A nurse is caring for a client on a ventilator. The nurse should include which of the following interventions in the plan of care to prevent ventilator associated pneumonia? (Select all that apply.)

Elevate the head of the bed 30 to 45 degrees.

Perform hand hygiene before touching the ventilator tubing.

Refrain from suctioning the client.

Provide mouth care every 2-4 hours.

Perform hand hygiene before touching the client.

Answer and Explanation

Correct Answer : A,B,D,E

A.   Elevating the head of the bed 30 to 45 degrees helps prevent aspiration, which is a risk factor for ventilator-associated pneumonia.
B.   Performing hand hygiene before touching the ventilator tubing is crucial to prevent the introduction of pathogens into the ventilator system.
C.   Refraining from suctioning the client is incorrect; suctioning should be performed as needed to keep the airway clear.
D.   Providing mouth care every 2-4 hours can reduce the risk of pathogens entering the lower respiratory tract.
E.   Performing hand hygiene before touching the client reduces the risk of transmitting infectious agents to the client.

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Correct Answer is A

Explanation

A. Hypokalemia: Furosemide is a loop diuretic that works by increasing urinary excretion of sodium, chloride, and water, which can lead to potassium loss. Hypokalemia is a common electrolyte imbalance associated with the use of loop diuretics like furosemide. Potassium depletion can cause various complications, including cardiac dysrhythmias, muscle weakness, and fatigue.

B. Hypocalcemia: Furosemide does not directly affect calcium levels, so hypocalcemia is not a common electrolyte imbalance associated with its use.

C. Hypernatremia: Furosemide promotes the excretion of sodium, so hypernatremia (elevated serum sodium levels) is not typically a concern with its use.

D. Hyperkalemia: Furosemide can cause potassium loss, so hyperkalemia is not a risk associated with its use.

A. Dyspnea on exertion B. Increased urination C. Weight gain of 2 pounds in a week D. Weight gain of 3 pounds in 24 hours

Correct Answer is D

Explanation

A. Dyspnea on exertion: Dyspnea on exertion is a common symptom in clients with heart failure and may indicate worsening heart function. While it warrants monitoring and potential intervention, it is not as urgent as rapid weight gain.

B. Increased urination: Increased urination may be expected with the use of diuretics, as they promote the excretion of excess fluid from the body. This finding is not typically concerning unless accompanied by other symptoms.

C. Weight gain of 2 pounds in a week: A weight gain of 2 pounds in a week may indicate fluid retention, but it is not as concerning as a rapid weight gain over a shorter period.

D. Weight gain of 3 pounds in 24 hours: A rapid weight gain of 3 pounds in 24 hours is significant and may indicate fluid overload, potentially leading to exacerbation of heart failure symptoms. It should be reported promptly to the healthcare provider for further evaluation and management.

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A nurse is caring for a client on a ventilator. The nurse should include which of the following interventions in the plan of care to prevent ventilator associated pneumonia? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is D

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