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 A

Explanation

Answer: A

Rationale:

A) Place the client in a room with negative airflow: Disseminated herpes zoster (shingles) requires airborne precautions because the virus can become aerosolized. A room with negative airflow helps prevent the spread of the virus to other areas, protecting healthcare workers and other patients from infection.

B) Remove isolation gown after leaving the client's room: Isolation gowns should be removed before leaving the client's room to prevent the spread of contaminants to other areas. This intervention is important for infection control but is not specific to the requirement for negative airflow in cases of disseminated herpes zoster.

C) Apply ketoconazole to the lesions three times per day: Ketoconazole is an antifungal medication and is not used for treating herpes zoster, which is caused by a viral infection. Antiviral medications, such as acyclovir, are appropriate for treating herpes zoster lesions.

D) Provide the client with eye protection for ultraviolet B light therapy: Eye protection is necessary during UVB light therapy to protect the eyes, but UVB light therapy is not a standard treatment for disseminated herpes zoster. The priority intervention is to prevent the spread of the infection by using a negative airflow room.

A. Decreased NG tube drainage. B. Potassium 3.3 mEq/L. C. Increased heart rate. D. Hematocrit 46%.

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.

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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 planning care for a client who has disseminated herpes zoster (shingles). Which of the following interventions should the nurse include?

Correct Answer is A

Explanation

A nurse is caring for a client who has an NG tube to suction and is receiving IV fluids to maintain fluid volume balance. Which of the following findings should indicate to the nurse that this therapy is effective?

Correct Answer is A

Explanation

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