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 : A,B,C
Choice A rationale:
The nurse should wear a protective gown when suctioning the client's airway to prevent the spread of infection. During suctioning, there is a risk of exposure to the client's respiratory secretions, which may contain infectious organisms. Wearing a gown will help protect the nurse from contact with these secretions.
Choice B rationale:
Monitoring for oral secretions every 2 hours is essential to prevent the accumulation of mucus or saliva in the client's mouth. Excessive secretions can increase the risk of aspiration, which may lead to ventilator-associated pneumonia (VAP).
Choice C rationale:
Providing oral care every 2 hours is crucial to maintain oral hygiene and reduce the growth of bacteria in the mouth. Oral bacteria can potentially enter the lungs during mechanical ventilation, contributing to the development of VAP.
Choice D rationale:
Maintaining the client in a supine position is not recommended as it can increase the risk of VAP. The supine position may cause secretions to pool in the back of the throat, making it more likely for the client to aspirate these secretions.
Choice E rationale:
Assessing the client daily for readiness for extubation is important but not directly related to decreasing the risk of VAP. Extubation refers to the removal of the endotracheal tube, which helps prevent complications associated with prolonged intubation but does not specifically address VAP prevention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Dispose of the client's feces and urine in a special container.
Choice A rationale:
This is the correct choice. Brachytherapy involves the placement of a radiation source in or near the tumor. To minimize radiation exposure to others, the client's bodily fluids (feces and urine) should be considered radioactive and disposed of properly in a designated container.
Choice B rationale:
While limiting the time of visitors can be a good measure to reduce radiation exposure, it is not the priority intervention. The primary concern is proper handling and disposal of radioactive bodily fluids.
Choice C rationale:
Keeping the client's linens in the room until after removal of the radiation source is not the correct choice. Radioactive linens should be handled and laundered separately, following appropriate safety protocols.
Choice D rationale:
Providing one dosimeter badge for staff to share while caring for the client is not adequate. Each staff member involved in direct care should have their dosimeter badge to monitor their individual radiation exposure levels.
Correct Answer is A
Explanation
Choice A rationale:
Diplopia, or double vision, is a common manifestation of multiple sclerosis (MS). MS is a neurological disorder that affects the central nervous system, leading to various visual disturbances, including diplopia.
Choice B rationale:
A masklike expression is not associated with multiple sclerosis. This manifestation is more commonly seen in Parkinson's disease, not MS.
Choice C rationale:
Twitching of the face is not a typical manifestation of multiple sclerosis. Twitching or spasms are more commonly seen in conditions like hemifacial spasms or tic disorders.
Choice D rationale:
Agitation is not a specific manifestation of multiple sclerosis. MS symptoms primarily involve neurological deficits and not emotional disturbances like agitation.
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