Which of the following are components of the Institute for Healthcare Improvement's (IHI's) ventilator bundle? (Select all that apply.)
a. Interrupt sedation each day to assess readiness to extubate.
b. Maintain head of bed at least 30 degrees elevation.
c. Provide deep vein thrombosis prophylaxis.
d. Provide prophylaxis for peptic ulcer disease.
e. Swab the mouth with foam swabs every 2 hours.
A, B, C, D
Options A, B, C, and D are components of the IHI ventilator bundle. Oral care with chlorhexidine has recently been added to the IHI bundle. Swabbing alone provides comfort care.
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The nurse uses a variety of teaching strategies when working with clients. A nurse who encourages the learner to problem solve through trial and error is using which theory of human learning:
1. Behaviorism 2. Humanism 3. Cognitivism 4. Life-long learning
A terminally ill patient is admitted to the CCU for stabilization and palliative procedures. The nurse encourages this awake and alert patient to complete paperwork for advance directives. What is the best rationale for this nursing action?
A) Required by the admission protocol for the hospital and the unit B) Allows the patient to express his or her choices for some treatment decisions C) Prevents estranged family from interfering with competent patient decisions D) Allows the physician to apply his or her best judgment for care decisions
A priority nursing assessment for a patient who is to receive an alpha- or beta-adrenergic antagonist would be to
A) assess heart rate. B) check blood glucose level. C) measure urine output. D) monitor respiratory rate.
A newly admitted client has taken thioridazine (Mellaril) for 2 years, with good symptom control. Symptoms exhibited on admission included paranoia and hallucinations. The nurse should recognize which potential cause for the return of these symptoms?
A. The client has developed tolerance to the antipsychotic medication. B. The client has not taken the medication with food. C. The client has not taken the medication as prescribed. D. The client has combined alcohol with the medication.