A nurse at a long-term care facility is reviewing prescriptions for a client receiving mechanical ventilation. Which of the following interventions should the nurse identify as the priority?

Providing the client with a communication board

Suctioning the airway as needed

Administering continuous feeding through a nasogastric tube

Applying thigh-high antiembolism stockings

Answer and Explanation

The Correct Answer is B

A.   Communication is crucial for clients on mechanical ventilation, especially if they are awake and able to use a communication board. However, addressing life-threatening issues takes precedence over communication aids.
B.   Maintaining a patent airway is critical for a client on mechanical ventilation. If the client is unable to clear secretions or if there are signs of airway obstruction (like decreased breath sounds or increased respiratory effort), suctioning is necessary to prevent complications such as hypoxia or ventilator- associated pneumonia.
C.   This option is important for nutritional support, but it is not the immediate priority. While providing nutrition is essential for recovery and maintaining the client's overall health, ensuring a clear and open airway is crucial for the client's immediate safety.
D.   This option is also important for preventing deep vein thrombosis (DVT) in clients who are immobile or on long-term ventilation. However, like the previous options, it is not as critical as ensuring airway patency.

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Correct Answer is A

Explanation

A. Clients should begin with manageable inhalation volumes and gradually increase them as their lung capacity improves. This approach helps to avoid fatigue and ensures the client becomes comfortable with the device.
B. Being too aggressive in increasing inhalation volumes can lead to discomfort, discourage use of the spirometer, and could result in ineffective deep breathing. It's important for clients to progress at a pace that feels comfortable to them.
C. This choice is inappropriate unless there is clear evidence that the spirometer is not functioning correctly. The focus should be on teaching the client how to use the device effectively rather than suggesting they switch devices prematurely.
D. While deep-breathing exercises are beneficial, they do not replace the use of an incentive spirometer. The spirometer is specifically designed to encourage deep breaths and improve lung expansion, which is especially important post-surgery or for individuals with respiratory issues.

Correct Answer is ["3"]

Explanation

Order: 7.5 mg of prednisone. Available: Prednisone 2.5 mg tablets.

Number of tablets = Available dose/Ordered dose 7.5mg/2.5mg

Number of tablets= 3

Therefore, you will administer 3 tablets of prednisone each time the medication is ordered (QID - four times a day).

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A nurse at a long-term care facility is reviewing prescriptions for a client receiving mechanical ventilation. Which of the following interventions should the nurse identify as the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who is having difficulty using an incentive spirometer. Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

Order: Prednisone 7.5 mg PO QID Available: Prednisone 2.5 mg tabs How much will you administer?

Correct Answer is ["3"]

Explanation

A nurse is preparing to administer prednisone 40 mg PO to an adolescent client. Available is prednisone oral solution 5 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

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