The nurse is preparing to administer medication using a client’s nasogastric tube. Which actions should the nurse take before administering the medication? Select all that apply.

Choice A Reason: Adherence to proper hand hygiene

Proper hand hygiene is a fundamental practice in preventing infections, including ventilator-associated pneumonia (VAP). Hand hygiene involves washing hands with soap and water or using an alcohol-based hand sanitizer before and after patient contact, after touching potentially contaminated surfaces, and before performing any aseptic procedures. This practice helps to reduce the transmission of pathogens that can cause infections in mechanically ventilated patients. Studies have shown that adherence to hand hygiene protocols significantly decreases the incidence of VAP and other healthcare-associated infections.

Choice B Reason: Suction the client at least every 2 hours

While suctioning is an important aspect of care for mechanically ventilated patients, routine suctioning every 2 hours is not recommended. Instead, suctioning should be performed based on the patient’s clinical condition and as needed. Over-suctioning can cause trauma to the airway and increase the risk of infection. Therefore, this choice is not included in the best practices for preventing VAP.

Choice C Reason: Administering antiulcer medication

Administering antiulcer medication is a recommended practice to prevent stress ulcers and gastrointestinal bleeding in mechanically ventilated patients. Stress ulcers can lead to complications such as aspiration of gastric contents, which can contribute to the development of VAP. Antiulcer medications, such as proton pump inhibitors or H2 receptor antagonists, help to reduce gastric acidity and the risk of ulcer formation. This practice is part of the comprehensive care plan to prevent VAP.

Choice D Reason: Providing oral care per protocol

Providing oral care per protocol is a critical component of VAP prevention. Oral care involves cleaning the patient’s mouth, teeth, and gums to reduce the colonization of harmful bacteria that can be aspirated into the lungs. Protocols for oral care typically include the use of antiseptic solutions, such as chlorhexidine, to disinfect the oral cavity. Regular oral care has been shown to significantly reduce the incidence of VAP in mechanically ventilated patients.

Choice E Reason: Elevating the head of the bed

Elevating the head of the bed to an angle of 30 to 45 degrees is a recommended practice to prevent VAP. This position helps to reduce the risk of aspiration of gastric contents into the lungs, which is a major risk factor for VAP. Elevating the head of the bed also promotes better lung expansion and ventilation, which can improve the patient’s respiratory status. This practice is widely recognized as an effective measure to prevent VAP.

Choice F Reason: Suctioning the client on a regular schedule

Similar to Choice B, routine suctioning on a regular schedule is not recommended. Suctioning should be performed based on the patient’s clinical needs and not on a fixed schedule. Over-suctioning can cause harm and increase the risk of infection. Therefore, this choice is not included in the best practices for preventing VAP.

Choice G Reason: Turning and positioning the client at least every 2 hours

Turning and positioning the client at least every 2 hours is an important practice to prevent complications such as pressure ulcers and to promote lung expansion. Regular repositioning helps to improve ventilation and drainage of secretions, reducing the risk of VAP. This practice is part of the standard care for mechanically ventilated patients to prevent various complications, including VAP.

Choice A Reason:

Continuing to monitor is the most appropriate action in this scenario. The patient has a regular heart rhythm and a heart rate of 60 beats per minute, which is within the normal range for sinus bradycardia. The PR interval is 0.20 seconds, which is at the upper limit of normal. The patient’s vital signs are stable, with a blood pressure of 118/68 mm Hg, a respiratory rate of 16 breaths per minute, and a temperature of 98.8°F (37°C). There are no signs of hemodynamic instability or symptoms that would necessitate immediate intervention. Therefore, ongoing monitoring is sufficient to ensure the patient’s condition remains stable.

Choice B Reason:

Administering clonidine is not appropriate in this situation. Clonidine is an antihypertensive medication that can lower blood pressure and heart rate. Given that the patient’s blood pressure and heart rate are within normal ranges, administering clonidine could potentially cause hypotension and bradycardia, leading to adverse effects. Therefore, clonidine is not indicated for this patient.

Choice C Reason:

Administering atropine is not necessary for this patient. Atropine is used to treat symptomatic bradycardia, where the heart rate is abnormally slow and causing symptoms such as dizziness, hypotension, or syncope. In this case, the patient’s heart rate is 60 beats per minute, which is within the normal range for sinus bradycardia, and there are no symptoms indicating the need for atropine. Therefore, atropine is not required.

Choice D Reason:

Administering digoxin is also not appropriate. Digoxin is a cardiac glycoside used to treat heart failure and certain types of arrhythmias, such as atrial fibrillation. It can slow the heart rate and increase the force of cardiac contractions. In this scenario, the patient does not have any indications for digoxin therapy, such as heart failure or atrial fibrillation, and their heart rate is already within the normal range. Therefore, digoxin is not indicated.