Author Question: The nurse is caring for a patient who is intubated and receiving positive pressure ventilation to ... (Read 39 times)

@Brianna17 · **on:** Jun 25, 2018

The nurse is caring for a patient who is intubated and receiving positive pressure ventilation to treat acute respiratory distress syndrome (ARDS). Which finding is most important to report to the health care provider?

a. Blood urea nitrogen (BUN) level 32 mg/dL
b. Red-brown drainage from orogastric tube
c. Scattered coarse crackles heard throughout lungs
d. Arterial blood gases: pH 7.31, PaCO2 50, PaO2 68

Question 2

Which nursing interventions included in the care of a mechanically ventilated patient with acute respiratory failure can the registered nurse (RN) delegate to an experienced licensed practical/vocational nurse (LPN/LVN) working in the intensive care unit?

a. Assess breath sounds every hour.
b. Monitor central venous pressures.
c. Place patient in the prone position.
d. Insert an indwelling urinary catheter.

SamMuagrove · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: B
The nasogastric drainage indicates possible gastrointestinal bleeding and/or stress ulcer, and should be reported. The pH and PaCO2 are slightly abnormal, but current guidelines advocating for permissive hypercapnia indicate that these would not indicate an immediate need for a change in therapy. The BUN is slightly elevated but does not indicate an immediate need for action. Adventitious breath sounds are commonly heard in patients with ARDS.

Answer to Question 2

ANS: D
Insertion of indwelling urinary catheters is included in LPN/LVN education and scope of practice and can be safely delegated to an LPN/LVN who is experienced in caring for critically ill patients. Placing a patient who is on a ventilator in the prone position requires multiple staff, and should be supervised by an RN. Assessment of breath sounds and obtaining central venous pressures require advanced assessment skills and should be done by the RN caring for a critically ill patient.