A nurse is planning care for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following interventions should the nurse include to reduce the client's risk for ventilator-associated pneumonia?
Perform oral care once each day.
Brush the client's teeth with a firm-bristle toothbrush.
Swab the client's mouth with chlorhexidine solution.
Raise the head of the bed 15° for oral care.
The Correct Answer is C
Choice A rationale:
Performing oral care once each day is not sufficient to reduce the risk of ventilator-associated pneumonia (VAP). Ventilated patients are at an increased risk of developing VAP due to the presence of an endotracheal tube that bypasses the body's natural defenses. Bacteria can accumulate in the mouth and respiratory tract, leading to pneumonia. Therefore, performing oral care only once a day is inadequate for maintaining oral hygiene and preventing VAP.
Choice B rationale:
Brushing the client's teeth with a firm-bristle toothbrush can cause trauma to the oral tissues, potentially leading to bleeding and irritation. In critically ill patients with an endotracheal tube, using a firm-bristle toothbrush can exacerbate the risk of infection and VAP. It is essential to use gentle and non-traumatic methods for oral care to maintain the integrity of the oral mucosa.
Choice C rationale:
Swabbing the client's mouth with chlorhexidine solution is the correct choice. Chlorhexidine is an antiseptic solution that effectively reduces the growth of bacteria in the oral cavity. Regular use of chlorhexidine mouthwash has been shown to decrease the risk of VAP in mechanically ventilated patients. By reducing the bacterial load in the mouth, the risk of aspiration and subsequent pneumonia is lowered, making it a crucial intervention for preventing VAP.
Choice D rationale:
Raising the head of the bed by 15° for oral care is an important measure to prevent aspiration during oral care. However, it alone is not sufficient to reduce the risk of VAP. While proper head positioning helps prevent the entry of oral secretions into the lower respiratory tract, it must be combined with effective oral hygiene practices, such as using chlorhexidine solution, to comprehensively reduce the risk of VAP.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale:
Dishwashing gloves are often made of latex, which can trigger an allergic reaction in individuals with a latex allergy. Direct contact with latex-containing items should be avoided to prevent allergic responses.
Choice B rationale:
Adhesive tape commonly contains latex and can lead to allergic reactions in individuals with a latex allergy. Avoiding contact with latex-containing items is crucial to prevent potential allergic symptoms.
Choice C rationale:
Macadamia nuts and bananas do not typically contain latex and are not known to trigger latex allergies. While these items can cause allergic reactions in some individuals, they are not relevant to a latex allergy.
Choice D rationale:
While macadamia nuts and bananas can cause allergies in some people, they do not contain latex and are not associated with latex allergies. Therefore, they are not items that the nurse needs to instruct the client to avoid due to their latex allergy.
Choice E rationale:
Rubber bands are often made from latex, which can provoke an allergic reaction in individuals with a latex allergy. Encouraging the client to steer clear of items like rubber bands helps prevent potential allergic responses.
Correct Answer is C
Explanation
Choice A rationale:
Dehydration is a serious condition, and a urine output of 40 mL/hr is indicative of decreased renal perfusion and potential renal failure. However, this situation does not require immediate intervention compared to other choices.
Choice B rationale:
Pain management is important, and a pain score of 4 out of 10 indicates mild to moderate pain. While addressing pain is essential for the client's comfort, it is not an immediate priority compared to the situation presented in another choice.
Choice C rationale:
(Correct Choice) A respiratory rate of 40 breaths per minute in a client with asthma indicates severe respiratory distress. This client is at risk of respiratory failure and requires immediate assessment and intervention.
Choice D rationale:
A fasting blood glucose of 100 mg/dL in a client with diabetes mellitus is within a normal range and does not require immediate attention when compared to the urgent situation in another choice.
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