LIPPINCOT EXERCISE 2

Tracheal cuff pressure measurement: Results How often should you measure cuff pressure?

	At least every 4 hours
	At least once each shift
	At least every 8 hours
	At least once a day

Rationale: Measuring cuff pressure at least every 8 hours helps to ensure airway sealing.

Where should you place the stethoscope diaphragm when auscultating for an air leak?

	Over the trachea
	Over the sternum
	Over the diaphragm
	Over the lung apex

Rationale: Positioning the stethoscope diaphragm over the trachea optimizes your chances of auscultating sounds from an air leak.

What should you do if you don't hear an air leak?

	Gather your equipment because the cuff is adequately inflated.
	Completely deflate the cuff and then reinflate until you don't hear an air leak.
	Slowly release air from the cuff until the manometer reads 15 to 18 mm Hg.
	Slowly release air from the cuff until you hear an air leak and then add air until you don't hear a leak.

Rationale: Slowly releasing air from the cuff until you hear an air leak and then adding air until you don't hear a leak ensures that the minimal occlusive volume is achieved.

The minimum cuff pressure usually falls within what pressure range?

	15 to 18 mm Hg
	20 to 25 mm Hg
	12 to 15 mm Hg
	10 to 12 mm Hg

Rationale: The minimum cuff pressure usually falls between 20 and 25 mm Hg; this pressure is usually adequate to seal the airway yet lower than venous perfusion pressure, preventing necrosis of tracheal tissue.

Which sound indicates an air leak?

	Loud gurgling
	Soft whistling
	Low wheezing
	Smooth and hollow sounds

Rationale: Loud gurgling indicates an air leak.

Which complications may occur if an air leak is created during cuff pressure measurement?

	Aspiration of airway secretions, underventilation, and coughing spasms
	Tracheostomy tube migration and pneumonia
	Emesis and aspiration of airway secretions
	Pneumothorax and tracheal necrosis

Rationale: Aspiration of airway secretions, underventilation, and coughing spasms may occur. Avoid aspiration of airway secretions by suctioning before cuff measurement; avoid underventilation and coughing spasms by making sure the airway is adequately sealed.

Which patient population may require increased cuff pressures for adequate airway sealing?

	Patients with upper respiratory infections and active coughing
	Patients with emphysema
	Patients with tracheal stenosis
	Patients with tracheal malacia

Rationale: Patients with tracheal malacia have softened tracheal tissue that requires increased cuff pressures to ensure an adequate seal.

The ideal cuff pressure is also known as:

	optimum cuff volume.
	peak occlusion volume.
	minimal occlusive volume.
	minimum necessary volume.

Rationale: The ideal cuff pressure is also known as the minimal occlusive pressure, which is the minimum volume necessary to seal the airway without creating excessive pressure.

When preparing the equipment before cuff pressure measurement, what's the correct pressure to generate in the manometer tubing?

	15 mm Hg
	10 mm Hg
	5 mm Hg
	20 mm Hg

Rationale: You should prime the manometer tubing to 10 mm Hg to prevent sudden cuff deflation when the system is connected to the patient.

Blood pressure assessment: Results

 Which blood pressure reading indicates a patient with a narrowed pulse pressure?

	150/90 mm Hg
	102/82 mm Hg
	126/86 mm Hg
	132/80 mm Hg

Rationale: A narrow pulse pressure occurs when the difference between systolic pressure and diastolic pressure is less than 30 mm Hg.

How should you categorize a blood pressure of 152/88 mm Hg according to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood?

	Hypertension, stage 2
	Hypertension, stage 1
	Prehypertension
	Normal

Rationale: A systolic pressure of 140 to 159 mm Hg or a diastolic pressure of 90 to 99 mm Hg is categorized as hypertension, stage 1.

When selecting a blood pressure cuff for a patient, how much of the upper arm should be encircled by the bladder of the cuff?

	At least 80%
	At least 40%
	At least 20%
	At least 60%

Rationale: The bladder should encircle at least 80% of the upper arm.

Which action would be most appropriate when taking a blood pressure reading in a patient with an arteriovenous fistula on the left forearm?

	Use the right arm for a blood pressure reading.
	Continue taking the blood pressure on the left arm as long as a bruit is auscultated over the fistula.
	Continue taking the blood pressure on the left arm as long as a thrill is palpated over the fistula.
	Make sure the cuff isn't placed on the fistula on the left arm.

Rationale: You should avoid taking a blood pressure reading on an arm that has an arteriovenous fistula or hemodialysis shunt because blood flow through the vascular device may be compromised.

Which blood pressure reading indicates a patient with a widened pulse pressure?

