A nurse is following the Ventilator Bundle standards to prevent ...

[vicotolentino]

A nurse is following the Ventilator Bundle standards to prevent ventilator-associated pneumonia. Which strategies is the nurse using? (Select all that apply.)
 
  a. Head of bed elevation to 90 degrees at all times
  b. Daily oral care with chlorhexidine
  c. Cuff monitoring for adequate seal
  d. Clean technique when suctioning
  e. Daily sedation vacations
  f. Heart failure prophylaxis

Question 2

While the nurse is changing the ties on a tracheostomy collar, the patient coughs, dislodging the tracheostomy tube. Which action will the nurse take first?
 
  a. Press the emergency response button.
  b. Insert a spare tracheostomy with the obturator.
  c. Manually occlude the tracheostomy with sterile gauze.
  d. Place a face mask delivering 100 oxygen over the nose and mouth.

[irishcancer18]

Answer to Question 1

ANS: B, C, E
The key components of the Institute for Healthcare Improvement (IHI) Ventilator Bundle are:
Elevation of the head of the bed (HOB)elevation is 30 to 45 degrees
Daily sedation vacations and assessment of readiness to extubate
Peptic ulcer disease prophylaxis
Deep venous thrombosis prophylaxis
Daily oral care with chlorhexidine
Monitor cuff pressure frequently to ensure that there is an adequate seal to prevent aspiration of secretions is also included. Sterile technique is used for suctioning when on ventilators. Heart failure prophylaxis is not a component.

Answer to Question 2

ANS: B
The nurse's first priority is to establish a stable airway by inserting a spare trach into the patient's airway; ideally an obturator should be used. The nurse could activate the emergency response team if the patient is still unstable after the tracheostomy is placed. A patient with a tracheostomy breathes through the tube, not the nose or mouth; a face mask would not be an effective method of getting air into the lungs. Manually occluding pressure over the tracheostomy site is not appropriate and would block the patient's only airway.

[vicotolentino]

Both answers were spot on, thank you once again

[irishcancer18]

Great! Please up vote