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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Providing a continuous passive motion (CPM) device is not necessary for a client following a total hip arthroplasty. CPM devices are more commonly used after knee arthroplasty to improve joint mobility.
Choice B rationale:
Ensuring the client has an elevated toilet seat at home is important following a total hip arthroplasty. The elevated seat reduces the amount of hip flexion required during toileting, which helps prevent hip dislocation and strain on the surgical site.
Choice C rationale:
Providing a trapeze bar is not essential for a client following a total hip arthroplasty. Trapeze bars are typically used to assist with repositioning in bed for clients with limited mobility, but they are not specific to hip arthroplasty recovery.
Choice D rationale:
Providing a compression garment is not necessary after total hip arthroplasty. Compression garments are often used for conditions like venous insufficiency or to manage swelling, but they are not routinely used for hip arthroplasty recovery.
Correct Answer is B
Explanation
Choice A rationale:
Administering furosemide may be appropriate for managing ascites, but it is not directly related to preventing complications. Furosemide is a diuretic that helps reduce fluid retention but does not address other potential complications of liver cirrhosis.
Choice B rationale:
Weighing the client weekly is essential to monitor changes in body weight and fluid status, which is crucial in detecting worsening ascites or fluid retention. Sudden weight gain could indicate an exacerbation of ascites or other complications, warranting timely intervention.
Choice C rationale:
Offering the client a high-sodium diet is contraindicated in managing ascites. A high-sodium diet would lead to increased fluid retention and worsen the ascites, potentially exacerbating the client's condition and increasing the risk of complications.
Choice D rationale:
Administering heparin is not relevant to preventing complications in a client with liver cirrhosis and abdominal ascites. Heparin is an anticoagulant, and its use is not indicated for this particular condition.
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