Med-Surg Sp2017 ARDS & Mechanical Ventilation Question and answers correctly solved, Exams of Nursing

Download Med-Surg Sp2017 ARDS & Mechanical Ventilation Question and answers correctly solved and more Exams Nursing in PDF only on Docsity! Med-Surg Sp2017 ARDS & Mechanical Ventilation Unresponsive arterial hypoxemia Explanation: Acute respiratory distress syndrome (ARDS) can be thought of as a spectrum of disease, from its milder form (acute lung injury) to its most severe form of fulminate, life-threatening ARDS. This clinical syndrome is characterized by a severe inflammatory process causing diffuse alveolar damage that results in sudden and progressive pulmonary edema, increasing bilateral infiltrates on chest x-ray, hypoxemia unresponsive to oxygen supplementation regardless of the amount of PEEP, and the absence of an elevated left atrial pressure ( Dushianthan, Grott, Postle, et al., 2011). - correct answer The nurse is caring for a patient with suspected ARDS with a pO2 of 53. The patient is placed on oxygen via face mask and the PO2 remains the same. What does the nurse recognize as a key characteristic of ARDS? Unresponsive arterial hypoxemia Diminished alveolar dilation Tachypnea Increased PaO2 Hypovolemia secondary to leakage of fluid into the interstitial spaces Explanation: Systemic hypotension may occur in ARDS as a result of hypovolemia secondary to leakage of fluid into the interstitial spaces and depressed cardiac output from high levels of PEEP therapy. Pulmonary hypertension, not pulmonary hypotension, sometimes is a complication of ARDS, but it is not the cause of the patient becoming hypotensive. - correct answer The nurse is caring for a patient in the ICU admitted with ARDS after exposure to toxic fumes from a hazardous spill at work. The patient has become hypotensive. What is the cause of this complication to the ARDS treatment? Pulmonary hypotension due to decreased cardiac output Severe and progressive pulmonary hypertension Hypovolemia secondary to leakage of fluid into the interstitial spaces Increased cardiac output from high levels of PEEP therapy Unresponsive arterial hypoxemia. Explanation: Clinically, the acute phase of ARDS is marked by a rapid onset of severe dyspnea that usually occurs 12 to 48 hours after the initiating event. A characteristic feature is arterial hypoxemia that does not respond to supplemental oxygen. - correct answer A nurse is aware that the diagnostic feature of ARDS is sudden: Unresponsive arterial hypoxemia. Diminished alveolar dilation. Tachypnea Increased PaO2 Administer oxygen by nasal cannula as ordered. Explanation: When a pulmonary embolus places a client at risk for oxygen deprivation, the body compensates by hyperventilating. This causes respiratory alkalosis, as reflected in the client's ABG values. However, the most significant ABG value is the PaO2 value of 60 mm Hg, which indicates hypoxemia. To manage hypoxemia, the nurse should increase oxygenation by administering oxygen via nasal cannula as ordered. Instructing the client to breathe into a paper bag would cause depressed oxygenation when the client reinhaled carbon dioxide. Auscultating breath sounds or encouraging deep breathing and coughing wouldn't improve oxygenation. - correct answer A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3-) 25 mEq/L. What should the nurse do first? Explanation: Low pressure in the cuff can increase the risk for aspiration pneumonia. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis. - correct answer Which of the following is a potential complication of a low pressure in the endotracheal cuff? Aspiration pneumonia Tracheal bleeding Tracheal ischemia Pressure necrosis 50 and 50 Explanation: Acute respiratory failure (ARF) is classified as hypoxemic (decrease in arterial oxygen tension [PaO2] to <50 mm Hg on room air) and or hypercapnic (increase in arterial carbon dioxide tension [PaCO2] to >50 mm Hg with an arterial pH of <7.35). - correct answer Acute respiratory failure (ARF) occurs when oxygen tension (PaO2) falls to less than __________ mm Hg (hypoxemia) and carbon dioxide tension (PaCO2) rises to greater than __________ mm Hg (hypercapnia). 