Critical Care Exam 1

A patients vital signs are pulse 87, respirations 24, and BP of 128/64 mm Hg and cardiac output is 4.7L/min. The patients stroke volume is _____ mL. (Round to the nearest whole number.)

54 Stroke volume = cardiac output/heart rat

A newly admitted patient is diagnosed with hyponatremia. When making room assignments, the charge nurse should take which action? a. Assign the patient to a room near the nurse's station. b. Place the patient in a room nearest to the water fountain. c. Place the patient on telemetry to monitor for peaked T waves. d. Assign the patient to a semi-private room and place an order for a low-salt diet.

A. Assign the patient to a room near the nurse's station. The patient should be placed near the nurses station if confused in order for the staff to closely monitor the patient. To help improve serum sodium levels, water intake is restricted. Therefore a confused patient should not be placed near a water fountain. Peaked T waves are a sign of hyperkalemia, not hyponatremia. A confused patient could be distracting and disruptive for another patient in a semiprivate room. The patient needs sodium replacement, not restriction.

A nurse in the outpatient clinic is caring for a patient who has a magnesium level of 1.3 mg/dL. Which assessment would be most important for the nurse to make? a. Daily alcohol intake b. Intake of dietary protein c. Multivitamin/mineral use d. Use of over-the-counter (OTC) laxatives

A. Daily alcohol intake hypomagnesemia is associated with alcoholism. Protein intake would not have a significant effect on magnesium level. OTC laxatives (such as milk of magnesia) and use of multivitamin/mineral supplements would tend to increase magnesium levels.

A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question? a. Infuse 5% dextrose in water at 125 mL/hr. b. Administer IV morphine sulfate 4 mg every 2 hours PRN. c. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea. d. Administer 3% saline if serum sodium decreases to less than 128

A. Infuse 5% dextrose in water at 125ml/hr Because the patients gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringers solution would usually be ordered for this patient. The other orders are appropriate for a postoperative patient with gastric suction.

A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion? a. Lung sounds b. Urinary output c. Peripheral pulses d. Peripheral edema

A. Lung sounds Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are a serious manifestation of fluid excess. Bounding peripheral pulses, peripheral edema, or changes in urine output are also important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation.

A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

A. Metabolic acidosis The pH and HCO3 indicate that the patient has a metabolic acidosis. The ABGs are inconsistent with other responses.

A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication? a. Oral digoxin (Lanoxin) 0.25 mg daily b. Ibuprophen (Motrin) 400 mg every 6 hours c. Metoprolol (Lopressor) 12.5 mg orally daily d. Lantau insulin 24 U subcutaneously every evening

A. Oral digoxin (Lanoxin) 0.25 mg daily Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse will also need to do more assessment regarding the other medications., but they are not of as much concern with the potassium level.

An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation? a. Pallor b. Edema c. Confusion d. Restlessness

B. Edema The normal range for total protein is 6.4 to 8.3 g/dL. Low serum protein levels cause a decreased in plasma on optic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels.

IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take? a. Administer the KCl as a rapid IV bolus. b. Infuse the KCl at a rate of 10 mEq/hour. c. Only give the KCl through a central venous line. d. Discontinue cardiac monitoring during the infu

B. Infuse the KCL through a central venous line. IV KCl is administered at a maximal rate of 10 mEq/hr. Rapid IV infusion of KCl can cause cardiac arrest. Although the preferred concentration for KCl is no more than 40 mEq/L, concentrations up to 80 mEq/L may be used for some patients. KCl can cause inflammation of peripheral veins, but it can be administered by this route. Cardiac monitoring should be continued while patient is receiving potassium because of the risk for dysrhythmias

When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patients food tray? a. Grape juice b. Milk carton c. Mixed green salad d. Fried chicken breast

B. Milk carton Foods high in phosphate include milk and other dairy products, so these are restricted on low-phosphate diets. Green, leafy vegetables; high-fat foods; and fruit juices are not high in phosphate and are not restricted.

The nurse is caring for a patient who has central venous access device (CVAD). Which action by the nurse is appropriate? a. Avoid using friction when cleaning around the CVAD insertion site. B. Use the push-pause method to flush the CVAD after giving medications. c. Obtain an order from the health care provider to change CVAD dressing. D. Position the patients face toward the CVAD during injection cap changes.

B. Use the push-pause method to flush the CVAD after giving medications. The push-pause enhances the removal of debris from the CVAD lumen and decreases the risk for clothing. To decrease infection risk, friction should be used when cleaning the CVAD insertion site. The dressing should be changed whenever it becomes damp, loose, or visibly soiled. The patient should turn away from the CVAD during cap changes.

The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take? A. Give the prescribed PRN lorazepam (Ativan) B. Start the prescribed PRN oxygen at 2 to 4 L/min C. Administer the prescribed normal saline bolus and insulin D. Encourage the patient to take deep, slow breaths with guided imagery.

C. Administer the prescribed normal saline bolus and insulin. The rapid deep (Kussmaul) respiration s indicate a metabolic acidosis and the need for correction of the acidosis with a saline bolus to prevent hypovolemia followed by insulin administration to allow glucose to re-enter the cells. Oxygen therapy is not indicated because there is no indication that the increased respiratory rate is related to hypoxemia. The respiratory pattern is compensatory, and the patient will not be able to slow the respiratory rate. Lorazepam administration will slow the respiratory rate and increase the level of acidosis.

The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patients condition has improved? a. Hematocrit 28% b. Absence of skin tenting c. Decreased peripheral edema d. Blood pressure 110/72 mm Hg

C. Decreased peripheral edema Edema is caused by low on optic pressure in individuals with low serum protein levels. The decrease in edema indicates an improvement in the patients protein status. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status.

