Mechanical Ventilation (NCLEX) 100% CORRECT SOLUTIONS 2023//2024

Mechanical Ventilation (NCLEX) 100% CORRECT SOLUTIONS 2023//2024 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 - ANSWER 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 - ANSWER 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. - ANSWER 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 - ANSWER 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. - ANSWER D