Ventilatory Assist
The venturi mask
Allows better regulation of oxygen concentration and generally does not deliver more than 60% oxygen.
Simple face mask oxygen delivery
The simple face mask can deliver flows up to 60%
Which patient being cared for in the emergency department should the charge nurse evaluate first? a. A patient with a complete spinal injury at the C5 dermatome level b. A patient with a Glasgow Coma Scale score of 15 on 3-L nasal cannula c. An alert patient with a subdural bleed who is complaining of a headache d. An ischemic stroke patient with a blood pressure of 190/100 mm Hg
a. A patient with a complete spinal injury at the C5 dermatome level
The nurse responds to a high heart rate alarm for a patient in the neurological intensive care unit. The nurse arrives to find the patient sitting in a chair experiencing a tonic-clonic seizure. What is the best nursing action? a. Assist the patient to the floor and provide soft head support. b. Insert a nasogastric tube and connect to continuous wall suction. c. Open the patients mouth and insert a padded tongue blade. d. Restrain the patients extremities until the seizure subsides.
a. Assist the patient to the floor and provide soft head support.
The nurse is caring for a mechanically ventilated patient and responds to a high inspiratory pressure alarm. Recognizing possible causes for the alarm, the nurse assesses for which of the following? (Select all that apply.) a. Coughing or attempting to talk b. Disconnection from the ventilator c. Kinks in the ventilator tubing d. Need for suctioning
a. Coughing or attempting to talk c. Kinks in the ventilator tubing d. Need for suctioning Coughing, kinks, and mucus in the airway can cause the inspiratory pressure to increase; ventilator disconnects result in low-volume alarms. A disconnection from the ventilator would result in a low exhaled volume alarm, not a high-pressure alarm.
A patients ventilator settings are adjusted to treat hypoxemia. The fraction of inspired oxygen is increased from .60 to .70, and the positive end-expiratory pressure is increased from 10 to 15 cm H2O. Shortly after these adjustments, the nurse notes that the patients blood pressure drops from 120/76 mm Hg to 90/60 mm Hg. What is the most likely cause of this decrease in blood pressure? a. Decrease in cardiac output b. Hypovolemia c. Increase in venous return d. Oxygen toxicity
a. Decrease in cardiac output Positive end-expiratory pressure increases intrathoracic pressure and may result in decreased venous return. Cardiac output decreases as a result, and is reflected in the lower blood pressure. It is essential to assess the patient to identify optimal positive end-expiratory pressurethe highest amount that can be applied without compromising cardiac output. Although hypovolemia can result in a decrease in blood pressure, there is no indication that this patient has hypovolemia. As noted, higher levels of positive end-expiratory pressure may cause a decrease, not an increase, in venous return. Oxygen toxicity can occur in this case secondary to the high levels of oxygen needed to maintain gas exchange; however, oxygen toxicity is manifested in damage to the alveoli.
Which of the following devices is best suited to deliver 65% oxygen to a patient who is spontaneously breathing? a. Face mask with non-rebreathing reservoir b. Low-flow nasal cannula c. Simple face mask d. Venturi mask
a. Face mask with non-rebreathing reservoir Face masks with reservoirs (partial rebreathing and non-rebreathing reservoir masks) provide oxygen concentration of 60% or higher. The addition of the reservoir increases the amount of oxygen available to the patient during inspiration and allows for the delivery of concentrations of 35% to 60% (partial rebreather) or 60% to 80% (non-rebreather) depending on the flowmeter setting, the fit of the mask, and the patients respiratory pattern.
The nurse admits a patient to the critical care unit following a motorcycle crash. Assessment findings by the nurse include blood pressure 100/50 mm Hg, heart rate 58 beats/min, respiratory rate 30 breaths/min, and temperature of 100.5. The patient is lethargic, responds to voice but falls asleep readily when not stimulated. Which nursing action is most important to include in this patients plan of care? a. Frequent neurological assessments b. Side to side position changes c. Range of motion to extremities d. Frequent oropharyngeal suctioning
a. Frequent neurological assessments Nurses complete neurological assessments based on ordered frequency and the severity of the patients condition. The newly admitted patient has an altered neurological status so frequent neurological assessments are most important to include in the patients plan of care. Side to side position changes, range of motion exercises, and frequent oral suctioning are nursing actions that may need to be a part of the patients plan of care but in the setting of increased intracranial pressure should not be regularly performed unless indicated.
