chapter 66 questions

arterial systolic

105-160

PCWP

12-15

PA Systolic

15-30

CVP

2-10

CO (HR X SV)

4.5-9

PA Diastolic

5-12

PVR (PAM-PCWP) X 80/ CO

50-90

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

54 Stroke volume = cardiac output/heart rate

arterial diastolic

55-85

HR

60-100

SV (CO/HR)

60-120

MAP

70-110

SVR (MAP -CVP) x 80 / co

800-1200

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

ANS: 54 Stroke volume = cardiac output/heart rate

The nurse is caring for a patient who has an intraortic balloon pump (IABP) following a massive heart attack. When assessing the patient, the nurse notices blood backing up into the IABP catheter. In which order should the nurse take the following actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Ensure that the IABP console has turned off. b. Assess the patient's vital signs and orientation. c. Obtain supplies for insertion of a new IABP catheter. d. Notify the health care provider of the IABP malfunction.

ANS: A, B, D, C Blood in the IABP catheter indicates a possible tear in the balloon. The console will shut off automatically to prevent complications such as air embolism. Next, the nurse will assess the patient and communicate with the health care provider about the patient's assessment and the IABP problem. Finally, supplies for insertion of a new IABP catheter may be needed, based on the patient assessment and the decision of the health care provider.

Which assessment finding obtained by the nurse when caring for a patient with a right radial arterial line indicates 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.

ANS: A 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.

Following surgery for an abdominal aortic aneurysm, a patient's 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 patient's bed to 45 degrees.

ANS: B 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.

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 patient's a. lipase. b. temperature. c. urinary output. d. body mass index.

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

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 patient's position.

ANS: B 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 patient's head raised to 45 degrees or in the prone position. The anatomic position of the phlebostatic axis does not change when patients are repositioned.

When caring for a patient who has an arterial catheter in the left radial artery for arterial pressure-based cardiac output (APCO) monitoring, which information obtained by the nurse is most important to report to the health 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.

ANS: B 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.

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)

ANS: B Systemic vascular resistance reflects the resistance to ventricular ejection, or afterload. The other parameters will be monitored, but do not reflect afterload as directly.

When evaluating a patient with a central venous catheter, the nurse observes that the insertion site is red and tender to touch and the patient's 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

ANS: B 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 be discontinued to avoid further complications such as endocarditis.

When evaluating a patient with a central venous catheter, the nurse observes that the insertion site is red and tender to touch and the patient's 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.

ANS: B 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 be discontinued to avoid further complications such as endocarditis.

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.

ANS: B The patient's 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.

An intraaortic balloon pump (IABP) is being used for a patient who is in cardiogenic shock. Which assessment 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

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

ANS: C Monitoring urine output will help determine whether the patient's 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.

When caring for a patient with pulmonary hypertension, which parameter is most appropriate for the nurse to 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)

ANS: C 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.

Which action is a priority for the nurse to take when the low pressure alarm sounds for a patient who has an arterial 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.

ANS: C The low pressure alarm indicates a drop in the patient's 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.

The nurse is caring for a patient receiving a continuous norepinephrine (Levophed) IV infusion. Which patient 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.

ANS: C Vasoconstrictors such as norepinephrine (Levophed) will increase SVR, and this will increase the work of the heart 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.

Which action will the nurse need to do when preparing to assist with the insertion of a pulmonary artery catheter? 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.

ANS: D 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 monitoring for the effectiveness of treatment for a patient with a large anterior wall myocardial infarction, 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).

ANS: D 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.

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 post-percutaneous 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

ANS: D 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 provider's 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.

While waiting for cardiac transplantation, a patient with severe cardiomyopathy has a ventricular assist device (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.

ANS: D The insertion site for the VAD provides a source for transmission of infection to the circulatory system and requires frequent monitoring. Patient's 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 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.

ANS: D 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.

When caring for the patient with a pulmonary artery (PA) pressure catheter, the nurse observes that the PA waveform 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.

ANS: D When the catheter is in the wedge position, blood flow past the catheter is obstructed, placing the patient at risk for pulmonary infarction. A health care provider or advanced practice nurse should be called to reposition the catheter. The other actions will not correct the wedging of the PA catheter.

