Exam 2: Mechanical Ventilation (NCLEX)
2023, Answered
The peak pressure alarm is sounding on the ventilator of the client with a recent
tracheostomy. What intervention should be done first?
A. Assess the client's respiratory status
B. Decrease the sensitivity of the alarm
C. Ensure that the connecting tubing is not kinked
D. Suction the client
A
The client must always be assessed before attention is turned to equipment.
The client with respiratory failure has been intubated and placed on a ventilator
and is requiring 100% oxygen delivery to maintain adequate oxygenation. Twenty-
four hours later, the nurse notes new-onset crackles and decreased breath
sounds, and the most recent ABGs show a PaO2 level of 95 mm Hg. The
ventilator is not set to provide positive end-expiratory pressure (PEEP). Why is
the nurse concerned?
A. The low PaO2 level may result in oxygen toxicity
B. The 100% oxygen delivery requirement indicates immediate extubation
C. Lung sounds may indicate absorption atelectasis
D. The level of oxygen delivery may indicate absorption atelectasis
C
High levels of oxygen delivery can result in collapsed alveoli and absorption atelectasis.
PEEP can help alveoli remain properly inflated.
The medical nurse is creating the care plan of an adult patient requiring
mechanical ventilation. What nursing action is most appropriate?
A) Keep the patient in a low Fowlers position.
B) Perform tracheostomy care at least once per day.
C) Maintain continuous bedrest.
D) Monitor cuff pressure every 8 hours.
D
The acute medical nurse is preparing to wean a patient from the ventilator. Which
assessment parameter is most important for the nurse to assess?
A) Fluid intake for the last 24 hours
B) Baseline arterial blood gas (ABG) levels
C) Prior outcomes of weaning
D) Electrocardiogram (ECG) results
B
A patient recovering from thoracic surgery is on long-term mechanical ventilation
and becomes very frustrated when he tries to communicate. What intervention
should the nurse perform to assist the patient?
, A) Assure the patient that everything will be all right and that remaining calm is
the best strategy.
B) Ask a family member to interpret what the patient is trying to communicate.
C) Ask the physician to wean the patient off the mechanical ventilator to allow the
patient to speak freely.
D) Express empathy and then encourage the patient to write, use a picture board,
or spell words with an alphabet board.
D
The physician has ordered continuous positive airway pressure (CPAP) with the
delivery of a patients high-flow oxygen therapy. The patient asks the nurse what
the benefit of CPAP is. What would be the nurses best response?
A) CPAP allows a higher percentage of oxygen to be safely used.
B) CPAP allows a lower percentage of oxygen to be used with a similar effect.
C) CPAP allows for greater humidification of the oxygen that is administered.
D) CPAP allows for the elimination of bacterial growth in oxygen delivery
systems.
B
The nurse is caring for a patient who is ready to be weaned from the ventilator. In
preparing to assist in the collaborative process of weaning the patient from a
ventilator, the nurse is aware that the weaning of the patient will progress in what
order?
A) Removal from the ventilator, tube, and then oxygen
B) Removal from oxygen, ventilator, and then tube
C) Removal of the tube, oxygen, and then ventilator
D) Removal from oxygen, tube, and then ventilator
A
The critical care nurse and the other members of the care team are assessing the
patient to see if he is ready to be weaned from the ventilator. What are the most
important predictors of successful weaning that the nurse should identify?
A) Stable vital signs and ABGs
B) Pulse oximetry above 80% and stable vital signs
C) Stable nutritional status and ABGs
D) Normal orientation and level of consciousness
A
The nurse is caring for a client with an endotracheal tube who is on a ventilator.
When assessing the client, the nurse knows to maintain what cuff pressure to
maintain appropriate pressure on the tracheal wall?
A) Between 10 and 15 mm Hg
B) Between 15 and 20 mm Hg
C) Between 20 and 25 mm Hg
D) Between 25 and 30 mm Hg
2023, Answered
The peak pressure alarm is sounding on the ventilator of the client with a recent
tracheostomy. What intervention should be done first?
A. Assess the client's respiratory status
B. Decrease the sensitivity of the alarm
C. Ensure that the connecting tubing is not kinked
D. Suction the client
A
The client must always be assessed before attention is turned to equipment.
The client with respiratory failure has been intubated and placed on a ventilator
and is requiring 100% oxygen delivery to maintain adequate oxygenation. Twenty-
four hours later, the nurse notes new-onset crackles and decreased breath
sounds, and the most recent ABGs show a PaO2 level of 95 mm Hg. The
ventilator is not set to provide positive end-expiratory pressure (PEEP). Why is
the nurse concerned?
A. The low PaO2 level may result in oxygen toxicity
B. The 100% oxygen delivery requirement indicates immediate extubation
C. Lung sounds may indicate absorption atelectasis
D. The level of oxygen delivery may indicate absorption atelectasis
C
High levels of oxygen delivery can result in collapsed alveoli and absorption atelectasis.
PEEP can help alveoli remain properly inflated.
The medical nurse is creating the care plan of an adult patient requiring
mechanical ventilation. What nursing action is most appropriate?
A) Keep the patient in a low Fowlers position.
B) Perform tracheostomy care at least once per day.
C) Maintain continuous bedrest.
D) Monitor cuff pressure every 8 hours.
D
The acute medical nurse is preparing to wean a patient from the ventilator. Which
assessment parameter is most important for the nurse to assess?
A) Fluid intake for the last 24 hours
B) Baseline arterial blood gas (ABG) levels
C) Prior outcomes of weaning
D) Electrocardiogram (ECG) results
B
A patient recovering from thoracic surgery is on long-term mechanical ventilation
and becomes very frustrated when he tries to communicate. What intervention
should the nurse perform to assist the patient?
, A) Assure the patient that everything will be all right and that remaining calm is
the best strategy.
B) Ask a family member to interpret what the patient is trying to communicate.
C) Ask the physician to wean the patient off the mechanical ventilator to allow the
patient to speak freely.
D) Express empathy and then encourage the patient to write, use a picture board,
or spell words with an alphabet board.
D
The physician has ordered continuous positive airway pressure (CPAP) with the
delivery of a patients high-flow oxygen therapy. The patient asks the nurse what
the benefit of CPAP is. What would be the nurses best response?
A) CPAP allows a higher percentage of oxygen to be safely used.
B) CPAP allows a lower percentage of oxygen to be used with a similar effect.
C) CPAP allows for greater humidification of the oxygen that is administered.
D) CPAP allows for the elimination of bacterial growth in oxygen delivery
systems.
B
The nurse is caring for a patient who is ready to be weaned from the ventilator. In
preparing to assist in the collaborative process of weaning the patient from a
ventilator, the nurse is aware that the weaning of the patient will progress in what
order?
A) Removal from the ventilator, tube, and then oxygen
B) Removal from oxygen, ventilator, and then tube
C) Removal of the tube, oxygen, and then ventilator
D) Removal from oxygen, tube, and then ventilator
A
The critical care nurse and the other members of the care team are assessing the
patient to see if he is ready to be weaned from the ventilator. What are the most
important predictors of successful weaning that the nurse should identify?
A) Stable vital signs and ABGs
B) Pulse oximetry above 80% and stable vital signs
C) Stable nutritional status and ABGs
D) Normal orientation and level of consciousness
A
The nurse is caring for a client with an endotracheal tube who is on a ventilator.
When assessing the client, the nurse knows to maintain what cuff pressure to
maintain appropriate pressure on the tracheal wall?
A) Between 10 and 15 mm Hg
B) Between 15 and 20 mm Hg
C) Between 20 and 25 mm Hg
D) Between 25 and 30 mm Hg
