The nurse is caring for a patient who is being weaned from mechanical ventilation. Which finding indicates that the patient is not yet ready for extubation?
Vital capacity of 12 mL/kg and strong cough reflex
Respiratory rate of 36 breaths/min and shallow respirations
Oxygen saturation consistently above 94% on FiO₂ 0.4
Negative inspiratory force (NIF) of −30 cm H₂O
The Correct Answer is B
During weaning from mechanical ventilation, the nurse assesses respiratory strength, effort, and gas exchange to determine readiness for extubation. A high respiratory rate with shallow respirations indicates respiratory fatigue and inadequate ventilation, suggesting the patient is not yet ready for extubation.
Rationale for Correct Answer
2. Respiratory rate of 36 breaths/min and shallow respirations: A rapid, shallow breathing pattern reflects increased work of breathing and fatigue. This is a sign of poor ventilatory reserve, indicating the patient may fail extubation if removed from the ventilator prematurely.
Rationale for Incorrect Answers
1. Vital capacity of 12 mL/kg and strong cough reflex: Adequate vital capacity and a strong cough indicate the patient has sufficient lung expansion and airway clearance ability, supporting readiness for extubation.
3. Oxygen saturation consistently above 94% on FiO₂ 0.4: Adequate oxygenation on moderate FiO₂ suggests the patient can maintain sufficient gas exchange without high ventilatory support.
4. Negative inspiratory force (NIF) of −30 cm H₂O: NIF values more negative than −20 cm H₂O indicate adequate respiratory muscle strength for spontaneous breathing.
Take-Home Points
- Rapid, shallow breathing is a warning sign of ventilatory fatigue and extubation failure risk.
- Assess vital capacity, cough strength, oxygenation, and NIF to determine readiness for weaning.
- Extubation should only be attempted when the patient demonstrates adequate respiratory strength, effort, and oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Nursing management of a patient with an artificial airway requires careful attention to airway patency, patient safety, and monitoring for complications. Suctioning, while necessary, can stimulate the vagus nerve or irritate the myocardium, potentially causing cardiac dysrhythmias, making monitoring during the procedure essential.
Rationale for Correct Answer
3. Observing for cardiac dysrhythmias during suctioning: Suctioning an ET or tracheostomy tube can cause vagal stimulation, hypoxemia, or irritation of the myocardium, leading to bradycardia, PVCs, or other dysrhythmias. Continuous cardiac monitoring and pulse oximetry during suctioning allows for prompt recognition and intervention if complications occur.
Rationale for Incorrect Answers
1. Maintaining ET tube cuff pressure at 30 cm H₂O: Recommended cuff pressure is generally 20–25 cm H₂O to prevent tracheal injury while ensuring a seal; 30 cm H₂O is too high and increases the risk of tracheal necrosis.
2. Routine suctioning of the tube at least every 2 hours: Suctioning should be performed as needed based on secretions, breath sounds, and patient tolerance, not routinely on a fixed schedule, to reduce mucosal trauma and hypoxemia.
4. Preventing tube dislodgment by limiting mouth care to lubrication of the lips: Proper oral hygiene and tube stabilization are necessary to prevent infection and accidental extubation. Limiting care to lip lubrication does not adequately protect the airway.
Take-Home Points
- Monitor for cardiac dysrhythmias during airway suctioning due to vagal stimulation or hypoxia.
- Cuff pressures should be maintained at 20–25 cm H₂O to balance sealing and tissue safety.
- Suctioning should be based on patient need, not fixed intervals.
- Oral care and tube stabilization are critical to prevent infection and accidental extubation.
Correct Answer is A
Explanation
Positive end-expiratory pressure (PEEP) improves oxygenation by preventing alveolar collapse, but excessive PEEP increases intrathoracic pressure, which can impair venous return and reduce cardiac output. The earliest and most significant sign of this hemodynamic effect is decreased blood pressure.
Rationale for Correct Answer
1. Decreased blood pressure: Elevated intrathoracic pressure from high PEEP reduces venous return to the heart, lowering cardiac output and causing hypotension. This is an important early indicator of PEEP-induced hemodynamic compromise that requires prompt assessment and adjustment of ventilator settings.
Rationale for Incorrect Answers
2. Decreased PaO₂: PEEP is designed to improve oxygenation; a decrease in PaO₂ usually indicates a problem with lung compliance, secretions, or oxygen delivery, not direct hemodynamic compromise from PEEP.
3. Increased crackles: Crackles suggest pulmonary edema or fluid overload, which is not an immediate or reliable indicator of high PEEP effects.
4. Decreased spontaneous respirations: In ACV, the ventilator delivers full breaths; spontaneous respirations are minimal or absent and do not indicate PEEP-related hemodynamic compromise.
Take-Home Points
- High PEEP increases intrathoracic pressure, which can decrease venous return and cardiac output, causing hypotension.
- Monitor blood pressure and assess for signs of hemodynamic instability during PEEP therapy.
- Adjust PEEP carefully to balance oxygenation benefits with cardiovascular effects.
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