A patient undergoing mechanical ventilation is at risk for ventilator-associated pneumonia. Which intervention is most effective for prevention?

Correct Answer: B

Rationale: The correct answer is B) Performing oral care with chlorhexidine. Ventilator-associated pneumonia (VAP) is a common complication in mechanically ventilated patients due to the risk of aspiration and colonization of bacteria in the oral cavity. Performing oral care with chlorhexidine helps reduce the bacterial load in the mouth, decreasing the risk of VAP. Administering prophylactic antibiotics (Option A) is not recommended for VAP prevention due to concerns about antimicrobial resistance and the potential for selecting resistant organisms. Suctioning the airway every 2 hours (Option C) is important for airway clearance but is not the most effective intervention for preventing VAP. Over-suctioning can lead to mucosal damage and increased risk of infection. Keeping the patient sedated (Option D) may help with ventilator synchrony but does not directly address the prevention of VAP. Educationally, understanding the rationale behind each intervention is crucial for nurses and healthcare providers caring for mechanically ventilated patients. Emphasizing evidence-based practices like oral care with chlorhexidine can improve patient outcomes and reduce the incidence of complications like VAP.

Correct Answer: B

Rationale: The correct answer is B) "I can adjust my oxygen flow rate if I feel short of breath." This statement indicates a need for further teaching because patients on long-term oxygen therapy should not adjust their oxygen flow rate on their own without consulting their healthcare provider. Changing the flow rate without medical guidance can lead to serious complications like oxygen toxicity or inadequate oxygenation. Option A is correct as it indicates the patient's intention to follow the prescribed oxygen therapy plan, which is essential for managing COPD and maintaining adequate oxygen levels in the blood. Option C is also correct as checking oxygen tubing for kinks is a good practice to ensure the uninterrupted flow of oxygen, which is crucial for effective therapy. Option D is correct as well because it is important for patients using oxygen therapy to avoid open flames as oxygen supports combustion and can lead to fires. In an educational context, it is crucial to emphasize to patients the importance of following the prescribed oxygen therapy plan, not making adjustments without consulting healthcare providers, regularly checking equipment for proper functioning, and adhering to safety measures to prevent accidents. Patients should be educated on the potential risks associated with improper oxygen use and the necessity of seeking medical guidance for any concerns or changes in their condition.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Check for obstructions in the chest tube. This is the appropriate next step because the absent breath sounds on one side post-lobectomy indicate a potential issue with lung reinflation or air passage. Checking for obstructions in the chest tube is crucial as a blockage can prevent proper drainage of fluid or air from the pleural space, leading to lung collapse or other complications. Option A) Encouraging deep breathing is not the priority when there are absent breath sounds, as it does not address the underlying issue of potential tube obstruction. Option C) Repositioning the patient may not immediately resolve the absence of breath sounds and could delay necessary intervention. Option D) Notifying the healthcare provider is important but not the initial action needed to address the immediate concern of absent breath sounds and potential tube blockage. In an educational context, understanding the importance of prompt assessment and intervention in respiratory issues post-lobectomy is critical for nurses. This question highlights the significance of recognizing and responding to changes in breath sounds to prevent respiratory complications in post-surgical patients. Nurses must prioritize quick and accurate clinical assessments to provide timely and effective care to patients undergoing thoracic surgeries.

Correct Answer: B

Rationale: In this scenario, the nurse's priority should be option B) Assist the patient back to bed. This is the correct choice because a drop in oxygen saturation in a patient with COPD while ambulating indicates a potential worsening of their condition. Moving the patient back to bed will help decrease their oxygen demand and workload on the respiratory system, potentially improving oxygenation. Option A) Increase oxygen flow rate is incorrect because simply increasing oxygen flow may not address the underlying issue causing the drop in saturation. It is essential to assess the patient's overall condition first. Option C) Reassess oxygen saturation in 5 minutes is not the priority because the immediate action should be taken to address the drop in oxygen saturation and ensure the patient's safety. Option D) Encourage pursed-lip breathing is not the priority in this situation as it may not be effective enough to quickly improve oxygen saturation in a patient experiencing a drop while ambulating. In an educational context, this question highlights the importance of prioritizing patient safety and addressing acute changes in oxygenation levels promptly, especially in individuals with underlying respiratory conditions like COPD. Understanding the significance of oxygen saturation monitoring and appropriate interventions is crucial for nurses caring for patients with compromised respiratory function.

Correct Answer: A

Rationale: The correct answer is A) Peripheral neuropathy. Isoniazid, a medication commonly used to treat tuberculosis, can lead to peripheral neuropathy as a side effect. This occurs due to the depletion of vitamin B6 (pyridoxine) by isoniazid, leading to nerve damage. Monitoring for symptoms such as numbness, tingling, or burning sensations in the extremities is crucial to prevent worsening of this condition. Option B) Orange discoloration of body fluids is incorrect as this side effect is associated with rifampin, another medication used in TB treatment. Option C) Visual changes are not typically associated with isoniazid use. Option D) Hearing loss is not a known side effect of isoniazid. In an educational context, understanding the side effects of medications used in the treatment of tuberculosis is essential for nurses caring for patients with this condition. Monitoring for and recognizing potential adverse effects early can help in providing safe and effective care to patients undergoing TB treatment.