Deck 28: Assisting With Mechanical Ventilation

Question 1

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

A)Changing ventilator settings according to the primary care provider's order
B)Moving the location of the endotracheal tube from one side of the mouth to the other side
C)Measuring airway cuff pressure
D)Measuring vital signs

Answer 1

Measuring vital signs

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?

A)Increasing the oxygen concentration and quickly assessing the client
B)Removing the client from the ventilator and hyperoxygenating and hyperventilating the client
C)Assessing the client for airway obstruction
D)Checking ventilator settings

Answer 2

Assessing the client for airway obstruction

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?

A)Confirming airway placement by auscultating the lungs and checking the length marking of the tube at the lip
B)Assuring that tube cuff inflation is no greater than 15 cm H₂O,and that there is no audible air leak
C)Assuring ventilator tubing is secured and does not pull on the client's airway
D)Verifying correct ventilator settings

Answer 3

Assuring that tube cuff inflation is no greater than 15 cm H₂O,and that there is no audible air leak

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?

A)The details and length of the weaning trial
B)The client's oxygen saturation
C)The client's breath sounds
D)The client's respiratory rate

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?

A)Increase oxygen concentration
B)Increase flow rate
C)Increase tidal volume
D)Set PEEP at 6 cm H₂O

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?

A)Mental status
B)Oxygen saturation
C)Vital signs
D)Ability to speak

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?

A)"Assist control is a means of delivering ventilation that delivers a preset volume and/or pressure each time the client begins an inspiration."
B)"Assist control allows the client to breathe independently,but supplies a breath if the client does not begin an inhalation in a specified period of time."
C)"Assist control is used when weaning a client from the ventilator because the client must exercise the muscles of respiration in order to get a full breath."
D)"Assist control is often used when a client is receiving a paralytic agent."

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?

A)Providing oral care
B)Suctioning the airway
C)Checking for correct tube placement
D)Checking tube cuff inflation

Question 9

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

A)Assignment of suctioning to the unlicensed assistive personnel (UAP)
B)Client response to ventilator changes
C)Pertinent laboratory values,such as arterial blood gas results
D)Physical assessment findings
E)Pain rating using an appropriate pain rating scale

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?

A)Silencing the alarm
B)Removing the client from the ventilator and using a bag-valve device to oxygenate the client until the respiratory therapist can be summoned
C)Emptying the collected water from the ventilator tubing
D)Assessing the client