Mechanical Ventilation
Which of the following is a priority intervention during post-extubation follow-up?
A. Maintain deep sedation
B. Encouraging coughing and deep breathing
C. Restricting all patient movement
D. Avoiding supplemental oxygen
B. Encouraging coughing and deep breathing
Rationale: After extubation, the patient must be able to maintain a patent airway and effectively clear secretions. Coughing and deep breathing promote airway clearance, lung expansion, and prevention of atelectasis. Deep sedation and restricting movement can interfere with recovery, while supplemental oxygen may be appropriate when clinically indicated.
A mechanically ventilated patient suddenly triggers a ventilator alarm and has a noticeable decrease in oxygen saturation. What should the nurse prioritize?
A. Document the alarm
B. Assess the patient and airway
C. Wait to see if the alarm stops
D. Review the patient’s PFT results
B-Assess the patient and airway.
Rationale: The nurse should assess the patient before troubleshooting the equipment. A ventilator alarm accompanied by a decrease in oxygen saturation could indicate a serious airway or ventilation problem. The priority is the patient's airway, breathing, and oxygenation.
A patient with a chest tube for a pneumothorax has intermittent bubbling in the water-seal chamber. Which interpretation by the nurse is most appropriate?
A. This indicates a malfunction of the chest drainage system.
B. This is expected and may indicate that air is still leaving the pleural space.
C. The suction pressure should immediately be increased.
D. The chest tube should be clamped immediately.
B. This is expected and may indicate that air is still leaving the pleural space.
Rationale: Intermittent bubbling in the water-seal chamber can be expected in a patient with a pneumothorax because it indicates that air is still moving out of the pleural space. The nurse should continue to monitor the patient and drainage system. Constant vigorous bubbling, however, may indicate an air leak.
A patient has a decreased right atrial pressure and is suspected of having hypovolemia. Which assessment finding is most consistent with this condition?
A. JVD while sitting upright
B. Bounding peripheral pulses
C. Weak, thready pulse
D. Generalized
C—Weak, thready pulse.
Rationale: A decreased RAP indicates decreased venous return/preload, commonly caused by hypovolemia. The patient may develop tachycardia, hypotension, weak or thready pulses, flat neck veins, thirst, poor skin turgor, dry mucous membranes and decreased urine output
A client on continuous EKG monitoring suddenly develops a wide-complex rhythm at a rate of 180/min. The client has a pulse but is hypotensive, diaphoretic, and reports severe chest pain. Which intervention should the nurse anticipate?
A. Immediate defibrillation
B. Synchronized cardioversion
C. Atropine IV
D. Transcutaneous pacing
B. Synchronized cardioversion
Rationale: The client has ventricular tachycardia (VT) with a pulse and signs of instability (hypotension and chest pain). The treatment for unstable VT with a pulse is synchronized cardioversion. Defibrillation is used for pulseless VT/VF.
Which of the following is NOT a common complication of NIPPV?
A. Gastric distention
B. Nasal dryness
C. Skin irritation
D. Increased airway obstruction from an endotracheal tube
D. Increased airway obstruction from an endotracheal tube
Rationale: NIPPV does not require an endotracheal tube. Common complications include nasal or facial dryness, skin irritation from the mask, gastric distention from swallowed air, and discomfort or claustrophobia.
A patient has been experiencing persistent vomiting and is receiving continuous nasogastric suction. Which acid-base imbalance is the patient most at risk for developing?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
D. Metabolic alkalosis
Rationale: Persistent vomiting and gastric suction cause loss of hydrochloric acid from the stomach. Loss of hydrogen ions can increase blood pH, resulting in metabolic alkalosis.
The nurse is performing a comprehensive assessment of a patient with a chest tube. Which finding requires the most immediate follow-up?
A. Mild pain at the insertion site
B. Tidaling in the water-seal chamber
C. Subcutaneous emphysema around the insertion site
D. An occlusive dressing that is dry and intact
C—Subcutaneous emphysema around the insertion site.
Rationale: Subcutaneous emphysema occurs when air enters the tissues beneath the skin. In a patient with a chest tube, this can indicate an air leak and requires further assessment. Mild pain, tidaling, and a dry, intact occlusive dressing are generally expected findings.
The nurse is caring for a patient with dehydration and hypovolemic shock. Following IV fluid administration, which finding best indicates restoration of organ perfusion?
A. MAP increases from 60-65mmHg
B. Peripheral pulses are 2+
C. Urine output increases to 30mL/hr
D. JVD and ankle edema develop
C—urine output increases to 30mL/hr.
Rationale: The kidneys are highly sensitive to changes in perfusion. An increase in urine output to approximately 30mL/hr in an adult suggests that renal blood flow and overall tissue perfusion have improved.
