D 449 Western Governors University Critical
Care Nursing hesi C.488 study guide Questions
and Answers |With 100% Verified Solutions |
Updated & Verified Rationale 2026/2027
Graded A+
What should you do if you can't troubleshoot a ventilator
alarm and the patient is tachycardic with dropping O2
saturation?
Put an Ambu bag on the patient with 100% oxygen.Alarms -
make sure all alarms are on (check every 4 hours minimum)
NEVER SILENCE ALARM!
What are potential causes for high-pressure ventilator
alarms?👉High pressure = Hard to Push Air In →
OBSTRUCTION.
High-pressure alarm = "Blocked or Tight."
Secretions
• Wheezing/bronchospasm
• Tube displaced or kinked
,• Decreased lung compliance (ARDS, pneumothorax)
• Water in tubing
• Biting the tube
• Coughing/gagging
What are potential causes for low-pressure ventilator
alarms?👉Low = Lost Air → DISCONNECTION.
Low-pressure alarm = "Leak or Loose."
Obstructed ventilator tube, patient biting the tube or coughing,
disconnection or ET cuff leak in the ventilator circuit, leak in the
patient's airway cuff, or the patient has stopped breathing.
Disconnected tubing. Client stops breathing (apnea alarm on
some modes).
PEEP keeps a little pressure in the lungs at the end of
exhalation so the alveoli don't collapse.👉 PEEP = "Keeps the
lungs Puffed at the end of exhale."
Keeps alveoli open,Improves oxygenation,Used in ARDS,
atelectasis, pulmonary edema.
What is the typical setting for PEEP(Positive End-Expiratory
Pressure)in mechanical ventilation?"PEEP of 5 keeps the lungs
alive."most common "normal" setting)
PEEP is usually kept at 5cm H2O.
What is the purpose of high PEEP in patients with ARDS/Acute
Respiratory DistressSyndrome?👉High PEEP in ARDS keeps
alveoli open, improves oxygenation, and allows for lower
,FiO₂.
Memory trick: "High PEEP = Pops open stuck alveoli."
High PEEP lets us use a lower FiO₂, which helps prevent oxygen
toxicity.High PEEP (10-20 cm H₂O): ARDS, severe hypoxemia,
pulmonary edema.
FiO₂ explained:
FiO₂ = the percent of oxygen the ventilator delivers.
What nursing interventions should be performed for
mechanically ventilated patients?Memory trick:
"Airway, Alarms, ABGs, Aspiration — the 4 A's."
VS q4h,Suction as needed,Oral care q2h,Reposition ET tube
q24h,
Prevent ulcers & DVT (PPIs + anticoagulation),Sedation
vacations (daily wake-up to assess neuro/need for sedation).
How often should oral care be provided to mechanically
ventilated patients?
Every 2hr/Q2h at a min.
What is a sedation vacation?👉 "Wake them to check
them."Meaning: Briefly lighten/stop sedation so you can
assess:
Temporarily removing sedation to assess a patient's readiness
for weaning from the ventilator.
, What should be established for conscious patients on
mechanical ventilation?Memory trick:
"Conscious = Communicate & Comfort."
Methods of communication(picture board)
What is required for a patient to be considered for weaning
from mechanical ventilation?
Patient must show spontaneous breathing before extubation.
Confirm tube placement with CO₂ detector, bilateral breath
sounds, and chest X-ray.
If the patient is about to be intubated and has pneumonia with
white frothy sputum, suction first.
What are common clinical manifestations of pneumonia?
Fever, cough, purulent sputum, hemoptysis, dyspnea, chest
pain, and adventitious breath sounds.
What are the signs of ventilator-associated pneumonia (VAP)?
Ventilator Adds Pneumonia"
VAP occurs when microbes enter the lungs via the ET tube.
Prevention: Head of bed 30-45°, oral care q2h, suction as
needed. "HOP" = Head, Oral, Position/Suction.
Positive sputum culture, fever, and chest x-ray showing new
infiltrates.
What nursing actions can prevent VAP?