The nurse assesses a patient with a skull fracture to have a Glasgow Coma Scale score of 3. Additional vital signs assessed by the nurse include blood pressure 100/70 mm Hg, heart rate 55 beats/min, respiratory rate 10 breaths/min, oxygen saturation (SpO2) 94% on oxygen at 3 L per nasal cannula. What is the priority nursing action? a. Monitor the patients airway patency. b. Elevate the head of the patients bed. c. Increase supplemental oxygen delivery. d. Support bony prominences with padding.
a. Monitor the patients airway patency.
The nurse is caring for a patient who is mechanically ventilated. As part of the nursing care, the nurse understands that: a. communication with intubated patients is often difficult. b. controlled ventilation is the preferred mode for most patients. c. patients with chronic obstructive pulmonary disease wean easily from mechanical ventilation. d. wrist restraints are applied to all patients to avoid self-extubation.
a. communication with intubated patients is often difficult. Communication difficulties are common because of the artificial airway. Restraints must be determined individually. Patients with chronic obstructive pulmonary disease often have difficulty weaning. Synchronized intermittent mandatory ventilation and assist/control ventilation are the commonly used modes.
A patients endotracheal tube is not secured tightly. The respiratory care practitioner assists the nurse in taping the tube. After the tube is retaped, the nurse auscultates the patients lungs and notes that the breath sounds over the left lung fields are absent. The nurse suspects that: a. the endotracheal tube is in the right mainstem bronchus. b. the patient has a left pneumothorax. c. the patient has aspirated secretions during the procedure. d. the stethoscope earpiece is clogged with wax.
a. the endotracheal tube is in the right mainstem bronchus. The endotracheal tube can become dislodged during repositioning and is likely in the right mainstem bronchus. It is important to reassess breath sounds after the retaping procedure. A pneumothorax would also result in diminished or absent breath sounds; however, it is not associated with repositioning the endotracheal tube. Aspiration may occur during the procedure but would be manifested in changes in chest x-ray, hypoxemia, etc. The stethoscope is not a factor.
The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine injury who is complaining of a severe headache. The nurse assesses a blood pressure of 180/90 mm Hg, heart rate 60 beats/min, respirations 24 breaths/min, and 50 mL of urine via indwelling urinary catheter for the past 4 hours. What is the best action by the nurse? a. Administer acetaminophen as ordered for the headache. b. Assess for a kinked urinary catheter and assess for bowel impaction. c. Encourage the patient to take slow, deep breaths. d. Notify the physician of the patients blood pressure.
b. Assess for a kinked urinary catheter and assess for bowel impaction.
The nurse is assisting with endotracheal intubation and understands correct placement of the endotracheal tube in the trachea would be identified by which of the following? (Select all that apply.) a. Auscultation of air over the epigastrium b. Equal bilateral breath sounds upon auscultation c. Position above the carina verified by chest x-ray d. Positive detection of carbon dioxide (CO2) through CO2 detector devices
b. Equal bilateral breath sounds upon auscultation c. Position above the carina verified by chest x-ray d. Positive detection of carbon dioxide (CO2) through CO2 detector devices The position of the tube is assessed after intubation through auscultation of breath sounds, carbon dioxide testing, and chest x-ray. Auscultation of air over the epigastrium indicates placement in the esophagus rather than the trachea.
A 53-year-old, 80-kg patient is admitted to the cardiac surgical intensive care unit after cardiac surgery. Four hours after admission to the surgical intensive care unit at 4 PM, the patient has stable vital signs and normal arterial blood gases (ABGs), and is placed on a T-piece for ventilatory weaning. During the nurses 7 PM (1900) assessment, the patient is restless, heart rate has increased to 110 beats/min, respirations are 36 breaths/min, and blood pressure is 156/98 mm Hg. The cardiac monitor shows sinus tachycardia with 10 premature ventricular contractions (PVCs) per minute. Pulmonary artery pressures are elevated. The nurse suctions the patient and obtains pink, frothy secretions. Loud crackles are audible throughout lung fields. The nurse notifies the physician, who orders an ABG analysis, electrolyte levels, and a portable chest x-ray study. How does the nurse interpret the following blood gas levels? pH 7.28 PaCO2 46 mm Hg Bicarbonate 22 mEq/L PaO2 58 mm Hg O2 saturation 88% a. Hypoxemia and compensated respiratory alkalosis b. Hypoxemia and uncompensated respiratory acidosis c. Normal arterial blood gas levels d. Normal oxygen level and partially compensated metabolic acidosis
b. Hypoxemia and uncompensated respiratory acidosis These levels show respiratory acidosis. The bicarbonate is normal; therefore, no compensation has occurred. This patient is also hypoxemic.
