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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
A. Confusion and restlessness: Confusion and restlessness can indicate changes in cerebral perfusion as the body begins to shut down. These signs may occur as death approaches.
B. Increased appetite and thirst: Increased appetite and thirst are less likely as death approaches.
In fact, clients often have decreased appetite and thirst as the body's systems slow down.
C. Increase in urinary and bowel output: As death approaches, urinary and bowel output typically decrease as the body's metabolic processes slow down.
D. Increased fatigue and sleep: Increased fatigue and sleepiness are common as death approaches. The body's energy levels decrease, leading to increased periods of sleep and rest.
E. Excess secretions in the throat and decrease swallow reflex: Excess secretions in the throat and a decrease in the swallow reflex can occur as the body's ability to manage secretions diminishes. This can lead to a gurgling sound in the throat known as the death rattle.
Correct Answer is A
Explanation
A. Poorly coordinated care and nosocomial infections are examples of errors: Poorly coordinated care, such as miscommunication between healthcare providers or lack of continuity in care, and nosocomial infections (infections acquired in the healthcare setting) are examples of errors that can compromise patient safety and contribute to adverse events.
B. Handoff errors are not causes of adverse events: Handoff errors, including miscommunication during transitions of care, are significant contributors to adverse events in healthcare settings. Improper handoffs can lead to misunderstandings, delays in treatment, and errors in medication administration.
C. Medication errors are intentional: Medication errors are unintended and can occur due to various factors, including human error, system failures, and communication breakdowns. They are not intentional acts.
D. As many as 10% of medication errors are preventable: Medication errors are often preventable with the implementation of safety measures such as barcode scanning, medication reconciliation, and standardized protocols. The percentage of preventable medication errors may vary depending on the healthcare setting and the effectiveness of safety initiatives.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
