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 A
Explanation
Choice A rationale:
A decrease in NG tube drainage indicates that the client's stomach contents are not being aspirated excessively, which suggests that the IV fluids are effectively maintaining fluid volume balance. This finding is positive because it shows that the client is retaining the fluids they need, and it may also indicate improved gastrointestinal function and decreased risk of dehydration.
Choice B rationale:
The potassium level of 3.3 mEq/L (milliequivalents per liter) is low. The normal range for potassium is typically between 3.5 to 5.0 mEq/L. Hypokalemia (low potassium) can result from various factors and may cause muscle weakness, cardiac arrhythmias, and other complications. It is not a finding that indicates the effectiveness of fluid volume balance therapy.
Choice C rationale:
An increased heart rate may suggest that the client is experiencing fluid volume deficit or other physiological stress. It is not a finding that indicates the effectiveness of fluid volume balance therapy.
Choice D rationale:
A hematocrit level of 46% is within the normal range for adult males (typically around 38.8% to 50%) and indicates the proportion of red blood cells in the blood. While it can provide information about blood viscosity and hydration status, it does not directly indicate the effectiveness of fluid volume balance therapy.
Correct Answer is A
Explanation
Choice A rationale:
Tender, bleeding gums could be a sign of phenytoin-induced gingival hyperplasia, a serious adverse effect of phenytoin. This condition requires immediate medical attention to prevent further complications.
Choice B rationale:
Increased facial hair is not a common adverse effect of phenytoin and may not require immediate medical attention. It could be due to other factors or conditions.
Choice C rationale:
Constipation is a common side effect of many medications, including phenytoin. While it should be monitored, it does not require immediate reporting to the provider unless severe or persistent.
Choice D rationale:
A skin rash can be an adverse effect of phenytoin, but it does not necessarily require immediate reporting unless it is severe, accompanied by other symptoms, or indicative of a serious allergic reaction.
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