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 C

Explanation

Choice A rationale:

Leflunomide is a disease-modifying antirheumatic drug (DMARD) used for rheumatoid arthritis, but it does not typically result in decreased swelling within one week. It usually takes several weeks or even months for its full effect to be observed.

Choice B rationale:

Applying hot packs directly to the joint for pain relief is not recommended for rheumatoid arthritis, as heat can exacerbate inflammation. Cold packs or other anti-inflammatory measures are more appropriate.

Choice C rationale:

Steroid medications, such as prednisone, can lead to bone density loss and an increased risk of osteoporosis. Taking calcium and vitamin D supplements helps to mitigate this risk.

Choice D rationale:

The Varicella vaccine is not directly related to rheumatoid arthritis. It is important for immune support, but it is not specifically required for rheumatoid arthritis treatment.

A. Maintain affected leg elevated on several pillows. B. Instruct the client to wiggle the toes once every 4 hr. C. Use a hair dryer to promote drying of the cast. D. Apply heat to the client's cast to provide pain relief.

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.

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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.).

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