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
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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Related Questions
Correct Answer is A
Explanation
A. Place the client in a private room with a special ventilation system.
The primary method to prevent the transmission of tuberculosis is to place the client in a negative pressure room with adequate ventilation. This helps to reduce the risk of airborne transmission of the Mycobacterium tuberculosis bacteria.
B. Modify the protocol for donning and removing personal protective equipment before entering or leaving the client’s room:
Standard precautions should be followed, but the primary emphasis is on airborne precautions due to the potential for airborne transmission of TB. Modifications to donning and removing PPE are not the main focus.
C. Have staff and visitors wear gowns, masks, and gloves while in the client’s room:
Airborne precautions are more specific for suspected active tuberculosis. While gowns, masks, and gloves may be used for other infectious diseases, the key precaution for TB is a private room with negative pressure ventilation.
D. Assign the client to a room with other clients who require droplet precautions:
Tuberculosis is primarily transmitted through airborne particles, not droplets. Placing the client in a room with droplet precautions is not sufficient to prevent the spread of tuberculosis.
Correct Answer is ["1170"]
Explanation
To calculate the total fluid intake for a client during a 4-hour period, the nurse should convert all the measurements to milliliters (mL) and add them together. One cup is equal to 240 mL, one ounce is equal to 30 mL, and one teaspoon is equal to 5 mL. Therefore, the client consumes:
- 1 cup of coffee = 240 mL
- 4 oz of orange juice = 120 mL
- 3 oz of water = 90 mL
- 1 cup of flavored gelatin = 240 mL
- 1 cup of tea = 240 mL
- 5 oz of broth = 150 mL
- 3 oz of water = 90 mL
The total fluid intake is:
240 + 120 + 90 + 240 + 240 + 150 + 90 = 1170 mL
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