The health care provider orders positive end expiratory pressure (PEEP) to be added to the settings of a mechanically ventilated patient. Which is the most important information for the nurse to obtain when monitoring for the effectiveness of this intervention?

Choice A rationale

Administering antianxiety medication is a comfort measure but does not address the immediate physiological risks associated with suctioning. Suctioning induces transient hypoxia and increases myocardial oxygen demand, which can lead to dysrhythmias. While reducing patient distress is important for overall care, it is not the highest priority when compared to maintaining adequate cellular oxygenation during an invasive procedure that actively removes oxygen from the airway.

Choice B rationale

Instilling normal saline into the endotracheal tube was once common practice but is now discouraged because it does not effectively thin secretions. Instead, it can displace bacteria from the inner lumen of the tube deeper into the lower respiratory tract, increasing the risk of ventilator-associated pneumonia. It also decreases oxygen saturation significantly. Hydration and humidification are the preferred systemic methods for managing thick pulmonary secretions in intubated patients.

Choice C rationale

Suctioning removes both secretions and oxygen from the airway, which can lead to severe hypoxemia, bradycardia, or even cardiac arrest. Providing 100 percent FiO2 for at least 30 to 60 seconds prior to the procedure creates an oxygen reserve in the lungs. This prevents the hemoglobin saturation from dropping to dangerous levels during the periods of apnea and negative pressure. This action is the highest priority to ensure patient safety.

Choice D rationale

Auscultation is a necessary assessment to evaluate the effectiveness of the suctioning procedure and to ensure the airway is clear. However, it is an evaluative step performed after the intervention has occurred. While it helps determine if further suctioning is required, it does not prevent the immediate life-threatening complications of hypoxia that occur during the procedure itself. Therefore, it remains secondary to the proactive step of pre-oxygenation.

Choice A rationale

The pressure bag must be maintained at 300 mmHg to ensure a continuous flush of approximately 3 mL per hour through the system. This high pressure is necessary to overcome the patient’s arterial or pulmonary artery pressure and keep the catheter patent. If the bag is only at 100 mmHg, blood may back up into the tubing, causing clots and inaccurate readings. The nurse must immediately increase the pressure to prevent equipment failure and maintain accuracy.

Choice B rationale

Normal saline is the standard and appropriate fluid used for the flush bag in a hemodynamic monitoring system. It is isotonic and compatible with the patient’s blood, making it the safest choice for maintaining the patency of the invasive line. Since this is a correct and expected finding, the nurse would not need to correct it. Using other fluids, like hypotonic solutions, would be incorrect and could lead to hemolysis or other physiological complications.

Choice C rationale

Zeroing the transducer is a mandatory step to ensure that the monitor ignores atmospheric pressure and only measures the patient’s internal pressures. A good waveform indicates that the system is properly placed and functioning without dampening or interference. This finding represents a correctly set up system that is providing reliable data for clinical decision-making. Therefore, no corrective action is required by the nurse for this specific part of the assessment.

Choice D rationale

Secure connections are vital in any invasive pressure monitoring system to prevent accidental exsanguination or the entry of air into the vascular system. Loose connections can also cause air bubbles, which lead to dampened waveforms and inaccurate pressure readings. Because the connections are noted to be secure, the system is safe and functioning as intended. This is an ideal finding that requires no intervention from the nursing staff to rectify.