The nurse is documenting care for a ventilated client. Which items are appropriate for the nurse to include in the documentation?
Select all that apply.
1. Assignment of suctioning to the unlicensed assistive personnel (UAP)
2. Client response to ventilator changes
3. Pertinent laboratory values, such as arterial blood gas results
4. Physical assessment findings
5. Pain rating using an appropriate pain rating scale
Correct Answer: 2,3,4,5
When providing care to a ventilated client, the nurse will document the ventilator settings and client parameters using checklists, flowcharts, and narrative notes as appropriate. The nurse would include results of setting changes, suctioning, activity, physical assessments, and laboratory data. It is not appropriate for the UAP to suction an intubated client requiring mechanical ventilation.
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