A client is on mechanical ventilator settings that include the use of PEEP (positive end-expiratory pressure). Which finding indicates the client is developing a complication related to this therapy and requires immediate treatment?

HCO3 26 mmHg

BP 70/45

Central venous pressure of 7 mmHg

Ventilator RR set at 14 and the client initiating spontaneous breaths for a total rate of 18

Answer and Explanation

The Correct Answer is B

A. HCO₃ 26 mmHg is incorrect because this bicarbonate level is within normal range (22–28 mEq/L) and does not indicate a complication of PEEP therapy. PEEP primarily affects cardiovascular and pulmonary dynamics rather than directly altering serum bicarbonate.

B. BP 70/45 is correct because hypotension is a known and potentially serious complication of PEEP. Positive end-expiratory pressure increases intrathoracic pressure, which can reduce venous return (preload) to the heart. This decrease in preload lowers cardiac output, leading to hypotension. In severe cases, this can result in inadequate perfusion to vital organs, causing shock and organ failure. Immediate interventions may include lowering PEEP, administering intravenous fluids to increase intravascular volume, or starting vasopressors to support blood pressure. Continuous monitoring is essential.

C. Central venous pressure (CVP) of 7 mmHg is incorrect because this value is within normal limits (typically 2–8 mmHg). CVP helps estimate right ventricular preload, and a normal CVP does not indicate hemodynamic compromise. In PEEP-related complications, CVP may actually increase due to elevated intrathoracic pressure, but a value of 7 mmHg is not concerning.

D. Ventilator RR set at 14 and the client initiating spontaneous breaths for a total rate of 18 is incorrect because spontaneous breathing superimposed on ventilator settings is common and generally safe. A slight increase in total respiratory rate does not indicate a complication of PEEP and does not require immediate intervention.

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Correct Answer is ["A","C","D","F"]

Explanation

A. Adherence to proper hand hygieneis correct because hand hygiene is one of the most effective measures to prevent healthcare-associated infections, including ventilator-associated pneumonia (VAP). Proper handwashing or use of alcohol-based sanitizer before and after patient contact reduces transmission of pathogens.

B. Administering a prescribed proton pump inhibitoris incorrect because proton pump inhibitors (PPIs) reduce stomach acidity, which can actually increase the risk of VAPby allowing colonization of the gastrointestinal tract with pathogenic bacteria that can be aspirated into the lungs.

C. Elevating the head of the bedis correct because keeping the head of the bed elevated at 30–45°reduces the risk of aspiration of gastric contents, a major contributor to VAP.

D. Providing oral care per protocolis correct because oral hygiene with antiseptic solutions (e.g., chlorhexidine) decreases colonization of pathogenic bacteria in the oropharynx, lowering the risk of ventilator-associated pneumonia.

E. Suctioning the client every houris incorrect because routine or frequent suctioning is not recommended and can increase trauma or introduce infection. Suctioning should be performed as neededbased on assessment of secretions.

F. Turning and positioning the client at least every 2 hoursis correct because frequent repositioning helps mobilize secretions, prevent pooling of fluids, and reduce the risk of atelectasis and infection, which can contribute to VAP.

A. Assess breath sounds and respiratory efforts B. Establish vascular access with a large-bore catheter C. Remove clothing to perform a complete physical assessment D. Evaluate level of consciousness (LOC) using the Glasgow Coma Sale (GCS)

Correct Answer is A

Explanation

A. In an unconscious patient, airway and breathing take priorityaccording to the ABC (Airway, Breathing, Circulation) approachin emergency care. Even if the patient is breathing spontaneously, the nurse must assess for adequate oxygenation, airway patency, and signs of respiratory compromisebefore addressing other interventions. Immediate identification of airway obstruction or inadequate breathing can be life-saving.

B. Incorrect as the first action. While IV access is important for fluid resuscitation or medication administration, it does not take priority over ensuring airway and effective breathing, which are immediately life-sustaining.

C. Incorrect as the first action. A full physical assessment is important for identifying injuries, but airway and breathing must be addressed first. Removing clothing can occur after the patient is stabilized.

D. Incorrect as the first action. Assessing LOC is important to monitor neurological status, but it does not take priority over ensuring the patient can maintain adequate ventilation and oxygenation. LOC assessment can be done simultaneously or immediately after securing airway and breathing.

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A client is on mechanical ventilator settings that include the use of PEEP (positive end-expiratory pressure). Which finding indicates the client is developing a complication related to this therapy and requires immediate treatment?

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