Chapter 65: Artificial airway
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.
a. Verbally coach the patient to breathe with the ventilator. 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 is receiving 35% O2 via a Venturi mask. To ensure the correct amount of O2 delivery, which action by the nurse is important? a. Teach the patient to keep the mask on during meals. b. Keep the air entrainment ports clean and unobstructed. c. Give a high enough flow rate to keep the bag from collapsing. d. Drain moisture condensation from the corrugated tubing every hour.
b. Keep the air entrainment ports clean and unobstructed. The air entrainment ports regulate the O2 percentage delivered to the patient, so they must be unobstructed. The other options refer to other types of O2 devices. A high O2 flow rate is needed when giving O2by partial rebreather or nonrebreather masks. Draining O2 tubing is necessary when caring for a patient receiving mechanical ventilation. The mask can be removed or changed to a nasal cannula at a prescribed setting when the patient eats.
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 the connection between the ventilator tubing and the ET. d. The RN changes the ventilator circuit tubing routinely every 48 hours.
b. The RN uses a closed-suction technique to suction the patient. 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 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 and are not indicated routinely.
To verify the correct placement of an oral endotracheal tube (ET) after insertion, the best initial action by the nurse is to a. obtain a portable chest x-ray. b. use an end-tidal CO2 monitor. c. auscultate for bilateral breath sounds. d. observe for symmetrical chest movement.
b. use an end-tidal CO2 monitor. End-tidal CO2 monitors are currently recommended for rapid verification of ET placement. Auscultation for bilateral breath sounds and checking chest expansion are also used, but they are not as accurate as end-tidal CO2 monitoring. A chest x-ray confirms the placement but is done after the tube is secured.
The nurse notes thick, white secretions in the endotracheal tube (ET) of a patient who is receiving mechanical ventilation. Which intervention will most directly treat this finding? a. Reposition the patient every 1 to 2 hours. b. Increase suctioning frequency to every hour. c. Add additional water to the patient's enteral feedings. d. Instill 5 mL of sterile saline into the ET before suctioning.
c. Add additional water to the patient's enteral feedings. 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 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. Check the O2 saturation. b. Offer reassurance to the patient. c. Listen to the patient's breath sounds. d. Notify the patient's health care provider.
c. Listen to the patient's breath sounds. 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.
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 who was successfully weaned and extubated 4 hours ago and has no urine output for the last 6 hours d. Patient with a central venous O2 saturation (ScvO2) of 69% while on bilevel positive airway pressure (BiPAP)
c. Patient who was successfully weaned and extubated 4 hours ago and has no urine output for the last 6 hours 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.
Which assessment finding obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning? a. The patient was last suctioned 6 hours ago. b. The patient's oxygen saturation drops to 93%. c. The patient's respiratory rate is 32 breaths/min. d. The patient has occasional audible expiratory wheezes.
c. The patient's respiratory rate is 32 breaths/min. The increase in respiratory rate indicates that the patient may have decreased airway clearance and requires suctioning. Suctioning is done when patient assessment data indicate that it is needed and not on a scheduled basis. Occasional expiratory wheezes do not indicate poor airway clearance, and suctioning the patient may induce bronchospasm and increase wheezing. An O2 saturation of 93% is acceptable and does not suggest that immediate suctioning is needed.
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 resecure the endotracheal tube. d. The RN positions the patient with the head of bed at 10 degrees.
d. The RN positions the patient with the head of bed at 10 degrees. 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.
Four hours after mechanical ventilation is initiated, a 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. c. increase the respiratory rate. b. increase the tidal volume. d. decrease the respiratory rate.
d. decrease the respiratory rate. 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 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. O2 saturation of 93%. b. green nasogastric tube drainage. c. respirations of 20 breaths/minute. d. increased jugular venous distention.
d. increased jugular venous distention. 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.
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.
d. inject air into the cuff until a slight leak is heard only at peak inflation. 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.
