AH III Exam 2

A 242-pound client is being mechanically ventilated. To prevent lung injury, what setting should the nurse anticipate for tidal volume? (Record your answer using a whole number.) ___ m

660 mL A low tidal volume of 6 mL/kg is used to prevent lung injury. 242 pounds = 110 kg. 110 kg 6 mL/kg

The patient is a 53-year-old woman who had major abdominal surgery for a bowel resection 2 days ago. She is a current smoker with a 40 pack-year smoking history. She also has chronic obstructive pulmonary disease and had a right upper lobe lung removal in the past. The nursing assistant calls you to the patient's room because her pulse oximeter is alarming and indicates an SpO2 of 50%. The patient reports mild shortness of breath and her blood pressure is 76/42. 1. What should be your first actions? Provide a rationale for your choice(s). 2. The health care provider asks you to send a D-dimer laboratory test. Is this test diagnostic for a PE? Why or why not? 3. The health care provider believes that patient has a PE and wants to start anticoagulation before the patient has a CT scan for confirmation. Is this an appropriate action? Why or why not? 4. Your patient does have a PE and has completed her inpatient therapy. She is to be discharged to home on warfarin therapy. What are the important issues to include in the discharge plan? 5. What other interprofessional team members would be helpful to involve in this patient's care and why?

1. What should be your first actions? Provide a rationale for your choice(s). ANS: Provide supplemental oxygen or increase the delivered FiO2. This patient is very hypoxic. Call the rapid response team. The low blood pressure along with the hypoxemia indicates hemodynamic instability. She needs immediate assistance to prevent further clinical deterioration. The FiO2 should be increased to provide an oxygen saturation of at least 92%. She will most likely need IV fluids and vasopressors to manage the hypotension. 2. The health care provider asks you to send a D-dimer laboratory test. Is this test diagnostic for a PE? Why or why not? ANS: The D-dimer is the degradation product of fibrinogen. High levels can indicate the presence of a clot; low levels can rule out a clot. However, it is not specific for a pulmonary embolism and many factors can cause elevated levels, including surgery. Because this patient had major surgery only 2 days ago, this test would not be helpful to diagnose a PE. 3. The health care provider believes that patient has a PE and wants to start anticoagulation before the patient has a CT scan for confirmation. Is this an appropriate intervention order? Why or why not? ANS: If the health care provider has a high suspicion that the patient has a PE, it is appropriate to start parenteral anticoagulation even though she had surgery 2 days ago. Delaying anticoagulation therapy could result in extension of an existing clot and development of new clots. 4. What other interprofessional team members would be now helpful to involve in this patient's care and why? ANS: It is appropriate to involve the respiratory therapist and the pharmacist in addition to the Rapid Response Team and the healthcare provider. They can assist with providing optimal oxygen therapies and determining appropriate pharmacological interventions. It is also reasonable to involve pastoral care for spiritual support, and social work to start long-term planning, depending on the patient's needs. 5. Your patient does have a PE and has completed her inpatient therapy. She is to be discharged to home on warfarin therapy. What are some important issues to include in the discharge plan? ANS: Because the patient is being discharged on warfarin, she will need routine blood monitoring. This can be a barrier for many patients. Determine whether the patient will follow with her own health care provider, be referred to an anticoagulation clinic, or need to establish care with anew provider. Work with the discharge planner to arrange appointments before discharge. Ensure that the patient understands when and where she will need any blood work prior to her appointment. There are dietary interactions with warfarin and the patient may benefit from a nutrition consultation with a registered dietitian before or after discharge. The patient is a current smoker with significant pulmonary-related problems. Now her risk for PE is ongoing and is not helped by her continuing smoking. Although this topic can be difficult, she should be counseled about the benefits of smoking cessation and how to go about

A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the client will need as the priority? a. Alteplase (Activase) b. Enoxaparin (Lovenox) c. Unfractionated heparin d. Warfarin sodium (Coumadin)

ANS: A Activase is a clot-busting agent indicated in large PEs in the setting of hemodynamic instability. The nurse knows this drug is the priority, although heparin may be started initially. Enoxaparin and warfarin are not indicated in this setting.