The nurse admits a patient to the emergency department (ED) with a suspected cervical spine injury. What is the priority nursing action? a. Keep the neck in the hyperextended position. b. Maintain proper head and neck alignment. c. Prepare for immediate endotracheal intubation. d. Remove cervical collar upon arrival to the ED.
b. Maintain proper head and neck alignment.
The nurse is caring for a patient 3 days following a complete cervical spine injury at the C3 level. The patient is in spinal shock. Following emergent intubation and mechanical ventilation, what is the priority nursing action? a. Maintain body temperature. b. Monitor blood pressure. c. Pad all bony prominences. d. Use proper hand washing.
b. Monitor blood pressure. Maintaining perfusion to the spinal cord is critical in the management of spinal cord injury. Monitoring blood pressure is a priority.
A 53-year-old, 80-kg patient is admitted to the cardiac surgical intensive care unit after cardiac surgery. Four hours after admission to the surgical intensive care unit at 4 PM, the patient has stable vital signs and normal arterial blood gases (ABGs) and is placed on a T-piece for ventilatory weaning. During the nurses 7 PM (1900) assessment, the patient is restless, heart rate has increased to 110 beats/min, respirations are 36 breaths/min, and blood pressure is 156/98 mm Hg. The cardiac monitor shows sinus tachycardia with 10 premature ventricular contractions (PVCs) per minute. Pulmonary artery pressures are elevated. The nurse suctions the patient and obtains pink, frothy secretions. Loud crackles are audible throughout lung fields. The nurse notifies the physician, who orders an ABG analysis, electrolyte levels, and a portable chest x-ray study. In communicating with the physician, which statement indicates the nurse understands what is likely occurring with the patient? a. May we have an order for cardiac enzymes? This patient is exhibiting signs of a myocardial infarction. b. My assessment indicates potential fluid overload. c. The patient is having frequent PVCs that are compromising the cardiac output. d. The patient is having a hypertensive crisis; what medications would you like to order?
b. My assessment indicates potential fluid overload. The crackles, high pulmonary artery pressure, and pink, frothy sputum indicate fluid volume overload. There are not any cues to suggest a myocardial infarction. The PVCs may be related to the surgery or hypoxemia; however, the blood pressure indicates adequate perfusion. The blood pressure is high secondary to fluid overload; treatment of the fluid overload will result in a decrease in blood pressure.
Select all of the factors that may predispose the patient to respiratory acidosis. a. anxiety and fear b. central nervous system depression c. diabetic ketoacidosis d. nasogastric suctioning e. overdose of sedatives
b. central nervous system depression e. overdose of sedatives Central nervous system depression and drug overdose may result in hypoventilation and cause respiratory acidosis. Anxiety is a cause of hyperventilation and respiratory alkalosis. Diabetic ketoacidosis is a cause of metabolic acidosis. Nasogastric suctioning is a cause of metabolic alkalosis.
A patient is having difficulty weaning from mechanical ventilation. The nurse assesses the patient for a potential cause of this difficult weaning, which includes: a. cardiac output of 6 L/min. b. hemoglobin of 8 g/dL. c. negative sputum culture and sensitivity. d. white blood cell count of 8000.
b. hemoglobin of 8 g/dL. The low hemoglobin level will decrease oxygen-carrying capacity and may make weaning difficult. A cardiac output of 6 L/min is normal. A negative sputum culture indicates absence of lower respiratory infection, which should promote rather than hinder weaning. A white blood cell count of 8000 is normal and indicates absence of infection, which should promote rather than hinder weaning.
