A nurse notes that a client's eyes are protruding slightly from their orbits. Which of the following laboratory findings should the nurse expect?

Rationale:
A. Wear a protective gown when suctioning the client's airway: While wearing appropriate personal protective equipment protects the nurse from contamination, it does not directly reduce the client’s risk for ventilator-associated pneumonia.

B. Monitor for oral secretions every 2 hr: Regular assessment for and removal of oral secretions reduces the risk of aspiration, which is a key contributor to the development of ventilator-associated pneumonia.

C. Provide oral care every 2 hr: Frequent oral hygiene decreases the colonization of bacteria in the oropharynx, thereby reducing the risk of these organisms being aspirated into the lungs and causing infection.

D. Maintain the client in a supine position: Keeping the client supine increases the risk of aspiration. To prevent VAP, the head of the bed should typically be elevated 30 to 45 degrees unless contraindicated.

E. Assess the client daily for readiness of extubation: Daily evaluation for weaning from the ventilator reduces the duration of mechanical ventilation, which directly lowers the risk of developing ventilator-associated pneumonia.

Rationale:
A. Prepare to intubate the client with an endotracheal tube: Intubation is an invasive intervention typically reserved for clients with severe or rapidly deteriorating respiratory failure. It is not the first step in managing hypoxia when simpler oxygen delivery methods may be effective.

B. Place a nonrebreather face mask: This is the priority action because a nonrebreather mask delivers high-concentration oxygen (up to 95–100%) and can rapidly correct hypoxia. It is the most appropriate next step when a nasal cannula at 5 L/min is insufficient.

C. Obtain a prescription for arterial blood gases: While important for assessing the severity of hypoxia and guiding further treatment, this diagnostic action does not immediately address the client’s oxygenation needs.

D. Apply noninvasive positive-pressure ventilation: This intervention is beneficial for clients with certain conditions like COPD or heart failure but may not be the first-line response for general hypoxia. A nonrebreather mask is simpler and faster to apply in an acute setting.