a nurse is contributing to the plan of care for a client who is receiving mechanical ventilation which of the following interventions should the nurse

ATI LPN

ATI PN Comprehensive Predictor 2023

1. A healthcare professional is contributing to the plan of care for a client who is receiving mechanical ventilation. Which of the following interventions should the healthcare professional recommend?

A. Suction the airway every hour
B. Keep the head of the bed at 30 degrees
C. Change the ventilator tubing every day
D. Administer a bronchodilator every 2 hours

Correct answer: B

Rationale: The correct answer is to keep the head of the bed at 30 degrees. This position helps reduce the risk of aspiration and improves ventilation. Suctioning the airway every hour may lead to mucosal damage and increase the risk of infection. Changing the ventilator tubing every day is not necessary unless there are specific indications to do so, as it can increase the risk of contamination and infection. Administering a bronchodilator every 2 hours is not a standard practice and should be done based on the client's individualized treatment plan.

2. A nurse is collecting data from a client who delivered a full-term newborn 16 hours ago. The nurse notes excessive lochia discharge. Which of the following actions should the nurse take first?

A. Administer pain medication
B. Perform a fundal massage for the client
C. Check the baby's heart rate
D. Apply an ice pack

Correct answer: B

Rationale: The correct action the nurse should take first when noting excessive lochia discharge in a client who delivered a full-term newborn 16 hours ago is to perform a fundal massage. Fundal massage helps stimulate uterine contractions, which in turn reduces bleeding in postpartum clients. Administering pain medication (Choice A) is not the priority in this situation as addressing the excessive lochia discharge is crucial to prevent complications. Checking the baby's heart rate (Choice C) is important but not the first action to manage the mother's condition. Applying an ice pack (Choice D) is not appropriate for managing excessive lochia discharge; fundal massage is the initial intervention to address this issue effectively.

3. What are the key differences between viral and bacterial infections?

A. Viral infections typically last longer than bacterial infections.
B. Bacterial infections typically cause high fever.
C. Both bacterial and viral infections cause rashes.
D. Viral infections cause sudden onset of symptoms.

Correct answer: A

Rationale: The correct answer is A. Viral infections typically last longer than bacterial infections. This is because viral infections often require the body's immune system to fight off the virus, leading to a longer duration of illness. Bacterial infections, on the other hand, often cause a rapid onset of symptoms due to the toxins produced by bacteria. Choice B is incorrect because not all bacterial infections cause high fever. Choice C is incorrect because rashes can be caused by both bacterial and viral infections, but not always. Choice D is incorrect because while some viral infections may cause a sudden onset of symptoms, it is not a key distinguishing factor between viral and bacterial infections.

4. A nurse has agreed to serve as an interpreter for an older adult client who is assigned to another nurse. Which of the following statements by the nurse indicates an understanding of this role?

A. I will let the client know that I am available as the interpreter.
B. I will receive a small fee for interpreting for this client.
C. I am glad I am available today, but when I am not, you can use a family member.
D. I will let the client know that an interpreter is unavailable during the night shift.

Correct answer: A

Rationale: Choice A is correct because the nurse should inform the client of their availability to interpret, ensuring that communication is clear and culturally appropriate. Choice B is incorrect as interpreters in healthcare settings usually do not receive fees for providing interpretation services. Choice C is incorrect because suggesting the use of a family member as an interpreter may not ensure accurate communication, as they may not be trained or impartial. Choice D is incorrect because stating that an interpreter is unavailable during the night shift does not address the current situation where the nurse has agreed to interpret for the client.

5. What is the priority intervention for sepsis?

A. Administer IV antibiotics
B. Monitor blood pressure
C. Administer fluids
D. All of the above

Correct answer: D

Rationale: In the management of sepsis, prompt intervention is crucial. Administering IV antibiotics is essential to target the underlying infection. Monitoring blood pressure helps assess the patient's hemodynamic status. Administering fluids is vital to maintain adequate perfusion. Therefore, all the options are integral components of the initial management of sepsis, making 'All of the above' the correct answer. Choosing any single intervention over the others may delay optimal care and compromise patient outcomes.