Author Question: A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What ... (Read 73 times)

bio_gurl · **on:** Jun 25, 2018

A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by the nurse takes priority?

a. Assessing that the ventilator settings are correct
b. Ensuring there is a bag-valve-mask in the room
c. Obtaining personal protective equipment
d. Planning to suction the client upon arrival to the room

Question 2

A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate?

a. Assess the cause of the agitation.
b. Reassure the client that he or she is safe.
c. Restrain the client's hands.
d. Sedate the client immediately.

parker125 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: B
Having a bag-valve-mask device is critical in case the client needs manual breathing. The respiratory therapist is usually primarily responsible for setting up the ventilator, although the nurse should know and check the settings. Personal protective equipment is important, but ensuring client safety takes priority. The client may or may not need suctioning on arrival.

Answer to Question 2

ANS: A
The nurse needs to determine the cause of the agitation. The inability to communicate often makes clients anxious, even to the point of panic. Pain and confusion can also cause agitation. Once the nurse determines the cause of the agitation, he or she can implement measures to relieve the underlying cause. Reassurance is also important but may not address the etiology of the agitation. Restraints and more sedation may be necessary, but not as a first step.