Chapter 28: Supporting Ventilation Harding: Lewis’s

1. Which action would the nurse take to verify the correct placement of an oral endotracheal tube

(ET) immediately after insertion and before securing thetube?

a. Obtain a portable chest x-ray.

b. Use an end-tidal CO2 monitor.

c. Auscultate for bilateral breath sounds.

d. Observe for symmetrical chest movement.

ANS: B

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.

2. Which action would thenurse take to maintain proper endotracheal tube (ET) cuff pressure

when a patient is on mechanical ventilation?

a. Inflate thecuff with a minimum of 10 mL of air.

b. Inflate thecuff until thepilot balloon is firm on palpation.

c. Inject air into thecuff until a manometer shows 15 mm Hg pressure.

d. Inject air into thecuff until a slight leak is heard only at peak inflation.

ANS: D

The minimal occluding volume technique involves injecting air into thecuff until an air leak is

present only at peak inflation. thevolume to inflate thecuff varies with theET and thepatient‗s

size. Cuff pressure should be maintained at 20 to 30 mm Hg. An accurate assessment of cuff

pressure cannot be obtained by palpating thepilot balloon

3. The nurse notes premature ventricular contractions (PVCs) on the monitor while suctioning a

patient‗s endotracheal tube. Which action would the nurse take?

a. Plan to suction the patient more frequently.

b. Decrease the suction pressure to 80 mm Hg.

c. Give antidysrhythmic medications per protocol.

d. Ventilate the patient with 100% oxygen.

ANS: D

Dysrhythmias during suctioning may indicate hypoxemia or sympathetic nervous system

stimulation. thenurse should stop suctioning and ventilate thepatient with 100% O2. There is

no indication that more frequent suctioning is needed. Lowering thesuction pressure will

decrease theeffectiveness of suctioning without improving thehypoxemia. Because thePVCs

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.

4. Which assessment finding for a patient receiving mechanical ventilation indicates theneed for

suctioning?

a. The patient was last suctioned 6 hours ago.

b. The patient‗s oxygen saturation drops to 93%.

c. The patient‗s respiratory rate is 32 breaths/min.

d. The patient has occasional audible expiratory wheezes.

ANS: C

The increase in respiratory rate indicates that thepatient 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 thepatient may induce bronchospasm and increase wheezing. An

O2 saturation of 93% is acceptable and does not suggest that immediate suctioning is needed.

5. The nurse notes thick, white secretions in theendotracheal tube (ET) of a patient who is

receiving mechanical ventilation. Which intervention will most directly treat this finding?

a. Reposition thepatient every 1 to 2 hours.

b. Increase suctioning frequency to every hour.

c. Add additional water to thepatient‗s enteral feedings.

d. Instill 5 mL of sterile saline into theET before suctioning.

ANS: C

Because thepatient‗s secretions are thick, better hydration is indicated. Suctioning every hour

without any specific evidence for theneed will increase theincidence of mucosal trauma and

would not address theetiology of theineffective airway clearance. Instillation of saline does

not liquefy secretions and may decrease theSpO2. Repositioning thepatient is appropriate but

will not decrease thethickness of secretions.

6. 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 HCO - of 23

mEq/L (23 mmol/L). What change should thenurse anticipate to theventilator settings?

a. Increase theFIO2.

b. Increase thetidal volume.

c. Increase therespiratory rate.

d. Decrease therespiratory rate.

ANS: D

The patient‗s PaCO2 and pH indicate respiratory alkalosis caused by too high a respiratory

rate. thePaO2 is appropriate for a patient with COPD and increasing therespiratory rate and

tidal volume would further lower thePaCO2.

7. The nurse is weaning a patient who has chronic obstructive pulmonary disease (COPD) and

weighs 68-kg from mechanical ventilation. Which finding indicates that theweaning protocol

should be stopped?

a. The patient‗s heart rate is 97 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 450 mL.

ANS: C

Tachypnea is a sign that thepatient‗s work of breathing is too high to allow weaning to

proceed. thepatient‗s heart rate is within normal limits, but thenurse 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 theacceptable range.