	110/82 mm Hg
	130/90 mm Hg
	126/86 mm Hg
	152/90 mm Hg

Rationale: A widened pulse pressure occurs when the difference between systolic pressure and diastolic pressure is greater than 50 mm Hg./

When you wrap the blood pressure cuff around the patient's right upper arm, she tells you that she had a right-sided mastectomy 7 years ago and she has lymphedema. Which action should you take next?

	Continue taking the blood pressure on her right arm.
	Call the doctor.
	Remove the cuff and place it on her left arm.
	Remove the cuff and place it around her right forearm.

Rationale: Avoid taking a blood pressure reading on the arm affected by lymphedema after a mastectomy or lumpectomy because it may decrease already compromised lymphatic circulation, worsen edema, and damage the arm.

When taking a blood pressure, which action is most appropriate after you detect the last Korotkoff sound?

	Inflate the cuff to 10 mm Hg above the last Korotkoff sound.
	Slowly deflate the cuff to 0 mm Hg.
	Slowly deflate the cuff another 10 mm Hg.
	Inflate the cuff to 30 mm Hg above the last Korotkoff sound.

Rationale: After the last Korotkoff sound is heard, the cuff should be slowly deflated for at least another 10 mm Hg to ensure that no further sounds are audible.

When measuring a patient's blood pressure in the upper arm, where should you position the blood pressure cuff?

	2 to 3 cm above the radial pulse
	2 to 3 cm above the wrist
	3 to 4 cm above the antecubital fossa
	2 to 3 cm above the antecubital fossa

Rationale: Position the blood pressure cuff 2 to 3 cm above the antecubital fossa.

When taking a blood pressure measurement, you note the onset of a beat or tapping sound. You identify this sound as:

	the fourth Korotkoff sound.
	the first Korotkoff sound.
	the second Korotkoff sound.
	the third Korotkoff sound.

Rationale: The beat or tapping sound is the first of five Korotkoff sounds. The second sound resembles a murmur or swish; the third sound, crisp tapping; the fourth sound, a soft, muffled tone; and the fifth, the last sound heard.

How should you categorize a blood pressure of 170/102 mm Hg according to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood?

	Hypertension, stage 1
	Normal
	Hypertension, stage 2
	Prehypertension

Rationale: A systolic pressure greater than or equal to 160 mm Hg or a diastolic pressure greater than or equal to 100 mm Hg is categorized as hypertension, stage 2.

A patient has just rushed into the ambulatory care clinic, late for his appointment. How long should you have him rest before measuring his blood pressure?

	3 minutes
	2 minutes
	1 minute
	5 minutes

Rationale: Have the patient rest for at least 5 minutes before measuring his blood pressure.

Fall prevention: Results

 Medications that may increase the risk of patient falls include:

	antibiotics.
	hypertensives.
	anti-inflammatories.
	diuretics.

Rationale: Diuretics may increase the risk of falls in patients due to hypotension and urinary frequency.

The spouse of an ambulatory patient asks you if the patient may walk in the hallway. What's your best response?

	The patient should instead stay in his room and watch television to prevent boredom.
	The patient may walk in the hallway if nonskid socks or shoes are worn.
	The patient should instead occupy his time reading magazines.
	The patient may walk in the hallways as long as the spouse accompanies him as an added safety precaution.

Rationale: Proper footwear should be worn when ambulating. Nonskid soles prevent slipping on the floor.

An alternative to restraints is:

	instructing the patient's roommate to call if the patient tries to get out of bed.
	a pressure pad alarm.
	sedation.
	complete bed rest.

Rationale: Pressure pad alarms alert the nursing staff to patient movement and can eliminate the need for restraints.

Patients taking medications that can cause hypotension should be advised to:

	drink at least four glasses of water per day to maintain their blood pressure.
	never get up without assistance.
	sit on the edge of a bed or chair for a few minutes before rising.
	keep their medications at the bedside for easy access.

Rationale: Such medications as antipsychotics, antihypertensives, and diuretics may cause orthostatic hypotension. Patients should be taught to sit on the edge of the bed or chair for a few minutes before rising to allow their body time to adjust to the position change.

What should you check when assessing a room for safety?

	The head of the bed is elevated.
	A light remains on in the bathroom.
	The pathways are kept clear.
	The garbage can is empty.

Rationale: Pathways should remain free from clutter to prevent falls.

To prevent falls, you should check that:

	the bed has side rail pads.
	the bed wheels are locked.
	the bed is in its highest position.
	the bed has enough room on both sides for the patient to exit.

Rationale: The wheels on the bed should be locked at all times.

When should you complete a fall risk reassessment?

