Mechanical Ventilation and Respiratory Care, Exams of General Surgery

Download Mechanical Ventilation and Respiratory Care and more Exams General Surgery in PDF only on Docsity! ICU Exam 1 1. Which of the following is NOT an indication for the nurse to start a pt on mechanical ventilation? a. If the pt is in hypercarbic or hypoxemic respiratory failure b. To prevent or reverse atelectasis c. If the pt has aspirated or is at risk for aspiration d. To prevent or reverse respiratory muscle fatigue - Correct Answer: c. Rationale: A patient should not be intubated and put on mechanical ventilation simply because of aspiration or a risk for aspiration. To treat aspiration, clear the airway of whatever is causing the aspiration, provide extra oxygen if necessary, and take antibiotics if a resulting infection has occurred. All other choices are indications for starting a patient on mechanical ventilation. 2. Which of the following evidence-based strategies used by the nurse best support the family members of ICU patients at high risk of dying? Select all that apply. a. Building rapport b. Communicating with the family infrequently c. Demonstrating no concern d. Demonstrating professionalism e. Supporting decision-making - Correct Answers: a, d, e. Rationale: Strategies such as building rapport, demonstrating professionalism, and supporting decision- making have shown to help family members cope; to have hope, confidence, and trust; to prepare for and accept impending death; and to make decisions. Other strategies that work include frequent communication, demonstrating concern, and providing factual information. 3. The nurse suspects hypoxemia in her patient when she notices the following signs and symptoms. Select all that apply. a. Confusion b. Increase in blood pressure c. Warm extremities d. Dysrhythmias or a change in heart rate e. A lack of sweating - Correct Answers: a, b, d. Rational: Hypoxemia, a decrease in the arterial oxygen tension in the blood, is manifested by changed in mental status (progressing through impaired judgment, agitation, disorientation, confusion, lethargy, and coma), dyspnea, increase in blood pressure, changes in heart rate, dysrhythmias, central cyanosis (late sign), diaphoresis, and cool extremities. Hypoxemia can lead to hypoxia, a decrease in oxygen supply to the tissues and cells, which can be life threatening if left untreated. 4. The nurse knows that one of the following blood chemistry values is NOT essential to monitoring heart function: a. Phosphate (2.5-4.5 mg/dL) b. Calcium (8.6-10.2 mg/dL) c. Magnesium (1.3-2.3 mEq/dL) d. Potassium (3.5-5 mEq/dL) - Correct Answers: a. Rationale: Phosphate plays no role in cardiac function. -Calcium is necessary for blood coagulability, neuromuscular activity, and automaticity of the nodal cells (sinus and atrioventricular nodes). -Magnesium is necessary for the absorption of calcium, maintenance of potassium stores, and metabolism of adenosine triphosphate. -Potassium has a major role in cardiac electrophysiologic function. 5. The nurse knows that electrophysiologic testing is done primarily to: a. Determine the size, contour, and position of the heart b. Diagnose and determine the source of dysrhythmias c. Produce an image of the heart d. Evaluate myocardial blood flow and perfusion - Correct Answer: b. Rationale: The electrophysiology study (EPS) is an invasive procedure that plays a major role in the diagnosis and management of serious dysrhythmias. EPS may be indicated for patients with syncope, palpitations, or both, and for survivors of cardiac arrest from ventricular fibrillation. EPS does not determine the size, contour, and position of the heart; produce an image of the heart; or evaluate myocardial blood flow and perfusion. 1) Regarding PEEP (Positive End-Expiratory Pressure), which of the following are true: Select all that apply. a. it is the pressure maintained in the lungs at the end of expiration b. keeps the alveoli open at the end of expiration to maximize gas exchange c. PaCO2 values are greater than 50mmHg d. Normal value is 5-15 cm of H20 e. Normal value is 25-30cm of H20 - Answer: a, b, d Reasoning: As we learned in class the above underlined answers are true. The PaCO2 answer does not apply to PEEP and the values in the last answer are incorrect. The normal value should be 5-15 cm of H20. 