Chapter 66: Critical Care Med Surg Questions Flashcards
What factor will cause a decrease in cardiac output (CO)?
a. Decreased afterload
b. Decreased heart rate (HR)
c. Increased stroke volume (SV)
d. Decreased systemic vascular resistance (SVR)
b. Decreased heart rate (HR) causes decreased cardiac output (CO). The other options contribute to an increased CO.
A comatose patient with a possible cervical spine injury is intubated with a nasal endotracheal (ET) tube. The nurse recognizes that what is a disadvantage of a nasal ET tube in comparison with an oral ET tube?
a. Requires the placement of a bite block
b. Is more likely to cause laryngeal trauma
c. Requires greater respiratory effort in breathing
d. Requires the placement of an additional airway to keep the trachea open
c. A nasal endotracheal (ET) tube is longer and smaller
in diameter than an oral ET tube, creating more airway resistance and increasing the work of breathing. Suctioning and secretion removal are also more difficult with nasal ET tubes and they are more subject to kinking than are oral tubes. Oral tubes require a bite block to stop the patient from biting the tube and may cause more laryngeal damage because of their larger size.
In preparing a patient in the ICU for oral ET intubation, what should the nurse do?
a. Place the patient supine with the head extended and the neck flexed.
b. Tell the patient that the tongue must be extruded while the tube is inserted.
c. Position the patient supine with the head hanging over the edge of the bed to align the mouth and trachea.
d. Inform the patient that while it will not be possible to talk during insertion of the tube, speech will be possible
after it is correctly placed.
a. The patient is positioned with the mouth, pharynx, and trachea in direct alignment, with the head extended in the “sniffing position,” but the head must not hang over the edge of the bed. The patient may be asked to extrude the tongue during nasal intubation. Speaking is not possible during intubation or while the oral ET tube is in place because the tube separates the vocal cords.
Priority Decision: A patient has an oral ET tube inserted to relieve an upper airway obstruction and to facilitate
secretion removal. What is the first responsibility of the nurse immediately following placement of the tube?
a. Suction the tube to remove secretions.
b. Place an end tidal CO2 detector on the ET tube.
c. Secure the tube to the face with adhesive tape.
d. Assess for bilateral breath sounds and symmetric chest movement.
b. The first action of the nurse is to use an end tidal CO2 detector. If no CO2 is detected, the tube is in the esophagus. The second action by the nurse following ET intubation is to auscultate the chest to confirm bilateral breath sounds and observe to confirm bilateral chest expansion. If this evidence is present, the tube is secured and connected to an O2 source. Then the placement is confirmed immediately with x-ray and the tube is marked where it exits the mouth. The patient should be suctioned as needed.
The nurse uses the minimal occluding volume technique to inflate the cuff on an ET tube to minimize the incidence of what?
a. Infection
b. Hypoxemia
c. Tracheal necrosis
d. Accidental extubation
c. The minimal occluding volume (MOV) involves adding air to the ET tube cuff until no leak is heard at peak inspiratory pressure but ensures that minimal pressure is applied to the tracheal wall to prevent pressure necrosis of the trachea. The MOV should be between 20 and 25 cm H2O of pressure to prevent tracheal injury. The cuff does not secure the tube in place but rather prevents escape of ventilating gases through the upper airway.
When suctioning an ET tube, the nurse should use a suction pressure of mm Hg.
100 to 120 mm Hg
The nurse suctions the patient’s ET tube when the patient has what?
a. Peripheral wheezes in all lobes
b. Has not been suctioned for 2 hours
c. Coarse rhonchi over central airways
d. A need for stimulation to cough and deep breathe
c. Suctioning an ET tube is performed when adventitious
sounds over the trachea or bronchi confirm the presence of secretions that can be removed by suctioning. Visible secretions in the ET tube, respiratory distress, suspected aspiration, increase in peak airway pressures, and changes in oxygen status are other indications. Peripheral wheezes or crackles are not an indication for suctioning. Suctioning as a means of inducing a cough is not recommended because of the complications associated with suctioning.
What nursing care is included for the patient with an ET tube?
a. Check the cuff pressure every hour.
b. Keep a tracheostomy tray at the bedside.
c. Hyperoxygenate before and after suctioning.
d. Reuse the suction catheter at the bedside for 24 hours.
c. Nursing care for a patient with an ET tube includes (1) hyperoxygenation before and after suctioning, (2) keeping suctioning equipment and a self-inflating bag-valve-mask (BVM) at the bedside, and (3) using either one-time
use sterile suction catheters for open suction technique
or a suction catheter that is enclosed in a plastic sleeve connected directly to the patient ventilator circuit, which
is changed per facility protocol for the closed suction technique. Used suction catheters are not left at the bedside.
