The nurse caring for patients who are mechanically ventilated uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice?

Suctioning the patient on a regular schedule.

Adherence to proper hand hygiene.

Administering antiulcer medication.

Providing oral care per protocol.

Elevating the head of the bed.

Answer and Explanation

Correct Answer : B,D,E

Choice A reason:

Suctioning the patient on a regular schedule is not recommended as it can increase the risk of infection and trauma to the airway. Suctioning should be done as needed based on clinical assessment.

Choice B reason:

Adherence to proper hand hygiene is a fundamental practice in preventing infections, including ventilator-associated pneumonia. Hand hygiene helps prevent the transmission of pathogens.

Choice C reason:

Administering antiulcer medication is important for preventing stress ulcers but is not directly related to preventing ventilator-associated pneumonia.

Choice D reason:

Providing oral care per protocol is essential in reducing the risk of ventilator-associated pneumonia. Oral care helps decrease the bacterial load in the oropharynx and prevent aspiration of contaminated secretions.

Choice E reason:

Elevating the head of the bed to 30-45 degrees helps prevent aspiration of gastric contents and is a key practice in preventing ventilator-associated pneumonia.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason:

Providing small doses of opioid analgesia is important for pain management, but it is not the highest priority in a patient with a closed head injury on mechanical ventilation. Pain control should be balanced with the need to monitor neurological status.

Choice B reason:

Maintaining pCO2 of 35-45 is critical for patients with a closed head injury on mechanical ventilation. Proper pCO2 levels help manage intracranial pressure (ICP) and prevent secondary brain injury. Hyperventilation to lower pCO2 can reduce ICP but must be carefully controlled to avoid cerebral ischemia.

Choice C reason:

Administering an anti-anxiety agent can help manage agitation and anxiety, but it is not the highest priority. Sedation must be used cautiously in head injury patients to avoid masking changes in neurological status.

Choice D reason:

Monitoring blood pressure every four hours is necessary for overall patient care, but continuous monitoring and immediate interventions are more critical in managing intracranial pressure and preventing secondary brain injury.

A. Maintaining proper body positioning B. Preventing infection C. Maintaining adequate organ perfusion D. Avoiding the use of vasopressors

Correct Answer is C

Explanation

Choice A reason:

Maintaining proper body positioning is important for the overall care of a patient, but it is not the priority in the context of organ donation. The primary focus should be on ensuring the viability of the organs for transplantation.

Choice B reason:

Preventing infection is critical in any clinical setting, particularly in the care of an organ donor, as infections can compromise the quality of the organs. However, it is not the immediate priority action. The most crucial aspect is maintaining organ perfusion to ensure the organs remain viable for transplantation.

Choice C reason:

Maintaining adequate organ perfusion is the priority nursing action in caring for an organ donor. Adequate perfusion ensures that the organs receive sufficient blood flow and oxygen, which is essential for preserving their function until they can be transplanted. This action takes precedence over other considerations to ensure the success of the organ donation process.

Choice D reason:

Avoiding the use of vasopressors is important because they can impact organ perfusion and function. However, if necessary, vasopressors may be used to maintain adequate blood pressure and perfusion. The overall priority remains ensuring adequate perfusion to preserve organ function.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse caring for patients who are mechanically ventilated uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient with a closed head injury on mechanical ventilation. Which of the following actions is highest priority?

Correct Answer is B

Explanation

After brain death has been determined, which of the following is a priority nursing action in caring for an organ donor?

Correct Answer is C

Explanation

A patient is admitted to the emergency department with a spinal cord injury at the level of T2 following a traumatic fall from a roof. Which finding is of most concern to the nurse?

A nurse is caring for a patient who has a closed-head injury with ICP readings ranging from 16-22 mm Hg. What actions should the nurse take to decrease the potential for raising the client's ICP? Select all that apply.

The nurse caring for patients who are mechanically ventilated uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice?

A client with a spinal cord injury at the level C3 to C4 is being cared for by the nurse in the emergency department. What is the priority nursing action?

Why does the healthcare provider prescribe a ventilator setting to maintain partial pressure of arterial carbon dioxide (PaCO2) between 35 and 38 mmHg for a patient with traumatic brain injury?

A patient has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority?

A patient presents to the emergency department with signs of an epidural hematoma. Which manifestation is characteristic of this type of hematoma?

A charge nurse is reviewing the status of patients in the critical care unit. Which patient should the charge nurse notify the organ procurement team to evaluate for possible organ donation?