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 : 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.

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Correct Answer is C

Explanation

Choice A rationale:

Difficulty maintaining personal hygiene is not typically an early indication of mild Alzheimer's disease. In the early stages, individuals can still manage personal hygiene.

Choice B rationale:

Difficulty handling finances may occur in the later stages of Alzheimer's disease, but it is not an early indication. In the early stages, the person might still manage financial matters.

Choice C rationale:

Difficulty remembering the names of new friends is a common early sign of mild Alzheimer's disease. It reflects the impairment of short-term memory that often occurs in the early stages of the disease.

Choice D rationale:

Difficulty driving to and from familiar places is more likely to be a mid-to-late-stage symptom of Alzheimer's disease. In the early stages, individuals might still drive familiar routes with minimal difficulty.

A. A 23-year-old client who is in skeletal traction. B. A 67-year-old client who has coronary artery disease. C. A 32-year-old client who has a spinal cord injury. D. A 55-year-old client who has emphysema.

Correct Answer is C

Explanation

Choice A rationale:

A 23-year-old client in skeletal traction may be at risk of pressure injuries, but being young and presumably healthier than the other options, this client may have a lower risk compared to the other choices.

Choice B rationale:

A 67-year-old client with coronary artery disease may be at risk of pressure injuries, especially if the client has limited mobility or is bedridden. However, coronary artery disease alone does not significantly increase the risk of pressure injuries.

Choice C rationale:

A 32-year-old client with a spinal cord injury is most at risk of developing a pressure injury. Spinal cord injuries often result in paralysis or limited mobility, leading to prolonged pressure on specific areas of the body, which can cause pressure ulcers.

Choice D rationale:

A 55-year-old client with emphysema may have compromised lung function, but this alone does not significantly increase the risk of pressure injuries. Pressure injuries are primarily related to immobility and pressure on specific body areas.

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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 assessing a client for manifestations of mild Alzheimer's disease. Which of the following findings should the nurse expect as an early indication of the disease?

Correct Answer is C

Explanation

A nurse is caring for several clients who are at risk of developing a pressure injury. Which of the following clients is most at risk?

Correct Answer is C

Explanation

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