A nurse is caring for a client on a ventilator.
The nurse should include which of the following interventions in the plan of care to prevent ventilator associated pneumonia? (Select All that Apply)
Do not elevate the head of bed.
Provide mouth care every 2-4 hours.
Refrain from suctioning the client.
Complete hand hygiene before touching the client.
Perform hand hygiene before handling ventilatory tubing.
Correct Answer : B,D,E
Choice A rationale
Not elevating the head of the bed increases the risk of aspiration of oropharyngeal secretions and gastric contents into the lungs. Gravity helps prevent reflux. Elevating the head of the bed to 30-45 degrees reduces the risk of ventilator-associated pneumonia by minimizing aspiration and promoting gastric emptying, which is a key preventative strategy.
Choice B rationale
Providing mouth care every 2-4 hours is critical for preventing ventilator-associated pneumonia. The oral cavity of intubated clients rapidly colonizes with pathogenic bacteria. Regular mouth care, including brushing teeth and cleansing oral mucosa with antiseptic solutions like chlorhexidine, significantly reduces bacterial load, thereby decreasing the risk of aspiration and subsequent pneumonia.
Choice C rationale
Refraining from suctioning the client would lead to the accumulation of pulmonary secretions, providing a fertile ground for bacterial growth and increasing the risk of ventilator-associated pneumonia. Suctioning is a necessary intervention to remove secretions, maintain airway patency, and reduce the bacterial burden in the lower respiratory tract, thus preventing infection.
Choice D rationale
Completing hand hygiene before touching the client is paramount for infection control. Microorganisms are commonly transmitted via healthcare workers' hands. Proper hand hygiene (washing with soap and water or using alcohol-based hand rub) before any client contact prevents the introduction of pathogens to the client, especially critical for immunocompromised or intubated individuals.
Choice E rationale
Performing hand hygiene before handling ventilatory tubing is essential to prevent the introduction of pathogens into the closed ventilator circuit. The tubing can serve as a conduit for microorganisms directly into the client's airways. Strict adherence to hand hygiene protocols before manipulating any part of the ventilator system minimizes the risk of contamination and subsequent infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.5"]
Explanation
Step 1 is: Calculate the number of tablets needed. 7.5 mg ÷ (5 mg/tablet) = 1.5 tablets.
Correct Answer is C
Explanation
Choice A rationale
Administering antibiotics to family members without a confirmed bacterial infection is not scientifically sound. Antibiotics target bacterial pathogens, and their prophylactic use in healthy individuals can contribute to antibiotic resistance, a significant public health concern. Additionally, it disrupts the normal microbial flora, potentially increasing susceptibility to other infections.
Choice B rationale
Limiting visits based solely on age, like "under 12," lacks specific scientific merit for infection prevention in chemotherapy patients. While young children may have less developed immune systems and be more prone to transmitting common childhood illnesses, the critical factor is adherence to strict infection control practices, such as hand hygiene and avoiding visits when ill, regardless of age.
Choice C rationale
Practicing strict hand hygiene, including thorough washing with soap and water or using alcohol-based hand rub, is the single most effective method for preventing the transmission of healthcare-associated infections. This physically removes or inactivates transient microorganisms on the skin, thereby breaking the chain of infection and protecting immunocompromised patients from potential pathogens.
Choice D rationale
Wearing gowns, gloves, masks, and shoe coverings for all client care is an excessive and unnecessary measure for general infection prevention in a chemotherapy patient's family members unless the client is on strict isolation precautions for a highly transmissible pathogen. Overuse of personal protective equipment can lead to complacency and is not supported by evidence for routine family interactions.
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