8. The nurse responding to a ventilator alarm finds thepatient lying in bed gasping and

theendotracheal tube on thefloor. Which action would thenurse take next?

a. Activate therapid response team.

b. Provide reassurance to thepatient.

c. Call thehealth care provider to reinsert thetube.

d. Manually ventilate thepatient with 100% oxygen.

ANS: D

The nurse should ensure maximal patient oxygenation by manually ventilating with a

bag-valve-mask system. Offering reassurance to thepatient, notifying thehealth care provider

about theneed to reinsert thetube, and activating therapid response team are also appropriate

after thenurse has stabilized thepatient‗s oxygenation.

9. The nurse notes that a patient‗s endotracheal tube (ET), which was at the22-cm mark, is now

at the25-cm mark, and the patient is anxious and restless. Which action would the nurse take

next?

a. Check theO2 saturation.

b. Offer reassurance to the patient.

c. Listen to the patient‗s breath sounds.

d. Notify the patient‗s health care provider.

ANS: C

The nurse should first determine whether theET tube has been displaced into theright

mainstem bronchus by listening for unilateral breath sounds. If so, assistance will be needed

to reposition thetube immediately. theother actions are also appropriate, but detection and

correction of tube malposition are themost critical actions.

10. The charge nurse is evaluating thecare that a new registered nurse (RN) provides to a patient

receiving mechanical ventilation. Which action by thenew RN indicates theneed for more

education?

a. The RN increases theFIO2 to 100% before suctioning.

b. The RN secures a bite block in place using adhesive tape.

c. The RN asks for assistance to resecure theendotracheal tube.

d. The RN positions thepatient with thehead of bed at 10 degrees.

ANS: D

The head of thepatient‗s bed should be positioned at 30 to 45 degrees to prevent

ventilator-associated pneumonia. theother actions by thenew RN are appropriate.

11. A patient who is orally intubated and receiving mechanical ventilation is anxious and is ―fighting‖ the ventilator. Which action would the nurse take first?

a. Verbally coach the patient to breathe with the ventilator.

b. Sedate the patient with the ordered PRN lorazepam (Ativan).

c. Manually ventilate the patient with a bag-valve-mask device.

d. Increase the rate for the ordered propofol (Diprivan) infusion.

ANS: A

The initial response by the nurse should be to try to decrease the patients anxiety by coaching

the patient about how to coordinate respirations with the ventilator. the other actions may also

be helpful if the verbal coaching is ineffective in reducing the patient‗s anxiety.

12. A patient is receiving mechanical ventilation with 15 cm H2O of peak end-expiratory pressure

(PEEP). Which action by thenurse promotes patient safety?

a. Planning to suction thepatient at least every 1 to 2 hours.

b. Using a closed-suction technique when suctioning is needed.

c. Changing theventilator circuit tubing routinely every 48 hours.

d. Taping theconnection between theventilator tubing and theET.

ANS: B

The closed-suction technique is used when patients require high levels of PEEP (>10 cm H2O)

to prevent theloss of PEEP that occurs when disconnecting thepatient from theventilator.

Suctioning should not be scheduled routinely, but it should be done only when patient

assessment data indicate theneed for suctioning. Taping connections between theET and

ventilator tubing would restrict theability of thetubing to swivel in response to patient

repositioning. Ventilator tubing changes increase therisk for ventilator-associated pneumonia

and are not indicated routinely.

13. Which finding by thenurse should result in postponing thespontaneous breathing trial for a

patient receiving positive pressure ventilation?

a. New dysrhythmias are observed on thecardiac monitor.

b. Enteral nutrition is being given through an orogastric tube.

c. Scattered rhonchi are heard when auscultating breath sounds

d. Hydromorphone (Dilaudid) is being used to treat postoperative pain.

d. Hydromorphone (Dilaudid) is being used to treat postoperative pain.

ANS: A

New dysrhythmias may indicate cardiac ischemia and weaning should be postponed until

further investigation and/or treatment can be done. Ventilator weaning can proceed when

opioids are used for pain management, abnormal lung sounds are present, or enteral nutrition

is being delivered.

