Chapter 66 Flashcards
After change-of-shift report on a ventilator weaning unit, which patient should the nurse assess first?
a. Patient who failed a spontaneous breathing trial and has been placed in a rest mode on the ventilator
b. Patient who is intubated and has continuous partial pressure end-tidal CO2 (PETCO2) monitoring
c. Patient with a central venous oxygen saturation (ScvO2) of 69% while on bilevel positive airway pressure
(BiPAP)
d. Patient who was successfully weaned and extubated 4 hours ago and now has no urine output for the last
6 hours
ANS: D
The decreased urine output may indicate acute kidney injury or that the patient’s cardiac output
and perfusion of vital organs have decreased. Any of these causes would require rapid action.
The data about the other patients indicate that their conditions are stable and do not require
immediate assessment or changes in their care. Continuous PETCO2 monitoring is frequently
used when patients are intubated. The rest mode should be used to allow patient recovery
after a failed SBT, and an ScvO2 of 69% is within normal limits
After change-of-shift report, which patient should the progressive care nurse assess first?
a. Patient who was extubated in the morning and has a temperature of 101.4° F (38.6° C)
b. Patient with bilevel positive airway pressure (BiPAP) for sleep apnea whose respiratory rate is 16
c. Patient with arterial pressure monitoring who is 2 hours post-percutaneous coronary intervention who
needs to void
d. Patient who is receiving IV heparin for a venous thromboembolism and has a partial thromboplastin time
(PTT) of 98 sec
ANS: D
The findings for this patient indicate high risk for bleeding from an elevated (nontherapeutic)
PTT. The nurse needs to adjust the rate of the infusion (dose) per the health care provider’s
parameters. The patient with BiPAP for sleep apnea has a normal respiratory rate. The patient
recovering from the percutaneous coronary intervention will need to be assisted with voiding
and this task could be delegated to unlicensed assistive personnel. The patient with a fever may
be developing ventilator-associated pneumonia, but addressing the bleeding risk is a higher
priority
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 7.51, PaO2 of 82 mm Hg, PaCO2 of 26
mm Hg, and HCO3- of 23 mEq/L (23 mmol/L). The nurse will anticipate the need to
a. increase the FIO2.
b. increase the tidal volume.
c. increase the respiratory rate.
d. decrease the respiratory rate.
ANS: D
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 and increasing the respiratory rate and
tidal volume would further lower the PaCO2
The nurse educator is evaluating the care that a new registered nurse (RN) provides to a patient receiving
mechanical ventilation. Which action by the new RN indicates the need for more education?
a. The RN increases the FIO2 to 100% before suctioning.
b. The RN secures a bite block in place using adhesive tape.
c. The RN asks for assistance to reposition the endotracheal tube.
d. The RN positions the patient with the head of bed at 10 degrees.
ANS: D
The head of the patient’s bed should be positioned at 30
to 45 degrees to prevent ventilator-associated pneumonia.
The other actions by the new RN are appropriate
The nurse educator is evaluating the performance of a new registered nurse (RN) who is providing care to a
patient who is receiving mechanical ventilation with 15 cm H2O of peak end-expiratory pressure (PEEP).
Which action indicates that the new RN is safe?
a. The RN plans to suction the patient every 1 to 2 hours.
b. The RN uses a closed-suction technique to suction the patient.
c. The RN tapes connection between the ventilator tubing and the ET.
d. The RN changes the ventilator circuit tubing routinely every 48 hours.
ANS: B
The closed-suction technique is used when patients require high levels of PEEP (>10 cm H2O) to prevent the
loss of PEEP that occurs when disconnecting the patient from the ventilator. Suctioning should not be
scheduled routinely, but it should be done only when patient assessment data indicate the need for
suctioning. Taping connections between the ET and the ventilator tubing would restrict the ability of the
tubing to swivel in response to patient repositioning. Ventilator tubing changes increase the risk for
ventilator-associated pneumonia (VAP) and are not indicated routinely
The nurse is caring for a patient with a subarachnoid hemorrhage who is intubated and placed on a
mechanical ventilator with 10 cm H2O of peak end-expiratory pressure (PEEP). When monitoring the patient,
the nurse will need to notify the health care provider immediately if the patient develops
a. oxygen saturation of 93%.
b. respirations of 20 breaths/minute.
c. green nasogastric tube drainage.
d. increased jugular venous distention.