19.A client in the emergency department has several broken ribs. What care measure will best promote comfort? a. Allowing the client to choose the position in bed b. Humidifying the supplemental oxygen c. Offering frequent, small drinks of water d. Providing warmed blankets

ANS: A Allow the client with respiratory problems to assume a position of comfort if it does not interfere with care. Often the client will choose a more upright position, which also improves oxygenation. The other options are less effective comfort measures.

A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best? a. Assess for other manifestations of hypoxia. b. Change the sensor on the pulse oximeter. c. Obtain a new oximeter from central supply. d. Tell the client to take slow, deep breaths.

ANS: A Pulse oximetry is not always the most accurate assessment tool for hypoxia as many factors can interfere, producing normal or near-normal readings in the setting of hypoxia. The nurse should conduct a more thorough assessment. The other actions are not appropriate for a hypoxic client.

A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate? a. Assess the cause of the agitation. b. Reassure the client that he or she is safe. c. Restrain the clients hands. d. Sedate the client immediately.

ANS: A The nurse needs to determine the cause of the agitation. The inability to communicate often makes clients anxious, even to the point of panic. Pain and confusion can also cause agitation. Once the nurse determines the cause of the agitation, he or she can implement measures to relieve the underlying cause. Reassurance is also important but may not address the etiology of the agitation. Restraints and more sedation may be necessary, but not as a first step.

A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.) a. Allow visitors at the clients bedside. b. Ensure the client can communicate if awake. c. Keep the television tuned to a favorite channel. d. Provide back and hand massages when turning. e. Turn the client every 2 hours or more

ANS: A, B, D, E There are many basic care measures that can be employed for the client who is on a ventilator. Allowing visitation, providing a means of communication, massaging the clients skin, and routinely turning and repositioning the client are some of them. Keeping the TV on will interfere with sleep and res

1. Which laboratory values are most important for a nurse to monitor for a client who is receiving a heparin infusion for treatment of a pulmonary embolism when warfarin is added to the drug therapy? (Select all that apply.) a. Activated partial thromboplastin time b. Albumin levels c. Factor V levels d. Hepatic function tests e. International normalized ratio f. Platelet count g. Serum osmolarity

ANS: A, E, F Heparin dosing is monitored and adjusted with activated partial thromboplastin times (aPTT) and platelet counts. Warfarin dosing is monitored and adjusted based on the international normalized ratio (INR). Although warfarin is protein-bound and hypoalbuminemia may affect dosing, it is not routinely monitored at the initiation of warfarin therapy. Hepatic function and Factor V assessment are not part of dose monitoring for either heparin or warfarin.

.A nurse is caring for a client on the medical stepdown unit. The following data are related to this client: Subjective Information Laboratory Analysis Physical Assessment Shortness of breath for 20 minutes Feels frightened Cant catch my breath pH: 7.12 PaCO2: 28 mm Hg PaO2: 58 mm Hg SaO2: 88% Pulse: 120 beats/min Respiratory rate: 34 breaths/min Blood pressure 158/92 mm Hg Lungs have crackles What action by the nurse is most appropriate? a. Call respiratory therapy for a breathing treatment. b. Facilitate a STAT pulmonary angiography. c. Prepare for immediate endotracheal intubation. d. Prepare to administer intravenous anticoagulants.

ANS: B This client has manifestations of pulmonary embolism (PE); however, many conditions can cause the clients presentation. The gold standard for diagnosing a PE is pulmonary angiography. The nurse should facilitate this test as soon as possible. The client does not have wheezing, so a respiratory treatment is not needed. The client is not unstable enough to need intubation and mechanical ventilation. IV anticoagulants are not given without a diagnosis of PE.

6.A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred? a. Hemoglobin: 14.2 g/dL b. Platelet count: 82,000/L c. Red blood cell count: 4.8/mm3 d. White blood cell count: 8.7/mm3

ANS: B This platelet count is low and could indicate heparin-induced thrombocytopenia. The other values are normal for either gender.

2.A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active and has no known risk factors for PE. What action by the nurse is most appropriate? a. Encourage the client to walk 5 minutes each hour. b. Refer the client to smoking cessation classes. c. Teach the client about factor V Leiden testing. d. Tell the client that sometimes no cause for disease is found.

ANS: C Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events, including PE. A client with no known risk factors for this disorder should be referred for testing. Encouraging the client to walk is healthy, but is not related to the development of a PE in this case, nor is smoking. Although there are cases of disease where no cause is ever found, this assumption is prematu

A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)? a. Assess the client for sedation needs. b. Get family permission for restraints. c. Provide frequent oral care per protocol. d. Use nonverbal pain assessment tools.

