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skills

front 1

The nurse is caring for a client who is mechanically ventilated and is monitoring for complications of mechanical ventilation. Which assessment finding, if noted by the nurse, indicates the need for follow-up?

1.Muscle weakness in the arms and legs

2.A temperature of 98.6º F (37º C), decreased from 99.0º F (37.2º C)

3.A blood pressure of 90/60 mm Hg, decreased from 112/78 mm Hg

4.A heart rate of 80 beats/minute, decreased from 85 beats/minute

back 1

3.A blood pressure of 90/60 mm Hg, decreased from 112/78 mm Hg

Complications of mechanical ventilation include the following: hypotension caused by application of positive pressure, which increases intrathoracic pressure and inhibits blood return to the heart; pneumothorax or subcutaneous emphysema as a result of positive pressure; gastrointestinal alterations such as stress ulcers; malnutrition if nutrition is not maintained; infections; muscular deconditioning; and ventilator dependence or inability to wean. Some muscle weakness is expected. Options 1, 2, and 4 present normal assessment findings.

front 2

The nurse has assisted the primary health care provider and the anesthesiologist with placement of an endotracheal (ET) tube for a client in respiratory distress. What is the initial nursing action to evaluate proper ET tube placement?

1.Tape the ET tube in place, and note the centimeter marking at the lip line.

2.Ask the radiology department to obtain a stat portable radiograph at the client's bedside.

3.Use an Ambu (resuscitation) bag to ventilate the client and assess for bilateral breath sounds.

4.Attach the ET tube to the ventilator and determine whether the client is able to tolerate the tidal volume prescribed.

back 2

3.Use an Ambu (resuscitation) bag to ventilate the client and assess for bilateral breath sounds.

Rationale:
The nurse verifies the placement of an ET tube immediately by ventilating the client using an Ambu bag and by auscultating for breath sounds bilaterally, which ensures ventilation of both lungs. After this initial assessment, placement is checked radiographically. The nurse marks the ET tube at the point where it enters the nose or mouth for ongoing monitoring of correct placement, but this will not determine initial adequate placement of the ET tube. Noting the tidal volume and the client's toleration of the tidal volume prescribed is not a measure of appropriate ET tube placement.

front 3

The nurse is changing the tracheostomy securement device on a client with a tracheostomy and is assessing the security of the ties. Which method is used to ensure that the ties are not too tightly placed?

1.The ties leave no marks on the neck.

2.The tracheotomy can be pulled slightly away from the neck.

3.The nurse places 1 finger loosely between the tie and the neck.

4.The nurse uses a 12-inch tie that is tightly affixed with hook-and-loop closures.

back 3

3.The nurse places 1 finger loosely between the tie and the neck.

Rationale:
The nurse should assess the tracheostomy securement device to ensure that it is not too tight. The nurse ensures that there is room for 1 finger loosely or 2 fingers snugly to slide comfortably under the device. Options 1, 2, and 4 are incorrect actions.

front 4

The nurse is preparing for removal of an endotracheal (ET) tube from a client. In assisting the primary health care provider with this procedure, which is the initial nursing action?

1.Deflate the cuff.

2.Suction the ET tube.

3.Turn off the ventilator.

4.Obtain a code cart, and place it at the bedside.

back 4

2.Suction the ET tube.

Rationale:
Once the client has been weaned successfully and has achieved an acceptable level of consciousness to sustain spontaneous respiration, an ET tube may be removed. The ET tube is suctioned first, and then the cuff is deflated and the tube is removed. Placing a code cart at the bedside is unnecessary and may cause alarm and concern in the client. In addition, resuscitative equipment should already be available at the client's bedside. Option 3 is not the initial action.

front 5

The nurse is performing nasotracheal suctioning of a client. The nurse determines that the client is tolerating the procedure if which observation is made?

1.The skin color becomes cyanotic.

2.Secretions are becoming bloody.

3.Coughing occurs with suctioning.