An older adult patient reports having used an "iron lung" after contracting polio as a child. The nurse knows this patient is referring to which type of mechanical ventilation? 1 Positive pressure 2 Negative pressure 3 Volume ventilation 4 Pressure ventilation
2 Negative pressure The "iron lung" was the first form of negative pressure ventilation, developed during the polio epidemic. Negative pressure uses the chambers encasing the chest and surrounding it with intermittent negative pressure; expiration is passive, and the negative pressure is delivered by noninvasive measures. Pressure ventilation means the peak inspiratory pressure is predetermined and the tidal volume delivered varies based on the patient. Volume ventilation has a predetermined tidal volume delivered with each inspiration and the pressure varies based on the patient. Positive pressure ventilation is the primary method used with acutely ill patients, where air is pushed into the lungs during inspiration under positive pressure.
While evaluating a mechanically ventilated patient, the nurse notes that the auto-PEEP has been activated. Which mode of mechanical ventilation does the nurse suspect? 1 Volume mode 2 Pressure mode 3 Continuous positive airway pressure 4 Positive end-expiratory pressure mode
2 Pressure mode The auto-PEEP is a pressure mode that provides a pressure-limited breath delivered at a set rate that may permit spontaneous breathing. The positive end-expiratory pressure (PEEP) mode is a ventilator maneuver in which positive pressure is applied to the airway during exhalation. Continuous positive airway pressure (CPAP) is similar to PEEP, but the pressure is delivered continuously during spontaneous breathing, preventing the patient's airway pressure from falling to zero. Volume modes require that rate, tidal volume, inspiratory time, sensitivity, and/or PEEP are set for the patient
The nurse working in a critical care unit understands that tidal volume is an important setting in a mechanical ventilator. Which statement appropriately describes tidal volume? 1 Number of breaths the ventilator delivers per minute 2 Volume of gas delivered to patient during each ventilator breath 3 Positive pressure used to augment patient's inspiratory pressure 4 Positive pressure applied at the end of expiration of ventilator breaths
2 Volume of gas delivered to patient during each ventilator breath Tidal volume is the volume of gas delivered to a patient during each ventilator breath. The number of breaths the ventilator delivers per minute is called the respiratory rate. The positive pressure used to augment the patient's inspiratory pressure is called pressure support. The positive pressure applied at the end of expiration of ventilator breaths is called positive end-expiratory pressure.
A patient is to be intubated for respiratory failure. Which factor indicates that tracheotomy would be preferable to endotracheal intubation? 1 The patient is at high risk for aspiration. 2 The patient is unable to clear secretions. 3 A long-term airway is probably necessary. 4 An upper airway obstruction is impairing the patient's ventilation.
3 A long-term airway is probably necessary. A tracheotomy is indicated when the need for an artificial airway is expected to be long term. Aspiration risk, an inability to clear secretions, and upper airway obstruction are indications for an artificial airway, but these are not specific indications for tracheotomy.
A patient is being mechanically ventilated. A high-pressure ventilation alarm sounds. The nurse should assess for what cause of this type of alarm? 1 Power failure 2 Insufficient gas flow 3 Condensate in tubing 4 Tracheotomy cuff leak
3 Condensate in tubing Presence of condensate or water in tubing triggers a high-pressure ventilation alarm. Power failure triggers ventilator inoperative or low battery alarm. Insufficient gas flow and tracheotomy cuff leak triggers low tidal volume or minute ventilation alarm.
When planning care for a patient on a mechanical ventilator, the nurse understands that the application of positive end-expiratory pressure (PEEP) to the ventilator settings has which therapeutic effect? 1 Increased inflation of the lungs 2 Prevention of barotrauma to the lung tissue 3 Prevention of alveolar collapse during expiration 4 Increased fraction of inspired oxygen concentration (FIO2) administration
3 Prevention of alveolar collapse during expiration PEEP is positive pressure that is applied to the airway during exhalation. This positive pressure prevents the alveoli from collapsing, improving oxygenation and enabling a reduced FIO2 requirement. PEEP does not cause increased inflation of the lungs or prevent barotrauma. Auto-PEEP resulting from inadequate exhalation time may contribute to barotrauma.
