A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following actions should the nurse take?
Monitor the client's vital signs every 8 hours
Reposition the endotracheal tube every 12 hours.
Place the client in a supine position.
Perform oral care every 2 hours
The Correct Answer is D
Performing oral care every 2 hours is an important nursing intervention for a client receiving mechanical ventilation via an endotracheal tube. This helps to reduce the risk of ventilator-associated pneumonia.
a) Monitoring the client's vital signs is important, but it should be done more frequently than every 8 hours.
b) Repositioning the endotracheal tube is not necessary unless there is a specific indication.
c) Placing the client in a supine position is not recommended as it increases the risk of aspiration.
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Related Questions
Correct Answer is D
No explanation
Correct Answer is C
Explanation
The nurse should clarify the prescription for cefazolin with the provider. Cefazolin is a cephalosporin antibiotic, and there is a risk of cross-reactivity in individuals who have an allergy to penicillin.
a) Doxycycline and b) Vibramycin (which is another name for doxycycline) are tetracycline antibiotics and are not related to penicillin.
d) Gentamicin is an aminoglycoside antibiotic and is also not related to penicillin.
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