A 70-year-old patient in the ICU has become agitated and inattentive since his heart surgery. The nurse knows that this ICU psychosis frequently occurs in individuals with pre-existing dementia, history of alcohol abuse, and severe disease. What interventions should the nurse provide this patient to improve the patient's cognition (select all that apply)? a Improve oxygenation. b Provide a small amount of beer. c Have the family stay with the patient. d Enable the patient to sleep on a schedule with dim lights. e Decrease sensory overload by conversing away from patient's room

a Improve oxygenation. d Enable the patient to sleep on a schedule with dim lights. e Decrease sensory overload by conversing away from patient's room. ICU psychosis is from delirium in most ICU patients. Improving oxygenation, enabling the patient to sleep, and decreasing sensory overload along with orientation is all helpful in improving the patient's cognition. The beer may or may not be allowed for this patient, and the nurse should not assume that it will help. Having a family member stay with the patient to reorient the patient is helpful, but the family group may increase sensory overload with conversations not involving the patient.

Original Alphabetical The nurse is caring for a 72-year-old man in cardiogenic shock after an acute myocardial infarction. Which clinical manifestations would be of most concern to the nurse? a Restlessness, heart rate of 124 beats/minute, and hypoactive bowel sounds b Mean arterial pressure of 54 mm Hg, increased jaundice, and cold, clammy skin c PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and bleeding from puncture sites d Agitation, respiratory rate of 32 breaths/minute, and serum creatinine level of 2.6 mg/dL c PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and bleeding from puncture sites Severe hypoxemia, lactic acidosis, and bleeding are clinical manifestations of the irreversible state of shock. Recovery from this stage is not likely because of multiple organ system failure. Restlessness, tachycardia, and hypoactive bowel sounds are clinical manifestations that occur during the compensatory stage of shock. Decreased mean arterial pressure, jaundice, cold/ clammy skin, agitation, tachypnea, and increased serum creatinine are clinical manifestations of the progressive stage of shock. A 64-year-old woman is admitted to the emergency department vomiting bright red blood. The patient's vital signs are blood pressure 78/58 mm Hg, pulse 124 beats/minute, respirations 28 breaths/minute, and temperature 97.2° F (36.2° C). Which physician order should the nurse complete first? a Obtain a 12-lead ECG and arterial blood gases. b Rapidly administer 1000 mL normal saline solution IV. c Administer norepinephrine (Levophed) by continuous IV infusion. d Carefully insert a nasogastric tube and an indwelling bladder catheter.

b Rapidly administer 1000 mL normal saline solution IV. Isotonic crystalloids, such as normal saline solution, should be used in the initial resuscitation of hypovolemic shock. Vasopressor drugs (e.g., norepinephrine) may be considered if the patient does not respond to fluid resuscitation and blood products. Other orders (e.g., insertion of nasogastric tube and indwelling bladder catheter and obtaining the diagnostic studies) can be initiated after fluid resuscitation is initiated.

