BKAT Study Set 2024-2025
Questions and Correct
Answers
What may a high pressure vent alarm indicate? -
ANSWERS-Pt is biting on the tubing,
excessive secretions in the tubing, kinked tubing
What may a low pressure vent alarm indicate? -
ANSWERS-cuff leak or the tubing is disconnected
somewhere
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How do you verify positioning of an
endotracheal tube? - ANSWERS--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 - ANSWERS-FALSE-- they should be
suctioned on an as needed basis
what should ET tube cuff pressure be kept at? -
ANSWERS-20-25 mmHg
What measures should nurses take to avoid ET tube
problems? - ANSWERS--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
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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? - ANSWERS- STOP and manually
hyperventilate with 100% oxygen
Measures to prevent aspiration? - ANSWERS-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? - ANSWERS-manage
ventilated patients without sedatives whenever
possible
-interrupt sedation once a day (spontaneous
breathing trials)
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-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? - ANSWERS-
BREATHING-- the diaphragm is innervated by C3-
C5 levels
C4-diaphragm
will likely need mechanical ventilation mgmt