A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take to reduce the risk of ventilator associated pneumonia?
Position the head of the client’s bed in the flat position.
Brush the client’s teeth with a suction toothbrush every 12 hr.
Provide humidity by maintaining moisture within the ventilator tubing.
Turn the client every 4 hr.
The Correct Answer is B
Choice A reason: Positioning the head of the client’s bed in the flat position is not a good way to reduce the risk of ventilator associated pneumonia. This position can increase the risk of aspiration of oral secretions or gastric contents into the lungs, which can cause infection. The nurse should elevate the head of the bed to 30 to 45 degrees to prevent aspiration and promote drainage of secretions.
Choice B reason: Brushing the client’s teeth with a suction toothbrush every 12 hr is an effective way to reduce the risk of ventilator associated pneumonia. Oral hygiene can reduce the number of bacteria in the mouth and prevent the formation of dental plaque, which can harbor pathogens that can cause pneumonia. The nurse should use a suction toothbrush to remove debris and secretions from the mouth and prevent them from entering the lungs.
Choice C reason: Providing humidity by maintaining moisture within the ventilator tubing is not a helpful way to reduce the risk of ventilator associated pneumonia. Humidity can increase the growth of bacteria and fungi in the ventilator circuit, which can contaminate the air delivered to the lungs. The nurse should change the ventilator tubing and filters regularly and use sterile water to fill the humidifier.
Choice D reason: Turning the client every 4 hr is not a sufficient way to reduce the risk of ventilator associated pneumonia. Turning can help prevent pressure ulcers and improve blood circulation, but it does not prevent the accumulation of secretions in the lungs, which can cause infection. The nurse should use chest physiotherapy, suctioning, and coughing techniques to mobilize and clear secretions from the airways.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: The client is unable to make vocal sounds. This conclusion is not based on the GCS score of 5 for best verbal response, which indicates that the client is oriented and converses normally. The client may have other reasons for being unable to make vocal sounds, such as intubation or injury to the vocal cords.
Choice B reason: The client opens his eyes when spoken to. This conclusion is based on the GCS score of 3 for eye opening, which indicates that the client responds to verbal stimuli. This is the highest level of eye opening response on the GCS.
Choice C reason: The client is unconscious. This conclusion is not based on the GCS score of 13 (3+5+5), which indicates that the client has a mild level of impaired consciousness. The client is not unconscious, but may have reduced awareness or attention.
Choice D reason: The client can follow simple motor commands. This conclusion is not based on the GCS score of 5 for best motor response, which indicates that the client localizes pain. This means that the client moves their limbs away from a painful stimulus, but does not necessarily follow commands.
Correct Answer is A
Explanation
The correct answer is: a. Development of subcutaneous emphysema
Choice A: Development of subcutaneous emphysema
Reason: Subcutaneous emphysema occurs when air gets trapped under the skin, often due to a leak from the lung or chest tube. This can indicate a serious complication such as a pneumothorax or a malfunctioning chest tube, requiring immediate medical intervention. The presence of subcutaneous emphysema can lead to discomfort, respiratory distress, and further complications if not addressed promptly.
Choice B: Chest tube eyelets not visible
Reason: The eyelets of a chest tube are small holes at the end of the tube that allow air and fluid to drain from the pleural space. These eyelets are typically covered by a dressing and may not be visible. This is not necessarily a cause for concern unless there are other signs of malfunction or complications.
Choice C: Continuous bubbling in the suction control chamber
Reason: Continuous bubbling in the suction control chamber is expected and indicates that the suction is functioning properly. It does not indicate a problem unless the bubbling is in the water seal chamber, which would suggest an air leak.
Choice D: Presence of tidal fluctuation in the water seal chamber
Reason: Tidal fluctuation, or tidaling, in the water seal chamber is a normal finding. It indicates that the chest tube is patent and functioning correctly, as the water level rises with inhalation and falls with exhalation. The absence of tidaling could indicate a blockage or that the lung has fully re-expanded.
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