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 D

Explanation

A. Encourage oral intake of at least 3,000 mL of fluids per day:
This is not a priority intervention for ARDS. While maintaining adequate hydration is important, the primary focus in ARDS is on respiratory support and oxygenation. Excessive fluid intake may exacerbate pulmonary edema in these patients.

B. Offer high-protein and high-carbohydrate foods frequently:
Nutritional support is important in ARDS, but the primary concern is oxygenation and respiratory function. Offering high-protein and high-carbohydrate foods can support the client's overall nutritional needs, but it may not directly address the respiratory distress.

C. Administer low-flow oxygen continuously via nasal cannula:
This is not typically sufficient for ARDS. ARDS often requires higher levels of oxygen support, and low-flow oxygen may not meet the increased oxygen demand. More aggressive oxygenation strategies, such as non-invasive positive pressure ventilation (NIPPV) or mechanical ventilation, may be necessary.

D. Place in a prone position:
Placing the patient in a prone position is a recommended intervention for ARDS. Prone positioning can improve oxygenation by optimizing ventilation-perfusion matching and reducing pressure on the lungs. This intervention is aimed at improving respiratory function in ARDS patients.

A. The AP’s rapport with clients B. The AP’s ability to complete the task without assistance C. The AP has the knowledge and sail to perform the task D. The AP’s ability to prioritize

Correct Answer is C

Explanation

A. The AP’s rapport with clients:
While a positive rapport with clients is valuable, it is not a direct factor in determining whether an AP is suitable for a specific task based on the five rights of delegation.

B. The AP’s ability to complete the task without assistance:
The ability to complete a task without assistance is relevant but does not guarantee that the AP has the necessary knowledge and skill for the task. The focus should be on competence rather than independence.

C. The AP has the knowledge and skill to perform the task
When considering the five rights of delegation, one of the crucial factors is ensuring that the assistive personnel (AP) has the knowledge and skill necessary to perform the delegated task safely and effectively. Delegated tasks should align with the AP's competence and training to maintain the safety and well-being of the client.

D. The AP’s ability to prioritize:
Prioritization skills are important for healthcare providers, but the focus of delegation, as per the five rights, is on the AP's competence to perform the specific task.

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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

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan?

Correct Answer is D

Explanation

When planning delegation of tasks to assistive personnel (AP), a nurse considers the five rights of delegation. Which of the following should the nurse consider when using one of the five rights of delegation?

Correct Answer is C

Explanation

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