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When assisting with oral intubation of a patient who is receiving mechanical ventilation, place the following actions in the correct order.
- A. Preoxygenate with a bag-valve-mask system for 3-5 minutes.
- B. Place the patient in a supine position.
- C. Perform a chest x-ray to verify tube placement.
- D. Inflate the cuff on the endotracheal tube.
- E. Use an end-tidal CO2 sensor to check tube placement.
Correct Answer: B,E,C,D,A
Rationale: The patient is placed in a supine position and preoxygenated with a bag-valve-mask system for 3-5 minutes before intubation. Following the intubation, the cuff on the endotracheal tube is inflated to occlude and protect the airway. Tube placement is assessed first with an end-tidal CO2 sensor, and then with a chest x-ray.
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Which of the following actions should the nurse do to inflate the cuff of an endotracheal tube (ET) when the patient is on mechanical ventilation?
- A. Inflate the cuff until the pilot balloon is firm.
- B. Inflate the cuff with a minimum of 10 mL of air.
- C. Inject air into the cuff until a manometer shows 15 mm Hg pressure.
- D. Inject air into the cuff until a slight leak is heard only at peak inflation.
Correct Answer: D
Rationale: The minimal occluding volume technique involves injecting air into the cuff until an air leak is present only at peak inflation. The volume to inflate the cuff varies with the ET and the patient's size. Cuff pressure should be maintained at 20-25 mm Hg. An accurate assessment of cuff pressure cannot be obtained by palpating the pilot balloon.
The nurse is assessing a patient with a central venous catheter notes the catheter insertion site is red and tender with the patient's temperature 38.8°C (101.8°F). Which of the following actions should the nurse implement?
- A. Administer analgesics and antibiotics.
- B. Check the site frequently for any swelling.
- C. Discontinue the catheter and culture the tip.
- D. Change the flush system and monitor the site.
Correct Answer: C
Rationale: The information indicates that the patient has a local and systemic infection caused by the catheter and the catheter should be discontinued. Changing the flush system, administration of analgesics, and continued monitoring will not help prevent or treat the infection. Administration of antibiotics is appropriate, but the line should still be discontinued to avoid further complications such as endocarditis.
Premature ventricular contractions (PVCs) occur while the nurse is suctioning a patient's endotracheal tube. Which of the following actions by the nurse is best?
- A. Decrease the suction pressure to 80 mm Hg.
- B. Stop and ventilate the patient with 100% oxygen.
- C. Document the dysrhythmia in the patient's chart.
- D. Give prescribed PRN antidysrhythmic medications.
Correct Answer: B
Rationale: Dysrhythmias during suctioning may indicate hypoxemia or sympathetic nervous system stimulation, and the nurse should stop suctioning and ventilate the patient with 100% oxygen. Lowering the suction pressure will decrease the effectiveness of suctioning without improving the hypoxemia. Because the PVCs occurred during suctioning, there is no need for antidysrhythmic medications (which may have adverse effects) unless they recur when the patient is well oxygenated.
To determine the effectiveness of medications that a patient has received to reduce left ventricular afterload, which of the following hemodynamic parameters should the nurse monitor?
- A. Central venous pressure (CVP)
- B. Systemic vascular resistance (SVR)
- C. Pulmonary vascular resistance (PVR)
- D. Pulmonary artery wedge pressure (PAWP)
Correct Answer: B
Rationale: Systemic vascular resistance reflects the resistance to ventricular ejection, or afterload. The other parameters will be monitored, but do not reflect afterload as directly.
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.