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 ["A","B","D"]

Explanation

Choice A rationale:

The nurse should administer oxygen to the client experiencing a sickle cell crisis. Sickle cell crisis can cause vaso-occlusion, leading to tissue hypoxia and pain. Administering oxygen helps to improve tissue oxygenation and relieve symptoms.

Choice B rationale:

Administering opioids is appropriate for managing the severe pain associated with a sickle cell crisis. Opioids are effective analgesics that can help alleviate the acute pain experienced by the client.

Choice C rationale:

Administering whole blood is not typically indicated for a sickle cell crisis. Whole blood transfusion is reserved for specific indications, such as severe anemia or acute blood loss, but it is not a standard treatment for sickle cell crisis pain.

Choice D rationale:

Elevating the head of the bed to 30° can improve oxygenation and reduce the workload on the respiratory system, which is beneficial for clients experiencing a sickle cell crisis. It helps to optimize lung expansion and alleviate hypoxia.

Choice E rationale:

Keeping the client NPO (nothing by mouth) is not necessary in a sickle cell crisis. There is no indication that the client cannot tolerate oral intake, so allowing them to eat and drink as usual is appropriate.

A. Left leg is warm to the touch. B. Left pedal pulse strength is 2. C. The client reports pain in the foot of the left leg. D. Capillary refill in the left foot is 3 seconds.

Correct Answer is D

Explanation

Choice A rationale:
A warm left leg is a normal finding and does not require immediate intervention. Warmth indicates adequate circulation to the limb.
Choice B rationale:
A pedal pulse strength of 2 in the left leg indicates diminished pulse but does not require immediate intervention. The nurse should continue to monitor the pulse and report any significant changes to the healthcare provider.
Choice C rationale:
The client's report of pain in the foot of the left leg is an expected finding due to the fractured left femur. Pain is a subjective symptom, and the nurse should address the client's pain appropriately but not intervene immediately based on this finding.
Choice D rationale:
This is the correct choice. A capillary refill time of 3 seconds in the left foot suggests impaired circulation, which could be indicative of compartment syndrome or other circulation-related issues. The nurse should intervene immediately by notifying the healthcare provider to prevent further complications.

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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 in an emergency department is caring for a client who is in a sickle cell crisis. Which of the following actions should the nurse take?(Select all that apply.).

Correct Answer is ["A","B","D"]

Explanation

A nurse is performing a neurovascular assessment on a client who has a fractured left femur. For which of the following findings should the nurse intervene immediately?

Correct Answer is D

Explanation

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