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 D

Explanation

Answer: D. Contact the provider who will be performing the procedure.

Rationale:

A) Provide teaching about the surgical procedure for the client:

While nurses play an essential role in patient education, it is the responsibility of the healthcare provider performing the procedure to ensure the patient fully understands the details, risks, and benefits. Nurses can clarify information but should not provide the initial comprehensive explanation of the procedure.

B) Instruct the client's spouse to sign the consent form:

The client is the one who needs to provide informed consent, not the spouse, unless the client is legally unable to do so. In such cases, legal documentation, such as a power of attorney, is required. Instructing the spouse to sign without proper authorization is inappropriate and potentially legally problematic.

C) Read the consent form to the client using words the client will understand:

While simplifying the language of the consent form can help, it is not sufficient if the client does not fully understand the procedure. Full understanding requires a detailed discussion about the procedure, risks, benefits, and alternatives, which should be done by the provider performing the procedure.

D) Contact the provider who will be performing the procedure:

The provider performing the procedure has the responsibility to ensure the client understands all aspects of the surgery. Contacting the provider to provide a thorough explanation ensures that the client receives accurate and complete information, allowing for truly informed consent.

A. Prolonged sun exposure. B. Reduced intake of vitamin E. C. Drinking one glass of wine per day. D. Exposure to second-hand tobacco smoke.

Correct Answer is ["A","D"]

Explanation

Choice A rationale:

Prolonged sun exposure is a risk factor for osteoporosis because it can lead to vitamin D deficiency. Vitamin D is essential for calcium absorption, and low levels of vitamin D can contribute to reduced bone density and increased risk of fractures.

Choice B rationale:

Reduced intake of vitamin E is not a well-established risk factor for osteoporosis. Vitamin E is an antioxidant and plays a role in various bodily processes, but its association with osteoporosis is not supported by strong evidence.

Choice C rationale:

Drinking one glass of wine per day is not a risk factor for osteoporosis. In fact, moderate alcohol consumption has been suggested to have a protective effect on bone density in some studies.

Choice D rationale:

Exposure to second-hand tobacco smoke is a risk factor for osteoporosis. Smoking and exposure to tobacco smoke have been linked to decreased bone density and increased risk of fractures, making this an important point to include in the teaching.

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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 assessing a client's understanding of a surgical procedure prior to witnessing their signature on the informed consent form. The nurse determines that the client does not understand what the procedure will involve. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is teaching a group of middle adult clients about osteoporosis. Which of the following risk factors should the nurse include?

Correct Answer is ["A","D"]

Explanation

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