NCLEX style questions based on intubation, mechanical

NCLEX style questions based on intubation, mechanical ventilation, and trach care Leave the first rating Students also studied Terms in this set (10) Science MedicineNursing Save NCLEX Mechanical Ventilation Ques...Teacher 6 terms emeltineRNPreview Chest Tube NCLEX questions

• terms

francis_j_crupi Preview

Exam 2: Mechanical Ventilation (NC...

62 terms LayalOverline Preview ARDS a 82 terms shif A patient is being intubated for acute respiratory failure.After intubation, the nurse notes that breath sounds are only present on the right side of the chest. What is the most appropriate initial action?

• Notify the healthcare provider.
• Deflate the cuff and reposition the endotracheal tube

slightly.

• Prepare for emergency extubation.
• Obtain a chest X-ray.
• Deflate the cuff and reposition the endotracheal tube slightly.

Rationale: Absence of breath sounds on the left side indicates possible right

mainstem bronchus intubation. Repositioning the tube can resolve the issue. A chest X-ray can confirm placement, but repositioning takes priority.During mechanical ventilation, the patient's high-pressure alarm is sounding. Which intervention should the nurse implement first?

• Suction the patient for secretions.
• Reassess ventilator settings.
• Check for kinks or obstructions in the tubing.
• Administer a sedative.
• Check for kinks or obstructions in the tubing.

Rationale: A high-pressure alarm often indicates an obstruction, such as a kink in the tubing or secretions. Always assess the equipment first before considering other interventions like suctioning or sedation.A patient with a tracheostomy tube has thick, dry secretions and is becoming agitated. What is the best initial nursing action?

• Suction the patient immediately.
• Administer humidified oxygen via the tracheostomy.
• Encourage deep breathing and coughing.
• Instill saline into the tracheostomy tube.
• Administer humidified oxygen via the tracheostomy.

Rationale: Dry secretions can be prevented by humidifying oxygen, which helps

thin the secretions and make them easier to clear.

When caring for a patient on mechanical ventilation, which intervention is the highest priority to prevent ventilator-associated pneumonia (VAP)?

• Suctioning the airway every hour.
• Elevating the head of the bed to 30-45 degrees.
• Administering antibiotics prophylactically.
• Performing oral care with chlorhexidine every 8 hours.
• Elevating the head of the bed to 30-45 degrees.

Rationale: Elevating the head of the bed is the most effective intervention to

reduce the risk of aspiration, which can lead to VAP. Oral care is also important but secondary to positioning.A patient is being weaned off mechanical ventilation.Which assessment finding would indicate that the patient is ready for extubation?

• The patient is alert but confused.
• The patient has a weak cough but can tolerate minimal

secretions.

• The patient has adequate tidal volume and is not

tachypneic.

• The patient has minimal secretions but requires a FiO2

of 60%.

• The patient has adequate tidal volume and is not tachypneic.

Rationale: Extubation criteria include adequate tidal volume, stable vital signs, and no signs of respiratory distress. Tachypnea or excessive FiO2 requirements would indicate that the patient is not ready for extubation.The patient on a mechanical ventilator begins showing signs of respiratory distress. Which assessment should the nurse prioritize?

• Auscultate breath sounds.
• Check the ventilator settings.
• Check the patient's tidal volume.
• Assess oxygen saturation levels.
• Auscultate breath sounds.

Rationale: In respiratory distress, assessing breath sounds is crucial to identify any problems with air movement, such as pneumothorax or tube displacement, before addressing ventilator settings.A patient with a tracheostomy requires suctioning. How can the nurse prevent hypoxia during this procedure?

• Apply suction continuously for no longer than 30

seconds.

• Limit suction passes to no more than 5 times.
• Hyperoxygenate the patient before and after

suctioning.

• Use a larger catheter to remove secretions faster.
• Hyperoxygenate the patient before and after suctioning.

Rationale: Hyperoxygenating the patient helps prevent suction-induced hypoxia,

which can occur due to the temporary removal of oxygen during the suctioning process.A patient with ARDS is being mechanically ventilated. The healthcare provider orders prone positioning. What is the primary goal of this intervention?

• To promote airway clearance.
• To reduce airway pressure.
• To improve oxygenation by optimizing lung perfusion.
• To prevent pressure injuries.
• To improve oxygenation by optimizing lung perfusion.

Rationale: Prone positioning allows better oxygenation by improving the

distribution of ventilation and perfusion in ARDS patients, particularly to the dorsal regions of the lungs.A patient receiving mechanical ventilation develops a pneumothorax. Which finding is consistent with this diagnosis?

• Decreased oxygen saturation and sudden chest pain.
• Crackles on auscultation and hypotension.
• Increased breath sounds on the affected side.
• Bilateral chest expansion.
• Decreased oxygen saturation and sudden chest pain.

Rationale: A pneumothorax will cause sudden onset of chest pain, dyspnea, and

decreased oxygen saturation due to the collapse of the lung.

A patient with a new tracheostomy is anxious and has difficulty communicating. What nursing intervention should be implemented first?

• Provide a communication board.
• Explain that anxiety is common and expected.
• Administer a sedative to reduce anxiety.
• Teach the patient how to use the call light for

assistance.

• Provide a communication board.

Rationale: Establishing a means of communication is a priority in addressing the patient's anxiety and ensuring their needs can be met while intubated.