The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider? a. Oral temperature 100.1 F b. Serum sodium level of 138 mEq/L (138 mmol/L) c. Gradually decreasing level of consciousness (LOC) D. Weight gain of 2 pounds (1 kg) above the admission weight

C. Gradually decreasing level of consciousness (LOC) The patient history and change in LOC could be indicative of fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information is needed to determine the cause of the change in LOC and the appropriate interventions. The weight gain, elevated temperature, crackles, and serum sodium level also will be reported, but not indicate a need for rapid action to avoid complications.

A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient complains of just blowing up and has peripheral edema and shortness of breath. Which assessment should the nurse complete first? a. Skin turgor b. Heart sounds c. Mental status d. Capillary refill

C. Mental status increases in extracellular fluid (ECF) can lead to swelling of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds also may be affected by increases in ECF, these are signs that do not have immediate impact on patient outcomes as cerebral edema.

An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately? a. K+ 3.4 mEq/L (3.4 mmol/L) b. Ca+2 7.8 mg/dL (1.95 mmol/L) c. Na+ 154 mEq/L (154 mmol/L) d. PO4-3 4.8 mg/dL (1.55 mmol/L)

C. Na+ 154 mEq/L (154 mmol/L) The elevated serum sodium level is consistent with the patients neurologic symptoms and indicates a need for immediate action to prevent further serious complications such as seizures. The potassium and calcium levels vary slightly. From normal but do not require immediate action by the nurse. The phosphate level is normal.

A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a peripherally inserted central catheter was inserted. Which response by the nurse is most appropriate? a. There is a decreased risk for infection when 25% dextrose is infused through a central line. B. The prescribed infusion can be given much more rapidly when the patient has a central line. c. The 25% dextrose is hypertonic and will be more rapidly diluted when given through a central line. D. The required blood glucose monitoring is more accurate when samples are obtained from a central line.

C. The 25% dextrose is hypertonic will be more rapidly diluted when given through a central line. The 25% dextrose solution is hypertonic. Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered IV. Blood glucose testing is not more accurate when samples are obtained from a central line. The infection risk is higher with a central catheter than with peripheral IV lines. Hypertonic or concentrated IV solutions are not given rapidly.

The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan? a. Maintain the patient on bed rest b. Auscultated lung sounds every 4 hours. c. Monitory for Trousseaus and Chvosteks signs. D. Encourage fluid intake up to 4000 mL every day

D. Encorage fluid intake up to 4000 mL every day To decrease the risk for renal calculi, the patient should have a fluid intake of 3000 to 4000 mL daily. Ambulating helps decrease the loss of calcium from bone and is encouraged in patients with hypercalcemia. Trousseaus and Chvosteks signs are monitored when there is a possibility of hypocalcemia. There is no indication that the patient needs frequent assessment of lung sounds, although these would be assessed every shift.

Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective? a. I will try to drink at least 8 glasses of water every day. b. I will use a salt substitute to decrease my sodium intake. c. I will increase my intake of potassium-containing foods. d. I will drink apple juice instead of orange juice for breakfast

D. I will drink apple juice instead of orange juice for breakfast Because spironolactone is a potassium-sparing diuretic, patients should be taught to choose low-potassium foods (e.g., apple juice) rather than foods that have higher levels of potassium (e.g., citrus fruits). Because the patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid intake. Teach patients to avoid salt substitutes, which are high in potas

A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85mm Hg, PaCO2 32mm Hg, and HCO3 25 mEq/L? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

D. Respiratory alkalosis The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO3.

The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse? a. Blood pressure is 90/40 mm Hg. b. Urine output is 30 mL over the last hour. c. Oral fluid intake is 100 mL for the last 8 hours. d. There is prolonged skin tenting over the sternum.

a. Blood pressure is 90/40 mm Hg. The blood pressure indicates that the patient may be developing hypovolemic shock as a result of intravascularfluid loss due to the burn injury. This finding will require immediate intervention to prevent the complicationsassociated with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting allindicate the need for increasing the patients fluid intake but not as urgently as the hypotensio

The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake? a. Increase fluids if your mouth feels dry. b. More fluids are needed if you feel thirsty. c. Drink more fluids in the late evening hours. d. If you feel lethargic or confused, you need more to drink

a. Increase fluids if your mouth feels dry. An alert, older patient will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an accurate indicator of volume depletion. Many older patients prefer to restrict fluids slightly in the evening to improve sleep quality. The patient will not be likely to notice and act appropriately when changes in level of consciousness occur

The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action should the nurse take next? a. Monitor ionized calcium level. b. Give oral calcium citrate tablets. c. Check parathyroid hormone level. d. Administer vitamin D supplements.

a. Monitor ionized calcium level. This patient with chronic malnutrition is likely to have a low serum albumin level, which will affect the totalserum calcium. A more accurate reflection of calcium balance is the ionized calcium level. Most of thecalcium in the blood is bound to protein (primarily albumin). Alterations in serum albumin levels affect theinterpretation of total calcium levels. Low albumin levels result in a drop in the total calcium level, althoughthe level of ionized calcium is not affected. The other actions may be needed if the ionized calcium is alsodecreased

A patient who is receiving positive pressure ventilation is scheduled for a spontaneous breathing trial(SBT). Which finding by the nurse is most important to discuss with the health care provider before startingthe SBT? a. New ST segment elevation is noted on the cardiac monitor. b. Enteral feedings are being given through an orogastric tube. c. Scattered rhonchi are heard when auscultating breath sounds. d. HYDROmorphone (Dilaudid) is being used to treat postoperative pain

a. New ST segment elevation is noted on the cardiac monitor. Myocardial ischemia is a contraindication for ventilator weaning. The ST segment elevation is an indication that weaning should be postponed until further investigation and/or treatment for myocardial ischemia can be done. The other information will also be shared with the health care provider, but ventilator weaning can proceed when opioids are used for pain management, abnormal lung sounds are present, or enteral feedings are being used.