The nurse is caring for a 72-year-old man in cardiogenic shock after an acute myocardial infarction. Which clinical manifestations would be of most concern to the nurse? a Restlessness, heart rate of 124 beats/minute, and hypoactive bowel sounds b Mean arterial pressure of 54 mm Hg, increased jaundice, and cold, clammy skin c PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and bleeding from puncture sites d Agitation, respiratory rate of 32 breaths/minute, and serum creatinine level of 2.6 mg/dL c PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and bleeding from puncture sites Severe hypoxemia, lactic acidosis, and bleeding are clinical manifestations of the irreversible state of shock. Recovery from this stage is not likely because of multiple organ system failure. Restlessness, tachycardia, and hypoactive bowel sounds are clinical manifestations that occur during the compensatory stage of shock. Decreased mean arterial pressure, jaundice, cold/ clammy skin, agitation, tachypnea, and increased serum creatinine are clinical manifestations of the progressive stage of shock. A 64-year-old woman is admitted to the emergency department vomiting bright red blood. The patient's vital signs are blood pressure 78/58 mm Hg, pulse 124 beats/minute, respirations 28 breaths/minute, and temperature 97.2° F (36.2° C). Which physician order should the nurse complete first? a Obtain a 12-lead ECG and arterial blood gases. b Rapidly administer 1000 mL normal saline solution IV. c Administer norepinephrine (Levophed) by continuous IV infusion. d Carefully insert a nasogastric tube and an indwelling bladder catheter. b Rapidly administer 1000 mL normal saline solution IV. Isotonic crystalloids, such as normal saline solution, should be used in the initial resuscitation of hypovolemic shock. Vasopressor drugs (e.g., norepinephrine) may be considered if the patient does not respond to fluid resuscitation and blood products. Other orders (e.g., insertion of nasogastric tube and indwelling bladder catheter and obtaining the diagnostic studies) can be initiated after fluid resuscitation is initiated. A 50-year-old woman with a suspected brain tumor is scheduled for a computed tomography (CT) scan with contrast media. The nurse notifies the physician that the patient reported an allergy to shellfish. Which response by the physician should the nurse question? a Infuse IV diphenhydramine prior to the procedure. b Administer lorazepam (Ativan) before the procedure. c Complete the CT scan without the use of contrast media. d Premedicate with hydrocortisone sodium succinate (Solu-Cortef). b Administer lorazepam (Ativan) before the procedure. An individual with an allergy to shellfish is at an increased risk to develop anaphylactic shock if contrast media is injected for a CT scan. To prevent anaphylactic shock, the nurse should always confirm the patient's allergies before diagnostic procedures (e.g., CT scan with contrast media). Appropriate interventions may include cancelling the procedure, completing the procedure without contrast media, or premedication with diphenhydramine or hydrocortisone. IV fluids may be given to promote renal clearance of the contrast media and prevent renal toxicity and acute kidney injury. The use of an antianxiety agent such as lorazepam would not be effective in preventing an allergic reaction to the contrast media. The nurse is caring for a 29-year-old man who was admitted a week ago with multiple rib fractures, a pulmonary contusion, and a left femur fracture from a motor vehicle crash. After the attending physician tells the family that the patient has developed sepsis, the family members have many questions. Which information should the nurse include in explaining the early stage of sepsis? a Antibiotics are not useful once an infection has progressed to sepsis. bWeaning the patient away from the ventilator is the top priority in sepsis. c Large amounts of IV fluid are required in sepsis to fill dilated blood vessels. d The patient has recovered from sepsis if he has warm skin and ruddy cheeks. c Large amounts of IV fluid are required in sepsis to fill dilated blood vessels. Patients with sepsis may be normovolemic but because of acute vasodilation, relative hypovolemia and hypotension occur. Patients in septic shock require large amounts of fluid replacement and may require frequent fluid boluses to maintain circulation. Antibiotics are an important component of therapy for patients with septic shock. They should be started after cultures (e.g., blood, urine) are obtained and within the first hour of septic shock. Oxygenating the tissues is the top priority in sepsis, so efforts to wean septic patients from mechanical ventilation halt until sepsis is resolving. Addititonal respiratory support may be needed during sepsis. Although cool and clammy skin is present in other early shock states, the patient in early septic shock may feel warm and flushed because of a hyperdynamic state. The nurse is assisting in the care of several patients in the critical care unit. Which patient is at greatest risk for developing multiple organ dysfunction syndrome (MODS)? a 22-year-old patient with systemic lupus erythematosus who is admitted with a pelvic fracture after a motor vehicle accident b 48-year-old patient with lung cancer who is admitted for syndrome of inappropriate antidiuretic hormone and hyponatremia c 65-year-old patient with coronary artery disease, dyslipidemia, and primary hypertension who is admitted for unstable angina d 82-year-old patient with type 2 diabetes mellitus and chronic kidney disease who is admitted for peritonitis related to a peritoneal dialysis catheter infection d 82-year-old patient with type 2 diabetes mellitus and chronic kidney disease who is admitted for peritonitis related to a peritoneal dialysis catheter infection A patient with peritonitis is at high risk for developing sepsis. In addition, a patient with diabetes is at high risk for infections and impaired healing. Sepsis and septic shock are the most common causes of MODS. Individuals at greatest risk for developing MODS are older adults and persons with significant tissue injury or preexisting disease. MODS can be initiated by any severe injury or disease process that activates a massive systemic inflammatory response. When caring for a patient in acute septic shock, what should the nurse anticipate? a Infusing large amounts of IV fluids b Administering osmotic and/or loop diuretics c Administering IV diphenhydramine (Benadryl) d Assisting with insertion of a ventricular assist device (VAD) a Infusing large amounts of IV fluids Septic shock is characterized by a decreased circulating blood volume. Volume expansion with the administration of IV fluids is the cornerstone of therapy. The administration of diuretics is inappropriate. VADs are useful for cardiogenic shock not septic shock. Diphenhydramine (Benadryl) may be used for anaphylactic shock but would not be helpful with septic shock. When caring for a critically ill patient who is being mechanically ventilated, the nurse will astutely monitor for which clinical manifestation