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?

Choice A reason: Increasing the rate of IV fluid administration is not the priority action in this situation. Although maintaining adequate fluid levels is important for patients with traumatic brain injuries, the symptoms described (pulse change, increased pulse pressure, and respiratory irregularities) indicate that the patient may be experiencing increased intracranial pressure (ICP). Fluid administration alone will not address this issue and could potentially worsen the condition if not managed carefully.

Choice B reason: The priority action is to notify the provider immediately. The changes in vital signs (decreased pulse, increased pulse pressure, and respiratory irregularities) suggest that the patient may be experiencing increased intracranial pressure (ICP), which is a medical emergency. Immediate notification of the provider is essential for timely intervention to prevent further neurological damage or complications.

Choice C reason: Preparing to give IV pain medication is not the priority in this situation. While managing pain is important, the patient's vital sign changes indicate a more serious underlying issue (potential increased intracranial pressure) that requires immediate medical attention. Pain medication alone will not address the root cause of the symptoms.

Choice D reason: Notifying respiratory therapy for a breathing treatment is not the priority action in this scenario. Although respiratory irregularities are present, the vital sign changes suggest that the patient is experiencing increased intracranial pressure. This requires immediate medical intervention by the provider to manage the underlying condition, rather than solely focusing on respiratory support.

Choice A reason: Explaining that diarrhea is expected and that it is how the body gets rid of ammonia is accurate. Lactulose is often prescribed for patients with hepatic encephalopathy, and its purpose is to reduce blood ammonia levels by promoting bowel movements. Diarrhea is a common and anticipated side effect, as it helps eliminate ammonia from the body.

Choice B reason: Recommending Kaopectate for loose stools is not appropriate in this context. Kaopectate is an anti-diarrheal medication, and using it would counteract the effect of lactulose, which aims to promote bowel movements to reduce ammonia levels.

Choice C reason: Instructing the patient to stop taking the medication until stools firm up is incorrect. Lactulose should be continued as prescribed to maintain its therapeutic effect of reducing blood ammonia levels. Stopping the medication would negate its benefits and potentially worsen the patient's condition.

Choice D reason: Suggesting to send a stool specimen to the laboratory is unnecessary in this scenario. Diarrhea is an expected side effect of lactulose, and there is no indication that a stool specimen needs to be analyzed unless there are signs of infection or other complications.