14. After change-of-shift report, which patient would thenurse assess first?

a. Patient who failed a spontaneous breathing trial and has been placed in a rest mode

on theventilator

b. Patient who is intubated and has continuous partial pressure end-tidal CO2

(PETCO2) monitoring

c. Patient who was successfully weaned and extubated 4 hours ago and has no urine

output for thelast 6 hours

d. Patient with an O2 saturation (SaO2) of 93% while on bilevel positive airway

pressure (BiPAP)

ANS: C

The decreased urine output may indicate acute kidney injury or that thepatient‗s cardiac

output and perfusion of vital organs have decreased. Any of these causes would require rapid

action. thedata about theother patients indicate that their conditions are stable and do not

require immediate assessment or changes in their care. Continuous PETCO2 monitoring is

frequently used when patients are intubated. therest mode should be used to allow patient

recovery after a failed SBT. A ScvO2 of 69% is within normal limits.

15. A patient on a positive pressure ventilator is receiving a neuromuscular blocking agent

(NMBA) to prevent asynchronous breathing. Which situation requires action by thenurse?

a. No sedative is ordered for thepatient.

b. The patient does not respond to voice.

c. The patient‗s oxygen saturation is 90% to 93%.

d. The patient has no cough reflex when suctioned.

ANS: A

Because neuromuscular blockade is extremely anxiety provoking, it is essential that patients

who are receiving neuromuscular blockade receive concurrent sedation and analgesia.

Absence of response to stimuli is expected in patients receiving neuromuscular blockade.

theO2 saturation is adequate.

16. The nurse has just auscultated coarse crackles bilaterally on a patient with a tracheostomy tube

in place. If thepatient is unsuccessful in coughing up secretions, which action would thenurse

take?

a. Encourage increased incentive spirometer use.

b. Encourage thepatient to increase oral fluid intake.

c. Put on sterile gloves and use a sterile catheter to suction.

d. Preoxygenate thepatient for 3 minutes before suctioning.

ANS: C

This patient needs suctioning to secure a patent airway. Sterile gloves and a sterile catheter are

used when suctioning a tracheostomy. Preoxygenation for 3 minutes is not necessary; 30

seconds is recommended. Incentive spirometer use opens alveoli and can induce coughing,

which can mobilize secretions. However, thepatient with a tracheostomy may not be able to

use an incentive spirometer. Increasing oral fluid intake would not moisten and help mobilize

secretions in a timely manner.

17. A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which

action would thenurse include in theplan of care in collaboration with thespeech therapist?

a. Leave thetracheostomy inner cannula inserted at all times.

b. Place thedecannulation cap in thetube before cuff deflation.

c. Assess theability to swallow before using thefenestrated tube.

d. Inflate thetracheostomy cuff during use of thefenestrated tube.

ANS: C

Because thecuff is deflated when using a fenestrated tube, thepatient‗s risk for aspiration

should be assessed before changing to a fenestrated tracheostomy tube. thedecannulation cap

is never inserted before cuff deflation because to do so would obstruct thepatient‗s airway.

thecuff is deflated, and theinner cannula removed to allow air to flow across thepatient‗s vocal

cords when using a fenestrated tube.

18. The nurse is caring for a mechanically ventilated patient who has a cuffed tracheostomy tube.

Which action by thenurse would determine if thecuff has been properly inflated?

a. Use a hand-held manometer to measure cuff pressure.

b. Review thehealth record for theprescribed cuff pressure.

c. Suction thepatient through a fenestrated inner cannula to clear secretions.

d. Insert thedecannulation plug before removing thenonfenestrated inner cannula.

Measurement of cuff pressure using a manometer to ensure that cuff pressure is 20-30 mm Hg

or lower will avoid compression of thetracheal wall and capillaries. Never insert

thedecannulation plug in a tracheostomy tube until thecuff is deflated and thenonfenestrated

inner cannula is removed. Otherwise, thepatient‗s airway is occluded. A health care provider‗s

order is not required to determine safe cuff pressure. A nonfenestrated inner cannula must be

used to suction a patient to prevent tracheal damage occurring from thesuction catheter

passing through thefenestrated openings.

