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Lewis's Medical-Surgical Nursing (12th Ed)
Respiratory Bundle: Chapters 28, 30, & 32
(Ventilation, Lower Respiratory, ARDS)
Contents
Lewis Chapter 28 supporting ventilation ........................................................................................ 2
Chapter 30: Lower Respiratory Problems Harding: Lewis’s Medical-Surgical Nursing, 12th
Edition ........................................................................................................................................... 20
Chapter 32: Acute Respiratory Failure and Acute Respiratory Distress Syndrome Harding:
Lewis's Medical-Surgical Nursing ................................................................................................ 52
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Lewis Chapter 28 supporting ventilation
1. Which action would thenurse take to verify thecorrect placement of an oral endotracheal
tube (ET) immediately after insertion and before securing thetube?
a. Obtain a portable chest x-ray.
b. Use an end-tidal CO2 monitor.
c. Auscultate for bilateral breath sounds.
d. Observe for symmetrical chest movement.
Use an end-tidal CO2 monitor.
End-tidal CO2 monitors are currently recommended for rapid verification of ET placement.
Auscultation for bilateral breath sounds and checking chest expansion are also used, but they are
not as accurate as end-tidal CO2 monitoring. A chest x-ray confirms theplacement but is done
after thetube is secured.
Which action would the nurse take to maintain proper endotracheal tube (ET) cuff
pressure when a patient is on mechanical ventilation?
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.
. Inject air into the cuff until a slight leak is heard only at peak inflation.
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 patients
size. Cuff pressure should be maintained at 20 to 30 mm Hg. An accurate assessment of cuff
pressure cannot be obtained by palpating the pilot balloon.
The nurse notes premature ventricular contractions (PVCs) on the monitor while
suctioning a patients endotracheal tube. Which action would the nurse take?
a. Plan to suction the patient more frequently.
b. Decrease the suction pressure to 80 mm Hg.
c. Give antidysrhythmic medications per protocol.
d. Ventilate thepatient with 100% oxygen.
Ventilate the patient with 100% oxygen.
Dysrhythmias during suctioning may indicate hypoxemia or sympathetic nervous system
stimulation. the nurse should stop suctioning and ventilate the patient with 100% O2. There is no
indication that more frequent suctioning is needed. Lowering the suction pressure will decrease
the effectiveness of suctioning without improving the hypoxemia. Because thePVCs occurred
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during suctioning, there is no need for antidysrhythmic medications (which may have adverse
effects) unless they recur when the suctioning is stopped, and patient is well oxygenated.
Which assessment finding for a patient receiving mechanical ventilation indicates the need
for suctioning?
a. The patient was last suctioned 6 hours ago.
b. The patients oxygen saturation drops to 93%.
c. The patients respiratory rate is 32 breaths/min.
d. The patient has occasional audible expiratory wheezes.
. The patients respiratory rate is 32 breaths/min.
The increase in respiratory rate indicates that thepatient may have decreased airway clearance
and requires suctioning. Suctioning is done when patient assessment data indicate that it is
needed and not on a scheduled basis. Occasional expiratory wheezes do not indicate poor airway
clearance. Suctioning thepatient may induce bronchospasm and increase wheezing. An O2
saturation of 93% is acceptable and does not suggest that immediate suctioning is needed.
The nurse notes thick, white secretions in the endotracheal tube (ET) of a patient who is
receiving mechanical ventilation. Which intervention will most directly treat this finding?
a. Reposition the patient every 1 to 2 hours.
b. Increase suctioning frequency to every hour.
c. Add additional water to the patients enteral feedings.
d. Instill 5 mL of sterile saline into theET before suctioning.
Add additional water to the patients enteral feedings.
Because the patients secretions are thick, better hydration is indicated. Suctioning every hour
without any specific evidence for the need will increase the incidence of mucosal trauma and
would not address the etiology of the ineffective airway clearance. Instillation of saline does not
liquefy secretions and may decrease theSpO2. Repositioning the patient is appropriate but will
not decrease the thickness of secretions
Four hours after mechanical ventilation is initiated, a patient's arterial blood gas (ABG)
results include a pH of 7.51, PaO2 of 82 mm Hg, PaCO2 of 26 mm Hg, and HCO - of 23
mEq/L (23 mmol/L). What change should the nurse anticipate to the ventilator settings?
a. Increase theFIO2.
b. Increase the tidal volume.
c. Increase the respiratory rate.
d. Decrease the respiratory rate.
