A nurse is planning care for a client at risk of developing ventilator-associated pneumonia (VAP). Which of the following interventions should the nurse include?

Correct Answer: B

Rationale: The correct answer is B: Elevate the head of the bed to 45 degrees. This intervention helps prevent aspiration and reduces the risk of VAP by promoting proper lung expansion and drainage of secretions. Elevating the head of the bed also decreases the risk of reflux and aspiration of oral secretions. Limiting oral hygiene (A) to once a day can increase the risk of bacterial buildup in the mouth. Performing deep suctioning (C) every 2 hours can cause trauma to the airway and increase the risk of infection. Placing the client in the prone position (D) can lead to decreased lung expansion and impaired secretion drainage, increasing the risk of VAP.

Correct Answer: B

Rationale: The correct answer is B because taking over-the-counter decongestants can worsen pulmonary hypertension by increasing pulmonary vascular resistance. A is correct as weight monitoring can detect fluid retention. C is correct as strenuous activities can strain the heart. D is correct as increased shortness of breath may indicate worsening condition.

Correct Answer: C

Rationale: The correct answer is C: Providing chest physiotherapy. This intervention helps mobilize and clear thick mucus secretions in the lungs, improving breathing and preventing infections. Chest physiotherapy involves techniques like percussion and postural drainage to loosen and remove mucus. Encouraging a low-fat diet (choice A) is important for overall health but not directly related to managing mucus secretions. Administering pancreatic enzymes (choice B) is necessary for digestion in cystic fibrosis but does not address mucus clearance. Encouraging daily exercise (choice D) is beneficial for overall lung function but may not be as effective in managing thick mucus secretions as chest physiotherapy.

Correct Answer: B

Rationale: The correct answer is B: To prevent drying of the respiratory mucosa. Humidification of oxygen helps maintain the moisture of the respiratory mucosa, preventing irritation and damage. Dry mucosa can lead to discomfort, increased risk of infection, and impaired mucociliary function. Choices A, C, and D are incorrect because while promoting healing, enhancing oxygen delivery, and reducing infection risk are important considerations in tracheostomy care, the primary purpose of humidification in this scenario is to prevent mucosal drying.

Correct Answer: C

Rationale: The correct answer is C: Hold your breath for 10 seconds after inhaling. This instruction is crucial as it allows the medication to reach deep into the lungs for better absorption and effectiveness. Holding the breath helps prevent the medication from being exhaled too soon. Choice A is incorrect as shaking the inhaler is not necessary for all types of MDIs. Choice B is not the most important instruction as exhaling completely is a general step for using inhalers but not the most critical. Choice D is incorrect as waiting between puffs allows for better absorption and prevents overdose.