2) How can a mechanical ventilator affect the cardiac system? a. Delivers high levels of PEEP and increases the intra-thoracic pressure and the pressure in the chest can compress the heart b. Decreases intra-throacic pressure c. Delivers low levels of PEEP d. Delivers low levels of PEEP and decreases the intra-thoracic pressure and the pressure in the chest can compress the heart. - Answer: a Rationale: Indications for hemodynamic monitoring are decreased cardiac output, deficient fluid volume and excess fluid volume. Ineffective tissue perfusion can also be an option but increased cardiac output is not a indication for use of hemodynamic monitoring. 1. What are some of the benefits of a tracheostomy tube vs endotracheal tube? Select all that apply: a. Decreased need for sedation b. Decreased oxygenation requirements c. Increased comfort d. Ease of taking patient on an off ventilator without risk e. Easier insertion - Answer: a, c, d Rationale: Patients who cannot be separated from the ventilator for prolonged periods of time eventually require tracheostomy placement in order to reduce the risk of complications from long-term use of an endotracheal tube. Tracheostomy tubes also offer the benefits of decreased sedation needs, increased patient comfort, increased chances for the patient to eat or speak, ease of patient transfer and ease of taking the patient on and off the ventilator without the need for reintubation and its associated risks if they fail a period of spontaneous breathing. 2. What is the term that is used to describe the intervention where an ET tube is inserted into a patient's airway? a. Intrusive ventilation b. Invasive ventilation c. Aggressive ventilation d. Internal ventilation - Answer: b Rationale: There are two forms of mechanical ventilation: -invasive mechanical ventilation, in which an endotracheal tube is inserted in the patient's airway -noninvasive ventilation 3. Which of the following is not involved in the ethics advisory committee when determining whether a case of continued life-sustaining therapy is inappropriate or harmful? a. Physician b. Clergy c. Friends d. All of the above can be involved - Answer: d Rationale: A 3-phase review process by the institution's ethics advisory committee to determine whether a case of continued life-sustaining therapy is inappropriate or harmful: -Review by members of the committee -Review including the care team -Review including patient and/or supporting individuals, including surrogate and possibly clergy, friends, etc. 4. Which of the following are indications for the use of a small-volume nebulizer? Select all that apply: a. Secretions b. Ineffective breathing and coughing c. Decreased Sp02 d. Unsuccessful trials of other means of clearing airway - Answer: a, b, d Rationale: Indications for the use of a small-volume nebulizer include difficulty in clearing respiratory secretions, reduced vital capacity with ineffective deep breathing and coughing, and unsuccessful trials of simpler and less costly methods for clearing secretions, delivering aerosol, or expanding the lungs 5. (True or False) The cuff on the tracheostomy or endotracheal tube should be deflated when the patient is receiving mechanical ventilation a. True b. False - Answer: b Rationale: The cuff on an endotracheal or tracheostomy tube should be inflated if the patient requires mechanical ventilation or is at high risk for aspiration. 1. The cuff on an endotracheal tube should be inflated to what pressure? a. 5-10 psi b. 15-20 mm Hg c. 8-12 mm Hg d. 3-5 psi - Answer: b Rationale: If the cuff on an endotracheal tube is underinflated, hypoxia or aspiration become very real possibilities. An overinflated cuff can cause tracheal bleeding, ischemia, and pressure necrosis. Great care for the proper pressure must be taken in order for proper functioning and to avoid injury. 2. In addition to respiratory failure or a compromised airway, what are some clinical indications that would corroborate the need for endotracheal intubation and mechanical ventilation. Select all that apply. a. a continuous decrease in oxygenation (PaO2) b. a worsening of crackles in the lower lobes of the lungs c. an increase in arterial carbon dioxide levels (PaCO2) d. a persistent acidosis (decreased pH) - Answer: a, c, d Rationale: A decrease in PaO2 signifies poor oxygenation and perfusion. An increase in PaCO2 demonstrates that gas exchange in the lungs has become inefficient. A persistent acidosis (respiratory) indicates that the build up of CO2 in the lungs. All three of these scenarios are further evidence for the need to intubate. Worsening crackles in the lower lobes of the lungs could be involved in a case in which mechanical ventilation is needed, but it is not a strong indicator of the need for intubation. 