A nurse is assisting with weaning a client from the ventilator. Which of the following parts of the ABCDEF assessment tool does the weaning process represent?
Choice of Analgesia and Sedation
Assess, Prevent, and Manage Pain
Delirium: Assess, Prevent, and Manage
Breathing: Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT)
The Correct Answer is D
A. The "Choice of Analgesia and Sedation" component of the ABCDEF assessment tool focuses on selecting appropriate pain relief and sedation strategies for the patient but does not directly relate to the weaning process.
B. "Assess, Prevent, and Manage Pain" involves ensuring the patient is comfortable and free from pain, which is important but not specifically related to weaning from the ventilator.
C. "Delirium: Assess, Prevent, and Manage" addresses the cognitive status of the patient, particularly the prevention and management of delirium, which is a critical aspect of care but not directly related to ventilator weaning.
D. "Breathing: Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT)" directly involves the weaning process, as it includes assessing the patient's ability to breathe independently by reducing or removing sedation (SAT) and evaluating their capacity for spontaneous breathing (SBT).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
In cases of acute bacterial sinusitis that last longer than 10 days, worsen after initial improvement, or present with severe symptoms (such as fever and significant facial pain), oral antibiotics are generally indicated. First-line options typically include amoxicillin-clavulanate.
Other options listed, such as nasal saline irrigation, oral decongestants, or intranasal corticosteroids, may help alleviate symptoms but would not address the bacterial infection, making antibiotics the most appropriate primary treatment in this case.
Correct Answer is D
Explanation
A. Provide mouth care: Mouth care is important for overall comfort and hygiene but is not the first step in preparing for chest percussion, vibration, and postural drainage. The priority is to prepare the client for the procedures that will aid in clearing lung secretions.
B. Cup hands and tap on the client's chest repeatedly: This action is part of chest percussion and should be performed after positioning the client correctly. Percussion should be done on the appropriate lung areas based on the positioning.
C. Auscultate lung fields: Auscultation of lung fields is essential for assessing lung sounds and determining the effectiveness of therapy. However, it should be done after positioning the client to ensure that the correct areas are being treated and assessed.
D. Position the client so that the lung area to be drained is above the client's trachea: Proper positioning is crucial for effective postural drainage, as it allows gravity to assist in moving secretions from the lung areas to the central airways. This should be done before performing chest percussion or vibration.
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