33. Which nursing actions would most likely help prevent the development of ventilator-associated pneumonia (VAP) in a client who is mechanically ventilated? Select all that apply.
33. Which nursing actions would most likely help prevent the development of ventilator-associated pneumonia (VAP) in a client who is mechanically ventilated? Select all that apply.
. Oral hygiene every 2 hours.
. Elevation of the head of bed at least 20 degrees.
. Proper hand hygiene between clients.
. Routinely remove condensation from ventilator tubing.
. Change ventilator tubing every 12 hours.
Test-Taking Tip
Think about basic care and the prevention of aspiration and infection.
Content Area: Adult Health, Respiratory; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Complications of Diagnostic Tests/Treatments/Procedures
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Answer 1 is correct because frequent oral hygiene prevents the pooling of oral secretions, which may lead to aspiration. Answer 2 is incorrect because the head of the bed should be elevated to at least 30 to 45 degrees, unless contraindicated, to prevent gastric reflux, which can cause VAP. Answer 3 is correct because washing hands before and after every contact with clients prevents cross-contamination of microorganisms. Answer 4 is correct because draining the condensation prevents the potential for aspiration of the collected fluid. Answer 5 is incorrect because changing the ventilator tubing has not been shown to prevent VAP.