3. What does decreased pulse pressure reflect? a. tachycardia b. reduced distensibility of the arteries c. reduced stroke volume d. elevated stroke volume - Answer: c Rationale: Decreased pulse pressure reflects reduced stroke volume and ejection velocity or obstruction to blood flow during systole. Increased pulse pressure would indicate reduced distensibility of the arteries, along with bradycardia. 4. The client with a diagnosis of heart failure reports frequently awakening during the night with the need to urinate. The nurse offers which explanation? a. edema is collected in dependent extremities during the day; at night when the client lays down, it is reabsorbed into the circulation and excreted by the kidneys. b. when the client is in the recumbent position, more pressure is put on the bladder with the result of increased need to urinate. c. the blood pressure is lower when the client is recumbent and this causes the kidneys to work harder; therefore, more urine is produced. d. fluid that is held in the lungs during the day becomes part of the circulation at night and the kidneys produce an increased amount of urine. - Answer: a Rationale: Nocturia is common in patients with heart failure. Fluid collected in dependent areas during the day is reabsorbed into the circulation at night when the client is recumbent. The kidneys excrete more urine with the increased circulating volume. 5. The nurse is reviewing the results of the patient's echocardiogram and observes that the ejection fraction is 35%. The nurse anticipates that the patient will receive treatment for what condition? a. pulmonary embolism b. myocardial infarction c. pericarditis d. heart failure - Answer: d Rationale: An ejection fraction of less than 40% indicates that the patient has decreased left ventricular function and likely requires treatment for heart failure. 1. What is hemodynamic monitoring? a. Use of pressure monitoring devices to directly measure cardiovascular function b. Invasive procedure used to measure cardiac chamber pressures and assess patency of coronary arteries c. Test used to evaluate functioning of the heart during a period of increased oxygen demand d. Process of continuous electrocardiographic monitoring by the transmission of radio waves from a battery-operated transmitter - Answer: a Rationale: -b. refers to cardiac catheterization -c. refers to cardiac stress test -d. refers to telemetry 2. Men typically develop coronary artery disease (CAD) later than women. a. True d. INCORRECT: Although proper hand hygiene and the use of gloves have been shown to reduce the risk of VAP, prophylactic intravenous antibiotic therapy is not recommended. A broad-spectrum antibacterial oral rinse (chlorhexidine) has been used in conjunction with thorough oral care with good results. 4. The nurse is caring for a man who was involved in an auto accident the previous day. The client has a double-lumen tracheostomy tube with a cuff. Which of the following actions should the nurse perform? a. Changing the tracheostomy dressing every 8 hours and PRN. b. Change the tracheostomy ties every 48 hours. c. Keep the inner cannula of the tracheostomy in place at all times. d. Push the outer cannula back in if it accidently "blows outs." - Answer: a a. CORRECT: Changing the tracheostomy dressing should be done every 8 hours and PRN to prevent infection; use pre-cut gauze pads. b. INCORRECT: Keep old ties on until new ties are in place; 1 finger space between tie and neck. c. INCORRECT: The tracheostomy tried should be removed and cleaned every 8 hours and PRN. d. INCORRECT: Do not reinsert the outer cannula, instead maintain open airway and contact the physician. 5. The nurse is preparing a female client for a cardiac catheterization with the femoral approach. The nurse should do which of the following when the client returns to her room after the procedure? a. Elevate the head of the bed 45 degrees. b. Keep the client's arm immobilized for the first 24 hours. c. Keep the client's leg immobilized for the first 12 hours. d. Tell the client to lie on the procedural side for 2 hours. - Answer: c a. INCORRECT: The head of the bed should be elevated to no more than 30 degrees to reduce the risk of bleeding and promote healing. b. INCORRECT: The arm is immobilized if the brachial approach is used. c. CORRECT: The affected leg is immobilized for the first 12 hours to prevent hemorrhage. d. INCORRECT: The client should be instructed to lie on her back for the first 12 hours to reduce the risk of bleeding and promote healing. 