Nokea
A charge nurse is rounding on several older clients on ventilators in the Intensive Care Unit whom the nurse identifies as being at high risk for ventilator-associated pneumonia. To reduce this risk what activity would the nurse delegate to the assistive personnel (AP)?
- A. Encourage between-meal snacks.
- B. Monitor temperature every 4 hours.
- C. Provide oral care every 4 hours.
- D. Report any new onset of cough.
Correct Answer: C
Rationale: The correct answer is C: Provide oral care every 4 hours. Oral care helps prevent ventilator-associated pneumonia by reducing the risk of oral bacteria being aspirated into the lungs. The AP can assist with oral care under the nurse's supervision.
A: Encouraging between-meal snacks does not directly address pneumonia risk.
B: Monitoring temperature is important but not specific to ventilator-associated pneumonia prevention.
D: Reporting new cough onset is important but does not directly reduce the risk of ventilator-associated pneumonia.
You may also like to solve these questions
Life-long nonsmokers live an average of how much longer than those who, in their mid-twenties, smoked two packs of cigarettes a day?
- A. 6 months
- B. 1-2 years
- C. over 12 years
- D. 7-9 years
Correct Answer: C
Rationale: The correct answer is C: over 12 years. Life-long nonsmokers live significantly longer than those who smoke heavily in their mid-twenties. Smoking two packs of cigarettes a day significantly increases the risk of various health conditions leading to premature death. On average, smoking can reduce life expectancy by over 10 years. Therefore, the correct answer is over 12 years. Choices A, B, and D are incorrect as they underestimate the impact of smoking on life expectancy and do not adequately reflect the significant difference in longevity between smokers and life-long nonsmokers.
The pneumotaxic center of the pons
- A. sets the at-rest respiratory pattern
- B. prolongs inspiration
- C. modifies the rate and depth of breathing
- D. suppresses the expiratory center in the medulla
Correct Answer: C
Rationale: The correct answer is C because the pneumotaxic center in the pons modifies the rate and depth of breathing by sending inhibitory signals to the dorsal respiratory group in the medulla, which controls inspiration and expiration. It does not set the at-rest respiratory pattern like option A, prolong inspiration like option B, or suppress the expiratory center in the medulla like option D. This center plays a crucial role in fine-tuning breathing patterns to maintain appropriate oxygen levels in the body.
The nurse is caring for a 30-year-old American Indian female who is taking Rifater, a drug
containing rifampin, isoniazid, and pyrazinamide. The patient asks how long she will have to
take the medication. Which response explains when the patient may discontinue the
medication?
- A. When the sputum culture comes back negative.
- B. When the medication has been taken for 9 months
- C. When three consecutive sputum cultures are negative
- D. When the tuberculin skin test (TST) is no longer positive
Correct Answer: C
Rationale: The correct answer is C: When three consecutive sputum cultures are negative. This indicates successful treatment completion and eradication of the tuberculosis infection. A negative sputum culture confirms that the patient is no longer infectious and can safely discontinue the medication.
Choice A is incorrect because a single negative sputum culture does not guarantee complete eradication of the infection. Choice B is incorrect as the standard treatment duration for tuberculosis is typically 6-9 months, but discontinuation should be based on sputum culture results. Choice D is incorrect as the TST can remain positive even after successful treatment, as it reflects exposure to the tuberculosis bacteria, not active infection status.
An increase in the level of carbon dioxide in the blood will result in a(n):
- A. decrease in the rate of breathing.
- B. increase of the respiratory rate.
- C. decrease of pulmonary ventilation.
- D. decrease of the alveolar ventilation rate.
Correct Answer: B
Rationale: The correct answer is B: an increase of the respiratory rate. When carbon dioxide levels rise in the blood, it triggers the body to increase the rate of breathing to eliminate excess carbon dioxide through exhalation. This is known as the respiratory drive, controlled by the respiratory centers in the brainstem. Increasing the respiratory rate helps to restore the balance of gases in the blood.
Incorrect Choices:
A: Decrease in the rate of breathing - This is incorrect because high levels of carbon dioxide would stimulate an increase in breathing rate, not a decrease.
C: Decrease of pulmonary ventilation - This is incorrect as an increase in carbon dioxide would typically lead to an increase, not a decrease, in pulmonary ventilation.
D: Decrease of the alveolar ventilation rate - This is incorrect because an increase in carbon dioxide would prompt an increase in alveolar ventilation to remove excess carbon dioxide from the blood.
What is the best action for the nurse to do?
- A. a. Leave the patient alone to rest in a quiet, calm environment.
- B. b. Stay with the patient and encourage slow, pursed lip breathing.
- C. c. Reassure the patient that the attack can be controlled with treatment.
- D. Let the patient know that frequent monitoring is being done using measurement of vital signs and SpO. 2
Correct Answer: B
Rationale: The best action for the nurse to do is to stay with the patient and encourage slow, pursed lip breathing. This helps the patient focus on their breathing and can help alleviate the asthma attack symptoms.