Medical Surgical Pneumonia #1

Question

The nurse develops a nursing care plan for a client at risk of having hospital-acquired pneumonia. Which factor(s) places this client at highest risk for developing hospital-acquired pneumonia? Select all that apply.

Answers

  1. A client on a ventilator.
    • Rationale:

      This answer is correct because hospital-acquired pneumonia risk factors include mechanical ventilation and constitutes more than 85% of all cases with pneumonia that occurs in 9-27% of ventilator clients. The highest risk occurs during the first 10 days following intubation.

  2. A client with dysphagia.
    • Rationale:

      This answer is correct because clients with dysphagia may experience aspiration which will predispose them to developing aspiration pneumonia.

  3. A client who did not receive the pneumococcal vaccine.
    • Rationale:

      This answer is not correct because the question asks to identify the highest risk factors leading to the development of hospital-acquired pneumonia. By not receiving the influenza vaccine does not place a client at high risk for developing hospital-acquired pneumonia.

  4. A client who did not receive the influenza vaccine.
    • Rationale:

      This answer is not correct because the question asks to identify the highest risk factors leading to the development of hospital-acquired pneumonia. By not receiving the pneumococcal vaccine does not place a client at high risk for developing hospital-acquired pneumonia.

  5. A client with a decreased level of consciousness.
    • Rationale:

      This answer is correct because a decreased level of consciousness prevents the client from fully protecting their airway when eating or drinking. Aspiration of food or drink can lead to aspiration pneumonia.

Overview

The focus of this question is determining risk factors for hospital-acquired pneumonia. Mechanical ventilation, difficulty swallowing, and a decreased level of consciousness prevents the client from fully protecting their airway placing them at high risk for hospital acquired pneumonia.

Explanation

Learning Outcomes

Hospital-acquired pneumonia (HAP) refers to any type of pneumonia that developed within 48-72 hours upon admission to a hospital. Clients who are admitted to the hospital are at risk for contracting HAP for many reasons. Ventilated clients are at risk for developing ventilator-associated pneumonia (VAP). A client with dysphagia and clients with decreased levels of consciousness are at risk for aspiration pneumonia as they are less likely to be able to protect their airways effectively.

Test Taking Tip

This is a risk factor question. Any condition that causes a client’s airway to be compromised in any way is a very high risk factor for the development of hospital-acquired pneumonia

Video Rationale