NUR 265 Advanced Concepts of Medical–Surgical Nursing
Exam 2
Question:
What should be done when a patient is in respiratory distress?
Answer:
*Call for help, disconnect the vent, start bagging the patient, then reassess*
Question:
What are ways to prevent VAP?
Answer:
*Remove water from circuits* *HOB up to 30 degrees* Turn Q2h Suction Oral care Q2H Prevent aspiration Lip moisturizer Percussion 1 / 3
Question:
Give examples of what could cause a high pressure alarm.
Answer:
Blocked airway Coughing Tension pneumothorax
Anxiety/Pain: Sedate them
Kinks in tubing
Decreased lung compliance: ARDS
*Assess the patient not the monitor*
Question:
Give examples of what could cause a low pressure alarm.
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*
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Question:
What are some things we have to do when caring for a vented patient?
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
Question:
What are some risk factors for a PE?
Answer:
Immobility Central Lines Surgery Obesity DVT's Birth Control Pills Smoking
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