A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube

Last UpdatedMarch 5, 2024

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Abstract. A nurse is caring for a patient who is receiving mechanical ventilation via endotracheal tube. increase FiO2 setting d. The nurse asks the health care provider whether this process should be delayed temporarily, based on administration of which medication to the client in the last hour?, The nurse is caring for a client who is anxious Together they are caring for a patient who has a tracheostomy tube and is receiving mechanical ventilation. Which of the following should the nurse expect to find in the bundle? a. Which of the following actions should the nurse take? A. To prevent ventilator-associated pneumonia (VAP), which action is most important to include in the plan of care? A. Blood pressure B. To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care? a. ) Excess secretions B. Vesicular sounds, In which order would the nurse take these actions when suctioning a client who is receiving mechanical ventilation through an endotracheal tube? 1 Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is receiving mechanical ventilation when the low pressure alarm sounds. Which of the following assessments is the best method for the nurse to use to determine the effectiveness of the current treatment regimen? A. Communicate: Patients on mechanical ventilators are usually looked after by an interprofessional group of healthcare professionals that may include an intensivist, critical care nurse, nutritionist, infectious disease consult, respiratory therapist, primary care Tidal volume of 8. Choices B, C, and D are incorrect. The plan of care for the tube would include which nursing intervention? Verify that an inner cannula is in place. b) Nasogastric tube placement. Which of the following actions should the nurse take first? Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has asthma and is receiving albuterol for which of the following adverse effects should the nurse monitor the client. The patient has subcutaneous emphysema on the upper a) Cover the chest tube insertion site opening with petroleum gauze, and apply pressure. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs? 1. " b. Room temperature B. Assess the client's airway. It is most important for the nurse to assess for: Symmetry of the client's chest expansion. B)Daily arterial blood gases (ABGs) are necessary. 17 hours ago · Study with Quizlet and memorize flashcards containing terms like When a client has a right pneumothorax, which type of breath sounds will the nurse expect to hear on the right chest? 1. Endotracheal tube. A nurse is caring for a client receiving mechanical ventilation via an endotracheal tube. c. Hyperoxygenate the patient before The sounding of a ventilator alarm has no relationship to the apical pulse. Perform oral care once per shift C. 17 hours ago · A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube. Assess for secretion clearance. 1) The nurse suctions the patient's airway when she hears noisy respirations. inflates the cuff until the pilot balloon is firm. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is 9 days postoperative following a total laryngectomy. biting on the endotracheal tube, A nurse is Apply an occlusive dressing and notify the physician. 1)Hyperventilate the client. Urinary retention. a. , A nurse is caring for a patient undergoing mechanical ventilation who is also receiving positive end-expiratory pressure (PEEP). -Monitor the The nurse is preparing to suction the client's endotracheal tube using a closed suctioning system. Increase suctioning frequency to every hour. To decrease alveolar volume 3. 8° F) to 37° C (98. VAP in critically ill patients is an adverse outcome and a national patient-safety concern. Give enteral feedings at no more than 10 mL/hr. The nurse notes thick, white secretions in the endotracheal tube (ET) of a patient who is receiving mechanical ventilation. The client will be too sedated to be aware of the details of care. C) Check ventilator connections. Administer Observe for symmetrical chest movement. Change the tracheostomy tube every week. Never apply suctioning while inserting the catheter. Apply mittens if self-extubation is attempted B. Respiratory rate of 24 breaths per minute D. Mar 11, 2011 · Patients receiving mechanical ventilation are more likely to develop hospital-acquired infections than those who aren’t. Suction the endotracheal tube. Review the nursing actions and match them with the appropriate rationale. d) 10 to 15 seconds. The client is able to make sounds. -Monitor the A client is brought to the emergency department in acute respiratory distress. An elevated temperature is a manifestation of dehydration. Monitor the pressure in the cuff at least every 8 hours. Which of the following assessments is the nurse's priority. This article reviews the top five evidence-based nursing practices for reducing VAP risk in critically ill adults. Pale skin C. which piece of information are critical to communicate to the next nurse who will be caring for this client? a. inject air into the cuff until a manometer shows 15 mm Hg pressure. Monitor ventilator settings as needed D. Following the administration of sumatriptan, the nurse should monitor for _____ due to the risk of _____. 