Critical Care - UWorld

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? 1. Avoid suctioning the client 2. Pre-oxygenate the client 3. Raise the head of the bed 4. Reduce the amount of sedation medication

1 Arterial blood gases (ABGs) indicate the acid-base balance in the body and how well oxygen is being carried to the tissues. It is common to measure ABGs after a ventilator change to assess how well the client has tolerated it. Factors such as changes in the client's activity level or oxygen settings, or suctioning within 20 minutes prior to the blood draw can cause inaccurate results. Unless the client's condition dictates otherwise, the nurse should avoid suctioning as it will deplete the client's oxygen level and cause inaccurate test results. (Option 2) Pre-oxygenation should occur prior to suctioning and possibly before position changes. It will affect ABG results. (Option 3) The head of the bed should be maintained at 30 degrees or higher in an intubated client to prevent aspiration and allow for adequate chest expansion. This position will not affect ABG results. (Option 4) If a client is being weaned from the ventilator, sedation may be reduced. A client with reduced sedation may become anxious and have an increased activity level; these could affect the ABG results. Educational objective: If the client's condition allows, the nurse should avoid suctioning or changing activity or oxygenation levels prior to drawing of ABGs. These actions can result in inaccurate ABG results.

A client with dilated cardiomyopathy has the rhythm shown in the exhibit (ventricular tachycardia). Which action should the nurse take first? 1. Assess the client for a pulse 2. Assess the oxygen saturation 3. Initiate cardiopulmonary resuscitation (CPR) 4. Prepare to defibrillate the client

1 Clients in ventricular tachycardia (VT) can be pulseless or have a pulse. Treatment is based on this important initial assessment. VT with a pulse should be further assessed for clinical stability or instability. Signs of instability include hypotension, altered mental status, signs of shock, chest pain, and acute heart failure. The unstable client in VT with a pulse is treated with synchronized cardioversion. The stable client in VT with a pulse is treated with antiarrhythmic medications (eg, amiodarone, procainamide, sotalol). (Option 2) Oxygen saturation should be assessed after the presence of a pulse has been established. (Options 3 and 4) CPR and defibrillation should be initiated only in a client who is pulseless. Educational objective: The client in VT must be assessed for the presence or absence of a pulse before further assessment or treatment is initiated. The unstable (hypotensive) client in VT with a pulse is treated with synchronized cardioversion.

A client with palpitations is admitted with supraventricular tachycardia. The client's heart rate is 210/min. Which is the most appropriate initial intervention? 1. Ask the client to bear down as if having a bowel movement 2. Grab the crash cart and apply hands-free defibrillation pads 3. Place ECG leads on client to further assess electrical activity 4. Place IV line distally from the heart for adenosine administration

1 Clients with paroxysmal supraventricular tachycardia (SVT) (regular, narrow QRS complex tachycardia) are initially treated with vagal maneuvers. The act of "bearing down" as if having a bowel movement (Valsalva) is an example of these maneuvers and may need to be attempted more than once. Vagal maneuvers work by increasing intra-thoracic pressure and stimulating the vagus nerve, which supplies parasympathetic nerve fibers to the heart, resulting in slowed electrical conduction through the atrioventricular node. (Option 2) Cardioversion (not defibrillation) is used with this type of arrhythmia when it is refractory to medication. Cardioversion delivers a synchronized electrical current to the heart. This works by stopping the electrical activity to the heart and briefly allowing a normal heartbeat to return. (Option 3) An ECG is used to diagnose SVT and can be obtained while or after the client is asked to perform the vagal maneuvers as it is not therapeutic. (Option 4) Adenosine is the drug of choice to treat SVT and has a 5- to 6-second half-life (the time it takes for the drug to be reduced to half of its original concentration). Placing the IV line as close as possible, not distal, to the heart is essential for the drug to have full effect. Adenosine is given rapidly over 1-2 seconds and then followed by a rapid 20-mL normal saline flush. Transient asystole is common, and clients often experience flushing and dizziness. Educational objective: Supraventricular tachycardia is a regular, narrow QRS complex tachycardia with a rate of around 150-220/min. The best treatment is vagal maneuvers and adenosine IV push.

