NUR 265 Exam 2
How is an ET tube placement confirmed? Correct Answer: From first to last
ETCO2 20-40mmHg
Chest symmetry
Listen to
... [Show More] left/right/abdomen
Chest X-Ray
Describe the A/C vent mode. Correct Answer: The vent does everything for the patient. It delivers a set amount of breaths per minute
Describe SIMV vent mode. Correct Answer: The pt attempts to breath and the vent assists with their breaths
What are the different ventilator settings? Correct Answer: Mode
FiO2
Rate
Tidal Volume (Vt)
PEEP
What is PEEP? Correct Answer: It is positive pressure that tells the alveoli in the lungs to stay open a little longer. It helps with gas exchange.
What are some complications of PEEP? Correct Answer: Pneumothorax
SubQ Emphysema (crepatus)
Decreased pre-load
What are the 3 buttons that a nurse is able to touch on a vent? Correct Answer: Silence
Restart
100% Oxygen (before suctioning a patient)
When is it acceptable to shut off a vent alarm? Correct Answer: NEVER
What should be done when a patient is in respiratory distress? Correct Answer: *Call for help, disconnect the vent, start bagging the patient, then reassess*
What are ways to prevent VAP? Correct Answer: *Remove water from circuits*
*HOB up to 30 degrees*
Turn Q2h
Suction
Oral care Q2H
Prevent aspiration
Lip moisturizer
Percussion
Give examples of what could cause a high pressure alarm. Correct Answer: Blocked airway
Coughing
Tension pneumothorax
Anxiety/Pain: Sedate them
Kinks in tubing
Decreased lung compliance: ARDS
*Assess the patient not the monitor*
Give examples of what could cause a low pressure alarm. Correct Answer: Not getting enough air (in or out)
Air leak in the cuff: Check the pilot balloon
Disconnected tubing
Low Vt
*Assess the patient not the monitor*
What are some things we have to do when caring for a vented patient? Correct Answer: Lung assessment
Frequent vital signs (every 4 hours)
I&O (look at balances)
Foley
NPO
Nutrition (NG Tube for all vent patients)
Skin Care
Monitor ABG/labs
VTE prophylaxis
What are some risk factors for a PE? Correct Answer: Immobility
Central Lines
Surgery
Obesity
DVT's
Birth Control Pills
Smoking
What is the best way to prevent a PE? Correct Answer: *Move the patient post op.*
What should be done immediately after the nurse notes s/s of a PE? Correct Answer: *Notify the Rapid Response Team*
What are ways to manage the symptoms of a PE? Correct Answer: ABC: might need intubation
Anticoags (heparin/warfarin/fibrinolytics)
High Fowlers
Telemetry
Safety/bleeding precatutions
100% non rebreather
What is a pulmonary contusion? Correct Answer: A "bruise" of the lung
What is the treatment/nursing interventions for a pulmonary contusion? Correct Answer: PEEP to try and fix itself (bruise will desolve itself)
Monitor ABC's
Is an increase in output from a chest tube expected? Correct Answer: *NO* [Show Less]