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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. Turn the client every 4 hours.
- B. Brush the client’s teeth with a suction toothbrush every 12 hours.
- C. Provide humidity by maintaining moisture within the ventilator tubing.
- D. Position the head of the client’s bed in the flat position.
Correct Answer: B
Rationale: The correct answer is B: Brush the client's teeth with a suction toothbrush every 12 hours. This action helps reduce the risk of ventilator-associated pneumonia by preventing the buildup of bacteria in the oral cavity that could be aspirated into the lungs. Ventilator-associated pneumonia is often caused by bacteria from the oral cavity entering the respiratory system. Regular oral care, including brushing the teeth, helps to reduce the bacterial load in the mouth. Turning the client every 4 hours (choice A) helps prevent pressure ulcers but does not directly reduce the risk of ventilator-associated pneumonia. Providing humidity in the ventilator tubing (choice C) is important for maintaining airway moisture but does not specifically target pneumonia prevention. Positioning the head of the client's bed flat (choice D) is important for proper ventilation but does not address oral care and bacterial buildup.
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A nurse is triaging clients following a mass casualty event. Which of the following clients should the nurse assess first?
- A. A client who has a small circular partial-thickness burn of the left calf.
- B. A client who has severe respiratory stridor and a deviated trachea.
- C. A client who has a splinted open fracture of the left medial malleolus.
- D. A client who has a massive head injury and is experiencing seizures.
Correct Answer: B
Rationale: The correct answer is B. The client with severe respiratory stridor and a deviated trachea should be assessed first as this indicates a compromised airway, which is a life-threatening emergency. Immediate intervention is crucial to prevent respiratory arrest. Clients with airway issues should always be the top priority in triage.
Other choices are incorrect because:
A: Small circular partial-thickness burn of the left calf is not immediately life-threatening and can be addressed after addressing more critical conditions.
C: Splinted open fracture of the left medial malleolus, while serious, does not present an immediate threat to the client's life compared to compromised airway.
D: Massive head injury and seizures are also serious, but in this scenario, the client with compromised airway takes precedence as airway issues can lead to rapid deterioration.
A nurse working for a home health agency is assessing an older adult male client. Which of the following findings is the priority for the nurse to address?
- A. Pruritus
- B. Swollen gums
- C. Dysphagia
- D. Urinary hesitancy
Correct Answer: C
Rationale: The correct answer is C: Dysphagia. Dysphagia, difficulty swallowing, is a priority finding in an older adult male as it can lead to aspiration and malnutrition. The nurse needs to address this promptly to prevent complications. Pruritus (choice A) is itching and can be managed. Swollen gums (choice B) may indicate dental issues but are not immediately life-threatening. Urinary hesitancy (choice D) can be indicative of a urinary problem but does not pose an immediate risk compared to dysphagia.
A nurse is planning care for a client who is 1 day postoperative following spinal fusion. Which of the following actions should the nurse include?
- A. Assist the client to sit upright in a chair for 4 hours at a time.
- B. Expect clear drainage on the spinal dressing.
- C. Log roll the client every 2 hours.
- D. Perform neurological checks every 8 hours.
Correct Answer: C
Rationale: The correct answer is C: Log roll the client every 2 hours. This action is crucial for preventing complications such as pressure ulcers and maintaining spinal alignment post spinal fusion surgery. Log rolling helps to keep the spine in proper alignment and reduces the risk of injury to the surgical site. Assisting the client to sit upright for 4 hours at a time (choice A) can put excessive pressure on the surgical site and hinder the healing process. Expecting clear drainage on the spinal dressing (choice B) is not appropriate as drainage may vary and is not necessarily an indicator of infection. Performing neurological checks every 8 hours (choice D) is important but should be done more frequently in the immediate postoperative period.
A nurse is caring for a client who asks how albuterol helps his breathing. Which of the following responses should the nurse make? (Select all that apply)
- A. The medication will reduce inflammation.
- B. The medication will decrease coughing episodes.
- C. The medication will prevent wheezing.
- D. The medication will open the airway.
- E. The medication will stimulate the flow of mucus.
Correct Answer: C,D
Rationale: Correct Answer: C,D
Rationale:
C: The medication will prevent wheezing. Albuterol is a bronchodilator that works by relaxing the muscles in the airways, preventing and relieving wheezing.
D: The medication will open the airway. Albuterol acts by opening the airways, making it easier for the client to breathe.
Summary:
A: The medication will reduce inflammation. Albuterol does not directly reduce inflammation; it primarily works as a bronchodilator.
B: The medication will decrease coughing episodes. While albuterol may indirectly reduce coughing by improving breathing, its primary action is not to decrease coughing.
E: The medication will stimulate the flow of mucus. Albuterol does not stimulate mucus flow; it primarily works to open the airways and relieve bronchospasm.
A nurse is caring for a client who is participating in a research study for an experimental chemotherapy medication. After three treatments, the experimental medication is discontinued due to evidence of rapidly advancing kidney failure. The nurse should understand discontinuing this medication demonstrates which of the following ethical principles?
- A. Veracity
- B. Fidelity
- C. Nonmaleficence
- D. Autonomy
Correct Answer: C
Rationale: The correct answer is C: Nonmaleficence. This principle of ethics requires healthcare providers to do no harm to their patients. In this scenario, discontinuing the experimental chemotherapy medication after evidence of rapidly advancing kidney failure demonstrates the nurse's commitment to preventing further harm to the client. By stopping the medication that is causing harm, the nurse is upholding the principle of nonmaleficence.
Other choices are incorrect:
A: Veracity - Veracity pertains to truthfulness and honesty in communication with patients. Discontinuing the medication is not related to truthfulness.
B: Fidelity - Fidelity refers to the obligation to fulfill commitments and promises made to patients. Discontinuing the medication is not about fulfilling commitments.
D: Autonomy - Autonomy is the right of patients to make their own decisions about their healthcare. Discontinuing the medication is not about respecting the patient's autonomy in this context.