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The Nurse Is Caring for a Mechanically Ventilated Client with a Tracheostomy

Question 45

Multiple Choice

The nurse is caring for a mechanically ventilated client with a tracheostomy tube in the intensive care unit.  What client care tasks can the nurse safely delegate to the unlicensed assistive personnel?  Select all that apply.


A) Applying moisturizing solution to the oral mucosa and lips
B) Cleaning the area around tracheostomy stoma with normal saline
C) Educating the family to maintain the head of the bed at least 30 degrees
D) Obtaining and documenting respiratory rate and pulse oximetry readings
E) Performing passive and active range-of-motion exercises

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