Mechanical Ventilation Exam Questions And
Answers Verified 100% Correct
What precautions should the nurse take during mouth care and
repositioning of an oral ET tube to prevent and detect tube
dislodgement (select all that apply)?
a. Confirm bilateral breath sounds after care.
b. Use suction pressures less than 120 mm Hg.
c. Use humidified inspired gas to help thin secretions.
d. One staff member holds the tube and another performs care.
e. Move secretions into larger airways with turning every 2 hours. -
ANSWER -a. Confirm bilateral breath sounds after care.
d. One staff member holds the tube and another performs care.
To prevent dislodgement of the oral ET tube during care, 2 nurses
work together; one holds the tube while it is unsecured and the other
performs care. After completion of care, confirm the presence of
bilateral breath sounds to ensure that the position of the tube was not
changed and reconfirm cuff pressure. Suction pressure <120 mm Hg
will prevent tracheal mucosal damage. Humidified inspired gas helps
thin secretions. Secretions are moved to larger airways with turning,
postural drainage, and percussion. None of these other actions will
prevent or detect tube dislodgement.
What are appropriate nursing interventions to decrease the risk for
aspiration for a patient with an oral ET tube (select all that apply)?
a. Assess gag reflex.
b. Suction the patient's mouth frequently. c. Ensure that the cuff is
properly inflated. d. Keep the ventilator tubing cleared of
condensed water.
,e. Raise the head of the bed 30 to 45 degrees unless the patient is
unstable. - ANSWER -b. Suction the patient's mouth frequently.
c. Ensure that the cuff is properly inflated.
e. Raise the head of the bed 30 to 45 degrees unless the patient is
unstable.
Because the patient with an ET tube cannot protect the airway from
aspiration and cannot swallow, the cuff should always be inflated and
the head of the bed (HOB) elevated while the patient is receiving tube
feedings or mouth care is being done. The HOB elevated 30 to 45
degrees reduces risk of aspiration. The mouth and oropharynx should
be suctioned with Yankauer or tonsil suction to remove accumulated
secretions that cannot be swallowed. Clearing the ventilatory tubing
of condensed water is important to prevent ventilator-associated
pneumonia (VAP
Priority Decision: Although his oxygen saturation is above 92%, an
orally intubated, mechanically ventilated patient is restless and very
anxious. What interventions will most likely decrease the risk of
accidental extubation (select all that apply)?
a. Administer sedatives.
b. Have a caregiver stay with the patient.
c. Obtain an order and apply soft wrist restraints.
d. Remind the patient that he needs the tube inserted to breathe.
e. Move the patient to an area close to the nurses' station for closer
observation. - ANSWER -a. Administer sedatives.
b. Have a caregiver stay with the patient.
(Lecture states restraints as well)
, Sedation may be appropriate. As well, having someone the patient
knows at the bedside talking to him and reassuring him may decrease
his anxiety and calm him. Restraints have not been shown to be an
absolute deterrent to self-extubation, and the patient will need
ongoing and frequent assessment of need. Reminding the patient of
the need for the tube may help, but it may not be enough to prevent
him from pulling out the tube if he becomes extremely anxious.
Moving the patient near the nurses' station will not be enough to
prevent self-extubation because it can be done so quickly.
Which patient's medical diagnoses should the nurse know are most
likely to need mechanical ventilation (select all that apply)?
a. Sleep apnea
b. Cystic fibrosis
c. Acute kidney injury
d. Type 2 diabetes
e. Acute respiratory distress syndrome (ARDS) - ANSWER -b. Cystic
fibrosis
e. Acute respiratory distress syndrome (ARDS)
Cystic fibrosis and acute respiratory distress syndrome (ARDS) are
the most likely of these diagnoses to need mechanical ventilation
related to severe hypoxia or respiratory muscle fatigue. Other
indications for mechanical ventilation are apnea or impending
inability to breathe and acute respiratory failure.
