477 E2
A Client has been intubated and placed on a volume-cycled mechanical ventilator. The nurse carefully assess the client for findings associated with a risk associated with this type of ventilator. What is the risk? A. Hypoventilation B. Hypercapnia C. Respiratory acidosis D. Barotrauma
D. Barotrauma Rationale: the volume-cycled ventilator has the potential to increase pressure in order to deliver the set volume. barotrauma is a risk associated with this form of mechanical ventilation.
While positioning a patient in bed with increased ICP, it important to avoid? A. Midline positioning of the head B. Placing the HOB at 30-35 degrees C. Preventing flexion of the neck D. Flexion of the hips
D. Flexion of the hips The answer is D. Avoid flexing the hips because this can increase intra-abdominal/thoracic pressure, which will increase ICP.
When the ventilator alarm sounds, the nurse finds the patient lying in bed holding the endotracheal tube (ET). Which action should the nurse take first? A. Offer reassurance to the patient. B. Activate the hospital's rapid response team. 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 also are appropriate after the nurse has stabilized the patient's oxygenation.
During the eye assessment of a patient with increased ICP, you need to assess the oculocephalic reflex. If the patient has brain stem damage what response will you find? A. The eyes will roll down as the head is moved side to side. B. The eyes will move in the opposite direction as the head is moved side to side. C. The eyes will roll back as the head is moved side to side. D. The eyes will be in a fixed mid-line position as the head is moved side to side.
D. The eyes will be in a fixed mid-line position as the head is moved side to side. The answer is D. This is known as a negative doll's eye and represents brain stem damage. It is a very bad sign.
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.
Barotrauama
Damage to the lungs by positive pressure
Volutrauma
Damange to the lungs by excess volume to one lung over the other
A health care provider (HCP) writes a prescription to begin to wean the client from the mechanical ventilator by use of intermittent mandatory ventilation/synchronized intermittent mandatory ventilation (IMV/SIMV). The registered nurse determines that the new graduate nurse understands this modality of weaning if which statement is made? 1. "The respiratory rate is decreased gradually until the client can assume the work of breathing without ventilatory assistance." 2. "A T-piece will be attached to the ventilator and provide supplemental oxygen at a concentration that is 10% higher than the ventilator setting." 3. "It will provide pressure support to decrease the workload of breathing and increase the client's ability to initiate spontaneous breathing efforts." 4. "It involves removing the ventilator from the client and closely monitoring the client's ability to breathe spontaneously for a predetermined amount of time.
1. "The respiratory rate is decreased gradually until the client can assume the work of breathing without ventilatory assistance." IMV/SIMV is one of the methods used for weaning. With this method, the respiratory rate is gradually decreased until the client assumes all of the work of breathing on his or her own. This method works exceptionally well in the weaning of clients from short-term mechanical ventilation, such as that used in clients who have undergone surgery. The respiratory rate frequently is decreased in increments on an hourly basis until the client is weaned and is ready for extubation. Therefore, the remaining options are incorrect.
The nurse reads in the progress notes for a client with pneumonia that areas of the client's lungs are being perfused but are not being ventilated. How does the nurse correctly interpret this documentation? 1. A shunt unit exists. 2. Anatomical dead space is present. 3. Physiological dead space is present. 4. Ventilation-perfusion matching is occurring.
1. A shunt unit exists When there is no ventilation to an alveolar unit but perfusion continues, a shunt unit exists. As a result, no gas exchange occurs, and unoxgenated blood continues to circulate. Anatomical dead space normally is present in the conducting airways, where pulmonary capillaries are absent. Physiological dead space occurs with conditions such as emphysema and pulmonary embolism. Ventilation-perfusion matching refers to a matching distribution of blood flow in the pulmonary capillaries and air exchange in the alveolar units of the lungs
The nurse is preparing to assist a client with a cuffed tracheostomy tube to eat. What intervention is the priority before the client is permitted to drink or eat? 1. Inflate the cuff on the tracheostomy tube. 2. Deflate the cuff on the tracheostomy tube. 3. Maintain the head of the bed in low Fowler's position. 4. Place the tray in a comfortable position in front of the client.