ANS: C The client on mechanical ventilation needs frequent oral care, which can be delegated to the UAP. The other actions fall within the scope of practice of the nurse.

5.A client has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority? a. Apply oxygen at 100%. b. Assess the respiratory rate. c. Ensure a patent airway. d. Start two large-bore IV lines.

ANS: C The priority for any chest trauma client is airway, breathing, circulation. The nurse first ensures the client has a patent airway. Assessing respiratory rate and applying oxygen are next, followed by inserting IVs

2.A student nurse asks for an explanation of refractory hypoxemia. What answer by the nurse instructor is best? a. It is chronic hypoxemia that accompanies restrictive airway disease. b. It is hypoxemia from lung damage due to mechanical ventilation. c. It is hypoxemia that continues even after the client is weaned from oxygen. d. It is hypoxemia that persists even with 100% oxygen administration.

ANS: D Refractory hypoxemia is hypoxemia that persists even with the administration of 100% oxygen. It is a cardinal sign of acute respiratory distress syndrome. It does not accompany restrictive airway disease and is not caused by the use of mechanical ventilation or by being weaned from oxygen.

14.A client is on mechanical ventilation and the clients spouse wonders why ranitidine (Zantac) is needed since the client only has lung problems. What response by the nurse is best? a. It will increase the motility of the gastrointestinal tract. b. It will keep the gastrointestinal tract functioning normally. c. It will prepare the gastrointestinal tract for enteral feedings. d. It will prevent ulcers from the stress of mechanical

ANS: D Stress ulcers occur in many clients who are receiving mechanical ventilation, and often prophylactic medications are used to prevent them. Frequently used medications include antacids, histamine blockers, and proton pump inhibitors. Zantac is a histamine blocking agent.

.A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what should the nurse ensure as a priority? a. The client is able to initiate spontaneous breaths. b. The inspired oxygen has adequate humidification. c. The upper peak airway pressure limit alarm is off. d. The upper peak airway pressure limit alarm is on.

ANS: D The upper peak airway pressure limit alarm will sound when the airway pressure reaches a preset maximum. This is critical to prevent damage to the lungs. Alarms should never be turned off. Initiating spontaneous breathing is important for some modes of ventilation but not others. Adequate humidification is important but does not take priority over preventing injury

A client is brought to the emergency department after sustaining injuries in a severe car crash. The clients chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. What action by the nurse is the priority? a. Administer oxygen and reassess. b. Auscultate the clients lung sounds. c. Facilitate a portable chest x-ray. d. Prepare to assist with intubation.

ANS: D This client has manifestations of flail chest and, with the other signs, needs to be intubated and mechanically ventilated immediately. The nurse does not have time to administer oxygen and wait to reassess, or to listen to lung sounds. A chest x-ray will be taken after the client is intubated.

The patient is a 26-year-old who was admitted to the surgical floor 2 days ago after a motor vehicle crash. His injuries include a thoracic fracture, for which he must remain flat, and some chest bruising. He was started on enteral feeding yesterday. His IV fluid rate is 150 cc/hr, and he is receiving IV morphine every 2 hours for pain. At change of shift, your assessment findings include that the patient is dyspneic and slightly confused. Lung sounds are diminished in the right base and he is febrile to 101.5 (38.6). Pulse is 120 bpm; respirations are 36 per minute and shallow. Blood pressure is 88/56 mm Hg, pulse oximetry shows an SpO2 of 88%, and an end-tidal CO2 (ETCO2) shows 48. 1. Is this patient experiencing ventilatory failure, oxygen failure, or combination of ventilatory and oxygenation failure? Explain your answer. 2. What are some possible causes of the patient's distress? 3. Which interprofessional team members should you contact now and why? 4. What diagnostic tests should you anticipate the healthcare provide to order? Suggested Responses:

