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.

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Correct Answer is D

Explanation

Choice A reason:

Administering fluids is important for maintaining hemodynamic stability, but it is not the immediate priority for a patient with compromised respiration and low oxygen saturation.

Choice B reason:

Giving pain medications is necessary for patient comfort but is not the priority in a situation where the patient's respiratory status is severely compromised.

Choice C reason:

Preparing the patient for a CT scan can help assess internal injuries but is not the immediate priority when the patient is cyanotic and has low oxygen saturation. Immediate respiratory support is required first.

Choice D reason:

Preparing to assist with intubation is the priority action. The patient's oxygen saturation is critically low, and the chest wall is not moving normally, indicating potential respiratory failure. Intubation and mechanical ventilation are necessary to secure the airway and provide adequate oxygenation.

A. Lower levels of arterial carbon dioxide facilitate brain oxygenation. B. Carbon dioxide is a waste product that must be eliminated from the body. C. Carbon dioxide is a vasodilator that can cause increased intracranial pressure. D. Lower levels of arterial carbon dioxide (PaCO2) are essential for gas exchange.

Correct Answer is C

Explanation

Choice A reason:

Lower levels of arterial carbon dioxide do not directly facilitate brain oxygenation. While maintaining appropriate CO2 levels is important for overall respiratory function, the primary reason for targeting a specific PaCO2 range in traumatic brain injury is related to intracranial pressure control.

Choice B reason:

Although carbon dioxide is indeed a waste product that must be eliminated from the body, this statement does not explain why specific PaCO2 levels are targeted in the context of traumatic brain injury. The primary concern is the impact of CO2 on intracranial pressure.

Choice C reason:

Carbon dioxide is a potent vasodilator, and elevated levels can lead to increased intracranial pressure (ICP). By maintaining PaCO2 within a range of 35-38 mmHg, the healthcare provider aims to prevent hypercapnia and the resulting vasodilation, which can exacerbate intracranial hypertension in patients with traumatic brain injury.

Choice D reason:

Lower levels of arterial carbon dioxide are not specifically essential for gas exchange. The primary concern with PaCO2 management in traumatic brain injury is controlling intracranial pressure, rather than optimizing gas exchange alone.

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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 patient is brought to the emergency department after sustaining injuries in a severe car crash. The patient's chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the patient is cyanotic. What action by the nurse is the priority?

Correct Answer is D

Explanation

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?

Correct Answer is C

Explanation

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