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 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.
Correct Answer is C
Explanation
Choice A: Head of bed 45 degrees is not enough to prevent aspiration or choking, as the patient may still have difficulty swallowing and clearing their airway.
Choice B: Patient should be on a regular diet to rebuild their swallowing ability is not correct, as the patient may need a modified diet depending on their level of dysphagia or swallowing impairment. A regular diet may pose a risk of aspiration or choking.
Choice C: Have patient sit upright 90 degrees in bed or chair is correct, as this position helps the patient align their head and neck and use gravity to facilitate swallowing and prevent aspiration.
Choice D: All of the above is not correct, as only choice C is appropriate for assisting a stroke patient with feeding.
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