ICU

A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first?

Place on cardiac monitor. After an electrical burn, the patient is at risk for fatal dysrhythmias and should be placed on a cardiac monitor.

Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the family members of a patient with ARDS is accurate?

"PEEP prevents the lung air sacs from collapsing during exhalation."

The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed?

400 mL of blood in the collection chamber The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock.

A patient who is orally intubated and receiving mechanical ventilation is anxious and is "fighting" the ventilator. Which action should the nurse take next?

Verbally coach the patient to breathe with the ventilator.

What degrees should the bed be positioned to prevent VAP

30-45 degrees

A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be administered in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids?

938 mL/hour

Tidal volume (V1)

Volume of gas delivered to patient during ventilator breath Setting: 6-10

The emergency department (ED) triage nurse is assessing four victims involved in a motor vehicle collision. Which patient has the highest priority for treatment?

A patient with paradoxic chest movements.

To evaluate the effectiveness of ordered interventions for a patient with ventilatory failure, which diagnostic test will be most useful to the nurse? To evaluate the effectiveness of ordered interventions for a patient with ventilatory failure, which diagnostic test will be most useful to the nurse?

ABG analysis

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?

Add additional water to the patient's enteral feedings.

Which action will the nurse include in the plan of care for a patient in the rehabilitation phase after a burn injury to the right arm and chest?

Apply water-based cream to burned areas frequently. Application of water-based emollients will moisturize new skin and decrease flakiness and itching.

A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first?

Auscultate the patient's lung sounds.

A nurse is caring for a patient who is orally intubated and receiving mechanical ventilation. To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care?

Elevate head of bed to 30 to 45 degrees.

A nurse is caring for a patient who has burns of the ears, head, neck, and right arm and hand. The nurse should place the patient in which position?

Elevate the right arm and hand on pillows and extend the fingers.

patient with respiratory failure has a respiratory rate of 6 breaths/minute and an oxygen saturation (SpO2) of 88%. The patient is increasingly lethargic. Which intervention will the nurse anticipate?

Endotracheal intubation and positive pressure ventilation

A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current. What is the priority nursing assessment?

Extremity movement All patients with electrical burns should be considered at risk for cervical spine injury, and assessments of extremity movement will provide baseline data.

O2 concentration (FIO2)

Fraction of inspired O2 delivered to patient. May be set to 21%-100% Maintain PaO2 level >60 mm Hg or spO2 level >90%

On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse anticipate taking now?

Increase the rate of the ordered IV solution. The patient's laboratory data show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased.

A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain adequate nutrition, the nurse should plan to take which action?

Insert a feeding tube and initiate enteral feedings. Enteral feedings can usually be initiated during the emergent phase at low rates and increased over 24 to 48 hours to the goal rate

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?

Listen to the patient's breath sounds.

A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a right pneumothorax. Which action will the nurse anticipate taking next?

Lower the positive end-expiratory pressure (PEEP).

During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion?

Measure hourly urine output.

A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take?

Notify the health care provider and prepare for endotracheal intubation.

A patient who was found unconscious in a burning house is brought to the emergency department by ambulance. The nurse notes that the patient's skin color is bright red. Which action should the nurse take first?

Place the patient on 100% oxygen using a non-rebreather mask. The patient's history and skin color suggest carbon monoxide poisoning, which should be treated by rapidly starting oxygen at 100%

Positive end-expiratory pressure (PEEP)

Positive pressure applied at the end of expiration of vent breaths Usual setting 5 cm H2O

The nurse notes premature ventricular contractions (PVCs) while suctioning a patient's endotracheal tube. Which action by the nurse is a priority?

Stop and ventilate the patient with 100% oxygen.

A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is most appropriate?

Take no further action with the collection device. Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax

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?

The arterial pressure is 90/46. 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.

A nurse is caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP). Which assessment finding by the nurse indicates that the PEEP may need to be reduced?

The patient has subcutaneous emphysema on the upper thorax.

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?

The patient respiratory rate is 32 breaths/min.

Which assessment finding obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning?

The patient's respiratory rate is 32 breaths/minute.

A nurse is caring for a patient undergoing mechanical ventilation who is also receiving positive end-expiratory pressure (PEEP). The nurse recognizes that the purpose of PEEP is:

To expand collapsed alveoli

Eight hours after a thermal burn covering 50% of a patient's total body surface area (TBSA) the nurse assesses the patient. Which information would be a priority to communicate to the health care provider?

Urine output is 20 mL per hour for the past 2 hours.

A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital. Which action should the nurse take first?

Use pulse oximetry to check the oxygen saturation.

A patient who has experienced blunt abdominal trauma during a motor vehicle collision is complaining of increasing abdominal pain. The nurse will plan to teach the patient about the purpose of

abdominal ultrasonography.

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

decrease the respiratory rate.

The purpose of prone positioning with patient with ARDS is to

improve the patient's oxygenation as indicated by the PaO2 and SaO2

2. While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient's oxygen saturation (SpO2) from 94% to 88%. Which action should the nurse take next?

increase oxygen flow rate because the problem is with perfusion

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

increased jugular venous distention.

Negative Pressure ventilation

involves the use of chambers that encase the chest or body and surround it with intermittent subatmospheric (negative) pressure delivered by noninvasive ventilation, does not need invasive intubation

Types of mechanical ventilation

negative pressure ventilation positive pressure ventilation

To verify the correct placement of an oral endotracheal tube (ET) after insertion, the best initial action by the nurse is to

use an end-tidal CO2 monitor to check for placement in the trachea.