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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. “I have not received any of my medications today.”
The statement "I have not received any of my medications today" requires follow-up from the nurse because it indicates a potential issue with the client's medication administration. It's important to ensure that the client receives the prescribed medications in a timely manner.
B. “Do you know when I will be going home?”
This is a question about the discharge plan and does not indicate an immediate issue that requires follow-up.
C. “I do not know how to make the remote control work.”
While it's a statement about the client's understanding of the remote control, it is not an urgent matter that requires immediate attention.
D. “My dressing was changed earlier this morning.”
This statement indicates that a care task (dressing change) has been completed and does not suggest a problem that requires urgent follow-up.
Correct Answer is D
Explanation
A. Metabolic alkalosis with full compensation:
This is not the correct interpretation. Metabolic alkalosis is characterized by an elevated pH and elevated bicarbonate (HCO3-) levels. In this case, the pH is low (acidosis), and the bicarbonate level is within the normal range, suggesting a respiratory issue rather than a metabolic one.
B. Respiratory alkalosis with partial compensation:
This is not the correct interpretation. Respiratory alkalosis is characterized by an elevated pH and decreased PaCO2. In this case, the pH is low (acidosis), and the PaCO2 is elevated, indicating respiratory acidosis rather than alkalosis.
C. Metabolic acidosis with partial compensation:
This is not the correct interpretation. Metabolic acidosis is characterized by a low pH and decreased bicarbonate (HCO3-) levels. In this case, the bicarbonate level is within the normal range, and the elevated PaCO2 suggests a respiratory issue, not metabolic acidosis.
D. Respiratory acidosis with no compensation:
This is the correct interpretation. Respiratory acidosis is characterized by a low pH and an elevated PaCO2. The normal bicarbonate level indicates that compensatory mechanisms (such as the kidneys increasing bicarbonate reabsorption) have not fully corrected the pH imbalance, leading to respiratory acidosis with no compensation.
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