4.Heart rate decreases from 78 to 54 beats/minute.

back 5

3.Coughing occurs with suctioning.

Rationale:
The nurse monitors for adverse effects of suctioning, which include cyanosis, excessively rapid or slow heart rate, and sudden development of bloody secretions. If any of these signs is observed, the nurse immediately stops suctioning and reports the adverse effect to the primary health care provider. Coughing is a normal response to suctioning for the client with an intact cough reflex and does not indicate that he or she cannot tolerate the procedure.

front 6

The nurse is monitoring the respiratory status of a client after creation of a tracheostomy. Which coexisting condition in the client may cause an inaccurate pulse oximetry reading?

1.Fever

2.Epilepsy

3.Hypotension

4.Respiratory failure

back 6

3. Hypotension

Rationale:
Hypotension, shock, or the use of peripheral vasoconstricting medications may result in inaccurate pulse oximetry readings as a result of impaired peripheral perfusion. Fever and epilepsy would not affect the accuracy of measurement. Respiratory failure also would not affect the accuracy of measurement, although the readings may be abnormally low.

front 7

The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs?

1.Suctioning is required frequently.

2.The client's skin and mucous membranes are light pink.

3.Aspiration of gastric contents occurs during suctioning.

4.Excessive secretions are suctioned from the tube and stoma.

back 7

3.Aspiration of gastric contents occurs during suctioning.

Necrosis of the tracheal wall can lead to formation of an abnormal opening between the posterior trachea and the esophagus. The opening, called a tracheoesophageal fistula, allows air to escape into the stomach, causing abdominal distention. It also causes aspiration of gastric contents. Options 1, 2, and 4 are not signs of this complication.

front 8

The nurse is caring for a client with an endotracheal tube attached to a mechanical ventilator. The high-pressure alarm sounds, and the nurse assesses the client. The nurse determines that the cause of the alarm is most likely to be due to which complication?

1.A kink in the ventilator circuit

2.A leak in the endotracheal tube cuff

3.Displacement of the endotracheal tube

4.A disconnection of the ventilator tubing

back 8

1.A kink in the ventilator circuit

Rationale:
A high-pressure alarm occurs if the amount of pressure needed for ventilating a client exceeds the preset amount. Causes of high-pressure alarm activation include excess secretions; mucous plugs; the client biting on the endotracheal tube; kinks in the ventilator tubing; and the client coughing, gagging, or attempting to talk. The remaining options would trigger the low-pressure alarm.

front 9

A primary health care provider (PHCP) tells the nurse that a client's chest tube is to be removed. The nurse should bring which dressing materials to the bedside for the PHCP's use?

1.Telfa dressing and Neosporin ointment

2.Petrolatum gauze and sterile 4 × 4 gauze

3.Benzoin spray and a hydrocolloid dressing

4.Sterile 4 × 4 gauze, Neosporin ointment, and tape

back 9

2.Petrolatum gauze and sterile 4 × 4 gauze

Rationale:
On removal of the chest tube, sterile petrolatum gauze and sterile 4 × 4 gauze is placed at the insertion site. The entire dressing is securely taped to make sure it is occlusive. The use of Telfa dressing, Neosporin ointment, hydrocolloid dressing, and benzoin spray is not indicated. Elastoplast tape may be used at the discretion of the PHCP as the tape of choice to make the dressing occlusive.

front 10

The nurse caring for a client with a closed chest drainage system notes that the fluctuation (tidaling) in the water seal chamber has stopped. On the basis of this assessment finding, the nurse would suspect which occurrence?

1.The system needs changing.

2.Suction needs to be increased.

3.Suction needs to be decreased.

4.The chest tube may be obstructed.

back 10

4.The chest tube may be obstructed.

Rationale:
Fluid in the water seal chamber should rise with inspiration and fall with expiration (tidaling). When tidaling occurs, the drainage tubes are patent and the apparatus is functioning properly. Tidaling stops when the lung has reexpanded or if the chest drainage tubes are kinked or obstructed. The remaining options are incorrect interpretations.