Nokea
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.
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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.
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.
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 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.
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.