A patient with renal failure has been taking aluminum hydroxide/magnesium hydroxide suspension(Maalox) at home for indigestion. The patient arrives for outpatient hemodialysis and is unresponsive toquestions and has decreased deep tendon reflexes. Which action should the dialysis nurse take first? a. Notify the patients health care provider. b. Obtain an order to draw a potassium level. c. Review the magnesium level on the patients chart. d. Teach the patient about the risk of magnesium-containing antacids

a. Notify the patients health care provider. The health care provider should be notified immediately. The patient has a history and manifestationsconsistent with hypermagnesemia. The nurse should check the chart for a recent serum magnesium level andmake sure that blood is sent to the laboratory for immediate electrolyte and chemistry determinations. Dialysisshould correct the high magnesium levels. The patient needs teaching about the risks of taking magnesium-containing antacids. Monitoring of potassium levels also is important for patients with renal failure, but thepatients current symptoms are not consistent with hyperkalemia

Following a thyroidectomy, a patient complains of a tingling feeling around my mouth. Which assessment should the nurse complete immediately? a. Presence of the Chvosteks sign b. Abnormal serum potassium level c. Decreased thyroid hormone level d. Bleeding on the patients dressing

a. Presence of the Chvosteks sign The patients symptoms indicate possible hypocalcemia, which can occur secondary to parathyroidinjury/removal during thyroidectomy. There is no indication of a need to check the potassium level, the thyroidhormone level, or for bleeding

A patient with respiratory failure has arterial pressurebased cardiac output (APCO) monitoring and isreceiving mechanical ventilation with peak end-expiratory pressure (PEEP) of 12 cm H2O. Which informationindicates that a change in the ventilator settings may be required? a. The arterial pressure is 90/46. b. The heart rate is 58 beats/minute. c. The stroke volume is increased. d. The stroke volume variation is 12%

a. The arterial pressure is 90/46. The hypotension suggests that the high intrathoracic pressure caused by the PEEP may be decreasing venousreturn and (potentially) cardiac output. The other assessment data would not be a direct result of PEEP andmechanical ventilation

A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider? a. The patient is experiencing laryngeal stridor. b. The patient complains of generalized fatigue. c. The patients bowels have not moved for 4 days. d. The patient has numbness and tingling of the lips

a. The patient is experiencing laryngeal stridor. Hypocalcemia can cause laryngeal stridor, which may lead to respiratory arrest. Rapid action is required to correct the patients calcium level. The other data are also consistent with hypocalcemia, but do not indicate a need for as immediate action as laryngospasm

Which assessment finding obtained by the nurse when caring for a patient with a right radial arterial lineindicates a need for the nurse to take immediate action? a. The right hand is cooler than the left hand. b. The mean arterial pressure (MAP) is 77 mm Hg. c. The system is delivering 3 mL of flush solution per hour. d. The flush bag and tubing were last changed 3 days previously

a. The right hand is cooler than the left hand. The change in temperature of the left hand suggests that blood flow to the left hand is impaired. The flush system needs to be changed every 96 hours. A mean arterial pressure (MAP) of 75 mm Hg is normal. Flush systems for hemodynamic monitoring are set up to deliver 3 to 6 mL/hour of flush solution

A patient who is orally intubated and receiving mechanical ventilation is anxious and is fighting the ventilator. Which action should the nurse take next? a. Verbally coach the patient to breathe with the ventilator. b. Sedate the patient with the ordered PRN lorazepam (Ativan). c. Manually ventilate the patient with a bag-valve-mask device. d. Increase the rate for the ordered propofol (Diprivan) infusion

a. Verbally coach the patient to breathe with the ventilator. The initial response by the nurse should be to try to decrease the patients anxiety by coaching the patient about how to coordinate respirations with the ventilator. The other actions may also be helpful if the verbal coaching is ineffective in reducing the patients anxiety

While family members are visiting, a patient has a respiratory arrest and is being resuscitated. Which action by the nurse is best? a. Tell the family members that watching the resuscitation will be very stressful. b. Ask family members if they wish to remain in the room during the resuscitation. c. Take the family members quickly out of the patient room and remain with them. d. Assign a staff member to wait with family members just outside the patient room

b. Ask family members if they wish to remain in the room during the resuscitation. Research indicates that family members want the option of remaining in the room during procedures such as cardiopulmonary resuscitation (CPR) and that this decreases anxiety and facilitates grieving. The other options may be appropriate if the family decides not to remain with the patient

A patient comes to the clinic complaining of frequent, watery stools for the last 2 days. Which action should the nurse take first? a. Obtain the baseline weight. b. Check the patients blood pressure. c. Draw blood for serum electrolyte levels d. Ask about any extremity numbness or tingling

b. Check the patients blood pressure. Because the patients history suggests that fluid volume deficit may be a problem, assessment for adequatecirculation is the highest priority. The other actions are also appropriate, but are not as essential as determiningthe patients perfusion status.