A PaCO2 of 48 mm Hg is associated with: a. hyperventilation. b. hypoventilation. c. increased absorption of O2. d. increased excretion of HCO3.
b. hypoventilation PaCO2 rises in patients with hypoventilation. Hyperventilation results in a decrease in PaCO2. PaCO2 does not affect oxygen absorption. Increased excretion of bicarbonate would result in metabolic acidosis
A 65-year-old patient is admitted to the progressive care unit with a diagnosis of community-acquired pneumonia. The patient has a history of chronic obstructive pulmonary disease and diabetes. A set of arterial blood gases obtained on admission without supplemental oxygen shows pH 7.35; PaCO2 55 mm Hg; bicarbonate 30 mEq/L; PaO2 65 mm Hg. These blood gases reflect: a. hypoxemia and compensated metabolic alkalosis. b. hypoxemia and compensated respiratory acidosis. c. normal oxygenation and partly compensated metabolic alkalosis. d. normal oxygenation and uncompensated respiratory acidosis.
b. hypoxemia and compensated respiratory acidosis. The PaO2 of 65 mm Hg is lower than normal range (80-100 mm Hg), indicating hypoxemia. The high PaCO2 indicates respiratory acidosis. The elevated bicarbonate indicates metabolic alkalosis. Because the pH is normal, the underlying acid-base alteration is compensated. Given the patients history of chronic pulmonary disease and a pH that is at the lower end of normal range, it can be determined that this patient is hypoxemic with fully compensated respiratory acidosis.
Oxygen saturation (SaO2) represents: a. alveolar oxygen tension. b. oxygen that is chemically combined with hemoglobin. c. oxygen that is physically dissolved in plasma. d. total oxygen consumption.
b. oxygen that is chemically combined with hemoglobin. Oxygen saturation value reflects the saturation of the hemoglobin.
One of the early signs of the effect of hypoxemia on the nervous system is: a. cyanosis. b. restlessness. c. tachycardia. d. tachypnea.
b. restlessness. Decreased oxygenation to the nervous system may result in restlessness and agitationearly signs of hypoxemia. Cyanosis is a late sign. Tachycardia and tachypnea may occur, but CNS changes tend to occur earlier.
The physician has opted to treat a patient with a complete spinal cord injury with glucocorticoids. The physician orders 30 mg/kg over 15 minutes followed in 45 minutes with an infusion of 5.4 mg/kg/min for 23 hours. What is the total 24-hour dose for the 70-kg patient? a. 2478 mg b. 5000 mg c. 10,794 mg d. 12,750 mg
c. 10,794 mg
While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mm Hg and a CPP of 85 mm Hg. What is the best interpretation by the nurse? a. Both pressures are high. b. Both pressures are low. c. ICP is high; CPP is normal. d. ICP is high; CPP is low.
c. ICP is high; CPP is normal. The ICP is above the normal level of 15 mm Hg. The CPP is within the normal range.
The nurse is caring for a mechanically ventilated patient with a brain injury. Arterial blood gas values indicate a PaCO2 of 60 mm Hg. The nurse understands this value to have which effect on cerebral blood flow? a. Altered cerebral spinal fluid production and reabsorption b. Decreased cerebral blood volume due to vessel constriction c. Increased cerebral blood volume due to vessel dilation d. No effect on cerebral blood flow (PaCO2 of 60 mm Hg is normal)
c. Increased cerebral blood volume due to vessel dilation Cerebral vessels dilate when PaCO2 levels increase, increasing cerebral blood volume. Cerebral vessels dilate when CO2 levels increase, increasing cerebral blood volume. To compensate for increased cerebral blood volume, cerebral spinal fluid may be displaced, but the scenario is asking for the effect of hypercarbia (elevated PaCO2) on cerebral blood flow. PaCO2 of 60 mm Hg is elevated, which would cause cerebral vasodilation and increased cerebral blood volume.
A 53-year-old, 80-kg patient is admitted to the cardiac surgical intensive care unit after cardiac surgery with the following arterial blood gas (ABG) levels. What is the nurses interpretation of these values? pH 7.4 PaCO2 40 mm Hg Bicarbonate 24 mEq/L PaO2 95 mm Hg O2 saturation 97% Respirations 20 breaths per minute a. Compensated metabolic acidosis b. Metabolic alkalosis c. Normal ABG values d. Respiratory acidosis
c. Normal ABG values These are normal values. All parameters are within normal limits.
