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 D

Explanation

Choice A reason: An epidural hematoma is a type of traumatic brain injury where blood accumulates between the dura mater and the skull. While it can cause severe symptoms, including headache, loss of consciousness, and neurological deficits, it does not typically present with ecchymosis behind the ears (Battle's sign) or bleeding from the ears. These signs are more indicative of a basilar skull fracture.

Choice B reason: An ischemic stroke occurs when a blood clot blocks or narrows an artery leading to the brain, causing reduced blood flow and oxygen to the brain tissue. Symptoms of an ischemic stroke include sudden weakness, numbness, difficulty speaking, and vision problems. However, it does not cause ecchymosis behind the ears or bleeding from the ears, which are specific signs of a basilar skull fracture.

Choice C reason: A subarachnoid hemorrhage is bleeding into the space between the brain and the tissue covering the brain (subarachnoid space). It often presents with a sudden, severe headache, nausea, vomiting, and loss of consciousness. While it is a serious condition, it does not typically cause ecchymosis behind the ears or bleeding from the ears.

Choice D reason: A basilar skull fracture is

The correct answer. This type of fracture involves the base of the skull and can cause characteristic signs such as ecchymosis behind the ears (Battle's sign) and bleeding from the ears due to the proximity of the fracture to the auditory canal and other structures. These symptoms are key indicators of a basilar skull fracture and require immediate medical attention.

A. Provide at least 5000 kcal/day. B. Start an oral diet on the first day. C. Administer a diet high in protein. D. Collaborate with a registered dietitian. E. Offer frequent high-calorie snacks.

Correct Answer is ["A","C","D","E"]

Explanation

Choice A reason: Providing at least 5000 kcal/day is essential for a patient with burn injuries. Burns significantly increase the body's metabolic rate and caloric needs to support the healing process and prevent catabolism. Ensuring an adequate caloric intake helps meet the energy demands required for tissue repair and recovery.

Choice B reason: Starting an oral diet on the first day may not be appropriate for all burn patients, particularly those with extensive burns or those who are not yet stable. Nutrition needs should be carefully assessed, and feeding may begin via alternative methods such as enteral nutrition until the patient is ready for oral intake.

Choice C reason: Administering a diet high in protein is crucial for burn patients, as protein is essential for wound healing, maintaining lean body mass, and supporting the immune system. Protein intake should be increased to help repair damaged tissues and promote recovery.

Choice D reason: Collaborating with a registered dietitian is important to create an individualized nutrition plan that meets the specific needs of the burn patient. A dietitian can provide expertise in calculating caloric and protein requirements, recommending appropriate supplements, and monitoring the patient's nutritional status.

Choice E reason: Offering frequent high-calorie snacks helps ensure that the patient meets their increased caloric needs. Small, frequent meals and snacks can be more manageable for patients with reduced appetite or those who have difficulty consuming large meals. High-calorie snacks provide additional energy to support healing and recovery.

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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

Naxlex Comprehensive Predictor Exams

What condition does the nurse suspect when a patient involved in a motor vehicle accident arrives at the emergency department with ecchymosis behind the ears and bleeding from the ears?

Correct Answer is D

Explanation

A nurse plans care for a patient with burn injuries. Which interventions would the nurse include in this patient's plan of care to ensure adequate nutrition? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

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