In order to prevent sepsis in a critical care ventilated patient, which nursing interventions would the nurse include in the patient's plan of care?
1. use clean gloves when conducting endotracheal suctioning
2. position patient in a supine position
3. provide oral care every 2 to 4 hours
4. turn patient from side to side every 8 hours
3
Rationale: Providing oral care every 2 to 4 hours is correct because research has found that the oral flora of critically ill patients is a predominately gram-negative organism that can potentially cause ventilator-associated pneumonia. Oral care will help reduce the organisms in the oral flora. The nurse should use sterile gloves when conducting endotracheal suctioning of the patient. Position patient in a supine position is incorrect because patients should have the head of the bed elevated during mechanical ventilation. Turn patient from side to side every 8 hours is incorrect because patients need to be turned at least every 2 hours to prevent accumulation of mucus leading to pneumonia.
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