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 C

Explanation

A. Weight loss is not a typical sign of organ rejection.
B. Insomnia is not a common manifestation of rejection.
C. Oliguria (decreased urine output) can indicate kidney transplant rejection due to impaired kidney function.
D. A normal or low temperature is not indicative of rejection; fever would be more concerning.

A. take? B. Keep the collection device below the level of the client's chest. C. Lay the client flat to avoid leaks in the tubing. D. Clamp the tube when the client is ambulating... E. Coil the tubes carefully to prevent kinking.

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.

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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?

Nursing Test Bank

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