A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention would the nurse complete prior to the procedure? The nurse assesses the client after a thoracentesis. Which assessment finding warrants immediate action? You should have 2 responses for this question: 1 for Intervention and 1 for Assessment.

Choice A reason:

Baclofen is primarily used to treat muscle symptoms caused by multiple sclerosis, including muscle spasms, stiffness, and pain1. It acts on the spinal cord nerves to decrease the number and severity of muscle spasms, thereby improving muscle movement2. The effectiveness of baclofen in managing multiple sclerosis symptoms is best evaluated by assessing the reduction in muscle spasms.

Choice B reason:

While mood and affect are important aspects of a patient’s overall well-being, they are not the primary indicators of baclofen’s effectiveness. Baclofen does not have a direct impact on mood and affect, as its main function is to relieve muscle spasms and improve muscle movement.

Choice C reason:

Appetite is not a primary concern when evaluating the effectiveness of baclofen. This medication is not known to significantly affect appetite. The main therapeutic goal of baclofen is to reduce muscle spasms and improve mobility in patients with multiple sclerosis.

Choice D reason:

Sleep pattern, although important for overall health, is not the primary measure of baclofen’s effectiveness. Baclofen’s primary role is to alleviate muscle spasms and improve muscle function. While it may have some impact on sleep due to its muscle-relaxing properties, this is not the main criterion for evaluating its effectiveness.

Choice A Reason: Adherence to proper hand hygiene

Proper hand hygiene is a fundamental practice in preventing infections, including ventilator-associated pneumonia (VAP). Hand hygiene involves washing hands with soap and water or using an alcohol-based hand sanitizer before and after patient contact, after touching potentially contaminated surfaces, and before performing any aseptic procedures. This practice helps to reduce the transmission of pathogens that can cause infections in mechanically ventilated patients. Studies have shown that adherence to hand hygiene protocols significantly decreases the incidence of VAP and other healthcare-associated infections.

Choice B Reason: Suction the client at least every 2 hours

While suctioning is an important aspect of care for mechanically ventilated patients, routine suctioning every 2 hours is not recommended. Instead, suctioning should be performed based on the patient’s clinical condition and as needed. Over-suctioning can cause trauma to the airway and increase the risk of infection. Therefore, this choice is not included in the best practices for preventing VAP.

Choice C Reason: Administering antiulcer medication

Administering antiulcer medication is a recommended practice to prevent stress ulcers and gastrointestinal bleeding in mechanically ventilated patients. Stress ulcers can lead to complications such as aspiration of gastric contents, which can contribute to the development of VAP. Antiulcer medications, such as proton pump inhibitors or H2 receptor antagonists, help to reduce gastric acidity and the risk of ulcer formation. This practice is part of the comprehensive care plan to prevent VAP.

Choice D Reason: Providing oral care per protocol

Providing oral care per protocol is a critical component of VAP prevention. Oral care involves cleaning the patient’s mouth, teeth, and gums to reduce the colonization of harmful bacteria that can be aspirated into the lungs. Protocols for oral care typically include the use of antiseptic solutions, such as chlorhexidine, to disinfect the oral cavity. Regular oral care has been shown to significantly reduce the incidence of VAP in mechanically ventilated patients.

Choice E Reason: Elevating the head of the bed

Elevating the head of the bed to an angle of 30 to 45 degrees is a recommended practice to prevent VAP. This position helps to reduce the risk of aspiration of gastric contents into the lungs, which is a major risk factor for VAP. Elevating the head of the bed also promotes better lung expansion and ventilation, which can improve the patient’s respiratory status. This practice is widely recognized as an effective measure to prevent VAP.

Choice F Reason: Suctioning the client on a regular schedule

Similar to Choice B, routine suctioning on a regular schedule is not recommended. Suctioning should be performed based on the patient’s clinical needs and not on a fixed schedule. Over-suctioning can cause harm and increase the risk of infection. Therefore, this choice is not included in the best practices for preventing VAP.

Choice G Reason: Turning and positioning the client at least every 2 hours

Turning and positioning the client at least every 2 hours is an important practice to prevent complications such as pressure ulcers and to promote lung expansion. Regular repositioning helps to improve ventilation and drainage of secretions, reducing the risk of VAP. This practice is part of the standard care for mechanically ventilated patients to prevent various complications, including VAP.