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? 1. Attaching the cardiac monitor 2. Covering the client's head 3. Drawing blood for electrolytes and glucose 4. Placing an additional large-bore IV catheter

1 Hypothermia occurs when the core temperature is below 95 F (35 C) and the body is unable to compensate for heat loss. As the core temperature decreases, the cold myocardium becomes extremely irritable and prone to dysrhythmias. The client should be handled gently as spontaneous ventricular fibrillation could develop when moved or touched. Therefore, placing the client on a cardiac monitor is a high priority; the nurse should anticipate defibrillation in these clients. (Option 2) Covering the client's head is indicated to prevent heat loss; however, this can be done after the cardiac monitor has been attached. Depending on the severity of the hypothermia, the trunk should be warmed before the extremities to reduce the risk of afterdrop (core temperature drops further). This is due to cold peripheral blood returning to the central circulation. (Option 3) A blood draw for laboratory testing is important but should be performed after the cardiac monitor is attached. (Option 4) Two large-bore IV catheters are preferred; this can be accomplished after the cardiac monitor has been attached. Educational objective: Cardiac monitoring and gentle handling of the client are a high priority with hypothermia. The cold myocardium is extremely irritable and prone to dysrhythmias. The nurse should anticipate defibrillation in these clients.

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? 1. Cold and clammy skin 2. Oxygen saturation of 92% 3. Sinus tachycardia of 108/min 4. Urine output of 0.6 mL/kg/hr

1 Hypovolemic (hemorrhagic) shock may occur after abdominal trauma or surgery as mesenteric edema resolves and previously compressed sites of bleeding reopen. The shock continuum is staged in severity from initial (I) to irreversible (IV). During the initial stage, there is inadequate oxygen to supply the demand at the cellular level and anaerobic metabolism develops. At this point, there may be no recognizable signs or symptoms. As shock progresses to the compensatory stage, sympathetic compensatory mechanisms are activated to maintain homeostasis (eg, oxygenation, cardiac output). Cold, clammy skin indicates failing compensatory mechanisms (ie, progressive stage), and immediate intervention is necessary to prevent irreversible shock and death (Option 1). (Option 2) Slightly low oxygen saturation may occur when there is inadequate oxygen supply and increased metabolic demand. It is not the most important finding to report. (Option 3) Sinus tachycardia is part of the compensatory response to maintain cardiac output and oxygen demand. It is not the most important finding to report. (Option 4) As shock continues, the kidneys decrease filtration and increase reabsorption to maintain blood pressure, eventually resulting in decreased urinary output. Normal urine output is 0.5-1 mL/kg/hr or >30 mL/hr. Educational objective: Cold, clammy skin in a client with shock indicates that compensatory mechanisms are failing and that hypoperfusion is occurring. This should be reported promptly to the health care provider as immediate intervention is necessary to prevent irreversible shock.

The nurse is caring for a client who is 1 day postoperative extensive abdominal surgery for ovarian cancer. The client is receiving IV Ringer's lactate at 100 mL/hr and continual epidural morphine for pain control. The Foley catheter urine output has decreased to <20 mL/hr over the past 2 hours. The postoperative hematocrit is 36% (0.36), and the hemoglobin is 12 g/dL (120 g/L). Which action should the nurse carry out first? 1. Assess vital signs 2. Increase the IV rate to 125 mL/hr 3. Notify the health care provider 4. Perform a bladder scan