Is this patient experiencing ventilatory failure, oxygen failure, or combination of ventilatory and oxygenation failure? Explain your answer. ANS: The patient is likely experiencing a combination of ventilatory and oxygenation failure. His respirations are rapid and shallow with poor tidal volumes and an ETCO2 of 48. An ABG which shows hypercarbia (PCO2 >45) with acidosis (pH <7.35) indicates ventilatory failure. His SpO2 of 88% suggests hypoxia, which can also be confirmed with an ABG. 2. What are some possible causes of the patient's distress? ANS: Potential causes of ventilatory failure are poor inspiratory effort due to chest injury, over-sedation due to pain medication, PE, pneumothorax, ARDS. Potential causes of oxygenation failure are pneumonia (potentially an aspiration pneumonia or community acquired as it is less likely a hospital-acquired pneumonia on hospital day 2), PE, hypotension/hypovolemic shock. 3. Which interprofessional team members should you contact now and why? ANS: The healthcare providers are responsible for the patient. They need to be informed about the change in the patient's condition and may order additional diagnostic tests. The respiratory therapist should be contacted to assist with providing supplemental oxygen, additional respiratory treatments as indicated including aerosols, and hyperinflation therapy. 4. What diagnostic tests should you anticipate the healthcare provide to order? ANS: Titrate oxygen to maintain an SpO2 >92%, ABGs, chest X-ray (to evaluate for potential disease, i.e., pneumonia, collapse, pneumothorax), blood cultures with initiation of antibiotics (febrile patient, concern for infection), decrease IV fluid rate (concern for edema), CT chest to evaluate for pulmonary embolus. Some providers may discontinue enteral feedings until aspiration and/or decreased gastric motility is ruled out.

The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.) a. Adherence to proper hand hygiene b. Administering anti-ulcer medication c. Elevating the head of the bed d. Providing oral care per protocol e. Suctioning the client on a regular schedule

ANS: A, B, C, D The ventilator bundle is a group of care measures to prevent ventilator-associated pneumonia. Actions in the bundle include using proper hand hygiene, giving anti-ulcer medications, elevating the head of the bed, providing frequent oral care per policy, preventing aspiration, and providing pulmonary hygiene measures. Suctioning is done as needed.

A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.) a. Acknowledge the frightening nature of the illness. b. Delegate a back rub to the unlicensed assistive personnel (UAP). c. Give simple explanations of what is happening. d. Request a prescription for antianxiety medication. e. Stay with the client and speak in a quiet, calm voice.

ANS: A, B, C, E Clients with PEs are often anxious. The nurse can acknowledge the clients fears, delegate comfort measures, give simple explanations the client will understand, and stay with the client. Using a calm, quiet voice is also reassuring. Sedatives and antianxiety medications are not used routinely because they can contribute to hypoxia. If the clients anxiety is interfering with diagnostic testing or treatment, they can be used, but there is no evidence that this is the case.

The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this? (Select all that apply.) a. Chest wall stiffness b. Decreased muscle strength c. Inability to cooperate d. Less lung elasticity e. Poor vision and hearing

ANS: A, B, D Age-related changes that increase the difficulty of weaning older adults from mechanical ventilation include increased stiffness of the chest wall, decreased muscle strength, and less elasticity of lung tissue. Not all older adults have an inability to cooperate or poor sensory acuity.

.A student nurse is preparing to administer enoxaparin (Lovenox) to a client. What action by the student requires immediate intervention by the supervising nurse? a. Assessing the clients platelet count b. Choosing an 18-gauge, 2-inch needle c. Not aspirating prior to injection d. Swabbing the injection site with alcohol

ANS: B Enoxaparin is given subcutaneously, so the 18-gauge, 2-inch needle is too big. The other actions are appropriate.

4.A client is on intravenous heparin to treat a pulmonary embolism. The clients most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate? a. Decrease the heparin rate. b. Increase the heparin rate. c. No change to the heparin rate. d. Stop heparin; start warfarin (Coumadin).

ANS: B For clients on heparin, a PTT of 1.5 to 2.5 times the normal value is needed to demonstrate the heparin is working. A normal PTT is 25 to 35 seconds, so this clients PTT value is too low. The heparin rate needs to be increased. Warfarin is not indicated in this situation.

13.A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by the nurse takes priority? a. Assessing that the ventilator settings are correct b. Ensuring there is a bag-valve-mask in the room c. Obtaining personal protective equipment d. Planning to suction the client upon arrival to the

ANS: B Having a bag-valve-mask device is critical in case the client needs manual breathing. The respiratory therapist is usually primarily responsible for setting up the ventilator, although the nurse should know and check the settings. Personal protective equipment is important, but ensuring client safety takes priority. The client may or may not need suctioning on arrival.

