NCLEX^® QUESTION OF THE WEEK

Question of the Week – September 29, 2021

September 29, 2021

The nurse is caring for a patient with emphysema and respiratory failure who is receiving mechanical ventila- tion through an endotracheal tube. To prevent ventilator-associated pneumonia (VAP), which action is most important to include in the plan of

Show Answer Answer

Correct! The answer is number 3

Rationale:

Research indicates that nursing actions such as maintaining the head of the bed at 30 to 45 degrees decrease the incidence of VAP. These actions are part of the standard of care for patients who require mechanical ventilation. The other actions are also appropriate for this patient but will not decrease the incidence of VAP.

Test Taking Tip: Prevention of VAP has been a subject of research; as a result, a ventilator bundle order set has been devel- oped to apply to patients placed on ventilators with the goal of prevention of VAP.

Practice Question Sourced From: Resources for Prioritization, Delegation, and Assignment, 4th Edition