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 A
Explanation
The correct answer is A. Moderate.
Choice A: Moderate
A moderate traumatic brain injury (TBI) is characterized by a loss of consciousness (LOC) lasting between 30 minutes and 6 hours. In this scenario, the client lost consciousness for 45 minutes, which falls within this range. Moderate TBIs often result in more significant symptoms and may require more intensive medical intervention compared to mild TBIs.
Choice B: Severe
Severe TBIs are typically defined by a loss of consciousness lasting more than 6 hours. Since the client in this case was unconscious for only 45 minutes, this classification does not apply. Severe TBIs often involve extensive brain damage and can lead to long-term complications or disabilities.
Choice C: Mild
Mild TBIs, also known as concussions, are characterized by a loss of consciousness lasting less than 30 minutes. Given that the client was unconscious for 45 minutes, this classification is not appropriate. Mild TBIs usually result in temporary symptoms that resolve with minimal medical intervention.
Choice D: No traumatic brain injury
This option is incorrect because the client experienced a significant head injury with a loss of consciousness for 45 minutes. Such an event clearly indicates a traumatic brain injury, and it is essential to classify it correctly to ensure appropriate medical care.
Correct Answer is C
Explanation
Choice A reason: "Use simple, childlike statements when speaking." This response is not appropriate because it can be demeaning and disrespectful to the client. The client is an adult who knows what they want to say, but they have difficulty saying it. Using simple statements is helpful, but they should not be childlike or patronizing.
Choice B reason: "Use a higher pitched tone of voice when speaking." This response is not appropriate because it can be irritating and confusing to the client. The client may have normal hearing, or they may have hearing loss due to age or stroke. Using a higher pitched tone of voice can make the speech harder to understand and may imply that the client is not intelligent.
Choice C reason: "Incorporate nonverbal cues in the conversation." This response is appropriate because nonverbal cues, such as gestures, facial expressions, and drawings, can help the client understand and express themselves better. Nonverbal cues can also reduce frustration and anxiety for both the client and the family member.
Choice D reason: "Ask multiple choice questions as part of the conversation." This response is not appropriate because it can be overwhelming and stressful for the client. Multiple choice questions can be hard to process and remember for someone with aphasia. It is better to ask yes or no questions, or to provide options with visual cues.
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