1. Inflate the cuff on the tracheostomy tube Tracheostomy tubes are available in many sizes and are made of plastic or metal. The tubes may be reusable; however, most tubes are disposable. A tracheostomy tube may or may not have a cuff. It also may have an inner cannula. For clients receiving mechanical ventilation, a cuffed tube is used. A noncuffed tube may be used when mechanical ventilation is not required. If a client with a tracheostomy is allowed to eat and the tracheostomy has a cuff, the nurse should inflate the cuff to prevent aspiration of food or fluids. The cuff would not be deflated because of the risk of aspiration. Although the nurse would ensure that the meal tray is in a comfortable position for the client, this would not be the priority intervention. The head of the bed should always be elevated; low Fowler's position could lead to aspiration.
The nurse is reviewing the ventilator settings on a client with an endotracheal tube attached to mechanical ventilation. The nurse notes that the tidal volume is set at 700 mL. How does the nurse interpret this setting? 1. It is the amount of air delivered with each set breath. 2. It is a breath that has a greater volume than the preset tidal volume. 3. It is the number of breaths that the client will receive per minute by the ventilator. 4. It is the fraction of inspired oxygen (FiO2) that is delivered to the client through the ventilator.
1. It is the amount of air delivered with each set breath. Tidal volume is the amount of air delivered with each set breath on the mechanical ventilator. A sigh is a breath that has a greater volume than the preset tidal volume. The respiratory rate is the number of breaths to be delivered by the ventilator each minute. The FiO2 delivered to the client is indicated by the FiO2 indicator on the ventilator.
A client who is intubated and receiving mechanical ventilation is at risk for infection. The nurse should include which measures in the care of this client? Select all that apply. 1. Monitor the client's temperature. 2. Use sterile technique when suctioning. 3. Use the closed-system method of suctioning. 4. Monitor sputum characteristics and amounts. 5. Drain water from the ventilator tubing into the humidifier bottle.
1. Monitor the client's temperature. 2. Use sterile technique when suctioning. 3. Use the closed-system method of suctioning. 4. Monitor sputum characteristics and amounts. Monitoring temperature and sputum production is indicated in the care of the client. A closed-system method of suctioning and sterile technique decrease the risk of infection associated with suctioning. Water in the ventilator tubing should be emptied, not drained back into the humidifier bottle. This puts the client at risk of acquiring infection, especially Pseudomonas.
The nurse is providing care to a client with increased intracranial pressure (ICP). Which approach is beneficial in controlling the client's ICP from an environmental viewpoint? 1. Reduce environmental noise. 2. Allow visitors as desired by the client and family. 3. Awaken the client every 2 to 3 hours to monitor mental status. 4. Cluster nursing activities to reduce the number of interruptions.
1. Reduce environmental noise. Nursing interventions to control ICP include maintaining a calm, quiet, and restful environment. Environmental noise should be kept at a minimum. Visiting should be monitored to avoid emotional stress and interruption of sleep. Interventions should be spaced out over the shift to minimize the risk of a sustained rise in ICP.
The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding? 1. Rhythmic respirations with periods of apnea 2. Regular rapid and deep, sustained respirations 3. Totally irregular respiration in rhythm and depth 4. Irregular respirations with pauses at the end of inspiration and expiration
1. Rhythmic respirations with periods of apnea Cheyne-Stokes respirations are rhythmic respirations with periods of apnea and can indicate a metabolic dysfunction in the cerebral hemisphere or basal ganglia. Neurogenic hyperventilation is a regular, rapid and deep, sustained respiration that can indicate a dysfunction in the low midbrain and middle pons. Ataxic respirations are totally irregular in rhythm and depth and indicate a dysfunction in the medulla. Apneustic respirations are irregular respirations with pauses at the end of inspiration and expiration and can indicate a dysfunction in the middle or caudal pons.
The nurse is caring for a client immediately after removal of the endotracheal tube. The nurse should report which sign immediately if experienced by the client? 1. Stridor 2. Occasional pink-tinged sputum 3. Respiratory rate of 24 breaths/minute 4. A few basilar lung crackles on the right
1. Stridor Following removal of the endotracheal tube the nurse monitors the client for respiratory distress. The nurse reports stridor to the health care provider (HCP) immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction. Although the findings identified in the remaining options require monitoring, they do not require immediate notification of the HCP.
