Author Question: The patient is on a ventilator. The health care provider has indicated concern about the patient's ... (Read 114 times)

kodithompson · **on:** Jul 22, 2018

The patient is on a ventilator. The health care provider has indicated concern about the patient's acid-base status. The nurse anticipates that the health care provider will determine the acid-base levels via:

a. PaO2 measurement.
b. SaO2 levels.
c. chloride levels.
d. arterial blood gas analysis.

Question 2

A patient admitted to the intensive care unit was placed on ventilator support. The nurse caring for this patient identified on the plan of care that one of the outcomes was that the patient would not develop ventilator-acquired pneumonia (VAP).

To achieve this outcome, the nurse delegates the following to the unlicensed assistive personnel: Please perform oral care on the patient every 2 hours. In this situation oral care would include using the special swabs we have for our patients on VAP precautions so we can prevent pneumonia. Which of the five rights of delegation did the nurse use? a. Right route
b. Right direction/communication
c. Right dose
d. Right supervision

alexisweber49 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

D
Arterial blood gas (ABG) analysis is an effective method of evaluating acid-base balance and oxygenation. PaO2 is the partial pressure of oxygen in arterial blood. When PaO2 is within normal range, it has no primary role in acid-base regulation. SaO2 is the percentage of hemoglobin molecules that are carrying as much oxygen as is possible (saturated). SaO2, however, has no di-rect effect on acid-base balance. Hypochloremia is abnormally low blood chloride level. Hyper-chloremia is an abnormally high blood chloride level, which occurs with some types of acidosis, some renal conditions, and other electrolyte imbalances. Neither has unique signs and symptoms.

Answer to Question 2

B
The nurse used right direction/communication. Give a clear, concise description of the task, in-cluding its objective, limits, and expectations. Communication must be ongoing between the nurse and nursing assistive personnel during a shift of care. The nurse did not use right supervi-sion in this scenario. To provide right supervision, provide appropriate monitoring, evaluation, intervention as needed, and feedback. Nursing assistive personnel should feel comfortable asking questions and seeking assistance. There is no right dose or route in the five rights of delegation; right dose and route are included in the rights of medication administration.