The nurse is caring for a mechanically intubated patient with a history of developing pneumonia when intubated. Which of the following should the nurse do to prevent the onset of pneumonia for this patient?
1. Increase intravenous fluids.
2. Suction only when necessary.
3. Provide prophylactic medication to prevent stress ulcer formation.
4. Keep head of bed elevated and provide oral care.
4
Rationale: Positioning the patient upright decreases the risk of lower airway contamination by endotracheal secretions. Reduction of oral bacteria and secretions is crucial to prevent ventilator-acquired pneumonia so effective oral hygiene should include brushing, rinsing, and frequent removal of oral secretions. Frequent suctioning is needed to reduce the pooling of secretions as a source of bacteria. Medications that prevent stress ulcer formation create an alkaline pH in which bacteria multiply. Should the patient aspirate, the risk of pneumonia would be increased.
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