The nurse is caring for a client who is mechanically ventilated, and the high-pressure ventilator alarm is sounding. The nurse understands that which complications may cause this alarm? Select all that apply. 1. Water or a kink in the tubing 2. Biting on the endotracheal tube 3. Increased secretions in the airway 4. Disconnection or leak in the system 5. The client ceasing spontaneous breathing
1. Water or a kink in the tubing 2. Biting on the ET tube 3. Increased secretions in the airway Causes of high-pressure ventilator alarms include water or a kink in the tubing, biting on the endotracheal tube, increased secretions in the airway, wheezing or bronchospasm, displacement of the endotracheal tube, or the client fighting the ventilator. A disconnection or leak in the system and the client ceasing to spontaneously breathe are causes of a low-pressure ventilator alarm.
A registered nurse who is orienting a new nursing graduate to the hospital emergency department instructs the new graduate to monitor a client for one-sided chest movement on the right side while the client is being intubated by the health care provider (HCP). Which statement made by the new nursing graduate indicates understanding of the importance of this observation? 1. "It will enter the left main bronchus if inserted too far." 2. "It will enter the right main bronchus if inserted too far." 3. "It may enter the left main bronchus if not inserted far enough." 4. "It may enter the right main bronchus if not inserted far enough."
2. "It will enter the right main bronchus if inserted too far." If the endotracheal tube is inserted too far into the client's trachea, the tube will enter the right main bronchus. This occurs because the right bronchus is shorter and wider than the left and extends downward in a more vertical plane. If the tube is not inserted far enough, no chest expansion at all will occur. The other options are incorrect.
The nurse is teaching a client with pulmonary disease about fundamental concepts of gas exchange. When asked for further details by the client, the nurse explains that gas exchange occurs through which process? 1. Osmosis 2. Diffusion 3. Ionization 4.Active transport
2. Diffusion Gas exchange occurs by diffusion, which means that oxygen and carbon dioxide move across the alveolar-capillary membrane as a result of a pressure gradient. Osmosis is the process of movement according to a concentration gradient. Ionization refers to the process whereby a molecule gains or loses electrons. Active transport is movement of molecules by carrying them across a cell membrane.
The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate noting which sign in the client? 1. Coma 2. Flushing 3. Dizziness 4. Tachycardia
2. Flushing Carbon monoxide levels between 11% and 20% result in flushing, headache, decreased visual activity, decreased cerebral functioning, and slight breathlessness; levels of 21% to 40% result in nausea, vomiting, dizziness, tinnitus, vertigo, confusion, drowsiness, pale to reddish-purple skin, and tachycardia; levels of 41% to 60% result in seizure and coma; and levels higher than 60% result in death.
While changing the tapes on a newly inserted tracheostomy tube, the client coughs and the tube is dislodged. Which is the initial nursing action? 1. Call the health care provider to reinsert the tube. 2. Grasp the retention sutures to spread the opening. 3. Call the respiratory therapy department to reinsert the tracheotomy. 4. Cover the tracheostomy site with a sterile dressing to prevent infection.
2. Grasp the retention sutures to spread the opening If the tube is dislodged accidentally, the initial nursing action is to grasp the retention sutures and spread the opening. If agency policy permits, the nurse then attempts to replace the tube immediately. Calling ancillary services or the health care provider will delay treatment in this emergency situation. Covering the tracheostomy site will block the airway.