1. The low-pressure alarm sounds on a ventilator. A nurse assess the client and then attempts to determine the cause of the alarm. The nurse is unsuccessful in determining the cause of the alarm and takes what initial action? a. Administers oxygen b. Checks the clients vital signs c. Ventilates the client manually d. Starts cardiopulmonary resuscitation (CPR) - Answer: C Rationale: If at any time an alarm is sounding and the nurse cannot quickly ascertain the problem, the client is disconnected from the ventilator and manual resuscitation is used to support respirations until the problem can be corrected. No reason is given to begin CPR. Checking vital signs is not the initial action. Although oxygen is helpful, it will not provide ventilation to the client. 2. A client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A nurse checks the client when the high pressure alarm on the ventilator sounds, and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of: a. Right pneumothorax b. Pulmonary Embolism c. Displaced EndoTracheal Tube d. Acute Respiratory distress syndrome (ARDS) - Answer: A Rationale: Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left main stem bronchi. 3. The nurse is caring for a client who is taking Digoxin (Lanoxin) and wants to monitor for adverse effects. Which findings are characteristics of digoxin toxicity? Select all that apply. a. Tremors b. Diarrhea c. Irritability d. Blurred vision e. Nausea and vomiting - Answer: b, d, e Rationale: Digoxin is a cardiac glycoside. The risk of toxicity can occur with the use of this medication. Toxicity can lead to life-threatening events and the nurse needs to monitor the client closely for signs of toxicity. Early signs of toxicity include gastrointestinal problems such as anorexia, nausea, vomiting and diarrhea. Subsequent manifestations include headache, visual disturbances like diplopia, blurred vision, halos, drowsiness, fatigue and weakness. Cardiac rhythm abnormalities can also occur. The nurse also monitor the digoxin level. Therapeutic levels for digoxin range from 0.5 to 2 mg/ml. 4. When planning care for a patient on a mechanical ventilator, the nurse understands that the application of positive end-expiratory pressure (PEEP) to the ventilator settings has which therapeutic effect? a. Increased inflation of the lungs b. Prevention of barotrauma to the lung tissue c. Prevention of alveolar collapse during expiration d. Increased fraction of inspired oxygen concentration (FIO2) administration - Answer: c Rationale: PEEP is positive pressure that is applied to the airway during exhalation. This positive pressure prevents the alveoli from collapsing, improving oxygenation and enabling a reduced FIO2 requirement. PEEP does not cause increased inflation of the lungs or prevent barotrauma. Actually auto-PEEP resulting from inadequate exhalation overtime may contribute to barotrauma. 5. The nurse is caring for a patient with an endotracheal tube (ET). Which of the following nursing interventions is contraindicated? a. Deflating the cuff prior to tube removal b. Deflating the cuff routinely c. Checking the cuff pressure every 6 to 8 hours d. Ensuring that humidified oxygen is always introduced through the tube. - Answer: b Rationale: Routine cuff deflation is not recommended because of the increased risk for aspiration and hypoxia. The cuff is deflated before the ET is removed. Cuff pressures should be checked every 6 to 8 hours. Humidified oxygen should always be introduced through the tube. 1. A patient is being mechanically ventilated with an oral endotracheal tube in place. The nurse observes that the cuff pressure is 25 mmHg. Which of the following is NOT a potential complication associated with this cuff pressure? a. Tracheal ischemia b. Aspiration pneumonia c. Tracheal bleeding d. Pressure necrosis - Answer: b Rationale: Complications can occur from pressure exerted by the cuff on the tracheal wall. Cuff pressures should be maintained between 15 and 20 mm Hg. -High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis -Low cuff pressure can increase the risk of aspiration pneumonia. 