ANS: D
Increases in jugular venous distention in a patient with a subarachnoid
hemorrhage may indicate an increase in intracranial pressure (ICP) and that
the PEEP setting is too high for this patient. A respiratory rate of 20, O2
saturation of 93%, and green nasogastric tube drainage are within normal
limits
A nurse is weaning a 68-kg male patient who has chronic obstructive pulmonary disease (COPD) from
mechanical ventilation. Which patient assessment finding indicates that the weaning protocol should be
stopped?
a. The patient’s heart rate is 97 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 450 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 450 mL
is within the acceptable range
The nurse notes premature ventricular contractions (PVCs) while suctioning a patient’s
endotracheal tube. Which action by the nurse is a priority?
a. Decrease the suction pressure to 80 mm Hg.
b. Document the dysrhythmia in the patient’s chart.
c. Stop and ventilate the patient with 100% oxygen.
d. Give antidysrhythmic medications per protocol
ANS: C
Dysrhythmias during suctioning may indicate hypoxemia or sympathetic nervous system
stimulation. The nurse should stop suctioning and ventilate the patient with 100% oxygen.
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 patient is well oxygenated
The nurse notes that a patient’s endotracheal tube (ET), which was at the 22-cm mark, is now at
the 25-cm mark and the patient is anxious and restless. Which action should the nurse take
next?
a. Offer reassurance to the patient.
b. Bag the patient at an FIO2 of 100%.
c. Listen to the patient’s breath sounds.
d. Notify the patient’s health care provider.
ANS: C
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 are also appropriate, but detection and correction of tube
malposition are the most critical actions.
The nurse notes thick, white secretions in the endotracheal tube (ET) of a patient who is receiving mechanical
ventilation. Which intervention will be most effective in addressing this problem?
a. Increase suctioning to every hour.
b. Reposition the patient every 1 to 2 hours.
c. Add additional water to the patient’s enteral feedings.
d. Instill 5 mL of sterile saline into the 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
The nurse responds to a ventilator alarm and finds the patient lying in bed holding the
endotracheal tube (ET). Which action should the nurse take next?
a. Activate the rapid response team.
b. Provide reassurance to the patient.
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 are also appropriate after the
nurse has stabilized the patient’s oxygenation
A patient who is orally intubated and receiving mechanical ventilation is anxious and is “fighting”
the ventilator. Which action should the nurse take next?
a. Verbally coach the patient to breathe with the ventilator.
b. Sedate the patient with the ordered PRN lorazepam (Ativan).
c. Manually ventilate the patient with a bag-valve-mask device.
d. Increase the rate for the ordered propofol (Diprivan) infusion.
ANS: A
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 may also be helpful
if the verbal coaching is ineffective in reducing the patient’s anxiety.
A patient who is receiving positive pressure ventilation is scheduled for a spontaneous breathing trial (SBT).
Which finding by the nurse is most important to discuss with the health care provider before starting the
SBT?
a. New ST segment elevation is noted on the cardiac monitor.
b. Enteral feedings are being given through an orogastric tube.
c. Scattered rhonchi are heard when auscultating breath sounds.
d. HYDROmorphone (Dilaudid) is being used to treat postoperative pain.
ANS: A
Myocardial ischemia is a contraindication for ventilator weaning. The ST segment elevation is an
indication that weaning should be postponed until further investigation and/or treatment for
myocardial ischemia can be done. The other information will also be shared with the health
care provider, but ventilator weaning can proceed when opioids are used for pain
management, abnormal lung sounds are present, or enteral feedings are being used
A patient with respiratory failure has arterial pressure-based cardiac output (APCO) monitoring and is
receiving mechanical ventilation with peak end-expiratory pressure (PEEP) of 12 cm H2O. Which information
indicates that a change in the ventilator settings may be required?
a. The arterial pressure is 90/46.
b. The heart rate is 58 beats/minute.
c. The stroke volume is increased.
d. The stroke volume variation is 12%.
ANS: A
The hypotension suggests that the high intrathoracic pressure
caused by the PEEP may be decreasing venous return and
(potentially) cardiac output. The other assessment data would
not be a direct result of PEEP and mechanical ventilation
To maintain proper cuff pressure of an endotracheal tube (ET) when the patient is on
mechanical ventilation, the nurse should
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 mm Hg pressure.
d. inject 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
