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.
The nurse assesses the patient's ability to use the walker correctly
A nurse shows empathy to a client.
The nurse applies a pulse oximeter sensor on the client’s finger.
Historical Time Line of Regulatory Acts, Standards, and Organizations
Pneumonia patient’s chest x-ray. Note the irregular areas of density.
Dry hands and forearms thoroughly with clean paper towels to prevent chapping.