Exam 2: Mechanical Ventilation NCLEX

Exam 2: Mechanical Ventilation (NCLEX)

Leave the first rating Terms in this set (62) Science MedicineNursing Save The peak pressure alarm is sounding on the ventilator of the client with a recent tracheostomy. What intervention should be done first?

• Assess the client's respiratory

status

• Decrease the sensitivity of the

alarm

• Ensure that the connecting tubing

is not kinked

• Suction the client

A The client must always be assessed before attention is turned to equipment.

The client with respiratory failure has been intubated and placed on a ventilator and is requiring 100% oxygen delivery to maintain adequate oxygenation. Twenty-four hours later, the nurse notes new- onset crackles and decreased breath sounds, and the most recent ABGs show a PaO2 level of 95 mm Hg. The ventilator is not set to provide positive end-expiratory pressure (PEEP). Why is the nurse concerned?

• The low PaO2 level may result in

oxygen toxicity

• The 100% oxygen delivery

requirement indicates immediate extubation

• Lung sounds may indicate

absorption atelectasis

• The level of oxygen delivery may

indicate absorption atelectasis C High levels of oxygen delivery can result in collapsed alveoli and absorption atelectasis. PEEP can help alveoli remain properly inflated.The medical nurse is creating the care plan of an adult patient requiring mechanical ventilation.What nursing action is most appropriate?

• Keep the patient in a low Fowlers

position.

• Perform tracheostomy care at

least once per day.

• Maintain continuous bedrest.
• Monitor cuff pressure every 8

hours.D

The acute medical nurse is preparing to wean a patient from the ventilator.Which assessment parameter is most important for the nurse to assess?

• Fluid intake for the last 24 hours
• Baseline arterial blood gas (ABG)

levels

• Prior outcomes of weaning
• Electrocardiogram (ECG) results

B A patient recovering from thoracic surgery is on long-term mechanical ventilation and becomes very frustrated when he tries to communicate. What intervention should the nurse perform to assist the patient?

• Assure the patient that everything

will be all right and that remaining calm is the best strategy.

• Ask a family member to interpret

what the patient is trying to communicate.

• Ask the physician to wean the

patient off the mechanical ventilator to allow the patient to speak freely.

• Express empathy and then

encourage the patient to write, use a picture board, or spell words with an alphabet board.D

The physician has ordered continuous positive airway pressure (CPAP) with the delivery of a patients high-flow oxygen therapy. The patient asks the nurse what the benefit of CPAP is. What would be the nurses best response?

• CPAP allows a higher percentage

of oxygen to be safely used.

• CPAP allows a lower percentage

of oxygen to be used with a similar effect.

• CPAP allows for greater

humidification of the oxygen that is administered.

• CPAP allows for the elimination of

bacterial growth in oxygen delivery systems.B