While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the patients left naris. What is the best nursing action? a. Have the patient blow the nose until clear. b. Insert bilateral cotton nasal packing. c. Place a nasal drip pad under the nose. d. Suction the left nares until the drainage clears.
c. Place a nasal drip pad under the nose. In the presence of suspected cerebrospinal fluid leak, drainage should be unobstructed and free flowing. Small bandages may be applied to allow for fluid collection and assessment. Patients should be instructed not to blow their nose because that action may further aggravate the dural tear. Suction catheters should be inserted through the mouth rather than the nose to avoid penetrating the brain due to the dural tear.
A patient is being mechanically ventilated in the synchronized intermittent mandatory ventilation mode at a rate of 4 breaths/min. His spontaneous respirations are 12 breaths/min. He receives a dose of morphine sulfate, and his respirations decrease to 4 breaths/min. Which acid-base disturbance will likely occur? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis
c. Respiratory acidosis The morphine caused respiratory depression. As a result, the frequency and depth of respiration is compromised, which can lead to respiratory acidosis.
The nurse is caring for a patient who has a diminished level of consciousness and who is mechanically ventilated. While performing endotracheal suctioning, the patient reaches up in an attempt to grab the suction catheter. What is the best interpretation by the nurse? a. The patient is exhibiting extension posturing. b. The patient is exhibiting flexion posturing. c. The patient is exhibiting purposeful movement. d. The patient is withdrawing to stimulation.
c. The patient is exhibiting purposeful movement.
The nurse is assessing the exhaled tidal volume (EVT) in a mechanically ventilated patient. The rationale for this assessment is to: a. assess for tension pneumothorax. b. assess the level of positive end-expiratory pressure. c. compare the tidal volume delivered with the tidal volume prescribed. d. determine the patients work of breathing.
c. compare the tidal volume delivered with the tidal volume prescribed. The EVT is assessed to determine if the patient is receiving the tidal volume that is prescribed. Volume may be lost because of leaks in the ventilator circuit, around the endotracheal tube cuff, or around a chest tube. The assessment will not detect a pneumothorax and does not assess positive end-expiratory pressure or work of breathing.
A patients status worsens and needs mechanical ventilation. The pulmonologist wants the patient to receive 10 breaths/min from the ventilator but wants to encourage the patient to breathe spontaneously in between the mechanical breaths at his own tidal volume. This mode of ventilation is called: a. assist/control ventilation b. controlled ventilation c. intermittent mandatory ventilation d. positive end-expiratory pressure
c. intermittent mandatory ventilation The intermittent mandatory ventilation mode allows the patient to breathe spontaneously between breaths. The patient will receive a preset tidal volume at a preset rate. Any additional breaths that he initiates will be at his spontaneous tidal volume, which will likely be lower than the ventilator breaths. In assist/control ventilation, spontaneous effort results in a preset tidal volume delivered by the ventilator. Spontaneous effort during controlled ventilation results in patient/ventilator dyssynchrony. Positive end-expiratory pressure (PEEP) is application of positive pressure to breaths delivered by the ventilator. PEEP is an adjunct to both intermittent mandatory and assist/control ventilation.
The nurse is caring for a patient with an endotracheal tube. The nurse understands that endotracheal suctioning is needed to facilitate removal of secretions and that the procedure: a. decreases intracranial pressure. b. depresses the cough reflex. c. is done as indicated by patient assessment. d. is more effective if preceded by saline instillation to loosen secretions.
c. is done as indicated by patient assessment. Suctioning is performed as indicated by patients assessment. Suctioning is associated with increases in intracranial pressure; therefore, it is important to hyperoxygenate the patient prior to suctioning to reduce this complication. Suctioning can stimulate the cough reflex rather than depress this reflex. Saline instillation is associated with negative physiological outcomes and is not recommended as part of the suctioning procedure; it does not loosen secretions, which is a common misperception.
The nurse notes that the patients arterial blood gas levels indicate hypoxemia. The patient is not intubated and has a respiratory rate of 22 breaths/min. The nurses first intervention to relieve hypoxemia is to: a. call the physician for an emergency intubation procedure. b. obtain an order for bilevel positive airway pressure (BiPAP). c. notify the provider of values and obtain order for oxygen. d. suction secretions from the oropharynx.
c. notify the provider of values and obtain order for oxygen. Oxygen is administered to treat or prevent hypoxemia. Oxygen should be considered a first-line treatment in cases of hypoxemia. Emergency intubation is not warranted at this time. BiPAP may be considered if administration of supplemental oxygen does not correct the hypoxemia. There is no indication that the patient requires suctioning.