50 and 50 60 and 60 75 and75 80 and 80 Pleuritic pain Explanation: The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. Pleuritic pain is limited in distribution rather than diffuse; it usually occurs only on one side. The pain may become minimal or absent when the breath is held. It may be localized or radiate to the shoulder or abdomen. Later, as pleural fluid develops, the pain decreases. The scenario does not indicate any trauma to the patient, so a traumatic pneumothorax is implausible. Empyema is unlikely as there is no fever indicative of infection. Myocardial infarction would affect the patient's vital signs profoundly. - correct answer The nurse is caring for an 82-year-old patient with a diagnosis of tracheobronchitis. The patient begins complaining of right-sided chest pain that gets worse when he coughs or breathes deeply. Vital signs are within normal limits. What would you suspect this patient is experiencing? Traumatic pneumothorax Empyema Pleuritic pain Myocardial infarction Intubate the patient and control breathing with mechanical ventilation Explanation: A patient with ARDS may need mechanical ventilation to assist with breathing while the underlying cause of the pulmonary edema can be corrected. The other options are not appropriate. - correct answer A patient diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the patient's condition does not improve and the oxygen saturation level continues to decrease what procedure will the nurse expect to assist with in order to assist the patient to breathe easier? Intubate the patient and control breathing with mechanical ventilation Increase oxygen administration Administer a large dose of furosemide (Lasix) IVP stat Schedule the patient for pulmonary surgery Ask the client to write, use a picture board, or spell words with an alphabet board. Explanation: If the client uses an alternative method of communication, such as writing, using a picture board, or spelling words on an alphabet board, he'll feel more in control and be less frustrated. Assuring the client that everything will be all right offers false reassurance and telling him not to be upset minimizes his feelings. Neither of these methods helps the client to communicate. Family members are also likely to encounter difficulty interpreting the wishes of a client with an endotracheal tube or tracheostomy tube. Making them responsible for interpreting the client's gestures may frustrate them. The client may be weaned off a mechanical ventilator only when the physiologic parameters for weaning have been met. - correct answer A client on long-term mechanical ventilation becomes very frustrated when he tries to communicate. Which intervention should the nurse perform to assist the client? Assure the client that everything will be all right and that he shouldn't become upset. Ask a family member to interpret what the client is trying to communicate. Ask the physician to wean the client off the mechanical ventilator to allow the client to talk. Ask the client to write, use a picture board, or spell words with an alphabet board. Effective breathing at a rate of 16 breaths/minute through the established airway Explanation: Proper suctioning should produce a patent airway, as demonstrated by effective breathing through the airway at a normal respiratory rate of 12 to 20 breaths/minute. The other options suggest ineffective suctioning. A respiratory rate of 28 breaths/minute and accessory muscle use may indicate mild respiratory distress. Increased pulse rate, rapid respirations, and cyanosis are signs of hypoxia. Restlessness, pallor, increased pulse and respiratory rates, and bubbling breath sounds indicate respiratory secretion accumulation. - correct answer After suctioning a tracheostomy tube, the nurse assesses the client to determine the effectiveness of the suctioning. Which findings indicate that the airway is now patent? A respiratory rate of 28 breaths/minute with accessory muscle use Effective breathing at a rate of 16 breaths/minute through the established airway Increased pulse rate, rapid respirations, and cyanosis of the skin and nail beds Restlessness, pallor, increased pulse and respiratory rates, and bubbling breath sounds Malfunction of the alarm button Measure the patient's oxygen saturation. Explanation: The patient's response to suctioning is usually determined by performing chest auscultation and by measuring the patient's oxygen saturation. FET, incentive spirometry, and percussion are not normally used as evaluative techniques. - correct answer A nurse has performed tracheal suctioning on a patient who experienced increasing dyspnea prior to a procedure. When applying the nursing process, how can the nurse best evaluate the outcomes of this intervention? Determine whether the patient can now perform forced expiratory technique (FET). Percuss the patient's lungs and thorax. Measure the patient's oxygen saturation. Have the patient perform incentive spirometry. 