In the context of developing a care plan for a patient on a ventilator to prevent ventilator-associated pneumonia, which interventions should be included? Select all that apply.
Implement ventilator-weaning protocols.
Provide frequent oral care.
Suction the patient every hour.
Position the patient in a prone position.
Avoid suctioning the patient.
Correct Answer : A,B,D
Choice A rationale
Implementing ventilator-weaning protocols is a crucial intervention in the care plan for a patient on a ventilator to prevent ventilator-associated pneumonia. These protocols aim to minimize the patient’s exposure to mechanical ventilation, which is a significant risk factor for developing ventilator-associated pneumonia. By systematically reducing the level of ventilatory support, these protocols facilitate the earliest possible liberation from mechanical ventilation, thereby reducing the risk of ventilator-associated pneumonia.
Choice B rationale
Providing frequent oral care is another essential intervention in preventing ventilator- associated pneumonia. Oral health can quickly deteriorate in mechanically ventilated patients, leading to an increased risk of ventilator-associated pneumonia. Regular oral care, including the use of antiseptics, can help reduce the number of potential respiratory pathogens in the oral cavity and prevent their aspiration into the lower respiratory tract.
Choice C rationale
Suctioning the patient every hour is not typically recommended as a standard intervention to prevent ventilator-associated pneumonia. Over-suctioning can lead to trauma and inflammation in the airway, potentially increasing the risk of infection. Suctioning should be performed based on the patient’s needs and clinical signs, rather than on a fixed schedule.
Choice D rationale
Positioning the patient in a semi-upright position (30 to 45 degrees), rather than a prone position, is recommended to prevent ventilator-associated pneumonia. This position helps to reduce the risk of aspiration, which is a major risk factor for ventilator-associated pneumonia.
Choice E rationale
Avoiding suctioning the patient is not a recommended strategy for preventing ventilator- associated pneumonia. Suctioning is necessary to clear secretions from the airway, and its omission could potentially increase the risk of infection. However, as mentioned earlier, suctioning should be performed based on the patient’s needs and clinical signs, rather than on a fixed schedule.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Applying warm compresses can help relieve the pain and pressure associated with acute rhinosinusitis by reducing inflammation and promoting sinus drainage.
Choice B rationale
Completing prescribed antibiotics is crucial in treating acute bacterial rhinosinusitis. Antibiotics help eliminate the bacterial infection causing the inflammation and symptoms.
Choice C rationale
Smoking can irritate the nasal passages and exacerbate the symptoms of rhinosinusitis. Avoiding smoking can help reduce inflammation and promote healing.
Choice D rationale
Swimming, especially in chlorinated pools, can irritate the nasal passages and sinuses, potentially worsening the symptoms of rhinosinusitis. It’s recommended to avoid swimming until the condition has resolved.
Choice E rationale
Periorbital edema is not a normal finding and could indicate a complication of rhinosinusitis, such as a spread of the infection. If a client notices this symptom, they should seek medical attention.
Correct Answer is D
Explanation
Choice A rationale
While it’s true that appetite and sense of smell are closely linked, the return of appetite does not necessarily mean the return of the sense of smell, especially after a total laryngectomy.
Choice B rationale
The body does not develop an ability to smell through the stoma. The sense of smell is primarily mediated by the olfactory nerve (Cranial Nerve I), which is located in the upper part of the nasal cavity.
Choice C rationale
The sense of smell does not typically return after several months following a total laryngectomy. This is because the surgery involves removal of the larynx and separation of the airway from the mouth, nose and throat.
Choice D rationale
Breathing through a stoma after a total laryngectomy does alter the sense of smell. This is because the nose and mouth are bypassed during breathing, and these are the primary routes for smell.
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