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 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.
Correct Answer is D
Explanation
A. “I understand your fears, I was a smoker also.”
While sharing personal experiences can sometimes be relatable, it may not be the most therapeutic response in this situation. The focus should be on the client's feelings and concerns rather than the nurse's personal history.
B. “Don’t worry. The important thing is you have now quit smoking.”
Dismissing the client's fear with a "don't worry" statement may invalidate the client's emotions. It's important to acknowledge and address the client's feelings rather than downplaying them.
C. “Your doctor is a great surgeon. You will be fine.”
While it's positive to express confidence in the medical team, this response does not directly address the client's emotional concerns. The client's fear may extend beyond the surgical aspect, and it's essential to explore and discuss those fears.
D. “It’s okay to feel scared. Let’s talk about what you are afraid of.”
This response is the most therapeutic as it acknowledges the client's emotions, validates the fear, and opens the door for further communication. It invites the client to express her concerns and allows the nurse to provide support and information based on the client's specific fears.
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