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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.
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The nurse is caring for a patient with a head injury intubated and placed on a mechanical ventilator. When monitoring the patient, which of the following findings should the nurse report to the health care provider?
- A. Oxygen saturation of 94%.
- B. Respirations of 18 breaths/minute.
- C. Green nasogastric tube drainage.
- D. Increased jugular venous distention.
Correct Answer: D
Rationale: Increases in JVD in a patient with head injury may indicate an increase in intra-cranial pressure (ICP) and that the PEEP setting is too high for this patient. A respiratory rate of 18, saturation of 94%, and green nasogastric tube drainage are normal.
The nurse is preparing to assist with the insertion of a pulmonary artery catheter in a patient. Which of the following actions will the nurse implement?
- A. Check cardiac enzymes before insertion.
- B. Auscultate heart sounds during insertion.
- C. Place the patient on NPO status before the procedure.
- D. Attach cardiac monitoring leads before the procedure.
Correct Answer: D
Rationale: Dysrhythmias can occur as the catheter is floated through the right atrium and ventricle, and it is important for the nurse to monitor for these during insertion. Pulmonary artery catheter insertion does not require anaesthesia, and the patient will not need to be NPO. Changes in cardiac enzymes or heart sounds are not expected during pulmonary artery catheter insertion.
The family members of a patient who has just been admitted to the intensive care unit (ICU) with multiple traumatic injuries have just arrived in the ICU waiting room. Which of the following actions should the nurse take first?
- A. Immediately take the family members to the patient's room.
- B. Discuss ICU visitation policies and encourage family visits.
- C. Describe the patient's injuries and the care that is being provided.
- D. Invite the family to participate in a multidisciplinary care conference.
Correct Answer: C
Rationale: Lack of information is a major source of anxiety for family members and should be addressed first. Family members should be prepared for the patient's appearance and the ICU environment before visiting the patient for the first time. ICU visiting should be individualized to each patient and family rather than being dictated by rigid visitation policies. Inviting the family to participate in a multidisciplinary conference is appropriate but should not be the initial action by the nurse.
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.
The nurse notes that a patient's endotracheal tube (ET), which was at the 21-cm mark, is now at the 24-cm mark and the patient appears anxious and restless. Which of the following actions should the nurse take first?
- A. Listen to the patient's lungs.
- B. Offer reassurance to the patient.
- C. Bag the patient at an FIO2 of 100%.
- D. Notify the patient's health care provider.
Correct Answer: A
Rationale: The nurse should first determine whether the ET tube has been displaced into the right mainstem bronchus by listening for unilateral breath sounds. If so, assistance will be needed to reposition the tube immediately. The other actions also are appropriate, but detection and correction of tube malposition are the most critical actions.