19. After a laryngectomy, a patient coughs violently during suctioning and dislodges

thetracheostomy tube. Which action would thenurse take first?

a. Arrange for arterial blood gases to be drawn immediately.

b. Cover stoma with sterile gauze and ventilate through stoma.

c. Attempt to reinsert thetracheostomy tube with theobturator in place.

d. Assess thepatient‗s oxygen saturation and notify thehealth care provider.

ANS: C

The first action should be to attempt to reinsert thetracheostomy tube to maintain thepatient‗s

airway. Covering thestoma with a dressing and manually ventilating thepatient may be an

appropriate action if thenurse is unable to reinsert thetracheostomy tube. Assessing

thepatient‗s oxygenation is an important action, but it is not as appropriate until there is an

established airway.

20. Which nursing action could theregistered nurse (RN) delegate to an experienced licensed

practical/vocational nurse (LPN/LVN) caring for a patient with a permanent tracheostomy?

a. Assess thepatient‗s risk for aspiration.

b. Suction thetracheostomy when directed.

c. Teach thepatient to provide tracheostomy self-care.

d. Determine theneed for tracheostomy tube replacement.

ANS: B

Suctioning of a stable patient can be delegated to LPNs/LVNs. theRN should do patient

assessment and patient teaching.

21. Which finding by thenurse most specifically indicates that a patient is not able to effectively

clear theairway?

a. Weak cough effort

b. Profuse green sputum

c. Respiratory rate of 28 breaths/minute

d. Resting pulse oximetry (SpO2) of 85%

ANS: A

The weak cough effort indicates that thepatient is unable to clear theairway effectively.

theother data suggest problems with gas exchange and breathing pattern.

22. A patient with bacterial pneumonia has coarse crackles and thick sputum. Which intervention

would thenurse plan to promote airway clearance?

a. Restrict oral fluids during theday.

b. Encourage pursed-lip breathing technique.

c. Help thepatient to splint thechest when coughing.

d. Encourage thepatient to wear thenasal O2 cannula.

ANS: C

Coughing is less painful and more likely to be effective when thepatient splints thechest

during coughing. Fluids should be encouraged to help liquefy secretions. Nasal O2 will

improve gas exchange but will not improve airway clearance. Pursed-lip breathing is used to

improve gas exchange in patients with chronic obstructive pulmonary disease but will not

improve airway clearance.

23. A postoperative patient has a right-sided pleural chest tube connected to a chest drainage

device. There is continuous bubbling in thesuction-control chamber of thewet-suction

collection device. Which action would thenurse take?

a. Adjust thedial on thewall regulator.

b. Continue to monitor thecollection device.

c. Document thepresence of a large air leak.

d. Notify thesurgeon of a possible pneumothorax.

ANS: B

Continuous bubbling is expected in thesuction-control chamber of a wet-suction device and

indicates that thesuction-control chamber is connected to suction. An air leak would be

detected in thewater-seal chamber. There is no evidence of pneumothorax. Increasing or

decreasing thevacuum source will not adjust thesuction pressure. theamount of suction applied

is regulated by theamount of water in this chamber and not by theamount of suction applied to

thesystem.

24. The nurse is caring for a patient who has a right-sided chest tube after a right lower

lobectomy. Which nursing action could thenurse delegate to theassistive personnel (AP)?

a. Document theamount of drainage every 8 hours.

b. Obtain samples of drainage for culture from thesystem.

c. Assess patient pain level associated with thechest tube.

d. Check thewater-seal chamber for thecorrect fluid level.

ANS: A

AP education includes documentation of intake and output. theother actions are within

thescope of practice and education of licensed nursing personnel.

25. The nurse teaches a patient about pursed-lip breathing. Which action by thepatient would

indicate to thenurse that further teaching is needed?

a. The patient inhales slowly through thenose.

b. The patient puffs up thecheeks while exhaling.

c. The patient practices by blowing through a straw.

d. The patient‗s ratio of inhalation to exhalation is 1:3.

ANS: B

The patient should relax thefacial muscles without puffing thecheeks while exhaling during

pursed-lip breathing. theother actions by thepatient indicate a good understanding of

pursed-lip breathing.