The nurse is caring for a client who is at risk for increased intracranial pressure (ICP) after a stroke. Which activities performed by the nurse will assist with preventing increases in ICP? Select all that apply. 1. Clustering nursing activities 2. Hyperoxygenating before suctioning 3. Maintaining 20 degree flexion of the knees 4. Maintaining the head and neck in midline position 5. Maintaining the head of the bed (HOB) at 30 degrees elevation
2. Hyperoxygenating before suctioning 4. Maintaining the head and neck in midline position 5. Maintaining the head of the bed (HOB) at 30 degrees elevation Measures aimed at preventing increased ICP in the poststroke client include hyperoxgenating before suctioning to avoid transient hypoxemia and resultant ICP elevation from dilation of cerebral arteries; maintaining the head in a midline, neutral position to help promote venous drainage from the brain; and keeping the HOB elevated to between 25 and 30 degrees to prevent a decreased blood flow to the brain. Clustering activities can be stressful for the client and increase ICP. Maintaining 20 degree flexion of the knees increases intraabdominal pressure and consequently ICP.
The nurse notes that a client who has suffered a brain injury has an adequate heart rate, blood pressure, fluid balance, and body temperature. Based on these clinical findings, the nurse determines that which brain area is functioning properly? 1. Thalamus 2. Hypothalamus 3. Limbic system 4. Reticular activating system
2. Hypothalamus The hypothalamus is responsible for autonomic nervous system functions, such as heart rate, blood pressure, temperature, and fluid and electrolyte balance (among others). The thalamus acts as a relay station for sensory and motor information. The limbic system is responsible for emotions. The reticular activating system is responsible for the sleep-wake cycle.
The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? 1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure 2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure 3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure 4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure
2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may occur.
A client has a high level of carbon dioxide (CO2) in the bloodstream, as measured by arterial blood gases. The nurse anticipates that which underlying pathophysiology can occur as a result of this elevated CO2? 1. It will cause arteriovenous shunting. 2. It will cause vasodilation of blood vessels in the brain. 3. It will cause blood vessels in the circle of Willis to collapse. 4. It will cause hyperresponsiveness of blood vessels in the brain.
2. It will cause vasodilation of blood vessels in the brain. CO2 is one of the metabolic end products that can alter the tone of the blood vessels in the brain. High CO2 levels cause vasodilation, which may cause headache, whereas low CO2 levels cause vasoconstriction, which may cause lightheadedness. The statements included in the other options are incorrect effects.
The nurse is assessing the motor and sensory function of an unconscious client. The nurse should use which technique to test the client's peripheral response to pain? 1. Sternal rub 2. Nail bed pressure 3. Pressure on the orbital rim 4. Squeezing of the sternocleidomastoid muscle
2. Nail bed pressure Nail bed pressure tests a basic motor and sensory peripheral response. Cerebral responses to pain are tested using a sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.
The nurse is preparing for removal of an endotracheal (ET) tube from a client. In assisting the health care provider with this procedure, which is the initial nursing action? 1. Deflate the cuff. 2. Suction the ET tube. 3. Turn off the ventilator. 4. Obtain a code cart, and place it at the bedside.
2. Suction the ET tube Once the client has been weaned successfully and has achieved an acceptable level of consciousness to sustain spontaneous respiration, an ET tube may be removed. The ET tube is suctioned first, and then the cuff is deflated and the tube is removed. Placing a code cart at the bedside is unnecessary and may cause alarm and concern in the client. In addition, resuscitative equipment should already be available at the client's bedside. Option 3 is not the initial action.
A client who is experiencing respiratory difficulty asks the nurse, "Why it is so much easier to breathe out than in?" In providing a response, the nurse explains that breathing is easier on exhalation because of which respiratory responses? 1. Air flows by gravity. 2. The respiratory muscles relax. 3. The respiratory muscles contract. 4. Air is flowing against a pressure gradient.
2. The respiratory muscles relax. Exhalation is less taxing for the client because it is a passive process in which the respiratory muscles relax. This allows air to flow upward out of the lungs. Air flows according to a pressure gradient from higher pressure to lower pressure. It does not flow by gravity or against a pressure gradient.
The nurse is providing instructions to a client about diaphragmatic breathing. The nurse tells the client that this technique is helpful because in normal respiration, as the diaphragm contracts, it takes which action? 1. Aids in exhalation 2. Moves up and inward 3. Moves downward and out 4. Makes the thoracic cage smaller
3. Moves downward and out As the diaphragm contracts, it moves downward and out, becoming flatter and expanding the thoracic cage, to promote lung expansion. This process occurs during the inspiratory phase of the respiratory cycle. The incorrect options occur with exhalation and relaxation of the diaphragm.
