Practice Question
The client Is in the intensive care unit on a ventilator. Which intervention(s) should the nurse implement? (SELECT ALL THAT APPLY)
Answer Choices:
Correct Answer:
Assess the respiratory status hourly and as needed
Rationale:
🟠 Assess the respiratory status hourly and as needed
🔷 Clients on mechanical ventilation require frequent respiratory assessments to detect early signs of deterioration such as increased secretions, changes in oxygen saturation, or altered breath sounds.
🔷 Monitoring should include breath sounds, respiratory rate, airway patency, and ventilator synchrony.
🔷 This helps identify complications like ventilator-associated pneumonia, barotrauma, or accidental extubation quickly.
🔴 Ensure that a manual resuscitation bag is at the bedside
🔷 A manual resuscitation bag (Ambu bag) must be immediately accessible to provide emergency ventilation if the machine fails or the patient needs to be disconnected.
🔷 It is a standard emergency precaution in ICU protocols for ventilated patients.
🔷 This ensures continuous oxygen delivery during power outages, equipment failure, or transport.
🟢 Collaborate frequently with the respiratory therapist
🔷 Respiratory therapists play a vital role in managing ventilator settings and ensuring optimal gas exchange.
🔷 Frequent collaboration allows for timely adjustment of ventilator parameters based on the patient’s respiratory effort and ABG values.
🔷 It ensures safe, patient-centered care, especially for weaning protocols and secretion management.
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This question is from RN ATI MedSurg~300 Final Exam which contains 71 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI MedSurg
- Answer Choices: 5