A nurse is developing a plan of care for a patient on a ventilator, to prevent ventilator-associated pneumonia. The nurse recognizes that which of the following interventions should be included? Select all that apply.
Follow ventilator-weaning protocols.
Provide frequent mouth care.
Suction the patient every hour.
Place the patient in a prone position.
Refrain from suctioning the patient.
Correct Answer : A,B,D
Choice A rationale
Following ventilator-weaning protocols is an important intervention to prevent ventilator-associated pneumonia. Weaning protocols help to reduce the duration of mechanical ventilation, which is a risk factor for developing ventilator-associated pneumonia.
Choice B rationale
Providing frequent mouth care is a key intervention in preventing ventilator-associated pneumonia. Good oral hygiene can help to reduce the amount of bacteria in the mouth that can potentially be aspirated into the lungs.
Choice C rationale
Suctioning the patient every hour is not typically recommended as a method to prevent ventilator-associated pneumonia. Over-suctioning can potentially damage the lung tissue and mucous membranes, and it can also increase the risk of introducing bacteria into the lungs.
Choice D rationale
Placing the patient in a prone position can help to improve oxygenation and reduce the risk of ventilator-associated pneumonia. The prone position can help to drain secretions from the lungs, reducing the risk of bacteria growth and infection.
Choice E rationale
Refraining from suctioning the patient is not a recommended intervention to prevent ventilator-associated pneumonia. Suctioning is necessary to remove secretions from the airway, which can help to prevent infection.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
This response is more threatening than assertive. Threatening disciplinary action does not address the issue in a constructive manner and may create further conflict.
Choice B rationale
This response is more accusatory than assertive. It may make the colleague defensive and does not encourage open communication.
Choice C rationale
This response is more avoidant than assertive. It does not address the issue directly with the colleague and does not promote effective teamwork.
Choice D rationale
This response is assertive. It communicates the nurse’s feelings and needs clearly and respectfully, without blaming or threatening the colleague. It promotes open communication and effective teamwork.
Correct Answer is D
Explanation
Choice A rationale
Taking breaks outside in fresh air can help to clear the lungs of inhaled toxins to some extent. However, this measure alone is not sufficient to prevent inhalation exposure of job-related substances.
Choice B rationale
Consistently wearing a disposable paper mask can provide some protection against inhalable toxins. However, such masks may not be effective against all types of toxins and may not provide complete protection.
Choice C rationale
Keeping a fan blowing in the environment can help to disperse toxic substances and prevent them from becoming stagnant in the air. However, this measure alone may not be sufficient to prevent inhalation exposure, and in some cases, it could even spread the toxins more widely.
Choice D rationale
Wearing designated protective attire and devices when working with a toxic substance is the most effective measure to prevent inhalation exposure. This can include items such as respirators, which are designed to filter out specific toxins and protect the respiratory system.
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