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","C","D","E"]

Explanation

Choice A rationale:
Is appropriate to assess postoperative urinary function after transurethral resection of the prostate (TURP). It helps monitor the return of normal bladder function.
Choice B rationale:
Is not necessary and could potentially cause discomfort and increased risk of tube dislodgment. Securing the tube properly to the bed or clothing is a more appropriate method.
Choice C rationale:
Is essential to assess urinary function, and fluid balance, and identify any potential complications such as urinary retention or excessive bleeding.
Choice D rationale:
Helps alleviate discomfort and prevent spasms after TURP. Bladder spasms can be common after the procedure, and antispasmodics can aid in managing them.
Choice E rationale:
Is necessary to keep the catheter patent and prevent clot formation in the urinary tract. It helps maintain proper drainage and prevents complications.

A. "I will increase my consumption of foods high in potassium.". B. "I will apply lotion to my skin if I feel any itching.". C. "I will avoid sun exposure while taking this medication.". D. "I will keep the medication refrigerated.".

Correct Answer is C

Explanation

Choice A rationale:
Increasing potassium consumption is unrelated to cephalexin, an antibiotic. It is not a necessary precaution or action to take while on this medication.
Choice B rationale:
Applying lotion to the skin to relieve itching is not related to cephalexin use. Itching is not a common side effect of this antibiotic, so the client's statement indicates a misunderstanding of the teaching.
Choice C rationale:
Avoiding sun exposure is essential while taking cephalexin because it is known to cause photosensitivity reactions. Sun exposure can lead to severe skin reactions, so the client's statement indicates an understanding of the teaching.
Choice D rationale:
Keeping the medication refrigerated is not necessary for cephalexin oral suspension. It should be stored at room temperature unless specified otherwise by the manufacturer. The client's statement suggests a misunderstanding of the medication storage instructions.

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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 caring for a client who is 6 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following actions should the nurse include in the plan of care? (Select all that apply.).

Correct Answer is ["A","C","D","E"]

Explanation

A nurse is providing teaching to a client who has a new prescription for cephalexin oral suspension. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

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