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 D
Explanation
A. "The goal for your pain is 0 on a 0 to 10 scale.": A pain score of 0 may not always be realistic postoperatively. The goal is pain control, not complete elimination.
B. "It is better not to have visitors if you are in pain.": Social support can be beneficial in pain management, and visitors should not necessarily be restricted unless the patient finds them distressing.
C. "You will be given the lowest strength pain medication first.": Pain management is individualized, and stronger analgesics may be needed initially, especially after surgery.
D. "It is important that you request pain medication before the pain gets too severe.": Preemptive pain management helps prevent pain from becoming severe and difficult to control. Patients should be encouraged to ask for medication before pain intensifies.
Correct Answer is A
Explanation
A. "My fraternal grandfather was diagnosed with Depression.": Family history is a significant risk factor for major depressive disorder (MDD), supporting the genetic etiology.
B. "It makes me so sad when I think about the fact my grandmother died.": This statement describes a situational response to grief, not a genetic predisposition to depression.
C. “I feel like I just can't do anything right.”: This reflects a cognitive distortion associated with depression but does not indicate a genetic cause.
D. "My mood is 7 out of 10 today.": This provides information about current emotional state rather than genetic risk factors.
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