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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: He is NPO until the speech-language pathologist performs a swallowing evaluation.
This is the most appropriate response. NPO stands for “nil per os,” which means nothing by mouth. After a stroke, it is crucial to assess the patient’s ability to swallow safely to prevent aspiration, which can lead to pneumonia and other complications. A speech-language pathologist is trained to evaluate swallowing function and determine the safest diet for the patient. Until this evaluation is completed, the patient should not consume any food or liquids.
Choice B: Be sure to sit him up when you are feeding him to make him feel more natural.
While sitting the patient up during feeding is important to reduce the risk of aspiration, it is not sufficient on its own. Without a proper swallowing evaluation, feeding the patient could still pose significant risks. Therefore, this choice is not the most appropriate response.
Choice C: You may give him a full-liquid diet, but please avoid solid foods until he gets stronger.
A full-liquid diet might seem like a safer option, but without a swallowing evaluation, there is still a risk of aspiration. The patient’s ability to handle even liquids needs to be assessed by a professional before any oral intake is allowed.
Choice D: Just be sure to add some thickener in his liquids to prevent choking and aspiration.
Thickening liquids can help manage dysphagia, but this should only be done after a swallowing evaluation has determined the appropriate consistency. Administering thickened liquids without an evaluation could still result in aspiration if the patient has severe swallowing difficulties.
Correct Answer is D
Explanation
Choice A reason: No change to the heparin rate is not appropriate in this scenario. The normal range for PTT is generally between 25 to 35 seconds. However, for a client on heparin therapy, the target PTT is typically 1.5 to 2.5 times the normal range, which would be approximately 60 to 80 seconds. Since the client’s PTT is only 25 seconds, it indicates that the blood is clotting too quickly, and the heparin dose is insufficient.
Choice B reason: Decreasing the heparin rate would further reduce the anticoagulant effect, which is not advisable given the current PTT of 25 seconds. Lowering the heparin rate could increase the risk of thrombus formation and worsen the deep vein thrombosis (DVT) condition.
Choice C reason: Stopping heparin and starting warfarin is not an immediate solution. Warfarin takes several days to achieve its full anticoagulant effect, and during this transition period, the client would be at risk of clot formation. Heparin provides immediate anticoagulation, which is crucial in the acute management of DVT.
Choice D reason: Increasing the heparin rate is the correct action. The current PTT of 25 seconds is below the therapeutic range for a client on heparin therapy. Increasing the heparin rate will help achieve the desired anticoagulant effect, prolonging the PTT to the target range of 60 to 80 seconds.
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