A patient undergoing mechanical ventilation in the ICU develops ventilator-associated pneumonia (VAP) caused by multidrug-resistant organisms (MDROs). What intervention should the healthcare team prioritize to manage the patient's infection?

Correct Answer: A

Rationale: The most appropriate intervention for managing ventilator-associated pneumonia (VAP) caused by multidrug-resistant organisms (MDROs) is to administer combination antibiotic therapy targeting the specific resistant pathogens identified in the patient's culture results. MDROs are often resistant to multiple antibiotics, so combination therapy is required to maximize the chances of effectively treating the infection. Identifying the specific pathogens causing the VAP through cultures is crucial in tailoring the antibiotic therapy to target these organisms effectively. Implementing appropriate antibiotic therapy promptly is essential to improve outcomes and prevent further complications in patients with VAP caused by MDROs. Option A is the priority intervention in this case to address the multidrug-resistant nature of the infection and provide targeted treatment for the patient.

Correct Answer: C

Rationale: The most appropriate nursing action in this scenario is to notify the healthcare provider immediately. The client's presentation of calf pain, swelling, and warmth could be indicative of a deep vein thrombosis (DVT), which is a serious condition that requires prompt evaluation and intervention by the healthcare provider. DVT is a blood clot that forms in a deep vein, often in the leg, and if left untreated, it can lead to life-threatening complications such as pulmonary embolism. Therefore, timely communication with the healthcare provider is critical to ensure that the client receives the appropriate diagnostic testing and treatment to address the potential DVT. Applying warm compresses, encouraging ambulation, or administering NSAIDs would not be the first-line interventions for a suspected DVT and may even worsen the condition.

Correct Answer: D

Rationale: The principles of guidance in handling Richard involve understanding and addressing the behaviors and needs of the child, such as controlling temper tantrums, basing expectations within the child's limitations, and acceptance of certain behaviors like masturbation as normal but to be discouraged in public. However, reinforcing the correct use of language is not typically included as a principle specifically in handling Richard. Therefore, this choice is NOT included among the principles of guidance in this context.

Correct Answer: D

Rationale: The nurse should prioritize positioning the patient in a left lateral decubitus position during gastric lavage to ensure procedural effectiveness. This position helps to promote optimal drainage of fluid and gastric contents. Placing the patient in a left lateral position allows gravity to assist in the passage of fluid and prevents the risk of aspiration. It also helps to minimize the risk of complications such as reflux of lavage fluid into the respiratory tract. Proper positioning is essential in enhancing the success of the gastric lavage procedure and promoting patient safety.

Correct Answer: A

Rationale: The step of the nursing process that identifies the family's health-seeking behavior is Assessment. During the assessment phase, the nurse gathers information about the family's health practices, beliefs, priorities, and past experiences related to seeking healthcare. This helps the nurse understand how the family approaches health and healthcare, which is crucial for providing tailored and effective care. By assessing the family's health-seeking behavior, the nurse can better collaborate with them to address their health needs and promote positive health outcomes.

Correct Answer: A

Rationale: The most appropriate nursing diagnosis for this patient would be "Self-care deficit related to neuromuscular impairment." This diagnosis is supported by the information provided, which indicates that the patient is experiencing neuromuscular impairment that is likely affecting their ability to perform self-care activities. A self-care deficit diagnosis is relevant when a patient is unable to perform activities of daily living independently due to physical or cognitive limitations. In this case, the neuromuscular impairment is likely impacting the patient's ability to engage in self-care tasks, such as feeding, grooming, bathing, and dressing. By identifying and addressing this self-care deficit, the healthcare team can help the patient maintain optimal functioning and independence despite their neuromuscular impairment.

Correct Answer: B

Rationale: Long-term aspirin therapy, especially at higher doses, can increase the risk of gastrointestinal bleeding. Aspirin irreversibly inhibits cyclooxygenase enzyme, which is essential for the production of prostaglandins involved in mucosal protection of the gastrointestinal tract. Without these protective prostaglandins, the stomach lining becomes more susceptible to damage from gastric acid, leading to potential ulcer formation and bleeding. Patients with a history of coronary artery disease may be on aspirin for secondary prevention, and it is crucial to monitor for signs of bleeding such as black, tarry stools or abdominal pain. The benefits of aspirin in preventing cardiovascular events need to be weighed against the risk of adverse effects like gastrointestinal bleeding, especially in patients on long-term therapy.

Correct Answer: B

Rationale: Encouraging the patient to practice controlled coughing techniques would be the most appropriate intervention to address the symptoms of chronic cough and excessive sputum production in a patient with end-stage COPD receiving palliative care. Controlled coughing techniques can help the patient effectively clear respiratory secretions and improve airway clearance without the need for additional medications or interventions. This approach focuses on optimizing the patient's ability to manage their symptoms and maintain comfort, which aligns with the goals of palliative care. Administering bronchodilator medications, prescribing mucolytic medications, or referring the patient to a respiratory therapist for breathing exercises may have limited effectiveness in this advanced stage of the disease, and controlled coughing techniques would be a more practical and patient-centered approach to symptom management.

Correct Answer: B

Rationale: The medication given after a successful vaginal delivery that helps to hasten uterine contractility and control bleeding is typically an oxytocic agent, such as oxytocin. Oxytocin helps the uterus to contract effectively, which is important for preventing excessive bleeding after delivery. This medication is commonly used in the postpartum period to help the uterus return to its normal size and position. The supervisor reassured the newly hired nurse that everything will be fine because this medication will help promote uterine contractions and control bleeding, which are crucial steps in the postpartum management.