A client who is being mechanically ventilated is admitted to the care area. What should the nurse do to prevent this patient from developing ventilator-assisted complications? (Select all that apply.)
a. Suction the airway when needed.
b. Ensure adequate nutritional intake.
c. Adjust ventilator alarms to promote rest.
d. Keep the head of the bed at a 45 degree angle.
e. Provide oral care with 0.12% chlorhexidine solution.
ANS: A, B, D, E
Good nursing care is essential for preventing ventilator-associated complications and is accomplished by suctioning the airway when needed, ensuring adequate nutritional intake, keeping the head of the bed at a 45-degree angle to reduce the risk of aspiration, and providing oral care with 0.12% chlorhexidine solution. C. Ventilator alarms should be set to the appropriate level to alert the nurse of any potential respiratory problems.
You might also like to view...
The nurse manager is counseling a staff nurse who demonstrated reckless behavior. What should the manager say when meeting with this nurse?
1. "I have a handout that can help you." 2. "I realize that the design of the patient rooms contributed to the error." 3. "What outcomes do you think can occur if this happens again in the future?" 4. "This is the second time this has occurred and I think a few days off might be needed."
An often fatal food intoxication resulting from a toxin produced by anaerobic bacteria is:
1. Botulism 2. Hepatitis A 3. Salmonellosis 4. Trichinosis
A nurse has been called to testify in a lawsuit brought by a patient against his employer. This institution uses charting by exception (CBE). What type of legal problems does CBE pose?
A) The charting format is not ethical B) Details are often missing C) Subjective information is often missing D) It reflects poor assessment skills on the part of the nurse
A nurse has invited community members to participate as full partners in creating changes to improve the health of the community. Which of the following may be an unexpected consequence of this action?
a. A change in the distribution or redistribution of power and influence b. An increase in awareness of the importance of health c. Continued ongoing interest in community health activities d. Improved family functioning and involvement in health activities