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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.
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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?
- A. CPAP allows a higher percentage of oxygen to be safely used
- B. CPAP allows a lower percentage of oxygen to be used with a similar effect
- C. CPAP allows for greater humidification of the oxygen that is administered
- D. CPAP allows for the elimination of bacterial growth in oxygen delivery systems
Correct Answer: B
Rationale: Prevention of oxygen toxicity is achieved by using oxygen only as prescribed. Often, positive end-expiratory pressure (PEEP) or CPAP is used with oxygen therapy to reverse or prevent microatelectasis, thus allowing a lower percentage of oxygen to be used. Oxygen is moistened by passing through a humidification system. Changing the tubing on the oxygen therapy equipment is the best technique for controlling bacterial growth.
The nurse is discussing activity management with a patient who is postoperative following thoracotomy. What instructions should the nurse give to the patient regarding activity immediately following discharge?
- A. Walk 1 mile 3 to 4 times a week
- B. Use weights daily to increase arm strength
- C. Walk on a treadmill 30 minutes daily
- D. Perform shoulder exercises five times daily
Correct Answer: D
Rationale: The nurse emphasizes the importance of progressively increased activity. The nurse also instructs the patient on the importance of performing shoulder exercises five times daily. The patient should ambulate with limits and realize that the return of strength will likely be gradual and likely will not include weight lifting or lengthy walks.
The OR nurse is setting up a water-seal chest drainage system for a patient who has just had a thoracotomy. The nurse knows that the amount of suction in the system is determined by the water level. At what suction level should the nurse set the system?
- A. 20 cm H2O
- B. 15 cm H2O
- C. 10 cm H2O
- D. 5 cm H2O
Correct Answer: A
Rationale: The amount of suction is determined by the water level. It is usually set at 20 cm H2O; adding more fluid results in more suction.
While caring for a patient with an endotracheal tube, the nurses recognizes that suctioning is required how often?
- A. Every 2 hours when the patient is awake
- B. When adventitious breath sounds are auscultated
- C. When there is a need to prevent the patient from coughing
- D. When the nurse needs to stimulate the cough reflex
Correct Answer: B
Rationale: It is usually necessary to suction the patients secretions because of the decreased effectiveness of the cough mechanism. Tracheal suctioning is performed when adventitious breath sounds are detected or whenever secretions are present. Unnecessary suctioning, such as scheduling every 2 hours, can initiate bronchospasm and cause trauma to the tracheal mucosa.
The nurse is caring for a client with an endotracheal tube who is on a ventilator. When assessing the client, the nurse knows to maintain what cuff pressure to maintain appropriate pressure on the tracheal wall?
- A. Between 10 and 15 mm Hg
- B. Between 15 and 20 mm Hg
- C. Between 20 and 25 mm Hg
- D. Between 25 and 30 mm Hg
Correct Answer: B
Rationale: Complications can occur from pressure exerted by the cuff on the tracheal wall. Cuff pressures should be maintained between 15 and 20 mm Hg.