A nurse is caring for a client on mechanical ventilation. When ...

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A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what should the nurse ensure as a priority?
 
  a. The client is able to initiate spontaneous breaths.
  b. The inspired oxygen has adequate humidification.
  c. The upper peak airway pressure limit alarm is off.
  d. The upper peak airway pressure limit alarm is on.

Question 2

A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)?
 
  a. Assess the client for sedation needs.
  b. Get family permission for restraints.
  c. Provide frequent oral care per protocol.
  d. Use nonverbal pain assessment tools.

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Answer to Question 1

ANS: D
The upper peak airway pressure limit alarm will sound when the airway pressure reaches a preset maximum. This is critical to prevent damage to the lungs. Alarms should never be turned off. Initiating spontaneous breathing is important for some modes of ventilation but not others. Adequate humidification is important but does not take priority over preventing injury.

Answer to Question 2

ANS: C
The client on mechanical ventilation needs frequent oral care, which can be delegated to the UAP. The other actions fall within the scope of practice of the nurse.