A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take to reduce the risk of ventilator associated pneumonia?
Position the head of the client’s bed in the flat position.
Brush the client’s teeth with a suction toothbrush every 12 hr.
Provide humidity by maintaining moisture within the ventilator tubing.
Turn the client every 4 hr.
The Correct Answer is B
Choice A reason: Positioning the head of the client’s bed in the flat position is not a good way to reduce the risk of ventilator associated pneumonia. This position can increase the risk of aspiration of oral secretions or gastric contents into the lungs, which can cause infection. The nurse should elevate the head of the bed to 30 to 45 degrees to prevent aspiration and promote drainage of secretions.
Choice B reason: Brushing the client’s teeth with a suction toothbrush every 12 hr is an effective way to reduce the risk of ventilator associated pneumonia. Oral hygiene can reduce the number of bacteria in the mouth and prevent the formation of dental plaque, which can harbor pathogens that can cause pneumonia. The nurse should use a suction toothbrush to remove debris and secretions from the mouth and prevent them from entering the lungs.
Choice C reason: Providing humidity by maintaining moisture within the ventilator tubing is not a helpful way to reduce the risk of ventilator associated pneumonia. Humidity can increase the growth of bacteria and fungi in the ventilator circuit, which can contaminate the air delivered to the lungs. The nurse should change the ventilator tubing and filters regularly and use sterile water to fill the humidifier.
Choice D reason: Turning the client every 4 hr is not a sufficient way to reduce the risk of ventilator associated pneumonia. Turning can help prevent pressure ulcers and improve blood circulation, but it does not prevent the accumulation of secretions in the lungs, which can cause infection. The nurse should use chest physiotherapy, suctioning, and coughing techniques to mobilize and clear secretions from the airways.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Ask the client to read a Snellen chart. This method is used to assess cranial nerve II, which is the optic nerve. The optic nerve is responsible for vision and visual acuity. A Snellen chart is a tool that displays letters of different sizes and measures how well the client can see them from a distance of 20 feet.
Choice B reason: Ask the client to clench his teeth. This method is not used to assess cranial nerve II, but cranial nerve V, which is the trigeminal nerve. The trigeminal nerve is responsible for sensation and motor function of the face, mouth, and jaw. Clenching the teeth tests the strength and symmetry of the masseter and temporalis muscles, which are innervated by the trigeminal nerve.
Choice C reason: Listen to the client’s speech. This method is not used to assess cranial nerve II, but cranial nerves IX, X, and XII, which are the glossopharyngeal, vagus, and hypoglossal nerves. These nerves are responsible for speech production and swallowing. Listening to the client’s speech tests the quality, clarity, and articulation of the voice, as well as the movement and coordination of the tongue and palate.
Choice D reason: Ask the client to identify scented aromas. This method is not used to assess cranial nerve II, but cranial nerve I, which is the olfactory nerve. The olfactory nerve is responsible for smell and olfaction. Asking the client to identify scented aromas tests the ability to detect and recognize different odors.
Correct Answer is D
Explanation
Choice A reason: Take isoniazid with an antacid. This answer is incorrect because taking isoniazid with an antacid can reduce the absorption and effectiveness of the drug. Isoniazid should be taken on an empty stomach, one hour before or two hours after meals.
Choice B reason: Drink at least 8 ounces of water when you take the pyrazinamide tablet. This answer is incorrect because drinking water with pyrazinamide is not necessary, as this drug does not cause dehydration or kidney problems. However, drinking plenty of fluids is generally recommended for clients with tuberculosis to prevent dehydration and help clear the lungs of secretions.
Choice C reason: Expect your sputum cultures to be negative after 6 months of therapy. This answer is incorrect because expecting sputum cultures to be negative after 6 months of therapy is unrealistic and misleading. The duration of treatment for tuberculosis varies depending on the type and extent of the infection, the drug regimen, and the client's response to the therapy. Some clients may need longer than 6 months to achieve negative sputum cultures.
Choice D reason: Provide a sputum specimen every 2 weeks to the clinic for testing. This answer is correct because providing sputum specimens regularly is important to monitor the effectiveness of the treatment and to determine when the client is no longer infectious.
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