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 ["100"]
Explanation
Clindamycin is an antibiotic that can treat infections caused by staphylococci bacteria. It can be given by intermittent IV bolus, which means injecting the drug into a vein over a short period of time. To calculate the infusion rate for clindamycin, we need to use the formula:
Infusion rate (ml/hr) = Volume (ml) / Time (hr)
In this case, the volume is 50 ml and the time is 0.5 hr (30 min). Plugging these values into the formula, we get:
Infusion rate (ml/hr) = 50 ml / 0.5 hr
Infusion rate (ml/hr) = 100 ml/hr
Therefore, the nurse should set the IV pump to deliver 100 ml/hr of clindamycin.
Correct Answer is C
Explanation
A. Metallic taste in the mouth:
This is not a typical finding of oxygen toxicity. Metallic taste may be associated with other factors but is not a specific indicator of oxygen toxicity.
B. Facial flushing:
Facial flushing is not a typical finding in oxygen toxicity. It is more commonly associated with other conditions, such as certain allergic reactions or vasodilation.
C. Muscle twitching
Muscle twitching, also known as myoclonus, is a recognized symptom of central nervous system oxygen toxicity. High concentrations of oxygen, particularly at increased pressures, can cause neurotoxic effects leading to muscle twitching, dizziness, and even convulsions.
D. Periorbital edema:
Periorbital edema is not a common manifestation of oxygen toxicity. It is more commonly associated with conditions related to fluid balance or kidney function.
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