NCLEX Critical Care Questions
Where is the phlebostatic axis located?
The 4th ICS, at the midway point of the AP diameter (½ AP) of the chest wall. The stopcock nearest the transducer is placed here to assure accurate pressure measurements.
What is normal pulmonary artery wedge pressure (PAWP)?
normal value 6-12 mm Hg
What type of tube is gastric lavage done through?
orogastric tube
An intoxicated client not wearing a seatbelt drives into a metal barricade near the entrance to the emergency department. The client's head has hit the windshield, and the client is unconscious. What nurse actions are appropriate?
1) Assess the patient for a carotid pulse 2) Determine the glasgow coma scale score 3) Maintain airway with jaw thrust maneuver (done in those who may have possible spinal injuries 4) Place hard cervical collar on 5) Move from car and onto backboard
What is the treatment for stable VT vs. unstable VT (pulse vs. pulseless)?
1) The unstable client in VT with a pulse is treated with synchronized cardioversion. 2) The stable client in VT with a pulse is treated with antiarrhythmic medications (eg, amiodarone, procainamide, sotalol).
What is the rate of compressions for CPR on an adult?
100 - 120
What is torsades de pointes?
A polymorphic ventricular tachycardia characterized by QRS complexes that change size and shape in a characteristic twisting pattern. Torsades de pointes is usually due to a prolonged QT interval (more than half the RR interval), which is the result of electrolyte imbalances, especially hypomagnesemia, or some medications.
What is IV dopamine used for?
A vasopressor used to treat symptomatic hypotension.
What is decorticate posturing?
Abnormal flexion: Hands pulled to chest and hyper-extended. Internal rotation and adduction of the arms with flexion of the elbows, wrists & fingers. "flexor - toward the cord"
The client is brought to the emergency department after falling off a roof and landing on his back. A T1 spinal fracture is diagnosed. The client's blood pressure is 74/40 mm Hg, pulse is 50/min, and skin is pink and dry. What nursing action is a priority?
Administer IV NS
What is adenosine used for?
An anti-arrhythmic used to treat supraventricular tachycardia.
Where is the aortic area located?
An auscultatory area located at the 2nd ICS to the right of the sternal border.
Where is the mitral area (apex)?
An auscultatory area, and the point of maximal impulse are located at the 5th ICS at the MCL.
What are the criteria for calling the rapid response team?
Any provider worried about the client's condition OR An acute change in any of the following: Heart rate <40 or >130/min Systolic blood pressure <90 mm Hg Respiratory rate <8 or >28/min (Option 4) Oxygen saturation <90 despite oxygen Urine output <50 mL/4 hr Level of consciousness
The nurse is preparing to defibrillate a client who suddenly went into ventricular fibrillation. Which steps are essential prior to delivering a shock?
Apply defibrillator pads Call out all clear Continue chest compressions until ready to give shock
The nurse is caring for an intubated client whose oxygen saturation begins to drop. What action should the nurse do next?
Auscultate lungs sounds bilaterally - need to determine cause before you do something next
A client with palpitations is admitted with supraventricular tachycardia. The client's heart rate is 210/min. Which is the most appropriate initial intervention?
Ask the patient to bear down as if having a bowel movement - then use adenosine IV push if ineffective
A client with hypothermia has just arrived in the emergency department via ambulance. The client is being rewarmed with blankets, and the IV fluids are being changed over to warmed fluids. What additional intervention is a priority?
Attaching the cardiac monitor - v-fib can occur from hypothermia, anticipate defibrillation
The nurse is caring for a client on a mechanical ventilator. The settings on the ventilator have just been changed, and the standing prescription is to draw arterial blood gases 30 minutes after a ventilator change. In anticipation of this blood draw, what intervention should the nurse implement?
Avoid suctioning the patient
A client with acute respiratory distress syndrome is receiving positive pressure mechanical ventilation with 15 cm H2O (11 mm Hg) positive end-expiratory pressure (PEEP). The nurse should assess for which complication associated with PEEP?
Barotrauma - High PEEP is commonly used to prevent small airway/alveolar collapse in clients with ARDS. PEEP helps to reduce oxygen toxicity. However, high levels of PEEP (10-20 cm H2O [7.4-14.8 mm Hg]) can cause barotrauma to the lung, resulting in a pneumothorax, and decreased venous return causes hypotension.