What characteristics describe positive pressure ventilators (select all
that apply)? a. Require an artificial airway
b. Applied to outside of the body
c. Most similar to physiologic ventilation
Answers Verified 100% Correct
What precautions should the nurse take during mouth care and
repositioning of an oral ET tube to prevent and detect tube
dislodgement (select all that apply)?
a. Confirm bilateral breath sounds after care.
b. Use suction pressures less than 120 mm Hg.
c. Use humidified inspired gas to help thin secretions.
d. One staff member holds the tube and another performs care.
e. Move secretions into larger airways with turning every 2 hours. -
ANSWER -a. Confirm bilateral breath sounds after care.
d. One staff member holds the tube and another performs care.
To prevent dislodgement of the oral ET tube during care, 2 nurses
work together; one holds the tube while it is unsecured and the other
performs care. After completion of care, confirm the presence of
bilateral breath sounds to ensure that the position of the tube was not
changed and reconfirm cuff pressure. Suction pressure <120 mm Hg
will prevent tracheal mucosal damage. Humidified inspired gas helps
thin secretions. Secretions are moved to larger airways with turning,
postural drainage, and percussion. None of these other actions will
prevent or detect tube dislodgement.
What are appropriate nursing interventions to decrease the risk for
aspiration for a patient with an oral ET tube (select all that apply)?
a. Assess gag reflex.
b. Suction the patient's mouth frequently. c. Ensure that the cuff is
properly inflated. d. Keep the ventilator tubing cleared of
condensed water.
,e. Raise the head of the bed 30 to 45 degrees unless the patient is
unstable. - ANSWER -b. Suction the patient's mouth frequently.
c. Ensure that the cuff is properly inflated.
e. Raise the head of the bed 30 to 45 degrees unless the patient is
unstable.
Because the patient with an ET tube cannot protect the airway from
aspiration and cannot swallow, the cuff should always be inflated and
the head of the bed (HOB) elevated while the patient is receiving tube
feedings or mouth care is being done. The HOB elevated 30 to 45
degrees reduces risk of aspiration. The mouth and oropharynx should
be suctioned with Yankauer or tonsil suction to remove accumulated
secretions that cannot be swallowed. Clearing the ventilatory tubing
of condensed water is important to prevent ventilator-associated
pneumonia (VAP
Priority Decision: Although his oxygen saturation is above 92%, an
orally intubated, mechanically ventilated patient is restless and very
anxious. What interventions will most likely decrease the risk of
accidental extubation (select all that apply)?
a. Administer sedatives.
b. Have a caregiver stay with the patient.
c. Obtain an order and apply soft wrist restraints.
d. Remind the patient that he needs the tube inserted to breathe.
e. Move the patient to an area close to the nurses' station for closer
observation. - ANSWER -a. Administer sedatives.
b. Have a caregiver stay with the patient.
(Lecture states restraints as well)
, Sedation may be appropriate. As well, having someone the patient
knows at the bedside talking to him and reassuring him may decrease
his anxiety and calm him. Restraints have not been shown to be an
absolute deterrent to self-extubation, and the patient will need
ongoing and frequent assessment of need. Reminding the patient of
the need for the tube may help, but it may not be enough to prevent
him from pulling out the tube if he becomes extremely anxious.
Moving the patient near the nurses' station will not be enough to
prevent self-extubation because it can be done so quickly.
Which patient's medical diagnoses should the nurse know are most
likely to need mechanical ventilation (select all that apply)?
a. Sleep apnea
b. Cystic fibrosis
c. Acute kidney injury
d. Type 2 diabetes
e. Acute respiratory distress syndrome (ARDS) - ANSWER -b. Cystic
fibrosis
e. Acute respiratory distress syndrome (ARDS)
Cystic fibrosis and acute respiratory distress syndrome (ARDS) are
the most likely of these diagnoses to need mechanical ventilation
related to severe hypoxia or respiratory muscle fatigue. Other
indications for mechanical ventilation are apnea or impending
inability to breathe and acute respiratory failure.
What characteristics describe positive pressure ventilators (select all
that apply)? a. Require an artificial airway
b. Applied to outside of the body
c. Most similar to physiologic ventilation