A 68-year-old patient has been in the intensive care unit for 4 days and has a nursing diagnosis of disturbed sensory perception related to sleep deprivation. Which action should the nurse include in the plan of care? a. Administer prescribed sedatives or opioids at bedtime to promote sleep. b. Cluster nursing activities so that the patient has uninterrupted rest periods. c. Silence the alarms on the cardiac monitors to allow 30- to 40-minute naps. d. Eliminate assessments between 0100 and 0600 to allow uninterrupted slee

b. Cluster nursing activities so that the patient has uninterrupted rest periods. Clustering nursing activities and providing uninterrupted rest periods will minimize sleep-cycle disruption.Sedative and opioid medications tend to decrease the amount of rapid eye movement (REM) sleep and cancontribute to sleep disturbance and disturbed sensory perception. Silencing the alarms on the cardiac monitorswould be unsafe in a critically ill patient, as would discontinuing assessments during the nigh

A patient is admitted for hypovolemia associated with multiple draining wounds. Which assessment would be the most accurate way for the nurse to evaluate fluid balance? a. Skin turgor b. Daily weight c. Presence of edema d. Hourly urine output

b. Daily weight Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor variesconsiderably with age. Considerable excess fluid volume may be present before fluid moves into the interstitialspace and causes edema. Although very important, hourly urine outputs do not take account of fluid intake orof fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds

When evaluating a patient with a central venous catheter, the nurse observes that the insertion site is redand tender to touch and the patients temperature is 101.8 F. What should the nurse plan to do next? a. Give analgesics and antibiotics as ordered. b. Discontinue the catheter and culture the tip. c. Change the flush system and monitor the site d. Check the site more frequently for any swelling

b. Discontinue the catheter and culture the tip. The information indicates that the patient has a local and systemic infection caused by the catheter, and the catheter should be discontinued. Changing the flush system, giving analgesics, and continued monitoring will not help prevent or treat the infection. Administration of antibiotics is appropriate, but the line should still bed is continued to avoid further complications such as endocarditis

A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction and iscomplaining of anxiety and incisional pain. The patients respiratory rate is 32 breaths/minute and the arterialblood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first? a. Discontinue the nasogastric suction. b. Give the patient the PRN IV morphine sulfate 4 mg. c. Notify the health care provider about the ABG results. d. Teach the patient how to take slow, deep breaths when anxious

b. Give the patient the PRN IV morphine sulfate 4 mg. The patients respiratory alkalosis is caused by the increased respiratory rate associated with pain and anxiety. The nurses first action should be to medicate the patient for pain. Although the nasogastric suction may contribute to the alkalosis, it is not appropriate to discontinue the tube when the patient needs gastric suction. The health care provider may be notified about the ABGs but is likely to instruct the nurse to medicate for pain. The patient will not be able to take slow, deep breaths when experiencing pain

Following surgery for an abdominal aortic aneurysm, a patients central venous pressure (CVP) monitor indicates low pressures. Which action is a priority for the nurse to take? a. Administer IV diuretic medications. b. Increase the IV fluid infusion per protocol. c. Document the CVP and continue to monitor. d. Elevate the head of the patients bed to 45 degrees

b. Increase the IV fluid infusion per protocol. A low CVP indicates hypovolemia and a need for an increase in the infusion rate. Diuretic administration will contribute to hypovolemia and elevation of the head may decrease cerebral perfusion. Documentation and continued monitoring is an inadequate response to the low CVP

Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Administer IV antibiotics through the implantable port. b. Monitor the IV sites for redness, swelling, or tenderness. c. Remove the patients nontunneled subclavian central venous catheter. d. Adjust the flow rate of the 0.9% normal saline in the peripheral IV line

b. Monitor the IV sites for redness, swelling, or tenderness. An experienced LPN/LVN has the education, experience, and scope of practice to monitor IV sites for signs of infection. Administration of medications, adjustment of infusion rates, and removal of central catheters in critically ill patients require RN level education and scope of practice.

A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studiesare done. Which laboratory value will require the most immediate action by the nurse? a. Arterial blood pH is 7.32. b. Serum calcium is 18 mg/dL. c. Serum potassium is 5.1 mEq/L. d. Arterial oxygen saturation is 91%

b. Serum calcium is 18 mg/dL. The serum calcium is well above the normal level and puts the patient at risk for cardiac dysrhythmias. Thenurse should initiate cardiac monitoring and notify the health care provider. The potassium, oxygen saturation,and pH are also abnormal, and the nurse should notify the health care provider about these values as well, butthey are not immediately life threatening.

Which hemodynamic parameter is most appropriate for the nurse to monitor to determine the effectiveness of medications given to a patient to reduce left ventricular afterload? a. Mean arterial pressure (MAP) b. Systemic vascular resistance (SVR) c. Pulmonary vascular resistance (PVR) d. Pulmonary artery wedge pressure (PAWP

b. Systemic vascular resistance (SVR) Systemic vascular resistance reflects the resistance to ventricular ejection, or afterload. The other parameterswill be monitored, but do not reflect afterload as directly.