1 Third-spacing of fluids can occur 24-72 hours after extensive abdominal surgery as a result of increased capillary permeability due to tissue trauma. It occurs when too much fluid moves from the intravascular into the interstitial or third space, a place between cells where fluid does not normally collect (ie, injured site, peritoneal cavity). This fluid serves no physiologic purpose, cannot be measured, and leads to decreased circulating volume (hypovolemia) and cardiac output. The priority intervention is to assess vital signs as the manifestations associated with third-spacing include weight gain, decreased urinary output, and signs of hypovolemia, such as tachycardia and hypotension. If third-spacing is not recognized and corrected early on, postoperative hypotension can lead to decreased renal perfusion, prerenal failure, and hypovolemic shock (Option 1). (Option 2) Increasing the IV flow rate of the isotonic solution may be an appropriate intervention once the nurse has assessed the client, including taking a full set of vital signs. The nurse should intervene only after assessing to rule out other problems for which an increase in IV fluid intake would not be an appropriate solution (eg, Foley catheter obstruction). (Option 3) The nurse will notify the health care provider to report oliguria (<0.5 mL/kg/hr) after collecting all of the data necessary (ie, vital signs). This is not the nurse's first action. (Option 4) Urinary retention is possible following surgery due to the adverse effects of anesthesia, opioids, anticholinergic drugs, and immobility. However, a bladder scan is not an appropriate action in this situation as the client has a Foley catheter. Irrigating the catheter is the appropriate intervention if the nurse questions its patency. Educational objective: Third-spacing can occur following extensive abdominal surgery and can lead to hypovolemia, decreased cardiac output, hypotension and tachycardia, and decreased urine output. Monitoring vital signs and urine output, and maintaining IV fluids are appropriate interventions to prevent prerenal failure and hypovolemic shock.

A client with blunt trauma undergoes an exploratory laparotomy to repair the intraabdominal injury. After 24 hours, the client has a nasogastric tube attached to continual low suction, 2 Hemovac closed-wound suction abdominal drains, and is receiving IV Ringer's lactate and continual epidural morphine. The client now develops hypotension, tachycardia, oliguria, and severe nausea. What is the client's priority nursing diagnosis (ND) at this time? 1. Deficient fluid volume 2. Impaired urinary elimination 3. Nausea 4. Risk for infection

1 This client is exhibiting symptoms of hypovolemia, which include hypotension, tachycardia, and decreased urinary output. Therefore, the priority ND is deficient fluid volume related to active intravascular loss that is secondary to hemorrhage, gastric suction, wound drainage, and possible third spacing as evidenced by decreased urine output, hypotension, and tachycardia. The adverse effects of the epidural anesthesia can contribute to hypotension as well. This ND poses the greatest threat to survival because if not corrected, it can lead to decreased cardiac output, acute renal failure, and hypovolemic shock. (Option 2) Impaired urinary elimination refers to a dysfunction in urinary elimination, such as incontinence, retention, frequency, urgency, dysuria, hesitancy, and nocturia. It is not an appropriate ND for this client. (Option 3) Nausea is most likely an adverse effect of the morphine, and an antiemetic will be prescribed. It is an appropriate ND as dry heaving and vomiting can compromise the integrity of the abdominal wound incision. However, it is not the priority ND. (Option 4) Clients with trauma are at risk for microbial invasion secondary to inadequate primary defense (eg, skin barrier, catheters), secondary defenses (eg, decreased blood), and environmental exposure (eg, invasive procedures). However, this is not the priority ND. Educational objective: Deficient fluid volume, nausea, and risk for infection are appropriate NDs for a client who has undergone surgery for repair of a blunt trauma intraabdominal hemorrhagic injury. However, the priority ND addresses the highest level of risk to a client: airway, breathing, circulation (eg, hypovolemia, cardiac output), and vital signs (eg, hypotension, tachycardia).

