The nurse is caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotracheal tube. To prevent ventilator-associated pneumonia (VAP), which action is most important to include in the plan of care?

Choice A reason: Obtaining daily weights of the client is the best action to assess the therapeutic effect of furosemide in managing early chronic kidney disease. Daily weights provide valuable information about fluid balance and the effectiveness of the diuretic in reducing fluid retention. Consistent weight monitoring helps determine if the medication is achieving its goal of managing fluid overload, which is a common issue in CKD patients.

Choice B reason: Assessing acid-base balance is important in managing CKD, but it is not the primary action to assess the therapeutic effect of furosemide. While diuretics can influence electrolyte levels and acid-base balance, monitoring fluid status through daily weights is more directly related to evaluating the effectiveness of the medication.

Choice C reason: Assessing the client's serum creatinine is crucial for monitoring kidney function and progression of CKD. However, it is not the primary action to determine the therapeutic effect of furosemide. The focus of furosemide therapy is to manage fluid balance, and daily weights provide a more immediate and relevant assessment of this effect.

Choice D reason: Auscultating heart sounds is part of a comprehensive assessment of a CKD patient, but it is not the best action to evaluate the therapeutic effect of furosemide. Heart sounds can provide information about cardiac function and potential complications, but they do not directly measure the effectiveness of fluid management achieved by the diuretic.

Choice A reason: An epidural hematoma is a type of traumatic brain injury where blood accumulates between the dura mater and the skull. While it can cause severe symptoms, including headache, loss of consciousness, and neurological deficits, it does not typically present with ecchymosis behind the ears (Battle's sign) or bleeding from the ears. These signs are more indicative of a basilar skull fracture.

Choice B reason: An ischemic stroke occurs when a blood clot blocks or narrows an artery leading to the brain, causing reduced blood flow and oxygen to the brain tissue. Symptoms of an ischemic stroke include sudden weakness, numbness, difficulty speaking, and vision problems. However, it does not cause ecchymosis behind the ears or bleeding from the ears, which are specific signs of a basilar skull fracture.

Choice C reason: A subarachnoid hemorrhage is bleeding into the space between the brain and the tissue covering the brain (subarachnoid space). It often presents with a sudden, severe headache, nausea, vomiting, and loss of consciousness. While it is a serious condition, it does not typically cause ecchymosis behind the ears or bleeding from the ears.

Choice D reason: A basilar skull fracture is

The correct answer. This type of fracture involves the base of the skull and can cause characteristic signs such as ecchymosis behind the ears (Battle's sign) and bleeding from the ears due to the proximity of the fracture to the auditory canal and other structures. These symptoms are key indicators of a basilar skull fracture and require immediate medical attention.