When weaning a patient off a mechanical ventilator, you should ensure which of the following?
That the patient is pain free
That the patient does not have a fever
That the underlying problem prompting mechanical ventilation is improving or resolved.
That the patient has been on the ventilator for at least 1 week
The Correct Answer is C
A. That the patient is pain free: While pain management is important for overall comfort and cooperation, being completely pain-free is not the primary criterion for weaning. Pain alone does not determine ventilatory readiness.
B. That the patient does not have a fever: Absence of fever is beneficial for overall stability but is not the key factor in deciding readiness for weaning. The patient may still be weaned successfully if the underlying respiratory issue is improving.
C. That the underlying problem prompting mechanical ventilation is improving or resolved: Successful weaning requires that the initial cause of respiratory failure, such as pneumonia, COPD exacerbation, or ARDS, is improving or resolved. If the underlying problem persists, the patient is unlikely to sustain adequate spontaneous ventilation.
D. That the patient has been on the ventilator for at least 1 week: The duration of mechanical ventilation is not a determining factor for weaning readiness. Some patients may be ready to wean after a few days, while others require longer support depending on their condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Increase PEEP: Positive end-expiratory pressure helps keep alveoli open at the end of expiration, improving oxygenation by increasing functional residual capacity and preventing alveolar collapse. Since the patient’s PaO2 is low (58 mmHg), increasing PEEP is the most effective first step to enhance oxygenation.
B. Increase respiratory rate: Increasing the respiratory rate primarily improves CO2 elimination rather than oxygenation. In this patient, hypoxemia is the priority concern, so adjusting rate will not adequately address low PaO2.
C. Increase FIO2: Increasing the fraction of inspired oxygen can raise PaO2, but prolonged high FIO2 levels increase the risk of oxygen toxicity. PEEP adjustments are generally prioritized before raising FIO2 to high levels.
D. Increase tidal volume: Raising tidal volume mainly improves CO2 removal and ventilation but has limited effect on oxygenation in a patient with alveolar collapse or shunting. Additionally, increasing VT carries a risk of volutrauma.
Correct Answer is C
Explanation
A. SpO2 of 95% on room air: An oxygen saturation of 95% is within normal limits and does not suggest severe hypoxemia. While ongoing monitoring is important, this finding alone is not immediately concerning.
B. Respiratory rate of 16 breaths/minute: A respiratory rate within the normal range (12–20 breaths/minute) does not indicate significant respiratory distress. It is not a sign of hypoxemic respiratory failure.
C. Use of accessory muscles for breathing: Recruitment of accessory muscles, such as the sternocleidomastoid and intercostal muscles, indicates increased work of breathing and respiratory distress. This is a concerning sign of potential hypoxemic or impending respiratory failure and requires prompt assessment and intervention.
D. Ability to speak in full sentences: Being able to speak in full sentences suggests adequate ventilation and oxygenation. This is reassuring and indicates that the patient is not in severe respiratory distress at that moment.
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