Exam (elaborations)

NCLEX 285 Exam 2 Critical Care/Vent managment

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Course
NCLEX 285

Institution
NCLEX 285

To verify the correct placement of an endotracheal tube (ET) after insertion, the best initial action by the nurse is to a. auscultate for the presence of bilateral breath sounds. b. obtain a portable chest radiograph to check tube placement. c. observe the chest for symmetrical movement with ...

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NCLEX 285 Exam 2 Critical Care/Vent managment

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

a. auscultate for the presence of bilateral breath sounds.

b. obtain a portable chest radiograph to check tube placement.

c. observe the chest for symmetrical movement with ventilation.

d. use an end-tidal CO2 monitor to check for placement in the trachea. - ANS: D

End-tidal CO2 monitors are currently recommended for rapid verification of ET placement. Auscultation
for bilateral breath sounds and checking chest expansion also are used, but they are not as accurate as
end-tidal CO2 monitoring. A chest x-ray confirms the placement but is done after the tube is secured.

DIF: Cognitive Level: Application REF: 1701-1702 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

To inflate the cuff of an endotracheal tube (ET) when the patient is on mechanical ventilation, the nurse

a. inflates the cuff until the pilot balloon is firm.

b. inflates the cuff with a minimum of 10 mL of air.

c. injects air into the cuff until a manometer shows 15 mm Hg pressure.

d. injects air into the cuff until a slight leak is heard only at peak inflation. - ANS: D

The minimal occluding volume technique involves injecting air into the cuff until an air leak is present
only at peak inflation. The volume to inflate the cuff varies with the ET and the patient's size. Cuff
pressure should be maintained at 20 to 25 mm Hg. An accurate assessment of cuff pressure cannot be
obtained by palpating the pilot balloon.

DIF: Cognitive Level: Comprehension REF: 1701-1702

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

,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. - ANS: A

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.

DIF: Cognitive Level: Application REF: 1702-1704

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The nurse notes thick, white respiratory secretions for a patient who is receiving mechanical ventilation.
Which intervention will be most effective in resolving this problem?

a. Suction the patient every hour.

b. Reposition the patient every 2 hours.

c. Add additional water to the patient's enteral feedings.

d. Instill 5 mL of sterile saline into the endotracheal tube (ET) before suctioning. - ANS: C

Because the patient's secretions are thick, better hydration is indicated. Suctioning every hour without
any specific evidence for the need will increase the incidence of mucosal trauma and would not address
the etiology of the ineffective airway clearance. Instillation of saline does not liquefy secretions and may
decrease the SpO2. Repositioning the patient is appropriate but will not decrease the thickness of
secretions.

DIF: Cognitive Level: Application REF: 1703-1704

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

, 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 7.50, PaO2 of 80 mm Hg,
PaCO2 of 29 mm Hg, and HCO3- of 23 mEq/L (23 mmol/L). The nurse will anticipate the need to

a. increase the FIO2.

b. decrease the respiratory rate.

c. increase the tidal volume (VT).

d. leave the ventilator at the current settings. - ANS: B

The patient's PaCO2 and pH indicate respiratory alkalosis caused by too high a respiratory rate. The
PaO2 is appropriate for a patient with COPD, increasing the tidal volume would further lower the PaCO2,
and the PaCO2 and pH indicate a need to make the ventilator changes.

DIF: Cognitive Level: Analysis REF: 1710-1711 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

A patient with respiratory failure has hemodynamic monitoring and is receiving mechanical ventilation
with peak end-expiratory pressure (PEEP) of 10 cm H2O. Which information indicates that a change in
the ventilator settings may be required?

a. The arterial line shows a blood pressure of 90/46.

b. The pulmonary artery pressure (PAP) is decreased.

c. The cardiac monitor shows a heart rate of 58 beats/min.

d. The pulmonary artery wedge pressure (PAWP) is increased. - ANS: A

The hypotension indicates that the high intrathoracic pressure caused by the PEEP may be decreasing
venous return and cardiac output (CO). The other assessment data would not be caused by mechanical
ventilation.

DIF: Cognitive Level: Application REF: 1710 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

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