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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.
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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.
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.
A patient in the ICU has had an endotracheal tube in place for 3 weeks. The physician has ordered that a tracheostomy tube be placed. The patients family wants to know why the endotracheal tube cannot be left in place. What would be the nurses best response?
- A. The physician may feel that mechanical ventilation will have to be used long-term
- B. Long-term use of an endotracheal tube diminishes the normal breathing reflex
- C. When an endotracheal tube is left in too long it can damage the lining of the windpipe
- D. It is much harder to breathe through an endotracheal tube than a tracheostomy
Correct Answer: C
Rationale: Endotracheal intubation may be used for no longer than 2 to 3 weeks, by which time a tracheostomy must be considered to decrease irritation of and, trauma to, the tracheal lining, to reduce the incidence of vocal cord paralysis (secondary to laryngeal nerve damage), and to decrease the work of breathing. The need for long-term ventilation would not be the primary rationale for this change in treatment. Endotracheal tubes do not diminish the breathing reflex.
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.
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.