When assessing the settings of a patient's ventilator, the nurse knows that which parameter is abnormal? 1 PaO2 of 66 mm Hg 2 PEEP of 5 cm H 2O 3 Tidal volume of 12 mL/kg 4 Respiratory rate of 20 breaths/minute
3 Tidal volume of 12 mL/kg Usual tidal volume is 6-10 mL/kg; a tidal volume of 12 ml/kg is abnormally high. A respiratory rate of 20 breaths/minute is within normal; usual settings are 6-20 breaths/minute. A PaO2 level of 66 mm Hg is normal; the usual is greater than 60 mm Hg. PEEP of 5 cm H2O is the usual setting.
A patient is receiving mechanical ventilation after having a stroke. The nurse determines that the ventilator settings are based on which patient status? 1 Ideal body weight, vital signs, and family preference 2 Ethics committee results, current physiologic state, and ideal body weight 3 Respiratory muscle strength, ethics committee results, and family preference 4 Arterial blood gases (ABGs), current physiologic state, and respiratory muscle strength
4 Arterial blood gases (ABGs), current physiologic state, and respiratory muscle strength Settings on mechanical ventilators are based on the patient's physiologic status, such as ABGs, ideal body weight, current physiologic state, level of consciousness, and respiratory strength. Ethics committee results and family preference are psychosocial in nature and are not criteria used to determine mechanical ventilation settings.
The nurse is teaching the patient's caregiver about receiving positive pressure ventilation. What movements should the nurse tell the caregiver to avoid doing to the patient? 1 Arm circles 2 Knee bends 3 Quadriceps setting 4 External rotation of the hip
4 External rotation of the hip The nurse should advise the caregiver to avoid external rotation of the patient's hip; this movement can be avoided by properly positioning the patient and by the use of specialized mattresses and beds. Simple maneuvers such as arm circles, knee bends and quadriceps setting should be performed, because they maintain the muscle tone in the upper and lower extremities of the patient.
When taking care of a patient diagnosed with respiratory failure on a mechanical ventilator, the nurse hears the apnea alarm beeping. What assessment data should be gathered to determine the cause of the alarm? 1 Pain or anxiety 2 Partial ventilator disconnect 3 Secretions, coughing, or gagging 4 Oversedation with opioid analgesics
4 Oversedation with opioid analgesics The apnea alarm on mechanical ventilation may be caused by respiratory arrest, oversedation, change in patient condition, or loss of airway (total or partial extubation). The high-pressure limit alarm is caused by secretions, coughing, or gagging. The low tidal volume alarm can be caused by partial ventilator disconnect. The high tidal volume alarm can be caused by pain or anxiety.
A nurse is caring for a patient undergoing mechanical ventilation who is also receiving positive end-expiratory pressure (PEEP). What is the outcome that the nurse hopes to achieve with PEEP? 1 Expand collapsed alveoli 2 Decrease alveolar volume 3 Decrease bronchospasms 4 Prevent spontaneous breathing
1 Expand collapsed alveoli Positive end-expiratory pressure (PEEP) expands collapsed alveoli and improves resting lung volume by keeping the alveoli open and preventing them from collapsing during expiration. PEEP increases, not decreases, alveolar volume by keeping the alveoli expanded. PEEP has no direct effect on bronchospasms. PEEP allows, not prevents, spontaneous breathing of a patient undergoing mechanical respiration.
A feeding tube is placed in a patient receiving positive pressure ventilation to prevent inadequate nutrition. What should the nurse avoid while verifying the placement of the feeding tube? 1 Listening for air after injection 2 X-ray confirmation before initial use 3 Review of routine x-rays and aspirate 4 Marking and assessing the tube's exit site
1 Listening for air after injection While verifying the placement of feeding tube, the nurse should avoid listening for air after injection, because it is not a reliable method for verification of its placement. X-ray confirmation before initial use, review of routine x-rays, and marking and assessing the tube's exit site are all reliable methods for verifying the feeding tube placement.
A 68-yr-old male patient diagnosed with sepsis is orally intubated on mechanical ventilation. Which nursing action is most important? Use the open-suctioning technique. Administer morphine for discomfort. Limit noise and cluster care activities. Elevate the head of the bed 30 degrees.
