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 D

Explanation

A. Grilled chicken, white rice, sliced peaches: While grilled chicken is a lean protein source, white rice is low in fiber and may not be the best choice for someone experiencing severe diarrhea. Sliced peaches are a good fruit choice, but the meal lacks sufficient fiber and other nutrients.

B. Spaghetti with tomato sauce, meatballs, and garlic bread: This meal contains high-fat and high-carbohydrate foods, which may exacerbate diarrhea. Tomato sauce can be acidic and irritating to the digestive system for some individuals.

C. Fried shrimp, cauliflower, yogurt with granola: Fried foods are high in fat and may worsen diarrhea. Cauliflower is a good vegetable choice, but yogurt with granola may not be well- tolerated if the client is lactose intolerant or sensitive to dairy products.

D. Grilled salmon, brown rice, broccoli: Grilled salmon provides lean protein and omega-3 fatty acids, which can be beneficial for overall health. Brown rice is higher in fiber compared to white rice and can help regulate bowel movements. Broccoli is a good source of fiber and essential nutrients. This meal is well-balanced and nutritious, making it a suitable choice for someone experiencing diarrhea.

A. Hypokalemia B. Hypocalcemia C. Hypernatremia D. Hyperkalemia

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.

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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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