The nurse monitors the respiratory status of the client being treated for acute exacerbation of chronic obstructive pulmonary disease (COPD). Which assessment finding would indicate deterioration in ventilation? 1. Cyanosis 2. Hyperinflated chest 3. Rapid, shallow respirations 4. Coarse crackles auscultated bilaterally
3. Rapid, shallow respirations An increase in the rate of respirations and a decrease in the depth of respirations together indicate deterioration in ventilation. Cyanosis is not a good indicator of oxygenation in the client with COPD. Cyanosis may be present in some but not all clients. A hyperinflated chest (barrel chest) and hypertrophy of the accessory muscles of the upper chest and neck are common features of chronic COPD. During an exacerbation, coarse crackles are expected to be heard bilaterally throughout the lungs but do not indicate deterioration in ventilation.
The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing? 1. Flaccid paralysis of all extremities 2. Adduction of the arms at the shoulders 3. Rigid extension and pronation of the arms and legs 4. Abnormal flexion of the upper extremities and extension and adduction of the lower extremities
3. Rigid extension and pronation of the arms and legs Decerebrate (extension) posturing is characterized by the rigid extension and pronation of the arms and legs. Option 1 is incorrect. Options 2 and 4 describe decorticate (flexion) posturing.
A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client? 1. 100% oxygen via an aerosol mask 2. Oxygen via nasal cannula at 6 L/minute 3. Oxygen via nasal cannula at 15 L/minute 4. 100% oxygen via a tight-fitting, nonrebreather face mask
4. 100% oxygen via a tight-fitting, nonrebreather face mask If an inhalation injury is suspected, administration of 100% oxygen via a tight-fitting nonrebreather face mask is prescribed until carboxyhemoglobin levels fall (usually below 15%). In inhalation injuries, the oropharynx is inspected for evidence of erythema, blisters, or ulcerations. The need for endotracheal intubation also is assessed. Administration of oxygen by aerosol mask and cannula are incorrect and would not provide the necessary oxygen supply needed for adequate tissue perfusion for the client with a likely inhalation injury.
The low-exhaled volume alarm sounds on a mechanical ventilator of a client with an endotracheal tube. The nurse determines that the cause for alarm activation may be which complication? 1. Excessive secretions 2. Kinks in the ventilator tubing 3. The presence of a mucous plug 4. Displacement of the endotracheal tube
4. Displacement of the endotracheal tube The low-exhaled volume alarm will sound if the client does not receive the preset tidal volume. Possible causes of inadequate tidal volume include disconnection of the ventilator tubing from the artificial airway, a leak in the endotracheal or tracheostomy cuff, displacement of the endotracheal tube or tracheostomy tube, and disconnection at any location of the ventilator parts. Options 1, 2, and 3 would cause the high-pressure alarm to sound.
A client with a traumatic brain injury is on mechanical ventilation. The nurse promotes normal intracranial pressure (ICP) by ensuring that the client's arterial blood gas (ABG) results are within which ranges? 1. PaO2 60 to 100 mm Hg (60 to 100 mm Hg), PaCo2 25 to 30 mm Hg (25 to 30 mm Hg) 2. PaO2 60 to 100 mm Hg (60 to 100 mm Hg), PaCo2 30 to 35 mm Hg (30 to 35 mm Hg) 3. PaO2 80 to 100 mm Hg (80 to 100 mm Hg), PaCo2 25 to 30 mm Hg (25 to 30 mm Hg) 4. PaO2 80 to 100 mm Hg (80 to 100 mm Hg), PaCo2 35 to 38 mm Hg (35 to 38 mm Hg)
4. PaO2 80 to 100 mm Hg (80 to 100 mm Hg), PaCo2 35 to 38 mm Hg (35 to 38 mm Hg) The goal is to maintain the partial pressure of arterial carbon dioxide (PaCo2) at 35 to 38 mm Hg (35 to 38 mm Hg). Carbon dioxide is a very potent vasodilator that can contribute to increases in ICP. The PaO2 is not allowed to fall below 80 mm Hg (80 mm Hg), to prevent cerebral vasodilation from hypoxemia, which can also result in an increase in ICP. Therefore, the remaining options are incorrect.
