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
Administering a prescribed proton pump inhibitor
Elevating the head of the bed
Providing oral care per protocol
Suctioning the client every hour
Turning and positioning the client at least every 2 hours
Correct Answer : A,C,D,F
A. Adherence to proper hand hygiene is correct because hand hygiene is one of the most effective measures to prevent healthcare-associated infections, including ventilator-associated pneumonia (VAP). Proper handwashing or use of alcohol-based sanitizer before and after patient contact reduces transmission of pathogens.
B. Administering a prescribed proton pump inhibitor is incorrect because proton pump inhibitors (PPIs) reduce stomach acidity, which can actually increase the risk of VAP by allowing colonization of the gastrointestinal tract with pathogenic bacteria that can be aspirated into the lungs.
C. Elevating the head of the bed is correct because keeping the head of the bed elevated at 30–45° reduces the risk of aspiration of gastric contents, a major contributor to VAP.
D. Providing oral care per protocol is correct because oral hygiene with antiseptic solutions (e.g., chlorhexidine) decreases colonization of pathogenic bacteria in the oropharynx, lowering the risk of ventilator-associated pneumonia.
E. Suctioning the client every hour is incorrect because routine or frequent suctioning is not recommended and can increase trauma or introduce infection. Suctioning should be performed as needed based on assessment of secretions.
F. Turning and positioning the client at least every 2 hours is correct because frequent repositioning helps mobilize secretions, prevent pooling of fluids, and reduce the risk of atelectasis and infection, which can contribute to VAP.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Scene safety is the first principle in trauma care. Healthcare providers must ensure that the environment is safe for themselves, the patient, and bystandersbefore initiating care. Hazards may include traffic, fire, electrical lines, unstable structures, or exposure to infectious materials. Protecting the responders prevents further injuries and ensures effective patient care.
B. Trauma care often involves high exposure risk to blood and body fluids, making standard precautions and personal protective equipment (PPE) essential. Minimizing risk is important, but it is incorrect to state the risk is low.
C. Emergency responders frequently face multiple hazards, including environmental, chemical, biological, and physical dangers. Assuming minimal hazards can lead to injury or compromised patient care.
D. Scrubs and a lab jacket do not provide adequate protectionin trauma settings. PPE such as gloves, gown, face shield, mask, and sometimes helmets or high-visibility clothingmay be required depending on the scene.
Correct Answer is ["C","D","E"]
Explanation
A. While fever is a common symptom, it is usually a secondary complaint or part of an underlying conditionrather than a primary reason for emergency department (ED) visits. Patients with fever alone often seek primary care unless it is associated with severe infection or sepsis.
B. Headaches are common in the general population, but only severe or acute-onset headachesare typical ED presentations. Routine or mild headaches are usually managed in outpatient settings.
C. Poisonings, overdoses, and exposure to toxic substances are urgent issues that require immediate assessment and interventionin the ED. These cases frequently demand rapid evaluation, monitoring, and sometimes antidote administration.
D. Chest pain is a common and critical complaint in the EDbecause it may indicate life-threatening conditions such as myocardial infarction, pulmonary embolism, or aortic dissection. It is prioritized for immediate assessment and intervention.
E. Abdominal pain is one of the most frequent reasons for ED visits, ranging from minor issues to surgical emergencies such as appendicitis, bowel obstruction, or perforated ulcers. Prompt evaluation is essential to identify life-threatening conditions.
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