The nurse is caring for a patient on mechanical ventilation. The ...

[theo]

The nurse is caring for a patient on mechanical ventilation. The nurse determines that the endotracheal tube is properly placed by which assessment?
 
  a. Auscultating both lungs and watching the rise and fall of both sides of the chest
  b. Monitoring and comparing the blood pressure in both arms
  c. Observing and measuring inspiratory and expiratory rates
  d. Checking the settings on the ventilator and the low-pressure and high-pressure alarm settings

Question 2

The nurse is caring for a patient on a mechanical ventilator and the low-pressure alarm sounds. Which action by the nurse is most appropriate?
 
  a. Assess for secretions in the airway and suction the patient.
  b. Administer a sedative to the patient to prevent coughing.
  c. Assess the endotracheal tube cuff to make sure it is deflated.
  d. Check the ventilator tubing and reconnect if disconnected.

[1_Step_At_ATime]

Answer to Question 1

A
Verify placement of the endotracheal tube by auscultating the lungs and assessing chest wall symmetry. This ensures that the tube has not migrated into the right main stem bronchus. Many factors can cause blood pressure fluctuations and fluctuations in respiratory rate. Always assess the patient first. Once the patient is determined to be safe, the settings for the ventilator alarm can be checked as well.

Answer to Question 2

D
The low-pressure alarm sounds when the ventilator has no resistance to inflating the lung. The patient may be disconnected from the ventilator, or a leak may have developed in the ventilator circuit. The high-pressure alarm sounds when the ventilator has met resistance to delivery of the tidal volume. This may result from coughing, increased secretions, or biting on the endotracheal tube. The cuff of the endotracheal tube is inflated to create a seal for positive-pressure ventilation. A cuff that is leaking could cause the low-pressure alarm to sound.

[theo]

TYSM

[Joy Chen]

Gracias!