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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale
The use of a Passy Muir speaking valve can be important for communication, but it is not the highest priority for discharge teaching.
Choice B rationale
Having the phone number of the healthcare provider to report complications is important, but it is not the highest priority. The patient needs to know how to prevent and recognize complications first.
Choice C rationale
While having emergency personal identification that the patient is unable to speak is important, it is not the highest priority. The patient’s immediate post-operative needs should be addressed first.
Choice D rationale
The ability to perform tracheostomy care is the highest priority for discharge teaching. This is a new and critical skill that the patient must learn to prevent complications, maintain the airway, and manage their own care at home.

A. Report the absence of spontaneous respirations. B. Encourage the patient to attempt to breathe on their own. C. Provide passive range-of-motion exercises. D. Respond to ventilator alarms.

Correct Answer is D

Explanation

Choice A rationale
Reporting the absence of spontaneous respirations is important, but it is not the priority action. The patient is on mechanical ventilation, so the absence of spontaneous respirations is expected.
Choice B rationale
Encouraging the patient to attempt to breathe on their own is not the priority action. The patient is receiving mechanical ventilation, which means they are likely unable to breathe adequately on their own.
Choice C rationale
Providing passive range-of-motion exercises is important for overall patient mobility and prevention of complications such as deep vein thrombosis, but it is not the priority action in this case.
Choice D rationale
Responding to ventilator alarms is the priority action. Alarms may indicate a change in the patient’s condition or a problem with the ventilator. Immediate response is necessary to ensure the patient’s safety.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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