What does PEEP do?
PEEP opens up collapsed alveoli and improves gas exchange at a lower fraction of inspired oxygen (FiO2), resulting in increased, not decreased, oxygen saturation.
The nurse is caring for a client with surgical complications who requires continuous total parenteral nutrition (TPN). The nurse assists the health care provider with the insertion of a subclavian triple lumen central venous access device. What is the nurse's priority action before initiating the TPN infusion?
Check results of the chest x-ray
A client who is 2 hours post aortic valve replacement is in the intensive care unit (ICU). The low pressure alarm for the client's radial arterial line sounds. Which action should the nurse take first?
Check for bleeding at the tube connector sites
The nurse is caring for a client in the immediate postoperative period following an exploratory laparotomy after sustaining a gunshot wound to the abdomen. Which assessment finding is most important for the nurse to report to the health care provider?
Cold and clammy skin - Cold, clammy skin indicates failing compensatory mechanisms (ie, progressive stage), and immediate intervention is necessary to prevent irreversible shock and death.
Emergency medical service personnel are transporting a near-drowning victim who is currently hypothermic. Based on anticipated vital signs, the nurse needs to prepare for which interventions?
Covering patient with warm blankets Mechanical ventilation Warmed IV fluids
decerebrate vs decorticate
Decerebrate: - more severe position (means more brain damage) - arms and legs straight out, toes pointed down, and head and neck arched back (AWAY is WORSE) Decorticate: flexed in towards body
What is a square wave test?
Fast flush of the arterial line that verifies if the arterial line is functioning properly
What is Guillain-Barré syndrome (GBS)?
Guillain-Barré syndrome (GBS) is an acute, immune-mediated polyneuropathy that is most often accompanied by ascending muscle paralysis and absence of reflexes. Lower-extremity weakness progresses over hours to days to involve the thorax, arms, and cranial nerves (CNs).
What are the hemodynamic effects of PEEP?
Hemodynamic effects of PEEP include increased intrathoracic pressure, which leads to reduced venous return, decreased preload and cardiac output, and hypotension, not hypertension.
The nurse is caring for a client with sepsis and acute respiratory failure who was intubated and prescribed mechanical ventilation 3 days ago. The nurse assesses for which adverse effect associated with the administration of positive pressure ventilation (PPV)?
Hypotension - Positive pressure ventilation causes increased intrathoracic pressure and reduced venous return and cardiac output, which can result in hypotension.
Patient has BP of 82/58. What prescription should be given first?
IV bolus of NS 2L - if patient remains hypotensive, then give norepi
What type of fluids do patients in hypovolemic shock require?
Isotonic solutions (LR, 0.9% NS)
When is epi given during a code?
It is given after compressions and defibrillation
To obtain accurate continuous blood pressure readings via a radial arterial catheter, the nurse places the air-filled interface of the stopcock at the phlebostatic axis. Where is it located?
Level of atria at 4th intercostal space, 1/2 anterior - posterior (AP) diameter
The nurse is assisting with cardiopulmonary resuscitation of a client in cardiac arrest. The rhythm in the exhibit is displayed on the cardiac monitor. Which medication administration should the nurse anticipate?
Magnesium IV - used for torsades de pointes
A nurse is caring for a client on a mechanical ventilator. The ventilator is sounding an alarm and displaying an alert about low tidal volumes. The nurse has checked all connections and the endotracheal tube, but the alarm persists and the client's oxygen saturation is dropping. What should the nurse do next?
Manually ventilate with a resuscitation bag device attached to the ET tube - If a ventilator alarm cannot be readily resolved, the nurse should manually ventilate the client's lungs with a resuscitation bag device.
Upon arrival in the post-anesthesia care unit, the nurse performs the initial assessment of a client who had surgery under general anesthesia. Which assessment finding prompts the nurse to notify the health care provider immediately?
Muscle stiffness - Malignant hyperthermia (MH) is a rare, life-threatening inherited muscle abnormality that is triggered by certain drugs used to induce general anesthesia. The most specific characteristic signs and symptoms of MH include hypercapnia, muscle rigidity, and hyperthermia.
What is normal central venous pressure?
Normal central venous pressure is 2-8 mm Hg is 2-8 mm Hg
What is normal MAP?