Care Nursing hesi C.488 study guide Questions
and Answers |With 100% Verified Solutions |
Updated & Verified Rationale 2026/2027
Graded A+
What should you do if you can't troubleshoot a ventilator
alarm and the patient is tachycardic with dropping O2
saturation?
Put an Ambu bag on the patient with 100% oxygen.Alarms -
make sure all alarms are on (check every 4 hours minimum)
NEVER SILENCE ALARM!
What are potential causes for high-pressure ventilator
alarms?👉High pressure = Hard to Push Air In →
OBSTRUCTION.
High-pressure alarm = "Blocked or Tight."
Secretions
• Wheezing/bronchospasm
• Tube displaced or kinked
,• Decreased lung compliance (ARDS, pneumothorax)
• Water in tubing
• Biting the tube
• Coughing/gagging
What are potential causes for low-pressure ventilator
alarms?👉Low = Lost Air → DISCONNECTION.
Low-pressure alarm = "Leak or Loose."
Obstructed ventilator tube, patient biting the tube or coughing,
disconnection or ET cuff leak in the ventilator circuit, leak in the
patient's airway cuff, or the patient has stopped breathing.
Disconnected tubing. Client stops breathing (apnea alarm on
some modes).
PEEP keeps a little pressure in the lungs at the end of
exhalation so the alveoli don't collapse.👉 PEEP = "Keeps the
lungs Puffed at the end of exhale."
Keeps alveoli open,Improves oxygenation,Used in ARDS,
atelectasis, pulmonary edema.
What is the typical setting for PEEP(Positive End-Expiratory
Pressure)in mechanical ventilation?"PEEP of 5 keeps the lungs
alive."most common "normal" setting)
PEEP is usually kept at 5cm H2O.
What is the purpose of high PEEP in patients with ARDS/Acute
Respiratory DistressSyndrome?👉High PEEP in ARDS keeps
alveoli open, improves oxygenation, and allows for lower
,FiO₂.
Memory trick: "High PEEP = Pops open stuck alveoli."
High PEEP lets us use a lower FiO₂, which helps prevent oxygen
toxicity.High PEEP (10-20 cm H₂O): ARDS, severe hypoxemia,
pulmonary edema.
FiO₂ explained:
FiO₂ = the percent of oxygen the ventilator delivers.
What nursing interventions should be performed for
mechanically ventilated patients?Memory trick:
"Airway, Alarms, ABGs, Aspiration — the 4 A's."
VS q4h,Suction as needed,Oral care q2h,Reposition ET tube
q24h,
Prevent ulcers & DVT (PPIs + anticoagulation),Sedation
vacations (daily wake-up to assess neuro/need for sedation).
How often should oral care be provided to mechanically
ventilated patients?
Every 2hr/Q2h at a min.
What is a sedation vacation?👉 "Wake them to check
them."Meaning: Briefly lighten/stop sedation so you can
assess:
Temporarily removing sedation to assess a patient's readiness
for weaning from the ventilator.
, What should be established for conscious patients on
mechanical ventilation?Memory trick:
"Conscious = Communicate & Comfort."
Methods of communication(picture board)
What is required for a patient to be considered for weaning
from mechanical ventilation?
Patient must show spontaneous breathing before extubation.
Confirm tube placement with CO₂ detector, bilateral breath
sounds, and chest X-ray.
If the patient is about to be intubated and has pneumonia with
white frothy sputum, suction first.
What are common clinical manifestations of pneumonia?
Fever, cough, purulent sputum, hemoptysis, dyspnea, chest
pain, and adventitious breath sounds.
What are the signs of ventilator-associated pneumonia (VAP)?
Ventilator Adds Pneumonia"
VAP occurs when microbes enter the lungs via the ET tube.
Prevention: Head of bed 30-45°, oral care q2h, suction as
needed. "HOP" = Head, Oral, Position/Suction.
Positive sputum culture, fever, and chest x-ray showing new
infiltrates.
What nursing actions can prevent VAP?