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? 1. Administer IV normal saline 2. Determine if urinary occult blood is present 3. Perform a neurological assessment 4. Verify that there is no stool impaction

1 This presentation is classic for neurogenic shock, a distributive shock. Vascular dilation with decreased venous return to the heart is present due to loss of innervation from the spine. Classic signs/symptoms are hypotension, bradycardia, and pink and dry skin from the vasodilation. Neurogenic shock usually occurs in cervical or high thoracic injuries (T6 or higher). Systolic blood pressure should remain at 80 mm Hg or above to adequately perfuse the kidneys. Administration of fluids is a priority to ensure adequate kidney and other organ perfusion. (Option 2) Testing for the presence of blood in the urine is important in determining if kidney damage has occurred, but circulation stability is a priority. (Option 3) A neurological assessment is essential, but circulation stability is a priority ("C before D" [disability]). (Option 4) Bladder and stool impaction are etiologies for autonomic dysreflexia and generally occur in a client with a high-level fracture at T6 or above with a stimulation below the fracture. Autonomic dysreflexia is a medical emergency that presents with severe headache, hypertension, piloerection, and diaphoresis. It is seen weeks to years after the injury. Educational objective: Neurogenic shock/distributive shock can occur from vasodilation soon after spinal injury. Classic symptoms are hypotension, bradycardia, and pink and dry skin. The hypotension must be treated with isotonic fluids to maintain vital organ perfusion.

The nurse observes a nursing student performing chest compressions on an adult client. Which technique indicates that the student understands how to provide high-quality chest compressions during cardiopulmonary resuscitation? 1. Compressing the chest to a depth of at least 2 in (5 cm) 2. Pausing after each set of 15 compressions to allow for 2 rescue breaths 3. Placing the heel of the hand on the upper half of the client's sternum 4. Providing compressions at a rate of at least 80-100/min

1 The primary goal of cardiopulmonary resuscitation (CPR) is adequate perfusion to the brain and vital organs. High-quality chest compressions for adults are at least 2 in (5 cm) deep to adequately pump blood but no more than 2.4 in (6 cm) deep to prevent unnecessary client injury (Option 1). The chest should recoil completely after each compression to allow complete refilling of the heart chambers, which promotes effective perfusion. (Option 2) Interruption of compressions should be minimized; at least 60% (preferably more) of the total resuscitation time should be made up of compressions. For adults (and in single-rescuer CPR for any age), a cycle of 30 compressions followed by 2 rescue breaths provides the best outcome. If the client has an advanced airway, continuous compressions and 10 breaths/min should be provided. (Option 3) Correct hand placement is in the center of the chest, on the lower half of the sternum (breastbone). Hand placement on the upper half of the sternum does not provide adequate perfusion. (Option 4) Studies have shown better client outcomes due to improved perfusion with a compression rate of 100-120/min. Educational objective: For high-quality adult cardiopulmonary resuscitation, compressions should be in the center of the chest; at a rate of 100-120/min; and at least 2 in (5 cm) but no more than 2.4 in (6 cm) deep for adequate perfusion without unnecessary client injury. Compression interruption should be minimized (eg, 30 compressions to 2 rescue breaths).

The nurse is preparing to defibrillate a client who suddenly went into ventricular fibrillation. Which steps are essential prior to delivering a shock? Select all that apply. 1. Apply defibrillator pads 2. Call out and look around to ensure that everyone is "all clear" 3. Continue chest compressions until ready to deliver shock 4. Ensure adequate IV sedation has been given 5. Ensure that the synchronization button is turned on

1, 2, 3 Defibrillation is indicated in clients with ventricular fibrillation (Vfib) and pulseless ventricular tachycardia. Cardiopulmonary resuscitation (CPR) should be initiated and compressions continued until the shock is ready to be delivered (Option 3). Certain pulseless rhythms (asystole and pulseless electrical activity) do not need defibrillation. Steps to perform defibrillation are as follows: 1) Turn on the defibrillator 2) Place defibrillator pads on the client's chest (Option 1) 3)Charge defibrillator. Chest compressions should continue until defibrillator has charged and is ready to deliver the shock. 4) Before delivering the shock, ensure that the area is "all clear." Confirm that no personnel are touching the client, bed, or any equipment attached to the client (Option 2). 5) Deliver the shock 6) Immediately resume chest compressions (Option 4) IV sedation is not necessary for defibrillation as the client is already unconscious. It is often given prior to elective synchronized cardioversion to ease anxiety and decrease pain. (Option 5) 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). 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). Educational objective: The steps for defibrillation are as follows: Turn on the defibrillator, place pads on the client's chest, charge defibrillator, ensure the area is "all clear," deliver the shock, then resume compressions immediately.

