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. Assess the insertion site: Assessing the insertion site for bleeding, hematoma, or signs of infection is the priority action because complications at the insertion site can occur post- procedure and require immediate attention.

B. Keep the client NPO for 4 hr: Keeping the client NPO is not typically necessary after a cardiac catheterization unless there are specific orders or complications.

C. Keep the affected leg slightly flexed: The affected leg should actually be kept straight to prevent bleeding from the insertion site.

D. Elevate the head of the bed 45°: The head of the bed should usually be kept flat or only slightly elevated to reduce the risk of bleeding from the femoral site.

A. Docusate Sodium (Colace) B. Acetaminophen (Tylenol) C. Meperidine (Demerol) D. Atorvastatin (Lipitor)

Correct Answer is C

Explanation

A. Docusate Sodium (Colace) is a stool softener and is not contraindicated in chronic renal disease.
B. Acetaminophen (Tylenol) is generally safe for use in chronic renal disease, but dosing adjustments may be necessary based on renal function.
C. Meperidine (Demerol) is contraindicated in clients with chronic renal disease because its metabolites can accumulate in renal impairment, leading to neurotoxicity and seizures. It is often replaced with alternative opioid analgesics like morphine or fentanyl in these patients.
D. Atorvastatin (Lipitor) is a statin medication used to lower cholesterol levels and is generally safe in chronic renal disease, although dosing adjustments may be needed depending on the severity of renal impairment.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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