The nurse enters a client's room and observes the following EKG pattern: chaotic, irregular electrical activity with no identifiable P waves, QRS complexes, or T waves. The client is unresponsive and has no palpable pulse. Which action is the priority?
A. Administer IV adenosine
B. Perform synchronized cardioversion
C. Begin CPR and prepare for immediate defibrillation
D. Apply a transcutaneous pacemaker
C. Begin CPR and prepare for immediate defibrillation
Rationale: The rhythm described is ventricular fibrillation (VF). VF produces no effective cardiac output, so the client is pulseless. Treatment includes CPR and immediate unsynchronized defibrillation.
Which patient is most likely to benefit from NIPPV?
A. A patient with a completely obstructed airway
B. A patient who requires immediate endotracheal intubation
C. A patient with COPD and hypercapnia who can still breathe spontaneously
D. A patient who is apneic and cannot initiate breaths
C. A patient with COPD and hypercapnia who can still breathe spontaneously
Rationale: NIPPV is useful for patients who are spontaneously breathing but need assistance with ventilation or oxygenation. Patients with COPD and hypercapnia are common candidates. A completely obstructed airway, apnea without spontaneous respiratory effort, or a patient requiring immediate intubation requires a more definitive airway.
A mechanically ventilated patient develops an increasing PaCO2 level. Which problem does this finding most directly indicate?
A. Inadequate ventilation
B. Excessive oxygenation
C. Improved gas exchange
D. Decreased metabolic acid production
A. Inadequate ventilation.
Rationale: PaCO2 reflects the patient’s ability to eliminate carbon dioxide through ventilation. Increasing PaCO2 indicates CO2 retention and inadequate alveolar ventilation (remember PaCO2=ventilation, PaO2=oxygenation)
Which patient finding would best support the healthcare provider's decision to remove a chest tube?
A. Drainage of 250 mL during the previous 24 hours
B. Persistent air leak with each respiratory cycle
C. Improved and stable patient status with decreased drainage
D. Evidence of a worsening pneumothorax on chest x-ray
C—improved and stable patient status with decreased drainage.
Rationale: Chest tube removal may be considered when the patient's condition is improved and stable, drainage has decreased (the slides specify less than 100 mL/24 hours), the air leak has resolved, and the lung has re-expanded on chest x-ray while on water seal.
A patient has an elevated RAP with JVD, generalized edema, and ascites. Which intervention should the nurse anticipate?
A. Administer a rapid IV fluid bolus
B. Restrict sodium and fluids
C. Encourage increased oral fluid intake
D. Administer blood products
B—Restrict sodium and fluids.
Rationale: The patient demonstrates signs of fluid volume excess associated with elevated RAP. Treatment focuses on reducing fluid volume through fluid and sodium restriction and when prescribed, diuretics or vasodilators.
A client has the following EKG findings: regular rhythm, heart rate 38/min, normal p waves, each p wave followed by a QRS complex, client is confused and hypotensive. Which treatment should the nurse anticipate first?
A. Atropine
B. Defibrillation
C. Adenosine
D. Synchronized cardioversion
A. Atropine
Rationale: This is sinus bradycardia with symptomatic instability. When significant symptoms are present, atropine is commonly the initial pharmacologic treatment. If ineffective, the client may require transcutaneous pacing and/or other advanced interventions.
Which type of oxygen therapy provides PEEP?
A. 60% Venturi mask
B. 100% nonrebreather mask
C. BiPAP
D. A and B only
E. B and C only
C. BiPAP
Rationale: BiPAP provides positive airway pressure and includes an expiratory pressure component that functions as PEEP. A Venturi mask and nonrebreather mask provide supplemental oxygen but do not provide true PEEP in the same way positive-pressure ventilation does.
A patient with severe bronchospasm is experiencing hypoxia. Which medication would the nurse expect to administer to help improve airway airflow?
A. Bronchodilator
B. Diuretic
C. Antibiotic
D. Antacid
A. Bronchodilator
Rationale: Severe bronchospasm causes narrowing of the airways and difficulty moving air. Bronchodilators relax bronchial smooth muscle, improving airway diameter and airflow.
Which assessment finding is most consistent with a restrictive pulmonary disorder?
A. Difficulty exhaling due to increased airway resistance
B. Prolonged expiration with wheezing
C. Decreased lung expansion and reduced total lung capacity
D. Air trapping caused by narrowed bronchioles
C—Decreased lung expansion and reduced total lung capacity.
Rationale: Restrictive pulmonary diseases are characterized by difficulty expanding the lungs. This results in decreased lung volumes, including reduced total lung capacity (TLC). Examples include pulmonary fibrosis and other conditions that decrease lung compliance.
