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A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Assess the client for sedation needs
- B. Get family permission for restraints
- C. Provide frequent oral care per protocol
- D. Use nonverbal pain assessment tools
Correct Answer: C
Rationale: Frequent oral care is within the UAP's scope of practice and is essential for ventilated clients to prevent ventilator-associated pneumonia. The other tasks require nursing judgment and cannot be delegated.
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A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.)
- A. Client who had a reaction to contrast dye yesterday
- B. Client with a new spinal cord injury on a rotating bed
- C. Middle-aged man with an exacerbation of asthma
- D. Older client who is 1-day post hip replacement surgery
- E. Young obese client with a fractured femur
Correct Answer: B,D,E
Rationale: Risk factors for PE include prolonged immobility (spinal cord injury, post-hip surgery), obesity, and trauma (fractured femur). Contrast dye reaction and asthma are not associated with increased PE risk.
The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this? (Select all that apply.)
- A. Chest wall stiffness
- B. Decreased muscle strength
- C. Inability to cooperate
- D. Less lung elasticity
- E. Poor vision and hearing
Correct Answer: A,B,D
Rationale: Age-related changes like chest wall stiffness, decreased muscle strength, and reduced lung elasticity impair weaning from mechanical ventilation. Inability to cooperate and sensory deficits are not universal in older adults.
A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate?
- A. Assess the cause of the agitation
- B. Reassure the client that he or she is safe
- C. Restrain the client's hands
- D. Sedate the client immediately
Correct Answer: A
Rationale: Determining the cause of agitation (e.g., pain, hypoxia, or anxiety) is the first step to address the underlying issue. Restraints or sedation may be needed but are not the initial action.
A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best?
- A. Assess for other manifestations of hypoxia
- B. Change the sensor on the pulse oximeter
- C. Obtain a new oximeter from central supply
- D. Tell the client to take slow, deep breaths
Correct Answer: A
Rationale: Pulse oximetry can sometimes produce normal readings despite hypoxia due to factors like poor peripheral perfusion. A thorough assessment for other signs of hypoxia (e.g., tachycardia, confusion) is the most appropriate action to confirm the client's status.
A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.)
- A. Acknowledge the frightening nature of the illness
- B. Delegate a back rub to the unlicensed assistive personnel
- C. Give simple explanations of what is happening
- D. Request a prescription for anti-anxiety medication
- E. Stay with the client and speak in a quiet, calm voice
Correct Answer: A,B,C,E
Rationale: Anxiety is common in PE. Acknowledging fears, delegating comfort measures like a back rub, providing simple explanations, and staying with the client in a calming manner are appropriate to reduce anxiety without routinely using medications, which may worsen hypoxia.