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 C
Explanation
Choice A Reason:
Thirst is a common and expected symptom after an EGD, especially if the client has been fasting before the procedure. It does not typically indicate a complication and can be managed by gradually reintroducing fluids as tolerated. Therefore, thirst does not require further nursing assessment beyond routine post-procedure care.
Choice B Reason:
A sore throat is also a common symptom following an EGD. The procedure involves passing an endoscope through the throat, which can cause temporary irritation and discomfort. This symptom usually resolves on its own within a few days and does not indicate a serious complication. Therefore, a sore throat does not require further nursing assessment beyond providing comfort measures such as lozenges or warm saltwater gargles.
Choice C Reason:
Abdominal distention is a concerning symptom that requires further nursing assessment. It can indicate complications such as perforation, bleeding, or infection following the EGD. Perforation of the gastrointestinal tract is a rare but serious complication that can lead to peritonitis and sepsis if not promptly addressed. Therefore, any signs of abdominal distention should be reported to the provider immediately for further evaluation and intervention.
Choice D Reason:
Drowsiness is a common side effect of the sedatives used during the EGD procedure. It is expected that the client may feel drowsy or sleepy for a few hours after the procedure as the sedative wears off. This symptom does not typically require further nursing assessment unless it persists for an unusually long time or is accompanied by other concerning symptoms such as difficulty breathing or altered mental status.
Correct Answer is D
Explanation
Choice A: Rosebud-like Stoma Orifice
A rosebud-like stoma orifice is typically a normal appearance for a new stoma. The stoma should be moist, pink to red in color, and protrude slightly from the abdomen, resembling a rosebud. This appearance indicates good blood flow and proper healing. Therefore, this finding does not usually require immediate reporting to the provider.
Choice B: Stoma Oozing Red Drainage
While some minor bleeding or oozing can be normal immediately after surgery, persistent or significant red drainage from the stoma could indicate a complication such as infection or trauma to the stoma site. This finding should be monitored closely, but it is not as immediately concerning as a purplish-colored stoma, which indicates a more severe issue.
Choice C: Shiny, Moist Stoma
A shiny, moist stoma is a sign of a healthy stoma. The stoma should always appear moist and slightly shiny due to the mucus produced by the intestinal lining. This finding is normal and does not require reporting to the provider.
Choice D: Purplish-Colored Stoma
A purplish-colored stoma is an immediate concern and should be reported to the provider. This discoloration can indicate compromised blood flow to the stoma, which can lead to tissue necrosis if not addressed promptly. Ensuring adequate blood supply is crucial for the stoma’s viability and the patient’s overall health. Immediate medical intervention is necessary to prevent further complications.
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