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 ["A","D"]

Explanation

A. Decreased lung sounds
A decrease in lung sounds could indicate a pneumothorax, which is a potential complication of thoracentesis. It requires prompt evaluation.

B. Heart rate 110/min and regular
A heart rate of 110/min is within a normal range, and regular rhythm is generally acceptable post-thoracentesis. It may be related to pain or anxiety but is not an immediate concern.

C. Oxygen saturation of 95%
An oxygen saturation of 95% is within an acceptable range. While maintaining adequate oxygenation is important, this finding does not suggest an immediate complication.

D. Subcutaneous emphysema
Subcutaneous emphysema involves the presence of air in the subcutaneous tissues and can indicate a communication between the pleural space and subcutaneous tissues. This requires immediate attention.

E. Trachea midline
The trachea being midline is a normal finding and does not indicate an immediate problem post-thoracentesis.

F. Puncture site dry
A dry puncture site is expected after a thoracentesis. This finding is normal and indicates appropriate wound care. It is included in the list to ensure recognition of normal post-procedure findings.

A. Fluctuation of the fluid level within the water seal chamber B. Equal amounts of fluid drainage in each collection chamber C. Continuous bubbling within the water seal chamber D. Absence of fluid in the drainage tubing

Correct Answer is A

Explanation

A. Fluctuation of the fluid level within the water seal chamber
Fluctuation of the fluid level within the water seal chamber indicates that the chest tube is functioning properly. This fluctuation is a normal finding and reflects the movement of air in and out of the pleural space during the respiratory cycle. As the patient inhales, the fluid level drops, and as they exhale, it rises.

B. Equal amounts of fluid drainage in each collection chamber:
Equal amounts of drainage may suggest a problem with the drainage system or that the chest tube is not effectively draining air or fluid from the pleural space.

C. Continuous bubbling within the water seal chamber:
Continuous bubbling in the water seal chamber may indicate an air leak, which is not a normal finding. It should be investigated further.

D. Absence of fluid in the drainage tubing:
The absence of fluid in the drainage tubing may suggest that the chest tube is not effectively draining fluid from the pleural space or that there is a blockage in the system. It requires assessment and intervention.

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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

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