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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Tachycardia is an early compensatory sign of hypovolemic shock due to decreased circulating volume.
B. Increased temperature suggests infection or inflammation, not hypovolemic shock.
C. A slight decrease in urine output from 120 to 115 mL/hr is not significant; oliguria would be a more concerning sign.
D. A decrease in respiratory rate is not typical of hypovolemic shock, which usually causes tachypnea.
Correct Answer is B
Explanation
A. RBC count is typically not elevated in acute pancreatitis.
B. Amylase is an enzyme that increases in the blood during acute pancreatitis due to pancreatic inflammation and enzyme leakage.
C. Magnesium levels are not characteristically elevated.
D. Calcium levels are often decreased in acute pancreatitis due to fat saponification.
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