BKAT Study Set Questions and
Answers (100% Pass)
Normal blood gases; pH
✓ 7.35-7.45
Normal blood gases: CO2
✓ 35-45
Normal blood gases: HcO3
✓ 22-26
Normal blood gases: PO2
✓ 80 or above
Normal vacuum pressures for suction?
✓ 120-140 mmHg
What may a high pressure vent alarm indicate?
✓ Pt is biting on the tubing, excessive secretions in the tubing, kinked tubing
What may a low pressure vent alarm indicate?
✓ cuff leak or the tubing is disconnected somewhere
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How do you verify positioning of an endotracheal tube?
✓ -auscultate lung bases and apices for bilateral breath sounds
-observe chest for symmetric chest wall movement
-confirm with end tidal CO2 measure
GOLD STANDARD: chest x-ray
t/f: people with ET tubes should be suctioned routinely
✓ FALSE-- they should be suctioned on an as needed basis
what should ET tube cuff pressure be kept at?
✓ 20-25 mmHg
What measures should nurses take to avoid ET tube problems?
✓ -confirm that exit mark on ET tube remains constant when providing patient care,
repositioning, and transporting patient
-maintain proper cuff inflation (listen for an air leak-- if pt can talk, you must inflate more)
-continually monitor SpO2, RR, HR and rhythm, mental status, and ABGs
-pre-oxygenate before suctioning
What should be done if a patient is not tolerating ET tube suctioning?
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✓ STOP and manually hyperventilate with 100% oxygen
Measures to prevent aspiration?
✓ -avoid bolus tube feedings
-monitor tube feeding residuals
-maintain HOB at LEAST 30 degrees or greater
-maintain proper ET tube cuff inflation
-perform frequent oral pharyngeal suctioning
-maintain an NG tube connected to low, intermittent suction if feeding tube is placed below
the pylorus
what are recommendations for preventing ventilator associated pneumonia?
✓ -manage ventilated patients without sedatives whenever possible
-interrupt sedation once a day (spontaneous breathing trials)
-provide early exercise and mobility
-provide regular oral care
-minimize pooling of secretions above the ET tube cuff
-use ET tubes with subglottic secretion drainage for patients likely to require greater than
72 hours of intubation
-keep HOB elevated 30-45 degress
-change ventilator circuit only if visibly soiled or malfunctioning
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What is the biggest complication associated with high cervical spinal cord injuries?
✓ BREATHING-- the diaphragm is innervated by C3-C5 levels
C4-diaphragm
will likely need mechanical ventilation mgmt
signs and symptoms of increased intracranial pressure?
✓ -altered LOC
-headache
-bradycardia
-decreased respirations
-acute HTN with widening pulse pressure
-N/V
-worsening neuro deficits
-pupils that are nonreactive
What are the components of a neuro exam? (7)
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