A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take to reduce the risk of ventilator associated pneumonia?

Position the head of the client’s bed in the flat position.

Brush the client’s teeth with a suction toothbrush every 12 hr.

Provide humidity by maintaining moisture within the ventilator tubing.

Turn the client every 4 hr.

Answer and Explanation

The Correct Answer is B

Choice A reason: Positioning the head of the client’s bed in the flat position is not a good way to reduce the risk of ventilator associated pneumonia. This position can increase the risk of aspiration of oral secretions or gastric contents into the lungs, which can cause infection. The nurse should elevate the head of the bed to 30 to 45 degrees to prevent aspiration and promote drainage of secretions.

Choice B reason: Brushing the client’s teeth with a suction toothbrush every 12 hr is an effective way to reduce the risk of ventilator associated pneumonia. Oral hygiene can reduce the number of bacteria in the mouth and prevent the formation of dental plaque, which can harbor pathogens that can cause pneumonia. The nurse should use a suction toothbrush to remove debris and secretions from the mouth and prevent them from entering the lungs.

Choice C reason: Providing humidity by maintaining moisture within the ventilator tubing is not a helpful way to reduce the risk of ventilator associated pneumonia. Humidity can increase the growth of bacteria and fungi in the ventilator circuit, which can contaminate the air delivered to the lungs. The nurse should change the ventilator tubing and filters regularly and use sterile water to fill the humidifier.

Choice D reason: Turning the client every 4 hr is not a sufficient way to reduce the risk of ventilator associated pneumonia. Turning can help prevent pressure ulcers and improve blood circulation, but it does not prevent the accumulation of secretions in the lungs, which can cause infection. The nurse should use chest physiotherapy, suctioning, and coughing techniques to mobilize and clear secretions from the airways.

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Correct Answer is B

Explanation

Choice A reason: A history of neurologic deficits lasting less than 1 hr is not a typical manifestation of a hemorrhagic stroke. This could be a sign of a transient ischemic attack (TIA), which is a temporary blockage of blood flow to the brain that causes stroke like symptoms. A TIA is different from a hemorrhagic stroke, which is caused by bleeding in the brain due to a ruptured blood vessel.

Choice B reason: Manifestations preceded by a severe headache is a common manifestation of a hemorrhagic stroke. A ruptured cerebral aneurysm can cause sudden and intense pain in the head, often described as the worst headache of one's life. This is due to the increased pressure and irritation of the brain tissue and nerves by the blood leaking from the aneurysm.

Choice C reason: A gradual onset of several hours is not a usual manifestation of a hemorrhagic stroke. A hemorrhagic stroke is a medical emergency that requires immediate treatment, as the bleeding can cause rapid damage to the brain and increase the risk of death or disability. The symptoms of a hemorrhagic stroke usually develop suddenly and worsen quickly.

Choice D reason: Maintaining consciousness is not a likely manifestation of a hemorrhagic stroke. A hemorrhagic stroke can cause loss of consciousness, confusion, drowsiness, or coma due to the reduced blood flow and oxygen to the brain. The level of consciousness can also be affected by the location and extent of the bleeding, as well as the presence of complications such as hydrocephalus or vasospasm.

A. Blood glucose levels B. Thyroid function studies C. Gallbladder studies D. Liver function tests

Correct Answer is D

Explanation

Choice A reason: Blood glucose levels are not a necessary laboratory test for a client who has tuberculosis and new prescriptions for rifampin and pyrazinamide. Blood glucose levels measure the amount of sugar in the blood and are used to diagnose and monitor diabetes. Rifampin and pyrazinamide do not affect blood glucose levels directly, but they may interact with some medications used to treat diabetes, such as sulfonylureas or metformin. The nurse should advise the client to monitor their blood glucose levels regularly and report any changes to the provider.

Choice B reason: Thyroid function studies are not a required laboratory test for a client who has tuberculosis and new prescriptions for rifampin and pyrazinamide. Thyroid function studies measure the levels of thyroid hormones and thyroid stimulating hormone in the blood and are used to diagnose and monitor thyroid disorders. Rifampin and pyrazinamide do not affect thyroid function directly, but they may interact with some medications used to treat thyroid disorders, such as levothyroxine or propylthiouracil. The nurse should advise the client to take their thyroid medication at least 4 hours before or after rifampin and pyrazinamide and report any symptoms of thyroid imbalance to the provider.

Choice C reason: Gallbladder studies are not a relevant laboratory test for a client who has tuberculosis and new prescriptions for rifampin and pyrazinamide. Gallbladder studies include ultrasound, computed tomography (CT), or magnetic resonance imaging (MRI) scans of the gallbladder and are used to diagnose and monitor gallstones or gallbladder inflammation. Rifampin and pyrazinamide do not affect the gallbladder directly, but they may cause side effects such as nausea, vomiting, or abdominal pain, which can mimic gallbladder problems. The nurse should assess the client for signs of hepatotoxicity, such as jaundice, dark urine, or clay colored stools, and report any findings to the provider.

Choice D reason: Liver function tests are a vital laboratory test for a client who has tuberculosis and new prescriptions for rifampin and pyrazinamide. Liver function tests measure the levels of enzymes, proteins, and bilirubin in the blood and are used to diagnose and monitor liver damage or disease. Rifampin and pyrazinamide are both hepatotoxic drugs, which means they can cause liver injury or failure. The nurse should instruct the client to have liver function tests done before starting the medication regimen and periodically during the treatment. The nurse should also educate the client about the signs and symptoms of hepatotoxicity, such as fatigue, loss of appetite, nausea, vomiting, or yellowing of the skin or eyes, and advise them to stop taking the medication and seek medical attention if they occur.

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A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take to reduce the risk of ventilator associated pneumonia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?

Correct Answer is B

Explanation

A nurse is caring for a client who has tuberculosis and new prescriptions for rifampin and pyrazinamide. Which of the following laboratory tests should the nurse instruct the client will be required while on this medication regimen?

Correct Answer is D

Explanation

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