A nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions should the nurse implement to decrease the client's risk for ventilator-associated pneumonia (VAP)? (Select all that apply.).

Wear a protective gown when suctioning the client's airway.

Monitor for oral secretions every 2 hr.

Provide oral care every 2 hr.

Maintain the client in a supine position.

Assess the client daily for readiness of extubation.

Answer and Explanation

Correct Answer : B,C,E

Choice A rationale:

While wearing a protective gown is essential to minimize exposure to bodily fluids and to ensure the nurse's protection, it is not specifically aimed at decreasing the risk for ventilator-associated pneumonia (VAP). The key interventions to prevent VAP focus on maintaining airway hygiene and proper positioning, not just personal protective equipment during suctioning.

Choice B rationale:

Monitoring oral secretions every 2 hours is an important strategy in reducing the risk of VAP. Accumulation of secretions in the mouth and upper airway can promote bacterial growth, increasing the risk of aspiration and infection. By regularly assessing and removing secretions, the nurse can reduce the chances of bacteria being aspirated into the lungs and causing pneumonia.

Choice C rationale:

Oral care every 2 hours is a critical intervention to reduce the risk of VAP. Mechanical ventilation predisposes clients to the growth of bacteria in the oral cavity, and poor oral hygiene increases the risk of oral bacteria being aspirated into the lungs. Regular oral care, including brushing teeth, gums, and the tongue, as well as using antiseptic solutions, helps reduce the microbial load in the mouth and decreases the risk of VAP.

Choice D rationale:

Maintaining a client in a supine position is not recommended for preventing VAP. The best practice is to maintain the head of the bed elevated at a 30-45 degree angle (semi-Fowler's position) to reduce the risk of aspiration. A supine position increases the likelihood of gastric contents or secretions being aspirated into the lungs, which can lead to VAP.

Choice E rationale:

Assessing the client daily for readiness for extubation is an essential practice in preventing VAP. The longer a patient remains intubated, the higher the risk of developing VAP due to prolonged exposure of the endotracheal tube in the airway. Regular assessment for extubation helps to ensure that the client is appropriately weaned off the ventilator as soon as they are stable, reducing the risk of VAP and other complications associated with prolonged ventilation.

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Correct Answer is B

Explanation

Choice A rationale:
Is not a safe fall prevention strategy. Securing cords under carpeting can create tripping hazards. It is better to keep cords away from commonly used walking paths or use cord covers to prevent falls.
Choice B rationale:
Purchasing a skid-proof bathtub mat is a good fall-prevention strategy for an older adult client. It helps prevent slipping and falling in the bathroom, which is a common area for accidents in older adults.
Choice C rationale:
Is not a recommended fall prevention strategy. Leather soles can be slippery on smooth surfaces, increasing the risk of falls. Instead, the client should wear shoes with rubber soles that provide better traction.
Choice D rationale:
Is not the best option. Throw rugs, even with rubber backing, can still shift or bunch up, posing a tripping hazard. It's safer to avoid using throw rugs altogether or ensure they are firmly secured to the floor.

A. "I will take three sitz baths a week to relieve my discomfort.". B. "I should cleanse my lesions with 1/2 strength peroxide.". C. "I will avoid sexual activity until my lesions are healed.". D. "I am not contagious once I begin antiviral medication.".

Correct Answer is C

Explanation

Choice A rationale:

Taking sitz baths can provide comfort but will not directly address the transmission of herpes simplex virus type 2 (HSV-2). It is essential to avoid sexual activity during outbreaks to prevent spreading the infection to a partner.

Choice B rationale:

Cleansing lesions with 1/2 strength peroxide may irritate the affected area and delay healing. The recommended approach is to use gentle soap and water to clean the lesions.

Choice C rationale:

"I will avoid sexual activity until my lesions are healed.”. This statement indicates an understanding of the teaching because HSV-2 is highly contagious during active outbreaks. Avoiding sexual activity during this time is essential to prevent transmitting the virus to a partner.

Choice D rationale:

"I am not contagious once I begin antiviral medication.”. This statement is incorrect as antiviral medications can help manage outbreaks but do not eliminate the risk of transmission entirely. The virus remains contagious until lesions are completely healed.

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A nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions should the nurse implement to decrease the client's risk for ventilator-associated pneumonia (VAP)? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching an older adult client about fall prevention strategies at home. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is providing teaching to a female client who has herpes simplex virus type 2. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is C

Explanation

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