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","E","G"]

Explanation

A. Temperature (96.9°F / 36°C) – Mild hypothermia, but not immediately life-threatening; does not require immediate follow-up.

B. Bilirubin (6.2 mg/dL) – Significantly elevated and indicates worsening liver function, but this is expected in cirrhosis and does not require immediate action unless accompanied by signs of acute liver failure.

C. Blood pressure (82/58 mm Hg) – Requires immediate follow-up as this indicates hypotension, which can be due to complications like sepsis, hepatorenal syndrome, or third-spacing from ascites.

D. Scattered ecchymosis – Indicates coagulopathy, which is common in cirrhosis; important but not immediately life-threatening unless active bleeding is present.

E. Ammonia level (78 mcg/dL) – Requires immediate follow-up. This is markedly elevated and correlates with hepatic encephalopathy, especially in the presence of neurologic symptoms.

F. Abdominal girth increase – Suggests worsening ascites; needs management but not as urgent as hemodynamic instability or encephalopathy signs.

G. Asterixis (flapping tremor) – Requires immediate follow-up. This is a classic sign of hepatic encephalopathy, which can progress rapidly and lead to coma if untreated.

A. Decreased potassium B. Excessive thrombosis and bleeding C. Immediate sodium and fluid retention D. Progressive increase in platelet production

Correct Answer is B

Explanation

A. Decreased potassium is not a hallmark feature of DIC.
B. DIC is characterized by systemic activation of clotting pathways leading to widespread clot formation (thrombosis), which consumes platelets and clotting factors, ultimately resulting in excessive bleeding.
C. Sodium and fluid retention are not defining features of DIC.
D. Platelet production typically decreases or remains inadequate, not increases, due to consumption of platelets in widespread clotting.

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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

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has cirrhosis of the liver. Exhibits Which of the following assessment findings require immediate follow-up? Select all that apply.

Correct Answer is ["C","E","G"]

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Correct Answer is B

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