A charge nurse is rounding on several older clients on ventilators in the Intensive Care Unit whom the nurse identifies as being at high risk for ventilator-associated pneumonia. To reduce this risk what activity would the nurse delegate to the assistive personnel (AP)?

Correct Answer: C

Rationale: The correct answer is C: Provide oral care every 4 hours. Oral care helps prevent ventilator-associated pneumonia by reducing the risk of oral bacteria being aspirated into the lungs. The AP can assist with oral care under the nurse's supervision. A: Encouraging between-meal snacks does not directly address pneumonia risk. B: Monitoring temperature is important but not specific to ventilator-associated pneumonia prevention. D: Reporting new cough onset is important but does not directly reduce the risk of ventilator-associated pneumonia.

Correct Answer: D

Rationale: In this scenario, the correct sequence of steps for using a multidose inhaler without a spacer is to wait at least 1 minute between puffs (Option D). This is crucial to allow the medication to settle in the airways and maximize its effectiveness. Option A is incorrect because shaking the inhaler should be done before removing the cap. Option B is incorrect as the client should tilt their head back and breathe out after shaking the inhaler. Option C is incorrect as pressing down on the canister and breathing deeply through the mouth should follow tilting the head back and breathing out. In an educational context, it's important for the student nurse to understand the proper sequence of steps for using an inhaler to ensure the client receives the correct dosage of medication. Emphasizing the importance of following the correct order of steps can prevent potential errors and enhance patient outcomes. Educating patients on proper inhaler technique is crucial for managing respiratory conditions effectively.

Correct Answer: B

Rationale: The correct answer is B) Surfactant. Surfactant is a substance produced by type II alveolar cells in the lungs that reduces surface tension within the alveoli. This reduction in surface tension prevents the alveoli from collapsing by helping to keep them open during exhalation. Without surfactant, the alveoli would collapse at the end of each exhalation, making it difficult for gas exchange to occur efficiently. Option A) Carina is incorrect because the carina is a ridge of cartilage in the trachea that helps to separate the openings to the left and right main bronchi. It does not play a role in preventing alveolar collapse. Option C) Empyema is incorrect as it refers to a collection of pus in the pleural cavity, which is not directly related to the stability of the alveoli. Option D) Thoracic cage is incorrect as it refers to the framework of bones and cartilage that surrounds and protects the lungs. While the thoracic cage provides structural support to the lungs, it does not directly prevent alveolar collapse. Understanding the role of surfactant in maintaining the patency of alveoli is crucial in the study of respiratory physiology. This knowledge is essential for healthcare professionals to understand conditions such as respiratory distress syndrome in infants, where insufficient surfactant production can lead to alveolar collapse and breathing difficulties. It also underscores the importance of surfactant replacement therapy in managing such conditions.

Correct Answer: B

Rationale: In this scenario, option B is the best action for the nurse to take. Staying with the patient and encouraging slow, pursed lip breathing is the correct choice because it can help the patient manage their respiratory distress effectively. Pursed lip breathing can improve oxygenation and decrease respiratory rate, which is beneficial during respiratory distress episodes. Option A is incorrect as leaving the patient alone may increase their anxiety and worsen the situation. Option C, reassuring the patient that the attack can be controlled with treatment, is not as immediately helpful as providing breathing techniques. Option D, informing the patient about monitoring, is important but not as critical as providing direct intervention during a respiratory distress episode. In an educational context, it's crucial for nurses to be skilled in managing respiratory distress and providing immediate interventions like pursed lip breathing. This question highlights the importance of hands-on interventions during acute episodes and reinforces the significance of therapeutic communication and patient support in nursing practice.