The nursing is caring for a client in the Intensive Care Unit on a ventilator. Which intervention(s) should the nurse implement? (SELECT ALL THAT APPLY)
Monitor the client's pulse oximetry every shift
Assess the client's respiratory status at least every 1-2 hours
Ensure that a manual resuscitation bag is at the bedside
Check the ventilator settings every shift
Collaborate frequently with the respiratory therapist
Correct Answer : B,C,D,E
A) Monitor the client's pulse oximetry every shift:
Monitoring pulse oximetry every shift is not sufficient when caring for a client on a ventilator. Pulse oximetry provides valuable information about oxygen saturation, but it should be checked more frequently, especially in a critically ill patient on a ventilator. Continuous monitoring may be required to ensure that oxygenation is maintained at optimal levels. The nurse should assess the pulse oximetry regularly and take immediate action if there is a significant change in the client’s oxygen saturation.
B) Assess the client's respiratory status at least every 1-2 hours:
It is essential to assess the client's respiratory status frequently when they are on a ventilator. Respiratory assessments should be performed at least every 1-2 hours to monitor for complications such as ventilator-associated pneumonia, changes in oxygenation, or the need for adjustments to the ventilator settings. Regular assessment is critical to detect early signs of deterioration and respond promptly.
C) Ensure that a manual resuscitation bag is at the bedside:
Having a manual resuscitation bag (e.g., Ambu bag) at the bedside is a critical intervention for clients on a ventilator. In case of ventilator malfunction, extubation, or respiratory distress, the nurse must have immediate access to a resuscitation bag to manually ventilate the patient. This is a lifesaving piece of equipment that should always be present and ready for use.
D) Check the ventilator settings every shift:
It is essential to check ventilator settings every shift to ensure that the ventilator is functioning correctly and providing the appropriate levels of support for the patient. This includes checking settings such as tidal volume, respiratory rate, pressure, and FiO2 (fraction of inspired oxygen) to ensure they are appropriate for the client's condition. Regular checks can help detect problems such as changes in settings or malfunctioning equipment.
E) Collaborate frequently with the respiratory therapist:
Frequent collaboration with the respiratory therapist is crucial when managing a client on a ventilator. Respiratory therapists are experts in ventilator management and can provide valuable insight into adjusting settings, interpreting ABGs, troubleshooting equipment issues, and optimizing respiratory care. Collaborative care helps ensure that the client is receiving the most appropriate interventions and adjustments for their respiratory status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Expect fluctuations of symptoms with temperature change: While symptom fluctuations may occur due to various factors, temperature changes are not a hallmark feature of Huntington's Disease (HD). HD is characterized by progressive motor, cognitive, and psychiatric symptoms, including involuntary movements (chorea), cognitive decline, and mood disturbances. Although other neurological conditions may show symptom fluctuations with temperature changes, this is not specific to HD.
B. New surgical techniques offer the best hope for a cure: There are currently no cures for Huntington's Disease, and while medical management can help manage symptoms (such as using medications for chorea or psychiatric symptoms), surgical techniques do not offer a cure for HD. The disease is progressive, and interventions typically focus on symptom management rather than cure. Families should be informed that while research is ongoing, a cure is not currently available.
C. Information about genetic testing: Huntington's Disease (HD) is a genetic disorder caused by a mutation in the HTT gene. It is inherited in an autosomal dominant pattern, meaning that a person with a parent who has HD has a 50% chance of inheriting the disease. Genetic testing is a critical part of the diagnosis process, and it can confirm the presence of the mutated gene before symptoms appear, which is important for family planning and early intervention. However, while genetic testing can provide information about whether an individual will develop the disease, it does not alter the course of the disease or provide a cure. It is essential to provide this information to clients and families, so they understand the role of genetic counseling and testing in managing the disease.
D. The disease process is intense but short in duration: Huntington's Disease is progressive and long-lasting. The disease usually begins in mid-adulthood (typically between ages 30-50), and the symptoms worsen over time. Individuals with HD may live for 15-20 years after symptom onset. The disease duration is long-term, not short, and it becomes increasingly debilitating as it progresses. The intensity of symptoms increases over time, and the disease is not characterized by a short duration.
Correct Answer is ["56"]
Explanation
Calculate the infusion rate in mL/min.
The total volume to be infused is 500 mL.
The infusion time is 90 minutes.
The infusion rate = 500 mL / 90 minutes = 5.5556 mL/min.
Calculate the drip rate in gtt/min.
The drop factor is 10 gtt/mL.
We need to deliver 5.5556 mL/min.
To find the drip rate, we can set up a proportion:
10 gtt / 1 mL = x gtt / 5.5556 mL
Cross-multiplying:
x = 10 gtt/mL x 5.5556 mL = 55.5556 gtt
Round the answer to the nearest whole number.
56 gtt/min.
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