The nurse is caring for a mechanically ventilated patient admitted with a traumatic brain injury. Which arterial blood gas value assessed by the nurse indicates optimal gas exchange for a patient with this type of injury? a. pH 7.38; PaCO2 55 mm Hg; HCO3 22 mEq/L; PaO2 85 mm Hg b. pH 7.38; PaCO2 40 mm Hg; HCO3 24 mEq/L; PaO2 70 mm Hg c. pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg d. pH 7.38; PaCO2 28 mm Hg; HCO3 26 mEq/L; PaO2 65 mm Hg
c. pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg
Neuromuscular blocking agents are used in the management of some ventilated patients. Their primary mode of action is: a. analgesia. b. anticonvulsant. c. paralysis. d. sedation.
c. paralysis. Neuromuscular blocking agents cause respiratory muscle paralysis. They do not have sedative, analgesic, or anticonvulsant effects.
A mode of pressure-targeted ventilation that provides positive pressure to decrease the workload of spontaneous breathing through the endotracheal tube is: a. continuous positive airway pressure. b. positive end-expiratory pressure. c. pressure support ventilation. d. T-piece adapter.
c. pressure support ventilation. Pressure support (PS) is a mode of ventilation in which the patients spontaneous respiratory activity is augmented by the delivery of a preset amount of inspiratory positive pressure. Positive end-expiratory pressure provides positive pressure at end expiration during mechanical breaths, and continuous positive airway pressure provides positive pressure during spontaneous breaths. The T-piece adapter is used to provide oxygen with spontaneous, unassisted breaths.
When assessing the patient for hypoxemia, the nurse recognizes that an early sign of the effect of hypoxemia on the cardiovascular system is: a. heart block. b. restlessness. c. tachycardia. d. tachypnea.
c. tachycardia. Tachycardia can occur as a compensatory mechanism to increase cardiac output and oxygenation. Dysrhythmias may occur; however, they are not an early sign and tend to be premature ventricular contractions. Restlessness is an early neurological sign, whereas tachypnea is an early respiratory sign.
The nurse is caring for a patient admitted to the ED following a fall from a 10-foot ladder. Upon admission, the nurse assesses the patient to be awake, alert, and moving all four extremities. The nurse also notes bruising behind the left ear and straw-colored drainage from the left nare. What is the most appropriate nursing action? a. Insert bilateral ear plugs. b. Monitor airway patency. c. Maintain neutral head position. d. Apply a small nasal drip pad.
d. Apply a small nasal drip pad.
The nurse is caring for a patient with an ICP of 18 mm Hg and a GCS score of 3. Following the administration of mannitol (Osmitrol), which assessment finding by the nurse requires further action? a. ICP of 10 mm Hgb. b. CPP of 70 mm Hg c. GCS score of 5 d. CVP of 2 mm Hg
d. CVP of 2 mm Hg Osmotic diuretics draw water from normal brain cells, decreasing ICP and increasing CPP and urine output. An ICP of 10 mm Hg and CPP of 70 mm Hg are within normal limits. A GCS score of 5, while not optimum indicates a slight improvement. A CVP of 2 mm Hg indicates hypovolemia. To ensure adequate cerebral perfusion, further action on the part of the nurse is necessary.
The nurse admits a patient to the emergency department with new onset of slurred speech and right-sided weakness. What is the priority nursing action? a. Assess for the presence of a headache. b. Assess the patients general orientation. c. Determine the patients drug allergies. d. Determine the time of symptom onset.
d. Determine the time of symptom onset.
A patient is being mechanically ventilated in the synchronized intermittent mandatory ventilation mode at a rate of 4 breaths/min. His spontaneous respirations are 12 breaths/min. He receives a dose of morphine sulfate, and his respirations decrease to 4 breaths/min. What adjustments may need to be made to the patients ventilator settings? a. Add positive end-expiratory pressure (PEEP). b. Add pressure support. c. Change to assist/control ventilation at a rate of 4 breaths/min. d. Increase the synchronized intermittent mandatory ventilation respiratory rate.
d. Increase the synchronized intermittent mandatory ventilation respiratory rate. The morphine caused respiratory depression. As a result, the frequency and depth of respiration is compromised, which can lead to respiratory acidosis. The respiratory rate on the mechanical ventilator needs to be increased. The patient also may need to have naloxone administered to reverse the effects of the morphine. PEEP is added to improve oxygenation; it does not increase the rate or depth of respirations. Pressure support will not be effective in increasing the rate of spontaneous respiration. Changing to assist/control ventilation is an option; however, the rate needs to be set higher than 4 breaths/min.