26. Which finding will be most useful in evaluating theeffectiveness of treatment for a patient

with impaired gas exchange?

a. Even, unlabored respirations

b. Pulse oximetry reading of 92%

c. Absence of wheezes or crackles

d. Respiratory rate of 18 breaths/min

ANS: B

The best data for evaluation of gas exchange are arterial blood gases (ABGs) or pulse

oximetry. The other data may indicate either improvement or impending respiratory failure

caused by fatigue.

27. A patient is receiving 35% O2 via a Venturi mask. Which action by the nurse will help ensure

the correct dosage of O2?

a. Teach the patient to keep the mask on during meals.

b. Keep the air entrainment ports clean and unobstructed.

c. Use a high enough flow rate to keep the bag from collapsing.

d. Drain moisture condensation from the corrugated tubing hourly.

ANS: B

The air entrainment ports regulate the O2 percentage delivered to the patient, so they must be

unobstructed. The other options refer to other types of O2 devices. A high O2 flow rate is

needed when giving O2 by partial rebreather or nonrebreather masks. Draining O2 tubing is

necessary when caring for a patient receiving mechanical ventilation. The mask can be

changed to a nasal cannula at a prescribed setting when the patient eats.

28. Postural drainage with percussion and vibration is ordered twice daily for a patient with

chronic bronchitis. Which intervention would the nurse include in the plan of care?

a. Schedule the procedure 1 hour after the patient eats.

b. Maintain the patient in the lateral position for 20 minutes.

c. Give the prescribed bronchodilator before the therapy.

d. Perform percussion before assisting the patient to the drainage position.

ANS: C

Bronchodilators are administered before chest physiotherapy. Postural drainage, percussion,

and vibration should be done 1 hour before or 3 hours after meals. Patients remain in each

postural drainage position for 5 minutes. Percussion is done while the patient is in the postural

drainage position.

29. Which nursing action for a patient receiving supplemental oxygen could the nurse delegate to

experienced assistive personnel (AP)?

a. Measure O2 saturation using pulse oximetry.

b. Monitor for increased O2 need with exercise.

c. Teach the patient about safe use of O2 at home.

d. Adjust O2 to keep saturation in prescribed parameters.

ANS: A

AP can obtain O2 saturation (after being trained and evaluated in the skill). The other actions

require more education and a scope of practice that licensed practical/vocational nurses

(LPN/LVNs) or registered nurses (RNs) would have.

30. The nurse provides discharge instructions for a patient who has a new permanent

tracheostomy after a total laryngectomy. Which statement by the patient indicates that

additional instruction is needed?

a. ―I can participate in fitness activities except swimming.‖

b. ―I must keep the stoma covered with an occlusive dressing.‖

c. ―I need to have smoke and carbon monoxide detectors installed.‖

d. ―I will wear a Medic-Alert bracelet to identify me as a neck breather.‖

ANS: B

An occlusive dressing will completely block the patient‗s airway. The stoma may be covered

with clothing or a loose dressing, but this is not essential. The other patient comments are all

accurate and indicate that the teaching has been effective.

31.

After change-of-shift report, which patient should the stepdown unit nurse assess first?

a. Patient who was extubated this morning and has a temperature of 101.4F (38.6C)

b. Patient with bilevel positive airway pressure (BiPAP) for obstructive sleep apnea

and a respiratory rate of 16

c. Patient with arterial pressure monitoring who is 2 hours post-percutaneous

coronary intervention and needs to void

d. Patient who is receiving IV heparin for a venous thromboembolism and has a

partial thromboplastin time (PTT) of 101 seconds

ANS: D

The patient the nurse must assess first has a high risk for bleeding from an elevated

(nontherapeutic) PTT. The nurse needs to adjust the rate of the infusion (dose) per the health

care provider‗s parameters. The patient with BiPAP for sleep apnea has a normal respiratory

rate. The patient recovering from the percutaneous coronary intervention will need to be

assisted with voiding and this task could be delegated to unlicensed assistive personnel. The

patient with a fever may be developing ventilator-associated pneumonia but addressing the

bleeding risk is a higher priority.