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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.
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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?
- A. Assure the patient that everything will be all right and that remaining calm is the best strategy
- B. Ask a family member to interpret what the patient is trying to communicate
- C. Ask the physician to wean the patient off the mechanical ventilator to allow the patient to speak freely
- D. Express empathy and then encourage the patient to write, use a picture board, or spell words with an alphabet board
Correct Answer: D
Rationale: If the patient uses an alternative method of communication, he will feel in better control and likely be less frustrated. Assuring the patient that everything will be all right offers false reassurance, and telling him not to be upset minimizes his feelings. Neither of these methods helps the patient to communicate. In a patient with an endotracheal or tracheostomy tube, the family members are also likely to encounter difficulty interpreting the patients wishes. Making them responsible for interpreting the patients gestures may frustrate the family. The patient may be weaned off a mechanical ventilator only when the physiologic parameters for weaning have been met.
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 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.
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 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.