The nurse is admitting a client who is on a ventilator. The client has a medical diagnosis of acute respiratory distress syndrome (ARDS). Which infection control guideline is of greatest importance?

Hand washing before and after client contact

Placement of an indwelling urinary catheter using sterile technique

Initiate neutropenic precautions

Clean technique with central IV line care

Answer and Explanation

The Correct Answer is A

A. Hand washing before and after client contact: The most important infection control guideline when caring for a client with acute respiratory distress syndrome (ARDS) who is on a ventilator is hand hygiene. This is because ventilated patients are at high risk for ventilator-associated pneumonia (VAP) and other infections. Hand washing is the most effective method of preventing the spread of pathogens that could lead to nosocomial infections. The nurse should perform proper hand hygiene both before and after any patient interaction, as this is critical in preventing the transmission of bacteria or viruses, especially in patients with compromised respiratory systems.

Explanation of each option:

B. Placement of an indwelling urinary catheter using sterile technique:
While using sterile technique when placing an indwelling urinary catheter is essential to prevent urinary tract infections (UTIs), it is not the top priority for infection control in this situation. The primary concern for infection in ARDS patients who are on mechanical ventilation is preventing respiratory infections, particularly ventilator-associated pneumonia (VAP). Although catheter-associated infections should be prevented, the most immediate concern is preventing respiratory-related infections.

C. Initiate neutropenic precautions:
Neutropenic precautions are important for patients who have immunocompromised conditions (such as those undergoing chemotherapy or with bone marrow suppression) to protect them from infections. However, ARDS does not necessarily compromise the immune system in the same way. The priority infection control measure for a patient on a ventilator with ARDS is preventing respiratory infections. Therefore, neutropenic precautions would not be the most relevant or highest priority in this case.

D. Clean technique with central IV line care:
Maintaining clean technique with central intravenous (IV) line care is important to prevent infections, such as central line-associated bloodstream infections (CLABSI). However, the most critical infection control measure for a patient on a ventilator with ARDS is still to focus on preventing respiratory infections, particularly ventilator-associated pneumonia (VAP). While IV line care is important, it is secondary to preventing respiratory tract infections in this scenario.

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Correct Answer is B

Explanation

A. Guidewire-induced dysrhythmia: Guidewire-induced dysrhythmia can occur if the guidewire or catheter irritates the heart during insertion, particularly when the catheter is placed in the central venous system. While this can lead to arrhythmias, it is typically more immediate and occurs during the procedure itself. The symptoms of dysrhythmia (e.g., irregular heartbeat) would more likely present right after insertion or during the manipulation of the guidewire. The signs of restlessness, JVD, and tachycardia observed 30 minutes after placement are more suggestive of a pneumothorax than of a guidewire-induced dysrhythmia.

B. Pneumothorax: Pneumothorax is a potential complication of central venous catheter (CVC) placement, particularly when the catheter is inserted into the subclavian vein. The right subclavian vein is located near the apex of the lung, so inadvertent puncture of the lung during catheter placement can lead to air entering the pleural space, causing a pneumothorax. The symptoms of pneumothorax may include restlessness, tachycardia, jugular vein distention (JVD), and respiratory distress. A heart rate of 120 beats per minute is consistent with tachycardia due to hypoxia or distress, and JVD can be a sign of increased intrathoracic pressure or impaired venous return, which occurs with a pneumothorax. These symptoms warrant immediate assessment for pneumothorax, which can be confirmed with a chest x-ray.

C. Pulmonary infarction: Pulmonary infarction occurs when a blockage in the pulmonary arteries prevents blood flow to lung tissue, resulting in tissue death. This can be caused by a pulmonary embolism or other issues, but it is not a typical complication of central venous catheter placement. The symptoms described (restlessness, JVD, and tachycardia) are more consistent with a pneumothorax than a pulmonary infarction, which would likely cause chest pain, hemoptysis, or dyspnea rather than these signs.

D. Venous thrombosis: While venous thrombosis (or clot formation) is a potential complication of central venous catheter placement, it typically manifests as swelling, redness, or pain at the catheter insertion site, rather than with the systemic symptoms of restlessness, tachycardia, and JVD. Venous thrombosis could cause some of the described symptoms in the long term, but it is less likely to be the cause of acute symptoms 30 minutes post-procedure. The immediate concern in this case is more likely to be pneumothorax, which can occur more suddenly and cause these symptoms.Top of FormBottom of Form

A. hyperglycemia B. Urinary retention C. Respiratory failure D. Hypertension

Correct Answer is C

Explanation

A. Hyperglycemia:
Although hyperglycemia can occur as a result of stress or corticosteroid use during the treatment of GBS (such as in the case of plasma exchange or IV immunoglobulin (IVIG) therapy), it is not the primary complication associated with GBS. While hyperglycemia requires monitoring and management, respiratory failure is a more immediate and critical concern.

B. Urinary retention:
Urinary retention can occur in some clients with neurologic disorders like GBS, but it is not as life-threatening as respiratory failure. The autonomic nervous system, which controls bladder function, may be affected, but urinary retention is usually manageable with intermittent catheterization or other interventions. It does not carry the same immediate risks to life or organ function as respiratory failure.

C. Respiratory failure:
In Guillain-Barré syndrome (GBS), the immune system attacks the peripheral nervous system, which can lead to progressive muscle weakness and paralysis. The most significant and potentially life-threatening complication of GBS is respiratory failure. This occurs because the paralysis can affect the muscles involved in breathing, including the diaphragm and intercostal muscles, leading to impaired ventilation. As the weakness progresses, the client may become unable to maintain effective breathing, requiring mechanical ventilation. Monitoring for signs of respiratory distress (e.g., increasing work of breathing, tachypnea, decreased breath sounds, or a drop in oxygen saturation) is critical in GBS, especially during the acute phase of the disease.

D. Hypertension:
Hypertension may be seen in some cases of GBS, particularly during the early stages of the disease, due to the autonomic dysfunction that can result from nerve involvement. However, hypotension (low blood pressure) is more commonly associated with the autonomic dysfunction in GBS rather than hypertension. Regardless, respiratory failure remains the most urgent complication to monitor for in clients with GBS.

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The nurse is admitting a client who is on a ventilator. The client has a medical diagnosis of acute respiratory distress syndrome (ARDS). Which infection control guideline is of greatest importance?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse is caring for the client experiencing Guillain-Barre syndrome (GBS). It is most important for the nurse to monitor the client for which complication?

Correct Answer is C

Explanation

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