Critical Care Vent management questions and answers

To verify the correct placement of an endotracheal tube (ET) after insertion, the best initial action by the nurse is to a. auscultate for the presence of bilateral breath sounds. b. obtain a portable chest radiograph to check tube placement. c. observe the chest for symmetrical movement with ventilation. d. use an end-tidal CO2 monitor to check for placement in the trachea. ANS: D End-tidal CO2 monitors are currently recommended for rapid verification of ET placement. Auscultation for bilateral breath sounds and checking chest expansion also are 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. DIF: Cognitive Level: Application REF: TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity To inflate the cuff of an endotracheal tube (ET) when the patient is on mechanical ventilation, the nurse a. inflates the cuff until the pilot balloon is firm. b. inflates the cuff with a minimum of 10 mL of air. c. injects air into the cuff until a manometer shows 15 mm Hg pressure. d. injects air into the cuff until a slight leak is heard only at peak inflation. 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 25 mm Hg. An accurate assessment of cuff pressure cannot be obtained by palpating the pilot balloon. DIF: Cognitive Level: Comprehension REF: TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity Which assessment information obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning? a. The respiratory rate is 32 breaths/min. b. The pulse oximeter shows a SpO2 of 93%. c. The patient has not been suctioned for the last 6 hours. d. The lungs have occasional audible expiratory wheezes. ANS: A 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, not on a scheduled basis. Occasional expiratory wheezes do not indicate poor airway clearance, and suctioning the patient may induce bronchospasm and increase wheezing. An SpO2 of 93% is acceptable and does not suggest that immediate suctioning is needed. DIF: Cognitive Level: Application REF: TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity The nurse notes thick, white respiratory secretions for a patient who is receiving mechanical ventilation. Which intervention will be most effective in resolving this problem? a. Suction the patient every hour. b. Reposition the patient every 2 hours. c. Add additional water to the patient's enteral feedings. d. Instill 5 mL of sterile saline into the endotracheal tube (ET) before suctioning. ANS: C Because the patient's secretions are thick, better hydration is indicated. Suctioning every hour without any specific evidence for the need will increase the incidence of mucosal trauma and would not address the etiology of the ineffective airway clearance. Instillation of saline does not liquefy secretions and may decrease the SpO2. Repositioning the patient is appropriate but will not decrease the thickness of secretions. DIF: Cognitive Level: Application REF: TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity Four hours after mechanical ventilation is initiated for a patient with chronic obstructive pulmonary disease (COPD), the patient's arterial blood gas (ABG) results include a pH of 7.50, PaO2 of 80 mm Hg, PaCO2 of 29 mm Hg, and HCO3- of 23 mEq/L (23 mmol/L). The nurse will anticipate the need to a. increase the FIO2. b. decrease the respiratory rate. c. increase the tidal volume (VT). d. leave the ventilator at the current settings. ANS: B The patient's PaCO2 and pH indicate respiratory alkalosis caused by too high a respiratory rate. The PaO2 is appropriate for a patient with COPD, increasing the tidal volume would further lower the PaCO2, and the PaCO2 and pH indicate a need to make the ventilator changes. DIF: Cognitive Level: Analysis REF: TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity A patient with respiratory failure has hemodynamic monitoring and is receiving mechanical ventilation with peak end-expiratory pressure (PEEP) of 10 cm H2O. Which information indicates that a change in the ventilator settings may be required? a. The arterial line shows a blood pressure of 90/46. b. The pulmonary artery pressure (PAP) is decreased. c. The cardiac monitor shows a heart rate of 58 beats/min. d. The pulmonary artery wedge pressure (PAWP) is increased. ANS: A The hypotension indicates that the high intrathoracic pressure caused by the PEEP may be decreasing venous return and cardiac output (CO). The other assessment data would not be caused by mechanical ventilation. DIF: Cognitive Level: Application REF: 1710 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity When the nurse is weaning a patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation, which patient assessment indicates that the weaning protocol should be discontinued? a. The patient heart rate is 98 beats/min. b. The patient's oxygen saturation is 93%. c. The patient respiratory rate is 32 breaths/min. d. The patient's spontaneous tidal volume is 500 mL. ANS: C Tachypnea is a sign that the patient's work of breathing is too high to allow weaning to proceed. The patient's heart rate is within normal limits, although the nurse should continue to monitor it. An oxygen saturation of 93% is acceptable for a patient with COPD. A spontaneous tidal volume of 500 mL is within the acceptable range. DIF: Cognitive Level: Application REF: 1713 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity While assessing a patient with a central venous catheter, the nurse notes the catheter insertion site is red and tender and the patient's temperature is 101.8° F. The nurse will plan to a. administer analgesics and antibiotics. b. check the site frequently for any swelling. c. discontinue the catheter