The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply)
Adherence to proper hand hygiene
Suction the client at least every 2 hours
Administering antiulcer medication
Providing oral care per protocol
Elevating the head of the bed
Suctioning the client on a regular schedule
Turning and positioning the client at least every 2 hours
Correct Answer : A,C,D,E,G
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A reason: A buffalo hump is a characteristic sign of Cushing’s syndrome. It refers to the accumulation of fat on the back of the neck and shoulders. This symptom occurs due to the excessive production of cortisol, which leads to abnormal fat distribution in the body.
Choice B reason: Moon face is another hallmark of Cushing’s syndrome. It describes the rounding and fullness of the face, which results from fat deposits. This symptom is also caused by prolonged exposure to high levels of cortisol.
Choice C reason: Hypertension, or high blood pressure, is commonly associated with Cushing’s syndrome. Cortisol increases blood pressure by enhancing the sensitivity of blood vessels to catecholamines and by promoting sodium and water retention.
Choice D reason: Purple striations, or stretch marks, are often seen in individuals with Cushing’s syndrome. These marks typically appear on the abdomen, thighs, breasts, and arms. They result from the thinning of the skin and the breakdown of collagen due to elevated cortisol levels.
Choice E reason: Tremors are not typically associated with Cushing’s syndrome. While Cushing’s syndrome can cause a variety of symptoms, tremors are more commonly linked to other conditions such as hyperthyroidism or neurological disorders.
Correct Answer is B
Explanation
Choice A: You May Bring Some Music to Listen to for Distraction
Bringing music for distraction is generally not a standard instruction given before an EEG. While listening to music might help some patients relax, it is not a critical part of the preparation for the test. The primary focus of EEG preparation is to ensure accurate readings of brain activity, which can be influenced by various factors such as medication and sleep.
Choice B: Do Not Take Any Sedatives 12 to 24 Hours Before the Test
Avoiding sedatives before an EEG is crucial because these medications can alter brain activity and affect the test results. Sedatives can suppress the electrical activity in the brain, leading to inaccurate readings. Therefore, it is essential for patients to avoid taking any sedatives 12 to 24 hours before the test to ensure the EEG captures the brain’s natural activity.
Choice C: You Will Need to Have Someone to Drive You Home
This instruction is typically given if the patient is expected to be sedated or if the test involves procedures that might impair their ability to drive. However, for a standard EEG, patients are usually not sedated, and there is no need for someone to drive them home. This instruction is more relevant for other types of medical procedures that involve sedation.
Choice D: Please Do Not Have Anything to Eat or Drink After Midnight
Fasting is not a standard requirement for an EEG. Patients are generally allowed to eat and drink before the test. However, they are often advised to avoid caffeine as it can affect brain activity. The instruction to avoid food and drink after midnight is more commonly associated with procedures that require anesthesia or sedation, not an EEG.
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