Ventilator Modes, Settings, Alarms, & Weaning Questions Pulm 1

Which of the following arterial blood gas values would indicate a need for oxygen therapy?

a.

PaO2 of 80 mm Hg

b.

PaCO2 of 35 mm Hg

c.

HCO3- of 24 mEq

d.

SaO2 of 87%

ANS: D

The amount of oxygen administered depends on the pathophysiologic mechanisms affecting the patient's oxygenation status. In most cases, the amount required should provide an arterial partial pressure of oxygen (PaO2) of greater than 60 mm Hg or an arterial hemoglobin saturation (SaO2) of greater than 90% during both rest and exercise.

Which of the following oxygen administration devices can deliver oxygen concentrations of 90%?

a.

Nonrebreathing mask

b.

Nasal cannula

c.

Simple face mask

d.

All of the above

ANS: A

With an FiO2 of 55% to 70%, a nonrebreathing mask with a tight seal over the face can deliver 90% to 100% oxygen. It is used in emergencies and short-term therapy requiring moderate to high FiO2.

The finding of normal breath sounds on the right side of the chest and absent breath sounds on the left side of the chest in a newly intubated patient is probably caused by a

a.

right mainstem intubation.

b.

left pneumothorax.

c.

right hemothorax.

d.

gastric intubation.

ANS: A

The finding of normal breath sounds on the right side of the chest and absent breath sounds on the left side of the chest in a newly intubated patient is probably caused by a right mainstem intubation

*When intubating, the provider can go too far and usually the ETT ends up in the right side because of how it is anatomically positioned.

Long-term ventilator management over 21 days is best handled through use of a(n)

a.

oropharyngeal airway.

b.

esophageal obturator airway.

c.

tracheostomy tube.

d.

endotracheal intubation.

ANS: C

Although no ideal time to perform the procedure has been identified, it is commonly accepted that if a patient has been intubated or is anticipated to be intubated for longer than 7 to 10 days, a tracheostomy should be performed.

Nursing interventions to limit the complications of suctioning include

a.

inserting the suction catheter no more than 5 inches.

b.

premedicating the patient with atropine.

c.

hyperoxygenating the patient with 100% oxygen.

d.

increasing the suction to 150 mm Hg.

ANS: C

Hypoxemia can be minimized by giving the patient three hyperoxygenation breaths (breaths at 100% FiO2) with the ventilator before the procedure and again after each pass of the suction catheter

Which of the following statements best describes the effects of positive-pressure ventilation on cardiac output?

a.

Positive-pressure ventilation increases intrathoracic pressure, which increases venous return and cardiac output.

b.

Positive-pressure ventilation decreases venous return, which increases preload and cardiac output.

c.

Positive-pressure ventilation increases venous return, which decreases preload and cardiac output.

d.

Positive-pressure ventilation increases intrathoracic pressure, which decreases venous return and cardiac output.

ANS: D

Positive-pressure ventilation increases intrathoracic pressure, which decreases venous return to the right side of the heart. Impaired venous return decreases preload, which results in a decrease in cardiac output.

A patient was admitted to the critical care unit with acute respiratory failure. The patient has been on a ventilator for 3 days and is being considered for weaning. The ventilator high-pressure alarm keeps going off. What is the primary action the nurse would take?

a.

Troubleshoot the ventilator until the problem is found.

b.

Take the patient off the ventilator and manually ventilate her.

c.

Call the respiratory therapist for help.

d.

Silence the ventilator alarms until the problem is resolved.

ANS: B

Ensure emergency equipment is at bedside at all times (e.g., manual resuscitation bag connected to oxygen, masks, suction equipment or supplies), including preparations for power failures. If the ventilator malfunctions, the patient should be removed from the ventilator and ventilated manually with a manual resuscitation bag.

A patient was admitted to the critical care unit with acute respiratory failure. The patient has been on a ventilator for 3 days and is being considered for weaning. The ventilator high-pressure alarm keeps going off. All of the following conditions would set off the high-pressure alarm except

a.

a leak in the patient's ET tube cuff

b.

a kink in the ET tubing

c.

coughing

d.

increased secretions in the patient's airway

ANS: A

Low inspiratory pressure alarms will sound because of altered settings, unattached tubing or a leak around the endotracheal tube (ETT), the ETT displaced into the pharynx or esophagus, poor cuff inflation or leak, tracheoesophageal fistula, peak flows that are too low, low tidal volume (Vt), decreased airway resistance resulting from decreased secretions or relief of bronchospasm, increased lung compliance resulting from decreased atelectasis, reduction in pulmonary edema, resolution of ARDS, or a change in position. High-pressure alarms will sound because of improper alarm setting; airway obstruction resulting from patient fighting ventilator (holding breath as ventilator delivers Vt); patient circuit collapse; kinked tubing; the ETT in the right mainstem bronchus or against the carina; cuff herniation; increased airway resistance resulting from bronchospasm, airway secretions, plugs, and coughing; water from the humidifier in the ventilator tubing; and decreased lung compliance resulting from tension pneumothorax, change in patient position, acute respiratory distress syndrome, pulmonary edema, atelectasis, pneumonia, or abdominal distention.

A patient was admitted to the critical care unit with acute respiratory failure. The patient has been on a ventilator for 3 days and is being considered for weaning. The ventilator high-pressure alarm keeps going off. Which of the following criteria would indicate that the patient is not tolerating weaning?

a.

A decrease in heart rate from 92 to 80 beats/min

b.

An SpO2 of 92%

c.

An increase in respiratory rate from 22 to 38 breaths/min

d.

