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The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply)

Adherence to proper hand hygiene

Suction the client at least every 2 hours

Administering antiulcer medication

Providing oral care per protocol

Elevating the head of the bed

Suctioning the client on a regular schedule

Turning and positioning the client at least every 2 hours

Answer and Explanation

Correct Answer : A,C,D,E,G

Choice A Reason: Adherence to proper hand hygiene

Proper hand hygiene is a fundamental practice in preventing infections, including ventilator-associated pneumonia (VAP). Hand hygiene involves washing hands with soap and water or using an alcohol-based hand sanitizer before and after patient contact, after touching potentially contaminated surfaces, and before performing any aseptic procedures. This practice helps to reduce the transmission of pathogens that can cause infections in mechanically ventilated patients. Studies have shown that adherence to hand hygiene protocols significantly decreases the incidence of VAP and other healthcare-associated infections.

Choice B Reason: Suction the client at least every 2 hours

While suctioning is an important aspect of care for mechanically ventilated patients, routine suctioning every 2 hours is not recommended. Instead, suctioning should be performed based on the patient’s clinical condition and as needed. Over-suctioning can cause trauma to the airway and increase the risk of infection. Therefore, this choice is not included in the best practices for preventing VAP.

Choice C Reason: Administering antiulcer medication

Administering antiulcer medication is a recommended practice to prevent stress ulcers and gastrointestinal bleeding in mechanically ventilated patients. Stress ulcers can lead to complications such as aspiration of gastric contents, which can contribute to the development of VAP. Antiulcer medications, such as proton pump inhibitors or H2 receptor antagonists, help to reduce gastric acidity and the risk of ulcer formation. This practice is part of the comprehensive care plan to prevent VAP.

Choice D Reason: Providing oral care per protocol

Providing oral care per protocol is a critical component of VAP prevention. Oral care involves cleaning the patient’s mouth, teeth, and gums to reduce the colonization of harmful bacteria that can be aspirated into the lungs. Protocols for oral care typically include the use of antiseptic solutions, such as chlorhexidine, to disinfect the oral cavity. Regular oral care has been shown to significantly reduce the incidence of VAP in mechanically ventilated patients.

Choice E Reason: Elevating the head of the bed

Elevating the head of the bed to an angle of 30 to 45 degrees is a recommended practice to prevent VAP. This position helps to reduce the risk of aspiration of gastric contents into the lungs, which is a major risk factor for VAP. Elevating the head of the bed also promotes better lung expansion and ventilation, which can improve the patient’s respiratory status. This practice is widely recognized as an effective measure to prevent VAP.

Choice F Reason: Suctioning the client on a regular schedule

Similar to Choice B, routine suctioning on a regular schedule is not recommended. Suctioning should be performed based on the patient’s clinical needs and not on a fixed schedule. Over-suctioning can cause harm and increase the risk of infection. Therefore, this choice is not included in the best practices for preventing VAP.

Choice G Reason: Turning and positioning the client at least every 2 hours

Turning and positioning the client at least every 2 hours is an important practice to prevent complications such as pressure ulcers and to promote lung expansion. Regular repositioning helps to improve ventilation and drainage of secretions, reducing the risk of VAP. This practice is part of the standard care for mechanically ventilated patients to prevent various complications, including VAP.

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Correct Answer is D

Explanation

Choice A Reason:

Low oxygen saturation is not a common side effect of donepezil. Donepezil is a cholinesterase inhibitor used to treat symptoms of Alzheimer’s disease by increasing the levels of acetylcholine in the brain. While it can have various side effects, respiratory issues like low oxygen saturation are not typically associated with this medication. Therefore, monitoring for low oxygen saturation is not a primary concern for patients starting donepezil.

Choice B Reason:

High blood pressure is also not a common side effect of donepezil. The medication primarily affects the central nervous system and does not typically cause significant changes in blood pressure. While it is always important to monitor a patient’s overall health, high blood pressure is not a side effect specifically linked to donepezil use. Therefore, it is not a primary focus for monitoring in this context.

Choice C Reason:

Elevated body temperature is not commonly associated with donepezil. The side effects of donepezil are more likely to involve gastrointestinal issues such as nausea, vomiting, and diarrhea, as well as muscle cramps and fatigue. Elevated body temperature is not a typical reaction to this medication, so it is not a primary concern for monitoring.

Choice D Reason:

Low pulse rate, or bradycardia, is a known side effect of donepezil. Donepezil can increase the levels of acetylcholine, which can affect the heart’s electrical conduction system and lead to a slower heart rate. This can be particularly concerning in elderly patients or those with pre-existing heart conditions. Therefore, it is crucial for the nurse to teach the family to monitor the client’s pulse rate regularly and report any significant decreases to the healthcare provider.

A. Increased serum albumin B. Decreased serum bilirubin C. Decreased serum ammonia D. Decreased serum alanine aminotransferase (ALT)

Correct Answer is C

Explanation

Choice A Reason: Increased Serum Albumin

Increased serum albumin is not a direct indicator of the therapeutic effect of lactulose in patients with chronic hepatitis. Albumin is a protein made by the liver, and its levels can be affected by liver function. However, lactulose primarily works by reducing ammonia levels in the blood, not by increasing albumin levels. Normal serum albumin levels range from 3.5 to 5.5 grams per deciliter (g/dL). While improved liver function might eventually lead to increased albumin levels, this is not the primary therapeutic effect of lactulose.

Choice B Reason: Decreased Serum Bilirubin

Decreased serum bilirubin is also not a direct indicator of lactulose’s therapeutic effect. Bilirubin is a byproduct of the normal breakdown of red blood cells and is processed by the liver. Elevated bilirubin levels can indicate liver dysfunction, but lactulose’s main role is to reduce ammonia levels, not bilirubin. Normal serum bilirubin levels are typically between 0.1 to 1.2 milligrams per deciliter (mg/dL). While improved liver function might reduce bilirubin levels, this is not the primary goal of lactulose therapy.

Choice C Reason: Decreased Serum Ammonia

Decreased serum ammonia is the correct indicator of the therapeutic effect of lactulose in patients with chronic hepatitis. Lactulose is used to treat hepatic encephalopathy, a condition caused by high levels of ammonia in the blood due to liver dysfunction. Lactulose works by converting ammonia into ammonium, which is then excreted from the body. Normal serum ammonia levels are less than 50 micromoles per liter (µmol/L) in adults56. A decrease in serum ammonia levels indicates that lactulose is effectively reducing the toxic levels of ammonia in the blood, thereby achieving its desired therapeutic effect.

Choice D Reason: Decreased Serum Alanine Aminotransferase (ALT)

Decreased serum alanine aminotransferase (ALT) is not a direct indicator of lactulose’s therapeutic effect. ALT is an enzyme found in the liver that helps convert proteins into energy for liver cells. Elevated ALT levels can indicate liver damage. Normal ALT levels range from 7 to 56 units per liter (U/L). While improved liver function might reduce ALT levels, lactulose’s primary role is to reduce ammonia levels, not directly affect ALT.

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The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

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