NUR 417 Exam 2
how is the placement of an ET tube INITIALLY verified? ANS: auscultate the lungs
auscultate the epigastrium
observe chest wall
use CO2 detector
if the ET tube is placed correctly, auscultating the lungs should show... ANS: bilateral breath sounds
if the ET tube is placed correctly, auscultating the epigastrium should show... ANS: absence of air sounds
if the ET tube is placed correctly, observing the chest wall should show... ANS: symmetrical movement
types of CO2 detectors ANS: EtCO2 detector
colorimeter CO2 detector
if the ET tube is placed correctly, an EtCO2 detector should show... ANS: presence of exhaled CO2 from
the lungs
steadily rising CO2 value & presence of a waveform
,if the ET tube is placed correctly, a colorimeter CO2 detector will show... ANS: a color change or a
number indicating presence of CO2 over 5-6 exhalations
how is the placement of an ET tube OFFICIALLY verified? ANS: chest x-ray
the chest x-ray of a client with a ET tube should show a tube located at... ANS: 2-3 cm above the carina
what is a premature ventricular contraction (PVC)? ANS: a contraction coming from an ectopic focus in
the ventricles
(premature occurrence of a QRS)
what is an ectopic focus? ANS: area of spontaneous firing other than the SA node
what can cause a PVC? ANS: stimulants
electrolyte imbalances
hypoxia (!)
fever
exercise
emotional stress
,how are PVC's treated? ANS: in relation to the cause of the PVC
if the PVC is related to hypoxia, what is the indicated treatment? ANS: O2 therapy
what are the priority assessments the nurse should perform on a client who is mechanically ventilated
to assess oxygenation? ANS: respiratory rate and rhythm
auscultate the lungs!
what is weaning? ANS: the process of gradually reducing ventilator support and allowing the client to
assume greater responsibility for breathing spontaneously
what types of weaning are there? ANS: spontaneous awakening trial
spontaneous breathing trial
what do these trials do? ANS: help assess the ability of the client to maintain a stable respiratory drive
and adequate O2 saturation
during a weaning trial, what assessment finding would indicate a need to end the trial? ANS: tachypnea
dyspnea
tachycardia
dysrhythmias
, sustain desaturation (<92%)
hyper- or hypotension
agitation
diaphoresis
anxiety
change in mental status
what are ventilator alarms set to do? ANS: alert potentially dangerous situations like:
-client-ventilator dyssynchrony
-ventilator disconnection/malfunction
-unplanned extubation
ventilator alarms should always be... ANS: ON
(some allow silencing for 2 mins to suction after which it automatically turns back on)
what should the nurse plan for should a ventilator alarm go off? ANS: immediate need to manually
ventilate with 100% oxygen
(assume the worst!)
how is the placement of an ET tube INITIALLY verified? ANS: auscultate the lungs
auscultate the epigastrium
observe chest wall
use CO2 detector
if the ET tube is placed correctly, auscultating the lungs should show... ANS: bilateral breath sounds
if the ET tube is placed correctly, auscultating the epigastrium should show... ANS: absence of air sounds
if the ET tube is placed correctly, observing the chest wall should show... ANS: symmetrical movement
types of CO2 detectors ANS: EtCO2 detector
colorimeter CO2 detector
if the ET tube is placed correctly, an EtCO2 detector should show... ANS: presence of exhaled CO2 from
the lungs
steadily rising CO2 value & presence of a waveform
,if the ET tube is placed correctly, a colorimeter CO2 detector will show... ANS: a color change or a
number indicating presence of CO2 over 5-6 exhalations
how is the placement of an ET tube OFFICIALLY verified? ANS: chest x-ray
the chest x-ray of a client with a ET tube should show a tube located at... ANS: 2-3 cm above the carina
what is a premature ventricular contraction (PVC)? ANS: a contraction coming from an ectopic focus in
the ventricles
(premature occurrence of a QRS)
what is an ectopic focus? ANS: area of spontaneous firing other than the SA node
what can cause a PVC? ANS: stimulants
electrolyte imbalances
hypoxia (!)
fever
exercise
emotional stress
,how are PVC's treated? ANS: in relation to the cause of the PVC
if the PVC is related to hypoxia, what is the indicated treatment? ANS: O2 therapy
what are the priority assessments the nurse should perform on a client who is mechanically ventilated
to assess oxygenation? ANS: respiratory rate and rhythm
auscultate the lungs!
what is weaning? ANS: the process of gradually reducing ventilator support and allowing the client to
assume greater responsibility for breathing spontaneously
what types of weaning are there? ANS: spontaneous awakening trial
spontaneous breathing trial
what do these trials do? ANS: help assess the ability of the client to maintain a stable respiratory drive
and adequate O2 saturation
during a weaning trial, what assessment finding would indicate a need to end the trial? ANS: tachypnea
dyspnea
tachycardia
dysrhythmias
, sustain desaturation (<92%)
hyper- or hypotension
agitation
diaphoresis
anxiety
change in mental status
what are ventilator alarms set to do? ANS: alert potentially dangerous situations like:
-client-ventilator dyssynchrony
-ventilator disconnection/malfunction
-unplanned extubation
ventilator alarms should always be... ANS: ON
(some allow silencing for 2 mins to suction after which it automatically turns back on)
what should the nurse plan for should a ventilator alarm go off? ANS: immediate need to manually
ventilate with 100% oxygen
(assume the worst!)
