The nurse is caring for a client requiring mechanical ventilation ...

[bobbysung]

The nurse is caring for a client requiring mechanical ventilation who is deeply sedated and receiving paralytic medications. Which nursing intervention would assist the client to optimize oxygenation?
 
  1. Hyperventilating the client once an hour
  2. Hyperoxygenating the client once an hour
  3. Encouraging coughing and deep breathing
  4. Frequent repositioning

Question 2

The nurse finds the client sitting upright and leaning on the arms or elbows. Which piece of documentation accurately describes the client's position?
 
  1. The client has assumed the orthopneic position.
  2. The client has assumed the COPD position.
  3. The client has assumed the tripod position.
  4. The client is sitting upright.

[katheyjon]

Answer to Question 1

Correct Answer: 4

An important nursing intervention to prevent atelectasis is frequent repositioning, and this client may be placed on a specialized bed to move him continuously. If he is not placed on a specialized bed, the nurse should reposition the client at least every 2 hours. Hyperoxygenating and hyperventilating the client would be important prior to suctioning, but would not be routine interventions or the most important interventions to improve oxygenation. Because the client is receiving a paralytic medication, coughing and deep breathing would not be possible.

Answer to Question 2

Correct Answer: 3

The position described is the tripod position, often seen in clients with COPD but not called the COPD position. The orthopneic position is an adaptation of the high-Fowler's position with the client sitting upright.