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

Answer and Explanation

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

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Correct Answer is D

Explanation

A. "Check your oxygen equipment once each week.": Oxygen equipment should be checked daily for proper function and leaks, not just weekly.

B. "Use wool blankets on your bed.": Wool and synthetic fabrics generate static electricity, which can ignite oxygen. Cotton blankets should be used instead.

C. "Store unused oxygen tanks horizontally.": Oxygen tanks should always be stored upright and secured to prevent tipping over.

D. "Do not adjust the oxygen flow rate.": Clients should not change the oxygen flow rate unless instructed by the provider, as improper adjustments can cause oxygen toxicity or hypoxia.

A. Verifying the information with the patient's family members at the bedside B. Placing an alert bracelet on the patient before leaving the unit C. Asking the patient to describe the reaction that occurs D. Documenting the information on the patient's medical record

Correct Answer is C

Explanation

A. Verifying the information with the patient's family members at the bedside: While family members can provide insight, the most critical step is gathering information directly from the patient about the reaction.

B. Placing an alert bracelet on the patient before leaving the unit: While this is necessary, the nurse should first confirm the details of the allergy.

C. Asking the patient to describe the reaction that occurs: The nurse must determine whether the reaction is a true allergy (e.g., anaphylaxis, rash, difficulty breathing) or an intolerance (e.g., nausea, drowsiness). This ensures appropriate precautions are taken.

D. Documenting the information on the patient's medical record: Documentation is crucial but should follow verification of the allergy details.

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The nurse provides care to a patient who is mechanically ventilated. Which nursing action is most effective in decreasing the risk for aspiration?

Nursing Test Bank

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