Exam 2: CH. 17 and Ch. 66 (mechanical ventilation, endotracheal intubation, and ABGs)
35. Which action should the nurse take first when a patient complains of acute chest pain and dyspnea soon after insertion of a centrally inserted IV catheter? a.Notify the health care provider. b.Offer reassurance to the patient. c.Auscultate the patient's breath sounds. d.Give the prescribed PRN morphine sulfate IV.
ANS: C The initial action should be to assess the patient further because the history and symptoms are consistent with several possible complications of central line insertion, including embolism and pneumothorax. The other actions may be appropriate, but further assessment of the patient is needed before notifying the health care provider, offering reassurance, or administration of morphine. DIF: Cognitive Level: Apply (application) REF: 311 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
21. 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. DIF: Cognitive Level: Analyze (analysis) REF: 1615-1616 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
36. 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. DIF: Cognitive Level: Apply (application) REF: 1626 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
22. 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. DIF: Cognitive Level: Apply (application) REF: 1622-1624 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
33. 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. DIF: Cognitive Level: Apply (application) REF: 1623 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
15. A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results? a. Metabolic acidosis b.Metabolic alkalosis c.Respiratory acidosis d.Respiratory alkalosis
ANS: A The pH and HCO3 indicate that the patient has a metabolic acidosis. The ABGs are inconsistent with the other responses. DIF: Cognitive Level: Apply (application) REF: 304-306 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
34. 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. DIF: Cognitive Level: Apply (application) REF: 1616 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
26. A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction and is complaining of anxiety and incisional pain. The patient's respiratory rate is 32 breaths/minute and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first? a.Discontinue the nasogastric suction. b.Give the patient the PRN IV morphine sulfate 4 mg. c.Notify the health care provider about the ABG results. d.Teach the patient how to take slow, deep breaths when anxious.
ANS: B The patient's respiratory alkalosis is caused by the increased respiratory rate associated with pain and anxiety. The nurse's first action should be to medicate the patient for pain. Although the nasogastric suction may contribute to the alkalosis, it is not appropriate to discontinue the tube when the patient needs gastric suction. The health care provider may be notified about the ABGs but is likely to instruct the nurse to medicate for pain. The patient will not be able to take slow, deep breaths when experiencing pain. DIF: Cognitive Level: Apply (application) REF: 300 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
20. 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. DIF: Cognitive Level: Apply (application) REF: 1617 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
18. 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. DIF: Cognitive Level: Apply (application) REF: 1616 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
24. A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient complains of "just blowing up" and has peripheral edema and shortness of breath. Which assessment should the nurse complete first? a.Skin turgor b.Heart sounds c.Mental status d.Capillary refill
ANS: C Increases in extracellular fluid (ECF) can lead to swelling of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds also may be affected by increases in ECF, these are signs that do not have as immediate impact on patient outcomes as cerebral edema. DIF: Cognitive Level: Apply (application) REF: 292 | 295 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
23. 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. DIF: Cognitive Level: Apply (application) REF: 1627 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
19. Which assessment finding obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning? a.The patient's oxygen saturation is 93%. b.The patient was last suctioned 6 hours ago. c.The patient's respiratory rate is 32 breaths/minute. d.The patient has occasional audible expiratory wheezes.
ANS: C 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, 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 oxygen saturation of 93% is acceptable and does not suggest that immediate suctioning is needed. DIF: Cognitive Level: Apply (application) REF: 1616 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
31. 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. DIF: Cognitive Level: Apply (application) REF: 1614 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
16. To verify the correct placement of an oral endotracheal tube (ET) after insertion, the best initial action by the nurse is to a.auscultate for the presence of bilateral breath sounds. b.obtain a portable chest x-ray to check tube placement. c.observe the chest for symmetric chest movement with ventilation. d.use an end-tidal CO2 monitor to check for placement in the trachea.
ANS: D 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 CO2monitoring. A chest x-ray confirms the placement but is done after the tube is secured. DIF: Cognitive Level: Apply (application) REF: 1614-1615 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
35. 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, O2saturation of 93%, and green nasogastric tube drainage are within normal limits. DIF: Cognitive Level: Apply (application) REF: 1623-1624 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
37. 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. DIF: Cognitive Level: Analyze (analysis) REF: 1625 | 1627 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
32. 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. DIF: Cognitive Level: Apply (application) REF: 1623 OBJ: Special Questions: Delegation TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment
17. 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. DIF: Cognitive Level: Understand (comprehension) REF: 1615 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
30. 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. DIF: Cognitive Level: Apply (application) REF: 1617 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
10. A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L? a.Metabolic acidosis b.Metabolic alkalosis c.Respiratory acidosis d.Respiratory alkalosis
ANS: D The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO3. DIF: Cognitive Level: Apply (application) REF: 306 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
