After change-of-shift report on a ventilator weaning unit, which patient should the nurse assess first?
a. Patient who failed a spontaneous breathing trial and has been placed in a rest mode on the ventilator
b. Patient who is intubated and has continuous partial pressure end-tidal CO2 (PETCO2) monitoring
c. Patient with a central venous oxygen saturation (ScvO2) of 69% while on bilevel positive airway pressure (BiPAP)
d. Patient who was successfully weaned and extubated 4 hours ago and now has no urine output for the last 6 hours
ANS: D
The decreased urine output may indicate acute kidney injury or that the patient's cardiac output and perfusion of vital organs have decreased. Any of these causes would require rapid action. The data about the other patients indicate that their conditions are stable and do not require immediate assessment or changes in their care. Continuous PETCO2 monitoring is frequently used when patients are intubated. The rest mode should be used to allow patient recovery after a failed SBT, and an ScvO2 of 69% is within normal limits.
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