A nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following should the nurse include in the teaching?
Apply a vest restraint if self-extubation is attempted.
Monitor ventilator settings every 8 hours.
Document tube placement in centimeters at the angle of the jaw.
Assess breath sounds every 1 to 2 hours.
The Correct Answer is D
Routine assessment of a patient receiving mechanical ventilation via an endotracheal tube (ETT) requires frequent monitoring to ensure adequate ventilation, early detection of complications, and tube placement verification. Assessing breath sounds every 1 to 2 hours allows the nurse to identify problems such as tube migration, obstruction, or pneumothorax promptly.
Rationale for Correct Answer
4. Assess breath sounds every 1 to 2 hours: Frequent auscultation helps detect unequal or absent breath sounds, which may indicate ETT displacement, mucus plugging, or lung collapse. This assessment is critical for ensuring adequate oxygenation and ventilation and should be part of routine care for all mechanically ventilated patients.
Rationale for Incorrect Answers
1. Apply a vest restraint if self-extubation is attempted: Restraints are used only as a last resort and not as part of routine assessment. Priority interventions should focus on sedation, monitoring, and safety precautions.
2. Monitor ventilator settings every 8 hours: Ventilator settings should be monitored continuously or at least every 1–2 hours, not only every 8 hours, to detect sudden changes in ventilation or patient-ventilator synchrony.
3. Document tube placement in centimeters at the angle of the jaw: ETT placement is typically documented at the lip or teeth, not the jaw, and should be checked frequently rather than once during orientation.
Take-Home Points
- Frequent auscultation of breath sounds (every 1–2 hours) is essential to detect early complications.
- Continuous monitoring of ventilator settings and patient response ensures safe mechanical ventilation.
- Tube security and placement must be verified frequently to prevent accidental extubation or malposition.
- Restraints and sedation are secondary safety measures, not routine assessment steps.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Respiratory alkalosis in a patient receiving assist-control ventilation (ACV) usually results from hyperventilation, which causes excessive CO₂ elimination. The primary intervention is to reduce the ventilator rate to allow CO₂ to accumulate to normal levels, restoring acid-base balance.
Rationale for Correct Answer
1. Decrease the ventilator rate: Lowering the respiratory rate reduces minute ventilation, allowing PaCO₂ to rise and correcting respiratory alkalosis. This adjustment directly targets the cause of excessive alveolar ventilation.
Rationale for Incorrect Answers
2. Increase the FiO₂ level: FiO₂ affects oxygenation, not CO₂ elimination. Increasing FiO₂ does not correct alkalosis caused by hyperventilation.
3. Increase the tidal volume: Increasing tidal volume would further increase CO₂ elimination, worsening respiratory alkalosis rather than correcting it.
4. Add positive end-expiratory pressure (PEEP): PEEP improves oxygenation and alveolar recruitment, but it does not correct PaCO₂ or respiratory alkalosis.
Take-Home Points
- Respiratory alkalosis in mechanically ventilated patients is usually caused by hyperventilation.
- Decreasing the ventilator rate is the primary adjustment to normalize PaCO₂.
- Monitor ABGs after ventilator adjustments to ensure correction without compromising oxygenation.
- Always assess patient comfort, anxiety, and pain, as these can contribute to hyperventilation.
Correct Answer is D
Explanation
During endotracheal suctioning, a patient may develop bradycardia with premature ventricular contractions (PVCs) due to vagal stimulation and transient hypoxia. The priority intervention is to stop suctioning immediately and reoxygenate the patient with 100% oxygen using a bag-valve-mask (BVM) until the heart rate stabilizes and oxygenation improves.
Rationale for Correct Answer
4. Stop suctioning and ventilate the patient with a BVM device with 100% oxygen until the heart rate returns to baseline: This response directly addresses the cause of the bradycardia and PVCs—hypoxia and vagal stimulation. Providing 100% oxygen restores oxygen saturation, reverses vagal-induced bradycardia, and prevents further dysrhythmias. Reoxygenation before and after suctioning is essential for patient safety.
Rationale for Incorrect Answers
1. Stop the suctioning and assess the patient for spontaneous respirations: Although assessment is important, the priority is to restore oxygenation immediately rather than simply observe the patient.
2. Attempt to resuction the patient with reduced suction pressure and pass time: Resuctioning at this point would worsen hypoxia and bradycardia. Suctioning should be resumed only after stabilization and reoxygenation.
3. Stop the suctioning and ventilate the patient with slow, small-volume breaths using a BVM device: Ventilating with small-volume breaths does not ensure adequate reoxygenation. The patient needs 100% oxygen to rapidly reverse the hypoxic state.
Take-Home Points
- Bradycardia and PVCs during suctioning indicate vagal stimulation and hypoxia.
- Immediately stop suctioning and administer 100% oxygen with a BVM until stability returns.
- Always preoxygenate for 30 seconds before suctioning and reoxygenate afterward.
- Continuous cardiac and oxygen monitoring is crucial during suctioning of intubated patients.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.