Which nursing interventions are appropriate for managing the care of a client receiving mechanical ventilation and continuous IV sedation? Select all that apply. 1. Maintain the head of the bed at 30-45 degrees 2. Mute ventilator alarms at night to allow the client to rest 3. Pause sedation daily to assess weaning readiness 4. Perform oral care with chlorhexidine solution 5. Place a manual resuscitation bag at the bedside

1, 3, 4, 5 Clients requiring mechanical ventilation are at risk for a variety of ventilator-associated complications (eg, aspiration, pneumonia). When caring for a client receiving mechanical ventilation, the nurse should: - Monitor respiratory status (eg, lung sounds, breathing pattern), airway patency, and ventilator functionality (eg, settings, alarm parameters). - Maintain the head of the bed at 30-45 degrees to reduce aspiration risk (Option 1). - Use the minimum amount of sedation necessary for client comfort (eg, compliant with ventilator, opens eyes to voice). Continuous IV sedation should be paused daily for evaluation of spontaneous respiratory effort and appropriateness for weaning off the ventilator (Option 3). - Perform oral care with chlorhexidine oral solution every 2 hours, or per facility policy (Option 4). Perform tracheal suctioning as needed. - Monitor correct endotracheal tube placement by noting insertion depth. - Place emergency equipment at bedside (eg, manual resuscitation bag) (Option 5). (Option 2) Although the client should have a quiet environment at night, ventilator alarms should never be muted, as they may indicate life-threatening complications (eg, accidental extubation, tubing disconnection). Educational objective: When caring for a client requiring mechanical ventilation, the nurse should monitor respiratory status and airway patency (eg, breath sounds, insertion depth of endotracheal tube), maintain an appropriate level of sedation, assess for weaning readiness, prevent ventilator-associated infection (eg, oral care with chlorhexidine, head of the bed at 30-45 degrees), and implement safety measures (eg, emergency equipment at bedside, ventilator alarms on).

A nurse is caring for an intubated client receiving a continuous sedative infusion. Which interventions by the nurse reflect correct understanding of preventing ventilator-acquired pneumonia? Select all that apply. 1. Elevating the head of the bed 30-45 degrees 2. Performing hourly in-line endotracheal suctioning 3. Practicing strict hand hygiene 4. Providing frequent oral care with chlorhexidine 5. Scheduling daily sedation vacations

1, 3, 4, 5 Mechanically ventilated clients are at risk for developing ventilator-associated pneumonia (VAP) due to sedation and impairment of natural defenses (eg, coughing) by artificial airways. Interventions to reduce the risk of VAP include: - Elevating the head of the bed 30-45 degrees (ie, semi-Fowler position) (Option 1) - Providing oral care with antiseptic solutions (eg, chlorhexidine mouthwash) and suctioning subglottic secretions (Option 4) - Performing scheduled daily sedation vacations and maintaining appropriate client sedation levels (Option 5) - Practicing strict hand hygiene (Option 3) (Option 2) Endotracheal suctioning should be performed only when clinically indicated (eg, adventitious breath sounds, coughing, elevated peak airway pressure). Frequent suctioning increases the risk for tracheal and bronchial trauma, bleeding, and hypoxia. Educational objective: Mechanically ventilated clients are at risk for developing ventilator-associated pneumonia (VAP) due to sedation and use of an artificial airway. VAP prevention includes elevating the head of the bed 30-45 degrees, providing regular oral hygiene with chlorhexidine solution, practicing strict hand hygiene, and performing daily sedation vacations.