The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at the scene briefly but is now conscious upon arrival at the emergency department (ED) with a GCS score of 15. One hour later, the nurse assesses a GCS score of 3. What is the priority nursing action? a. Stimulate the patient hourly. b. Continue to monitor the patient. c. Elevate the head of the bed. d. Notify the physician immediately.
d. Notify the physician immediately.
The nurse is caring for a mechanically ventilated patient with a sustained ICP of 18 mm Hg. The nurse needs to perform an hourly neurological assessment, suction the endotracheal tube, perform oral hygiene care, and reposition the patient to the left side. What is the best action by the nurse? a. Hyperoxygenate during endotracheal suctioning. b. Elevate the patients head of the bed 30 degrees. c. Apply bilateral heel protectors after repositioning. d. Provide rest periods between nursing interventions.
d. Provide rest periods between nursing interventions. Sustained increases in ICP lasting longer than 5 minutes should be avoided. This is accomplished by spacing nursing care activities to allow for rest between activities. All other nursing actions are a part of the patients plan of care; however, spacing out interventions is the priority.
While caring for a patient with a closed head injury, the nurse assesses the patient to be alert with a blood pressure 130/90 mm Hg, heart rate 60 beats/min, respirations 18 breaths/min, and a temperature of 102 F. To reduce the risk of increased intracranial pressure (ICP) in this patient, what is (are) the priority nursing action(s)? a. Ensure adequate periods of rest between nursing interventions. b. Insert an oral airway and monitor respiratory rate and depth. c. Maintain neutral head alignment and avoid extreme hip flexion. d. Reduce ambient room temperature and administer antipyretics.
d. Reduce ambient room temperature and administer antipyretics.
The physician orders the following mechanical ventilation settings for a patient who weighs 75 kg. The patients spontaneous respiratory rate is 22 breaths/min. What arterial blood gas abnormality may occur if the patient continues to be tachypneic at these ventilator settings? Tidal volume: 600 mL (8 mL per kg) FiO2: 0.5 Respiratory rate: 14 breaths/min Mode assist/control Positive end-expiratory pressure: 10 cm H2O a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis
d. Respiratory alkalosis Assist/control ventilation may result in respiratory alkalosis, especially when the patient is breathing at a high rate. Each time the patient initiates a spontaneous breathing this case 22 times per minute the ventilator will deliver 600 mL of volume.
The nurse is caring for a mechanically ventilated patient. The physicians are considering performing a tracheostomy because the patient is having difficulty weaning from mechanical ventilation. Related to tracheostomy, the nurse understands which of the following? a. Patient outcomes are better if the tracheostomy is done within a week of intubation. b. Percutaneous tracheostomy can be done safely at the bedside by the respiratory therapist. c. Procedures performed in the operating room are associated with fewer complications. d. The greatest risk after a percutaneous tracheostomy is accidental decannulation.
d. The greatest risk after a percutaneous tracheostomy is accidental decannulation. Optimal timing of tracheostomy is not yet known. Percutaneous procedures done at the bedside are not associated with any higher risks than those done in the operating room. Trained physicians safely perform percutaneous tracheostomies at the bedside. The greatest risk for percutaneous tracheostomy is accidental decannulation because the trachea is not surgically attached.
Positive end-expiratory pressure (PEEP) is a mode of ventilatory assistance that produces the following condition: a. Each time the patient initiates a breath, the ventilator delivers a full preset tidal volume. b. For each spontaneous breath taken by the patient, the tidal volume is determined by the patients ability to generate negative pressure. c. The patient must have a respiratory drive, or no breaths will be delivered. d. There is pressure remaining in the lungs at the end of expiration that is measured in cm H2O.
d. There is pressure remaining in the lungs at the end of expiration that is measured in cm H2O. PEEP is the addition of positive pressure into the airways during expiration. PEEP is measured in centimeters of water.
