Chapter 28: Supporting Ventilation -
Exam 1 with 31 complete solutions.
Chapter 28: Supporting Ventilation -
Exam 1 with 31 complete solutions.
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. - ANSWER 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.
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 mmHg pressure.
d. Inject air into the cuff until a slight leak is heard only at peak inflation. - ANSWER 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.
The nurse notes premature ventricular contractions (PVCs) on the monitor while suctioning a patient's
endotracheal tube. Which action would the nurse take?
a. Plan to suction the patient more frequently.
, Chapter 28: Supporting Ventilation -
Exam 1 with 31 complete solutions.
b. Decrease the suction pressure to 80 mmHg.
c. Give antidysrhythmic medications per protocol.
d. Ventilate the patient with 100% oxygen. - ANSWER 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 the 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. - ANSWER ANS: C
The increase in respiratory rate indicates that the patient may have decreased airway clearance and
require 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.
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.
c. Add additional water to the patient's enteral feedings.
d. Instill 5 mL of sterile saline into the ET before suctioning. - ANSWER 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
Exam 1 with 31 complete solutions.
Chapter 28: Supporting Ventilation -
Exam 1 with 31 complete solutions.
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. - ANSWER 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.
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 mmHg pressure.
d. Inject air into the cuff until a slight leak is heard only at peak inflation. - ANSWER 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.
The nurse notes premature ventricular contractions (PVCs) on the monitor while suctioning a patient's
endotracheal tube. Which action would the nurse take?
a. Plan to suction the patient more frequently.
, Chapter 28: Supporting Ventilation -
Exam 1 with 31 complete solutions.
b. Decrease the suction pressure to 80 mmHg.
c. Give antidysrhythmic medications per protocol.
d. Ventilate the patient with 100% oxygen. - ANSWER 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 the 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. - ANSWER ANS: C
The increase in respiratory rate indicates that the patient may have decreased airway clearance and
require 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.
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.
c. Add additional water to the patient's enteral feedings.
d. Instill 5 mL of sterile saline into the ET before suctioning. - ANSWER 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
