NUR 265 Exam 2
How is an ET tube placement confirmed? - ANS-From first to last
ETCO2 20-40mmHg
Chest symmetry
Listen to left/right/abdomen
Chest X-Ray
Describe the A/C vent mode. - ANS-The vent does everything for the patient. It delivers a set
amount of breaths per minute
Describe SIMV vent mode. - ANS-The pt attempts to breath and the vent assists with their
breaths
What are the different ventilator settings? - ANS-Mode
FiO2
Rate
Tidal Volume (Vt)
PEEP
What is PEEP? - ANS-It is positive pressure that tells the alveoli in the lungs to stay open a little
longer. It helps with gas exchange.
What are some complications of PEEP? - ANS-Pneumothorax
SubQ Emphysema (crepatus)
Decreased pre-load
What are the 3 buttons that a nurse is able to touch on a vent? - ANS-Silence
Restart
100% Oxygen (before suctioning a patient)
When is it acceptable to shut off a vent alarm? - ANS-NEVER
What should be done when a patient is in respiratory distress? - ANS-*Call for help, disconnect
the vent, start bagging the patient, then reassess*
What are ways to prevent VAP? - ANS-*Remove water from circuits*
*HOB up to 30 degrees*
Turn Q2h
Suction
Oral care Q2H
, Prevent aspiration
Lip moisturizer
Percussion
Give examples of what could cause a high pressure alarm. - ANS-Blocked airway
Coughing
Tension pneumothorax
Anxiety/Pain: Sedate them
Kinks in tubing
Decreased lung compliance: ARDS
*Assess the patient not the monitor*
Give examples of what could cause a low pressure alarm. - ANS-Not getting enough air (in or
out)
Air leak in the cuff: Check the pilot balloon
Disconnected tubing
Low Vt
*Assess the patient not the monitor*
What are some things we have to do when caring for a vented patient? - ANS-Lung assessment
Frequent vital signs (every 4 hours)
I&O (look at balances)
Foley
NPO
Nutrition (NG Tube for all vent patients)
Skin Care
Monitor ABG/labs
VTE prophylaxis
What are some risk factors for a PE? - ANS-Immobility
Central Lines
Surgery
Obesity
DVT's
Birth Control Pills
Smoking
What is the best way to prevent a PE? - ANS-*Move the patient post op.*
What should be done immediately after the nurse notes s/s of a PE? - ANS-*Notify the Rapid
Response Team*
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