A nurse is developing a plan of care for a patient on a ventilator, to prevent ventilator-associated pneumonia. The nurse recognizes that which of the following interventions should be included? Select all that apply.
Follow ventilator-weaning protocols.
Provide frequent mouth care.
Suction the patient every hour.
Place the patient in a prone position.
Refrain from suctioning the patient.
Correct Answer : A,B,D
Choice A rationale
Following ventilator-weaning protocols is an important intervention to prevent ventilator-associated pneumonia. Weaning protocols help to reduce the duration of mechanical ventilation, which is a risk factor for developing ventilator-associated pneumonia.
Choice B rationale
Providing frequent mouth care is a key intervention in preventing ventilator-associated pneumonia. Good oral hygiene can help to reduce the amount of bacteria in the mouth that can potentially be aspirated into the lungs.
Choice C rationale
Suctioning the patient every hour is not typically recommended as a method to prevent ventilator-associated pneumonia. Over-suctioning can potentially damage the lung tissue and mucous membranes, and it can also increase the risk of introducing bacteria into the lungs.
Choice D rationale
Placing the patient in a prone position can help to improve oxygenation and reduce the risk of ventilator-associated pneumonia. The prone position can help to drain secretions from the lungs, reducing the risk of bacteria growth and infection.
Choice E rationale
Refraining from suctioning the patient is not a recommended intervention to prevent ventilator-associated pneumonia. Suctioning is necessary to remove secretions from the airway, which can help to prevent infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Efficiency in healthcare refers to the optimal use of resources to achieve the desired health outcomes. Reducing wait times in the emergency department is an example of improving efficiency, as it involves streamlining processes to provide timely care.
Choice B rationale
Utilizing the CAUTI bundle to prevent urinary tract infections when placing indwelling urinary catheters is more related to the safety and effectiveness domains of healthcare quality.
Choice C rationale
Using an interpreter for patients who do not speak the healthcare provider’s language is related to the equity and patient-centeredness domains of healthcare quality.
Choice D rationale
Opening and utilizing supplies that are necessary for the task is a basic requirement in healthcare, but it does not specifically relate to the efficiency domain of healthcare quality.
Correct Answer is D
Explanation
Choice A rationale
While skin breakdown can occur due to prolonged bed rest, it is not directly related to shallow respirations and refusal to cough or get out of bed.
Choice B rationale
Pneumonia is a possible complication due to immobility and shallow breathing. However, it is not the most immediate risk for a postoperative client who is refusing to cough or get out of bed.
Choice C rationale
Thrombosis is a risk associated with immobility, but it is not directly related to shallow respirations.
Choice D rationale
Atelectasis, or the collapse of alveoli in the lungs, is a common complication after surgery due to shallow breathing and lack of movement. This condition leads to reduced or absent gas exchange, which can further complicate the client’s recovery.
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