Author Question: The nurse is caring for a patient with a subarachnoid hemorrhage who is intubated and placed on a ... (Read 81 times)

CharlieWard · **on:** Jun 25, 2018

The nurse is caring for a patient with a subarachnoid hemorrhage who is intubated and placed on a mechanical ventilator with 10 cm H2O of peak end-expiratory pressure (PEEP).

When monitoring the patient, the nurse will need to notify the health care provider immediately if the patient develops
a. oxygen saturation of 93.
b. respirations of 20 breaths/minute.
c. green nasogastric tube drainage.
d. increased jugular venous distention.

Question 2

The nurse educator is evaluating the performance of a new registered nurse (RN) who is providing care to a patient who is receiving mechanical ventilation with 15 cm H2O of peak end-expiratory pressure (PEEP).

Which action indicates that the new RN is safe?
a. The RN plans to suction the patient every 1 to 2 hours.
b. The RN uses a closed-suction technique to suction the patient.
c. The RN tapes connection between the ventilator tubing and the ET.
d. The RN changes the ventilator circuit tubing routinely every 48 hours.

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

Answer to Question 1

ANS: D
Increases in jugular venous distention in a patient with a subarachnoid hemorrhage may indicate an increase in intracranial pressure (ICP) and that the PEEP setting is too high for this patient. A respiratory rate of 20, O2 saturation of 93, and green nasogastric tube drainage are within normal limits.

Answer to Question 2

ANS: B
The closed-suction technique is used when patients require high levels of PEEP (>10 cm H2O) to prevent the loss of PEEP that occurs when disconnecting the patient from the ventilator. Suctioning should not be scheduled routinely, but it should be done only when patient assessment data indicate the need for suctioning. Taping connections between the ET and the ventilator tubing would restrict the ability of the tubing to swivel in response to patient repositioning. Ventilator tubing changes increase the risk for ventilator-associated pneumonia (VAP) and are not indicated routinely.