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
Choice A reason: No fluctuations in the water seal chamber. This finding indicates that the lung has expanded and there is no more air leaking from the pleural space. Fluctuations in the water seal chamber are normal when the client breathes, but they should stop when the lung is fully expanded.
Choice B reason: No reports of pleuritic chest pain. This finding does not indicate that the lung has expanded, as pleuritic chest pain can be caused by other factors, such as inflammation or infection of the pleura. Pleuritic chest pain is a sharp pain that worsens with breathing or coughing.
Choice C reason: Occasional bubbling in the water seal chamber. This finding does not indicate that the lung has expanded, as occasional bubbling can be normal or due to a small air leak. Continuous bubbling, however, indicates a large air leak and requires immediate attention.
Choice D reason: Oxygen saturation of 95%. This finding does not indicate that the lung has expanded, as oxygen saturation can be normal or high even with a collapsed lung. Oxygen saturation is the percentage of hemoglobin that is bound to oxygen in the blood.
Correct Answer is D
Explanation
Choice A reason: Administer low flow oxygen continuously via nasal cannula. This intervention is not appropriate because it does not provide enough oxygen to meet the needs of a client with ARDS. A client with ARDS requires high flow oxygen delivered by a mechanical ventilator or a noninvasive positive pressure device.
Choice B reason: Encourage oral intake of at least 3,000 mL of fluids per day. This intervention is not appropriate because it can worsen the pulmonary edema and hypoxemia that occur in ARDS. A client with ARDS requires fluid restriction and diuretics to reduce the fluid accumulation in the lungs.
Choice C reason: Offer high protein and high carbohydrate foods frequently. This intervention is appropriate because it provides adequate nutrition and energy to support the client's metabolic needs and prevent muscle wasting. A client with ARDS has increased caloric and protein requirements due to the increased work of breathing and the inflammatory response.
Choice D reason: Place in a prone position. This intervention is effective because it improves oxygenation and ventilation by increasing lung volume and reducing the effects of gravity on the lungs.
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