The nurse educator is evaluating the performance of a new registered nurse (RN) who is providing care to apatient who is receiving mechanical ventilation with 15 cm H2O of peak end-expiratory pressure (PEEP).Which action indicates that the new RN is safe? a. The RN plans to suction the patient every 1 to 2 hours. b. The RN uses a closed-suction technique to suction the patient. c. The RN tapes connection between the ventilator tubing and the ET. d. The RN changes the ventilator circuit tubing routinely every 48 hours

b. The RN uses a closed-suction technique to suction the patient. The closed-suction technique is used when patients require high levels of PEEP (>10 cm H2O) to prevent the loss of PEEP that occurs when disconnecting the patient from the ventilator. Suctioning should not be scheduled routinely, but it should be done only when patient assessment data indicate the need for suctioning. Taping connections between the ET and the ventilator tubing would restrict the ability of the tubing to swivel in response to patient repositioning. Ventilator tubing changes increase the risk for ventilator-associated pneumonia (VAP) and are not indicated routinely

When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which finding should the nurse report to the health care provider immediately? a. The bibasilar breath sounds are decreased. b. The patellar and triceps reflexes are absent. c. The patient has been sleeping most of the day. d. The patient reports feeling sick to my stomach

b. The patellar and triceps reflexes are absent. The loss of the deep tendon reflexes indicates that the patients magnesium level may be reaching toxic levels. Nausea and lethargy also are side effects associated with magnesium elevation and should be reported, but they are not as significant as the loss of deep tendon reflexes. The decreased breath sounds suggest that the patient needs to cough and deep breathe to prevent atelectasis

When caring for a patient who has an arterial catheter in the left radial artery for arterial pressurebasedcardiac output (APCO) monitoring, which information obtained by the nurse is most important to report to thehealth care provider? a. The patient has a positive Allen test. b. There is redness at the catheter insertion site. c. The mean arterial pressure (MAP) is 86 mm Hg. d. The dicrotic notch is visible in the arterial waveform

b. There is redness at the catheter insertion site. Redness at the catheter insertion site indicates possible infection. The Allen test is performed before arterial line insertion, and a positive test indicates normal ulnar artery perfusion. A MAP of 86 is normal and the dicrotic notch is normally present on the arterial waveform

An 81-year-old patient who has been in the intensive care unit (ICU) for a week is now stable and transfer to the progressive care unit is planned. On rounds, the nurse notices that the patient has new onset confusion. The nurse will plan to a. give PRN lorazepam (Ativan) and cancel the transfer. b. inform the receiving nurse and then transfer the patient. c. notify the health care provider and postpone the transfer. d. obtain an order for restraints as needed and transfer the patient

b. inform the receiving nurse and then transfer the patient. The patients history and symptoms most likely indicate delirium associated with the sleep deprivation and sensory overload in the ICU environment. Informing the receiving nurse and transferring the patient is appropriate. Postponing the transfer is likely to prolong the delirium. Benzodiazepines and restraints contribute to delirium and agitation

The intensive care unit (ICU) nurse educator will determine that teaching about arterial pressure monitoring for a new staff nurse has been effective when the nurse a. balances and calibrates the monitoring equipment every 2 hours. b. positions the zero-reference stopcock line level with the phlebostatic axis. c. ensures that the patient is supine with the head of the bed flat for all readings. d. rechecks the location of the phlebostatic axis when changing the patients position

b. positions the zero-reference stopcock line level with the phlebostatic axis. For accurate measurement of pressures, the zero-reference level should be at the phlebostatic axis. There is no need to rebalance and recalibrate monitoring equipment hourly. Accurate hemodynamic readings are possible with the patients head raised to 45 degrees or in the prone position. The anatomic position of the phlebostatic axis does not change when patients are repositioned

The central venous oxygen saturation (ScvO2) is decreasing in a patient who has severe pancreatitis. To determine the possible cause of the decreased ScvO2, the nurse assesses the patients a. lipase. b. temperature. c. urinary output. d. body mass index

b. temperature. Elevated temperature increases metabolic demands and oxygen use by tissues, resulting in a drop in oxygen saturation of central venous blood. Information about the patients body mass index, urinary output, and lipase will not help in determining the cause of the patients drop in ScvO2

The nurse notes thick, white secretions in the endotracheal tube (ET) of a patient who is receivingmechanical ventilation. Which intervention will be most effective in addressing this problem? a. Increase suctioning to every hour. b. Reposition the patient every 1 to 2 hours. c. Add additional water to the patients enteral feedings. d. Instill 5 mL of sterile saline into the ET before suctioning

c. Add additional water to the patients enteral feedings. Because the patients secretions are thick, better hydration is indicated. Suctioning every hour without anyspecific evidence for the need will increase the incidence of mucosal trauma and would not address theetiology of the ineffective airway clearance. Instillation of saline does not liquefy secretions and may decreasethe SpO2. Repositioning the patient is appropriate but will not decrease the thickness of secretions

Which action is a priority for the nurse to take when the low pressure alarm sounds for a patient who has anarterial line in the left radial artery? a. Fast flush the arterial line. b. Check the left hand for pallor. c. Assess for cardiac dysrhythmias. d. Rezero the monitoring equipment

c. Assess for cardiac dysrhythmias. The low pressure alarm indicates a drop in the patients blood pressure, which may be caused by cardiac dysrhythmias. There is no indication to rezero the equipment. Pallor of the left hand would be caused by occlusion of the radial artery by the arterial catheter, not by low pressure. There is no indication of a need for flushing the line.

Which action should the nurse take first when a patient complains of acute chest pain and dyspnea soon after insertion of a centrally inserted IV catheter? a. Notify the health care provider. b. Offer reassurance to the patient. c. Auscultate the patients breath sounds. d. Give the prescribed PRN morphine sulfate IV

c. Auscultate the patients breath sounds. The initial action should be to assess the patient further because the history and symptoms are consistent with several possible complications of central line insertion, including embolism and pneumothorax. The other actions may be appropriate, but further assessment of the patient is needed before notifying the health care provider, offering reassurance, or administration of morphine.

