Nokea
A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what should the nurse ensure as a priority?
- A. The client is able to initiate spontaneous breaths
- B. The inspired oxygen has adequate humidification
- C. The upper peak airway pressure limit alarm is off
- D. The upper peak airway pressure limit alarm is on
Correct Answer: D
Rationale: The upper peak airway pressure limit alarm must be on to prevent lung injury from excessive pressure. This is the priority to ensure client safety.
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An intubated client's oxygen saturation has dropped to 88%. What action by the nurse takes priority?
- A. Determine if the tube is kinked
- B. Ensure all connections are patent
- C. Listen to the client's lung sounds
- D. Suction the endotracheal tube
Correct Answer: C
Rationale: For an intubated client with hypoxia, the nurse should first assess for DOPE (displaced tube, obstruction, pneumothorax, equipment problems). Listening to lung sounds to confirm tube placement is the priority, as a displaced tube is the most common cause of hypoxia.
A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority?
- A. Ensure the client has adequate sedation
- B. Find another provider to intubate
- C. Interrupt the procedure to give oxygen
- D. Monitor the client's oxygen saturation
Correct Answer: C
Rationale: Intubation attempts should not exceed 30 seconds to prevent hypoxia. Interrupting the procedure to provide oxygen is the priority to ensure the client's safety.
A 242-pound client is being mechanically ventilated. To prevent lung injury, what setting should the nurse anticipate for tidal volume? (Record your answer using a whole number.) mL
- A. 600 mL
- B. 660 mL
- C. 700 mL
- D. 750 mL
Correct Answer: B
Rationale: A tidal volume of 6 mL/kg is used to prevent lung injury. For a 242-pound (110 kg) client, 110 kg ? 6 mL/kg = 660 mL.
A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate?
- A. Decrease the heparin rate
- B. Increase the heparin rate
Correct Answer: B
Rationale: A PTT of 25 seconds is below the therapeutic range (typically 1.5"?2.5 times the control value of ~30 seconds), indicating insufficient anticoagulation. Increasing the heparin rate is necessary to achieve therapeutic levels and effectively treat the pulmonary embolism.
A nurse is caring for a client on the medical stepdown unit. The following data are related to this client: Subjective Information Shortness of breath for 20 minutes, PCO2: 28 mm Hg, Respiratory rate: 34, Feels frightened, PO2: 88 mm Hg, Can't catch my breath, SPO2: 88%, Blood pressure 158/92 mm Hg, Lungs have crackles. What action by the nurse is most appropriate?
- A. Call respiratory therapy for a breathing treatment
- B. Facilitate a STAT pulmonary angiography
- C. Prepare for immediate endotracheal intubation
- D. Prepare to administer intravenous anticoagulants
Correct Answer: B
Rationale: The client's symptoms and data (tachypnea, hypoxia, low PCO2, crackles, and anxiety) suggest a pulmonary embolism. STAT pulmonary angiography is the most appropriate action to confirm the diagnosis.