Elevate the head of the bed 30 degrees. The two major complications of endotracheal intubation are unplanned extubation and aspiration. To prevent aspiration, all intubated patients and patients receiving enteral feedings must have the head of the bed elevated a minimum of 30 to 45 degrees unless medically contraindicated. Closed-suction technique is preferred over the open-suction technique because oxygenation and ventilation are maintained during suctioning, and exposure to secretions is reduced. The nurse should provide comfort measures such as morphine to relieve anxiety and pain associated with intubation. To promote rest and sleep, the nurse should limit noise and cluster activities.
A patient in the intensive care unit has been intubated for the relief of airway obstruction. What nursing actions should be performed to prevent complications after intubation? Select all that apply. 1 Obtain a chest x-ray exam to confirm the placement. 2 Immediately catheterize the patient and check for urine output. 3 Obtain a computed tomography (CT) scan to note the placement. 4 Auscultate lungs bilaterally and also epigastrium for breath sounds. 5 Use an end-tidal carbon dioxide detector to note presence of exhaled carbon dioxide.
1 Obtain a chest x-ray exam to confirm the placement. 4 Auscultate lungs bilaterally and also epigastrium for breath sounds. 5 Use an end-tidal carbon dioxide detector to note presence of exhaled carbon dioxide. Following an intubation, it is important to confirm the placement of the endotracheal (ET) tube. This confirmation is obtained by x-ray after visualizing the ET tube correctly placed in the trachea. Auscultating lungs for breath sounds confirms that air is going into the lungs and not in the stomach. If the sounds are heard over the epigastrium, it indicates that the ET tube has gone in the stomach. Presence of carbon dioxide in exhaled air also confirms that the tube has gone into the lungs, and the breathing effort is normal. In this case, a CT scan is redundant. However, an x-ray is sufficient to confirm the placement of the ET tube. The patient may require a urinary catheter, but it is not an immediate intervention and can be done after intubation.
patient is weaned from artificial ventilation. What interventions should the nurse perform during weaning? Select all that apply. 1 Obtain baseline vital signs and respiratory parameters. 2 Make the patient walk a bit and then proceed with the trial. 3 Anesthetize or restrain the patient to avoid any resistance. 4 Place the patient in a comfortable sitting or semirecumbent position. 5 Closely monitor for signs and symptoms that may signal intolerance and a need to end the trial.
1 Obtain baseline vital signs and respiratory parameters. 4 Place the patient in a comfortable sitting or semirecumbent position. 5 Closely monitor for signs and symptoms that may signal intolerance and a need to end the trial. During a weaning trial, the patient is placed in a comfortable sitting or semirecumbent position. Baseline vital signs and respiratory parameters should be obtained. The patient should be closely monitored for signs and symptoms that may signal intolerance and a need to end the trial. The patient should not be anesthetized or made to walk
The nurse working in the intensive care unit (ICU) is taking care of a patient on a mechanical ventilator who had a motor vehicle accident two weeks ago. What does the nurse know about this situation? 1 The patient has severe hypoxia due to acute respiratory failure. 2 The ventilator will support the patient until he or she can breathe on his or her own. 3 The patient suffered from a chronic pulmonary disease before the accident. 4 The patient will be on long-term ventilation until the family decides to withdraw ventilator support.
2 The ventilator will support the patient until he or she can breathe on his or her own. Mechanical ventilation is not curative. It is a means of supporting patients until they recover the ability to breathe independently. The decision to use, withhold, or withdraw mechanical ventilation will be made carefully, involving the agency's ethics committee for assistance. The patient's medical history or diagnosis is not known; the nurse does not know if the patient suffered from chronic pulmonary disease or if he has severe hypoxia.
A patient is diagnosed with an exacerbation of chronic pulmonary disease. What is an appropriate nursing action? 1 Consult with the agency's ethics committee. 2 Warn the family about the patient's need for ventilator support. 3 Discuss how critically ill the patient will become without ventilator support. 4 Discuss mechanical ventilation with the patient, family, and healthcare providers.
