Which of the following clients should the nurse identify as being at increased risk for developing ventilator-associated pneumonia (VAP)? Select all that apply.

A client who is postoperative and has received local anesthesia

A massive stroke client who has dysphagia

A client who has myasthenia gravis

A client who has AIDS

A client who has a closed head injury and is receiving mechanical ventilation

A client who was vaccinated for pneumococcus and influenza 6 months ago

Answer and Explanation

Correct Answer : B,C,D,E

Ventilator-associated pneumonia (VAP) is a hospital-acquired infection that develops in patients who are mechanically ventilated for more than 48 hours. It occurs due to impaired airway defenses, aspiration of contaminated secretions, and colonization of the respiratory tract. Risk increases in clients with reduced level of consciousness, impaired swallowing, neuromuscular weakness, immunosuppression, and prolonged ventilation. Identifying high-risk patients is essential for implementing preventive measures such as oral care, elevation of the head of the bed, and suctioning protocols.

Rationale:
A. A postoperative client who has received local anesthesia is not at increased risk for ventilator-associated pneumonia because they are not typically mechanically ventilated or experiencing impaired airway protective reflexes. Local anesthesia does not significantly affect consciousness or swallowing ability, so aspiration risk remains low compared to ventilated or neurologically impaired patients.

B. A massive stroke client with dysphagia is at high risk for VAP due to impaired swallowing and reduced gag reflex. These deficits increase the likelihood of aspiration of oral or gastric contents into the lungs, which can lead to infection, especially if the client is intubated or requires mechanical ventilation.

C. A client with myasthenia gravis is at increased risk because neuromuscular weakness can impair respiratory muscle function and cough effectiveness. This condition often leads to respiratory failure requiring mechanical ventilation, which significantly increases the risk of ventilator-associated pneumonia due to secretion retention and impaired airway clearance.

D. A client with AIDS is at increased risk due to immunosuppression, which reduces the body’s ability to fight respiratory infections. Opportunistic pathogens can more easily colonize the respiratory tract, especially in ventilated patients, making VAP more likely and more severe in this population.

E. A client with a closed head injury receiving mechanical ventilation is at high risk because of reduced consciousness, impaired cough reflex, and prolonged ventilator dependence. These factors promote aspiration and bacterial colonization of the lower respiratory tract, significantly increasing the likelihood of developing VAP.

F. A client vaccinated for pneumococcus and influenza 6 months ago is not specifically at increased risk for VAP due to vaccination status. While vaccines help prevent certain respiratory infections, they do not eliminate the risk of hospital-acquired infections related to mechanical ventilation and airway management.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

Angina occurs due to myocardial ischemia from reduced coronary blood flow, but the pattern, triggers, and response to rest or medication help distinguish its severity. Stable angina is predictable and relieved with rest, while unstable angina is more dangerous, occurs unpredictably (often at rest), and is part of acute coronary syndrome. Recognizing unstable angina is critical because it can progress to myocardial infarction.

Rationale:

• Chest pain that occurs at rest and increases in severity and duration over time: Pain at rest with increasing frequency and intensity is a hallmark of unstable angina. It indicates worsening coronary artery obstruction and reduced myocardial oxygen supply. This pattern reflects acute coronary syndrome and is not predictable or activity-related. It requires urgent evaluation due to high risk of infarction.

• Chest pain triggered by physical activity and relieved by rest or nitroglycerin: Stable angina is caused by predictable myocardial oxygen demand during exertion. It occurs with activity and resolves with rest or nitroglycerin, which improves coronary perfusion. The pattern is consistent over time and does not typically worsen rapidly. This makes it distinguishable from unstable angina.

• Pain typically resolves within minutes and does not require emergent medical attention: Stable angina episodes are brief and self-limiting once the triggering activity stops. The pain usually lasts only a few minutes and is relieved by rest or medication. It does not represent immediate myocardial injury. Therefore, it is not considered an emergency condition.

• May progress to myocardial infarction if not treated promptly: Unstable angina reflects plaque rupture and partial coronary artery occlusion, placing the client at high risk for complete blockage. Without treatment, it can rapidly progress to myocardial infarction. It is considered a medical emergency within the spectrum of acute coronary syndrome. Early recognition and intervention are essential to prevent myocardial damage.

A. WBC count of 1,800 mm3 B. WBC count of 3,500 mm3 C. Hemoglobin level of 11.5 g/dL D. Platelet count of 150,000 mm3

Correct Answer is D

Explanation

Bone marrow suppression leads to decreased production of blood cells, resulting in leukopenia, anemia, and thrombocytopenia depending on the affected cell line. Oprelvekin is a hematopoietic growth factor primarily used to stimulate platelet production in clients with chemotherapy-induced thrombocytopenia. It acts on bone marrow megakaryocyte progenitor cells to increase platelet formation and reduce bleeding risk. Improvement in therapy is best reflected by rising platelet counts toward the normal range.

Rationale:
A. A WBC count of 1,800 mm³ remains significantly below the normal range and indicates ongoing leukopenia. This level suggests continued bone marrow suppression and increased risk for infection. It does not reflect improvement in hematopoietic function or response to therapy.

B. A WBC count of 3,500 mm³, while improved compared to severe leukopenia, is still below the normal range (typically 4,000–11,000 mm³). Although it may suggest partial recovery of white blood cell production, oprelvekin does not primarily target WBC production. Therefore, this is not the best indicator of therapeutic response.

C. A hemoglobin level of 11.5 g/dL reflects mild anemia but is not directly related to the action of oprelvekin. This medication does not primarily stimulate red blood cell production but instead targets megakaryocyte proliferation. Hemoglobin improvement would be more relevant to erythropoietin therapy rather than oprelvekin.

D. A platelet count of 150,000 mm³ indicates improvement into the lower limit of the normal range (150,000–450,000 mm³). This reflects effective stimulation of megakaryocyte activity by oprelvekin and improved bone marrow recovery. Since the drug is specifically used to increase platelet production, this value best demonstrates therapeutic effectiveness.

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Which of the following clients should the nurse identify as being at increased risk for developing ventilator-associated pneumonia (VAP)? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

A nurse is reviewing the laboratory values of a client with bone marrow suppression and is receiving Oprelvekin. Which of the following values would indicate an improvement in the client's condition?

Correct Answer is D

Explanation

A client on mechanical ventilation has a high pressure alarm triggered. Which of the following actions should the nurse prioritize to address this alarm?

A nurse is caring for a client with pneumonia who is on mechanical ventilation and exhibits a respiratory rate of 34 breaths per minute. The client's ABG results show a pH of 7.5, PaCO2 of 28 mm Hg, and HCO3 of 22 mEq/L. Which nursing action should be prioritized?

A client with a tracheostomy tube requires suctioning to clear secretions. Which of the following actions should a nurse prioritize to ensure the client's safety and effective airway clearance during the suctioning process?

A nurse is assessing a client who has been prescribed lactulose for the management of hepatic encephalopathy. Which of the following statements by the client about the effects of lactulose indicates that the nurse must provide further education?

A nurse is reviewing the laboratory values of a client with bone marrow suppression and is receiving filgrastim. Which of the following values would indicate an improvement in the client's condition?

When initiating oxygen therapy for a client with respiratory failure and monitoring their response, which assessment finding would most warrant immediate intervention?

A client with portal hypertension develops bleeding esophageal varices. Which intervention should the nurse prioritize to prevent further complications?