2. D)Assess breath sounds every 1-2 hrs. The client's history includes chronic obstructive pulmonary disease (COPD) and coronary artery disease. ) Biting on the endotracheal tube, a nurse is The nurse is caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotracheal tube. Monitor ventilator settings every 8 hours. The nurse removes the client's NG tube and initiates oral feedings. A nurse is caring for a client who is in the fourth stage of labor and is receiving oxytocin via continuous IV infusion. Inflate the cuff until the pilot balloon is firm on palpation. Which intervention should the nurse prepare for the client? a) Intubation with mechanical ventilation. D) Call the physician. Ensure all connections are patent. Therefore, they need to know about all aspects of providing ventilatory support. Place the following steps in the correct order. Insert the catheter without suction. 1. Suction the endotracheal tube every 2 Sep 8, 2020 · Issues of Concern. inflate the cuff until the pilot balloon is firm on palpation. Determine if the tube is kinked. Check the function of the suction catheter. Arterial blood gases D. Compare the nurses's time management skills to the skills of coworkers. Answered step-by-step. The nurse reports which of the following signs immediately if experienced by the client. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has acute respiratory distress syndrome (ARDS), and requires mechanical ventilation. 2)Turn the catheter safety cap to enable the suction button. . Assess oxygen saturation, bilateral breath sounds Don sterile gloves. In Brief. The nurse should recognize that which of the following complications is associated with long-term mechanical ventilation? Elevated blood pressure Dehydration Stress ulcers Hypernatremia A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. The nurse should assess the breath sounds of a client on mechanical ventilation every 1-2 hours. Review the nurses' notes and the client's vital signs. Caregivers should be encouraged to provide stimulation and diversion. To inflate the cuff of an endotracheal tube (ET) when the patient is on mechanical ventilation, the nurse. Same patient. Hypotension E. Apply a vest restraint if self-extubation is attempted. hydroxyzine B. 4) The nurse asks that another nurse help her while she changes the tracheostomy ties for the first time. Increasing the oxygen percentage and ventilating with a handheld mechanical ventilator wouldn't correct the airflow blockage. D)The cough reflex is The nurse is caring for a client admitted to the critical care unit with multiple traumatic injuries sustained in a motor vehicle collision. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is unconscious and has a breathing pattern A m nurse is providing Teaching to a parent of a child who has a permanent tracheostomy tube. A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39. Vesicular sounds, In which order would the nurse take these actions when suctioning a client who is receiving mechanical ventilation through an endotracheal tube? 1 The nurse notes thick, white secretions in the endotracheal tube (ET) of a patient who is receiving mechanical ventilation. d) Notify the physician. Because of these history findings, the nurse closely monitors the oxygen flow and the client's respiratory status. Stridor B. What action should the critical care nurse recommend when caring for the cuff? -Deflate the cuff overnight to prevent tracheal tissue trauma. Which of the following statements should the nurse make? a. Increase respiratory rate setting b. What is the nurse's first action? a. 5 mL/kg. A nurse is caring for a client in the emergency department. B) Monitor ventilator settings every 8 hr. What would the nurse recognize as a disadvantage of endotracheal tubes? A)Cognition is decreased. b. Bradycardia D. A) Apply a vest restraint if self-extubation is attempted. C) Document tube placement in centimeters at the angle of jaw. The client has an endotracheal tube present with the cuff inflated to 15 mm Hg. Asked by luxurybix. Vital signs: Blood pressure 148/90, heart rate 122, respiratory rate 30, and SpO2 is 88% on room air. Monitor the pressure in the cuff at least every 8 hours b. Suction the client's mouth. The endotracheal tube should be retaped every 24 hours, not every 12 hours, to prevent skin breakdown and to ensure that the tube is secured properly. Abdominal bloating. Question. Assess breath sounds every 1 to 2 hours. Add additional water to the patient's enteral feedings. The client appears anxious and restless, and the high-pressure alarm is sounding. A client with an oral endotracheal tube attached to a mechanical ventilator is about to begin the weaning process. Rationale: Ventilator connections should be check initially and loose connections or disconnections should be fixed. 