The nursing is caring for a client in the Intensive Care Unit on a ventilator. Which intervention(s) should the nurse implement? (SELECT ALL THAT APPLY)

Monitor the client's pulse oximetry every shift

Assess the client's respiratory status at least every 1-2 hours

Ensure that a manual resuscitation bag is at the bedside

Check the ventilator settings every shift

Collaborate frequently with the respiratory therapist

Answer and Explanation

Correct Answer : B,C,D,E

A) Monitor the client's pulse oximetry every shift:
Monitoring pulse oximetry every shift is not sufficient when caring for a client on a ventilator. Pulse oximetry provides valuable information about oxygen saturation, but it should be checked more frequently, especially in a critically ill patient on a ventilator. Continuous monitoring may be required to ensure that oxygenation is maintained at optimal levels. The nurse should assess the pulse oximetry regularly and take immediate action if there is a significant change in the client’s oxygen saturation.

B) Assess the client's respiratory status at least every 1-2 hours:
It is essential to assess the client's respiratory status frequently when they are on a ventilator. Respiratory assessments should be performed at least every 1-2 hours to monitor for complications such as ventilator-associated pneumonia, changes in oxygenation, or the need for adjustments to the ventilator settings. Regular assessment is critical to detect early signs of deterioration and respond promptly.

C) Ensure that a manual resuscitation bag is at the bedside:
Having a manual resuscitation bag (e.g., Ambu bag) at the bedside is a critical intervention for clients on a ventilator. In case of ventilator malfunction, extubation, or respiratory distress, the nurse must have immediate access to a resuscitation bag to manually ventilate the patient. This is a lifesaving piece of equipment that should always be present and ready for use.

D) Check the ventilator settings every shift:
It is essential to check ventilator settings every shift to ensure that the ventilator is functioning correctly and providing the appropriate levels of support for the patient. This includes checking settings such as tidal volume, respiratory rate, pressure, and FiO2 (fraction of inspired oxygen) to ensure they are appropriate for the client's condition. Regular checks can help detect problems such as changes in settings or malfunctioning equipment.

E) Collaborate frequently with the respiratory therapist:
Frequent collaboration with the respiratory therapist is crucial when managing a client on a ventilator. Respiratory therapists are experts in ventilator management and can provide valuable insight into adjusting settings, interpreting ABGs, troubleshooting equipment issues, and optimizing respiratory care. Collaborative care helps ensure that the client is receiving the most appropriate interventions and adjustments for their respiratory status.

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Correct Answer is D

Explanation

A. In the prone position:
The prone position has been shown to be beneficial in certain respiratory conditions, particularly in acute respiratory distress syndrome (ARDS), where it can help improve oxygenation by redistributing blood flow in the lungs. However, prone positioning is typically not the first choice for pneumonia, especially when it is localized to specific lobes of the lung. It is more commonly used in cases of diffuse bilateral lung injury or severe hypoxemia. Therefore, while prone positioning can improve oxygenation in ARDS, it is not specifically targeted for secretion removal in localized pneumonia.

B. In high-Fowler's position:
The high-Fowler's position (sitting up at a 60-90 degree angle) can help with dyspnea and promote lung expansion in conditions like heart failure or dyspneic states. However, for pneumonia, it is not as effective as lateral positioning for facilitating secretion drainage from specific lung lobes. The high-Fowler's position may be useful for promoting overall comfort and reducing dyspnea, but it is not the best position for improving secretion removal from the right middle and lower lobes.

C. On the left side:
Positioning the patient on the left side is not ideal for right middle and lower lobe pneumonia, as it would not optimize drainage from the affected lobes. The right middle and lower lobes are better drained when the patient is positioned on the right side, as gravity can help move the secretions from the affected lobes toward the larger airways for easier clearance.

D. On the right side: In the case of right middle and lower lobe pneumonia, positioning the client on the right side can help optimize ventilation and promote better secretion removal from the affected areas of the lung. This position allows gravity to assist in draining secretions from the right middle and lower lobes toward the larger airways, where they can be more easily cleared by coughing or suctioning. This positioning can improve oxygenation and facilitate secretion management, which is crucial for improving respiratory function in pneumonia.

Correct Answer is ["56"]

Explanation

Calculate the infusion rate in mL/min.

The total volume to be infused is 500 mL.

The infusion time is 90 minutes.

The infusion rate = 500 mL / 90 minutes = 5.5556 mL/min.

Calculate the drip rate in gtt/min.

The drop factor is 10 gtt/mL.

We need to deliver 5.5556 mL/min.

To find the drip rate, we can set up a proportion:

10 gtt / 1 mL = x gtt / 5.5556 mL

Cross-multiplying:

x = 10 gtt/mL x 5.5556 mL = 55.5556 gtt

Round the answer to the nearest whole number.

56 gtt/min.

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The nursing is caring for a client in the Intensive Care Unit on a ventilator. Which intervention(s) should the nurse implement? (SELECT ALL THAT APPLY)

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client diagnosed with acute respiratory failure as a result of right middle and lower lobe pneumonia. To optimize ventilation and secretion removal the nurse should position the client:

Correct Answer is D

Explanation

A patient is prescribed 500 ml of Normal Saline to be infused over 90 minutes. The drop factor on the tubing is 10 gtt/mL. At what rate should the nurse regulate the IV (gtt/min)? (Round to the nearest whole number)

Correct Answer is ["56"]

Explanation

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