Decrease the respiratory rate
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The patients PaCO2 and pH indicate respiratory alkalosis caused by too high a respiratory rate.
thePaO2 is appropriate for a patient with COPD and increasing the respiratory rate and tidal
volume would further lower thePaCO2.
The nurse is weaning a patient who has chronic obstructive pulmonary disease (COPD)
and weighs 68-kg from mechanical ventilation. Which finding indicates that the weaning
protocol should be stopped?
a. The patients heart rate is 97 beats/min.
b. The patients oxygen saturation is 93%.
c. The patient respiratory rate is 32 breaths/min.
d. The patients spontaneous tidal volume is 450 mL.
The patient respiratory rate is 32 breaths/min.
Tachypnea is a sign that the patients work of breathing is too high to allow weaning to proceed.
the patients heart rate is within normal limits, but the nurse should continue to monitor it. An O2
saturation of 93% is acceptable for a patient with COPD. A spontaneous tidal volume of 450 mL
is within the acceptable range
The nurse responding to a ventilator alarm finds the patient lying in bed gasping and the
endotracheal tube on the floor. Which action would the nurse take next?
a. Activate the rapid response team.
b. Provide reassurance to the patient
c. Call the health care provider to reinsert the tube.
d. Manually ventilate the patient with 100% oxygen.
Manually ventilate the patient with 100% oxygen.
The nurse should ensure maximal patient oxygenation by manually ventilating with a bag-valve-
mask system. Offering reassurance to the patient, notifying the health care provider about the
need to reinsert the tube, and activating the rapid response team are also appropriate after the
nurse has stabilized the patients oxygenation.
The nurse notes that a patients endotracheal tube (ET), which was at the22-cm mark, is
now at the25-cm mark, and the patient is anxious and restless. Which action would the
nurse take next?
a. Check theO2 saturation.
b. Offer reassurance to the patient.
c. Listen to the patients breath sounds.
d. Notify the patients health care provider.
. Listen to the patients breath sounds.
Lewis's Medical-Surgical Nursing (12th Ed)
Respiratory Bundle: Chapters 28, 30, & 32
(Ventilation, Lower Respiratory, ARDS)
Contents
Lewis Chapter 28 supporting ventilation ........................................................................................ 2
Chapter 30: Lower Respiratory Problems Harding: Lewis’s Medical-Surgical Nursing, 12th
Edition ........................................................................................................................................... 20
Chapter 32: Acute Respiratory Failure and Acute Respiratory Distress Syndrome Harding:
Lewis's Medical-Surgical Nursing ................................................................................................ 52
,2|Page
Lewis Chapter 28 supporting ventilation
1. Which action would thenurse take to verify thecorrect placement of an oral endotracheal
tube (ET) immediately after insertion and before securing thetube?
a. Obtain a portable chest x-ray.
b. Use an end-tidal CO2 monitor.
c. Auscultate for bilateral breath sounds.
d. Observe for symmetrical chest movement.
Use an end-tidal CO2 monitor.
End-tidal CO2 monitors are currently recommended for rapid verification of ET placement.
Auscultation for bilateral breath sounds and checking chest expansion are also used, but they are
not as accurate as end-tidal CO2 monitoring. A chest x-ray confirms theplacement but is done
after thetube is secured.
Which action would the nurse take to maintain proper endotracheal tube (ET) cuff
pressure when a patient is on mechanical ventilation?
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.
. Inject air into the cuff until a slight leak is heard only at peak inflation.
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 patients
size. Cuff pressure should be maintained at 20 to 30 mm Hg. An accurate assessment of cuff
pressure cannot be obtained by palpating the pilot balloon.
The nurse notes premature ventricular contractions (PVCs) on the monitor while
suctioning a patients endotracheal tube. Which action would the nurse take?
a. Plan to suction the patient more frequently.
b. Decrease the suction pressure to 80 mm Hg.
c. Give antidysrhythmic medications per protocol.
d. Ventilate thepatient with 100% oxygen.
Ventilate the patient with 100% oxygen.
