The nurse caring for patients who are mechanically ventilated uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice?

Suctioning the patient on a regular schedule.

Adherence to proper hand hygiene.

Administering antiulcer medication.

Providing oral care per protocol.

Elevating the head of the bed.

Answer and Explanation

Correct Answer : B,D,E

Choice A reason:

Suctioning the patient on a regular schedule is not recommended as it can increase the risk of infection and trauma to the airway. Suctioning should be done as needed based on clinical assessment.

Choice B reason:

Adherence to proper hand hygiene is a fundamental practice in preventing infections, including ventilator-associated pneumonia. Hand hygiene helps prevent the transmission of pathogens.

Choice C reason:

Administering antiulcer medication is important for preventing stress ulcers but is not directly related to preventing ventilator-associated pneumonia.

Choice D reason:

Providing oral care per protocol is essential in reducing the risk of ventilator-associated pneumonia. Oral care helps decrease the bacterial load in the oropharynx and prevent aspiration of contaminated secretions.

Choice E reason:

Elevating the head of the bed to 30-45 degrees helps prevent aspiration of gastric contents and is a key practice in preventing ventilator-associated pneumonia.

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Correct Answer is ["83"]

Explanation

To calculate the infusion rate, divide the total volume of fluid to be infused by the total time over which the infusion should occur.

$\frac{330 \text{ mL}}{4 \text{ hours}} = 82.5 \text{ mL/hr}$

Rounding to the nearest whole number, the nurse should set the pump to deliver 83 mL/hr.

A. Increased oxygen saturation. B. Urine output less than 30 mL/hr. C. Decreased level of consciousness. D. Heart rate of 34 beats/min.

Correct Answer is ["B","D"]

Explanation

Choice A reason:

Increased oxygen saturation is not typically associated with neurogenic shock. Neurogenic shock usually involves bradycardia, hypotension, and potential respiratory issues, but not an increase in oxygen saturation.

Choice B reason:

Urine output less than 30 mL/hr is a sign of decreased perfusion to the kidneys, which can occur in neurogenic shock due to hypotension. This reduced urine output is a concerning manifestation that the nurse should monitor closely.

Choice C reason:

A decreased level of consciousness can be related to many factors, including hypoxia, hypotension, or other complications from the spinal cord injury. While it is an important sign to monitor, it is not a definitive marker of neurogenic shock.

Choice D reason:

A heart rate of 34 beats/min (bradycardia) is a common sign of neurogenic shock, which results from the loss of sympathetic tone due to the spinal cord injury. Bradycardia and hypotension are key indicators of neurogenic shock.

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The nurse caring for patients who are mechanically ventilated uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to infuse one unit, 330 mL, of packed red blood cells over 4 hours to a patient with heart failure. The nurse should set the pump to deliver how many mL/hr? Round to the nearest whole number.

Correct Answer is ["83"]

Explanation

A nurse assesses a patient who experienced a spinal cord injury at the T5 level 24 hours ago. Which manifestations would the nurse correlate with neurogenic shock? Select all that apply.

Correct Answer is ["B","D"]

Explanation

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