The nurse working with a student nurse is providing care for a ...

[DyllonKazuo]

The nurse working with a student nurse is providing care for a client requiring mechanical ventilation. The student nurse asks the meaning of assist control. Which response by the nurse is the most appropriate?
 
  1. Assist control is a means of delivering ventilation that delivers a preset volume and/or pressure each time the client begins an inspiration.
  2. Assist control allows the client to breathe independently, but supplies a breath if the client does not begin an inhalation in a specified period of time.
  3. Assist control is used when weaning a client from the ventilator because the client must exercise the muscles of respiration in order to get a full breath.
  4. Assist control is often used when a client is receiving a paralytic agent.

Question 2

When capping the client's tracheostomy tube with a speaking valve, the nurse assesses the client's breath sounds around the tube and hears no air leak. Which nursing action is the most appropriate based on this assessment finding?
 
  1. Allowing the cap to remain in place as long as the client tolerates it
  2. Documenting the placement of the cap and relevant data regarding client assessment
  3. Removing the valve and notifying the health care provider
  4. Assisting the client out of bed

[leeeep]

Answer to Question 1

Correct Answer: 1

Assist control allows the client to begin inspiration, but the ventilator provides a preset pressure or volume to boost the client's tidal volume. If the ventilator is set to provide a breath only when the client doesn't breathe, it is not assist control but Synchronized Intermittent Mandatory Ventilation (SIMV). Because the ventilator provides the breath begun by the client, it does not improve muscle function. Assist control would not be used for the client receiving a paralytic agent because he would be unable to initiate a breath.

Answer to Question 2

Correct Answer: 3

The valve should be removed and the health care provider notified because lack of an air leak indicates the client will not be able to exhale and, as a result, will not tolerate the valve. Only after calling the health care provider would the nurse document the inability to use the valve. There would be no need to assist the client out of bed.

[DyllonKazuo]

Thank you

[leeeep]

No problemo