A nurse is implementing the ventilator care bundle for a client who is receiving mechanical ventilation. Which of the following should the nurse expect to find in the bundle?

Instructions on how to change ventilator settings

Instructions on mouth care

Instructions to suction the client’s tracheostomy every 2 hr

Instructions to place the client in a supine position

Answer and Explanation

The Correct Answer is B

A. Instructions on how to change ventilator settings:
Ventilator settings are typically adjusted by respiratory therapists or healthcare providers based on the client's respiratory status. While nurses may be involved in monitoring, changing ventilator settings is not part of the routine nursing care bundle.

B. Instructions on mouth care
Mouth care is an important component of the ventilator care bundle to prevent ventilator-associated pneumonia (VAP). Proper oral hygiene, including regular mouth care, can help reduce the risk of infection.

C. Instructions to suction the client’s tracheostomy every 2 hr:
Suctioning frequency is determined based on the client's needs and is not a fixed component of the ventilator care bundle. Suctioning is performed as necessary to maintain airway patency.

D. Instructions to place the client in a supine position:
The positioning of the client may be individualized based on the clinical condition. However, placing the client in a supine position is not a fixed component of the ventilator care bundle. The emphasis is on practices that prevent complications associated with mechanical ventilation.

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Correct Answer is D

Explanation

A. Encourage oral intake of at least 3,000 mL of fluids per day:
This is not a priority intervention for ARDS. While maintaining adequate hydration is important, the primary focus in ARDS is on respiratory support and oxygenation. Excessive fluid intake may exacerbate pulmonary edema in these patients.

B. Offer high-protein and high-carbohydrate foods frequently:
Nutritional support is important in ARDS, but the primary concern is oxygenation and respiratory function. Offering high-protein and high-carbohydrate foods can support the client's overall nutritional needs, but it may not directly address the respiratory distress.

C. Administer low-flow oxygen continuously via nasal cannula:
This is not typically sufficient for ARDS. ARDS often requires higher levels of oxygen support, and low-flow oxygen may not meet the increased oxygen demand. More aggressive oxygenation strategies, such as non-invasive positive pressure ventilation (NIPPV) or mechanical ventilation, may be necessary.

D. Place in a prone position:
Placing the patient in a prone position is a recommended intervention for ARDS. Prone positioning can improve oxygenation by optimizing ventilation-perfusion matching and reducing pressure on the lungs. This intervention is aimed at improving respiratory function in ARDS patients.

A. Loop the tubing of the chest tube on the client’s bed. B. Strip the client’s chest tube every 2 hrs. C. Place the chest tube drainage system below the level of the client’s heart. D. Tape the connections on the client’s chest tube.

Correct Answer is C

Explanation

A. Loop the tubing of the chest tube on the client’s bed:
Looping the tubing may create dependent loops that can trap drainage and prevent effective functioning of the chest tube. It can impede the drainage of air or fluid from the pleural space.

B. Strip the client’s chest tube every 2 hrs:
Stripping or milking the chest tube is an outdated practice. It can cause trauma to the tissue surrounding the chest tube and increase the risk of complications, including damage to the lung tissue or tubing.

C. Place the chest tube drainage system below the level of the client’s heart:
This is the correct action. Placing the chest tube drainage system below the level of the client's chest allows gravity to assist with drainage and prevents backflow or accumulation of fluids within the chest tube.

D. Tape the connections on the client’s chest tube:
Taping the connections on the chest tube is not recommended. It is important to keep connections secure, but taping can make it difficult to quickly identify and address any issues with the chest tube system during monitoring and assessment.

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A nurse is implementing the ventilator care bundle for a client who is receiving mechanical ventilation. Which of the following should the nurse expect to find in the bundle?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan?

Correct Answer is D

Explanation

A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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