Chapter 21 AC

A patient is being mechanically ventilated with an oral endotracheal tube in place. The nurse observes that the cuff pressure is 25 mm Hg. The nurse is aware of what complications that can be caused by this pressure? (Select all that apply.)

-Tracheal ischemia -Tracheal bleeding -Pressure necrosis.

A patient with emphysema informs the nurse, "The surgeon will be removing about 30% of my lung so that I will not be so short of breath and will have an improved quality of life." What surgery does the nurse understand the surgeon will perform?

A lung volume reduction

A patient is to receive an oxygen concentration of 70%. What is the best way for the nurse to deliver this concentration?

A partial rebreathing mask.

A patient with COPD requires oxygen administration. What method of delivery does the nurse know would produce optimal results for this patient?

A venturi mask

A patient is brought into the emergency department with carbon monoxide poisoning after escaping a house fire. What should the nurse monitor this patient for?

Anemic hypoxia

A new ICU nurse is observed by her preceptor entering a patient's room to suction the tracheostomy after performing the task 15 minutes before. What should the preceptor educate the new nurse to do to ensure that the patient needs to be suctioned?

Auscultate the lung for adventitious sounds

The nurse assesses a patient with a heart rate of 42 bpm and a blood pressure of 70/ 46 mm HG. What type of hypoxia does the nurse determine this patient is displaying?

Circulatory hypoxia

A patient is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this patient?

Continuous positive airway pressure

The nurse is transporting a patient with chest tubes to a treatment room. The chest tube becomes disconnected and falls between the bed rail. What is the priority action by the nurse?

Cut the contaminated tip of the tube and insert a sterile connector and reattach.

The nurse hears the patient's ventilator alarm sound and attempts to find the cause. What is the priority action of the nurse when the cause of the alarm is not able to be determined?

Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved.

A patient is being educated in the use of incentive spirometry prior to having a surgical procedure. What should the nurse be sure to include in the education?

Encourage the patient to take approximately 20 breaths per hour, while awake.

The nurse is educating a patient with COPD about the technique for performing pursed lip breathing. What does the nurse inform the patient is the importance of using this technique?

It prolongs exhalation.

The nurse is assessing a patient with chest tubes connected to a drainage system. What should the first action be when the nurse observes excessive bubbling in the water seal chamber?

Notify the healthcare provider

A patient with emphysema is placed on continuous oxygen at 2L/min at home. Why is it important for the nurse to educate the patient and family that they must have No smoking signs placed on the doors?

Oxygen supports combustion

A patient has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the patient reports tingling in the fingers and shortness of breath, is extremely restless, and describes pain beneth the breastbone. What condition should the nurse suspect?

Oxygen toxicity

The nurse is admitting a patient with COPD. The decrease of what substance in the blood gas analysis would indicate to the nurse that the patient is experiencing hypoxemia?

PaO2

The nurse suctions a patient through the endotracheal tube for 20 seconds and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient?

The patient is hypoxic from suctioning.

A patient in the ICU has been orally intubated and on mechanical ventilation for 2 weeks after having a severe stroke. What action does the nurse anticipate the healthcare provider will take now that the patient has been intubated for this length of time?

The patient will have an insertion of a tracheostomy tube.

The nurse is using an in-line suction kit to suction a patient who is intubated and on a mechanical ventilator. What benefits does in-line suction have for the patient? (Select all that apply.)

- Decreases hypoxemia - Decreases patient anxiety - Sustains positive end expiratory pressure (PEEP)

The nurse is educating the patient in the use of mini-nebulizer. What should the nurse encourage the patient to do? (Select all that apply)

-Hold the breath at the end of inspiration for a few seconds. -Cough frequently. -Frequently evaluate progress.