4 Discuss mechanical ventilation with the patient, family, and healthcare providers. The nurse should encourage all patients with chronic illnesses to discuss the possibility of mechanical ventilation with their families and health care providers. The patient may or may not become critically ill without ventilator support. The decision to use, withhold, or withdraw mechanical ventilation will be made carefully, respecting the wishes of the patient and caregiver; however, if disagreements occur, the agency's ethics committee may be consulted for assistance.
When assisting with oral intubation of a patient who is having respiratory distress, in which order will the nurse take these actions? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Obtain a portable chest-x-ray. b. Position the patient in the supine position. c. Inflate the cuff of the endotracheal tube after insertion. d. Attach an end-tidal CO2 detector to the endotracheal tube. e. Oxygenate the patient with a bag-valve-mask device for several minutes.
ANS: E, B, C, D, A The patient is pre-oxygenated with a bag-valve-mask system for 3 to 5 minutes before intubation and then placed in a supine position. After the intubation, the cuff on the endotracheal tube is inflated to occlude and protect the airway. Tube placement is assessed first with an end-tidal CO2 sensor and then with chest x-ray examination.
The postanesthesia care unit (PACU) has several patients with endotracheal tubes. Which patient should receive the least amount of endotracheal suctioning? Transplantation of a kidney Replacement of aortic valve Cerebral aneurysm resection Formation of an ileal conduit
Cerebral aneurysm resection The nurse should avoid suctioning the patient after a craniotomy until it is necessary because suctioning will increase this patient's intracranial pressure. The patients with a kidney transplantation, aortic valve replacement, or formation of an ileal conduit will not be negatively affected by suctioning, although it should only be done when needed, not routinely.
The nurse is caring for a patient intubated and on a mechanical ventilator for several days. Which weaning parameter would tell the nurse if the patient has enough muscle strength to breathe without assistance? Tidal volume Minute ventilation Forced vital capacity Negative inspiratory force
Negative inspiratory force The negative inspiratory force measures inspiratory muscle strength. Tidal volume and minute ventilation assess the patient's respiratory endurance. Forced vital capacity is not used as a measure to determine weaning from a ventilator
The nurse is caring for a 65-yr-old man with acute respiratory distress syndrome (ARDS) who is on pressure support ventilation (PSV), fraction of inspired oxygen (FIO2) at 80%, and positive end-expiratory pressure (PEEP) at 15 cm H2O. The patient weighs 72 kg. What finding would indicate that treatment is effective? PaO2 of 60 mm Hg Tidal volume of 700 mL Cardiac output of 2.7 L/min Inspiration to expiration ratio of 1:2
PaO2 of 60 mm Hg Severe hypoxemia (PaO2 less than 40 mm Hg) occurs with ARDS, and PEEP is increased to improve oxygenation and prevent oxygen toxicity by reducing FIO2. A PaO2 level of 60 mm Hg indicates that treatment is effective and oxygenation status has improved. Decreased cardiac output is a complication of PEEP. Normal cardiac output is 4 to 8 L/minute. Normal tidal volume is 6 to 10 mL/kg. PSV delivers a preset pressure but the tidal volume varies with each breath. I:E ratio is usually set at 1:2 to 1:1.5 and does not indicate patient improvement.
Which interventions should the nurse perform before using an open-suctioning technique for a patient with an endotracheal (ET) tube (select all that apply.)? Put on clean gloves. Administer a bronchodilator. Perform a cardiopulmonary assessment. Hyperoxygenate the patient for 30 seconds. Perform hand hygiene before performing the procedure. Insert a few drops of normal saline into the ET to break up secretions.
Perform a cardiopulmonary assessment. Hyperoxygenate the patient for 30 seconds. Suctioning is preceded by a thorough assessment and hyperoxygenation for 30 seconds. Sterile, not clean, gloves are necessary, and it is not necessary to administer a bronchodilator. Instillation of normal saline into the ET tube is not an accepted standard practice.
