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
Explanation
As individuals age, there is a natural decline in kidney function. This can result in a reduced ability to filter and excrete medications and their metabolites from the body. The decreased kidney function can lead to a longer half-life of medications, increased drug accumulation, and an increased risk of adverse drug reactions. It is important for the nurse to adjust medication dosages and frequencies based on the individual's renal function to prevent drug toxicity.
Increased liver function: Aging is associated with a gradual decline in liver function. While there may be some individual variations, in general, liver function decreases rather than increases with age. However, changes in liver function can affect the metabolism and elimination of medications. Some medications may require dosage adjustments based on liver function, but it is not a common physiological change in older adults.
Increased metabolism: Aging is generally associated with a decrease in metabolism rather than an increase. The metabolic rate tends to slow down with age, which can affect the pharmacokinetics of medications. Slower metabolism can result in medications taking longer to be metabolized and cleared from the body, potentially leading to prolonged drug effects.
Correct Answer is A
Explanation
a . Provide a tour of the perioperative area prior to surgery.
The correct answer is a. Provide a tour of the perioperative area prior to surgery.
Explanation:
When caring for an adolescent scheduled for surgery, providing a tour of the perioperative area prior to the procedure is an important action for the nurse to take. Adolescents may experience fear and anxiety related to the unfamiliar environment and procedures associated with surgery. Providing a tour allows the adolescent to become familiar with the surroundings, equipment, and healthcare team, which can help alleviate anxiety and promote a sense of control.
Explanation for the other options:
b. Explain that anesthesia is a special type of sleep: While it is important to provide information about anesthesia to the adolescent, describing it as a "special type of sleep" may be misleading. Anesthesia is a medical procedure that involves more than just being asleep, and it is important to provide accurate information to the adolescent.
c. Keep medical equipment out of the client's sight: While it is important to create a comfortable and non- threatening environment for the adolescent, completely hiding medical equipment may not be feasible or necessary. Instead, the nurse should address any specific fears or concerns the adolescent may have and provide age-appropriate explanations and reassurance.
d. Wait until after surgery to explain the importance of coughing and deep breathing: It is important to provide preoperative education to the adolescent to promote their understanding and cooperation. Explaining the importance of coughing and deep breathing before surgery helps the adolescent prepare and participate in their own recovery. Waiting until after surgery may result in missed opportunities for early postoperative interventions.
In summary, providing a tour of the perioperative area prior to surgery helps familiarize the adolescent with the environment, reducing anxiety and promoting a sense of control.
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