A nurse is planning care for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following interventions should the nurse include to reduce the client's risk for ventilator-associated pneumonia?
Perform oral care once each day.
Brush the client's teeth with a firm-bristle toothbrush.
Swab the client's mouth with chlorhexidine solution.
Raise the head of the bed 15° for oral care.
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Determining what the client knows about coronary artery disease is an important step in assessing the client's baseline knowledge. However, it's not the first step in developing teaching strategies. First, the nurse should establish a collaborative relationship with the client to set mutual learning goals.
Choice B rationale:
Identifying resources that will help support the client's lifestyle changes is an essential aspect of the teaching process, but it's not the initial step. The nurse needs to work with the client to set goals and develop a plan before seeking external resources.
Choice C rationale:
Establishing mutual learning goals with the client is the most crucial first step. This approach ensures that the teaching plan aligns with the client's needs and preferences, fostering a sense of partnership and increasing the likelihood of successful lifestyle changes.
Choice D rationale:
Scheduling a teaching session about coronary artery disease in a quiet setting is an important consideration for effective teaching, but it comes after the nurse and the client have identified mutual learning goals. The nurse should engage the client in goal-setting before planning specific teaching sessions.
Correct Answer is B
Explanation
Choice A rationale:
Using the cane to support body weight is not the correct technique. The purpose of a cane is to provide balance and support, not to bear the entire body weight. Placing the entire body weight on the cane can lead to instability and falls.
Choice B rationale:
Placing the cane next to the unaffected leg (right leg in this case) is the correct technique. This positioning provides additional support and stability on the side opposite to the affected leg. This helps in maintaining balance and reducing the risk of falling.
Choice C rationale:
The type of cane is not as relevant as using it correctly. The material of the cane doesn't impact the client's understanding of how to use it safely. While using a wooden cane might be acceptable, the material itself is not an indication of the client's understanding of safe cane use.
Choice D rationale:
Moving the right leg forward first is not the correct technique for using a cane. The correct foot to move forward first is the affected leg, in this case, the left leg. This allows the client to maintain a stable base of support while moving.
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