NCLEX SATA Quiz: Physiological Adaptation

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1. The intensive care nurse is caring for a client requiring mechanical ventilation. Which of the following are interventions the nurse should take to help prevent ventilator-associated pneumonia (VAP)? Select all that apply.*
- 1. Reposition the client at least every 2 hours and maintain the head of the bed upright at 30–45 degrees.
- 2. Promote nutrition with the use of a nasogastric tube and high-calorie feedings.
- 3. Suction oral and pharynx secretions, and provide thorough oral care at least every 2 hours.
- 4. Assess the client for sedation reduction and weaning/extubation readiness.
- 5. Perform hand hygiene before and after care of the client, and implement prophylactic intravenous antibiotic therapy.

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