4. b) 20 to 25 seconds. If the patient has a tracheostomy, check that the ties or Velcro straps are secure and that the stoma appears healthy. Apply suction for up to 10 seconds. The nurse asks the health care provider whether this process should be delayed temporarily, based on administration of which medication to the client in the last hour? Click the card to flip 👆. Hyperoxygenate the client. Administer ordered antibiotics as scheduled. . The settings include fraction of inspired oxygen (FIO2) of 80%, tidal volume of 450, rate of 16/minute, and positive end-expiratory pressure (PEEP) of 5 cm. To prevent ventilator-associated pneumonia (VAP), which action is most important to include in the plan of care? a. Steps: 1. , A nurse is caring for a client who has a tracheostomy tube and who is undergoing mechanical ventilation. Elevate the client's head of bed. Ask another staff nurse to evaluate the nurse's time management skills. The nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement, by: using the minimal-leak technique with cuff pressure less than 25 cm H2O. Mechanical ventilation (MV) is a complex, labor-intensive, often life-saving process that requires a knowledgeable team to manage. C)Slight tracheal bleeding is anticipated. Check cuff inflation on the endotracheal tube. Which ofthe following actions should the nrse 17 hours ago · Dim the lights in the clients room. Confusion B. The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. 9% sodium chloride irrigation. 3)Grasp the catheter and advance it to the predetermined length. Instructions to place the client in a supine position. Apply suction while rotating the catheter. "It is no longer possible for you to choke on or A nurse is implementing the ventilator care bundle for a client who is receiving mechanical ventilation. The nurse is caring for a client who is receiving mechanical ventilation via an endotracheal (ET) tube and is unable to speak. A nurse is caring for a patient with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation using synchronized intermittent mandatory ventilation (SIMV). Maintain regular notes about the nurses's time management skills. Review client satisfaction reports about the nurses' performance. D) Assess breath sounds every 1-2 hours. The nurse should recognize that which of the following complications is associated with long-term mechanical ventilation? Elevated blood pressure Dehydration Stress ulcers Hypernatremia Respiratory Care Modalities. D. Wheezing 3. verapamil, The psychiatric nurse knows that which of the following medications are often used in the treatment of panic A nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Answer: C- Check ventilator connections. Prepare for patient extubation c. When providing care for a client receiving mechanical ventilation through an endotracheal tube, which collaborative action would the nurse anticipate when the client's partial pressure of end-tidal carbon dioxide (PETCO2) is 60 mm Hg? a. A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis. Choice A is correct. B) Put air into the endotracheal tube cuff. 10 to 15 seconds. Most patients undergoing mechanical ventilation may benefit from the application of PEEP at 5 cm H2O to limit the atelectasis that frequently accompanies endotracheal intubation, sedation, paralysis, and/or supine positioning. Despite recent initiatives to measure complications of mechanical ventilation and a decrease in incidence over the past few years, VAP remains an issue for critically ill adults, with mortality estimated as high as 10%. Which nursing action is the priority? 1 Reposition the patient 2 Auscultate lung sounds 3 Reposition the endotracheal (ET) tube 4 Ensure the airway is a) 30 to 35 seconds. What is a cardinal sign of lung cancer?, For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan?, A nurse reading a chart notes that the client had a Mantoux skin test 2. This is one finding that indicates successful endotracheal A nurse is caring for an older adult client with pneumonia experiencing dyspnea. Deflate the cuff overnight to The nurse is caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotracheal tube. A. After a client is intubated, the ETT tube can be attached to a mechanical ventilator to deliver oxygen and breaths to the client, which allows the client’s respiratory muscles to rest to promote healing and recovery. Nurses play a critical role in caring for adults receiving MV. Which prescription from the primary healthcare physician (PHCP) should the nurse anticipate? A. Purulent discharge. ) clean the stoma with 0. The client has a 6 on the Glasgow Coma Scale (GCS). Instructions on how to change ventilator settings. , A nurse in the emergency room is caring for a client who is experiencing acute respiratory failure which of the following laboratory findings should the nurse expect Arterial pH A nurse is attempting to wean a client after 2 days on the mechanical ventilator. , Which action would the nurse take to maintain proper endotracheal tube (ET) cuff pressure when a patient is on mechanical ventilation? a. Identify the sequence of steps the parent should follow to perform tracheostomy care. ) Hyperoxygenate the patient before D. The client's family is frightened that the client has a permanent loss of their voice. Care Essentials for Patients on Mechanical Ventilation. Which of the following actions should the nurse take first? A. which of the following situations should the nurse recognize as a possible cause of the alarm? A. The nurse recognizes that this medication is for which of the following purposes?, A nurse is observing the closed chest drainage system of a client who is 24 B. For safety, certain key features of mechanical ventilation are vital. What action should the critical care nurse recommend when caring for the cuff? Click the card to flip 👆. Amount of vaginal bleeding. The international normalized ratio (INR) is 6. Applying suction for 30 to 35 seconds is hazardous and may result in A nurse is caring for a client who is in acute respiratory failure and is receiving mechanical ventilation. 