A nurse is caring for a 20-year-old client who has a fever and reports severe headache.

Exhibits

A nurse is preparing the client for a lumbar puncture. Which of the following actions should the nurse take? Select all that apply.

A. This response acknowledges the parent's concern but maintains confidentiality regarding the report. It offers to involve the supervisor, which is a reasonable step. However, it may leave the parent feeling uneasy or uncertain.
B. This response directly informs the parent about the legal obligation of the nurse to report suspected child abuse. It provides clarity on why the nurse took action. However, it might be perceived as abrupt or lacking empathy.
C. This response suggests that someone else (possibly a healthcare provider or another authority figure) will explain the situation later. It doesn't directly address the reason for the nurse's action or the legal requirement to report.
D. This response explains the chain of events, from reporting to the supervisor's decision to contact authorities. It provides information but might not directly address the parent's emotional concern or the legal obligation of the nurse.

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.