An intraaortic balloon pump (IABP) is being used for a patient who is in cardiogenic shock. Whichassessment data indicate to the nurse that the goals of treatment with the IABP are being met? a. Urine output of 25 mL/hr b. Heart rate of 110 beats/minute c. Cardiac output (CO) of 5 L/min d. Stroke volume (SV) of 40 mL/beat

c. Cardiac output (CO) of 5 L/min A CO of 5 L/min is normal and indicates that the IABP has been successful in treating the shock. The low SV signifies continued cardiogenic shock. The tachycardia and low urine output also suggest continued cardiogenic shock

The family members of a patient who has just been admitted to the intensive care unit (ICU) with multipletraumatic injuries have just arrived in the ICU waiting room. Which action should the nurse take next? a. Explain ICU visitation policies and encourage family visits. b. Immediately take the family members to the patients bedside. c. Describe the patients injuries and the care that is being provided. d. Invite the family to participate in a multidisciplinary care conference

c. Describe the patients injuries and the care that is being provided. Lack of information is a major source of anxiety for family members and should be addressed first. Family members should be prepared for the patients appearance and the ICU environment before visiting the patient for the first time. ICU visiting should be individualized to each patient and family rather than being dictated by rigid visitation policies. Inviting the family to participate in a multidisciplinary conference is appropriate but should not be the initial action by the nurse

The nurse notes that a patients endotracheal tube (ET), which was at the 22-cm mark, is now at the 25-cmmark and the patient is anxious and restless. Which action should the nurse take next? a. Offer reassurance to the patient. b. Bag the patient at an FIO2 of 100%. c. Listen to the patients breath sounds. d. Notify the patients health care provider

c. Listen to the patients breath sounds The nurse should first determine whether the ET tube has been displaced into the right mainstem bronchus by listening for unilateral breath sounds. If so, assistance will be needed to reposition the tube immediately. The other actions are also appropriate, but detection and correction of tube malposition are the most critical actions

The nurse is caring for a patient who has an intraaortic balloon pump in place. Which action should beincluded in the plan of care? a. Position the patient supine at all times. b. Avoid the use of anticoagulant medications. c. Measure the patients urinary output every hour. d. Provide passive range of motion for all extremities

c. Measure the patients urinary output every hour. Monitoring urine output will help determine whether the patients cardiac output has improved and also help monitor for balloon displacement. The head of the bed can be elevated up to 30 degrees. Heparin is used to prevent thrombus formation. Limited movement is allowed for the extremity with the balloon insertion site to prevent displacement of the balloon

After receiving change-of-shift report, which patient should the nurse assess first? a. Patient with serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping b. Patient with serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water c. Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes d. Patient with serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium-phosphate precipitates

c. Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes The low magnesium level and neuromuscular irritability suggest that the patient may be at risk for seizures.The other patients have mild electrolyte disturbances and/or symptoms that require action, but they are not atrisk for life-threatening complication

When caring for a patient with pulmonary hypertension, which parameter is most appropriate for the nurseto monitor to evaluate the effectiveness of the treatment? a. Central venous pressure (CVP) b. Systemic vascular resistance (SVR) c. Pulmonary vascular resistance (PVR) d. Pulmonary artery wedge pressure (PAWP)

c. Pulmonary vascular resistance (PVR) PVR is a major contributor to pulmonary hypertension, and a decrease would indicate that pulmonary hypertension was improving. The other parameters also may be monitored but do not directly assess for pulmonary hypertension.

A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretichormone (SIADH). The nurse should notify the health care provider about which assessment finding? a. Reported weight gain b. Serum hematocrit of 42% c. Serum sodium level of 120 mg/dL d. Total urinary output of 280 mL during past 8 hour

c. Serum sodium level of 120 mg/dL Hyponatremia is the most important finding to report. SIADH causes water retention and a decrease in serumsodium level. Hyponatremia can cause confusion and other central nervous system effects. A critically lowvalue likely needs to be treated. At least 30 mL/hr of urine output indicates adequate kidney function. Thehematocrit level is normal. Weight gain is expected with SIADH because of water retentio

The nurse notes premature ventricular contractions (PVCs) while suctioning a patients endotracheal tube. Which action by the nurse is a priority? a. Decrease the suction pressure to 80 mm Hg. b. Document the dysrhythmia in the patients chart. c. Stop and ventilate the patient with 100% oxygen. d. Give antidysrhythmic medications per protocol

c. Stop and ventilate the patient with 100% oxygen. Dysrhythmias during suctioning may indicate hypoxemia or sympathetic nervous system stimulation. The nurse should stop suctioning and ventilate the patient with 100% oxygen. Lowering the suction pressure will decrease the effectiveness of suctioning without improving the hypoxemia. Because the PVCs occurred during suctioning, there is no need for antidysrhythmic medications (which may have adverse effects) unless they recur when the suctioning is stopped and patient is well oxygenated

The nurse is caring for a patient receiving a continuous norepinephrine (Levophed) IV infusion. Whichpatient assessment finding indicates that the infusion rate may need to be adjusted? a. Heart rate is 58 beats/minute. b. Mean arterial pressure (MAP) is 56 mm Hg. c. Systemic vascular resistance (SVR) is elevated. d. Pulmonary artery wedge pressure (PAWP) is low

c. Systemic vascular resistance (SVR) is elevated. Vasoconstrictors such as norepinephrine (Levophed) will increase SVR, and this will increase the work of theheart and decrease peripheral perfusion. The infusion rate may need to be decreased. Bradycardia, hypotension(MAP of 56 mm Hg), and low PAWP are not associated with norepinephrine infusion

