Which action by the nurse would prevent ventilator-associated pneumonia (VAP)?

Correct Answer: C

Rationale: Certainly. The correct answer is C, providing oral care with chlorhexidine. This action helps reduce the risk of VAP by decreasing the oral bacterial load, preventing aspiration of pathogens into the lungs. Suctioning the airway every 2 hours (A) can irritate the airway and increase the risk of infection. Administering antibiotics prophylactically (B) can lead to antibiotic resistance and should be reserved for specific indications. Keeping the patient sedated (D) may increase the risk of aspiration due to reduced cough reflex.

Correct Answer: C

Rationale: The correct answer is C: Provide low-flow oxygen therapy. In COPD, hypoxemia (low PaO2) is the primary concern. Administering oxygen can help improve oxygenation and prevent further complications. Bronchodilators (choice A) may be indicated for symptom relief but not the priority. Pursed-lip breathing (choice B) can help with exhalation and symptom management but does not address the immediate hypoxemia. Assessing the patient's level of consciousness (choice D) is important but providing oxygen to improve oxygenation takes precedence in this case.

Correct Answer: C

Rationale: Rationale: Choice C indicates the need for further teaching because forcefully exhaling after inhaling the medication can reduce the amount of medication reaching the lungs. The correct technique is to hold the breath for 10 seconds to allow the medication to be absorbed effectively. Choices A, B, and D are all correct techniques for using a metered-dose inhaler and do not indicate the need for further teaching.

Correct Answer: A

Rationale: The correct answer is A: Administer supplemental oxygen. This is the priority intervention for a patient with a suspected pulmonary embolism because it helps improve oxygenation and prevents further hypoxia. Oxygen therapy is crucial in stabilizing the patient's condition and should be initiated promptly. Summary of other choices: B: Notifying the healthcare provider is important, but administering oxygen takes precedence due to the immediate need for oxygenation. C: While a CT scan is important for confirming the diagnosis, providing oxygen is more urgent to address the patient's hypoxia. D: Starting anticoagulant therapy is a critical treatment for pulmonary embolism, but ensuring oxygenation is the immediate priority to stabilize the patient's condition.

Correct Answer: B

Rationale: The correct answer is B: Kussmaul respirations. The ABG results indicate metabolic acidosis (low pH, low HCO3-), causing respiratory compensation to lower PaCO2. Kussmaul respirations are deep, rapid breaths to blow off CO2 and normalize pH. Intercostal retractions (A) are seen in respiratory distress, not metabolic acidosis. Low SpO2 (C) is not directly related to the ABG results. Decreased venous O2 pressure (D) is not a typical finding in this scenario.