of multiple organ dysfunction syndrome (MODS)? a Increased serum albumin b Decreased respiratory compliance c Increased gastrointestinal (GI) motility d Decreased blood urea nitrogen (BUN)/creatinine ratio b Decreased respiratory compliance Clinical manifestations of MODS include symptoms of respiratory distress, signs and symptoms of decreased renal perfusion, decreased serum albumin and prealbumin, decreased GI motility, acute neurologic changes, myocardial dysfunction, disseminated intravascular coagulation (DIC), and changes in glucose metabolism. A massive gastrointestinal bleed has resulted in hypovolemic shock in an older patient. What is a priority nursing diagnosis? a Acute pain b Impaired tissue integrity c Decreased cardiac output d Ineffective tissue perfusion d Ineffective tissue perfusion The many deleterious effects of shock are all related to inadequate perfusion and oxygenation of every body system. This nursing diagnosis supersedes the other diagnoses. What laboratory finding fits with a medical diagnosis of cardiogenic shock? a Decreased liver enzymes b Increased white blood cells c Decreased red blood cells, hemoglobin, and hematocrit d Increased blood urea nitrogen (BUN) and serum creatinine levels d Increased blood urea nitrogen (BUN) and serum creatinine levels The renal hypoperfusion that accompanies cardiogenic shock results in increased BUN and creatinine levels. Impaired perfusion of the liver results in increased liver enzymes, while white blood cell levels do not typically increase in cardiogenic shock. Red blood cell indices are typically normal because of relative hypovolemia. A patient's localized infection has progressed to the point where septic shock is now suspected. What medication is an appropriate treatment modality for this patient? a Insulin infusion b IV administration of epinephrine c Aggressive IV crystalloid fluid resuscitation d Administration of nitrates and β-adrenergic blockers c Aggressive IV crystalloid fluid resuscitation Patients in septic shock require large amounts of crystalloid fluid replacement. Nitrates and β-adrenergic blockers are most often used in the treatment of patients in cardiogenic shock. Epinephrine is indicated in anaphylactic shock, and insulin infusion is not normally necessary in the treatment of septic shock (but can be). The nurse would recognize which clinical manifestation as suggestive of sepsis? a Sudden diuresis unrelated to drug therapy b Hyperglycemia in the absence of diabetes c Respiratory rate of seven breaths per minute d Bradycardia with sudden increase in blood pressure b Hyperglycemia in the absence of diabetes Hyperglycemia in patients with no history of diabetes is a diagnostic criterion for sepsis. Oliguria, not diuresis, typically accompanies sepsis along with tachypnea and tachycardia. Following coronary artery bypass graft surgery a patient has postoperative bleeding that requires returning to surgery to repair the leak. During surgery, the patient has a myocardial infarction (MI). After restoring the patient's body temperature to normal, which patient assessment is the most important for planning nursing care? a Cardiac index (CI) 5 L/min/m2 b Central venous pressure 8 mm Hg c Mean arterial pressure (MAP) 86 mm Hg d Pulmonary artery pressure (PAP) 28/14 mm Hg d Pulmonary artery pressure (PAP) 28/14 mm Hg Pulmonary hypertension as indicated by an elevated PAP indicates impaired forward flow of blood because of left ventricular dysfunction or hypoxemia. Both can be due to the MI. The CI, CVP, and MAP readings are normal. The critical care nurse is caring for a 55-year-old man who has a catheter in the right radial artery that is being used for continuous arterial blood pressure monitoring following his abdominal aortic aneurysm surgery. Which observation by the nurse would require an emergency intervention? a Calculated mean arterial pressure is 74 mm Hg. b Patient's head of bed elevation is at 30 degrees. c Capillary refill time in the right hand is 5 seconds. d Pressure bag attached to the arterial line is inflated to 270 mm Hg. c Capillary refill time in the right hand is 5 seconds. Neurovascular status distal to the arterial insertion site is monitored hourly. If arterial flow is compromised, the limb will be cool and pale, with capillary refill time longer than 3 seconds. Symptoms of neurologic impairment include paresthesia, pain, or paralysis. Neurovascular impairment can result in loss of a limb and is an emergency. The pressure bag should be inflated to 300 mm Hg. Normal range for mean arterial pressure is 70 to 105 mm Hg. The backrest elevation may be up to 45 degrees unless the patient has orthostatic changes. The nurse is caring for a 34-year-old woman with acute decompensated heart failure who has a pulmonary artery catheter. Which assessment best indicates that the patient's condition is improving? a Cardiac output (CO) is 3.5 L/minute. b Central venous pressure (CVP) is 10 mm Hg. c Pulmonary artery wedge pressure (PAWP) is 10 mm Hg. d Systemic vascular resistance (SVR) is 1500 dynes/sec/cm-5. c Pulmonary artery wedge pressure (PAWP) is 10 mm Hg. PAWP is the most sensitive indicator of cardiac function and fluid volume status. Normal range for PAWP is 6 to 12 mm Hg. PAWP is increased in heart failure. Normal range for CVP is 2 to 8 mm Hg. An elevated CVP indicates right-sided heart failure or volume overload. Normal cardiac output is 4 to 8 L/minute. CO is decreased in heart failure. SVR is increased in left-sided heart failure. Normal SVR is 800 to 1200 dynes/sec/cm-5. A 68-year-old male patient diagnosed with sepsis is orally intubated on mechanical ventilation. Which action is most important for the nurse to take? a Use the open-suctioning technique. b Administer morphine for discomfort. c Limit noise and cluster care activities. d Elevate the head of the bed 30 degrees. d Elevate the head of the bed 30 degrees. The two major complications of endotracheal intubation are unplanned extubation and aspiration. To prevent aspiration all intubated patients and patients receiving enteral feedings must have the head of the bed (HOB) elevated a minimum of 30 to 45 degrees unless medically contraindicated. Closed-suction technique is preferred over the open-suction technique because oxygenation and ventilation are maintained during suctioning, and exposure to secretions is reduced. The nurse should provide comfort measures such as morphine to relieve anxiety and pain associated with intubation. To promote rest and sleep the nurse should limit noise and cluster activities. A 64-year-old male patient admitted to the critical care unit for gastrointestinal hemorrhage complains of feeling tense and nervous. He appears restless with an increase in blood pressure and pulse. If the physical assessment shows no other changes, it is most important for the critical care nurse to take which action? a Administer prescribed IV dose of lorazepam (Ativan). b Stay with the patient and encourage expression of concerns. c Ask a family member to remain at the bedside with the patient. d Teach the patient how to use guided imagery to reduce anxiety.