The nurse instructs a client to use the pursed-lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states that the primary purpose of pursed-lip breathing is to promote which outcome? 1. Promote oxygen intake. 2. Strengthen the diaphragm. 3. Strengthen the intercostal muscles. 4. Promote carbon dioxide elimination.
4. Promote carbon dioxide elimination Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options 1, 2, and 3 are not the purposes of this type of breathing.
What are strategies to prevent Ventilator-associated Pneumonia? select all that apply A. Oral care every 4 hours B. HOB elevated 30-45 degrees unless contraindicated by the patient's condition C. HOB elevated 10-15 degrees, unless contraindicated by the patient's condition D. Allow family to suction patient as needed to remove secretions
A. Oral care Q4hB. C. HOB elevated 30-45 degrees unless contraindicated by patients condition.
You're collecting vital signs on a patient with ICP. The patient has a Glascoma Scale rating of 4. How will you assess the patient's temperature? A. Rectal B. Oral C. Axillary
A. Rectal The answer is A. This GCS rating demonstrates the patient is unconscious. If a patient is unconscious the nurse should take the patient's temperature either via the rectal, tympanic, or temporal method. Oral and axillary are not reliable.
Select the main structures below that play a role with altering intracranial pressure: A. Brain B. Neurons C. Cerebrospinal Fluid D. Blood E. Periosteum F. Dura mater
A. Brain, C. Cerebrospinal Fluid, D. Blood Inside the skull are three structures that can alter intracranial pressure. They are the brain, cerebrospinal fluid (CSF), and blood.
A patient is being treated for increased intracranial pressure. Which activities below should the patient avoid performing? A. Coughing B. Sneezing C. Talking D. Valsalva maneuver E. Vomiting F. Keeping the head of the bed between 30- 35 degrees
A. Coughing B. Sneezing D. Valsalva maneuver E. Vomiting
Select all the signs and symptoms that occur with increased ICP: A. Decorticate posturing B. Tachycardia C. Decrease in pulse pressure D. Cheyne-stokes E. Hemiplegia F. Decerebrate posturing
A. Decorticate posturing D. Cheyne-stokes E. Hemiplegia F. Decerebrate posturing The answers are A, D, E, and F. Option B is wrong because bradycardia (not tachycardia) happens in the late stage along with an INCREASE (not decrease) in pulse pressure.
A patient's ventilator settings are adjusted to treat hypoxemia. The fraction of inspired oxygen is increased from 0.6 to 0.7, and the positive end-expiratory pressure is increased from 10 to 15 cm H2O. Shortly after these adjustments, the nurse notes that the patient's 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 pressure—the 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.
A patient is placed on volume-cycled ventilation. The nurse plans care for this client based on which characteristic of this method of ventilation? A. Delivers a set volume, which will help overcome the client's airway resistance changes. B. The mechanism by which the phase of the breath switches from inspiration to expiration. C. Provides a consistent tidal volume. D. Delivers a preset volume of gas to the lungs to generate high pressures.
A. Delivers a set volume, which will help overcome the client's airway resistance changes. Rationale: Volume- cycled ventilation delivers a preset volume of gas to the lungs, making volume constant therefore, overcoming the changes in lung compliance and airway resistance.
The nurse notes that a patient's endotracheal tube (ET), which was at the 21-cm mark, is now at the 24-cm mark and the patient appears anxious and restless. Which action should the nurse take first? A. Listen to the patient's lungs. B. Offer reassurance to the patient. C. Bag the patient at an FIO2 of 100%. D. Notify the patient's health care provider.
A. Listen to the patient's lungs 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 also are appropriate, but detection and correction of tube malposition are the most critical actions.
