Author Question: The nurse is providing care for a client requiring mechanical ventilation. When the nurse enters the ... (Read 49 times)

lunatika · **on:** Jun 25, 2018

The nurse is providing care for a client requiring mechanical ventilation. When the nurse enters the room at the beginning of the shift, the client's monitor displays a heart rate of 64 and oxygen saturation of 88. Which nursing action is the priority?

1. Increasing the oxygen concentration and quickly assessing the client
2. Removing the client from the ventilator and hyperoxygenating and hyperventilating the client
3. Assessing the client for airway obstruction
4. Checking ventilator settings

Question 2

The nurse is providing care for the client requiring mechanical ventilation. Which action by the nurse would be inappropriate when providing care to this client?

1. Confirming airway placement by auscultating the lungs and checking the length marking of the tube at the lip
2. Assuring that tube cuff inflation is no greater than 15 cm H2O, and that there is no audible air leak
3. Assuring ventilator tubing is secured and does not pull on the client's airway
4. Verifying correct ventilator settings

guyanai · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 3

Remembering the nursing process, the nurse would not intervene until assessing for the cause of the client's distress. All of the actions described might be the next priority action, but first and foremost, the nurse must assess the client.

Answer to Question 2

Correct Answer: 2

Tube cuff inflation is normally set at 20-30 cm H2O. The other care is correct.