10 to 15 seconds Explanation: In general, the nurse should apply suction no longer than 10 to 15 seconds because hypoxia and dysrhythmias may develop, leading to cardiac arrest. Applying suction for 30 to 35 seconds is hazardous and may result in the patient's developing hypoxia, which can lead to dysrhythmias and, ultimately, cardiac arrest. Applying suction for 20 to 25 seconds is hazardous and may result in the patient's developing hypoxia, which can lead to dysrhythmias and, ultimately, cardiac arrest. Applying suction for 0 to 5 seconds would provide too little time for effective suctioning of secretions. - correct answer When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods? 0 to 5 seconds 10 to 15 seconds 30 to 35 seconds 20 to 25 seconds Continues assessing the client's respiratory status frequently Explanation: The SIMV setting on a ventilator allows the client to breathe spontaneously with no assistance from the ventilator for those extra breaths. Data in the stem suggest that the ventilator is working correctly. The nurse would continue making frequent respiratory assessments of the client. There are not sufficient data to suggest the client could be removed from the ventilator. There is no reason to increase the ventilator's setting to 14 breaths per minute or to contact respiratory therapy to report the machine is not working properly. - correct answer A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse Consults with the physician about removing the client from the ventilator Changes the setting on the ventilator to increase breaths to 14 per minute Continues assessing the client's respiratory status frequently Contacts the respiratory therapy department to report the ventilator is malfunctioning acute respiratory distress syndrome (ARDS). Explanation: A client who receives massive fluid resuscitation or blood transfusions or who aspirates stomach contents is at highest risk for ARDS, which is associated with catastrophic events, such as multiple trauma, bacteremia, pneumonia, near drowning, and smoke inhalation. COPD refers to a group of chronic diseases, including bronchial asthma, characterized by recurring airflow obstruction in the lungs. Although renal failure may occur in a client with multiple trauma (depending on the organs involved), this client's history points to an assault on the respiratory system secondary to aspiration of stomach contents and massive fluid resuscitation. - correct answer A client admitted with multiple traumatic injuries receives massive fluid resuscitation. Later, the physician suspects that the client has aspirated stomach contents. The nurse knows that this client is at highest risk for: chronic obstructive pulmonary disease (COPD). bronchial asthma. acute respiratory distress syndrome (ARDS). renal failure. pH 7.25, Pa<sc>CO2 48, HCO3 24 Explanation: pH 7.25, Pa<sc>CO2 48, HCO3 24 = respiratory acidosis pH 7.87, Pa<sc>CO2 38, HCO3 28 = metabolic alkalosis pH 7.47, Pa<sc>CO2 28, HCO3 30 = respiratory alkalosis pH 7.49, Pa<sc>CO2 34, HCO3 25 = respiratory alkalosis - correct answer The nurse is interpreting blood gases for a patient with acute respiratory distress syndrome (ARDS). Which set of blood gas values indicates respiratory acidosis? pH 7.87, Pa<sc>CO2 38, HCO3 28 pH 7.47, Pa<sc>CO2 28, HCO3 30 pH 7.49, Pa<sc>CO2 34, HCO3 25 pH 7.25, Pa<sc>CO2 48, HCO3 24 Restoration of adequate gas exchange Explanation: The objectives of treatment are to correct the underlying cause of respiratory failure and to restore adequate gas exchange in the lung. This is priority over coping and self-care. Long-term ventilation may or may not be indicated. - correct answer A patient who involved in a workplace accident suffered a penetrating wound of the chest that led to acute respiratory failure. What goal of treatment should the care team prioritize when planning this patient's care? Facilitation of long-term intubation Restoration of adequate gas exchange pH 7.28, PaO2 50 mm Hg pH 7.46, PaO2 80 mm Hg pH 7.36, PaCO2 32 mm Hg pH 7.35, PaCO2 48 mm Hg Pneumothorax Explanation: Pneumothorax (air in the pleural space) is a potential complication of all central venous access devices. Signs and symptoms include chest pain, dyspnea, shoulder or neck pain, irritability, palpitations, light- headedness, hypotension, cyanosis, and unequal breath sounds. A chest X-ray reveals the collapse of the affected lung that results from pneumothorax. Triple-lumen catheter insertion through the subclavian vein isn't associated with pulmonary embolism, MI, or heart failure. - correct answer A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect? Pulmonary embolism Myocardial infarction (MI) Heart failure Pneumothorax Rapid onset of severe dyspnea Explanation: The acute phase of ARDS is marked by a rapid onset of severe dyspnea that usually occurs less than 72 hours after the precipitating event - correct answer The nurse is assessing a patient who, following an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which early, most common sign of ARDS? Rapid onset of severe dyspnea Inspiratory crackles Bilateral wheezing Cyanosis Sudden onset in client who