The nurse is caring for a patient who is mechanically ventilated understands which of the following statements is true?
Controlled ventilation is the preferred mode for most patients.
Communication with intubated patients is often difficult.
Wrist restraints are applied to all patients to avoid self-extubation
Patients with chronic obstructive pulmonary disease wean easily from
The Correct Answer is B
Rationale:
A. Controlled ventilation is the preferred mode for most patients is incorrect because controlled ventilation (CMV) is typically reserved for patients who are heavily sedated, paralyzed, or unable to initiate breaths. Most patients tolerate assisted or synchronized modes (like SIMV or PSV) better, which allow some spontaneous breathing and reduce complications associated with full control ventilation.
B. Communication with intubated patients is often difficult is correct because mechanical ventilation via an endotracheal tube or tracheostomy prevents verbal speech. Patients may experience anxiety, frustration, and difficulty expressing needs. Nurses often use nonverbal communication tools, such as writing boards, communication apps, or hand signals, to facilitate interaction.
C. Wrist restraints are applied to all patients to avoid self-extubation is incorrect because restraints are not routinely applied. They are used only when necessary to protect the patient from removing tubes or lines. Overuse of restraints can cause physical and psychological harm and should be avoided whenever possible.
D. Patients with chronic obstructive pulmonary disease wean easily from ventilation is incorrect because patients with COPD often have difficulty weaning due to limited pulmonary reserve, hypercapnia, and respiratory muscle fatigue. Weaning requires careful assessment, gradual reduction of ventilator support, and sometimes adjunct therapies like bronchodilators or noninvasive ventilation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A.ARDS is characterized by decreased lung compliance due to stiff, non-compliant lungs from alveolar edema, inflammation, and collapse. Increased FiO₂ does not reverse the stiff lung mechanics.
B. Respiratory acidosis is not typically associated with hyperventilation. In early ARDS, patients often hyperventilate, leading to respiratory alkalosis. Respiratory acidosis can occur later if the patient fatigues or cannot maintain adequate ventilation.
C. ARDS is associated with decreased alveolar surfactant levels, which contributes to alveolar collapse, impaired gas exchange, and decreased lung compliance. Surfactant loss is a hallmark of the pathophysiology.
D. Decreasing PaO₂ despite increased FiO₂ administration reflects refractory hypoxemia, a hallmark of ARDS. This occurs because alveoli are filled with fluid, collapsed, or nonfunctional, preventing oxygen from effectively diffusing into the blood. Even high concentrations of supplemental oxygen cannot fully correct the hypoxemia.
Correct Answer is B
Explanation
Rationale:
A. This is incorrect because simply stimulating the patient hourly is insufficient. A rapid decline from GCS 15 to 3 indicates a life-threatening neurological emergency that requires immediate intervention.
B. This is correct because a sudden drop in GCS from 15 to 3 suggests severe neurological deterioration, possibly from an epidural or subdural hematoma, intracranial hemorrhage, or increased intracranial pressure. Prompt notification of the primary care provider or ED physician is essential for immediate assessment and possible emergency interventions such as imaging, surgery, or advanced airway management.
C. Elevating the head of the bed is a supportive measure to help reduce intracranial pressure, but it is not the priority in the face of rapid neurological decline. Immediate medical evaluation takes precedence.
D. Continuing to monitor the patient without action is incorrect because the patient’s condition is critical. Delaying intervention could result in permanent brain injury or death.
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