Author Question: Which assessment finding obtained by the nurse when caring for a patient receiving mechanical ... (Read 81 times)

james · **on:** Jun 25, 2018

Which assessment finding obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning?

a. The patient's oxygen saturation is 93.
b. The patient was last suctioned 6 hours ago.
c. The patient's respiratory rate is 32 breaths/minute.
d. The patient has occasional audible expiratory wheezes.

Question 2

To maintain proper cuff pressure of an endotracheal tube (ET) when the patient is on mechanical ventilation, the nurse should

a. inflate the cuff with a minimum of 10 mL of air.
b. inflate the cuff until the pilot balloon is firm on palpation.
c. inject air into the cuff until a manometer shows 15 mm Hg pressure.
d. inject air into the cuff until a slight leak is heard only at peak inflation.

kardosa007 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: C
The increase in respiratory rate indicates that the patient may have decreased airway clearance and requires suctioning. Suctioning is done when patient assessment data indicate that it is needed, not on a scheduled basis. Occasional expiratory wheezes do not indicate poor airway clearance, and suctioning the patient may induce bronchospasm and increase wheezing. An oxygen saturation of 93 is acceptable and does not suggest that immediate suctioning is needed.

Answer to Question 2

ANS: D
The minimal occluding volume technique involves injecting air into the cuff until an air leak is present only at peak inflation. The volume to inflate the cuff varies with the ET and the patient's size. Cuff pressure should be maintained at 20 to 25 mm Hg. An accurate assessment of cuff pressure cannot be obtained by palpating the pilot balloon.