had normal lung function Explanation: Acute respiratory failure occurs suddenly in a client who previously had normal lung function. - correct answer The new client on the unit was admitted with acute respiratory failure. What are the signs and symptoms of acute respiratory failure? Insidious onset in client who had normal lung function Sudden onset in client who had normal lung function Insidious onset in client who had compromised lung function Sudden onset in client who had compromised lung function Atelectasis Explanation: A shallow, monotonous respiratory pattern coupled with immobility places the patient at an increased risk of developing atelectasis. These specific factors are less likely to result in pulmonary embolism or aspiration. ARDS involves an exaggerated inflammatory response and does not normally result from factors such as immobility and shallow breathing. - correct answer A perioperative nurse is caring for a postoperative patient. The patient has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the patient's increased risk for what complication? Acute respiratory distress syndrome (ARDS) Atelectasis Aspiration Pulmonary embolism Partial pressure of arterial oxygen (PaO2) Explanation: In acute respiratory failure, administering supplemental oxygen elevates the PaO2. In acute respiratory distress syndrome, elevation of the PaO2 requires positive end-expiratory pressure. In both situations, the PaCO2 is elevated and the pH and HCO3- are depressed. - correct answer A client has hypoxemia of pulmonary origin. What portion of arterial blood gas results is most useful in distinguishing between acute respiratory distress syndrome and acute respiratory failure? Partial pressure of arterial oxygen (PaO2) Partial pressure of arterial carbon dioxide (PaCO2) pH Bicarbonate (HCO3-) Nutritional support Explanation: Aggressive, supportive care must be provided to compensate for the severe respiratory dysfunction. This supportive therapy almost always includes intubation and mechanical ventilation. In addition, circulatory support, adequate fluid volume, and nutritional support are important. Oral intake is contraindicated by intubation. Counseling and occupational therapy would not be priorities during the acute stage of ARDS. - correct answer A firefighter was trapped in a fire and is admitted to the ICU for smoke inhalation. After 12 hours, the firefighter is exhibiting signs of ARDS and is intubated. What other supportive measures are initiated in a patient with ARDS? Psychological counseling of aspiration and hypoxia. - correct answer A patient is being mechanically ventilated with an oral endotracheal tube in place. The nurse observes that the cuff pressure is 25 mm Hg. The nurse is aware of what complications that can be caused by this pressure? (Select all that apply.) Tracheal aspiration Hypoxia Tracheal ischemia Tracheal bleeding Pressure necrosis Gastrointestinal hemorrhage Explanation: Gastrointestinal hemorrhage occurs in approximately 25% of clients receiving prolonged mechanical ventilation. Other possible complications include incorrect ventilation, oxygen toxicity, fluid imbalance, decreased cardiac output, pneumothorax, infection, and atelectasis. Immunosuppression and pulmonary emboli are not direct consequences of mechanical ventilation. - correct answer The nurse should monitor a client receiving mechanical ventilation for which of the following complications? Gastrointestinal hemorrhage Immunosuppression Increased cardiac output Pulmonary emboli Vital capacity of 13 mL/kg Tidal volume of 8.5 mL/kg PaO2 of 64 mm Hg Explanation: Weaning criteria for clients are as follows: Vital capacity 10 to 15 mL/kg; Maximum inspiratory pressure at least -20 cm H2; Tidal volume: 7 to 9 mL/kg; Minute ventilation: 6 L/min; Rapid/shallow breathing index below 100 breaths/min; PaO2 > 60 mm Hg; FiO2 < 40% - correct answer Which of the following are indicators that a client is ready to be weaned from a ventilator? Select all that apply. Vital capacity of 13 mL/kg Tidal volume of 8.5 mL/kg Rapid/shallow breathing index of 112 breaths/min PaO2 of 64 mm Hg FiO2 45% Assist control Explanation: Assist-control ventilation provides full ventilator support by delivering a preset tidal volume and respiratory rate. IMV provides a combination of mechanically assisted breaths and spontaneous breaths. SIMV delivers a preset tidal volume and number of breaths per minute. Between ventilator-delivered breaths, the patient can breathe spontaneously with no assistance from the ventilator for those extra breaths. - correct answer Which of the following ventilator modes provides full ventilatory support by delivering a present tidal volume and respiratory rate? IMV SIMV Assist control Pressure support Cleaning the