Nokea
A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.)
- A. Allow visitors at the client's bedside
- B. Ensure the client can communicate if awake
- C. Keep the television tuned to a favorite channel
- D. Provide back and hand massages when turning
- E. Turn the client every 2 hours or more
Correct Answer: A,B,D,E
Rationale: Comfort measures for ventilated clients include allowing visitors, enabling communication (e.g., via writing boards), providing massages during turning, and frequent repositioning to prevent pressure injuries. Keeping the TV on may disrupt rest.
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A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by the nurse takes priority?
- A. Assessing that the ventilator settings are correct
- B. Ensuring there is a bag-valve-mask in the room
- C. Obtaining personal protective equipment
- D. Planning to suction the client upon arrival to the room
Correct Answer: B
Rationale: A bag-valve-mask is critical for manual ventilation in case of ventilator failure, making it the priority to ensure client safety.
A client is brought to the emergency department after sustaining injuries in a severe car crash. The client does not appear to be moving normally with respirations, oxygen saturation is 92%. What action by the nurse is best?
- A. Administer oxygen via non-rebreather mask
- B. Perform a rapid trauma assessment
- C. Prepare for chest tube insertion
- D. Obtain a chest X-ray immediately
Correct Answer: A
Rationale: The client's abnormal respiratory movement and low oxygen saturation suggest a traumatic chest injury, possibly pneumothorax or hemothorax. Administering oxygen via a non-rebreather mask is the priority to address hypoxia while further assessment is conducted.
An intubated client's oxygen saturation has dropped to 88%. What action by the nurse takes priority?
- A. Determine if the tube is kinked
- B. Ensure all connections are patent
- C. Listen to the client's lung sounds
- D. Suction the endotracheal tube
Correct Answer: C
Rationale: For an intubated client with hypoxia, the nurse should first assess for DOPE (displaced tube, obstruction, pneumothorax, equipment problems). Listening to lung sounds to confirm tube placement is the priority, as a displaced tube is the most common cause of hypoxia.
The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.)
- A. Adherence to proper hand hygiene
- B. Administering anti-ulcer medication
- C. Elevating the head of the bed
- D. Providing oral care per protocol
- E. Suctioning the client on a regular schedule
Correct Answer: A,B,C,D
Rationale: The ventilator bundle to prevent ventilator-associated pneumonia includes hand hygiene, anti-ulcer medications, elevating the head of the bed (30"?45 degrees), and frequent oral care. Suctioning is performed as needed, not on a fixed schedule.
A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority?
- A. Ensure the client has adequate sedation
- B. Find another provider to intubate
- C. Interrupt the procedure to give oxygen
- D. Monitor the client's oxygen saturation
Correct Answer: C
Rationale: Intubation attempts should not exceed 30 seconds to prevent hypoxia. Interrupting the procedure to provide oxygen is the priority to ensure the client's safety.