The nurse has observed an increase in the occurrence of pressure injuries among patients in the Intensive Care Unit (ICU). After documenting these findings, the nurse collaborated with the manager to create and implement a new policy that emphasizes the consistent use of a pressure injury risk assessment scale.

Which term best characterizes the nurse’s actions?

Quality Improvement.

Collaboration.

Case Management.

Advocacy.

Answer and Explanation

The Correct Answer is A

Choice A rationale
The nurse’s actions are an example of Quality Improvement. Quality Improvement involves systematic actions that lead to measurable improvement in health care services and the health status of targeted patient groups. In this case, the nurse identified a problem (increase in pressure injuries), collected data (documented findings), and implemented a change (new policy for consistent use of a pressure injury risk assessment scale) to improve patient outcomes.
Choice B rationale
While collaboration was part of the process (the nurse collaborated with the manager), the overall actions taken represent a Quality Improvement process.
Choice C rationale
Case Management typically involves coordinating the care and services of select patient populations, such as those with chronic illnesses or complex health needs. It does not directly apply to this scenario.
Choice D rationale
Advocacy involves supporting or promoting the interests of others, such as patients or colleagues. Although the nurse’s actions could be seen as advocating for the patients’ well- being, the term that best characterizes these actions is Quality Improvement.

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

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

Explanation

Choice A rationale
Following ventilator-weaning protocols is an important intervention to prevent ventilator-associated pneumonia. Weaning protocols help to reduce the duration of mechanical ventilation, which is a risk factor for developing ventilator-associated pneumonia.
Choice B rationale
Providing frequent mouth care is a key intervention in preventing ventilator-associated pneumonia. Good oral hygiene can help to reduce the amount of bacteria in the mouth that can potentially be aspirated into the lungs.
Choice C rationale
Suctioning the patient every hour is not typically recommended as a method to prevent ventilator-associated pneumonia. Over-suctioning can potentially damage the lung tissue and mucous membranes, and it can also increase the risk of introducing bacteria into the lungs.
Choice D rationale
Placing the patient in a prone position can help to improve oxygenation and reduce the risk of ventilator-associated pneumonia. The prone position can help to drain secretions from the lungs, reducing the risk of bacteria growth and infection.
Choice E rationale
Refraining from suctioning the patient is not a recommended intervention to prevent ventilator-associated pneumonia. Suctioning is necessary to remove secretions from the airway, which can help to prevent infection.

A. Limit oral fluids to minimize labored breathing. B. Lie in a low Fowler’s position to promote lung expansion. C. Perform hourly incentive spirometry to inflate lungs and mobilize secretions. D. Perform pursed lip breathing to expel trapped carbon dioxide from the alveoli.

Correct Answer is C

Explanation

Choice A rationale
Limiting oral fluids is not the best action for a client with pneumonia and copious tracheobronchial secretions. Adequate hydration can actually help thin and loosen pulmonary secretions, making them easier to expel.
Choice B rationale
While lying in a low Fowler’s position can aid in lung expansion, it is not the priority action in this case. The client has copious tracheobronchial secretions, and the most effective way to mobilize these secretions is through incentive spirometry.
Choice C rationale
Performing hourly incentive spirometry can help inflate the lungs and mobilize secretions, which is particularly beneficial for a client with pneumonia who has copious tracheobronchial secretions. This is the priority action as it directly addresses the client’s issue of labored breathing due to excessive secretions.
Choice D rationale
Pursed lip breathing is a technique used primarily to slow the pace of breathing and can help maintain open airways longer. However, it is not the most effective method for mobilizing tracheobronchial secretions.

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Naxlex Comprehensive Predictor Exams

A nurse is developing a plan of care for a patient on a ventilator, to prevent ventilator-associated pneumonia. The nurse recognizes that which of the following interventions should be included? Select all that apply.

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

Explanation

A nurse is caring for a client diagnosed with pneumonia who has labored breathing and copious tracheobronchial secretions. What priority action should the nurse encourage with the client?

Correct Answer is C

Explanation

A nurse is analyzing arterial blood gas results for a client diagnosed with chronic obstructive pulmonary disease (COPD). What abnormal finding should the nurse anticipate?

A nurse is caring for a patient who reports experiencing an alteration in sense of smell following surgery for a total laryngectomy. The nurse should address the patient’s concern through which of the following responses?

A patient reports that they avoid being around sick people, however, they have experienced repeated colds over the past several weeks. A nurse should respond to the patient’s concern by providing which of the following teaching?

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A nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD). Which precaution should the nurse prioritize when administering nasal oxygen therapy to the client?

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