31 Questions
What are potential complications in a patient with a depressed LOC and inability to protect the airway or maintain respiratory function?
Pneumonia, aspiration, and respiratory failure
Why are vital signs and respiratory function monitored closely in patients with a depressed LOC?
To identify signs of respiratory failure or distress
What assessments are performed to determine the adequacy of oxygen transport in patients with a depressed LOC?
Complete blood count and arterial blood gas measurements
What interventions are initiated to prevent respiratory complications like pneumonia in unconscious patients?
Chest physiotherapy and suctioning
What is a key nursing action for a mechanically ventilated patient to prevent complications?
Providing frequent oral care
Why is it important for nurses to maintain the patency of the endotracheal tube or tracheostomy in mechanically ventilated patients?
To ensure proper oxygenation
What is considered a restraint by The Joint Commission when all four side rails are raised?
Limiting patient's mobility
Why is it important for nurses to identify potential sources of injury for a patient who is comatose?
To prevent falls or other injuries
How can nurses ensure protection and dignity for a patient with altered level of consciousness (LOC)?
Providing privacy and positive communication
Which of the following is NOT a potential complication for a patient with altered level of consciousness?
Hypoglycemia
Which of the following is the MOST important nursing goal for a patient with altered level of consciousness?
Compensating for the absence of protective reflexes
Which of the following is NOT listed as a goal of care for a patient with altered level of consciousness?
Maintenance of cognitive function
Which of the following statements is TRUE regarding the quality of nursing care for a patient with altered level of consciousness?
The quality of nursing care may mean the difference between life and death.
Which of the following is NOT a nursing intervention mentioned in the text for managing a patient with altered level of consciousness?
Administering intravenous fluids
What is the primary purpose of intermittent catheterization for a patient who is not voiding?
To reduce the risk of urinary tract infection
Why is it crucial to inspect the area around the urethral orifice for drainage and routinely cleanse it?
To prevent urinary tract infections
When should a urinary catheter be typically removed for a patient who has been using intermittent catheterization?
If the patient did not have voiding dysfunction before coma
What is a recommended method for managing urinary incontinence in unconscious male patients who can urinate spontaneously?
External catheter (condom catheter)
What strategies should be used to address factors that contribute to impaired skin integrity?
All of the above
Which of the following interventions should be implemented for patients at risk for venous thromboembolism (VTE)?
All of the above
If a patient develops a pressure injury, which of the following interventions should be implemented?
All of the above
What is the primary reason for administering IV fluids slowly in patients with intracranial conditions?
To minimize the risk of increasing intracranial pressure (ICP)
What is the recommended timeframe for initiating enteral nutrition in patients who cannot take adequate fluids and calories orally?
Within 48 hours of injury
What is the recommended practice for endotracheal tube positioning in intubated patients to prevent ulceration of the mouth and lips?
Moving the tube to the opposite side of the mouth daily
Which of the following statements is true regarding the importance of oral care in intubated and mechanically ventilated patients?
Good oral care is necessary to prevent complications related to the endotracheal tube
According to the information provided, what is the primary reason for moving the endotracheal tube to the opposite side of the mouth daily in intubated patients?
To prevent ulceration of the mouth and lips due to prolonged pressure
Which of the following statements is NOT supported by the information provided in the text?
Enteral nutrition should be initiated as soon as possible, regardless of the timeframe
What is the key purpose of maintaining skin integrity as mentioned in the text?
Avoiding pressure ulcers
Which action should be avoided to prevent skin damage according to the text?
Dragging or pulling the patient in bed
What is the main benefit of turning patients regularly as per the text?
Prevents pressure ulcers
Why are passive exercises of the extremities important in patient care as discussed in the text?
To prevent contractures
Test your knowledge on oral care interventions for mechanically ventilated patients to maintain oral health and reduce pneumonia risk. Learn about obtaining cultures to identify organisms in case of pneumonia. Explore strategies to prevent skin breakdown and pressure injuries in patients with altered levels of consciousness.
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