The nurse is caring for an 11-month-old child in the pediatric hospital. Which of these child's findings would be a common criterion to activate the rapid response team? Select all that apply. 1. New-onset right-sided paralysis of extremities 2. Pulse rate sustained at 120/min 3. Respirations continued at 38/min 4. Sudden inability to be aroused to an awake state 5. Temperature of 101.3 F (38.5 C)

1, 4 Rapid response teams are formed as a means to get critical care specialists to the bedside of clients who are not in a critical care unit when acute, significant changes occur in their condition. Each institution sets its own criteria, but it usually includes acute changes in heart rate, systolic blood pressure, respiratory rate, oxygen saturation, level of consciousness, and/or urine output. Although strokes occur more commonly in adults, they can occur in children. Symptoms found in both groups can be similar, such as unilateral paralysis, which is usually found with vessel abnormalities or a hematologic complication (eg, sickle cell, cancer) (Option 1). Just as in adults, emergency treatment for children should be activated. A sudden loss of consciousness is emergent in any client (Option 4). (Option 2) Normal heart rate for an infant (1-12 months) is 100-160/min. (Option 3) Normal respiration rate for an infant (1-12 months) is 30-60/min. (Option 5) A fever is ordinarily not an emergency situation that meets the criteria to activate the rapid response team. It can signal a serious condition in infants who are age <1 month or in children age <2 years who have a temperature >104 F (40 C) without a localized source (due to an immature immune system). However, in this case, it would probably be more effective to call a health care provider to prescribe appropriate diagnostic tests (eg, complete blood count, cultures) and treatment (eg, antibiotics). A fever does not usually require immediate life-saving intervention. Educational objective: Rapid response teams are formed as a means to get critical care assistance to the bedside of clients (not in intensive care) with acute significant changes in their condition. Common criteria include sudden, significant changes in pulse rate, respiration rate, systolic blood pressure, oxygen saturation, level of consciousness, and/or urine output.

The nurse caring for a client with pulmonary edema responds to the mechanical ventilator high-pressure alarm. The nurse would assess for which conditions that can trigger the high-pressure alarm? Select all that apply. 1. Biting endotracheal tube 2. Disconnected ventilator tubing 3. Endotracheal tube cuff leak 4. Excessive airway secretions 5. Kinked ventilator tubing

1, 4, 5 Mechanical ventilator alarms (eg, high- or low-pressure limit) alert the nurse to potential problems caused by a change in the client's condition, a problem with the artificial airway (eg, endotracheal or tracheostomy tube), and/or a problem with the ventilator. Peak airway pressure is the amount of pressure required to deliver a tidal volume. Any condition that increases the peak airway pressure can trigger the ventilator high-pressure limit alarm. When this alarm sounds, the nurse should assess for conditions that increase airway resistance and/or decrease lung compliance, such as: - Excessive secretions: Obstruct the airway, increasing resistance (Option 4) - Biting the endotracheal tube and kinked ventilator tubing: Air flow is obstructed, increasing resistance (Options 1 and 5) (Options 2 and 3) Any condition that decreases airway resistance (eg, tubing disconnect, extubation, endotracheal or tracheostomy tube cuff leak) can trigger the low-pressure limit alarm. Educational objective: When the mechanical ventilator high-pressure limit alarm sounds, the nurse should assess for causes of increased airway resistance in the client (eg, bronchospasm), artificial airway (eg, excessive secretions, biting the endotracheal tube), and/or ventilator system (eg, kinked tubing), as well as for causes of decreased lung compliance (eg, pneumothorax).

