Which actions should the nurse initiate to reduce the risk for ...

[savannahhooper]

Which actions should the nurse initiate to reduce the risk for ventilator-associated pneumonia (VAP) (select all that apply)?
 
  a. Obtain arterial blood gases daily.
  b. Provide a sedation holiday daily.
  c. Elevate the head of the bed to at least 30.
  d. Give prescribed pantoprazole (Protonix).
  e. Provide oral care with chlorhexidine (0.12) solution daily.

Question 2

During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient is breathing and has an unobstructed airway. Which action should the nurse take next?
 
  a. Palpate extremities for bilateral pulses.
  b. Observe the patient's respiratory effort.
  c. Check the patient's level of consciousness.
  d. Examine the patient for any external bleeding.

[bdobbins]

Answer to Question 1

ANS: B, C, D, E
All of these interventions are part of the ventilator bundle that is recommended to prevent VAP. Arterial blood gases may be done daily but are not always necessary and do not help prevent VAP.

Answer to Question 2

ANS: B
Even with a patent airway, patients can have other problems that compromise ventilation, so the next action is to assess the patient's breathing. The other actions are also part of the initial survey but assessment of breathing should be done immediately after assessing for airway patency.

[savannahhooper]

Gracias!

[at]

TYSM