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 ["B","C","G"]
Explanation
Choice A Reason:
Breath sounds diminished on auscultation indicate that there may still be fluid or air in the pleural space, suggesting that the chest tube is still needed to drain the pleural cavity. This is not an appropriate reason to discontinue a chest tube as it indicates ongoing issues that need to be resolved.
Choice B Reason:
Improved respiratory status is a key indicator that the chest tube has successfully resolved the underlying issue, such as a pneumothorax or pleural effusion. When the patient shows signs of stable and improved breathing, it suggests that the chest tube has served its purpose and can be safely removed.
Choice C Reason:
Symmetrical rise and fall of the chest during respiration indicate that both lungs are expanding and contracting normally. This symmetry is a sign that the pleural space is no longer compromised, making it an appropriate reason to remove the chest tube.
Choice D Reason:
Oxygen saturation at least 90% is a general indicator of adequate oxygenation but does not specifically address the condition of the pleural space. While important, it is not a direct reason to discontinue a chest tube without other supporting signs.
Choice E Reason:
Continuous bubbling in the water seal chamber indicates an ongoing air leak, which means that the chest tube is still necessary to evacuate air from the pleural space. This is not an appropriate reason to remove the chest tube.
Choice F Reason:
An asymmetrical chest on inspiration and expiration suggests that there is still an issue with lung expansion, possibly due to fluid or air in the pleural space. This condition requires the chest tube to remain in place until resolved.
Choice G Reason:
Bilateral breath sounds clear on auscultation indicate that both lungs are free of fluid and air, and are functioning normally. This is a strong indicator that the chest tube has achieved its purpose and can be safely removed.
Correct Answer is C
Explanation
Choice A: Severe Hypertension
Severe hypertension can be a sign of increased intracranial pressure (ICP), but it is not typically the earliest sign. Hypertension often occurs as a compensatory mechanism to maintain cerebral perfusion pressure. While it is a significant finding, it usually follows other more immediate signs of increased ICP.
Choice B: Dilated and Nonreactive Pupils
Dilated and nonreactive pupils are a late sign of increased ICP and indicate severe brainstem compression. This finding suggests that the pressure has reached a critical level, leading to brain herniation. It is a very serious sign but not the earliest indicator of increasing ICP.
Choice C: Decreased Level of Consciousness
A decreased level of consciousness is often the earliest and most sensitive indicator of increasing ICP. Changes in consciousness can range from confusion and lethargy to complete unresponsiveness. This symptom reflects the brain’s response to increased pressure and reduced cerebral perfusion, making it a critical early sign that requires immediate attention.
Choice D: Projectile Vomiting
Projectile vomiting can occur with increased ICP due to pressure on the vomiting centers in the brainstem. However, it is not typically the earliest sign. Vomiting often accompanies other symptoms such as headache and changes in consciousness.
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