A patient has coronary artery bypass graft surgery and is transported to the surgical intensive care unit at noon. He is placed on mechanical ventilation. Interpret his initial arterial blood gas levels: pH 7.31 PaCO2 48 mm Hg Bicarbonate 22 mEq/L PaO2 115 mm Hg O2 saturation 99% a. Normal arterial blood gas levels with a high oxygen level b. Partly compensated respiratory acidosis, normal oxygen c. Uncompensated metabolic acidosis with high oxygen levels d. Uncompensated respiratory acidosis; hyperoxygenated
d. Uncompensated respiratory acidosis; hyperoxygenated The high PaO2 level reflects hyperoxygenation; the PaCO2 and pH levels show respiratory acidosis. The respiratory acidosis is uncompensated as indicated by a pH of 7.31 (acidosis) and a normal bicarbonate level. No metabolic compensation has occurred.
The nurse is caring for a patient whose ventilator settings include 15 cm H2O of positive end-expiratory pressure (PEEP). The nurse understands that although beneficial, PEEP may result in: a. fluid overload secondary to decreased venous return. b. high cardiac index secondary to more efficient ventricular function. c. hypoxemia secondary to prolonged positive pressure at expiration. d. low cardiac output secondary to increased intrathoracic pressure
d. low cardiac output secondary to increased intrathoracic pressure Positive end-expiratory pressure, especially at higher levels, can result in a decreased cardiac output and index secondary to increased intrathoracic pressure, which impedes venous return. Fluid overload is not an expected finding. The cardiac index would likely decrease, not increase, along with cardiac output. PEEP is used to treat hypoxemia; it does not cause it.
The nurse is caring for a mechanically ventilated patient and notes the high pressure alarm sounding. The nurse cannot quickly identify the cause of the alarm and notes the patients oxygen saturation is decreasing and heart rate and respiratory rate are increasing. The nurses priority action is to: a. ask the respiratory therapist to get a new ventilator. b. call the rapid response team to assess the patient. c. continue to find the cause of the alarm and fix it. d. manually ventilate the patient while calling for a respiratory therapist.
d. manually ventilate the patient while calling for a respiratory therapist. The nurse must quickly assess the patient and determine possible causes of the alarm. If the cause is not assessed within seconds, the nurse must manually ventilate the patient and secure assistance in troubleshooting the problem. The patient must be treated while the causes are being assessed by the nurse and respiratory therapist. Continuing to assess for the cause without manually ventilating the patient can result in patient compromise. The respiratory therapist, not the rapid response team, will assess and remedy the problem. A new ventilator may be needed, but that would be determined after the respiratory therapist has assessed the situation.
Pulse oximetry measures: a. arterial blood gases. b. hemoglobin values. c. oxygen consumption. d. oxygen saturation.
d. oxygen saturation. Pulse oximetry measures oxygen saturation in the peripheral tissues. It does not measure arterial blood gases, but it does estimate the PaO2 that is obtained via a blood gas analysis. It does not measure hemoglobin levels or oxygen consumption.
Current guidelines recommend the oral route for endotracheal intubation. The rationale for this recommendation is that nasotracheal intubation is associated with a greater risk for: a. basilar skull fracture. b. cervical hyperextension. c. impaired ability to mouth words. d. sinusitis and infection.
d. sinusitis and infection. Nasotracheal intubation is associated with an increased risk for sinusitis, which may contribute to ventilator- associated infection. Nasal intubation is contraindicated in patients with basilar skull fracture. The procedure is sometimes performed in patients with cervical spine injury; the procedure can be done without hyperextending the neck. Patients with nasotracheal tubes are generally more comfortable and have a greater ability to mouth words.
A patient presents to the emergency department demonstrating agitation and complaining of numbness and tingling in his fingers. His arterial blood gas levels reveal the following: pH 7.51, PaCO2 25, HCO3 25. The nurse interprets these blood gas values as: a. compensated metabolic alkalosis. b. normal values. c. uncompensated respiratory acidosis. d. uncompensated respiratory alkalosis.
d. uncompensated respiratory alkalosis. The low PaCO2 and high pH values show respiratory alkalosis. The bicarbonate level is normal.
The amount of effort needed to maintain a given level of ventilation is termed: a. compliance. b. resistance. c. tidal volume. d. work of breathing.
d. work of breathing. Work of breathing is the amount of effort needed to maintain a given level of ventilation. Compliance is a measure of the distensibility, or stretchability, of the lung and chest wall. Resistance refers to the opposition to the flow of gases in the airways. Tidal volume is the volume of air in a typical breath.