5.A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic testing reveals the client has an alteration in the gene CYP2C19. What action by the nurse is best? a. Instruct the client to eliminate all vitamin K from the diet. b. Prepare preoperative teaching for an inferior vena cava (IVC) filter. c. Refer the client to a chronic illness support group. d. Teach the client to use a soft-bristled toothbrush

ANS: B Often clients are discharged from the hospital on warfarin (Coumadin) after a PE. However, clients with a variation in the CYP2C19 gene do not metabolize warfarin well and have higher blood levels and more side effects. This client is a poor candidate for warfarin therapy, and the prescriber will most likely order an IVC Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 257 filter device to be implanted. The nurse should prepare to do preoperative teaching on this procedure. It would be impossible to eliminate all vitamin K from the diet. A chronic illness support group may be needed, but this is not the best intervention as it is not as specific to the client as the IVC filter. A soft-bristled toothbrush is a safety measure for clients on anticoagulation therapy.

A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority? a. Assess the clients lung sounds. b. Notify the Rapid Response Team. c. Provide reassurance to the client. d. Take a full set of vital signs

ANS: B This client has manifestations of a pulmonary embolism, and the most critical action is to notify the Rapid Response Team for speedy diagnosis and treatment. The other actions are appropriate also but are not the priority

.A nurse is teaching a client about warfarin (Coumadin). What assessment finding by the nurse indicates a possible barrier to self-management? a. Poor visual acuity b. Strict vegetarian c. Refusal to stop smoking d. Wants weight loss surgery

ANS: B Warfarin works by inhibiting the synthesis of vitamin Kdependent clotting factors. Foods high in vitamin K thus interfere with its action and need to be eaten in moderate, consistent amounts. A vegetarian may have trouble maintaining this diet. The nurse should explore this possibility with the client. The other options are not related.

16.A client is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the client needs more education regarding this medication? a. Hamburger and French fries b. Large chefs salad and muffin c. No selection; spouse brings pizza d. Tuna salad sandwich and chips

ANS: B Warfarin works by inhibiting the synthesis of vitamin Kdependent clotting factors. Foods high in vitamin K thus interfere with its action and need to be eaten in moderate, consistent amounts. The chefs salad most likely has too many leafy green vegetables, which contain high amounts of vitamin K. The other selections, while not particularly healthy, will not interfere with the medications mechanism of action.

A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.) a. Client who had a reaction to contrast dye yesterday b. Client with a new spinal cord injury on a rotating bed c. Middle-aged man with an exacerbation of asthma d. Older client who is 1-day post hip replacement surgery e. Young obese client with a fractured femur

ANS: B, D, E Conditions that place clients at higher risk of developing PE include prolonged immobility, central venous catheters, surgery, obesity, advancing age, conditions that increase blood clotting, history of thromboembolism, smoking, pregnancy, estrogen therapy, heart failure, stroke, cancer (particularly lung or prostate), and trauma. A contrast dye reaction and asthma pose no risk for PE.

A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the clients oxygen saturation has not significantly improved. What response by the nurse is best? a. Breathing so rapidly interferes with oxygenation. b. Maybe the client has respiratory distress syndrome. c. The blood clot interferes with perfusion in the lungs. d.The client needs immediate intubation and mechanical ventilation.

ANS: C A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless the clot is dissolved, this process will continue unabated. Hyperventilation can interfere with oxygenation by shallow breathing, but there is no evidence that the client is hyperventilating, and this is also not the most precise physiologic answer. Respiratory distress syndrome can occur, but this is not as likely. The client may need to be mechanically ventilated, but without concrete data on FiO2 and SaO2, the nurse cannot make that judgment.

8.A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority? a. Ensure the client has adequate sedation. b. Find another provider to intubate. c. Interrupt the procedure to give oxygen. d. Monitor the clients oxygen saturation.

ANS: C Each intubation attempt should not exceed 30 seconds (15 is preferable) as it causes hypoxia. The nurse should interrupt the intubation attempt and give the client oxygen. The nurse should also have adequate sedation during the procedure and monitor the clients oxygen saturation, but these do not take priority. Finding another provider is not appropriate at this time.

