A child is mechanically ventilated. Which assessment finding indicates that a priority goal is being met?

A.
Enteral feeding tube present
B.
PaCO2: 40 mm Hg
C.
Intact skin integrity
D.
Ventilator on control mode


ANS: B
The PaCO2 reading is normal, indicating that goals for the diagnosis of impaired gas exchange are being met. The presence of an enteral feeding tube indicates that goals for nutrition are being met, but this is not the priority over gas exchange. Maintaining intact skin is also an important goal, but is not a priority over gas exchange. Having the ventilator on control mode shows that breathing patterns are being maintained, but this does not give any information about the clinical status of the child.

Nursing

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