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 C
Explanation
Choice A reason: "I will be able to tell how much oxygen I'm getting by looking at the flowmeter." This statement is correct because the flowmeter shows the amount of oxygen delivered in liters per minute. The client should check the flowmeter regularly and adjust it according to the prescription.
Choice B reason: "I should call my doctor if I find it harder to concentrate." This statement is correct because difficulty concentrating can be a sign of low oxygen levels or carbon dioxide retention. The client should monitor their symptoms and report any changes to their doctor.
Choice C reason: "I will wear synthetic clothing and woolen socks when using my oxygen." This statement is incorrect because synthetic clothing and woolen socks can create static electricity and increase the risk of fire when using oxygen. The client should wear cotton clothing and avoid materials that can cause sparks.
Choice D reason: "I will make sure my visitors smoke outside." This statement is correct because smoking near oxygen can cause a fire or explosion. The client should keep oxygen away from open flames, smoking materials, and heat sources.
Correct Answer is B
Explanation
Choice A reason: Administering an inhaled glucocorticoid is not the priority intervention for a child with status asthmaticus. Inhaled glucocorticoids are anti-inflammatory drugs that reduce airway inflammation and prevent asthma attacks, but they do not provide immediate relief of bronchoconstriction.
Choice B reason: Administering a short acting beta agonist (SABA) is the priority intervention for a child with status asthmaticus. SABAs are bronchodilators that relax the smooth muscles of the airways and improve airflow within minutes. They are the first line treatment for acute asthma symptoms and exacerbations.
Choice C reason: Determining the cause of the acute exacerbation is not the priority intervention for a child with status asthmaticus. While it is important to identify and avoid potential triggers of asthma, such as allergens, infections, or stress, this is not an urgent action during a severe asthma attack.
Choice D reason: Obtaining a peak flow reading is not the priority intervention for a child with status asthmaticus. Peak flow is a measure of how quickly the child can blow air out of the lungs, and it can indicate the degree of airway obstruction. However, peak flow measurement is not reliable or feasible during a severe asthma attack, and it should not delay the administration of bronchodilators.
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