Nokea
A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take to reduce the risk of ventilator-associated pneumonia?
- A. Provide oral care every 4 hours and as needed
- B. Position the head of the client's bed in the flat position
- C. Turn the client every 4 hours
- D. Provide humidity by maintaining moisture within the ventilator tubing
Correct Answer: A
Rationale: Regular oral care reduces bacterial colonization that could lead to VAP.
You may also like to solve these questions
A client in the emergency department has suspected stomach perforation due to a peptic ulcer. The nurse is completing the assessment and should expect which of the following findings? (Select all that apply).
- A. Tachycardia
- B. Rebound tenderness
- C. Rigid abdomen
- D. Elevated blood pressure
Correct Answer: A,B,C
Rationale: These are classic signs of perforation and peritonitis: tachycardia from pain/stress, rebound tenderness and rigidity from peritoneal irritation.
A client is admitted to the emergency room with renal calculi. Upon assessment, which of the following findings should the nurse expect?
- A. Bradycardia
- B. Bradypnea
- C. Severe pain
- D. Nocturia
Correct Answer: C
Rationale: Severe pain (renal colic) is the most common symptom of renal calculi, caused by the stone moving and blocking the ureter.
A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider immediately?
- A. Bubbling of the water in the water seal chamber with exhalation
- B. Crepitus in the area above and surrounding the insertion site
- C. Movement of the trachea toward the unaffected side
- D. Eyelets are not visible
Correct Answer: B
Rationale: Crepitus indicates subcutaneous emphysema, which requires immediate attention as it suggests air leaking into tissues.
A nurse is teaching a group of nurses about the administration of nitroglycerin. Which of the following routes of administration provides the most rapid onset for the client?
- A. Topical ointment
- B. Sustained-release
- C. Sublingual
- D. Transdermal patch
Correct Answer: C
Rationale: Sublingual nitroglycerin has the fastest onset (1-3 minutes) due to direct absorption into bloodstream.
The nurse is caring for a client with advanced cirrhosis. Which of the following clinical manifestations should the nurse recognize as a serious complication of this condition?
- A. Frequent nosebleeds and bruising
- B. Urinary retention
- C. No bowel movement in three days
- D. Increased blood glucose
Correct Answer: A
Rationale: Coagulopathy (evidenced by bleeding) is serious in cirrhosis due to impaired clotting factor production.