and culture the tip. d. change the flush system and monitor the site. ANS: C The information indicates that the patient has a local and systemic infection caused by the catheter and the catheter should be discontinued. Changing the flush system, administration of analgesics, and continued monitoring will not help prevent or treat the infection. Administration of antibiotics is appropriate, but the line should still be discontinued to avoid further complications such as endocarditis. DIF: Cognitive Level: Application REF: 1696 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity An elderly patient who has stabilized after being in the intensive care unit (ICU) for a week is preparing for transfer to the step down unit when the nurse notices that the patient has new onset confusion. The nurse will plan to a. inform the receiving nurse and then transfer the patient. b. notify the health care provider and postpone the transfer. c. administer PRN lorazepam (Ativan) and cancel the transfer. d. obtain an order for restraints as needed and transfer the patient. ANS: A The patient's history and symptoms most likely indicate delirium associated with the sleep deprivation and sensory overload in the ICU environment, and informing the receiving nurse and transferring the patient is appropriate. Postponing the transfer is likely to prolong the delirium. Benzodiazepines and restraints contribute to delirium and agitation. DIF: Cognitive Level: Application REF: 1686 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity The family members of a patient who has just been admitted to the intensive care unit (ICU) with multiple traumatic injuries have just arrived in the ICU waiting room. Which action should the nurse take first? a. Immediately take the family members to the patient's room. b. Discuss ICU visitation policies and encourage family visits. c. Describe the patient's injuries and the care that is being provided. d. Invite the family to participate in a multidisciplinary care conference. ANS: C Lack of information is a major source of anxiety for family members and should be addressed first. Family members should be prepared for the patient's appearance and the ICU environment before visiting the patient for the first time. ICU visiting should be individualized to each patient and family rather than being dictated by rigid visitation policies. Inviting the family to participate in a multidisciplinary conference is appropriate but should not be the initial action by the nurse. DIF: Cognitive Level: Application REF: OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity When the ventilator alarm sounds, the nurse finds the patient lying in bed holding the endotracheal tube (ET). Which action should the nurse take first? a. Offer reassurance to the patient. b. Activate the hospital's rapid response team. c. Call the health care provider to reinsert the tube. d. Manually ventilate the patient with 100% oxygen. ANS: D The nurse should ensure maximal patient oxygenation by manually ventilating with a bag-valve-mask system. Offering reassurance to the patient, notifying the health care provider about the need to reinsert the tube, and activating the rapid response team also are appropriate after the nurse has stabilized the patient's oxygenation. DIF: Cognitive Level: Application REF: OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity The nurse notes that a patient's endotracheal tube (ET), which was at the 21-cm mark, is now at the 24-cm mark and the patient appears anxious and restless. Which action should the nurse take first? a. Listen to the patient's lungs. b. Offer reassurance to the patient. c. Bag the patient at an FIO2 of 100%. d. Notify the patient's health care provider. ANS: A The nurse should first determine whether the ET tube has been displaced into the right mainstem bronchus by listening for unilateral breath sounds. If so, assistance will be needed to reposition the tube immediately. The other actions also are appropriate, but detection and correction of tube malposition are the most critical actions. DIF: Cognitive Level: Application REF: OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity When the charge nurse is evaluating the care that a new RN staff member provides to a patient receiving mechanical ventilation, which action by the new RN indicates the need for more education? a. The RN turns the FIO2 up to 100% before suctioning. b. The RN secures a bite block in place using adhesive tape. c. The RN positions the patient with the head of bed at 10 degrees. d. The RN asks for assistance to turn the patient to the prone position. ANS: C The head of the patient's bed should be positioned at 30 to 45 degrees to prevent ventilator-acquired pneumonia. The other actions by the new RN are appropriate. DIF: Cognitive Level: Application REF: 1711 OBJ: Special Questions: Delegation TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment A patient who is receiving mechanical ventilation is anxious and is "fighting" the ventilator. Which action should the nurse take first? a. Ventilate the patient with a manual resuscitation bag. b. Verbally coach the patient to breathe with the ventilator. c. Sedate the patient with the ordered PRN lorazepam (Ativan). d. Increase the rate for the ordered propofol (Diprivan) infusion. ANS: B The initial response by the nurse should be to try to decrease the patient's anxiety by coaching the patient about how to coordinate respirations with the ventilator. The other actions also may be helpful if the verbal coaching is ineffective in reducing the patient's anxiety. DIF: Cognitive Level: Application REF: OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity