Care Manager Certification Practice Exam

What should the nurse expect to find in the ventilator care bundle for a client receiving mechanical ventilation?

1. Instructions on mouth care.

2. Instructions to place the client in a supine position.

3. Instructions on how to change ventilator settings.

4. Instructions to suction the clients' tracheostomy every 2hrs.

The correct answer is: Instructions on mouth care.

In the context of a ventilator care bundle, the inclusion of instructions on mouth care is essential because maintaining oral hygiene is critical for patients receiving mechanical ventilation. Ventilated patients are at a higher risk for ventilator-associated pneumonia (VAP), which can be exacerbated by poor oral hygiene. Proper mouth care can help reduce bacterial colonization and promote overall oral health, thereby lowering the risk of infections related to mechanical ventilation. While positioning the client in a supine position could be a consideration in some contexts, research has shown that semi-upright positioning may be more beneficial in preventing aspiration and enhancing ventilation. Changing ventilator settings typically falls under the responsibilities of the respiratory therapist or physician rather than nursing staff, so it wouldn’t be part of the care bundle directed at nurses. Lastly, routine suctioning of a tracheostomy every two hours could cause trauma and discomfort; suctioning should be based on clinical assessment rather than a fixed schedule, making it less relevant in the context of a comprehensive care bundle.