nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take to reduce the risk of ventilator-associated pneumonia?

Assess ventilator settings every 48 hours.

Position the head of the client's bed in the flat position.

Brush the client's teeth with a suction toothbrush routinely and as needed.

Turn the client every 8 hours.

Answer and Explanation

The Correct Answer is C

A. Ventilator settings should be assessed frequently, not just every 48 hours.
B. The head of the bed should be elevated (30–45 degrees), not flat, to reduce aspiration risk.
C. Maintaining oral hygiene reduces the risk of ventilator-associated pneumonia by minimizing bacterial colonization.
D. Turning the client more frequently than every 8 hours (typically every 2 hours) is standard to prevent complications but is less directly related to preventing ventilator-associated pneumonia compared to oral care.

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Correct Answer is A

Explanation

A. Keeping the collection device below the level of the client’s chest prevents backflow of drainage into the pleural space.
B. The client should be positioned to promote lung expansion, often sitting up, not necessarily flat.
C. Clamping the chest tube is generally avoided as it can cause tension pneumothorax or other complications.
D. Tubing should be kept straight without coiling to prevent kinking and obstruction.

A. Pacemaker B. Alcohol use disorder C. Breast cancer survivor for 8 years D. 65-years of age

Correct Answer is B

Explanation

A. Having a pacemaker is not an absolute contraindication for kidney transplant, though it requires careful evaluation.
B. Active substance abuse, including alcohol use disorder, is generally considered a contraindication for kidney transplantation due to concerns about adherence to medical regimens and potential for complications.
C. Being a breast cancer survivor for 8 years is usually not a contraindication if the client has been cancer-free for a significant period and is deemed stable.
D. Age 65 years is not an absolute contraindication; many older adults can be candidates for transplant based on overall health status rather than age alone.

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nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take to reduce the risk of ventilator-associated pneumonia?

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