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Lewis's chapter 28 (12 edition) Questions
with Detailed Verified Answers (100%
Correct Answers) /Already Graded A+
1. Which action would the nurse take to verify the correct placement of an oral
endotracheal tube (ET) immediately after insertion and before securing the tube?
a. Obtain a portable chest x-ray.
b. Use an end-tidal CO2 monitor.
c. Auscultate for bilateral breath sounds.
d. Observe for symmetrical chest movement
Ans: ANS: B
End-tidal CO2 monitors are currently recommended for rapid verification of ET placement.
Auscultation for bilateral breath sounds and checking chest expansion are also used, but they
are not as accurate as end-tidal CO2 monitoring. A chest x-ray confirms the placement but is
done after the tube is secured.
2. Which action would the nurse take to maintain proper endotracheal tube (ET)
cuff pressure when a patient is on mechanical ventilation?
a. Inflate the cuff with a minimum of 10 mL of air.
b. Inflate the cuff until the pilot balloon is firm on palpation.
c. Inject air into the cuff until a manometer shows 15 mm Hg pressure.
d. Inject air into the cuff until a slight leak is heard only at peak inflation.
Ans: ANS: D
The minimal occluding volume technique involves injecting air into the cuff until an air leak is
present only at peak inflation. the volume to inflate the cuff varies with the ET and the
patient's
size. Cuff pressure should be maintained at 20 to 30 mm Hg. An accurate assessment of cuff
pressure cannot be obtained by palpating the pilot balloon.
3. The nurse notes premature ventricular contractions (PVCs) on the monitor while
suctioning a patient's endotracheal tube. Which action would the nurse take?
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a. Plan to suction the patient more frequently.
b. Decrease the suction pressure to 80 mm Hg.
c. Give antidysrhythmic medications per protocol.
d. Ventilate the patient with 100% oxygen.
Ans: ANS: D
Dysrhythmias during suctioning may indicate hypoxemia or sympathetic nervous system
stimulation. the nurse should stop suctioning and ventilate the patient with 100% O2. There is
no indication that more frequent suctioning is needed. Lowering the suction pressure will
decrease the effectiveness of suctioning without improving the hypoxemia. Because the PVCs
occurred during suctioning, there is no need for antidysrhythmic medications (which may
have adverse effects) unless they recur when the suctioning is stopped, and patient is well
oxygenated.
Which assessment finding for a patient receiving mechanical ventilation indicates
the need for
suctioning?
a. The patient was last suctioned 6 hours ago.
b. The patient's oxygen saturation drops to 93%.
c. The patient's respiratory rate is 32 breaths/min.
d. The patient has occasional audible expiratory wheezes.
Ans: ANS: C
The increase in respiratory rate indicates that the patient may have decreased airway
clearance
and requires suctioning. Suctioning is done when patient assessment data indicate that it is
needed and not on a scheduled basis. Occasional expiratory wheezes do not indicate poor
airway clearance. Suctioning the patient may induce bronchospasm and increase wheezing. An
O2 saturation of 93% is acceptable and does not suggest that immediate suctioning is
needed.
5. The nurse notes thick, white secretions in the endotracheal tube (ET) of a
patient who is
receiving mechanical ventilation. Which intervention will most directly treat this
finding?
a. Reposition the patient every 1 to 2 hours.
b. Increase suctioning frequency to every hour.
Click here for more: Preppass - Stuvia
Lewis's chapter 28 (12 edition) Questions
with Detailed Verified Answers (100%
Correct Answers) /Already Graded A+
1. Which action would the nurse take to verify the correct placement of an oral
endotracheal tube (ET) immediately after insertion and before securing the tube?
a. Obtain a portable chest x-ray.
b. Use an end-tidal CO2 monitor.
c. Auscultate for bilateral breath sounds.
d. Observe for symmetrical chest movement
Ans: ANS: B
End-tidal CO2 monitors are currently recommended for rapid verification of ET placement.
Auscultation for bilateral breath sounds and checking chest expansion are also used, but they
are not as accurate as end-tidal CO2 monitoring. A chest x-ray confirms the placement but is
done after the tube is secured.
2. Which action would the nurse take to maintain proper endotracheal tube (ET)
cuff pressure when a patient is on mechanical ventilation?
a. Inflate the cuff with a minimum of 10 mL of air.
b. Inflate the cuff until the pilot balloon is firm on palpation.
c. Inject air into the cuff until a manometer shows 15 mm Hg pressure.
d. Inject air into the cuff until a slight leak is heard only at peak inflation.
Ans: ANS: D
The minimal occluding volume technique involves injecting air into the cuff until an air leak is
present only at peak inflation. the volume to inflate the cuff varies with the ET and the
patient's
size. Cuff pressure should be maintained at 20 to 30 mm Hg. An accurate assessment of cuff
pressure cannot be obtained by palpating the pilot balloon.
3. The nurse notes premature ventricular contractions (PVCs) on the monitor while
suctioning a patient's endotracheal tube. Which action would the nurse take?
, Page | 2
Click here for more: Preppass - Stuvia
a. Plan to suction the patient more frequently.
b. Decrease the suction pressure to 80 mm Hg.
c. Give antidysrhythmic medications per protocol.
d. Ventilate the patient with 100% oxygen.
Ans: ANS: D
Dysrhythmias during suctioning may indicate hypoxemia or sympathetic nervous system
stimulation. the nurse should stop suctioning and ventilate the patient with 100% O2. There is
no indication that more frequent suctioning is needed. Lowering the suction pressure will
decrease the effectiveness of suctioning without improving the hypoxemia. Because the PVCs
occurred during suctioning, there is no need for antidysrhythmic medications (which may
have adverse effects) unless they recur when the suctioning is stopped, and patient is well
oxygenated.
Which assessment finding for a patient receiving mechanical ventilation indicates
the need for
suctioning?
a. The patient was last suctioned 6 hours ago.
b. The patient's oxygen saturation drops to 93%.
c. The patient's respiratory rate is 32 breaths/min.
d. The patient has occasional audible expiratory wheezes.
Ans: ANS: C
The increase in respiratory rate indicates that the patient may have decreased airway
clearance
and requires suctioning. Suctioning is done when patient assessment data indicate that it is
needed and not on a scheduled basis. Occasional expiratory wheezes do not indicate poor
airway clearance. Suctioning the patient may induce bronchospasm and increase wheezing. An
O2 saturation of 93% is acceptable and does not suggest that immediate suctioning is
needed.
5. The nurse notes thick, white secretions in the endotracheal tube (ET) of a
patient who is
receiving mechanical ventilation. Which intervention will most directly treat this
finding?
a. Reposition the patient every 1 to 2 hours.
b. Increase suctioning frequency to every hour.