b Stay with the patient and encourage expression of concerns. Anxiety is a common problem for critically ill patients. The nurse should first stay with the patient and encourage the patient to express concerns and needs. After expression of feelings, the nurse should determine the appropriate intervention if needed (e.g., lorazepam, guided imagery, family presence) and closely monitor the patient's hemodynamic parameters.

The hemodynamic changes the nurse expects to find after successful initiation of IABP therapy in a patient with cardiogenic shock include (select all that apply): a. decreased SV b. decreased SVR c. decreased PAWP d. increased diastolic BP e. a decreased myocardial oxygen consumption

b. decreased SVR c. decreased PAWP d. increased diastolic BP e. a decreased myocardial oxygen consumption

The critical care nurse is caring for a 55-year-old man who has a catheter in the right radial artery that is being used for continuous arterial blood pressure monitoring following his abdominal aortic aneurysm surgery. Which observation by the nurse would require an emergency intervention? a Calculated mean arterial pressure is 74 mm Hg. b Patient's head of bed elevation is at 30 degrees. c Capillary refill time in the right hand is 5 seconds. d Pressure bag attached to the arterial line is inflated to 270 mm Hg.

c Capillary refill time in the right hand is 5 seconds. Neurovascular status distal to the arterial insertion site is monitored hourly. If arterial flow is compromised, the limb will be cool and pale, with capillary refill time longer than 3 seconds. Symptoms of neurologic impairment include paresthesia, pain, or paralysis. Neurovascular impairment can result in loss of a limb and is an emergency. The pressure bag should be inflated to 300 mm Hg. Normal range for mean arterial pressure is 70 to 105 mm Hg. The backrest elevation may be up to 45 degrees unless the patient has orthostatic changes.

