefruit juice is essential with lurasidone as it can interfere with the drug's metabolism and increase the risk of side effects.
Choice C rationale:
Changing positions slowly is relevant for medications that can cause orthostatic hypotension, but lurasidone is not typically associated with this side effect.
Choice D rationale:
Lurasidone can cause insomnia in some individuals, so it is important for the client to be aware of this potential side effect. It is best taken in the evening to minimize this effect.
Choice E rationale:
While involuntary movements (extrapyramidal symptoms) can occur with some antipsychotic medications, lurasidone has a lower risk of causing these side effects compared to older antipsychotics. It is not a major concern with lurasidone treatment.
Correct Answer is C
Explanation
Choice A rationale:
The nurse should not advise the client with multiple sclerosis to schedule all physical activities for the morning hours. While some individuals with multiple sclerosis may experience increased fatigue later in the day, the best approach is to encourage the client to schedule activities at times when they feel the most energetic and to balance physical activity with rest throughout the day.
Choice B rationale:
Monitoring blood pressure is essential while taking fingolimod, a medication used to treat multiple sclerosis, as it can cause a transient decrease in heart rate and blood pressure.
Therefore, the nurse should include this statement in the teaching to ensure the client's safety and early detection of any issues.
Choice C rationale:
This is the correct statement to include in the teaching. Clients with multiple sclerosis should avoid rigorous activities that increase body temperature, as this can worsen their symptoms due to the sensitivity of demyelinated nerves to heat. Activities such as hot baths or engaging in strenuous exercise in hot weather should be avoided.
Choice D rationale:
Corticosteroids are not typically used as a long-term treatment for multiple sclerosis. Instead, they are used for short courses during exacerbations to reduce inflammation and manage acute symptoms. Long-term use of corticosteroids can lead to significant adverse effects, so the nurse should not include this statement in the teaching.
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