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 : 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Testicular cancer may present as a painless lump or swelling in the testicle. It's important for the client to monitor for any new or unusual lumps, as they could be indicative of cancer.
Choice B rationale:
A decreased size of the testicle is not a typical manifestation of testicular cancer. It is more commonly associated with conditions like testicular atrophy due to other causes.
Choice C rationale:
Asymmetry in the position of the testicles, with one testicle descending lower than the other, is a normal variation and not a sign of testicular cancer.
Choice D rationale:
Dilated veins above the testicle can be a sign of a varicocele, which is a separate condition from testicular cancer. It is caused by abnormal enlargement of veins in the scrotum and is generally not associated with cancer.
Correct Answer is C
Explanation
Choice A rationale:
Preparing an endotracheal tube for intubation is not the first action the nurse should take in this situation. Intubation is an invasive procedure and should be reserved for cases where other, less invasive methods of airway management have failed.
Choice B rationale:
Inserting a plastic oral airway may help maintain the airway in some situations, but it is not the first action to take when the client's airway is obstructing and their oxygen saturation is low.
Choice C rationale:
Providing oxygen using a manual resuscitation bag (bag-valve-mask device) is the correct first action. This allows the nurse to manually assist the client's breathing and deliver oxygen more effectively than just providing supplemental oxygen through a nasal cannula or face mask.
Choice D rationale:
Performing a head tilt with a chin-lift is a basic airway maneuver, but it may not be sufficient in this situation, especially if the airway is completely obstructed. Providing oxygen with a manual resuscitation bag takes precedence.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today