10. Which of the following is contraindicated in a patient with increased ICP? A. Lumbar puncture B. Midline position of the head C. Hyperosmotic diuretics D. Barbiturates medications
A. Lumbar puncture LP can lead to brain herniation in patients with increased ICP
Which assessment information obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning? A. The respiratory rate is 32 breaths/min. B. The pulse oximeter shows a SpO2 of 93%. C. The patient has not been suctioned for the last 6 hours. D. The lungs have occasional audible expiratory wheezes.
A. The 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, 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 SpO2 of 93% is acceptable and does not suggest that immediate suctioning is needed.
. You're providing education to a group of nursing students about ICP. You explain that when cerebral perfusion pressure falls too low the brain is not properly perfused and brain tissue dies. A student asks, "What is a normal cerebral perfusion pressure level?" Your response is: A. 5-15 mmHg B. 60-100 mmHg C. 30-45 mmHg D. >160 mmHg
B. 60-100 mmHg
What assessment finding requires immediate intervention if found while a patient is receiving Mannitol? A. An ICP of 10 mmHg B. Crackles throughout lung fields C. BP 110/72 D. Patient complains of dry mouth and thirst
B. Crackles throughout the lung fields The answer is B. Mannitol can cause fluid volume overload that leads to heart failure and pulmonary edema. Crackles in the lung fields represent pulmonary edema and requires immediate intervention. Option A is a normal ICP reading and shows the mannitol is being effective. BP is within normal limits, and dry mouth/thirst will occur with this medication because remember we are trying to dehydrate the brain to keep edema and intracranial pressure decreased.
During the assessment of a patient with increased ICP, you note that the patient's arms are extended straight out and toes pointed downward. You will document this as: A. Decorticate posturing B. Decerebrate posturing C. Flaccid posturing
B. Decerebrate posturing
The healthcare provider is caring for a patient on a ventilator with an endotracheal tube in place. What assessment data indicate the tube has migrated too far down the trachea? A. A high pressure alarm sounds B. Decreased breath sounds on the left side of the chest C. Low pressure alarm sounds D. Increased crackles auscultation bilaterally
B. Decreased breath sounds on the left side of the chest A low pressure alarm indicates a disconnection or a leak in the circuit. A high pressure alarm warns of rising pressures. If the endotracheal tube is inserted too far, it often goes into the right main stem bronchus. Air will then be delivered to the right lung and not the left.
A patient is having difficulty weaning from mechanical ventilation. The nurse assesses the patient for which potential cause of this difficult weaning? 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.
External ventricular drains monitor ICP and are inserted where? A. Subarachnoid space B. Lateral Ventricle C. Epidural space D. Right Ventricle
B. Lateral Ventricle
A patient is receiving Mannitol for increased ICP. Which statement is INCORRECT about this medication? A. Mannitol will remove water from the brain and place it in the blood to be removed from the body. B. Mannitol will cause water and electrolyte reabsorption in the renal tubules. C. When a patient receives Mannitol the nurse must monitor the patient for both fluid volume overload and depletion. D. Mannitol is not for patients who are experiencing anuria.
B. Mannitol will cause water and electrolyte reabsorption in the renal tubules. The answer is B. All the other options are correct. Mannitol will PREVENT (not cause) water and electrolytes (specifically sodium and chloride) from being reabsorbed....hence it will leave the body as urine.
The Monro-Kellie hypothesis explains the compensatory relationship among the structures in the skull that play a role with intracranial pressure. Which of the following are NOT compensatory mechanisms performed by the body to decrease intracranial pressure naturally? Select all that apply: A. Shifting cerebrospinal fluid to other areas of the brain and spinal cord B. Vasodilation of cerebral vessels C. Decreasing cerebrospinal fluid production D. Leaking proteins into the brain barrier
B. Vasodilation of cerebral vessels D. Leaking proteins into the blood barrier The answers are B and D. These are NOT compensatory mechanisms, but actions that will actually increase intracranial pressure. Vasoconstriction (not dilation) decreases blood flow and helps lower ICP. Leaking of protein actually leads to more swelling of the brain tissue. Remember water is attracted to protein (oncotic pressure).