The nurse is reviewing assessment findings for two patients. Which finding would the nurse associate with decreased RAP rather than elevated RAP?
A. Ascites
B. Dependent edema
C. Distended neck veins
D. Thirst and dry mucous membranes
D--Thirst and dry mucous membranes
Rationale: Indicate fluid volume deficit, which is associated with decreased RAP
A client's monitor displays an organized rhythm with a rate of 70/min and identifable QRS complexes. However, the client is unresponsive and has no palpable pulse. Which rhythm does the nurse suspect, and what is the appropriate treatment?
A. Ventricular tachycardia; synchronized cardioversion
B. Ventricular fibrillation; defibrillation
C. Pulseless electrical activity; CPR and epinephrine
D. Sinus bradycardia; atropine
C. Pulseless electrical activity; CPR and epinephrine
Rationale: PEA occurs when organized electrical activity is present on the monitor, but the heart is not producing a palpable pulse. PEA is a non-shockable rhythm. Treatment includes high-quality CPR, epinephrine, and identification/treatment of reversible causes.
A patient is mechanically ventilated following acute respiratory failure. The nurse is reviewing the ventilator settings and notes that the patient is receiving AC/VC ventilation with a tidal volume of 500 mL, respiratory rate of 14/min, and PEEP of 5 cm H₂O.
The patient becomes increasingly tachypneic and begins taking additional spontaneous breaths at a rate of 24/min.
Which statement by the nursing student demonstrates the BEST understanding of AC/VC ventilation?
A. “The patient’s additional breaths will not receive a full tidal volume because the set respiratory rate has already been reached.”
B. “Each patient-triggered breath will receive the set tidal volume, which may result in a higher minute ventilation.”
C. “The ventilator will limit every breath to a preset inspiratory pressure regardless of the patient’s tidal volume.”
D. “The patient must be sedated because spontaneous breathing is not permitted with AC/VC.”
B. In assist-control volume control (AC/VC), the ventilator delivers the preset tidal volume with each mandatory or patient-triggered assisted breath. If the patient initiates additional breaths, each receives the set tidal volume, potentially increasing minute ventilation and causing respiratory alkalosis if excessive. PCV, in contrast, sets a target inspiratory pressure, while the resulting tidal volume can vary depending on lung compliance and airway resistance.
A client with respiratory failure is being assessed by the nurse. Which combination is most consistent with respiratory failure?
A. Hypoxemia and hypercapnia
B. Hyperoxemia and hypocapnia
C. Hypotension and hypoglycemia
D. Hypercapnia and hypertension
A. Hypoxemia and hypercapnia
Rationale: Respiratory failure occurs when the respiratory system cannot adequately oxygenate the blood and/or eliminate carbon dioxide. Hypoxemia and hypercapnia are classic findings.
A patient with ARDS develops worsening hypoxemia despite receiving supplemental oxygen. Which intervention should the nurse anticipate?
A. Decreasing oxygen therapy to prevent hypoventilation
B. Preparing the patient for mechanical ventilation with positive end-expiratory pressure (PEEP)
C. Encouraging the patient to breathe rapidly and shallowly
D. Administering a bronchodilator as the primary treatment
B—Preparing the patient for mechanical ventilation with positive end-expiratory pressure (PEEP).
Rationale: Severe ARDS can cause significant hypoxemia that does not adequately respond to supplemental oxygen alone. PEEP helps keep alveoli open at the end of expiration, improving alveolar recruitment and oxygenation. Mechanical ventilation may therefore be required in patients with worsening respiratory failure.
A patient with elevated RAP is prescribed diuretic therapy. Which finding would best indicate that the treatment is effective?
A. Increased JVD
B. Increased abdominal girth
C. Decreased peripheral edema
D. Development of hypotension and tachycardia
C—Decreased peripheral edema.
Rationale: Diuretics promote the excretion of excess fluid. Decreased peripheral edema indicates that fluid accumulation is improving and that the patient is responding to treatment.
A client on continuous EKG monitoring develops a rhythm with the following characteristics: Irregularly irregular ventricular rhythm, no identifiable P waves, narrow QRS complexes, heart rate of 140/min. The client is awake and reports palpitations but has a blood pressure of 128/76 mmHg. Which intervention should the nurse anticipate?
A. Immediate defibrillation
B. Synchronized cardioversion
C. Rate-control medication such as a beta-blocker or calcium channel blocker
D. Transcutaneous pacing
C. Rate control medication such as a beta blocker or calcium channel blocker
Rationale: The EKG findings are consistent with atrial fibrillation with a rapid ventricular response. Because the client is currently hemodynamically stable, treatment generally focuses on controlling the ventricular rate, commonly with medications such as BB or CCB.