patient's mouth with chlorhexidine daily Explanation: The five key elements of the VAP bundle include the following: elevation of the head of the bed (30 to 45 degrees: semi-Fowler's position), daily "sedation vacations," and assessment of readiness to extubate (see below); peptic ulcer disease prophylaxis (with histamine-2 receptor antagonists, such as ranitidine [Zantac]); deep venous thrombosis (DVT) prophylaxis; and daily oral care with chlorhexidine (0.12% oral rinses). The patient should be turned and repositioned every 2 hours to prevent complications of immobility and atelectasis and to optimize lung expansion. - correct answer The nurse is caring for a patient in the ICU who is receiving mechanical ventilation. Which of the following nursing measures are implemented in an effort to reduce the patient's risk of developing ventilator-associated pneumonia (VAP)? Cleaning the patient's mouth with chlorhexidine daily Maintaining the patient in a high Fowler's position Ensuring that the patient remains sedated while intubated Turning and repositioning the patient every 4 hours 20 minutes Explanation: ABGs should be obtained to measure carbon dioxide partial pressure (PaCO), pH, and PaO after 20 minutes of continuous mechanical ventilation. - correct answer Arterial blood gases should be obtained at which timeframe following the initiation of continuous mechanical ventilation? 10 minutes 15 minutes 20 minutes 25 minutes Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved. Explanation: ET suctioning removes oxygen, lowering the partial pressure of arterial oxygen; this, in turn, may induce a cardiac arrhythmia. Hyperventilating and hyperoxygenating the client before and during (or after) suctioning helps prevent this complication. Subcutaneous emphysema occurs when air from the pleural cavity leaks into subcutaneous tissue; it isn't a complication associated with suctioning. Hyperventilation and hyperoxygenation can't prevent a pneumothorax because this condition itself indicates air in the pleural space. Pulmonary edema is associated with cardiac dysfunction, not ET suctioning. - correct answer A client in acute respiratory distress is brought to the emergency department. After endotracheal (ET) intubation and initiation of mechanical ventilation, the client is transferred to the intensive care unit. Before suctioning the ET tube, the nurse hyperventilates and hyperoxygenates the client. What is the rationale for these interventions? They help prevent subcutaneous emphysema. They help prevent pneumothorax. They help prevent cardiac arrhythmias. They help prevent pulmonary edema. Reduced cardiac output Explanation: PEEP reduces cardiac output by increasing intrathoracic pressure and reducing the amount of blood delivered to the left side of the heart. It doesn't affect heart rate, but a decrease in cardiac output may reduce blood pressure, commonly causing compensatory tachycardia, not bradycardia. However, the resulting tachycardia isn't a direct effect of PEEP therapy itself. - correct answer Positive end-expiratory pressure (PEEP) therapy has which effect on the heart? Bradycardia Tachycardia Increased blood pressure Reduced cardiac output Wait several minutes and then repeat suctioning. Explanation: If additional suctioning is needed, the nurse should withdraw the catheter to the back of the pharynx, reassure the patient, and oxygenate for several minutes before resuming suctioning. Chest physiotherapy and postural drainage are not necessarily indicated. - correct answer The nurse is performing nasotracheal suctioning on a medical patient and obtains copious amounts of secretions from the patient's airway, even after inserting and withdrawing the catheter several times. How should the nurse proceed? Continue suctioning the patient until no more secretions are obtained. Perform chest physiotherapy rather than nasotracheal suctioning. Wait several minutes and then repeat suctioning. Perform postural drainage and then repeat suctioning. When adventitious breath sounds are auscultated Explanation: It is usually necessary to suction the patient's secretions because of the decreased effectiveness of the cough mechanism. Tracheal suctioning is performed when adventitious breath sounds are detected or whenever secretions are present. Unnecessary suctioning, such as scheduling every 2 hours, can initiate bronchospasm and cause trauma to the tracheal mucosa. - correct answer While caring for a patient with an endotracheal tube, the nurses recognizes that suctioning is required how often? Every 2 hours when the patient is awake When adventitious breath sounds are auscultated When there is a need to prevent the patient from coughing When the nurse needs to stimulate the cough reflex "When an endotracheal