A nurse is following the Ventilator Bundle standards to prevent
ventilator-associated pneumonia. Which strategies is the nurse using? (Selectall
... [Show More] that
apply.)
a. Head of bed elevation to 90 degrees at all times
b. Daily oral care with chlorhexidinec.
Cuff monitoring for adequate seal
d. Clean technique when suctioninge.
Daily “sedation vacations”
f. Heart failure prophylaxis
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 is30 to 45 degrees
Daily “sedation vacations” and assessment of readiness to extubate Pepticulcer 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.
2. A nurse is teaching a community health promotion class and discusses
the flu vaccine. Which information will the nurse include in the teachingsession?
(Select all that apply.)
2
a. It is given yearly.
3
b. It is given in a series of four doses.
c. It is safe for children allergic to eggs.
d. It is safe for adults with acute febrile illnesses.
e. The nasal spray is given to people over 50.
f. The inactivated flu vaccine is given to people over 50.
ANS: A, F
Annual (yearly) flu vaccines are recommended for all people 6 months and older. The
inactivated flu vaccine should be given to these individuals with chronic health problems
and those 50 and older. People with a known hypersensitivity to eggs or other components
of the vaccine should consult their health care provider before being vaccinated. There is a
flu vaccine madewithout egg proteins that is approved for adults 18 years of age and older.
Adults with an acute febrile illness should schedule the vaccination after theyhave
recovered. The live, attenuated nasal spray vaccine is given to people from 2 through 49
years of age if they are not pregnant or do not have certainlong-term health problems such
as asthma; heart, lung, or kidney disease; diabetes; or anemia.
3. A nurse is caring for a patient with sleep apnea. Which types of
ventilator support should the nurse be prepared to administer for this patient?(Select all
that apply.)
a. Assist-control (AC)
b. Pressure support ventilation (PSV)
c. Bilevel positive airway pressure (BiPAP [Show Less]