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 B
Explanation
Choice A: Unconsciousness, unarousable unresponsiveness is not a description of persistent vegetative state, but rather a description of coma, as it is a state of complete loss of consciousness and reflexes caused by severe brain injury.
Choice B: Devoid of cognitive function but has sleep-wake cycles is a description of persistent vegetative state, as it is a state of minimal awareness and responsiveness caused by widespread brain damage.
Choice C: Inability to move or respond except for eye movements due to a lesion affecting the pons is not a description of persistent vegetative state, but rather a description of locked-in syndrome, as it is a state of complete paralysis and preserved consciousness caused by damage to the brainstem.
Choice D: Unresponsiveness to the environment, makes no movement or sound but sometimes opens eyes is not a description of persistent vegetative state, but rather a description of akinetic mutism, as it is a state of severe apathy and reduced motor activity caused by damage to the frontal lobes or basal ganglia.
Correct Answer is A
Explanation
Choice A: Frequent monitoring of respiratory status and lung sounds and measures to maintain a patent airway is the first priority, as it can prevent hypoxia, hypercapnia, and increased ICP that can lead to brain herniation and death.
Choice B: Maintain a calm, quiet atmosphere and protect patient from stress is not the first priority, but rather a supportive measure to reduce stimuli and agitation that can increase ICP.
Choice C: Use strict aseptic technique for management of ICP monitoring system is not the first priority, but rather a preventive measure to avoid infection and meningitis that can worsen ICP.
Choice D: Position with head in neutral position and elevation of HOB 0 to 60 degrees to promote venous drainage is not the first priority, but rather a therapeutic measure to facilitate blood flow and reduce ICP.
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