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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Flexing the upper and extending the lower extremities in response to the painful stimulus is not an expected response for a client who has a traumatic head injury. This is a sign of decorticate posturing, which indicates damage to the cerebral hemispheres or the internal capsule. Decorticate posturing is a type of abnormal flexion that involves the abduction of the arms, internal rotation of the shoulders, flexion of the wrists, and extension of the legs.

Choice B reason: Pushing the painful stimulus away is not an expected response for a client who has a traumatic head injury. This is a sign of normal motor function, which indicates that the client can localize and withdraw from the painful stimulus. This is the highest level of motor response on the Glasgow Coma Scale (GCS), which is a neurological scoring system used to assess conscious level after head injury.

Choice C reason: Extending the body toward the painful stimulus is an expected response for a client who has a traumatic head injury. This is a sign of decerebrate posturing, which indicates damage to the brainstem or midbrain. Decerebrate posturing is a type of abnormal extension that involves the abduction of the arms, external rotation of the shoulders, extension of the wrists, and extension of the legs.

Choice D reason: Showing no reaction to the painful stimulus is not an expected response for a client who has a traumatic head injury. This is a sign of flaccid paralysis, which indicates damage to the spinal cord or peripheral nerves. Flaccid paralysis is a type of complete loss of muscle tone and reflexes that involves the absence of any voluntary or involuntary movements.

A. "I'll take this medication when I get an asthma attack." B. "I'll rinse my mouth after taking this medication." C. "I'll take this medication once a day in the evening." D. "I'll use a spacer device when I inhale this medication."

Correct Answer is C

Explanation

Choice A reason: Taking this medication when getting an asthma attack is not a correct way to use montelukast. Montelukast is a leukotriene modifier that helps to reduce inflammation and prevent asthma attacks and exercise induced bronchoconstriction. It is taken once a day in oral form and may cause side effects such as stomach pain, diarrhea, or mood changes. It is not a fast acting rescue medicine for asthma attacks and needs to be taken daily.

Choice B reason: Rinsing the mouth after taking this medication is not necessary or helpful for montelukast. Rinsing the mouth is usually recommended for inhaled corticosteroids, which can cause oral thrush, a fungal infection in the mouth. Montelukast is not an inhaled corticosteroid and does not cause oral thrush.

Choice C reason: Taking this medication once a day in the evening is the correct way to use montelukast. Montelukast works best when taken in the evening, as it can improve the symptoms of asthma and allergic rhinitis that occur at night or early in the morning. Taking it at the same time every day can also help to maintain a steady level of the drug in the body and prevent missed doses.

Choice D reason: Using a spacer device when inhaling this medication is not applicable or useful for montelukast. A spacer device is a tube that attaches to an inhaler and helps to deliver the medication more effectively to the lungs. Montelukast is not an inhaler, but a tablet or a granule that is swallowed.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A nurse is evaluating teaching on a client who has a new prescription for montelukast to treat asthma. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

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