The nurse is trouble-shooting multiple ventilator alarms sounding for a client who is intubated and being mechanically ventilated. The alarms persist despite suctioning, repositioning the client, and ensuring that the ventilator tubing is unobstructed. Which actions will the nurse perform next? Select all that apply. A. Turn off all ventilator alarms until a cause is found to prevent scaring the client. B. Page the primary health care provider to request additional sedation. C. Ensure that the endotracheal tube marking is at the client's incisor. D. Increase the PEEP to improve GAS EXCHANGE. E. Disconnect the client from the ventilator and use the manual resuscitation bag. F. Change all ventilator tubing. G. Stat page the respiratory therapist. H. Determine when the client received the last dose of the paralytic agent.
C, E, G
A patient's 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 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.
A patient with increased ICP has the following vital signs: blood pressure 99/60, HR 65, Temperature 101.6 'F, respirations 14, oxygen saturation of 95%. ICP reading is 21 mmHg. Based on these findings you would? A. Administered PRN dose of a vasopressor B. Administer 2 L of oxygen C. Remove extra blankets and give the patient a cool bath D. Perform suctioning
C. Remove extra blankets and give patient a cool bath The answer is C. It is important to monitor the patient for hyperthermia (a fever). A fever increases ICP and cerebral blood volume, and metabolic needs of the patient. The nurse can administer antipyretics per MD order, remove extra blankets, decrease room temperature, give a cool bath or use a cooling system. Remember it is important to prevent shivering (this also increases metabolic needs and ICP).
A patient who experienced a cerebral hemorrhage is at risk for developing increased ICP. Which sign and symptom below is the EARLIEST indicator the patient is having this complication? *** A. Bradycardia B. Decerebrate posturing C. Restlessness D. Unequal pupil size
C. Restlessness The answer is C. Mental status changes are the earliest indicator a patient is experiencing increased ICP. All the other signs and symptoms listed happen later.
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.
When the nurse is weaning a patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation, which patient assessment indicates that the weaning protocol should be discontinued? A. The patient heart rate is 98 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 500 mL.
C. The patients 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, 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 500 mL is within the acceptable range.
A patient is experiencing hyperventilation and has a PaCO2 level of 52. The patient has an ICP of 20 mmHg. As the nurse you know that the PaCO2 level will? A. cause vasoconstriction and decrease the ICP B. promote diuresis and decrease the ICP C. cause vasodilation and increase the ICP D. cause vasodilation and decrease the ICP
C. cause vasodilation and increase the ICP The answer is C. An elevated carbon dioxide level in the blood will cause vasodilation (NOT constriction), which will increase ICP (normal ICP 5 to 15 mmHg). Therefore, many patients with severe ICP may need to be mechanical ventilated so PaCO2 levels can be lowered (30-35), which will lead to vasoconstriction and decrease ICP (with constriction there is less blood volume and flow going to the brain and this helps decrease pressure)....remember Monro-Kellie hypothesis.
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 patient's 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.
When caring for a patient with a venturi mask, one strategy to reduce the fraction of inspired oxygen is (FiO2) yet maintain oxygentation is to convert to which device?
CPAP Rationale: CPAP provides cont. positive airway pressure, which increases volume and pressure of inhalation. This prevents alveolar collaspe, thereby enhancing gas/oxygen exchange
Biotrauma
Inflammatory response-mediated damage to alveoli
The nurse is caring for a client with intracranial pressure (ICP) monitoring. Which intervention is appropriate to include in the plan of care? 1. Place the client in Sims' position. 2. Change the drainage tubing every 48 hours. 3. Level the transducer at the lowest point of the ear. 4. Use strict aseptic technique when touching the monitoring system.
Use strict aseptic technique when touching the monitoring system. Because there is a foreign body embedded in the client's brain, vigilant aseptic technique should be implemented. Sims' is a side-lying, flat position. With a client who has increased ICP, the head of the bed should be elevated at least 30 degrees to improve jugular outflow. The drainage tubing should not be routinely changed. It should remain for the duration of the monitoring. To obtain accurate ICP pressure readings, the transducer is zeroed at the level of the foramen of Monro, which is approximated by placing the transducer 1 inch above the level of the ear. Serial ICP readings should be done with the client's head in the same position.
Atelectrauma
shear injury to alveoli from opening and closing
