Nokea
The nurse is weaning a patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation. Which of the following patient assessments indicates that the weaning protocol should be discontinued?
- A. The patient heart rate is 98 beats/minute.
- B. The patient's oxygen saturation is 93%.
- C. The patient respiratory rate is 32 breaths/minute.
- D. The patient's spontaneous tidal volume is 500 mL.
Correct Answer: C
Rationale: A respiratory rate of 32 breaths/minute indicates respiratory distress and suggests that the patient is not tolerating the weaning process, necessitating discontinuation of the weaning protocol. A heart rate of 98 beats/minute, oxygen saturation of 93%, and spontaneous tidal volume of 500 mL are within acceptable ranges for weaning.
You may also like to solve these questions
The nurse is caring for a patient with pulmonary hypertension. Which of the following parameters should the nurse monitor as an index of right ventricular afterload?
- A. Mean arterial pressure (MAP)
- B. Central venous pressure (CVP)
- C. Pulmonary vascular resistance (PVR)
- D. Pulmonary artery wedge pressure (PAWP)
Correct Answer: C
Rationale: Pulmonary vascular resistance and pulmonary artery pressure are indexes of right ventricular afterload. The other parameters do not directly assess for right ventricular afterload.
The nurse is caring for a patient who has acute pancreatitis and the mixed venous oxygen saturation (SvO2) is decreasing. Which of the following parameters should the nurse assess to determine the possible cause of the decreased SvO2?
- A. Weight
- B. Amylase
- C. Temperature
- D. Urinary output
Correct Answer: C
Rationale: Elevated temperature increases metabolic demands and oxygen use by tissues, resulting in a drop in oxygen saturation of mixed venous blood. Information about the patient's weight, urinary output, and amylase will not help in determining the cause of the patient's drop in SvO2.
The nurse is caring for a patient with a left radial arterial line. Which of the following assessments indicates a need for the nurse to take action?
- A. The left hand is cooler than the right hand.
- B. The mean arterial pressure (MAP) is 75 mm Hg.
- C. The system is delivering only 3 mL of flush solution per hour.
- D. The flush bag and tubing were last changed 3 days previously.
Correct Answer: A
Rationale: The change in temperature of the left hand suggests that blood flow to the left hand is impaired. The flush system needs to be changed every 96 hours or per agency policy. A mean arterial pressure (MAP) of 75 mm Hg is normal. Flush systems for hemodynamic monitoring are set up to deliver 3-6 mL/hour of flush solution.
The nurse is caring for a patient with heart failure requiring a ventricular assist device (VAD) implanted and is waiting for cardiac transplantation. Which of the following actions should the nurse include in the plan of care?
- A. Administer of immuno-suppressive medications.
- B. Monitor the surgical incision for signs of infection.
- C. Teach the patient the reason for continuous bed rest.
- D. Prepare the patient to have the VAD in place permanently.
Correct Answer: B
Rationale: The insertion site for the VAD provides a source for transmission of infection to the circulatory system and requires frequent monitoring. Patients with VADs are able to have some mobility and may not be on bed rest. The VAD is a bridge to transplantation, not a permanent device. Immuno-suppression is not necessary for nonbiological devices like the VAD.
Which of the following information obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning?
- A. The respiratory rate is 17 breaths/minute.
- B. The pulse oximeter shows a SpO2 of 93%.
- C. The lungs have occasional audible expiratory wheezes.
Correct Answer: A
Rationale: The increase in respiratory rate indicates that the patient may have decreased airway clearance and requires suctioning. Suctioning is done when patient assessment data indicate that it is needed, not on a scheduled basis. Occasional expiratory wheezes do not indicate poor airway clearance, and suctioning the patient may induce bronchospasm and increase wheezing. An SpO2 of 93% is acceptable and does not suggest that immediate suctioning is needed.