BKAT STUDY SET COMPLETELY
SOLVED!!!
Normal blood gases; pH - ANSWER 7.35-7.45
Normal blood gases: CO2 - ANSWER 35-45
Normal blood gases: HcO3 - ANSWER 22-26
Normal blood gases: PO2 - ANSWER 80 or above
Normal vacuum pressures for suction? - ANSWER 120-140 mmHg
What may a high pressure vent alarm indicate? - ANSWER Pt is biting on the tubing,
excessive secretions in the tubing, kinked tubing
What may a low pressure vent alarm indicate? - ANSWER cuff leak or the tubing is
disconnected somewhere
How do you verify positioning of an endotracheal tube? - ANSWER -auscultate lung
bases and apices for bilateral breath sounds
-observe chest for symmetric chest wall movement
-confirm with end tidal CO2 measure
GOLD STANDARD: chest x-ray
t/f: people with ET tubes should be suctioned routinely - ANSWER FALSE-- they should
be suctioned on an as needed basis
what should ET tube cuff pressure be kept at? - ANSWER 20-25 mmHg
What measures should nurses take to avoid ET tube problems? - ANSWER -confirm
that exit mark on ET tube remains constant when providing patient care, repositioning,
and transporting patient
-maintain proper cuff inflation (listen for an air leak-- if pt can talk, you must inflate more)
-continually monitor SpO2, RR, HR and rhythm, mental status, and ABGs
-pre-oxygenate before suctioning
What should be done if a patient is not tolerating ET tube suctioning? - ANSWER STOP
and manually hyperventilate with 100% oxygen
Measures to prevent aspiration? - ANSWER -avoid bolus tube feedings
-monitor tube feeding residuals
-maintain HOB at LEAST 30 degrees or greater
, -maintain proper ET tube cuff inflation
-perform frequent oral pharyngeal suctioning
-maintain an NG tube connected to low, intermittent suction if feeding tube is placed
below the pylorus
what are recommendations for preventing ventilator associated pneumonia? - ANSWER
-manage ventilated patients without sedatives whenever possible
-interrupt sedation once a day (spontaneous breathing trials)
-provide early exercise and mobility
-provide regular oral care
-minimize pooling of secretions above the ET tube cuff
-use ET tubes with subglottic secretion drainage for patients likely to require greater
than 72 hours of intubation
-keep HOB elevated 30-45 degress
-change ventilator circuit only if visibly soiled or malfunctioning
What is the biggest complication associated with high cervical spinal cord injuries? -
ANSWER BREATHING-- the diaphragm is innervated by C3-C5 levels
C4-diaphragm
will likely need mechanical ventilation mgmt
signs and symptoms of increased intracranial pressure? - ANSWER -altered LOC
-headache
-bradycardia
-decreased respirations
-acute HTN with widening pulse pressure
-N/V
-worsening neuro deficits
-pupils that are nonreactive
What are the components of a neuro exam? (7) - ANSWER 1. LOC
2. mental status and cognitive function
3. cranial nerves
4. motor
5. sensory
6. coordination
7. reflexes
What are the three components of the glasgow coma scale? - ANSWER 1. eye opening
2. motor
3. verbal
What is a negative and positive babinski reflex? what do each indicate? - ANSWER
negative (normal) response: toes curl downward
SOLVED!!!
Normal blood gases; pH - ANSWER 7.35-7.45
Normal blood gases: CO2 - ANSWER 35-45
Normal blood gases: HcO3 - ANSWER 22-26
Normal blood gases: PO2 - ANSWER 80 or above
Normal vacuum pressures for suction? - ANSWER 120-140 mmHg
What may a high pressure vent alarm indicate? - ANSWER Pt is biting on the tubing,
excessive secretions in the tubing, kinked tubing
What may a low pressure vent alarm indicate? - ANSWER cuff leak or the tubing is
disconnected somewhere
How do you verify positioning of an endotracheal tube? - ANSWER -auscultate lung
bases and apices for bilateral breath sounds
-observe chest for symmetric chest wall movement
-confirm with end tidal CO2 measure
GOLD STANDARD: chest x-ray
t/f: people with ET tubes should be suctioned routinely - ANSWER FALSE-- they should
be suctioned on an as needed basis
what should ET tube cuff pressure be kept at? - ANSWER 20-25 mmHg
What measures should nurses take to avoid ET tube problems? - ANSWER -confirm
that exit mark on ET tube remains constant when providing patient care, repositioning,
and transporting patient
-maintain proper cuff inflation (listen for an air leak-- if pt can talk, you must inflate more)
-continually monitor SpO2, RR, HR and rhythm, mental status, and ABGs
-pre-oxygenate before suctioning
What should be done if a patient is not tolerating ET tube suctioning? - ANSWER STOP
and manually hyperventilate with 100% oxygen
Measures to prevent aspiration? - ANSWER -avoid bolus tube feedings
-monitor tube feeding residuals
-maintain HOB at LEAST 30 degrees or greater
, -maintain proper ET tube cuff inflation
-perform frequent oral pharyngeal suctioning
-maintain an NG tube connected to low, intermittent suction if feeding tube is placed
below the pylorus
what are recommendations for preventing ventilator associated pneumonia? - ANSWER
-manage ventilated patients without sedatives whenever possible
-interrupt sedation once a day (spontaneous breathing trials)
-provide early exercise and mobility
-provide regular oral care
-minimize pooling of secretions above the ET tube cuff
-use ET tubes with subglottic secretion drainage for patients likely to require greater
than 72 hours of intubation
-keep HOB elevated 30-45 degress
-change ventilator circuit only if visibly soiled or malfunctioning
What is the biggest complication associated with high cervical spinal cord injuries? -
ANSWER BREATHING-- the diaphragm is innervated by C3-C5 levels
C4-diaphragm
will likely need mechanical ventilation mgmt
signs and symptoms of increased intracranial pressure? - ANSWER -altered LOC
-headache
-bradycardia
-decreased respirations
-acute HTN with widening pulse pressure
-N/V
-worsening neuro deficits
-pupils that are nonreactive
What are the components of a neuro exam? (7) - ANSWER 1. LOC
2. mental status and cognitive function
3. cranial nerves
4. motor
5. sensory
6. coordination
7. reflexes
What are the three components of the glasgow coma scale? - ANSWER 1. eye opening
2. motor
3. verbal
What is a negative and positive babinski reflex? what do each indicate? - ANSWER
negative (normal) response: toes curl downward
