The nurse is caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotracheal tube. To prevent ventilator-associated pneumonia (VAP), which action is most important to include in the plan of care?

Keep the head of the bed elevated at least 30 degrees.

Administer ordered antibiotics as scheduled.

Hyperoxygenate the patient before suctioning.

Suction the airway every 2 hours.

Answer and Explanation

The Correct Answer is A

Choice A reason: Keeping the head of the bed elevated at least 30 degrees is crucial in preventing ventilator-associated pneumonia (VAP). Elevating the head of the bed reduces the risk of aspiration of gastric contents and oral secretions into the lungs, which can lead to infection. This positioning helps improve lung expansion and facilitates drainage, thereby decreasing the likelihood of VAP.

Choice B reason: Administering ordered antibiotics as scheduled is important for treating existing infections but is not a primary preventive measure for ventilator-associated pneumonia. While antibiotics play a role in managing infections, the focus here is on preventive strategies. Overreliance on antibiotics can also lead to antibiotic resistance, making infection control more challenging.

Choice C reason: Hyperoxygenating the patient before suctioning is a standard practice to prevent hypoxia during the procedure, but it is not directly related to preventing ventilator-associated pneumonia. While hyperoxygenation helps maintain adequate oxygen levels, it does not address the specific risk factors associated with the development of VAP.

Choice D reason: Suctioning the airway every 2 hours may be necessary for some patients to maintain airway patency and remove secretions. However, routine suctioning at fixed intervals is not always appropriate and can increase the risk of trauma to the airway and infection. Suctioning should be performed based on clinical assessment and the patient's needs rather than a fixed schedule to prevent complications and potential infections.

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Correct Answer is A

Explanation

Choice A reason: Carbon monoxide poisoning can cause the skin, particularly the face, to appear cherry-red. This occurs because carbon monoxide binds with hemoglobin in the blood, forming carboxyhemoglobin, which gives the skin this distinct color. It is a critical condition that requires immediate intervention as carbon monoxide displaces oxygen in the blood, leading to hypoxia and potentially life-threatening complications.

Choice B reason: Smoke inhalation is a common issue in burn victims and can cause respiratory distress, coughing, and airway irritation. However, it does not typically cause the face to turn a cherry-red color. The primary concerns with smoke inhalation are airway obstruction and lung damage rather than changes in skin color.

Choice C reason: Uremic poisoning, or uremia, results from severe kidney dysfunction and the accumulation of waste products in the blood. Symptoms can include fatigue, confusion, and a metallic taste in the mouth, but it does not cause a cherry-red discoloration of the face.

Choice D reason: Acute anemic hypertension is not a recognized medical condition. Anemia can cause pallor or a pale appearance of the skin, while hypertension typically does not cause skin discoloration. Therefore, this choice is not relevant to the described symptoms.

A. I must stop halfway up the stairs to catch my breath. B. I am awakened by the need to urinate at night. C. I have been drinking more water than usual. D. I have experienced blurred vision on several occasions.

Correct Answer is A

Explanation

Choice A reason: The statement "I must stop halfway up the stairs to catch my breath" is a significant indicator of left-sided heart failure. Left-sided heart failure leads to pulmonary congestion, resulting in symptoms such as shortness of breath, especially during physical activities. This occurs because the heart is unable to effectively pump blood to the body, causing fluid buildup in the lungs and leading to exertional dyspnea.

Choice B reason: The statement "I am awakened by the need to urinate at night" refers to nocturia, which can be associated with heart failure but is not as specific to left-sided heart failure as exertional dyspnea. Nocturia can occur due to fluid redistribution when lying down, but it is not a definitive sign of left-sided heart failure alone.

Choice C reason: The statement "I have been drinking more water than usual" is not directly related to left-sided heart failure. Increased water intake could be indicative of other conditions such as diabetes or dehydration, but it is not a specific symptom of left-sided heart failure.

Choice D reason: The statement "I have experienced blurred vision on several occasions" is not typically associated with left-sided heart failure. Blurred vision can result from various causes, including visual disturbances, blood pressure changes, or other medical conditions, but it is not a hallmark symptom of left-sided heart failure.

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The nurse is caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotracheal tube. To prevent ventilator-associated pneumonia (VAP), which action is most important to include in the plan of care?

Nursing Test Bank

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A nurse in the emergency room is performing an assessment on a burn victim. She notes his face is a cherry-red color and suspects which of the following problems?

Correct Answer is A

Explanation

A nurse assesses a patient in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure?

Correct Answer is A

Explanation

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