tube is left in too long it can damage the lining of the windpipe." Explanation: Endotracheal intubation may be used for no longer than 2 to 3 weeks, by which time a tracheostomy must be considered to decrease irritation of and, trauma to, the tracheal lining, to reduce the incidence of vocal cord paralysis (secondary to laryngeal nerve damage), and to decrease the work of breathing. The need for long-term ventilation would not be the primary rationale for this change in treatment. Endotracheal tubes do not diminish the breathing reflex. Reference: - correct answer A patient in the ICU has had an endotracheal tube in place for 3 weeks. The physician has ordered that a tracheostomy tube be placed. The patient's family wants to know why the endotracheal tube cannot be left in place. What would be the nurse's best response? "The physician may feel that mechanical ventilation will have to be used long-term." "Long-term use of an endotracheal tube diminishes the normal breathing reflex." "When an endotracheal tube is left in too long it can damage the lining of the windpipe." "It is much harder to breathe through an endotracheal tube than a tracheostomy." Impaired gas exchange related to ventilator setting adjustments Explanation: All the nursing diagnoses are appropriate for this client. Per Maslow's hierarchy of needs, airway, breathing, and circulation are the highest priorities within physiological needs. The client has an oxygen saturation of 91%, which is below normal. This places impaired gas exchange as the highest prioritized nursing diagnosis. - correct answer A nurse is attempting to wean a client after 2 days on the mechanical ventilator. The client has an endotracheal tube present with the cuff inflated to 15 mm Hg. The nurse has suctioned the client with return of small amounts of thin white mucus. Lung sounds are clear. Oxygen saturation levels are 91%. What is the priority nursing diagnosis for this client? Impaired gas exchange related to ventilator setting adjustments Risk for trauma related to endotracheal intubation and cuff pressure Risk for infection related to endotracheal intubation and suctioning Impaired physical mobility related to being on a ventilator synchronized intermittent mandatory ventilation (SIMV). Assess the CO2 level to determine if the patient requires suctioning. Have the patient cough. A patient requires permanent ventilation. Explanation: A tracheostomy permits long-term use of mechanical ventilation to prevent aspiration of oral and gastric secretions in the unconscious or paralyzed patient. Indications for a tracheostomy do not include a respiratory rate of 10 breaths per minute, symptoms of dyspnea, or respiratory acidosis. - correct answer What would the critical care nurse recognize as a condition that may indicate a patient's need to have a tracheostomy? A patient has a respiratory rate of 10 breaths per minute. A patient requires permanent ventilation. A patient exhibits symptoms of dyspnea. A patient has respiratory acidosis. Runs of ventricular tachycardia Explanation: Ventricular tachycardia indicates that the client isn't tolerating the weaning process. The weaning process should be stopped before lethal ventricular arrhythmias occur. A respiratory rate of 16 breaths/minute and an oxygen saturation of 93% are normal findings. Although the client's blood pressure has increased, it hasn't increased more than 20% over baseline, which would indicate that the client isn't tolerating the weaning process. - correct answer A nurse is weaning a client from mechanical ventilation. Which assessment finding indicates the weaning process should be stopped? Respiratory rate of 16 breaths/minute Oxygen saturation of 93% Runs of ventricular tachycardia Blood pressure increase from 120/74 mm Hg to 134/80 mm Hg Aspiration pneumonia Explanation: Low pressure in the cuff can increase the risk for aspiration pneumonia. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis. - correct answer Which of the following is a potential complication of a low pressure in the ET cuff? Tracheal bleeding Aspiration pneumonia Tracheal ischemia Pressure necrosis Volume cycled Explanation: With volume-cycled ventilation, the volume of air to be delivered with each inspiration is present. Negative pressure ventilators exert a negative pressure on the external chest. Time-cycled ventilators terminate or control inspiration after a preset time. When the pressure-cycled ventilator cycles on, it delivers a flow of air (inspiration) until it reaches a present pressure, and then cycles off, and expiration occurs passively. - correct answer Which type of ventilator has a pre-sent volume of air to be delivered with each inspiration? Negative pressure Volume cycled Time cycled Pressure cycled