Author Question: The nurse caring for mechanically ventilated clients uses best practices to prevent ... (Read 119 times)

faduma · **on:** Jun 25, 2018

The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.)

a. Adherence to proper hand hygiene
b. Administering anti-ulcer medication
c. Elevating the head of the bed
d. Providing oral care per protocol
e. Suctioning the client on a regular schedule

Question 2

A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.)

a. Client who had a reaction to contrast dye yesterday
b. Client with a new spinal cord injury on a rotating bed
c. Middle-aged man with an exacerbation of asthma
d. Older client who is 1-day post hip replacement surgery
e. Young obese client with a fractured femur

Ptupou85 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: A, B, C, D
The ventilator bundle is a group of care measures to prevent ventilator-associated pneumonia. Actions in the bundle include using proper hand hygiene, giving anti-ulcer medications, elevating the head of the bed, providing frequent oral care per policy, preventing aspiration, and providing pulmonary hygiene measures. Suctioning is done as needed.

Answer to Question 2

ANS: B, D, E
Conditions that place clients at higher risk of developing PE include prolonged immobility, central venous catheters, surgery, obesity, advancing age, conditions that increase blood clotting, history of thromboembolism, smoking, pregnancy, estrogen therapy, heart failure, stroke, cancer (particularly lung or prostate), and trauma. A contrast dye reaction and asthma pose no risk for PE.