Nokea
A critical care nurse is caring for a client with an endotracheal tube who is on a ventilator. The nurse knows that meticulous airway management of this patient is necessary. What is the main rationale for this?
- A. Maintaining a patent airway
- B. Preventing the need for suctioning
- C. Maintaining the sterility of the patients airway
- D. Increasing the patients lung compliance
Correct Answer: A
Rationale: Maintaining a patent (open) airway is achieved through meticulous airway management, whether in an emergency situation such as airway obstruction or in long-term management, as in caring for a patient with an endotracheal or a tracheostomy tube. The other answers are incorrect.
You may also like to solve these questions
The nurse caring for a patient with an endotracheal tube recognizes several disadvantages of an endotracheal tube. What would the nurse recognize as a disadvantage of endotracheal tubes?
- A. Cognition is decreased
- B. Daily arterial blood gases (ABGs) are necessary
- C. Slight tracheal bleeding is anticipated
- D. The cough reflex is depressed
Correct Answer: D
Rationale: There are several disadvantages of an endotracheal tube. Disadvantages include suppression of the patients cough reflex, thickening of secretions, and depressed swallowing reflexes. Ulceration and stricture of the larynx or trachea may develop, but bleeding is not an expected finding. The tube should not influence cognition and daily ABGs are not always required.
The critical care nurse is precepting a new nurse on the unit. Together they are caring for a patient who has a tracheostomy tube and is receiving mechanical ventilation. What action should the critical care nurse recommend when caring for the cuff?
- A. Deflate the cuff overnight to prevent tracheal tissue trauma
- B. Inflate the cuff to the highest possible pressure in order to prevent aspiration
- C. Monitor the pressure in the cuff at least every 8 hours
- D. Keep the tracheostomy tube plugged at all times
Correct Answer: C
Rationale: Cuff pressure must be monitored by the respiratory therapist or nurse at least every 8 hours by attaching a handheld pressure gauge to the pilot balloon of the tube or by using the minimal leak volume or minimal occlusion volume technique. Plugging is only used when weaning the patient from tracheal support. Deflating the cuff overnight would be unsafe and inappropriate. High cuff pressure can cause tissue trauma.
While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of the patients closed chest-drainage system. What should the nurse conclude?
- A. The system is functioning normally
- B. The patient has a pneumothorax
- C. The system has an air leak
- D. The chest tube is obstructed
Correct Answer: C
Rationale: Constant bubbling in the chamber often indicates an air leak and requires immediate assessment and intervention. The patient with a pneumothorax will have intermittent bubbling in the water-seal chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber.
The medical nurse is creating the care plan of an adult patient requiring mechanical ventilation. What nursing action is most appropriate?
- A. Keep the patient in a low Fowlers position
- B. Perform tracheostomy care at least once per day
- C. Maintain continuous bedrest
- D. Monitor cuff pressure every 8 hours
Correct Answer: D
Rationale: The cuff pressure should be monitored every 8 hours. It is important to perform tracheostomy care at least every 8 hours because of the risk of infection. The patient should be encouraged to ambulate, if possible, and a low Fowlers position is not indicated.
The critical care nurse and the other members of the care team are assessing the patient to see if he is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify?
- A. Stable vital signs and ABGs
- B. Pulse oximetry above 80% and stable vital signs
- C. Stable nutritional status and ABGs
- D. Normal orientation and level of consciousness
Correct Answer: A
Rationale: Among many other predictors, stable vital signs and ABGs are important predictors of successful weaning. Pulse oximetry must greatly exceed 80%. Nutritional status is important, but vital signs and ABGs are even more significant. Patients who are weaned may or may not have full level of consciousness.