Question 1

Which task could the nurse safely delegate to the unlicensed assistive personnel (UAP)?

Accepted Answer

Measuring vital signs is within the scope of practice of the UAP and can be safely delegated to them. Changing ventilator settings and moving the location of the endotracheal tube require specialized training and should only be performed by licensed personnel, such as a respiratory therapist or nurse trained in these procedures. Measuring airway cuff pressure also requires specialized training and should be performed by a licensed personnel.

Question 2

The nurse is providing care for a client requiring mechanical ventilation.When the nurse enters the room at the beginning of the shift,the client's monitor displays a heart rate of 64 and oxygen saturation of 88%.Which nursing action is the priority?

Accepted Answer

The priority action is to assess the client for airway obstruction, as this could be causing the low oxygen saturation. Identifying and addressing any obstruction is crucial to ensure adequate ventilation and oxygenation.

Question 3

The nurse is providing care for the client requiring mechanical ventilation.Which action by the nurse would be inappropriate when providing care to this client?

Accepted Answer

The correct cuff inflation pressure for an endotracheal or tracheostomy tube should not exceed 20-30 cm H2O to prevent tracheal damage and ensure a proper seal. The value provided in option B, "no greater than 15 cm HS," is incorrect as it suggests a lower threshold than recommended, potentially leading to an inadequate seal and risk of aspiration.

Question 4

When weaning the client from the ventilator,which item would the nurse document in addition to routine assessments performed for any client requiring mechanical ventilation with an artificial airway in place?

Accepted Answer

When weaning a client from a ventilator, it is important for the nurse to document the details and length of the weaning trial in addition to routine assessments such as oxygen saturation, breath sounds, and respiratory rate. This information will help track the client's progress and inform future weaning attempts.

Question 5

The nurse is caring for a client with atelectasis.Which prescription from the health care provider would the nurse anticipate to correct this problem?

Accepted Answer

Setting PEEP (positive end-expiratory pressure) at 6 cm H2O (as prescribed in option D) can help correct atelectasis by maintaining a pressure in the airways and preventing collapse of the alveoli during exhalation. Increasing oxygen concentration (option A) or flow rate (option B) may help with oxygenation, but will not necessarily address the underlying atelectasis. Increasing tidal volume (option C) may only be effective if the cause of the atelectasis is due to inadequate ventilation, and may not be appropriate in all cases (e.g. if the client has lung disease).

Question 6

The nurse is caring for a client being weaned from the ventilator.When performing a spontaneous breathing trial,which item is not a priority assessment?

Accepted Answer

While the ability to speak is important, it is not a priority assessment during a spontaneous breathing trial. Mental status, oxygen saturation, and vital signs are all critical assessments that should be monitored closely during the weaning process.

Question 7

The nurse working with a student nurse is providing care for a client requiring mechanical ventilation.The student nurse asks the meaning of assist control.Which response by the nurse is the most appropriate?

Accepted Answer

Assist control is a mode of mechanical ventilation that delivers a preset volume and/or pressure each time the client begins an inspiration. This mode ensures that the client receives a minimum number of breaths per minute and a consistent tidal volume, even if they initiate some of their own breaths.

Question 8

Immediately after moving the oral endotracheal airway to the other side of the client's mouth,which action by the nurse is the priority?

Accepted Answer

Checking for correct tube placement is the priority after moving the oral endotracheal airway to the other side of the client's mouth to ensure proper ventilation and prevent complications such as accidental extubation, aspiration, or incorrect placement in the esophagus. The nurse should use a reliable method such as auscultation, capnography, or chest X-ray to verify the tube placement before resuming other interventions such as suctioning or oral care. Checking the cuff inflation is also important but can be done after confirming the tube placement.

Question 9

The nurse is documenting care for a ventilated client.Which items are appropriate for the nurse to include in the documentation?

Accepted Answer

The nurse should document the client's response to ventilator changes, pertinent lab values like arterial blood gas results, physical assessment findings, and pain ratings. Suctioning should not be assigned to UAP as it requires skilled assessment and intervention.

Question 10

The nurse working in the intensive care unit is assigned a client requiring mechanical ventilation.When responding to the ventilator alarm,the nurse sees a high-pressure alarm.Which nursing action is the priority?

Accepted Answer

Assessing the client is the priority action when a high-pressure alarm sounds on a ventilator. This is because the alarm could indicate a problem such as increased airway resistance or decreased lung compliance, which could be due to various issues like secretions, kinking of the tube, pneumothorax, or the patient biting on the endotracheal tube. Immediate assessment is necessary to identify and address the underlying cause of the alarm.

Quiz 28: Assisting With Mechanical Ventilation

Which task could the nurse safely delegate to the unlicensed assistive personnel (UAP) ?