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Which actions should the nurse implement to prevent ventilator-associated pneumonia (VAP) in the client who is intubated and on mechanical ventilation?
- A. Practice meticulous hand hygiene.
- B. Maintain the head of the bed elevation at 10 degrees.
- C. Perform suctioning of oral cavity secretions every 4 hours.
- D. Have the respiratory therapist change the ventilator circuit tubing every 4 hours.
Correct Answer: A
Rationale: Because normal upper airway defenses are bypassed, clients who are intubated with mechanical ventilation are at risk for VAP. Prevention includes effective hand washing before and after suctioning, when touching ventilator equipment, and when in contact with respiratory secretions. To prevent aspiration of colonized secretions from the oral cavity, the client will need more frequent oral cavity suctioning and at least 30 degrees head of the bed elevation. The more frequently the circuit is broken, the greater the risk for pathogen entry.
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Which of the following impacts on the client's preferences in terms of hygiene routines and practices?
- A. Culture
- B. Locus of control
- C. Bodily surface area
- D. Diaphoresis
Correct Answer: A
Rationale: Culture significantly influences hygiene preferences, as beliefs and practices vary widely across cultural groups.
A client with chronic obstructive pulmonary disease is bedridden at home and gets little exercise. The nurse should assess the client for which of the following?
- A. Increased sodium retention.
- B. Increased calcium excretion.
- C. Increased insulin use.
- D. Increased red blood cell production.
Correct Answer: B
Rationale: Prolonged immobility in COPD increases calcium excretion due to bone resorption, risking osteoporosis. The other options are not directly related to immobility.
A client is reporting skin irritation from the edges of a cast that was applied the previous day. The nurse notes that the skin is pink and irritated. Which corrective action should the nurse take?
- A. Petal the edges of the cast with tape.
- B. Massage the skin at the rim of the cast.
- C. Shake a small amount of powder under the cast rim.
- D. Use a hair dryer set on a cool high setting to soothe the irritation.
Correct Answer: A
Rationale: The nurse should petal the edges of the cast with tape to minimize skin irritation. Massaging the skin will not help the problem. Powder should not be shaken under the cast because it could clump, become moist, and cause skin breakdown. A hair dryer is used on a cool low setting if a nonplaster cast becomes wet or if the client's skin itches under a cast.
The nurse is preparing a poster for a booth at a health fair to promote primary prevention of cervical cancer. Which recommendation should the nurse include on the poster?
- A. Use a commercial douche on a daily basis.
- B. Perform monthly breast self-examination (BSE).
- C. Seek treatment promptly if cervical infection is suspected.
- D. Use oral contraceptives as a preferred method of birth control.
Correct Answer: C
Rationale: Early treatment of cervical infection can help prevent chronic cervicitis, which can lead to dysplasia of the cervix. Cervical dysplasia is an early cell change that is considered to be premalignant. Douches and oral contraceptives do not decrease the risk for this type of cancer. BSE is useful for early detection of breast cancer, but is unrelated to cervical cancer.
A client with a history of ulcerative colitis is prescribed sulfasalazine (Azulfidine). The nurse should instruct the client to:
- A. Take the medication with meals.
- B. Avoid sun exposure.
- C. Stop the medication if diarrhea resolves.
- D. Take the medication on an empty stomach.
Correct Answer: B
Rationale: Sulfasalazine can cause photosensitivity, so clients should avoid sun exposure.