(Please select only one answer for each of the following questions)
1. While assessing a patient who is receiving mechanical ventilation through an ET tube, the nurse notes an increase in peak airway pressure and thick beige secretions. What is the most appropriate nursing action? Go to
Question 2
A. Sedate the patient before suctioning and assess whether airway pressure decreases.
B. Elevate the head of the bed and increase the set tidal volumes to decrease peak pressure.
C. Suction secretions from the patient’s airway using the closed-system technique and call for a chest radiograph immediately.
D. Hyperoxygenate by increasing the FIO2 on the ventilator and suction secretions from the patient’s airway using the closed-system technique.
2. The nurse is caring for a patient receiving mechanical ventilation with the following ventilator settings: FIO2, 80%; PEEP, +20 cm H2O; tidal volume, 500 ml; and a rate of 16 bpm. During open suctioning, the nurse notes a decrease in oxygen saturation from 95% to 85%. Before further suctioning attempts, what is the FIRST action the nurse should take? Go to
Question 3
A. Switch to a closed-suction or in-line suction system.
B. Stop suctioning and hyperoxygenate the patient for 30 to 60 seconds.
C. Obtain a PEEP valve for the MRB.
D. Instill normal saline solution into the ET tube.
3. When establishing a plan of care for a patient with cystic fibrosis who is intubated, what is the most important action for the nurse to consider? Go to
Question 4
A. Suctioning secretions every 2 hours, elevating the head of the bed, and hyperoxygenating before and after suctioning
B. Suctioning secretions hourly using normal saline to loosen secretions and using an in-line suction setup
C. Instilling normal saline solution before suctioning to loosen secretions and promote postural drainage and using the open-suction technique to decrease the risk for tracheal mucosa damage
D. Preoxygenating before suctioning, providing suction when the patient’s clinical status indicates the need, and promoting postural drainage
4. A nurse is caring for a patient with a tracheostomy. Which of the following actions would be appropriate? Go to
Question 5
A. Administering humidified oxygen to the patient
B. Using a special-tipped catheter to reduce the risk of mucosal damage
C. Discontinuing suctioning if the patient exhibits coughing
D. Hyperoxygenating the patient with a self-inflating manual resuscitation bag (MRB), using a catheter that is two-thirds of the diameter of the tracheostomy tube
5. A patient with a tracheostomy tube is receiving mechanical ventilation. The nurse notes a decrease in the patient’s oxygen saturation, an increase in peak airway pressure, and frequent coughing episodes. What is the most appropriate nursing action? Go to
Question 6
A. Hyperoxygenate the patient for 30 to 60 seconds by increasing the FIO2 on the ventilator to 100% and provide closed-system suctioning until the tube is clear (but not longer than 10 to 15 seconds).
B. Hyperoxygenate the patient with a mechanical sigh breath, instill sterile normal saline solution, and provide rigorous suction.
C. Preoxygenate the patient with an MRB, suction for 10 seconds, and then hyperoxygenate for 30 seconds.
D. Hyperoxygenate the patient for 30 seconds with an MRB and suction secretions with a coude catheter.
6. During suctioning of secretions from a patient who is intubated, the patient develops cardiac arrhythmias, with an acute drop in oxygen saturation. What is the nurse’s priority in this situation? Go to
Question 7
A. Continue the suction process while instilling lidocaine into the ET tube to decrease bronchospasm and prevent cardiac arrhythmias and desaturation.
B. Change to an in-line suction system for better removal of secretions.
C. Discontinue suction and hyperoxygenate the patient using ventilator-supplied 100% oxygen.
D. Continue the suction process to clear the airway and improve oxygenation, leading to improved cardiac status.
7. The nurse has just completed a single suction pass for a patient with an artificial airway. What is the next priority nursing action? Back to Top
