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.)

Elevate the head of the bed 30 to 45 degrees.

Perform hand hygiene before touching the ventilator tubing.

Refrain from suctioning the client.

Provide mouth care every 2-4 hours.

Perform hand hygiene before touching the client.

Answer and Explanation

Correct Answer : A,B,D,E

A.   Elevating the head of the bed 30 to 45 degrees helps prevent aspiration, which is a risk factor for ventilator-associated pneumonia.
B.   Performing hand hygiene before touching the ventilator tubing is crucial to prevent the introduction of pathogens into the ventilator system.
C.   Refraining from suctioning the client is incorrect; suctioning should be performed as needed to keep the airway clear.
D.   Providing mouth care every 2-4 hours can reduce the risk of pathogens entering the lower respiratory tract.
E.   Performing hand hygiene before touching the client reduces the risk of transmitting infectious agents to the client.

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Correct Answer is C

Explanation

A. Instruct the client to avoid high-potassium foods: While important for long-term management, it is not the priority when the client is experiencing hyperkalemia, as immediate interventions are necessary to prevent complications.

B. Redraw the potassium to verify results: Redrawing the potassium may be necessary if there is concern about sample contamination or if the result is significantly different from what is expected. However, it is not the priority when the client is at risk of complications from hyperkalemia.

C. Check the client's blood pressure: This is the priority action because hyperkalemia can lead to cardiac dysrhythmias, including potentially life-threatening arrhythmias. Checking the blood pressure helps assess the client's cardiovascular status and any potential effects of hyperkalemia on cardiac function.

D. Obtain a serum sodium level: While monitoring electrolyte levels is important in ESRD, sodium levels are not the priority when the client is experiencing hyperkalemia. Monitoring potassium and managing its effects take precedence.

A. Encourage mouth care before and after meals. B. Monitor the client for changes in mental status. C. Assess the client's laboratory work for increased calcium levels. D. Advise the client to keep a food diary. E. Instruct the client to drink extra fluids between meals.

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

Explanation

A. Encouraging mouth care before and after meals helps maintain oral hygiene, which is essential for appetite stimulation and preventing oral infections.

B. Monitoring the client for changes in mental status is important as malnutrition can lead to cognitive impairment and changes in mental status.

C. Assessing the client's laboratory work for increased calcium levels may not be directly related to malnutrition due to cancer. Elevated calcium levels are more commonly associated with conditions like hyperparathyroidism or certain cancers, but it's not typically a direct consequence of malnutrition.

D. Advising the client to keep a food diary helps track food intake, identify any patterns related to malnutrition, and guide dietary interventions.

E. Instructing the client to drink extra fluids between meals helps prevent dehydration, especially if the client's intake is compromised due to malnutrition or cancer-related treatments.

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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.)

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Naxlex Comprehensive Predictor Exams

A client diagnosed with End Stage Renal Disease (ESRD) has a potassium level of 6.8 mEq/L. Which of the following priority actions should the nurse implement?

Correct Answer is C

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