The patient has developed cardiogenic shock after a left anterior descending myocardial infection. Which circulatory-assist device should the nurse expect to use for this patient? a Cardiopulmonary bypass b Impedance cardiography (ICG) c Intraaortic balloon pump (IABP) d Central venous pressure (CVP) measurement

c Intraaortic balloon pump (IABP) The most commonly used mechanical circulatory-assist device is the intraaortic balloon pump (IABP), and it is used to decrease ventricular workload, increase myocardial perfusion, and augment circulation. Cardiopulmonary bypass provides circulation during open heart surgery. It is not used as an assist device after surgery. ICG is a noninvasive method to obtain cardiac output and assess thoracic fluid status. CVP measurement is an invasive measurement of right ventricular preload and reflects fluid volume problems.

The nurse is caring for a 72-year-old man in cardiogenic shock after an acute myocardial infarction. Which clinical manifestations would be of most concern to the nurse? a Restlessness, heart rate of 124 beats/minute, and hypoactive bowel sounds b Mean arterial pressure of 54 mm Hg, increased jaundice, and cold, clammy skin c PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and bleeding from puncture sites d Agitation, respiratory rate of 32 breaths/minute, and serum creatinine level of 2.6 mg/dL

c PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and bleeding from puncture sites Severe hypoxemia, lactic acidosis, and bleeding are clinical manifestations of the irreversible state of shock. Recovery from this stage is not likely because of multiple organ system failure. Restlessness, tachycardia, and hypoactive bowel sounds are clinical manifestations that occur during the compensatory stage of shock. Decreased mean arterial pressure, jaundice, cold/ clammy skin, agitation, tachypnea, and increased serum creatinine are clinical manifestations of the progressive stage of shock.

The nurse is caring for a 34-year-old woman with acute decompensated heart failure who has a pulmonary artery catheter. Which assessment best indicates that the patient's condition is improving? a Cardiac output (CO) is 3.5 L/minute. b Central venous pressure (CVP) is 10 mm Hg. c Pulmonary artery wedge pressure (PAWP) is 10 mm Hg. d Systemic vascular resistance (SVR) is 1500 dynes/sec/cm-5.

c Pulmonary artery wedge pressure (PAWP) is 10 mm Hg. PAWP is the most sensitive indicator of cardiac function and fluid volume status. Normal range for PAWP is 6 to 12 mm Hg. PAWP is increased in heart failure. Normal range for CVP is 2 to 8 mm Hg. An elevated CVP indicates right-sided heart failure or volume overload. Normal cardiac output is 4 to 8 L/minute. CO is decreased in heart failure. SVR is increased in left-sided heart failure. Normal SVR is 800 to 1200 dynes/sec/cm-5.

To establish hemodynamic monitoring for a patient, the nurse zeroes the: a. cardiac output monitoring system to the level of the left ventricle b. pressure monitoring system to the level of the catheter tip located in the patient c. pressure monitoring system to the level of the atrium, identified as the phlebostatic axis d. pressure monitoring system to the level of the atrium, identified as the midclavicular line

c. pressure monitoring system to the level of the atrium, identified as the phlebostatic axis

Following coronary artery bypass graft surgery a patient has postoperative bleeding that requires returning to surgery to repair the leak. During surgery, the patient has a myocardial infarction (MI). After restoring the patient's body temperature to normal, which patient assessment is the most important for planning nursing care? a Cardiac index (CI) 5 L/min/m2 b Central venous pressure 8 mm Hg c Mean arterial pressure (MAP) 86 mm Hg d Pulmonary artery pressure (PAP) 28/14 mm Hg

d Pulmonary artery pressure (PAP) 28/14 mm Hg Pulmonary hypertension as indicated by an elevated PAP indicates impaired forward flow of blood because of left ventricular dysfunction or hypoxemia. Both can be due to the MI. The CI, CVP, and MAP readings are normal.

Which hematologic problem most significantly increases the risks associated with pulmonary artery (PA) catheter insertion? a Leukocytosis b Hypovolemia c Hemolytic anemia d Thrombocytopenia

d Thrombocytopenia PA catheter insertion carries a significant risk of bleeding, a fact that is exacerbated when the patient has low levels of platelets. Leukocytosis, hypovolemia, and anemia are less likely to directly increase the risks associated with PA insertion.