A nurse in the emergency department is caring for a client.

Exhibits

Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

The client is at risk for developing

Exhibits

due to

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A. Proper oral hygiene is crucial for preventing ventilator-associated pneumonia (VAP), which is a common complication in ventilated patients. The bundle often includes instructions on how to perform mouth care to reduce the risk of bacterial colonization in the oral cavity and subsequent aspiration into the lungs.
B. Tracheostomy care, including suctioning as needed, is important to maintain airway patency and prevent complications like mucus plugging. However, specific instructions for suctioning frequency (e.g., every 2 hours) may vary based on the patient's clinical condition and the presence of secretions. It is not universally part of the ventilator care bundle but is an essential component of managing patients with tracheostomies.
C. Correct ventilator settings are critical to support adequate oxygenation and ventilation while minimizing lung injury. Nurses should be knowledgeable about how to monitor and adjust ventilator settings based on the patient's respiratory status. Education on ventilator settings may be included in

training related to mechanical ventilation management, but it is not typically part of a standardized ventilator care bundle.
D. The position of the patient can affect ventilation and respiratory mechanics. In the context of ventilator care, positioning recommendations may include elevating the head of the bed (semi-Fowler's position) to reduce the risk of aspiration and improve lung expansion. Placing the client in a supine position alone is not specific to the ventilator care bundle but may be considered based on the patient's clinical condition.

A. Notifying the laboratory is not the first action to take in this situation. While it's important to inform the laboratory about suspected transfusion reactions for further investigation and documentation, immediate patient care takes precedence to ensure the client's safety.

B. This is the correct action to take first. Stopping the infusion of blood is crucial to prevent further administration of the potentially harmful blood product. Suspecting an acute hemolytic reaction (symptoms like chills, back pain, and hypotension) necessitates immediate cessation of the transfusion to minimize complications.
C. Obtaining a urine specimen may be indicated later to assess for hemolysis and kidney function, but it is not the first action to take. The priority is to stop the transfusion and assess the client's condition to manage the suspected transfusion reaction.
D. While it's important to notify the provider promptly, stopping the transfusion (option B) is the first critical action to take in response to suspected acute transfusion reactions. The provider will need to be informed for further orders and management, but immediate cessation of the transfusion is essential to prevent worsening of the client's condition.