Difficulty: Medium
Average Score: 77%
Simulated
A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take to reduce the risk of ventilator associated pneumonia?
Correct answer
B
Rationale
Correct Answer: B - Brush the client's teeth with a suction toothbrush every 12 hr.
Rationale:
1. Dental hygiene helps prevent bacteria from entering the lungs, reducing the risk of ventilator-associated pneumonia.
2. Suction toothbrushes are designed to remove oral secretions effectively, decreasing the chance of aspiration.
3. Brushing every 12 hours maintains oral hygiene without causing trauma to the mucosa.
Incorrect Answers:
A. Positioning the client's bed flat can increase the risk of aspiration.
C. Providing humidity through the ventilator tubing can promote bacterial growth.
D. Turning the client every 4 hours is important for preventing pressure ulcers but does not directly reduce the risk of ventilator-associated pneumonia.
Rationale:
1. Dental hygiene helps prevent bacteria from entering the lungs, reducing the risk of ventilator-associated pneumonia.
2. Suction toothbrushes are designed to remove oral secretions effectively, decreasing the chance of aspiration.
3. Brushing every 12 hours maintains oral hygiene without causing trauma to the mucosa.
Incorrect Answers:
A. Positioning the client's bed flat can increase the risk of aspiration.
C. Providing humidity through the ventilator tubing can promote bacterial growth.
D. Turning the client every 4 hours is important for preventing pressure ulcers but does not directly reduce the risk of ventilator-associated pneumonia.