A nurse is weaning a 68-kg male patient who has chronic obstructive pulmonary disease (COPD) frommechanical ventilation. Which patient assessment finding indicates that the weaning protocol should be stopped? a. The patients heart rate is 97 beats/min. b. The patients oxygen saturation is 93%. c. The patient respiratory rate is 32 breaths/min. d. The patients spontaneous tidal volume is 450 mL

c. The patient respiratory rate is 32 breaths/min. Tachypnea is a sign that the patients work of breathing is too high to allow weaning to proceed. The patients heart rate is within normal limits, although the nurse should continue to monitor it. An oxygen saturation of93% is acceptable for a patient with COPD. A spontaneous tidal volume of 450 mL is within the acceptable range

Which assessment finding obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning? a. The patients oxygen saturation is 93%. b. The patient was last suctioned 6 hours ago. c. The patients respiratory rate is 32 breaths/minute d. The patient has occasional audible expiratory wheezes.

c. The patients respiratory rate is 32 breaths/minute The increase in respiratory rate indicates that the patient may have decreased airway clearance and requires suctioning. Suctioning is done when patient assessment data indicate that it is needed, not on a scheduled basis. Occasional expiratory wheezes do not indicate poor airway clearance, and suctioning the patient may induce bronchospasm and increase wheezing. An oxygen saturation of 93% is acceptable and does not suggest that immediate suctioning is needed

A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. It is most appropriate for the nurse to take which action? a. Assess for facial muscle spasms. b. Ask the patient about loose stools. c. Suggest that the patient avoid orange juice with meals d. Ask the health care provider to order a basic metabolic panel.

d. Ask the health care provider to order a basic metabolic panel. Generalized weakness is a manifestation of hypokalemia. After the health care provider orders the metabolicpanel, the nurse should check the potassium level. Facial muscle spasms might occur with hypocalcemia.Orange juice is high in potassium and would be advisable to drink if the patient was hypokalemic. Loose stoolsare associated with hyperkalemia

Which action will the nurse need to do when preparing to assist with the insertion of a pulmonary arterycatheter? a. Determine if the cardiac troponin level is elevated. b. Auscultate heart and breath sounds during insertion. c. Place the patient on NPO status before the procedure. d. Attach cardiac monitoring leads before the procedure

d. Attach cardiac monitoring leads before the procedure Dysrhythmias can occur as the catheter is floated through the right atrium and ventricle, and it is important for the nurse to monitor for these during insertion. Pulmonary artery catheter insertion does not require anesthesia, and the patient will not need to be NPO. Changes in cardiac troponin or heart and breath sounds are not expected during pulmonary artery catheter insertion

When caring for the patient with a pulmonary artery (PA) pressure catheter, the nurse observes that the PAwaveform indicates that the catheter is in the wedged position. Which action should the nurse take next? a. Zero balance the transducer. b. Activate the fast flush system. c. Notify the health care provider. d. Deflate and reinflate the PA balloon

d. Deflate and reinflate the PA balloon When the catheter is in the wedge position, blood flow past the catheter is obstructed, placing the patient at riskfor pulmonary infarction. A health care provider or advanced practice nurse should be called to reposition thecatheter. The other actions will not correct the wedging of the PA catheter.

The nurse responds to a ventilator alarm and finds the patient lying in bed holding the endotracheal tube(ET). Which action should the nurse take next? a. Activate the rapid response team. b. Provide reassurance to the patient. c. Call the health care provider to reinsert the tube. d. Manually ventilate the patient with 100% oxygen

d. Manually ventilate the patient with 100% oxygen The nurse should ensure maximal patient oxygenation by manually ventilating with a bag-valve-mask system. Offering reassurance to the patient, notifying the health care provider about the need to reinsert the tube, and activating the rapid response team are also appropriate after the nurse has stabilized the patients oxygenation

After change-of-shift report, which patient should the progressive care nurse assess first? a. Patient who was extubated in the morning and has a temperature of 101.4 F (38.6 C) b. Patient with bilevel positive airway pressure (BiPAP) for sleep apnea whose respiratory rate is 16 c. Patient with arterial pressure monitoring who is 2 hours postpercutaneous coronary intervention who needs to void d. Patient who is receiving IV heparin for a venous thromboembolism and has a partial thromboplastin time (PTT) of 98 sec

d. Patient who is receiving IV heparin for a venous thromboembolism and has a partial thromboplastin time (PTT) of 98 sec The findings for this patient indicate high risk for bleeding from an elevated (nontherapeutic) PTT. The nurse needs to adjust the rate of the infusion (dose) per the health care providers parameters. The patient with BiPAP for sleep apnea has a normal respiratory rate. The patient recovering from the percutaneous coronary intervention will need to be assisted with voiding and this task could be delegated to unlicensed assistive personnel. The patient with a fever may be developing ventilator-associated pneumonia, but addressing the bleeding risk is a higher priority

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

d. Patient who was successfully weaned and extubated 4 hours ago and now has no urine output for the last 6 hours The decreased urine output may indicate acute kidney injury or that the patients cardiac output and perfusionof vital organs have decreased. Any of these causes would require rapid action. The data about the otherpatients indicate that their conditions are stable and do not require immediate assessment or changes in theircare. Continuous PETCO2 monitoring is frequently used when patients are intubated. The rest mode should beused to allow patient recovery after a failed SBT, and an ScvO2 of 69% is within normal limits.