Priority Decision: While suctioning the ET tube of a spontaneously breathing patient, the nurse notes that the patient develops bradycardia with premature ventricular contractions. What should the nurse do first?
a. Stop the suctioning and assess the patient for spontaneous respirations.
b. Attempt to resuction the patient with reduced suction pressure and pass time.
c. Stop the suctioning and ventilate the patient with slow, small-volume breaths using a bag-valve-mask (BVM) device.
d. Stop suctioning and ventilate the patient with a BVM device with 100% oxygen until the HR returns to baseline.
d. If new dysrhythmias occur during suctioning, the suctioning should be stopped and the patient should be slowly ventilated via BVM with 100% oxygen until the dysrhythmia subsides. Patients with bradycardia should not be suctioned excessively. Ventilation of the patient with slow, small-volume breaths using the BVM is performed when severe coughing results from suctioning.
What precautions should the nurse take during mouth care and repositioning of an oral ET tube to prevent and detect tube dislodgement (select all that apply)?
a. Confirm bilateral breath sounds after care.
b. Use suction pressures less than 120 mm Hg.
c. Use water swabs to prevent mucosal drying.
d. Use humidified inspired gas to help thin secretions.
e. One staff member holds the tube and one performs care.
f. Move secretions into larger airways with turning every 2 hours.
a, e. To prevent dislodgement of the oral ET tube during care, two nurses work together; one holds the tube while it is unsecured and the other performs care. After completion of care, confirm the presence of bilateral breath sounds to ensure that the position of the tube was not changed and reconfirm cuff pressure. Suction pressure less than 120 mm Hg will prevent tracheal mucosal damage. Although the use of water swabs prevents mucosal drying, humidified inspired gas helps to thin secretions. Secretions are moved to larger airways with turning, postural drainage, and percussion; these actions will not prevent or detect tube dislodgement.
A patient with an oral ET tube has a nursing diagnosis of risk for aspiration related to presence of artificial airway.
What are appropriate nursing interventions for this patient (select all that apply)?
a. Assess gag reflex.
b. Ensure that the cuff is properly inflated.
c. Suction the patient’s mouth frequently.
d. Keep the ventilator tubing cleared of condensed water.
e. Raise the head of the bed 30 to 45 degrees unless the patient is unstable.
b, c, e. Because the patient with an ET tube cannot protect the airway from aspiration and cannot swallow, the cuff should always be inflated and the head of the bed (HOB) elevated while the patient is receiving tube feedings or mouth care is being performed. The HOB elevated 30
to 45 degrees reduces risk of aspiration. The mouth and oropharynx should be suctioned with Yankauer or tonsil suction to remove accumulated secretions that cannot be swallowed. Clearing the ventilatory tubing of condensed water is important to prevent respiratory infection.
Priority Decision: Although his oxygen saturation is above 92%, an orally intubated, mechanically ventilated patient is restless and very anxious. What intervention should be used first to decrease the risk of accidental extubation?
a. Obtain an order and apply soft wrist restraints.
b. Remind the patient that he needs the tube inserted to breathe.
c. Administer sedatives and have a caregiver stay with the patient.
d. Move the patient to an area close to the nurses’ station for closer observation.
c. Sedation may be appropriate. As well, having someone the patient knows at the bedside talking to him and reassuring him may decrease his anxiety and calm him. Restraints have not been shown to be an absolute deterrent to self-extubation and the patient will need ongoing and frequent assessment of need. Reminding the patient of the need for the tube may help but it may not be enough to prevent him from pulling out the tube if he becomes extremely anxious. Moving the patient near the nurses’ station will not be enough to prevent self-extubation since it can be done quickly.
Which patient’s medical diagnosis should the nurse know is most likely to need mechanical ventilation (select all that apply)?
a. Sleep apnea
b. Cystic fibrosis
c. Acute kidney failure
d. Type 2 diabetes mellitus
e. Acute respiratory distress syndrome (ARDS)
b, e. Cystic fibrosis and acute respiratory distress syndrome (ARDS) are the most likely of these diagnoses to need mechanical ventilation related to severe hypoxia or respiratory muscle fatigue. Other indications for mechanical ventilation are apnea or impending inability to breathe and acute respiratory failure.
What characteristics describe positive pressure ventilators (select all that apply)?
a. Require an artificial airway
b. Applied to outside of the body
c. Most similar to physiologic ventilation
d. Most frequently used with acutely ill patients
e. Frequently used in the home for neuromuscular or nervous system disorders
a, d. Positive pressure ventilators require an artificial airway and are most frequently used with acutely ill patients. The other options describe negative pressure ventilators.
What is included in the description of positive pressure ventilation (select all that apply)?
a. Peak inspiratory pressure predetermined
b. Consistent volume delivered with each breath
c. Increased risk for hyperventilation and hypoventilation
d. Preset volume of gas delivered with variable pressure based on compliance
e. Volume delivered varies based on selected pressure and patient lung compliance
a, c, e. Positive pressure ventilation has a predetermined peak inspiratory pressure, which increases the risk for hyperventilation and hypoventilation because the volume delivered varies based on the selected pressure and the patient’s lung compliance. The other options describe volume ventilation.
