Nokea
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.
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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.
A student nurse is preparing to administer enoxaparin (Lovenox) to a client. What action by the student requires immediate intervention by the supervising nurse?
- A. Assessing the client's platelet count
- B. Choosing an 18-gauge, 2-inch needle
- C. Not aspirating prior to injection
- D. Swabbing the injection site with alcohol
Correct Answer: B
Rationale: Enoxaparin is administered subcutaneously, requiring a smaller needle (e.g., 25"?26 gauge, 5/8 inch). An 18-gauge, 2-inch needle is inappropriate and could cause harm.
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 teaching a client about warfarin (Coumadin). What assessment finding by the nurse indicates a possible barrier to self-management?
- A. Poor visual acuity
- B. Strict vegetarian
- C. Refusal to stop smoking
- D. Wants weight loss surgery
Correct Answer: B
Rationale: A strict vegetarian diet high in vitamin K-rich foods can interfere with warfarin's anticoagulation effect, posing a barrier to consistent self-management.
When working with women who are taking hormonal birth control, what health promotion measures should the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.)
- A. Avoid drinking alcohol
- B. Eat more omega-3 fatty acids
- C. Exercise on a regular basis
- D. Maintain a healthy weight
- E. Stop smoking cigarettes
Correct Answer: C,D,E
Rationale: Hormonal birth control increases clotting risk. Health promotion measures to reduce PE risk include regular exercise, maintaining a healthy weight, and smoking cessation, as these address immobility, obesity, and smoking-related risks.