A client with acute respiratory distress syndrome following infection by COVID-19 is on a mechanical ventilator. What are the priority nursing interventions to prevent ventilator associated pneumonia (VAP) for this client? Select all that apply.

A. Maintaining cuff pressure between 20–30 cm H₂O: Adequate endotracheal tube cuff pressure creates a seal that minimizes microaspiration of contaminated oropharyngeal and gastric secretions into the lower respiratory tract. Pressures below this range allow leakage of secretions, while excessive pressure can impair tracheal mucosal perfusion. Maintaining this range reduces bacterial inoculation of the alveoli, a key mechanism in VAP pathogenesis. B. Positioning the client semi-Fowler’s: Elevating the head of the bed to 30–45 degrees reduces the risk of gastric reflux and aspiration of colonized secretions. Supine positioning promotes pooling of secretions above the cuff and facilitates their entry into the lower airways. Semi-Fowler’s positioning decreases VAP incidence by limiting aspiration-related lung contamination. C. Providing frequent oral care: The oropharynx becomes rapidly colonized with pathogenic bacteria in intubated clients. Regular oral hygiene, especially with antiseptic solutions, reduces bacterial load and biofilm formation, thereby decreasing the risk of aspiration of virulent organisms into the lungs. This interrupts a major source of pathogens responsible for VAP. D. Administering peptic ulcer prophylaxis: Stress ulcer prophylaxis increases gastric pH, which can promote bacterial overgrowth in the stomach. While it prevents gastrointestinal bleeding, it may paradoxically increase the risk of VAP due to colonization and subsequent aspiration, so it is not a primary preventive intervention for VAP. E. Positioning the client supine: Supine positioning increases the likelihood of aspiration of gastric and oropharyngeal contents into the lower respiratory tract. This promotes direct seeding of bacteria into the alveoli and significantly increases the risk of ventilator-associated pneumonia. F. Hyperoxygenating the client prior to suctioning: Pre-oxygenation helps prevent hypoxemia during suctioning by increasing oxygen reserves, but it does not reduce bacterial colonization or aspiration risk. This intervention is aimed at maintaining oxygenation rather than preventing VAP.