Dysrhythmias during suctioning may indicate hypoxemia or sympathetic nervous system
stimulation. the nurse should stop suctioning and ventilate the patient with 100% O2. There is no
indication that more frequent suctioning is needed. Lowering the suction pressure will decrease
the effectiveness of suctioning without improving the hypoxemia. Because thePVCs occurred
,3|Page
during suctioning, there is no need for antidysrhythmic medications (which may have adverse
effects) unless they recur when the suctioning is stopped, and patient is well oxygenated.
Which assessment finding for a patient receiving mechanical ventilation indicates the need
for suctioning?
a. The patient was last suctioned 6 hours ago.
b. The patients oxygen saturation drops to 93%.
c. The patients respiratory rate is 32 breaths/min.
d. The patient has occasional audible expiratory wheezes.
. The patients respiratory rate is 32 breaths/min.
The increase in respiratory rate indicates that thepatient may have decreased airway clearance
and requires suctioning. Suctioning is done when patient assessment data indicate that it is
needed and not on a scheduled basis. Occasional expiratory wheezes do not indicate poor airway
clearance. Suctioning thepatient may induce bronchospasm and increase wheezing. An O2
saturation of 93% is acceptable and does not suggest that immediate suctioning is needed.
The nurse notes thick, white secretions in the endotracheal tube (ET) of a patient who is
receiving mechanical ventilation. Which intervention will most directly treat this finding?
a. Reposition the patient every 1 to 2 hours.
b. Increase suctioning frequency to every hour.
c. Add additional water to the patients enteral feedings.
d. Instill 5 mL of sterile saline into theET before suctioning.
Add additional water to the patients enteral feedings.
Because the patients secretions are thick, better hydration is indicated. Suctioning every hour
without any specific evidence for the need will increase the incidence of mucosal trauma and
would not address the etiology of the ineffective airway clearance. Instillation of saline does not
liquefy secretions and may decrease theSpO2. Repositioning the patient is appropriate but will
not decrease the thickness of secretions
Four hours after mechanical ventilation is initiated, a patient's arterial blood gas (ABG)
results include a pH of 7.51, PaO2 of 82 mm Hg, PaCO2 of 26 mm Hg, and HCO - of 23
mEq/L (23 mmol/L). What change should the nurse anticipate to the ventilator settings?
a. Increase theFIO2.
b. Increase the tidal volume.
c. Increase the respiratory rate.
d. Decrease the respiratory rate.
Decrease the respiratory rate
, 4|Page
The patients PaCO2 and pH indicate respiratory alkalosis caused by too high a respiratory rate.
thePaO2 is appropriate for a patient with COPD and increasing the respiratory rate and tidal
volume would further lower thePaCO2.
The nurse is weaning a patient who has chronic obstructive pulmonary disease (COPD)
and weighs 68-kg from mechanical ventilation. Which finding indicates that the weaning
protocol should be stopped?
a. The patients heart rate is 97 beats/min.
b. The patients oxygen saturation is 93%.
c. The patient respiratory rate is 32 breaths/min.
d. The patients spontaneous tidal volume is 450 mL.
The patient respiratory rate is 32 breaths/min.
Tachypnea is a sign that the patients work of breathing is too high to allow weaning to proceed.
the patients heart rate is within normal limits, but the nurse should continue to monitor it. An O2
saturation of 93% is acceptable for a patient with COPD. A spontaneous tidal volume of 450 mL
is within the acceptable range
The nurse responding to a ventilator alarm finds the patient lying in bed gasping and the
endotracheal tube on the floor. Which action would the nurse take next?
a. Activate the rapid response team.
b. Provide reassurance to the patient
c. Call the health care provider to reinsert the tube.
d. Manually ventilate the patient with 100% oxygen.
Manually ventilate the patient with 100% oxygen.
The nurse should ensure maximal patient oxygenation by manually ventilating with a bag-valve-
mask system. Offering reassurance to the patient, notifying the health care provider about the
need to reinsert the tube, and activating the rapid response team are also appropriate after the
nurse has stabilized the patients oxygenation.
The nurse notes that a patients endotracheal tube (ET), which was at the22-cm mark, is
now at the25-cm mark, and the patient is anxious and restless. Which action would the
nurse take next?
a. Check theO2 saturation.
b. Offer reassurance to the patient.
c. Listen to the patients breath sounds.
d. Notify the patients health care provider.
. Listen to the patients breath sounds.
