The nursing is caring for a client in the Intensive Care Unit on a ventilator. Which intervention(s) should the nurse implement? (SELECT ALL THAT APPLY)

Monitor the client's pulse oximetry every shift

Assess the client's respiratory status at least every 1-2 hours

Ensure that a manual resuscitation bag is at the bedside

Check the ventilator settings every shift

Collaborate frequently with the respiratory therapist

Answer and Explanation

Correct Answer : B,C,D,E

A) Monitor the client's pulse oximetry every shift:
Monitoring pulse oximetry every shift is not sufficient when caring for a client on a ventilator. Pulse oximetry provides valuable information about oxygen saturation, but it should be checked more frequently, especially in a critically ill patient on a ventilator. Continuous monitoring may be required to ensure that oxygenation is maintained at optimal levels. The nurse should assess the pulse oximetry regularly and take immediate action if there is a significant change in the client’s oxygen saturation.

B) Assess the client's respiratory status at least every 1-2 hours:
It is essential to assess the client's respiratory status frequently when they are on a ventilator. Respiratory assessments should be performed at least every 1-2 hours to monitor for complications such as ventilator-associated pneumonia, changes in oxygenation, or the need for adjustments to the ventilator settings. Regular assessment is critical to detect early signs of deterioration and respond promptly.

C) Ensure that a manual resuscitation bag is at the bedside:
Having a manual resuscitation bag (e.g., Ambu bag) at the bedside is a critical intervention for clients on a ventilator. In case of ventilator malfunction, extubation, or respiratory distress, the nurse must have immediate access to a resuscitation bag to manually ventilate the patient. This is a lifesaving piece of equipment that should always be present and ready for use.

D) Check the ventilator settings every shift:
It is essential to check ventilator settings every shift to ensure that the ventilator is functioning correctly and providing the appropriate levels of support for the patient. This includes checking settings such as tidal volume, respiratory rate, pressure, and FiO2 (fraction of inspired oxygen) to ensure they are appropriate for the client's condition. Regular checks can help detect problems such as changes in settings or malfunctioning equipment.

E) Collaborate frequently with the respiratory therapist:
Frequent collaboration with the respiratory therapist is crucial when managing a client on a ventilator. Respiratory therapists are experts in ventilator management and can provide valuable insight into adjusting settings, interpreting ABGs, troubleshooting equipment issues, and optimizing respiratory care. Collaborative care helps ensure that the client is receiving the most appropriate interventions and adjustments for their respiratory status.

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Correct Answer is B

Explanation

A. Guidewire-induced dysrhythmia: Guidewire-induced dysrhythmia can occur if the guidewire or catheter irritates the heart during insertion, particularly when the catheter is placed in the central venous system. While this can lead to arrhythmias, it is typically more immediate and occurs during the procedure itself. The symptoms of dysrhythmia (e.g., irregular heartbeat) would more likely present right after insertion or during the manipulation of the guidewire. The signs of restlessness, JVD, and tachycardia observed 30 minutes after placement are more suggestive of a pneumothorax than of a guidewire-induced dysrhythmia.

B. Pneumothorax: Pneumothorax is a potential complication of central venous catheter (CVC) placement, particularly when the catheter is inserted into the subclavian vein. The right subclavian vein is located near the apex of the lung, so inadvertent puncture of the lung during catheter placement can lead to air entering the pleural space, causing a pneumothorax. The symptoms of pneumothorax may include restlessness, tachycardia, jugular vein distention (JVD), and respiratory distress. A heart rate of 120 beats per minute is consistent with tachycardia due to hypoxia or distress, and JVD can be a sign of increased intrathoracic pressure or impaired venous return, which occurs with a pneumothorax. These symptoms warrant immediate assessment for pneumothorax, which can be confirmed with a chest x-ray.

C. Pulmonary infarction: Pulmonary infarction occurs when a blockage in the pulmonary arteries prevents blood flow to lung tissue, resulting in tissue death. This can be caused by a pulmonary embolism or other issues, but it is not a typical complication of central venous catheter placement. The symptoms described (restlessness, JVD, and tachycardia) are more consistent with a pneumothorax than a pulmonary infarction, which would likely cause chest pain, hemoptysis, or dyspnea rather than these signs.

D. Venous thrombosis: While venous thrombosis (or clot formation) is a potential complication of central venous catheter placement, it typically manifests as swelling, redness, or pain at the catheter insertion site, rather than with the systemic symptoms of restlessness, tachycardia, and JVD. Venous thrombosis could cause some of the described symptoms in the long term, but it is less likely to be the cause of acute symptoms 30 minutes post-procedure. The immediate concern in this case is more likely to be pneumothorax, which can occur more suddenly and cause these symptoms.Top of FormBottom of Form

A. pH 7,44; Pa02 44 mmHg: PaCO2 35 mmHg; HCO3 25 mEq/L; 02 Sat 76% B. pH 7.30; Pa02 80 mmHg; PaCO2 62 mmHg; HCO3 25 mEq/L; 02 Sat 94% C. pH 7.35; Pa02 65 mmHg; PaCO2 40 mmHg: HCO3 26 mEq/L; 02 Sat 90% D. PH 7.48; Pa02 75 mmHg; PaCO2 41 mmHg: HCO3 28 mEg/L; 02 Sat 9386

Correct Answer is A

Explanation

A. pH 7.44; PaO2 44 mmHg; PaCO2 35 mmHg; HCO3 25 mEq/L; O2 Sat 76%: This set of arterial blood gas (ABG) values is consistent with hypoxemic respiratory failure. Hypoxemic respiratory failure is characterized by a PaO2 less than 60 mmHg, and this client has a PaO2 of 44 mmHg, which is significantly below the normal range of 80-95 mmHg. Despite the fact that the client is on a 100% non-rebreather mask (which should ideally deliver high levels of oxygen), the low PaO2 suggests that oxygenation is not being effectively improved. Additionally, the low O2 saturation of 76% further supports the diagnosis of hypoxemic respiratory failure.

B. pH 7.30; PaO2 80 mmHg; PaCO2 62 mmHg; HCO3 25 mEq/L; O2 Sat 94%: This ABG indicates respiratory acidosis (pH is low, PaCO2 is elevated), but the PaO2 of 80 mmHg is within the normal range, and the O2 saturation of 94% is also normal. Respiratory acidosis with a normal PaO2 would indicate an issue with ventilation (hypoventilation), not hypoxemic respiratory failure. The patient is retaining CO2 but is still oxygenating well, so this result does not indicate hypoxemic respiratory failure.

C. pH 7.35; PaO2 65 mmHg; PaCO2 40 mmHg; HCO3 26 mEq/L; O2 Sat 90%: This result shows a PaO2 of 65 mmHg, which is mildly low but not sufficiently low to meet the criteria for hypoxemic respiratory failure (PaO2 should be below 60 mmHg for this diagnosis). The O2 saturation of 90% is also slightly low but not critically low. This client may have mild hypoxia but is not in respiratory failure based on these values.

D. pH 7.48; PaO2 75 mmHg; PaCO2 41 mmHg; HCO3 28 mEq/L; O2 Sat 93%: In this case, the PaO2 of 75 mmHg is slightly low but still within an acceptable range, and the O2 saturation of 93% is adequate. The elevated pH and normal PaCO2 suggest the presence of respiratory alkalosis (likely caused by hyperventilation). These ABG results are not consistent with hypoxemic respiratory failure, as the oxygen levels are still within a safe range.

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The nursing is caring for a client in the Intensive Care Unit on a ventilator. Which intervention(s) should the nurse implement? (SELECT ALL THAT APPLY)

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Correct Answer is A

Explanation

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