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
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Inability to void without fluid retention. Urinary retention is a common post-op complication, especially after anesthesia, and requires monitoring to prevent bladder distension or kidney issues.
B. Persistent nausea without vomiting. Nausea can be managed with antiemetics and does not necessarily require prolonged monitoring.
C. Lethargy that resolves after several hours. Post-anesthesia drowsiness is expected and does not necessarily indicate a need for extended observation.
D. Pain management with opioid analgesics. Pain control with opioids is expected and does not, by itself, require extended monitoring.
Correct Answer is C
Explanation
A. Hypertension: Blood loss leads to hypovolemia, which usually causes hypotension, not hypertension.
B. Hypothermia: While hypothermia can occur postoperatively, it is not the most direct result of blood loss.
C. Tachycardia: Blood loss leads to decreased circulating volume, triggering tachycardia as a compensatory response to maintain oxygen delivery.
D. Bradypnea: Severe blood loss is more likely to cause tachypnea (rapid breathing) rather than slow respirations.
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