The nurse is caring for a ventilated patient in the ICU who has just undergone coronary artery bypass. The nurse is concerned that the patient may be at risk for ventilator-acquired pneumonia (VAP). What step will she take to minimize this risk?
a. Not provide oral hygiene because this may cause bacterial contamination of the airway.
b. Be careful not to use chlorhexidine in oral care because it provides a medium for bacterial growth.
c. Not use chlorhexidine in oral care because it enhances the rate at which VAP develops.
d. Include the use of a chlorhexidine rinse as part of oral hygiene to delay the development of VAP.
D
Guidelines for oral care in ventilator patients and those who need assistance with oral hygiene often include the use of a chlorhexidine rinse as a part of oral hygiene. Chlorhexidine early in the postintubation period may help delay the onset or development of VAP. Presently, chlorhexidine is recommended during the postoperative period for patients undergoing cardiac surgery. Ventilator-associated pneumonia results from the colonization of bacteria in the oral pharynx. These microorganisms then migrate from the mouth into the lungs. Dental plaque is also a reservoir for microorganisms causing VAP. Because of this evidence, guidelines for oral care in ventilator patients and those who need assistance with oral hygiene often include the use of a chlorhexidine rinse as a part of oral hygiene.
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A newly admitted elderly client seems to become confused and agitated every evening after dinner. This client most likely is suffering from:
a. Alzheimer's disease b. Acute dementia c. Sundown syndrome d. Delirium
What will the nurse hear during phase 2 of Korotkoff's sounds?
1. A muffled, whooshing, or swishing sound 2. Disappearance of sound 3. Faint, clear tapping sound 4. Increased intensity of sound
Which of the following accurately describes the mechanism of action of digoxin?
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A teen with an anxiety disorder is referred for biofeedback because her parents do not want her on anxiolytics. The nurse recognizes that the teen understands her health education on biofeedback when she states, "Biofeedback will
a. Allow me to direct my energies in an intentional way when stressed." b. Allow me to manipulate my stressed out joints." c. Help me with my thoughts, feelings, and physiological responses to stress." d. Let me assess and redirect my energy fields."