ATI NCLEX Medical Surgical Assessment 1

ATI NCLEX Medical Surgical Assessment 1 A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following actions should the nurse include in the plan A. Provide the client with a means of communication B. Maintain the head of the client's bed in a flat position C. Suction the client's endotracheal tube every 4 hr D. Perform oral hygiene for the client every 8 hr - CORRECT ANSWER A Use electronic tablet computer, programmable speech generating device, alphabet board, pencil and paper, etc -- B, keep head of bed higher than 30 degrees to prevent aspiration and ventilator associated pneumonia. Turn the client q 2hr to prevent complications related to immobility C, assess the need to suction q 2-4 hr, but not perform routine suctioning. Base the need for suctioning on assessments, not a schedule. Unnecessary suctioning can cause bronco spasms and injury tracheal mucosa D, oral hygiene should be performed q 2 hr to decrease the risk of ventilator associated pneumonia