Which essential nursing intervention should be done for each client on a mechanical ventilator?

Turn off ventilator alarms when suctioning client.

Suction the client every hour.

Check for presence of bilateral breath sounds at least every two-four hours.

Keep the client's hands restrained.

Answer and Explanation

The Correct Answer is C

A. Turn off ventilator alarms when suctioning client: Ventilator alarms are safety features that alert the nurse to changes in airway pressure or ventilation status. Turning them off can prevent timely detection of serious complications such as disconnection or obstruction, so this action is unsafe and not recommended.

B. Suction the client every hour: Routine suctioning on a fixed schedule can cause mucosal trauma, hypoxia, and infection. Suctioning should be performed only as needed, based on clinical assessment such as increased secretions, rhonchi, or decreased oxygen saturation.

C. Check for presence of bilateral breath sounds at least every two to four hours: Regular assessment of breath sounds ensures that both lungs are adequately ventilated and helps detect complications such as atelectasis, pneumothorax, or tube displacement. This is a critical ongoing intervention to maintain patient safety on a mechanical ventilator.

D. Keep the client's hands restrained: Restraints may sometimes be necessary to prevent accidental extubation, but they are not an essential intervention for all ventilated clients. Use of restraints should be minimized and based on individual risk assessment rather than applied routinely.

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Correct Answer is C

Explanation

A. Assessing mucous membranes: Moisture and color of mucous membranes can provide some indication of hydration status, but this assessment is subjective and may not reflect rapid changes in intravascular volume during the emergent phase of burn care. It is supportive but not the most reliable measure of fluid adequacy.

B. Monitoring the blood pressure: Blood pressure can indicate overall circulatory status, but it may remain stable until significant fluid loss occurs. Relying solely on BP can delay recognition of inadequate perfusion, making it less sensitive for immediate fluid assessment in burn patients.

C. Measuring hourly urine output: Hourly urine output is the most accurate and direct indicator of kidney perfusion and fluid adequacy. Maintaining a target output (typically 0.5–1 mL/kg/hr in adults) confirms that the client is receiving sufficient fluids to support organ perfusion during the critical emergent phase of burn management.

D. Checking daily weight: Daily weight is useful for tracking overall fluid balance over time but is not practical for assessing real-time fluid adequacy in the emergent phase. Acute fluid shifts in burn patients require more immediate and continuous measures, such as hourly urine output.

A. Right-sided weakness with a hyper-awareness of deficits B. Slow to perform with a tendency to be impulsive C. Left-sided hemiplegia and a tendency to be impulsive D. Left-sided hemiplegia with hyper-awareness of deficits

Correct Answer is C

Explanation

A. Right-sided weakness with a hyper-awareness of deficits: Right-sided weakness occurs with left hemisphere strokes, not right-sided strokes. Clients with right-brain strokes typically have left-sided motor deficits. Hyper-awareness of deficits is more characteristic of left-brain stroke.

B. Slow to perform with a tendency to be impulsive: Slow, cautious behavior is more typical of left-brain stroke. Impulsivity is associated with right-brain stroke, but this option does not include the expected motor deficits on the left side.

C. Left-sided hemiplegia and a tendency to be impulsive: Right hemisphere strokes often result in left-sided weakness or paralysis (hemiplegia) and can impair judgment, spatial perception, and attention, leading to impulsivity and poor safety awareness. This combination accurately reflects common deficits seen in right-brain strokes.

D. Left-sided hemiplegia with hyper-awareness of deficits: Clients with right-brain strokes usually have diminished awareness of deficits (anosognosia) rather than hyper-awareness. Hyper-awareness is more common in left-brain strokes, making this option inaccurate for right-sided stroke.

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Which essential nursing intervention should be done for each client on a mechanical ventilator?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During the emergent phase of burn care which nursing action will be most useful in determining whether the client is receiving adequate fluid infusion?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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