An older adult with pneumonia and an exacerbation of chronic obstructive pulmonary disease (COPD) was intubated for 14 days and was sucessfully extubated yesterday. Currently, the client has a weak cough and poor appetite. Which intervention(s) should the nurse implement? Select all that apply.

Encourage activity as tolerated.

Assess ability to swallow solids and liquids.

Assist client with active range of motion.

Reinforce deep breathing exercises.

Obtain dietary consult for meal supplements.

Answer and Explanation

Correct Answer : A,B,C,D,E

Rationale:
A. Encourage activity as tolerated: Gradual mobilization supports respiratory function, circulation, and muscle strength after prolonged intubation. Activity also helps reduce the risk of complications like atelectasis and deep vein thrombosis.

B. Assess ability to swallow solids and liquids: After extended intubation, clients are at risk for dysphagia, which can lead to aspiration pneumonia. A swallowing assessment is necessary to ensure safety before resuming a regular oral diet.

C. Assist client with active range of motion: Prolonged immobility in the ICU often leads to deconditioning and muscle weakness. Assisting with range of motion exercises promotes circulation, prevents contractures, and maintains joint flexibility.

D. Reinforce deep breathing exercises: Deep breathing promotes alveolar expansion, improves oxygenation, and prevents postoperative complications such as pneumonia or atelectasis, which are particularly concerning after extubation and in clients with COPD.

E. Obtain dietary consult for meal supplements: Poor appetite post-extubation can contribute to malnutrition and delayed recovery. A dietary consult ensures the client receives adequate caloric and protein intake through appropriate supplements.

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Correct Answer is C

Explanation

Rationale:

A. Go to the emergency department and complete assigned tasks: UAPs should remain on their assigned units unless directed otherwise by leadership. Relocating without orders could compromise continuity and safety in their current area.

B. Shut all doors to client rooms on the unit in case a fire erupts: There is no immediate threat of fire. This may increase client anxiety or hinder necessary observation in a power outage. Fire protocols are separate from internal disaster procedures unless a fire is confirmed.

C. Tell all their assigned clients to stay in their rooms: This maintains order and safety during a chaotic event. It prevents unnecessary movement in darkened or unfamiliar areas and reduces the risk of injury in the absence of full power.

D. Offer to assist in the intensive care unit with clients ventilator-dependent: UAPs are not qualified to assist with critical care clients, especially ventilator-dependent ones. They should remain within their competency and scope of practice.

A. Separate fluids from meals. B. Plan meals to include rice porridge. C. Eliminate acidic food choices. D. Offer more bread and cheese. E. Provide small frequent meals.

Correct Answer is ["A","E"]

Explanation

Rationale:

A. Separate fluids from meals: Fluids should be consumed at least 30 minutes before or after meals to prevent gastric overdistention and dumping syndrome, which are common after bariatric surgery.

B. Plan meals to include rice porridge: Rice porridge is high in simple carbohydrates, which can cause dumping syndrome and rapid gastric emptying. It is not ideal post-surgery.

C. Eliminate acidic food choices: Acidic foods like citrus or tomatoes may cause discomfort, but they are not universally contraindicated. Tolerance varies by individual, so elimination is not routinely necessary.

D. Offer more bread and cheese: Bread can form a sticky bolus that’s hard to swallow post-op, and cheese is high in fat. Both can cause discomfort or intolerance early in recovery.

E. Provide small frequent meals: After bariatric surgery, the stomach’s capacity is reduced, so clients need to eat small, frequent meals to meet nutritional needs and prevent nausea or vomiting.

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An older adult with pneumonia and an exacerbation of chronic obstructive pulmonary disease (COPD) was intubated for 14 days and was sucessfully extubated yesterday. Currently, the client has a weak cough and poor appetite. Which intervention(s) should the nurse implement? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Which dietary intervention(s) should the nurse include in the plan of care for a client who had bariatric surgery? Select all that apply.

Correct Answer is ["A","E"]

Explanation

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