A. Reassess the patient to determine the effectiveness of the intervention.
B. Document the procedure in the patient’s record.
C. Perform hand hygiene.
D. Perform nasal and oropharyngeal suctioning.
(โปรดเลือกเพียงหนึ่งคำตอบสำหรับแต่ละคำถามต่อไปนี้) 1. ขณะประเมินผู้ป่วยที่ได้รับเครื่องระบายผ่านท่อร้อยเอ็ด พยาบาลบันทึกการเพิ่มขึ้นของความดันสูงจำกัด(มหาชน)และหลั่งหนาสีเบจ ปฏิบัติการพยาบาลที่เหมาะสมที่สุดคืออะไร ลุยเลยคำถาม 2อ. sedate ผู้ป่วยก่อน suctioning และประเมินว่าลดความดันทำB. ยกระดับพันธมิตรหัวเตียง และเพิ่มวอลุ่มดาลชุดลดแรงดันสูงสุดC. ดูดจากทำให้ผู้ป่วยใช้เทคนิคระบบปิด และโทรทรวงอกทันทีD. Hyperoxygenate โดยการเพิ่ม FIO2 บนหลั่งระบายและดูดจากทำให้ผู้ป่วยใช้เทคนิคระบบปิด2 พยาบาล.มีเสน่ห์สำหรับผู้ป่วยที่รับเครื่องระบายอากาศ ด้วยค่าระบายต่อไปนี้: FIO2, 80% แอบดู +20 cm H2O ปริมาณดาล 500 ml และอัตราของ 16 bpm ระหว่าง suctioning เปิด พยาบาลบันทึกลดลงออกซิเจนความเข้มจาก 95% เป็น 85% ก่อนเพิ่มเติม suctioning ความพยายาม การดำเนินการแรกพยาบาลคืออะไรควรใช้ ลุยเลยคำถาม 3A. การสลับไปยังระบบดูด ดูดปิด หรือในบรรทัดB. หยุด suctioning และ hyperoxygenate ผู้ป่วย 30-60 วินาทีค.รับวาล์ว PEEP สำหรับ MRBD. ปลูกฝังน้ำเกลือปกติเป็นหลอด ET3. เมื่อกำหนดแผนการดูแลสำหรับผู้ป่วยด้วยโบรซิสที่เป็น intubated อะไรคือการดำเนินการที่สำคัญที่สุดสำหรับพยาบาลพิจารณา ลุยเลยQuestion 4A. Suctioning secretions every 2 hours, elevating the head of the bed, and hyperoxygenating before and after suctioningB. Suctioning secretions hourly using normal saline to loosen secretions and using an in-line suction setupC. Instilling normal saline solution before suctioning to loosen secretions and promote postural drainage and using the open-suction technique to decrease the risk for tracheal mucosa damageD. Preoxygenating before suctioning, providing suction when the patient’s clinical status indicates the need, and promoting postural drainage4. A nurse is caring for a patient with a tracheostomy. Which of the following actions would be appropriate? Go toQuestion 5A. Administering humidified oxygen to the patientB. Using a special-tipped catheter to reduce the risk of mucosal damageC. Discontinuing suctioning if the patient exhibits coughingD. Hyperoxygenating the patient with a self-inflating manual resuscitation bag (MRB), using a catheter that is two-thirds of the diameter of the tracheostomy tube5. A patient with a tracheostomy tube is receiving mechanical ventilation. The nurse notes a decrease in the patient’s oxygen saturation, an increase in peak airway pressure, and frequent coughing episodes. What is the most appropriate nursing action? Go toQuestion 6A. Hyperoxygenate the patient for 30 to 60 seconds by increasing the FIO2 on the ventilator to 100% and provide closed-system suctioning until the tube is clear (but not longer than 10 to 15 seconds).B. Hyperoxygenate the patient with a mechanical sigh breath, instill sterile normal saline solution, and provide rigorous suction.C. Preoxygenate the patient with an MRB, suction for 10 seconds, and then hyperoxygenate for 30 seconds.D. Hyperoxygenate the patient for 30 seconds with an MRB and suction secretions with a coude catheter.6. During suctioning of secretions from a patient who is intubated, the patient develops cardiac arrhythmias, with an acute drop in oxygen saturation. What is the nurse’s priority in this situation? Go toQuestion 7A. Continue the suction process while instilling lidocaine into the ET tube to decrease bronchospasm and prevent cardiac arrhythmias and desaturation.B. Change to an in-line suction system for better removal of secretions.C. Discontinue suction and hyperoxygenate the patient using ventilator-supplied 100% oxygen.D. Continue the suction process to clear the airway and improve oxygenation, leading to improved cardiac status.7. The nurse has just completed a single suction pass for a patient with an artificial airway. What is the next priority nursing action? Back to TopA. Reassess the patient to determine the effectiveness of the intervention.B. Document the procedure in the patient’s record.C. Perform hand hygiene.D. Perform nasal and oropharyngeal suctioning.
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