A patient being mechanically ventilated is exhibiting hypoxia, ...

[Lisaclaire]

A patient being mechanically ventilated is exhibiting hypoxia, with a pulse oximeter reading of 88. After ensuring the integrity of the ventilator tubing and assessing the patient, the nurse auscultates adventitious lung sounds.
 
  Which action should the nurse take next?
 
  1. suctioning the patient
  2. contacting the physician
  3. turning the patient to one side
  4. silencing the alarm

Question 2

The chest x-ray of a patient who was recently intubated shows the endotracheal tube located in the right bronchus. What does the nurse recognize related to this finding?
 
  1. The tube needs to be withdrawn slightly.
  2. The tube needs to be inserted further.
  3. The tube is correctly placed.
  4. The tube is incorrectly attached to the ventilator.

[Pswine]

Answer to Question 1

Correct Answer: 1
When the tubing integrity is intact and the pulse oximeter reading falls to 88 with adventitious breath sounds, the patient needs to be suctioned. The physician will not need to be contacted unless the nursing actions are unsuccessful at resolving the hypoxia. Turning the patient on the side has no purpose. Silencing the alarm will not resolve the issue.

Answer to Question 2

Correct Answer: 1
The right bronchus is easy to intubate due to the anatomy of the lung. If the tube is in the right bronchus, it will need to be withdrawn slightly so that both lungs can be ventilated. The tube is not correctly placed or incorrectly attached to the ventilator and does not need to be inserted further.

[Lisaclaire]

Excellent

[juliaf]

TYSM