A nurse is caring for a client who has a central venous access device. Which of the following actions should the nurse take?

Choice A rationale:

Performing oral care once each day is not sufficient to reduce the risk of ventilator-associated pneumonia (VAP). Ventilated patients are at an increased risk of developing VAP due to the presence of an endotracheal tube that bypasses the body's natural defenses. Bacteria can accumulate in the mouth and respiratory tract, leading to pneumonia. Therefore, performing oral care only once a day is inadequate for maintaining oral hygiene and preventing VAP.

Choice B rationale:

Brushing the client's teeth with a firm-bristle toothbrush can cause trauma to the oral tissues, potentially leading to bleeding and irritation. In critically ill patients with an endotracheal tube, using a firm-bristle toothbrush can exacerbate the risk of infection and VAP. It is essential to use gentle and non-traumatic methods for oral care to maintain the integrity of the oral mucosa.

Choice C rationale:

Swabbing the client's mouth with chlorhexidine solution is the correct choice. Chlorhexidine is an antiseptic solution that effectively reduces the growth of bacteria in the oral cavity. Regular use of chlorhexidine mouthwash has been shown to decrease the risk of VAP in mechanically ventilated patients. By reducing the bacterial load in the mouth, the risk of aspiration and subsequent pneumonia is lowered, making it a crucial intervention for preventing VAP.

Choice D rationale:

Raising the head of the bed by 15° for oral care is an important measure to prevent aspiration during oral care. However, it alone is not sufficient to reduce the risk of VAP. While proper head positioning helps prevent the entry of oral secretions into the lower respiratory tract, it must be combined with effective oral hygiene practices, such as using chlorhexidine solution, to comprehensively reduce the risk of VAP.

The correct answer is C.

Choice A reason: Walking on the client’s right side is incorrect because the nurse should walk on the client’s left side. This is the weaker side and the side where support is most needed.

Choice B reason: Instructing the client to look down at their feet when ambulating is incorrect because the client should be instructed to look straight ahead, not down at their feet, to maintain balance and prevent falls.

Choice C reason: Have the client sit on the side of the bed for at least 60 seconds before ambulating. This allows the nurse to assess the client’s tolerance and readiness for ambulation, and it helps prevent dizziness or fainting due to orthostatic hypotension.

Choice D reason: Placing the gait belt securely around the client’s lower chest is incorrect because the gait belt should be placed around the client’s waist, not the lower chest. This provides a secure grip for the nurse and allows for safer ambulation.