4° C). Elevate head of bed to 30 to 45 degrees. artificial airway cuff leak d. 17 hours ago · A client who has a temperature of 39° C (102° F) This temperature is greater than the expected reference range of 36° C (96. The nurse is unable to determine the cause of the alarm. PaO2 of 64 mm Hg. 9. Which of the following situations should the nurse recognize as a possible cause of the alarm? a. injects air into the cuff until a manometer shows 15 mm Hg pressure. If the client is unconscious, place him or her in the lateral Telemetry detects the ability of cardiac cells to generate a spontaneous and repetitive electrical impulse through the heart muscle. The artificial airway of the ventilator or the endotracheal (ET) tube can transmit microorganisms to the lungs. Heart rate A) Manually ventilate the client. To expand collapsed alveoli 2. Which intervention will most directly treat this finding? a. excess secretions b. Call the health care provider. experiencing respiratory distress, the nrse is unable to determine the cause pf the alarm. Oxygen saturation levels are 91%. Respiratory NCLEX. A nurse is planning to insert an indwelling catheter for a female client. 17 hours ago · The nurse is caring for a client who has a tracheostomy tube and is receiving mechanical ventilation. Occasional pink-tinged sputum C. rivastigmine D. What action should the critical care nurse recommend when caring for the cuff? a. Which assessment finding by the nurse indicates that the PEEP may need to be reduced? a. What is the rationale for these interventions? A client receiving mechanical ventilation is very anxious and agitated, and neuromuscular blocking agents are used to promote ventilation. The patient's PaO2 is 50 mm Hg and the SaO2 is 88%. A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. ) Artificial airway cuff leak D. Decreased sounds 4. c) Wipe the chest tube with alcohol and reinsert. Maintain a patent airway. inflate the cuff with a minimum of 10 mL of air. b) Auscultate the lung fields for breath sounds. ) Kinks in the tubing C. Metrics. Get a hint. Crackling 2. The ETT keeps the airway patent in order for oxygen to reach the client’s lungs. Reposition the patient every 1 to 2 hours. Study with Quizlet and memorize flashcards containing terms like A client with an oral endotracheal tube attached to a mechanical ventilator is about to begin the weaning process. These include the following actions: 1. PEEP increases end-expired lung volume and reduces airspace closure at the end of expiration. 2) The nurse inflates the trach cuff to 30 cm H2O. Study with Quizlet and memorize flashcards containing terms like A client with myasthenia gravis is receiving continuous mechanical ventilation. Question 5 of 10. A nurse is caring for a client who has dyspnea and will receive oxygen continuously. ) Administer ordered antibiotics as scheduled. Mechanical ventilation can be used in the A. A nrse is caring for a client receiving mechanical ventilation via an endotracheal tube The high pressure alarmis beeping and the. )Switch the patient to a nonrebreather mask at 95% to 100% fraction of inspired oxygen (FIO2) and call the health care provider to discuss the patient's status. The nurse is performing nasotracheal suctioning of a client. a nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube and has a gastrostomy tube for enteral feedings. Auscultate the lungs. Listen to the client's lung sounds. Which interventions should be included to prevent aspiration in this client? Select all that apply. An upper airway obstruction is impairing the patient's ventilation. A nurse must keep a bag valve mask for a client receiving mechanical ventilation at the bedside. Use all options. The client pulls out his endotracheal tube. Administer Rationale: The nurse should obtain the assistance of a second person to perform this procedure to help prevent accidental extubation. 3) The nurse ensures that there is an obturator at the patient's bedside. "Tuck your chin when you swallow so you won't choke. 3. C. Which pieces of information are critical to communicate to the next nurse who will be caring for this client? (Select all that apply. Suctioning is required frequently. Verify that a low-pressure cuff is in place. Med-Surg. Study with Quizlet and memorize flashcards containing terms like The nurse caring for a patient with an endotracheal tube recognizes several disadvantages of an endotracheal tube. A nurse is caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP). c) 0 to 5 seconds. The high pressure alarm is beeping and the client is experiencing respiratory distress. Capillary refill C. The client receives a prescription for pancuronium. A nurse is caring for a client who Resp. Listen carefully to the client. The nurse has suctioned the client with return of small amounts of thin white mucus. Study with Quizlet and memorize flashcards containing terms like a nurse is caring for a client who's receiving mechanical ventilation when the low-pressure alarm sounds. B. Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client receiving mechanical ventilation. kinks in the tubing c. Together they are caring for a client who has a tracheostomy tube and is receiving mechanical ventilation. The nurse asks the health care provider whether this process should be delayed temporarily, based on administration of which medication to the client in the last hour? A patient diagnosed with acute respiratory distress syndrome who is endotracheally intubated on mechanical ventilation has a decreasing oxygen saturation level with an increasing heart rate. Study with Quizlet and memorize flashcards containing terms like When a client has a right pneumothorax, which type of breath sounds will the nurse expect to hear on the right chest? 1. ) A. Which of the following are early clinical manifestations of hypoxemia? Select all that apply. Immediately after intubation, the nurse should check for symmetry of chest expansion. Nursing; Nursing questions and answers; 128. Advance the catheter until resistance is met and then pull the catheter back 1cm. Drag one condition and one client finding to fill in each blank in the following sentence. Inflate the cuff with a minimum of 10 mL of air. A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube and has a gastrostomy tube for enteral feedings. 17 hours ago · During assessment of a client with acute respiratory distress syndrome (ARDS), the nurse notes an oxygen saturation of 78% and a respiratory rate of 28 breaths/min. d. 6° F). This allows the nurse to promptly ventilate the client if there is a power failure or significant difficulty with mechanical ventilation. After endotracheal (ET) intubation and initiation of mechanical ventilation, the client is transferred to the intensive care unit. A client in acute respiratory distress is brought to the emergency department. Instructions on mouth care. Elevated blood pressure, A nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Prepare the client for reintubation. ) remove the inner cannula. -Inflate the cuff to the highest possible pressure in order to prevent aspiration. A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Document tube placement in centimeters at the angle of jaw. Apply intermittent suction while rotating and withdrawing the catheter. A nurse is caring for a patient who is orally intubated and receiving mechanical ventilation. ⦁ Raise the head of the bed to 45 degrees prior to insertion. using a cuffed Which of the following are early clinical manifestations of hypoxemia? Select all that apply. )change the tracheostomy collar. Click the card to flip 👆. Document tube placement in centimeters at the lips The practical nurse is assisting the registered nurse in creating a care plan for a client who is intubated, on mechanical ventilation, and receiving continuous enteral tube feedings via a small-bore nasogastric tube. Which of the following information should the nurse include in the teaching? To maintain proper cuff pressure of an endotracheal tube (ET) when the patient is on mechanical ventilation, the nurse should. Clean the tracheostomy once a day. Which one of these questions is most appropriate for the nurse to ask at this time?, The nurse is assessing a client who is receiving mechanical ventilation with Together they are caring for a patient who has a tracheostomy tube and is receiving mechanical ventilation. pantoprazole C. The client's skin and mucous membranes are light pink. Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client who developed GI bleeding 3 weeks after a diagnosis of pulmonary embolism (PE). The nurse recognizes that A. ⦁ Secure the catheter to the client's inner thigh. Per policy, note endotracheal (ET) tube position (centimeters) and confirm that it is secure. inflates the cuff with a minimum of 10 mL of air. The critical care nurse is precepting a new nurse on the unit. The nurse recognizes that the purpose of PEEP is: 1. The nurse notifies the healthcare provider and should prepare for intubation using which type of airway? Tracheostomy. 4)Depress the suction button Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has just been diagnosed with lung cancer. , The nurse is caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotracheal tube. In general, the nurse should apply suction no longer than 10 to 15 seconds because hypoxia and dysrhythmias may develop, leading to cardiac arrest. Lung sounds are clear. Which of the following actions should the nurse plan to take? ⦁ Collect urine specimen from the drainage bag 1 hr after insertion. When the high-pressure alarm on the ventilator sounds, what should the nurse do?, A client with a respiratory condition is receiving oxygen therapy. The nurse is caring for a client who is intubated with an endotracheal tube and on a mechanical ventilator. The provider has been attempting to intubate for 40 seconds. Study with Quizlet and memorize flashcards containing terms like 1) A nurse is caring for a patient with ARDS. The nurse is assisting a physician with an endotracheal intubation for a client in respiratory failure. A nurse is assisting the health care provider who is intubating a client. A few basilar crackles on the A male client admitted to an acute care facility with pneumonia is receiving supplemental oxygen, 2 L/minute via nasal cannula. Study with Quizlet and memorize flashcards containing terms like A nurse is working with a client immediately after removal of the endotracheal tube following a radical neck dissection. Before suctioning the ET tube, the nurse hyperventilates and hyperoxygenates the client. xh io gm or my my cf nw gg ye