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 D

Explanation

A. While providing information about nutrition is helpful, it is not the most effective intervention to enhance the nutritional status of a patient with COPD. Patients with COPD may experience dyspnea (shortness of breath) while eating, which can make it difficult to consume adequate amounts of food.
B. Consuming excess fluids with meals can lead to bloating and discomfort, which can make it difficult for patients with COPD to eat. It is important to encourage adequate hydration throughout the day, but fluids should be consumed separately from meals.
C. Exercising before meals can increase the risk of nausea and vomiting, which can make it difficult for patients with COPD to eat. It is best to avoid strenuous activity within 1-2 hours of eating.
D. This is the most effective intervention to enhance the nutritional status of a patient with COPD. Eating small, frequent meals throughout the day can help to avoid feeling overly full and can make it easier to consume adequate amounts of food.

A. The inhaler should be used on a PRN basis only B. Frequent oral hygiene is necessary C. Rinse and spit after inhalation of the medication D. When taking a steroid drug as well as a bronchodilator, the bronchodilator should be administered first E. Hold your breath for 10 seconds during inhalation of the medication

Correct Answer is ["B","C","D","E"]

Explanation

A. Steroid inhalers are typically used as maintenance therapy and are not intended for as-needed (PRN) use. Patients should use them regularly as prescribed to manage their underlying condition, such as asthma or COPD.
B. Patients using steroid inhalers are at risk for oral thrush (fungal infection) due to the immunosuppressive effects of steroids. Frequent oral hygiene helps prevent this side effect by keeping the mouth clean and reducing fungal growth.
C. Rinsing the mouth and spitting after using a steroid inhaler helps to remove residual medication from the oral cavity, further reducing the risk of oral thrush and other side effects associated with steroid use.
D. When both types of inhalers are used, the bronchodilator should be taken first. This opens the airways and allows for better penetration and effectiveness of the steroid medication that follows.
E. Holding the breath after inhalation allows the medication to settle in the lungs, improving its effectiveness. A 10-second hold is generally recommended to maximize drug delivery to the airways.

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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

What nursing intervention enhances the nutritional status of a patient with COPD?

Correct Answer is D

Explanation

Which principle(s) would be important to teach a patient about the use of a steroid inhaler? (SELECT ALL THAT APPLY)

Correct Answer is ["B","C","D","E"]

Explanation

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