.An intubated clients oxygen saturation has dropped to 88%. What action by the nurse takes priority? a. Determine if the tube is kinked. b. Ensure all connections are patent. c. Listen to the clients lung sounds. d. Suction the endotracheal tube.

ANS: C When an intubated client shows signs of hypoxia, check for DOPE: displaced tube (most common cause), obstruction (often by secretions), pneumothorax, and equipment problems. The nurse listens for equal, bilateral breath sounds first to determine if the endotracheal tube is still correctly placed. If this assessment is normal, the nurse would follow the mnemonic and assess the patency of the tube and connections and perform suction.

When working with women who are taking hormonal birth control, what health promotion measures should the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.) a. Avoid drinking alcohol. b. Eat more omega-3 fatty acids. c. Exercise on a regular basis. d. Maintain a healthy weight. e. Stop smoking cigarettes.

ANS: C, D, E Health promotion measures for clients to prevent thromboembolic events such as PE include maintaining a healthy weight, exercising on a regular basis, and not smoking. Avoiding alcohol and eating more foods containing omega-3 fatty acids are heart-healthy actions but do not relate to the prevention of PE.

The client from Clinical Judgement Challenge 32-2 (p. xxx) continues to deteriorate clinically and is to be intubated. What are the most important actions for the nurse to implement? (Select all that apply.) a. Obtain a cervical X-ray. b. Discontinue the IV fluids. c. Immediately page anesthesia or the Rapid Response Team (depending on institution policy). d. Confirm that suction is at the bedside and functioning properly. e. Have the crash cart available. f. Place client on nasal cannula oxygen. g. Have manual resuscitation bag with face mask at bedside. h. Verify bilateral breath sounds post-intubation.

ANS: C, D, E, G, H Arrange for intubation per institution protocols. Suction, resuscitation bag with mask, and crash cart should be readily available for procedure (in an ICU, the crash cart may be optional). Post-intubation the nurse should confirm the presence of bilateral breath sounds. A cervical X-ray is not indicated, but a CXR is needed to confirm ET placement. The IV fluids should not be discontinued for intubation. They are required to administer medications and for fluid boluses if the patient becomes hypotensive. The rate may be decreased or they may be discontinued after the procedure if there is a concern for edema

The nurse is trouble-shooting multiple ventilator alarms sounding for a client who is intubated and being mechanically ventilated. The alarms persist despite suctioning, repositioning the client, and ensuring the ventilator tubing is unobstructed. Which actions will the nurse perform next? (Select all that apply.) a. Turn off all ventilator alarms until a cause is found to prevent scaring the client. b. Page the healthcare provider to request additional sedation. c. Ensure the endotracheal tube marking is at the client's incisor. d. Increase the PEEP to improve oxygenation. e. Disconnect the client from the ventilator and use the manual resuscitation bag. f. Change all ventilator tubing. g. Start paging the respiratory therapist. h. Determine when the client received the last dose of the paralytic agent.

ANS: C, E, G Multiple alarms sounding indicate a serious problem with ventilating the client and the client is in danger of hypoventilation and death. When multiple alarms are sounding and the problem cannot be identified and corrected quickly, the priority is to assess whether the problem is with the client or with the ventilator. Ensuring gas exchange is critical. Care for the client first and the ventilator last. Paging the respiratory therapist immediately is critical because this interprofessional team member is the ventilator expert. Turning off the alarms is not consistent with National Patient Safety Goals or safe care. Additional sedation does not solve the problems with the ventilator or the client's gas exchange. Checking the timing of the paralytic dose wastes valuable time and does not improve the client's ventilation or gas exchange. Changing the tubing might be helpful eventually but does not help the client right now. It is possible that the endotracheal tube has advanced to the point that it is no longer reaching the client's trachea, and its position should be checked quickly and immediately. To ensure adequate gas exchange, disconnect the client from this ventilator and provide ventilation with the manual resuscitation bag until someone else fixes or changes the ventilator. Manual resuscitation allows assessment of the client and determining lung compliance by the amount of effort needed to compress the bag, observing for chest rise with compressions, and determining whether this action results in improvement in the client's oxygen saturation. If manual ventilation improves the client's saturation, the issue is with the ventilator. If the client's saturation does not improve, the issue is with the client, which would require immediate intervention by the healthcare provider or Rapid Response Team.