Question 1

The nurse provides care to a patient who is intubated and receiving mechanical ventilation. Which actions are appropriate for the nurse to implement if the high-pressure alarm sounds? Select all that apply.

Accepted Answer

The answer of The nurse provides care to a patient...

Question 2

The nurse is providing care to a patient who is mechanically ventilated. The high-pressure alarm is activated, and the nurse notes a collection of moisture in the ventilator tubing. Which action by the nurse is appropriate?

Accepted Answer

Emptying the water from the ventilator tubing is appropriate because moisture can cause increased resistance and trigger the high-pressure alarm.

Question 3

Which information does the nurse document when monitoring a patient's oxygen saturation via oximetry? Select all that apply.

Accepted Answer

The answer of Which information does the nurse document when...

Question 4

The nurse instructs a patient on the use of incentive spirometry. Which patient statement indicates the need to provide additional instruction?

Accepted Answer

The correct use of an incentive spirometer typically involves using the device about 10 times every hour while awake, not just 5 to 10 times per day. This frequency helps prevent pulmonary complications, such as pneumonia, by encouraging deep breathing.

Question 5

The nurse is providing care to a patient who is mechanically ventilated. The high-pressure alarm sounds and the nurse notes the patient is biting down on the endotracheal (ET) tube. Which action by the nurse is appropriate?

Accepted Answer

Inserting an oral airway is the appropriate action when a patient is biting down on the endotracheal tube. This prevents occlusion of the tube and ensures proper airflow. Suctioning, assessing for asymmetrical chest rise, and emptying water from the ventilator tubing do not directly address the issue of the patient biting the tube.

Question 6

The nurse is providing care to a patient who is mechanically ventilated. The high-pressure alarm sounds and the nurse notes a mucous plug in the endotracheal (ET) tube. Which action by the nurse is indicated?

Accepted Answer

Suctioning is indicated to remove the mucous plug that is causing the high-pressure alarm to sound, ensuring the patient's airway is clear and ventilation is effective.

Question 7

The nurse provides care to a patient who is intubated and receiving mechanical ventilation. Which actions are appropriate for the nurse to implement if the low-pressure alarm sounds? Select all that apply.

Accepted Answer

The answer of The nurse provides care to a patient...

Question 8

The patient is admitted to the Intensive Care Unit and placed on Synchronized Intermittent Mandatory Ventilation (SIMV) mode. The nurse notes that the patient is breathing 12 times per minute, and the ventilator is set at 8 breaths per minute. How many ventilator breaths is the patient receiving?

Accepted Answer

In Synchronized Intermittent Mandatory Ventilation (SIMV) mode, the ventilator allows the patient to initiate their own breaths while also delivering a set number of mandatory breaths. If the patient is breathing 12 times per minute and the ventilator is set to deliver 8 breaths per minute, the patient will receive all 8 of those ventilator breaths, as the ventilator's breaths are part of the total breaths but allow for additional spontaneous breaths initiated by the patient.

Question 9

Which statement by the patient receiving intermittent positive-pressure breathing (IPPB) treatments indicates that the nurse's teaching was effective?

Accepted Answer

IPPB treatments are often used to deliver aerosolized medications directly to the lungs, which can help with various respiratory conditions. This statement indicates the patient understands a key aspect of the treatment.

Question 10

In providing care to a patient on a mechanical ventilator, the nurse suctions the patient using in-line suctioning. Which information does the nurse document in the medical record after the procedure is completed? Select all that apply.

Accepted Answer

The answer of In providing care to a patient on...

Question 11

Which intervention does the nurse include in the plan of care for a patient being mechanically ventilated who is receiving care based on a ventilator bundle focused on reducing the risk of ventilator-associated pneumonia? Select all that apply.

Accepted Answer

Elevating the head of the bed helps prevent aspiration, a sedation vacation helps assess readiness for extubation, and peptic ulcer prophylaxis reduces the risk of stress ulcers, all of which are part of the ventilator bundle to reduce ventilator-associated pneumonia.

Question 12

The nurse recognizes that the patient on which mode of mechanical ventilation is at greatest risk for developing respiratory alkalosis?

Accepted Answer

Assist-control ventilation can lead to respiratory alkalosis because the ventilator delivers a set number of breaths at a set tidal volume, and the patient can also initiate additional breaths at the set tidal volume. If the patient initiates many additional breaths, this can lead to hyperventilation and subsequently respiratory alkalosis.

Question 13

The nurse is providing care for a patient on a mechanical ventilator in the assist-control mode. If the ventilator rate is set at 10 breaths per minute, and the patient is breathing 16 times per minute, how many ventilator breaths is the patient receiving?

Accepted Answer

The answer of The nurse is providing care for a...

Question 14

Which actions by the nurse are considered best practice when providing tracheostomy care? Select all that apply.

Accepted Answer

C) Applying appropriate personal protective equipment (PPE) is essential to protect both the nurse and the patient from infection. D) Inspecting the trach stoma for signs of infection, irritation, and skin breakdown is crucial for early detection of complications and ensuring the integrity of the skin around the stoma.

Question 15

The nurse is providing care to a patient who is being weaned from mechanical ventilation. Which finding would necessitate the continuation of mechanical ventilation if noted during the weaning process?

Accepted Answer

Decreased blood pressure during the weaning process from mechanical ventilation indicates hemodynamic instability, which necessitates the continuation of mechanical ventilation to ensure adequate oxygenation and perfusion.

Quiz 7: Oxygen Therapy Management