The client Is in the intensive care unit on a ventilator. Which intervention(s) should the nurse implement? (SELECT ALL THAT APPLY)

Assess the respiratory status hourly and as needed

Ensure that a manual resuscitation bag is at the bedside

Check the patient's pulse co once every shift

Adjust the ventilator settings based on the client’s level of consciousness

Collaborate frequently with the respiratory therapist

Answer and Explanation

Correct Answer : A,B,E

A) Assess the respiratory status hourly and as needed
It is essential for the nurse to frequently monitor and assess the respiratory status of a client on a ventilator, as changes can occur rapidly. Regular assessments allow the nurse to detect any early signs of respiratory distress, hypoxia, or ventilator malfunction. Hourly assessments are standard practice in the intensive care unit (ICU), and additional assessments may be necessary if there are concerns about the patient’s respiratory condition.

B) Ensure that a manual resuscitation bag is at the bedside
A manual resuscitation bag (Ambu bag) is a critical piece of emergency equipment that should always be available at the bedside of a patient on mechanical ventilation. In the event of ventilator failure, accidental extubation, or sudden respiratory distress, the nurse needs to be able to provide manual ventilation.
C) Check the patient's pulse oximetry once every shift
Although monitoring pulse oximetry is important in ICU patients on a ventilator, checking it only once per shift is insufficient. Continuous monitoring of oxygen saturation via pulse oximetry is a much more appropriate approach to ensure the patient is adequately oxygenated, especially when on a ventilator.

D) Adjust the ventilator settings based on the client’s level of consciousness
Adjusting the ventilator settings should be done by the healthcare provider or respiratory therapist, not the nurse, unless directed by the provider. While the patient's level of consciousness can influence their respiratory drive, the nurse does not have the authority or expertise to modify ventilator settings based on consciousness levels.

E) Collaborate frequently with the respiratory therapist
Collaboration with the respiratory therapist is essential for managing a patient on a ventilator. Respiratory therapists have specialized training in ventilator management and can assist with adjusting ventilator settings, monitoring the patient’s lung function, and troubleshooting ventilator malfunctions.

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Correct Answer is C

Explanation

A) Equal but sluggishly reactive pupils:
Pupillary changes, including sluggish or unequal responses, are significant signs of increasing intracranial pressure (ICP) and should be monitored closely. However, altered level of consciousness (LOC) is typically one of the earliest signs of increased ICP. The response of the pupils to light can become abnormal later, once pressure increases within the brain, particularly when brainstem function is impacted.

B) Widening pulse pressure:
A widening pulse pressure is part of Cushing’s triad, which is a late sign of increased ICP. Cushing’s triad consists of hypertension, bradycardia, and irregular respirations (often seen as Cheyne-Stokes). These changes occur in the later stages of elevated ICP as a compensatory mechanism to preserve cerebral perfusion. While this is an important finding, altered LOC would precede the development of Cushing’s triad.

C) Altered level of consciousness:
Altered level of consciousness (LOC) is typically the first and most sensitive indicator of increased ICP. As pressure increases within the skull, it compresses brain tissue and affects the brainstem, which controls basic functions like consciousness. LOC can range from mild confusion and disorientation to full loss of consciousness or coma, depending on the severity of the ICP increase.

D) Tachycardia and hypotension:
Tachycardia and hypotension can be associated with shock or other conditions, but they are not characteristic of early increased ICP. In fact, as ICP rises, the body typically responds with bradycardia (slower heart rate) and hypertension (increased blood pressure), which are part of the compensatory mechanisms.

A. IM epinephrine is the fastest route of administration B. IV epinephrine is only administered during cardiac arrest C. Epinephrine would not be administered in this situation D. IM epinephrine is less concentrated than IV.

Correct Answer is B

Explanation

A) IM epinephrine is the fastest route of administration:
While epinephrine is often administered intramuscularly in cases of anaphylaxis and allergic reactions, the speed of action is not the primary reason for choosing this route over intravenous (IV) administration in this situation. Intramuscular administration of epinephrine allows for a rapid onset of action, but it is not necessarily the fastest route compared to IV. IV administration would act more quickly in an emergency setting where immediate blood circulation is critical, but IM is preferred in allergic reactions to prevent excessive systemic effects and to avoid rapid peaks in plasma levels.

B) IV epinephrine is only administered during cardiac arrest:
Epinephrine is generally administered intravenously during life-threatening situations such as cardiac arrest or severe shock, where immediate circulatory effects are needed. In cases of anaphylaxis, however, intramuscular (IM) administration of epinephrine is the preferred route because it allows for a more controlled absorption rate and reduces the risk of excessive blood pressure and other adverse cardiovascular effects. This is the correct rationale for why epinephrine is administered IM in the context of an allergic reaction.

C) Epinephrine would not be administered in this situation:
Epinephrine is the first-line treatment for severe allergic reactions and anaphylaxis, especially in cases where symptoms like wheezing, shortness of breath, urticaria, and itching are present. Therefore, withholding epinephrine is not an appropriate response in this situation. Immediate intervention with epinephrine is critical to reverse the symptoms of anaphylaxis and prevent further respiratory distress or cardiovascular collapse.

D) IM epinephrine is less concentrated than IV:
The concentration of epinephrine used for IM and IV administration is the same. The primary reason for choosing the IM route over the IV route is the slower absorption and the fact that it minimizes the risk of a rapid increase in systemic blood pressure and other adverse reactions. While IM epinephrine may be absorbed more slowly than IV, its concentration is appropriate for treating anaphylaxis effectively. The choice of IM is based on safety and controlled response, not on the concentration of the drug.

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The client Is in the intensive care unit on a ventilator. Which intervention(s) should the nurse implement? (SELECT ALL THAT APPLY)

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