Exam 3)NR 324 Exam 3: Questions & Answers: Latest Updated A+ Guide Solution

When developing a mechanically ventilated client's plan of care for prevention of ventilator-associated pneumonia (VAP), the nurse should include which measures in the plan? Select all that apply. 1. Suction the oral cavity whenever needed. 2. Apply topical antibiotics to the oral cavity. 3. Change the ventilator circuit tubing every 2 hours. 4. Maintain the client in a supine position at all times. 5. Practice frequent oral hygiene, including teeth brushing. 6. Practice meticulous hand hygiene, and wear gloves when suctioning or handling the endotracheal tube. (Ans- 1. Suction the oral cavity whenever needed. 5. Practice frequent oral hygiene, including teeth brushing. 6. Practice meticulous hand hygiene, and wear gloves when suctioning or handling the endotracheal tube. The nurse should report which assessment finding to the health care provider (HCP) before initiating thrombolytic therapy in a client with pulmonary embolism? 1. Adventitious breath sounds 2. Temperature of 99.4° F orally3. Blood pressure of 198/110 mm Hg 4. Respiratory rate of 28 breaths/minute (Ans- 3. Blood pressure of 198/110 mm Hg Which should the nurse do when setting up an arterial line? 1. Tighten all tubing connections. 2. Use macrodrop intravenous tubing. 3. Level the transducer to the ventricle. 4. Raise the height of the normal saline infusion to prevent backup. (Ans- 1. Tighten all tubing connections. During the early postoperative period, a client who has undergone a cataract extraction complains of nausea and severe eye pain over the operative site. What should be the initial nursing action? 1. Call the health care provider (HCP). 2. Reassure the client that this is normal. 3. Turn the client onto his or her operative side. 4. Administer the prescribed pain medication and antiemetic. (Ans- 1. Call the health care provider (HCP). The nurse recognizes that which arterial blood gas value indicates impending hypoxemic respiratory failure?