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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

Using fingers to remove loose tissue is not an appropriate action for the nurse to take when providing hydrotherapy for a burn wound. This action can cause further trauma to the wound and increase the risk of infection.

Choice B rationale:

Opening small blisters to expose air is contraindicated in burn wound management. The blister roof provides a natural barrier against infection, and puncturing them increases the risk of infection and delays the healing process.

Choice C rationale:

The correct answer is to wash the burn with a mild soap. Cleaning the burn wound with mild soap and water helps remove debris and minimize the risk of infection without causing additional damage.

Choice D rationale:

Applying wet-to-dry dressings is an outdated and inappropriate practice for burn wound care. Wet-to-dry dressings can be painful, disrupt wound healing, and increase the risk of infection. Modern burn wound care focuses on maintaining a moist environment to support optimal healing.

A. Apply clean gloves when removing the old dressing from the catheter site. B. Cleanse the area by using a circular motion beginning at the catheter site and moving outward. C. Use warm water to cleanse the catheter site. D. Place an occlusive dressing over the catheter site after cleaning.

Correct Answer is A

Explanation

Choice A rationale:
Applying clean gloves when removing the old dressing from the catheter site is essential to prevent infection and maintain an aseptic technique during peritoneal dialysis catheter care. Gloves protect both the nurse and the patient from potential contamination.
Choice B rationale:
Cleansing the area by using a circular motion beginning at the catheter site and moving outward is not the correct technique. When caring for a dialysis catheter, the nurse should cleanse the site using an outward, circular motion starting from the insertion site to minimize the risk of contamination.
Choice C rationale:
Using warm water to cleanse the catheter site is not recommended. The peritoneal dialysis catheter site should be cleaned with an appropriate antiseptic solution or disinfectant, as warm water alone may not effectively remove bacteria or prevent infections.
Choice D rationale:
Placing an occlusive dressing over the catheter site after cleaning is not the standard practice for peritoneal dialysis catheter care. Typically, a clean, dry dressing is applied to the catheter site after cleaning to keep it clean and dry, but it should not be occlusive.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to provide hydrotherapy for a client who has a burn wound. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

A nurse is caring for a client who is receiving peritoneal dialysis. When caring for the client's dialysis catheter, which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

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