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 ["2 "]
Explanation
To calculate the number of tablets that the nurse should administer with each dose, the nurse needs to use the formula:
D/H x Q = X
where D is the desired dose, H is the dose on hand, Q is the quantity of the drug, and X is the amount to give.
In this case, D is 250 mg, H is 125 mg, Q is 1 tablet, and X is unknown. Plugging these values into the formula, we get:
250/125 x 1 = X
Simplifying, we get:
2 = X
Therefore, the nurse should administer 2 tablets with each dose of amoxicillin.
Correct Answer is C
Explanation
A. Discomfort at the puncture site:
Some discomfort at the puncture site is normal after a thoracentesis. It may be managed with pain medication as needed.
B. Serosanguineous drainage from the puncture site:
Serosanguineous drainage (a mix of clear and bloody fluid) is a common and expected finding after a thoracentesis. It is part of the normal post-procedure care.
C. Increased heart rate
Increased heart rate can be indicative of a complication following a thoracentesis, such as a pneumothorax or bleeding. This requires immediate attention, and the healthcare provider should be contacted promptly for further evaluation and intervention.
D. Decreased temperature:
A decreased temperature alone is not typically associated with complications following a thoracentesis. It may be related to other factors, but it is not an immediate concern compared to an increased heart rate.
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