The nurse provides care to a patient who is mechanically ventilated. Which nursing action is most effective in decreasing the risk for aspiration?

Ensure an NPC status is maintained for the length of the prescribed treatment

Perform chest physiotherapy as prescribed by the practitioner

Limit each suctioning event to no more than 10 seconds

Elevate the head of the bed between 30 to 45 degrees

Answer and Explanation

The Correct Answer is D

A. Ensure an NPO status is maintained for the length of the prescribed treatment: While some ventilated patients are NPO, others receive enteral feeding. NPO status alone does not prevent aspiration.

B. Perform chest physiotherapy as prescribed by the practitioner: Chest physiotherapy helps clear secretions but does not directly reduce aspiration risk.

C. Limit each suctioning event to no more than 10 seconds: While limiting suction time is important to avoid hypoxia, it does not directly prevent aspiration.

D. Elevate the head of the bed between 30 to 45 degrees: Keeping the head of the bed elevated reduces the risk of aspiration, partic

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Correct Answer is D

Explanation

A. Numbness of fingers. Numbness or tingling (paresthesia) is more common in respiratory alkalosis due to low CO₂ levels causing calcium binding changes.

B. Dry skin. Respiratory acidosis does not typically cause dry skin; rather, it may cause cyanosis or flushed skin due to CO₂ retention.

C. Abdominal pain. Abdominal pain is more commonly seen in metabolic acidosis, not respiratory acidosis.

D. Lethargy. Respiratory acidosis leads to CO₂ retention, which depresses the central nervous system, causing lethargy, confusion, and even coma in severe cases.

A. Polyuria B. Delirium C. Osteoporosis D. Anxiety and depression

Correct Answer is B

Explanation

A. Polyuria: COPD with chronic respiratory acidosis is not associated with excessive urine production. Instead, clients may experience fluid retention due to right-sided heart failure (cor pulmonale).

B. Delirium: Chronic respiratory acidosis leads to CO₂ retention, which can cause confusion, drowsiness, and even delirium due to cerebral vasodilation and altered mental status.

C. Osteoporosis: While COPD patients may have osteoporosis due to steroid use or inactivity, it is not a direct effect of chronic respiratory acidosis.

D. Anxiety and depression: While common in COPD due to lifestyle limitations, anxiety and depression are not direct physiological effects of respiratory acidosis.

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The nurse provides care to a patient who is mechanically ventilated. Which nursing action is most effective in decreasing the risk for aspiration?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has respiratory acidosis. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is caring for a client who has chronic respiratory acidosis due to chronic obstructive pulmonary disease (COPD). Which of the following findings should the nurse expect with this client?

Correct Answer is B

Explanation

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