Maintaining an airway would include:
Frequent vital sign monitoring including accurate blood sugars
Accurate intake and output records
Updating the patient's family on status
Head of bed 30 degrees, suctioning, oral hygiene and monitoring of respiratory status
The Correct Answer is D
Choice A: Frequent vital sign monitoring including accurate blood sugars is not a direct intervention for maintaining an airway, but rather a general measure to monitor the patient's condition and prevent complications.
Choice B: Accurate intake and output records is not a direct intervention for maintaining an airway, but rather a general measure to monitor the patient's fluid and electrolyte balance and prevent dehydration or overhydration.
Choice C: Updating the patient's family on status is not a direct intervention for maintaining an airway, but rather a supportive measure to provide information and emotional support to the patient's family.
Choice D: Head of bed 30 degrees, suctioning, oral hygiene and monitoring of respiratory status is a correct intervention for maintaining an airway, as it can reduce the risk of aspiration, infection, and obstruction of the airway.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: When patient no longer has numbness in extremities is incorrect because it is not a reliable indicator of cervical spine injury or recovery. Numbness in extremities can be caused by various factors such as nerve compression, inflammation, or medication. It can also persist or recur after the cervical collar is removed. The nurse should assess the patient's neurological status but should not remove the cervical collar based on this symptom alone.
Choice B: When patient states they have no pain in the neck is incorrect because it is also not a reliable indicator of cervical spine injury or recovery. Pain in the neck can be subjective, variable, or masked by other factors such as analgesics, shock, or distraction. It can also be absent or delayed after the cervical collar is removed. The nurse should assess the patient's pain level but should not remove the cervical collar based on this symptom alone.
Choice C: When doctor has cleared patient following a cervical X-ray is correct because it is the safest and most accurate way to determine if the patient has a cervical spine injury or not. A cervical X-ray can show any fractures, dislocations, or other abnormalities in the cervical vertebrae that may require immobilization or surgery. The nurse should follow the doctor's orders and remove the cervical collar only after the doctor has confirmed that there is no risk of further damage to the spinal cord or nerves.
Choice D: All of the above are incorrect because only choice c) is sufficient and necessary to remove the cervical collar from a head injury patient. Choices a) and b) are not valid criteria and may expose the patient to potential harm or complications. The nurse should use evidence-based practice and follow the protocols for head injury management and care.
Correct Answer is A
Explanation
Choice A: Speech therapist is correct, as they can assess and treat the patient's swallowing function and recommend appropriate diets and feeding strategies.
Choice B: Respiratory therapist is not correct, as they can help the patient with breathing problems and oxygen therapy, but not with nutrition.
Choice C: Physical therapist is not correct, as they can help the patient with mobility and exercise, but not with nutrition.
Choice D: Social worker is not correct, as they can help the patient with psychosocial and financial issues, but not with nutrition.
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