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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Tachypnea: Tachypnea, or rapid breathing, is a common symptom of pulmonary embolism. It occurs as the body attempts to compensate for decreased oxygenation and increased carbon dioxide levels resulting from impaired blood flow to the lungs. Tachypnea helps to improve gas exchange by increasing ventilation.
B. Wet cough: A wet or productive cough may occur in conditions such as pneumonia or chronic bronchitis but is not typically associated with pulmonary embolism. Pulmonary embolism is more commonly characterized by symptoms such as dyspnea, chest pain, and tachypnea.
C. Dull chest pain: Chest pain associated with pulmonary embolism is often sharp and pleuritic, meaning it worsens with deep breathing or coughing. It may be described as stabbing or like a "knife-like" sensation. Dull chest pain is not a typical finding in pulmonary embolism.
D. Episodes of apnea: While severe cases of pulmonary embolism can lead to respiratory failure and apnea, it is not a common presenting symptom. Most clients with pulmonary embolism will exhibit tachypnea as a compensatory mechanism to maintain adequate oxygenation.
Correct Answer is ["A","C","D"]
Explanation
A. Health care providers should be told about the diagnosis to deliver safe care: Health care providers need to know the client's diagnosis to provide appropriate and safe care. This includes administering medications, assessing for opportunistic infections, and implementing preventive measures.
B. Most people in current society would be accepting of the diagnosis: While stigma surrounding HIV/AIDS has decreased over time, disclosure is a personal decision, and not all individuals may be accepting of the diagnosis. Therefore, this statement may not always be accurate.
C. Intimate partners should be told so they can protect themselves: Disclosing the diagnosis to intimate partners is essential for their health and well-being, as it allows them to take necessary precautions to prevent transmission of the virus.
D. The diagnosis is reportable to the state health department: In many jurisdictions, HIV/AIDS diagnoses are reportable to the state health department for surveillance and public health monitoring purposes. This reporting is typically done without disclosing the client's identity.
E. Secrecy about the diagnosis is the privilege of the client: While confidentiality is crucial, it's important to balance it with public health considerations and the well-being of others who may be at risk of infection.
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