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 C
Explanation
Choice A rationale:
Increasing the intake of high-fiber foods is not relevant to addressing the client's dry mouth caused by benztropine. High-fiber foods are commonly recommended for managing constipation, a symptom often associated with Parkinson's disease, but it does not address the issue of dry mouth.
Choice B rationale:
Chewing sugarless gum can stimulate saliva production and help alleviate dry mouth. However, it is not the most appropriate recommendation for a client taking benztropine, as gum-chewing may interfere with the effectiveness of the medication or exacerbate other symptoms.
Choice C rationale:
Moistening the mouth with lemon-glycerin swabs is the most suitable recommendation for a client experiencing dry mouth due to benztropine. Lemon-glycerin swabs can help increase saliva production and provide relief from the discomfort of dry mouth without interfering with the medication's efficacy.
Choice D rationale:
Rinsing the mouth with nystatin is used to treat fungal infections in the mouth (oral thrush) and is not relevant to address the side effect of dry mouth caused by benztropine.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should maintain the client in a semi-Fowler's position to promote comfort and reduce the risk of complications related to appendicitis. This position helps to decrease pressure on the abdomen and may alleviate pain by reducing tension on the abdominal muscles.
Choice B rationale:
Administering an enema 1 hour prior to surgery is not indicated for a client with appendicitis. Enemas are generally not recommended for clients with suspected or confirmed appendicitis as they can potentially worsen inflammation and cause perforation of the inflamed appendix.
Choice C rationale:
Applying a warm pack to the client's lower abdomen is contraindicated in appendicitis. Heat can exacerbate inflammation and should be avoided in such cases.
Choice D rationale:
Placing the client on a clear liquid diet is not appropriate for appendicitis. Clients with appendicitis are typically NPO (nothing by mouth) to avoid stimulating the gastrointestinal tract and reduce the risk of rupture if surgery is needed.
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