A critical care nurse is aware of the high incidence of ventilator-associated pneumonia (VAP) in patients who are being treated for shock. What intervention should be specified in the patient's plan of care while the patient is ventilated?
A) Performing frequent oral care
B) Maintaining the patient in a supine position
C) Suctioning the patient every 15 minutes unless contraindicated
D) Administering prophylactic antibiotics, as ordered
Ans: A
Feedback:
Nursing interventions that reduce the incidence of VAP must also be implemented. These include frequent oral care, aseptic suction technique, turning, and elevating the head of the bed at least 30 degrees to prevent aspiration. Suctioning should not be excessively frequent and prophylactic antibiotics are not normally indicated.
You might also like to view...
The patient in what type of therapy gains knowledge that there are others with similar problems? _____________________
ANS:
Informed consent is based on the principle of
A) autonomy. B) fidelity. C) nonmalfeasance. D) beneficence.
A patient tells the nurse that she does not like to "go to the doctor" and is feeling anxious about "being in this place." When the nurse checks her blood pressure, it is elevated along with her heart rate
The nurse rechecks her blood pressure about 10 minutes later and it is normal. The patient asks the nurse if she should be concerned that she may have hypertension. What statement should guide the nurse's response? A) She should not worry; it was stress related and her regular blood pressure is good. B) The first blood pressure was part of a simple stress response; our long-term blood pressure is controlled by negative feedback systems. C) Blood pressure is only one measure of hypertension; she should review this with the doctor and plan to recheck it on a regular basis. D) The respiratory infection is the probably the cause of the elevated blood pressure, and, with treatment, her blood pressure should remain normal.
The nurse is caring for a patient receiving ethotoin to control seizure activity. When reviewing the patient's laboratory results, the nurse would assess the patient is in a therapeutic level when the lab result is within what range?
A) 5 to 15 mcg/mL B) 10 to 20 mcg/mL C) 15 to 50 mcg/mL D) 20 to 30 mcg/mL