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Which statement is true regarding oral care for the prevention of ventilator-associated pneumonia (VAP)? (Select all that apply.)
- A. Tooth brushing is performed every 2 hours for the greatest effect.
- B. Implementing a comprehensive oral care program is an intervention for preventing WWW .THENURSINGMASTERY.COM VAP.
- C. Oral care protocols should include oral suctioning and brushing teeth.
- D. Protocols that include chlorhexidine gluconate have beaebnirb e.cfofme/ctetsivt e in preventing VAP.
Correct Answer: B
Rationale: The correct answer is B. Implementing a comprehensive oral care program is an intervention for preventing VAP. This statement is true because proper oral care, including brushing teeth, oral suctioning, and using chlorhexidine gluconate, has been shown to reduce the risk of VAP by decreasing the colonization of pathogenic bacteria in the oral cavity. Regular oral care helps maintain oral hygiene and reduce the risk of aspiration of bacteria into the lungs, which is a common cause of VAP.
Incorrect Answer Analysis:
A: Tooth brushing every 2 hours may be excessive and could potentially cause harm to the oral mucosa, leading to increased risk of infection.
C: While oral suctioning and brushing teeth are important components of oral care, the statement is not comprehensive enough to address the full range of interventions needed to prevent VAP.
D: While chlorhexidine gluconate can be effective in preventing VAP, the statement implies that it is the only effective intervention, which is not true.
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The critical care unit environment is very stressful for patients, families, and staff. What nursing action is directed at reducing environmental stress?
- A. Constant expert evaluation of patient status
- B. Limiting visits to immediate family
- C. Bathing all patients during hours of sleep
- D. Maintaining a quiet environment during hours of sleep
Correct Answer: D
Rationale: The correct answer is D: Maintaining a quiet environment during hours of sleep. This action is directed at reducing environmental stress in the critical care unit because noise and disturbances during sleep can negatively impact patients' rest and recovery. By ensuring a quiet environment, patients can have uninterrupted sleep, which is crucial for healing.
Rationale:
1. Constant expert evaluation of patient status (A) may be important but does not directly address environmental stress.
2. Limiting visits to immediate family (B) may hinder patients' emotional support and can be stressful for families.
3. Bathing all patients during hours of sleep (C) may disrupt patients' rest and increase stress levels rather than reduce it.
The nurse caring for a patient diagnosed with acute respiratory failure identifies “Risk for Ineffective Airway Clearance” as a nursing diagnosis. Wh at nursing intervention is relevant to this diagnosis?
- A. Elevate head of bed to 30 degrees.
- B. Obtain order for venous thromboembolism prophylaxi s.
- C. Provide adequate sedation.
- D. Reposition patient every 2 hours.
Correct Answer: A
Rationale: The correct answer is A: Elevate head of bed to 30 degrees. Elevating the head of the bed helps promote optimal airway clearance by facilitating drainage of secretions and reducing the risk of aspiration. This position also improves lung expansion and oxygenation. Choice B is important for preventing venous thromboembolism but not directly related to airway clearance. Choice C may not be appropriate as excessive sedation can impair airway clearance. Choice D is important for preventing pressure ulcers but does not directly address airway clearance.
Peritoneal dialysis is different from hemodialysis in that peritoneal dialysis
- A. is more frequently used for acute kidney injury.
- B. uses the patient’s own semipermeable membrane (peritoneal membrane).
- C. is not useful in cases of drug overdose or electrolyte imbalance.
- D. is not indicated in cases of water intoxication.
Correct Answer: B
Rationale: The correct answer is B because peritoneal dialysis utilizes the patient's own semipermeable membrane, the peritoneal membrane, as the filtration surface. This allows for the exchange of waste products and excess fluids without the need for external dialysis equipment. Choice A is incorrect as peritoneal dialysis can be used for both acute and chronic kidney injury. Choice C is incorrect as peritoneal dialysis can help manage drug overdose and electrolyte imbalances. Choice D is incorrect as peritoneal dialysis can be used in cases of water intoxication to help remove excess fluids.
Family members are in the patient’s room when the patient has a cardiac arrest and the staff starts resuscitation measures. Which action should the nurse take next?
- A. Keep the family in the room and assign a staff member to explain the care given and answer questions.
- B. Ask the family to wait outside the patient’s room with a designated staff member to provide emotional support.
- C. Ask the family members whether they would prefer to remain in the patient’s room or wait outside the room.
- D. Tell the family members that patients are comforted by having family members present during resuscitation efforts.
Correct Answer: C
Rationale: The correct answer is C because it involves patient-centered care and respects the family's preferences. By asking the family members whether they would prefer to remain in the patient's room or wait outside, the nurse acknowledges their needs and allows them to make an informed decision based on their comfort level. This empowers the family members and promotes a supportive environment during a stressful situation.
Choice A is incorrect because it assumes that keeping the family in the room without their input is the best approach, which may not be the case for all families. Choice B is incorrect because asking the family to wait outside without considering their preferences may not be the most supportive action. Choice D is incorrect because it makes a blanket statement about patient comfort without considering individual family dynamics and preferences.
The nurse is assessing an older client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding?
- A. A nystagmus on the left.
- B. Exophthalmos on the right.
- C. Ptosis on the left eyelid.
- D. Astigmatism on the right.
Correct Answer: C
Rationale: The correct answer is C: Ptosis on the left eyelid. Ptosis refers to drooping of the eyelid, which is a common condition in older adults. In this scenario, the nurse should document the finding as ptosis on the left eyelid because the client's left upper eyelid is drooping, covering more of the iris than the right eyelid.
Explanation: Nystagmus (A) is an involuntary eye movement, not related to eyelid drooping. Exophthalmos (B) is the protrusion of the eyeball and not relevant to this scenario. Astigmatism (D) refers to a refractive error of the eye and does not cause eyelid drooping. Therefore, the correct choice is C as it accurately describes the client's condition.