You have a patient on mechanical ventilation who pulls out their endotracheal tube. Which of the following actions would be your priority?
Leave the patient to get the respiratory therapist
Provide adjunct oxygenation by manually ventilating patient with a bag mask valve and 100% oxygen
Check patient's blood pressure first
Lay patient's bed flat
The Correct Answer is B
A. Leave the patient to get the respiratory therapist: Leaving the patient without an airway is dangerous and can result in hypoxia or cardiac arrest within minutes. The nurse must remain with the patient, call for help, and begin manual ventilation immediately to maintain oxygenation.
B. Provide adjunct oxygenation by manually ventilating patient with a bag mask valve and 100% oxygen: When a patient self-extubates, restoring oxygenation is the highest priority. Using a bag-valve mask with 100% oxygen supports ventilation until the airway can be resecured, preventing rapid desaturation and hypoxemia.
C. Check patient’s blood pressure first: While vital signs are important, assessing and maintaining the airway takes precedence over circulatory assessment. Airway and breathing are addressed before circulation in all emergency situations according to the ABC priorities.
D. Lay patient’s bed flat: Laying the bed flat may increase aspiration risk and make manual ventilation more difficult. Keeping the head of the bed elevated or in a neutral position allows for easier airway access and promotes better ventilation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
A. Synchronized Intermittent Mandatory Ventilation (SIMV): SIMV delivers a preset number of mandatory breaths with a fixed tidal volume but allows the patient to breathe spontaneously between ventilator-delivered breaths. However, those spontaneous breaths are not assisted by the ventilator.
B. Pressure Support Ventilation (PSV): PSV is used for spontaneous breathing where each patient-initiated breath is supported by a preset inspiratory pressure. It does not deliver mandatory breaths or a fixed tidal volume.
C. Assist-Control (AC) Ventilation: AC mode delivers a preset tidal volume at a preset rate but also assists with every patient-initiated breath by delivering the same preset tidal volume. This ensures consistent ventilation while allowing the patient to initiate breaths, reducing the work of breathing in acute respiratory failure.
D. Continuous Positive Airway Pressure (CPAP): CPAP provides constant pressure throughout the respiratory cycle to keep airways open but does not deliver preset breaths or tidal volumes. It is primarily used for patients who can breathe spontaneously but need support to maintain oxygenation.
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