A nurse in an emergency department is caring for a client who is in a sickle cell crisis. Which of the following actions should the nurse take?(Select all that apply.).

Choice A rationale:

While wearing a protective gown is essential to minimize exposure to bodily fluids and to ensure the nurse's protection, it is not specifically aimed at decreasing the risk for ventilator-associated pneumonia (VAP). The key interventions to prevent VAP focus on maintaining airway hygiene and proper positioning, not just personal protective equipment during suctioning.

Choice B rationale:

Monitoring oral secretions every 2 hours is an important strategy in reducing the risk of VAP. Accumulation of secretions in the mouth and upper airway can promote bacterial growth, increasing the risk of aspiration and infection. By regularly assessing and removing secretions, the nurse can reduce the chances of bacteria being aspirated into the lungs and causing pneumonia.

Choice C rationale:

Oral care every 2 hours is a critical intervention to reduce the risk of VAP. Mechanical ventilation predisposes clients to the growth of bacteria in the oral cavity, and poor oral hygiene increases the risk of oral bacteria being aspirated into the lungs. Regular oral care, including brushing teeth, gums, and the tongue, as well as using antiseptic solutions, helps reduce the microbial load in the mouth and decreases the risk of VAP.

Choice D rationale:

Maintaining a client in a supine position is not recommended for preventing VAP. The best practice is to maintain the head of the bed elevated at a 30-45 degree angle (semi-Fowler's position) to reduce the risk of aspiration. A supine position increases the likelihood of gastric contents or secretions being aspirated into the lungs, which can lead to VAP.

Choice E rationale:

Assessing the client daily for readiness for extubation is an essential practice in preventing VAP. The longer a patient remains intubated, the higher the risk of developing VAP due to prolonged exposure of the endotracheal tube in the airway. Regular assessment for extubation helps to ensure that the client is appropriately weaned off the ventilator as soon as they are stable, reducing the risk of VAP and other complications associated with prolonged ventilation.

Choice A rationale:

This statement indicates the client's fear and concern about the colostomy's odor, showing a lack of adaptation to the situation.

Choice B rationale:

Comparing the stoma to a strawberry with a hole in it might suggest the client is not fully accepting or understanding the colostomy, indicating a lack of adaptation.

Choice C rationale:

This statement suggests that the client has delegated the task of emptying the colostomy bag to their partner, which indicates a level of acceptance and adaptation to the new situation.

The client trusts their partner with this intimate task, demonstrating a positive sign of adaptation.

Choice D rationale:

Eliminating many foods from the diet suggests difficulty in adjusting to the dietary changes required for managing a colostomy, indicating a lack of full adaptation.