	When the patient has been moved to a different room
	When the patient has been placed on intake and output monitoring
	When the patient has a new order for Percocet
	When the patient has a computed tomography scan

Rationale: A patient should be reassessed for falls with a change in condition or level of care or with the addition of medications that may increase the risk of falls.

Routine safety checks include:

	checking on the patient every 4 hours.
	making sure the call bell and frequently used items are within easy reach of the patient.
	checking on the patient every 10 minutes.
	avoiding medicating the patient for pain.

Rationale: Keeping the patient's call bell and frequently used items such as tissues and the telephone in easy reach helps prevent the patient from needing to rise or reach.

Fall risk assessment should include evaluating the patient for:

	a history of a recent fall and sensory deficits.
	allergies to multiple medications.
	constipation and fragile skin.
	poor diet in a patient younger than age 65.

Rationale: Assessing for a history of a recent fall and sensory deficits should be included in every fall risk assessment.

During your initial admission of a patient, which is a key safety measure to prevent falls?

	Providing orientation to the room and call bell
	Providing every patient with a rolling walker
	Giving written instructions to the patient on what he should do if he falls
	Directing the patient to help himself if you're busy

Rationale: Orientation to the room and call bell helps avoid falls related to an unfamiliar environment.

IV catheter insertion: Results

You suspect that your patient's IV catheter is infiltrated. Which signs and symptoms are most indicative of infiltration?

	Redness, tenderness, and swelling at the IV site
	Discomfort at the IV site with the absence of the radial pulse
	Blanching, tight feeling, and swelling at and above the IV site
	Warm and swollen IV site

Rationale: Blanching, tight feeling, and swelling at and above the IV site are signs and symptoms of IV infiltration.

Which vessel is preferred when inserting a peripheral IV catheter?

	External jugular vein
	Cephalic vein
	Scalp vessel
	Saphenous vein

Rationale: The cephalic vein is more convenient and has fewer risks of thrombophlebitis and infection.

You're assessing an IV site and suspect phlebitis. What should you do next?

	Discontinue the IV and restart a new IV infusion using a larger vein.
	Discontinue the access device, apply warm soaks, and notify the doctor.
	Stop the infusion and document the patient's condition.
	Monitor the IV and recommend antibiotic therapy.

Rationale: Redness and red streaks up the venous path are signs and symptoms of chemical phlebitis; you should immediately remove the device, apply warm soaks, and notify the doctor.

When selecting a venous access site, you should start at:

	the largest part of the extremity.
	the most proximal position of the arm.
	the most medial position of the arm.
	the most distal position of the arm.

Rationale: Start with a vein at the most distal site so that you can move proximally as needed for subsequent IV insertion sites.

What should you do before inserting a venous catheter into a patient?

	Place the bed in the high position.
	Explain the procedure to the patient.
	Premedicate the patient with pain medication.
	Explain the procedure to the patient's family.

Rationale: Explain the procedure to the patient to ensure cooperation and reduce anxiety.

How should you position a patient for establishing venous access in the patient's arm?

	Position the patient in an upright, sitting position with the arm in a dependent position.
	Position the patient in a reclining position with the arm in a dependent position.
	Position the patient in a reclining position, leaving the arm in an upright position.
	Position the patient in a reclining position with the arm in an upright position.

Rationale: Having the patient in a reclining position with the arm in a dependent position increases venous filling of the lower arms and hands.

How should you prepare to insert the needle into the skin?

	Hold the needle bevel down and enter the vein at a 90-degree angle.
	Hold the needle bevel down and enter the skin at a 0- to 15-degree angle.
	Hold the needle bevel up and enter the skin at a 0- to 15-degree angle.
	Hold the needle bevel down and enter the skin directly over the vein.

Rationale: When preparing the IV site, hold the needle bevel up and enter the skin at a 0- to 15-degree angle.

A patient with an IV catheter develops sudden onset of dyspnea, a weak pulse, and hypotension. You suspect that this is due to:

	a deep vein hematoma.
	an allergic reaction.
	thrombosis.
	an air embolism.

Rationale: Respiratory distress, unequal breath sounds, weak pulse, decreased blood pressure, and loss of consciousness are all signs and symptoms of an air embolism.

Which initial step should you take when gathering equipment for peripheral IV catheter insertion?

	Select normal saline or lactated Ringer's solution.
	Verify with your charge nurse that the IV solution is correct.
	Confirm that the blood product isn't expired.
	Verify that the solution corresponds with the doctor's orders.

Rationale: To prevent a medication error, you should compare the doctor's orders with the solution label to verify that the solution is correct.

Which needle device guards against accidental needlesticks?

	A precision glide needle
	A butterfly needle
	A large-bore nonretracting catheter
	A retracting peripheral IV catheter

Rationale: A retracting peripheral IV catheter guards against accidental needlesticks.