Spontaneous tidal volumes of 300 to 350 mL

ANS: C

Weaning intolerance indicators include (1) a decrease in level of consciousness; (2) a systolic blood pressure increased or decreased by 20 mm Hg; (3) a diastolic blood pressure greater than 100 mm Hg; (4) a heart rate increased by 20 beats/min; (5) premature ventricular contractions greater than 6/min, couplets, or runs of ventricular tachycardia; (6) changes in ST segment (usually elevation); (7) a respiratory rate greater than 30 breaths/min or less than 10 breaths/min; (8) a respiratory rate increased by 10 breaths/min; (9) a spontaneous tidal volume less than 250 mL; (10) a PaCO2 increased by 5 to 8 mm Hg or pH less than 7.30; (11) an SpO2 less than 90%; (12) use of accessory muscles of ventilation; (13) complaints of dyspnea, fatigue, or pain; (14) paradoxical chest wall motion or chest abdominal asynchrony; (15) diaphoresis; and (16) severe agitation or anxiety unrelieved with reassurance.

In preparing a patient in the ICU for oral ET intubation, what should the nurse do that is most important for successful intubation?

a. place the patient supine with the head extended and the neck flexed

b. tell the patient that the tongue must be extruded while the tube is inserted

c. position the patient supine with the head hanging over the edge of the bed to align the mouth and trachea

d. inform the patient that while it will not be possible to talk during insertion of the tube, speech will be possible after it is correctly placed

a. place the patient supine with the head extended and the neck flexed- this is the ideal position for intubation, aka "sniffing" position

Which mode of ventilation is used with critically ill patients and allows the patient to self-regulate the rate and depth of spontaneous respirations but may also deliver a preset volume and frequency of breaths?

a. volume assist-control ventilation

b. continuous positive airway pressure

c. pressure-controlled inverse ratio ventilation

d. synchronized intermittent mandatory ventilation

d - breaths that the patient can have their own tidal volumes and also be given a ventilator controlled breath is SIMV

A 68-yr-old male patient diagnosed with sepsis is orally intubated on mechanical ventilation. Which nursing action is most important?

a. Use the open-suctioning technique.

b. Administer morphine for discomfort.

c. Limit noise and cluster care activities.

d. Elevate the head of the bed 30 degrees.

d - this is critical to prevent aspiration and secondary pneumonia

All others are interventions as well except A but D prevents worsening of condition of sepsis

A means disconnecting circuit to provide suction which also may introduce pathogens

Four hours after mechanical ventilation is initiated for a patient with chronic obstructive pulmonary disease (COPD), the patients 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.

b - by decreasing the RR, the patient will blow off less co2, increasing the value which is low

The nurse notes that a patients 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 patients lungs.

b. Offer reassurance to the patient.

c. Bag the patient at an FIO2 of 100%.

d. Notify the patients health care provider.

a - listen for absent lung sounds indicating the tube which migrated further into trachea possibly ended up in the right bronchus

Going from 21 to 24 means tube was pushed in further. Going from 24 to 21 would mean tube was pulled out further.

After extubation of a patient, which finding would the nurse report to the health care provider immediately?

a. Respiratory rate of 25 breaths/min

b. Patient has difficulty speaking

c. Oxygen saturation of 93%

d. Crowing noise during inspiration

d - also known as strider, indicates tracheal edema or laryngospasm

All other answers could be expected; the RR of 25 is high but is not critically high with answer D

The nurse is educating a client's spouse about ventilator therapy. The ventilator is set at volume A/C respiratory rate 14, VT 450, Fi02 65%, PEEP 5 cm H20. What statement by the spouse indicates understanding about the therapy?

The ventilator will deliver a preset volume of air and my spouse can initiate their own breaths at any volume.

My spouse is ready to start weaning therapy and extubation.

My spouse can initiate their own breaths that will at least be 450 mL, but they will be given a set rate and amount if they do not initiate their own breaths.

The ventilator is giving a set amount of pressure during each inhalation to force the oxygen in the lungs.

My spouse can initiate their own breaths that will at least be 450 mL, but they will be given a set rate and amount if they do not initiate their own breaths.

Volume AC is the volume controlled every breath. They can exceed 450 on their own breaths and on their vent breaths, but they will get at least 450 every breath. There is a set rate for volume A/C as well.

The nurse is reviewing an ABG on a ventilated patient with acute respiratory failure. The pH is 7.2, PaC02 is 64 mmHg, HC03 is 26 mEq/L, and Pa02 is 80 mmHg. The ventilator settings are A/C respiratory rate of 12, VT 1000 mL, PEEP 8 cm H20, and Fi02 60%. Which ventilator setting would the nurse anticipate to change based on this ABG?

Decrease Fi02

Increase VT

Increase PEEP

Increase rate

Increase rate

Tidal volume is already a high amount, so increasing the rate should be anticipated as a safer intervention to reduce CO2.

Test taking tip: choose answers that will both improve the problem and are least likely to cause harm to the patient

The nurse enters the room after hearing a high priority ventilator alarm. The ventilator is saying "high peak pressures". What is the first nursing intervention?

Check the ETT cuff for deflation.

Notify the physician and obtain a stat chest Xray.

Hyperoxygenate and perform ETT suctioning.

Disconnect the patient from the ventilator and ambu-bag.

Hyperoxygenate and perform ETT suctioning

This is the first intervention. Cuff deflation would cause low pressure alarm. We don't jump straight to bagging as there are other appropriate interventions we can quickly try to fix the alarm.

prepare for questions that involve scenarios where patient harm will happen if you do not know the basics

Do not ask yourself “what if”; go with what is least invasive and will fix the problem as stated in the question (don't read into what if this is a tension pneumo or mucus plug - there would be other clues in the question to help you recognize that).