Which nursing interventions are appropriate for managing the care of a client receiving mechanical ventilation and continuous IV sedation? Select all that apply.

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11ecbb05_cb06_499c_b433_675fb1177a94_MD0009_00 Clients requiring mechanical ventilation are at risk for a variety of ventilator-associated complications (eg, aspiration, pneumonia). When caring for a client receiving mechanical ventilation, the nurse should: Monitor respiratory status (eg, lung sounds, breathing pattern), airway patency, and ventilator functionality (eg, settings, alarm parameters).Maintain the head of the bed at 30-45 degrees to reduce aspiration risk (Option A).Use the minimum amount of sedation necessary for client comfort (eg, compliant with ventilator, opens eyes to voice). Continuous IV sedation should be paused daily for evaluation of spontaneous respiratory effort and appropriateness for weaning off the ventilator (Option C).Perform oral care with chlorhexidine oral solution every 2 hours, or per facility policy (Option D). Perform tracheal suctioning as needed.Monitor correct endotracheal tube placement by noting insertion depth.Place emergency equipment at bedside (eg, manual resuscitation bag) (Option E). Monitor respiratory status (eg, lung sounds, breathing pattern), airway patency, and ventilator functionality (eg, settings, alarm parameters). Maintain the head of the bed at 30-45 degrees to reduce aspiration risk (Option A). Use the minimum amount of sedation necessary for client comfort (eg, compliant with ventilator, opens eyes to voice). Continuous IV sedation should be paused daily for evaluation of spontaneous respiratory effort and appropriateness for weaning off the ventilator (Option C). Perform oral care with chlorhexidine oral solution every 2 hours, or per facility policy (Option D). Perform tracheal suctioning as needed. Monitor correct endotracheal tube placement by noting insertion depth. Place emergency equipment at bedside (eg, manual resuscitation bag) (Option E). (Option B) Although the client should have a quiet environment at night, ventilator alarms should never be muted, as they may indicate life-threatening complications (eg, accidental extubation, tubing disconnection). Educational objective: When caring for a client requiring mechanical ventilation, the nurse should monitor respiratory status and airway patency (eg, breath sounds, insertion depth of endotracheal tube), maintain an appropriate level of sedation, assess for weaning readiness, prevent ventilator-associated infection (eg, oral care with chlorhexidine, head of the bed at 30-45 degrees), and implement safety measures (eg, emergency equipment at bedside, ventilator alarms on).

Which Nursing Interventions Are Appropriate for Managing the Care of a Client