2. A patient in the ICU has been orally incubated and on a mechanical ventilator for 2-weeks after having a severe stroke. What action does the nurse anticipate the physician will take now that the patient has been intubated for this length of time? a. The pt will have a tracheostomy tube inserted b. The pt will require manual ventilation hence forth c. The pt will be extubated & allowed to breathe on their own d. The pt will remain orally intubated and no action is necessary - Answer: a Rationale: Endotracheal intubation may be used for no longer than 14 to 21 days, by which time a tracheostomy must be considered to decrease irritation of and trauma to the tracheal lining, to reduce the incidence of vocal cord paralysis (secondary to laryngeal nerve damage), and to decrease the work of breathing. 3. A patient is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this patient? a. Endotracheal intubation b. Continuous positive airway pressure (CPAP) c. Bi-level positive airway pressure (Bi-PAP) d. Corticosteroid inhaler - Answer: b synchronized intermittent mandatory ventilation (SIMV) sets the peak inflation pressure and respiratory rate but doesn't specify the tidal volume. - Pressure control ventilation - tidal volume received by the pt varies based on the compliance of the respiratory system and the level of airway resistance. allows unrestricted, spontaneous breaths throughout the ventilatory cycle; on inspiration the patient receives a preset level of continuous positive airway pressure, and pressure is periodically released to aid expiration - airway pressure release ventilation (APRV) completely controls the patient's ventilation; rarely used except in paralyzed or anesthetized patients - continuous mandatory ventilation (CMV) combination of mechanically assisted breaths and spontaneous breaths - intermittent mandatory ventilation (IMV) preset positive pressure is delivered with spontaneous breaths to decrease work of breathing - pressure support ventilation (PSV) partial ventilatory support in proportion to the patient's inspiratory efforts; decreases the work of breathing - proportional assist ventilation (PAV) positive pressure applied throughout the respiratory cycle to a spontaneously breathing patient to promote alveolar and airway stability; may be administered with endotracheal or tracheostomy tube or by mask - continuous positive airway pressure (CPAP) medical futility - interventions that are unlikely to produce any significant benefit for the patient HCP need to provide to respiratory therapy and nursing for ventilator management - - mode of mechanical ventilation, the tidal volume, respiratory rate, inspired oxygen concentration (FiO2) and level of Positive End Expiratory Pressure - Need a Foley catheter, feeding tube, OG - prevent aspiration and instill tube feeding/bypass the gag reflex, some type of sedation, - patient's IDEAL weight because tidal volume is based on the patient's IDEAL body weight in an assisted Control Method of ventilation. How RR impacts the patient condition - incorrect respiratory rate can cause respiratory acidosis or alkalosis. It can also worsen the pH. Also a factor in determining tidal volume. If tidal volume is miscalculated, there will be a ventilation and perfusion mismatch (V/Q mismatch). Respiratory rate can be lowered to decrease the minute ventilation. FiO2 - fraction of inspired oxygen. - ideal FiO2 = 0.21 - FiO2 is typically kept below 0.5 (50%) to avoid oxygen toxicity When invasive ventilation is not enough to improve oxygenation, what other options does the team have to increase it? - - Positioning (Prone) - use gravity - Inhaled pulmonary vasodilator medications - vasodilates only in areas of the lung that receive adequate ventilation. - Administer bolus and/or drip of paralytic medication (vecuronium). The paralytic agent eliminates any muscular activity on the part of the patient which decreases oxygen consumption. It also eliminates any patient respiratory effort which might be contributing to dysynchrony with the ventilator and either ineffective ventilation or increased oxygen consumption. CVP - monitors the pressure in the vena cava, right atrium, pre-load. Used to determine hydration status and right sided heart failure Pulmonary Artery Pressure - monitors right atrial, pulmonary artery systolic and diastolic pressures, mean pulmonary MAP and pulmonary wedge pressures. Used to determine left ventricular fill pressures Arterial lines - continual blood pressure measurements Advance Directives Act of 1999 (TADA) - This act outlines a clear process for resolving futility disputes when a patient or surrogate requests life-sustaining treatment that the treating physician or health care facility believes to be ineffective, inappropriate, or futile