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 A
Explanation
Choice A rationale:
The nurse should maintain the affected leg elevated on several pillows to reduce swelling and promote venous return. Elevating the leg helps minimize edema, which can be beneficial for the healing process and overall comfort of the client.
Choice B rationale:
Instructing the client to wiggle the toes once every 4 hours is not necessary and may cause discomfort to the fractured tibia. Toe wiggling does not provide any significant benefit in this context and could potentially disrupt the healing process.
Choice C rationale:
Using a hair dryer to promote drying of the cast is not recommended. Applying heat to the fiberglass cast may alter its integrity and lead to uneven drying, potentially weakening the cast's support.
Choice D rationale:
Applying heat to the client's cast for pain relief is not advisable. Heat may also weaken the cast material and is unlikely to provide effective pain relief for a fractured tibia. Instead, the nurse should follow the prescribed pain management plan and use appropriate pain medications as ordered by the healthcare provider.
Correct Answer is B
Explanation
Choice A rationale:
Increasing the intake of dairy products is not recommended for a client with irritable bowel syndrome (IBS) as dairy can exacerbate symptoms in some individuals, particularly if they are lactose intolerant.
Choice B rationale:
Drinking ten glasses of water each day is a helpful recommendation for clients with IBS. Staying hydrated can aid in digestion and help alleviate symptoms like constipation.
Choice C rationale:
Decreasing daily fiber intake to 20 grams is not advisable for IBS management. Adequate fiber intake is essential for maintaining bowel regularity and overall gut health. Instead, it is recommended to focus on soluble fiber and gradually increase fiber intake to avoid exacerbating symptoms.
Choice D rationale:
Encouraging the intake of clear carbonated fluids is not ideal for clients with IBS. Carbonated beverages can cause bloating and gas, potentially worsening symptoms in individuals with sensitive digestive systems. It is better to recommend non-carbonated, non-caffeinated fluids for hydration.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.