To achieve the outcome of effective ventilation, which nursing intervention should be included in the plan of care for a client on a ventilator?

Suction the client as needed

Administer pantoprazole sodium IV

Apply sequential compression device (SCD)

Perform oral care with chlorhexidine

Answer and Explanation

The Correct Answer is A

A. Suction the client as needed: Suctioning is an essential nursing intervention for clients on mechanical ventilation to maintain effective ventilation. Ventilated clients are at risk for accumulating secretions in the airway, which can obstruct the endotracheal tube or tracheostomy, impairing ventilation and oxygenation. Regular or as-needed suctioning helps to clear secretions, ensuring that the airway remains patent and effective ventilation is maintained. This intervention directly supports the goal of maintaining optimal respiratory function and preventing complications such as atelectasis, pneumonia, or hypoxia.

B. Administer pantoprazole sodium IV: Pantoprazole is a proton pump inhibitor used to decrease stomach acid, typically to prevent stress ulcers in critically ill patients. While this is an important aspect of care for preventing gastrointestinal complications in ventilated patients, it does not directly support ventilation. Therefore, administering pantoprazole is not as directly related to ensuring effective ventilation as suctioning or other respiratory interventions.

C. Apply sequential compression device (SCD): While applying an SCD is important for preventing deep vein thrombosis (DVT) and promoting circulation in immobile patients, it does not directly address the client's ventilation or respiratory function. This intervention is more relevant for preventing venous thromboembolism, not for managing ventilation or airway clearance.

D. Perform oral care with chlorhexidine: Oral care with chlorhexidine is an important practice to reduce the risk of ventilator-associated pneumonia (VAP) and promote overall oral hygiene. It helps decrease the colonization of bacteria in the mouth and reduces the risk of infection. However, while oral care is an essential component of care for a ventilated patient, suctioning directly addresses the goal of effective ventilation by maintaining airway patency, making it the most immediate and relevant intervention for supporting ventilation.

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Correct Answer is ["A","C","D","E"]

Explanation

A. "How long have you had the pain?"
Asking about the duration of the pain is crucial in assessing a myocardial infarction (MI). The length of time the pain has been occurring can help the nurse determine if the pain is acute or has been ongoing. For instance, chest pain lasting more than 20 minutes or worsening in intensity could indicate an MI. Knowing the timing of the pain also helps establish whether it may be related to acute coronary syndrome (ACS), which requires immediate intervention.

B. "Do you have a history of coronary artery disease?"
While it’s important to understand the patient’s medical history, this question is more secondary during the initial assessment of a client with chest pain. This information is valuable for understanding the risk of cardiovascular events, but it is not the immediate focus when assessing the current pain. The nurse should prioritize questions that address the current symptoms and the characteristics of the pain first.

C. "How would you describe your pain?"
This question is essential to help differentiate the chest pain associated with a myocardial infarction from other causes, such as musculoskeletal pain or gastrointestinal issues. MI pain is typically described as a crushing, pressure-like, or squeezing sensation. Identifying the quality of the pain helps establish whether it’s consistent with a cardiac event. Understanding the description of the pain also provides information about the intensity and potential for myocardial damage.

D. "What were you doing when the pain began?"
This is an important question because activity-related chest pain can help determine the potential cause of the pain. Pain associated with physical exertion or emotional stress may point to an MI or angina. On the other hand, pain unrelated to activity might suggest other causes such as gastrointestinal issues or musculoskeletal pain. Inquiring about the onset of the pain can also provide insight into whether it is associated with physical strain or acute coronary syndrome.

E. "Can you rate your pain on a 0-10 scale?"
Pain assessment using a numeric pain scale (0-10) helps the nurse gauge the severity of the pain and track changes over time. It’s important for determining whether the pain is severe enough to be consistent with an acute myocardial infarction or if it might resolve on its own. This information is vital in deciding the urgency of interventions and treatment decisions.

A. dextromethorphan 10 mg PO q 4 r B. cromolyn MDI 2 puffs daily C. guaifenesin 200 mg PO q 4 hr D. methylprednisone 30 mg IV BID

Correct Answer is C

Explanation

A. Dextromethorphan 10 mg PO q 4 hr: Dextromethorphan is a cough suppressant, and while it may be useful for controlling a dry, non-productive cough, it is not appropriate for ineffective airway clearance in pneumonia. In fact, suppressing the cough in pneumonia could prevent the patient from clearing mucus from the airways, exacerbating the problem. It is more appropriate for a client who has a dry cough without significant mucus production.

B. Cromolyn MDI 2 puffs daily: Cromolyn is a mast cell stabilizer used for the prevention of asthma and allergy symptoms, and it is not typically used for treating pneumonia or ineffective airway clearance. It works by preventing the release of inflammatory mediators in response to allergens, but it does not address the issue of clearing mucus in the airways during a bacterial infection like pneumonia.

C. Guaifenesin 200 mg PO q 4 hr: Guaifenesin is an expectorant that helps loosen and thin mucus in the airways, making it easier for the client to cough up and clear secretions. This is the most appropriate medication for addressing ineffective airway clearance in a client with pneumonia, as the goal is to facilitate the removal of mucus and improve respiratory function. Guaifenesin does not suppress the cough reflex but instead promotes productive coughing, which is essential for clearing the airways during a respiratory infection like pneumonia.

D. Methylprednisolone 30 mg IV BID: Methylprednisolone is a corticosteroid used to reduce inflammation and control severe allergic or inflammatory conditions. While corticosteroids may be used in certain cases of pneumonia (e.g., in cases of significant inflammation or an underlying condition like COPD), they are not the first-line treatment for ineffective airway clearance. The priority in this case is to promote mucus clearance, which is better addressed by guaifenesin.

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To achieve the outcome of effective ventilation, which nursing intervention should be included in the plan of care for a client on a ventilator?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client comes to the emergency Department with chest pain and the nurse suspects a myocardial infarction. Which questions) should the nurse ask the client about the pain in the initial assessment? (SELECT ALL THAT APPLY)

Correct Answer is ["A","C","D","E"]

Explanation

The nurse is caring for a client diagnosed with pneumonia. Which medication will the nurse administer for treatment of client's problem of ineffective airway clearance?

Correct Answer is C

Explanation

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