The nurse provides care to a patient who is mechanically ventilated. Which nursing action is most effective in decreasing the risk for aspiration?
Ensure an NPC status is maintained for the length of the prescribed treatment
Perform chest physiotherapy as prescribed by the practitioner
Limit each suctioning event to no more than 10 seconds
Elevate the head of the bed between 30 to 45 degrees
The Correct Answer is D
A. Ensure an NPO status is maintained for the length of the prescribed treatment: While some ventilated patients are NPO, others receive enteral feeding. NPO status alone does not prevent aspiration.
B. Perform chest physiotherapy as prescribed by the practitioner: Chest physiotherapy helps clear secretions but does not directly reduce aspiration risk.
C. Limit each suctioning event to no more than 10 seconds: While limiting suction time is important to avoid hypoxia, it does not directly prevent aspiration.
D. Elevate the head of the bed between 30 to 45 degrees: Keeping the head of the bed elevated reduces the risk of aspiration, partic
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Discharge teaching: Phase III of post-anesthesia care focuses on preparing the patient for discharge, including teaching about post-operative care, medication instructions, and follow-up care.
B. Recovery from anesthesia: This occurs in Phase I, where patients are closely monitored as they emerge from anesthesia and regain protective reflexes.
C. Urinary catheterization if no voiding: This may be considered in Phase II, especially if urinary retention is present, but is not a defining activity of Phase III.
D. Vital signs every 15 to 30 minutes: Frequent monitoring of vital signs is a key part of Phase I, when patients are at the highest risk for complications.
Correct Answer is B
Explanation
A. Nonrebreather mask. A nonrebreather mask delivers high concentrations of oxygen but requires a tight seal around the face, which is not suitable for patients with facial trauma.
B. Face tent. A face tent is the best option for a patient with facial trauma as it provides high-flow oxygen without requiring direct contact with the face, preventing pressure on injured areas.
C. Nasal cannula. A nasal cannula provides low-flow oxygen and may be ineffective for a patient requiring high-flow therapy.
D. Venturi mask. A Venturi mask delivers precise oxygen concentrations but still requires a snug fit on the face, which may not be comfortable or feasible for a patient with facial trauma.
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