Normal central venous pressure is 2-8 mm Hg; normal mean arterial pressure ([systolic blood pressure + (2 x diastolic blood pressure)]/3) is 70-105 mm Hg
The nurse is caring for a client who was just resuscitated following an out-of-hospital cardiac arrest. The client does not follow commands and remains comatose. What intervention does the nurse anticipate being added to the client's plan of care?
Obtaining equipment and cold fluids for the induction of therapeutic hypothermia - Following return of spontaneous circulation in an out-of-hospital cardiac arrest, therapeutic hypothermia should be implemented for 24 hours in clients who are comatose or do not follow commands. Therapeutic hypothermia has been shown to improve neurologic outcomes and decrease mortality in these clients.
When caring for a client with a left radial artery catheter, which assessment data obtained by the nurse indicates the need to take immediate action?
Patient's left hand is cooler than the right
The charge nurse is evaluating the skills of a new registered nurse (RN) assigned to care for a client with shock. Which action taken by the new RN indicates a need for further education?
Places the patient with sepsis in high fowlers position - this causes BP to decrease
The emergency department nurse is caring for a client who requires gastric lavage for a drug overdose. Which action would be appropriate?
Prepare intubation and suction supplies at the bedside
A registered nurse is precepting a new nurse in the intensive care unit. The client is sedated with propofol, on a mechanical ventilator, and is receiving enteral feeding via nasogastric tube. The new nurse performs interventions to prevent aspiration. The preceptor should intervene if the new nurse performs which of the following actions?
Requests that the doctor change continuous feedings to bolus - bolus feedings are contraindicated in most CC patients due to aspiration risk
What is the life threatening complication of Guillain-Barré syndrome?
Respiratory compromise from the paralysis ascending into the thoracic region. - Monitoring for rate/depth of respirations and measuring serial bedside vital capacity (spirometry) help to detect this early in the disease course.
Which rhythms are ideal for synchronized cardioversion?
Rhythms that are ideal for synchronized cardioversion are supraventricular tachycardia, ventricular tachycardia with a pulse, and atrial fibrillation with rapid ventricular response. - If the defibrillator is not synchronized with the R wave in a client with a pulse, the shock may be delivered on the T wave and can cause a lethal arrhythmia (eg, Vfib).
The flight nurse assesses an alert and oriented client at an industrial accident scene who was impaled in the abdomen by a pair of scissors. Which nursing action is the immediate priority on arrival at the scene?
Stabilize the scissors with sterile, bulky dressings
The intensive care nurse is caring for a client who has just been extubated. Which interventions are appropriate at this time?
Start patient on a inceptive spirometer Provide oral care Give warmed, humidified O2
Which rhythms are NOT ideal for synchronized cardioversion?
Synchronized cardioversion delivers a shock on the R wave of the QRS complex and would not be appropriate for a client in Vfib (no identifiable QRS complexes).
The nurse in the intensive care unit is caring for a client who is postoperative from a cardiac surgery. The client has a mediastinal chest tube. During assessment, the nurse notes bubbling in the suction control chamber. Which nursing action is appropriate?
Take no action since the chest tube system is functioning appropriately
What is the angle of Louis?
The palpable raised notch where the manubrium and sternum are joined. - This anatomical location is useful in counting the ICSs and in finding auscultatory areas.
The nurse is caring for a client who had a near-drowning accident in cold weather. Which assessment finding indicates the most severe injury?
Toes pointed straight down - this indicates decerebrate posture which means the patient severe brain damage
What is an Allen's test?
a method of gauging the flow of blood in the hands it's used to determine adequate collateral blood flow in the hand by evaluating the patency of the radial and ulnar arteries - patient makes fist, occlude radial and ulnar arteries, open fist, palm shows pallor, release pressure on ulnar artery, color comes back to hand
What is normal systemic vascular resistance?
normal systemic vascular resistance is 800-1200 dynes/sec/cm-5
neurogenic shock
hypoperfusion due to nerve paralysis (sometimes caused by spinal cord injuries) resulting in the dilation of blood vessels that increases the volume of the circulatory system beyond the point where it can be filled.
What is pulmonary artery wedge pressure? (PAWP)
indirect measure of pressure in the left ventricle at the end of diastole - 6-12