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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
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.
Correct Answer is C
Explanation
A. Reports of joint pain: Joint pain is more indicative of musculoskeletal issues rather than chronic renal disease. While joint pain can occur in some types of kidney disease, progressive edema is a more specific symptom.
B. Increase in appetite: An increase in appetite is not typically associated with chronic renal disease. Instead, clients with kidney disease may experience a decrease in appetite due to various factors such as nausea, vomiting, and changes in taste.
C. Progressive edema: Progressive edema, especially in the lower extremities and around the eyes (periorbital edema), can be a significant indicator of declining kidney function. It results from fluid retention due to impaired kidney filtration.
D. Recent increase in thirst: While increased thirst can be a symptom of chronic renal disease, it is not as specific as progressive edema. Increased thirst may occur due to other conditions or factors such as diabetes mellitus or dehydration.
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