The nurse educator is evaluating the care that a new registered nurse (RN) provides to a patient receivingmechanical ventilation. Which action by the new RN indicates the need for more education? a. The RN increases the FIO2 to 100% before suctioning. b. The RN secures a bite block in place using adhesive tape. c. The RN asks for assistance to reposition the endotracheal tube. d. The RN positions the patient with the head of bed at 10 degrees

d. The RN positions the patient with the head of bed at 10 degrees The head of the patients bed should be positioned at 30 to 45 degrees to prevent ventilator-associated pneumonia. The other actions by the new RN are appropriate

A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data willrequire the most rapid response by the nurse? a. The patients radial pulse is 105 beats/minute. b. There is sediment and blood in the patients urine c. The blood pressure increases from 120/80 to 142/94. d. There are crackles audible throughout both lung fields

d. There are crackles audible throughout both lung fields Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a life-threatening adverse effect of hypertonic solutions. The increased pulse rate and blood pressure and the appearance of the urine also should be reported, but they are not as dangerous as the presence of fluid in the alveoli.

Four hours after mechanical ventilation is initiated for a patient with chronic obstructive pulmonary disease(COPD), the patients arterial blood gas (ABG) results include a pH of 7.51, PaO2 of 82 mm Hg, PaCO2 of 26mm Hg, and HCO3 of 23 mEq/L (23 mmol/L). The nurse will anticipate the need to a. increase the FIO2. b. increase the tidal volume. c. increase the respiratory rate. d. decrease the respiratory rate.

d. decrease the respiratory rate. The patients PaCO2 and pH indicate respiratory alkalosis caused by too high a respiratory rate. The PaO2 is appropriate for a patient with COPD and increasing the respiratory rate and tidal volume would further lower the PaCO2

The nurse is caring for a patient with a subarachnoid hemorrhage who is intubated and placed on a mechanical ventilator with 10 cm H2O of peak end-expiratory pressure (PEEP). When monitoring the patient, the nurse will need to notify the health care provider immediately if the patient develops a. oxygen saturation of 93%. b. respirations of 20 breaths/minute. c. green nasogastric tube drainage. d. increased jugular venous distention

d. increased jugular venous distention Increases in jugular venous distention in a patient with a subarachnoid hemorrhage may indicate an increase in intracranial pressure (ICP) and that the PEEP setting is too high for this patient. A respiratory rate of 20,O2saturation of 93%, and green nasogastric tube drainage are within normal limits

To maintain proper cuff pressure of an endotracheal tube (ET) when the patient is on mechanical ventilation, the nurse should a. inflate the cuff with a minimum of 10 mL of air b. inflate the cuff until the pilot balloon is firm on palpation. c. inject air into the cuff until a manometer shows 15 mm Hg pressure. d. inject air into the cuff until a slight leak is heard only at peak inflation

d. inject air into the cuff until a slight leak is heard only at peak inflation The minimal occluding volume technique involves injecting air into the cuff until an air leak is present only atpeak inflation. The volume to inflate the cuff varies with the ET and the patients size. Cuff pressure should bemaintained at 20 to 25 mm Hg. An accurate assessment of cuff pressure cannot be obtained by palpating thepilot balloon

While waiting for cardiac transplantation, a patient with severe cardiomyopathy has a ventricular assistdevice (VAD) implanted. When planning care for this patient, the nurse should anticipate a. giving immunosuppressive medications. b. preparing the patient for a permanent VAD. c. teaching the patient the reason for complete bed rest. d. monitoring the surgical incision for signs of infection

d. monitoring the surgical incision for signs of infection The insertion site for the VAD provides a source for transmission of infection to the circulatory system and requires frequent monitoring. Patients with VADs are able to have some mobility and may not be on bed rest. The VAD is a bridge to transplantation, not a permanent device. immunosuppression is not necessary for nonbiologic devices like the VAD

When monitoring for the effectiveness of treatment for a patient with a large anterior wall myocardialinfarction, the most important information for the nurse to obtain is a. central venous pressure (CVP). b. systemic vascular resistance (SVR). c. pulmonary vascular resistance (PVR). d. pulmonary artery wedge pressure (PAWP)

d. pulmonary artery wedge pressure (PAWP) PAWP reflects left ventricular end diastolic pressure (or left ventricular preload) and is a sensitive indicator of cardiac function. Because the patient is high risk for left ventricular failure, the PAWP must be monitored. An increase will indicate left ventricular failure. The other values would also provide useful information, but the most definitive measurement of changes in cardiac function is the PAWP

When assisting with the placement of a pulmonary artery (PA) catheter, the nurse notes that the catheter is correctly placed when the monitor shows a a. typical PA pressure waveform b. tracing of the systemic arterial pressure. c. tracing of the systemic vascular resistance. d. typical PA wedge pressure (PAWP) tracing

d. typical PA wedge pressure (PAWP) tracing The purpose of a PA line is to measure PAWP, so the catheter is floated through the pulmonary artery until the dilated balloon wedges in a distal branch of the pulmonary artery, and the PAWP readings are available. After insertion, the balloon is deflated and the PA waveform will be observed. Systemic arterial pressures are obtained using an arterial line and the systemic vascular resistance is a calculated value, not a waveform

To verify the correct placement of an oral endotracheal tube (ET) after insertion, the best initial action by the nurse is to a. auscultate for the presence of bilateral breath sounds. b. obtain a portable chest x-ray to check tube placement. c. observe the chest for symmetric chest movement with ventilation d. use an end-tidal CO2 monitor to check for placement in the trachea

d. use an end-tidal CO2 monitor to check for placement in the trachea End-tidal CO2 monitors are currently recommended for rapid verification of ET placement. Auscultation forbilateral breath sounds and checking chest expansion are also used, but they are not as accurate as end-tidalCO2monitoring. A chest x-ray confirms the placement but is done after the tube is secure