Which action by the registered nurse requires the LPN to intervene when assisting with a client on mechanical ventilation?

Which action by the registered nurse requires the LPN to intervene when assisting with a client on mechanical ventilation?

• A. Suctioning the client when the high-pressure alarm sounds
• B. Hyperventilating with 100% FiO2 prior to suctioning
• C. Performing oral care with a chlorhexidine solution
• D. Maintaining the head of the client's bed at 90 degrees

Answer: (D)

The action that requires intervention by the LPN is maintaining the head of the client's bed at 90 degrees. This positioning is not appropriate for a client on mechanical ventilation, as it can increase the risk of complications such as pressure ulcers and impede chest expansion. The optimal position for patients on mechanical ventilation is usually with the head of the bed elevated to about 30 to 45 degrees. This angle helps improve lung expansion, reduces the risk of aspiration, and promotes better venous return, making it safer for the patient. Other actions, such as suctioning when the high-pressure alarm sounds, are standard nursing practices that are typically performed by a registered nurse and may not necessitate intervention from the LPN if they have the training to recognize such situations. Hyperventilating with 100% FiO2 prior to suctioning is a protocol that can be utilized to prevent hypoxia during the procedure. Additionally, performing oral care with a chlorhexidine solution is a practice that is beneficial for preventing ventilator-associated pneumonia. Therefore, the only action that stands out as inappropriate in this context is maintaining the head of the bed at an unsafe angle of 90 degrees.

The action that requires intervention by the LPN is maintaining the head of the client's bed at 90 degrees. This positioning is not appropriate for a client on mechanical ventilation, as it can increase the risk of complications such as pressure ulcers and impede chest expansion. The optimal position for patients on mechanical ventilation is usually with the head of the bed elevated to about 30 to 45 degrees. This angle helps improve lung expansion, reduces the risk of aspiration, and promotes better venous return, making it safer for the patient.

Other actions, such as suctioning when the high-pressure alarm sounds, are standard nursing practices that are typically performed by a registered nurse and may not necessitate intervention from the LPN if they have the training to recognize such situations. Hyperventilating with 100% FiO2 prior to suctioning is a protocol that can be utilized to prevent hypoxia during the procedure. Additionally, performing oral care with a chlorhexidine solution is a practice that is beneficial for preventing ventilator-associated pneumonia. Therefore, the only action that stands out as inappropriate in this context is maintaining the head of the bed at an unsafe angle of 90 degrees.