NUR 417 Exam 2 Part 1 | Questions, Answers and Rationales
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Module
NUR 417
Institution
NUR 417
NUR 417 Exam 2 Part 1 | Questions, Answers and Rationales Which action would the nurse take to verify the correct placement of an oral endotracheal tube (ET) immediately after insertion and before securing the tube? 1. Obtain a portable chest x-ray. 2. Use an end-tidal CO2 monitor. 3. Auscultate...
Which action would the nurse take to verify the correct placement of an oral
endotracheal tube (ET) immediately after insertion and before securing the tube?
1. Obtain a portable chest x-ray.
2. Use an end-tidal CO2 monitor.
3. Auscultate for bilateral breath sounds.
4. Observe for symmetrical chest movement.
End-tidal CO2 monitors are currently recommended for rapid verification of ET
placement. Auscultation for bilateral breath sounds and checking chest expansion are
also 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.
Which action would the nurse take to maintain proper endotracheal tube (ET) cuff
pressure when a patient is on mechanical ventilation?
1. Inflate the cuff with a minimum of 10 mL of air.
2. Inflate the cuff until the pilot balloon is firm on palpation.
3. Inject air into the cuff until a manometer shows 15 mm Hg pressure.
4. Inject air into the cuff until a slight leak is heard only at peak inflation.
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 30 mm Hg. An
accurate assessment of cuff pressure cannot be obtained by palpating the pilot balloon.
The nurse notes premature ventricular contractions (PVCs) on the monitor while
suctioning a patient's endotracheal tube. Which action would the nurse take?
1. Plan to suction the patient more frequently.
2. Decrease the suction pressure to 80 mm Hg.
3. Give antidysrhythmic medications per protocol.
4. Ventilate the patient with 100% oxygen.
Dysrhythmias during suctioning may indicate hypoxemia or sympathetic nervous system
stimulation. the nurse should stop suctioning and ventilate the patient with 100% O2.
There is no indication that more frequent suctioning is needed. Lowering the suction
pressure will decrease the effectiveness of suctioning without improving the hypoxemia.
Because the PVCs occurred during suctioning, there is no need for antidysrhythmic
,medications (which may have adverse effects) unless they recur when the suctioning is
stopped, and patient is well oxygenated.
Which assessment finding for a patient receiving mechanical ventilation indicates the
need for suctioning?
1. The patient was last suctioned 6 hours ago.
2. The patient's oxygen saturation drops to 93%.
3. The patient's respiratory rate is 32 breaths/min.
4. The patient has occasional audible expiratory wheezes.
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 and not on a scheduled basis. Occasional expiratory wheezes
do not indicate poor airway clearance. Suctioning the patient may induce bronchospasm
and increase wheezing. An O2 saturation of 93% is acceptable and does not suggest
that immediate suctioning is needed.
The nurse notes thick, white secretions in the endotracheal tube (ET) of a patient who is
receiving mechanical ventilation. Which intervention will most directly treat this finding?
1. Reposition the patient every 1 to 2 hours.
2. Increase suctioning frequency to every hour.
3. Add additional water to the patient's enteral feedings.
4. Instill 5 mL of sterile saline into the ET before suctioning.
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.
Four hours after mechanical ventilation is initiated, a 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). What change should the nurse anticipate to the ventilator
settings?
1. Increase the FIO2.
2. Increase the tidal volume.
3. Increase the respiratory rate.
4. Decrease the respiratory rate.
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 and increasing the
respiratory rate and tidal volume would further lower the PaCO2.
, The nurse is weaning a patient who has chronic obstructive pulmonary disease (COPD)
and weighs 68-kg from mechanical ventilation. Which finding indicates that the weaning
protocol should be stopped?
1. The patient's heart rate is 97 beats/min.
2. The patient's oxygen saturation is 93%.
3. The patient respiratory rate is 32 breaths/min.
4. The patient's spontaneous tidal volume is 450 mL.
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, but the nurse should continue to
monitor it. An O2 saturation of 93% is acceptable for a patient with COPD. A
spontaneous tidal volume of 450 mL is within the acceptable range.
The nurse responding to a ventilator alarm finds the patient lying in bed gasping and the
endotracheal tube on the floor. Which action would the nurse take next?
1. Activate the rapid response team.
2. Provide reassurance to the patient.
3. Call the health care provider to reinsert the tube.
4. 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 are
also appropriate after the nurse has stabilized the patient's oxygenation.
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 would
the nurse take next?
1. Check the O2 saturation.
2. Offer reassurance to the patient.
3. Listen to the patient's breath sounds.
4. Notify the patient's health care provider.
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 are also appropriate, but
detection and correction of tube malposition are the most critical actions.
The charge nurse is evaluating the care that a new registered nurse (RN) provides to a
patient receiving mechanical ventilation. Which action by the new RN indicates the need
for more education?
1. The RN increases the FIO2 to 100% before suctioning.
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