The nurse in collaboration with respiratory therapy is determining a patient's readiness to wean from the ventilator. Which finding indicates the patient is not a candidate for weaning (select all that apply.)? Minute volume of 8 L/min Patient follow commands Serum hemoglobin of 6 g/dL Respirations of 28 breaths/min Mean arterial pressure (MAP) of 45 mm Hg Negative inspiratory force (NIF) of -15 cm H2O
Serum hemoglobin of 6 g/dL Mean arterial pressure (MAP) of 45 mm Hg Negative inspiratory force (NIF) of -15 cm H2O Findings that support readiness for weaning are minute volume of 8 L/min, patient is alert and follow commands, and respirations of 28 breaths/min. Findings that indicate the patient is not ready for weaning include serum hemoglobin of 6 g/dL, mean arterial pressure (MAP) of 45 mm Hg, and negative inspiratory force (NIF) of -15 cm H2O. Extubating a patient with severe anemia, poor perfusion, and weakened breathing effort will likely result in poor outcomes such as worsening of condition and reintubation.
A nurse is weaning a 68-kg 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.
The patient respiratory rate is 32 breaths/min. 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, but the nurse should continue to monitor it. An O2 saturation of 93% is acceptable for a patient with COPD. A spontaneous tidal volume of 450 mL is within the acceptable range.
An endotracheal (ET) tube is inserted in a patient. The nurse inflates the cuff to stabilize the tube. How much cuff pressure should be maintained to keep it inflated and ensure adequate tracheal perfusion? 1 10-15 cm H2O 2 20-25 cm H2O 3 30-35 cm H2O 4 40-45 cm H2O
2 20-25 cm H2O To ensure adequate tracheal perfusion, the nurse should maintain cuff pressure at 20 to 25 cm H2O. Excess cuff pressure can damage the tracheal mucosa. Lesser cuff pressure may cause the ET tube to become destabilized and extubate.
The nurse is caring for a group of patient's in the intensive care unit. Which patient is a candidate for bilevel positive airway pressure (BiPAP)? 1 Patient with shock 2 Patient with sleep apnea 3 Patient with altered mental status 4 Patient with increased airway secretions
2 Patient with sleep apnea Bilevel positive airway pressure (BiPAP) is used for patients with sleep apnea. Patients with shock, altered mental status and/or increased airway secretions are not candidates for BiPAP because of the risk of aspiration and the inability to remove the mask.
The nurse is assessing a patient placed on mechanical ventilation and hears breath sounds on the right but not on the left side of the chest. What common complication should the nurse immediately notify the health care provider about? 1 Hypertension 2 Pneumothorax 3 Electrolyte imbalance 4 Increased cardiac output
2 Pneumothorax Mechanical ventilation can cause pneumothorax as a result of excessive pressure applied to lung tissue. Hypertension is not a direct complication; however, a patient undergoing mechanical ventilation may be anxious and fearful, resulting in high blood pressure; sedation should be considered in this event. Electrolyte imbalance is not a related complication. Mechanical ventilation does increase intrathoracic pressure, which may then increase cardiac output, causing a beneficial secondary effect.
A patient who is receiving positive pressure ventilation is scheduled for a spontaneous breathing trial (SBT). Which finding by the nurse is most likely to result in postponing 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.
a. New ST segment elevation is noted on the cardiac monitor. 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. Ventilator weaning can proceed when opioids are used for pain management, abnormal lung sounds are present, or enteral feedings are being used.
The nurse responds to a ventilator alarm and finds the patient lying in bed gasping and holding the endotracheal tube (ET) in her hand. 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.
d. Manually ventilate the patient with 100% oxygen. 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.
The nurse notes premature ventricular contractions (PVCs) while suctioning a patient's endotracheal tube. Which next action by the nurse is indicated? a. Plan to suction the patient more frequently. b. Decrease the suction pressure to 80 mm Hg. c. Give antidysrhythmic medications per protocol. d. Stop and ventilate the patient with 100% oxygen.
d. Stop and ventilate the patient with 100% oxygen. Dysrhythmias during suctioning may indicate hypoxemia or sympathetic nervous system stimulation. The nurse should stop suctioning and ventilate the patient with 100% O2. There is no indication that more frequent suctioning is needed. 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.