A nurse in the intensive care unit (ICU) is caring for a client with sepsis who is on a mechanical ventilator (MV). The client is exposed to the noise of the MV, monitoring equipment, and infusion pump alarms during the day and night. What should the nurse identify as the priority nursing diagnosis (ND)? 1. Anxiety 2. Disturbed sleep pattern 3. Powerlessness 4. Risk for acute confusion

2 A disturbance in sleep pattern refers to time-limited interruptions of the amount and quality of a client's sleep due to external factors (eg, noise, lighting, noxious odors, interruptions due to medical and nursing care). Evidence shows that excessive noise and sleep disturbances in critically ill clients can affect outcomes as they can lead to significant psychologic (eg, delirium, post-traumatic stress disorder, anxiety) and physiologic (eg, circadian rhythm disturbance, decreased REM sleep, increased heart rate, impaired immunity) consequences. Sleep disturbance pattern can lead to anxiety, powerlessness, and acute confusion. Therefore, disturbed sleep pattern related to environmental factors such as excessive noise and changes in daylight-darkness exposure (circadian rhythm disturbance) is the priority ND. (Option 1) Anxiety in the ICU client is most often associated with pain and fear of the unknown and can be an appropriate ND. However, it is not the priority ND for this client. (Option 3) Powerlessness is the sense of lack of control over a situation, such as requiring critical care for a life-threatening condition, and can be an appropriate ND. However, it is not the priority ND for this client. (Option 4) Risk for acute confusion is the risk for developing a rapid-onset, reversible disturbance of consciousness, attention, and perception. It can be an appropriate ND, but it is not the priority. Educational objective: Disturbed sleep pattern related to environmental factors, such as excessive noise and circadian rhythm disturbance, is an important ND for a critically ill client. Lack of adequate uninterrupted sleep can lead to negative physiologic (eg, decreased REM sleep, increased heart rate) and psychologic (eg, delirium, anxiety, powerlessness, acute confusion) consequences that can affect client outcomes.

In the intensive care unit, the nurse cares for a client who is being treated for hypotension with a continuous infusion of dopamine. Which assessment finding indicates that the infusion rate may need to be adjusted? 1. Central venous pressure is 6 mm Hg 2. Heart rate is 120/min 3. Mean arterial pressure is 78 mm Hg 4. Systemic vascular resistance is 900 dynes/sec/cm-5

2 Dopamine (Intropin) is a sympathomimetic inotropic medication used therapeutically to improve hemodynamic status in clients with shock and heart failure. It enhances cardiac output by increasing myocardial contractility, increasing heart rate, and elevating blood pressure through vasoconstriction. Renal perfusion is also improved, resulting in increased urine output. The lowest effective dose of dopamine should be used as dopamine administration leads to an increased cardiac workload. Significant adverse effects include tachycardia, dysrhythmias, and myocardial ischemia. A heart rate of 120/min may indicate that the dopamine infusion needs to be reduced (Option 2). (Options 1, 3, and 4) These measurements fall within the respective reference ranges and do not indicate a need to adjust dopamine administration. 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; and normal systemic vascular resistance is 800-1200 dynes/sec/cm-5. Educational objective: Dopamine is a sympathomimetic inotropic agent that increases heart rate, blood pressure, cardiac output, and urine output. Vital signs should be monitored closely in these clients as a higher dose can result in dangerous tachycardia and tachyarrhythmias.

The student nurse and the registered nurse are caring for a mechanically ventilated client with an acute lung injury. Which statement by the student nurse indicates a need for further education? 1. "I will auscultate the neck to assess for endotracheal cuff leaks." 2. "I will perform endotracheal suctioning routinely after oral care." 3. "I will provide oral care and oral suctioning every 2 hours." 4. "I will reposition the client from side-to-side at least every 2 hours."

2 Endotracheal (ET) suctioning improves ventilation in mechanically ventilated clients by removing mucus and secretions from the ET tube. Suctioning is performed based on clinical findings such as adventitious breath sounds, elevated peak airway pressure, coughing, or signs of acute respiratory distress. Frequent suctioning increases the risk of tracheal and bronchial trauma, bleeding, and hypoxia. Suctioning should be performed only when needed to reduce the risk for injury (Option 2). (Option 1) Auscultating the neck to monitor for an ET tube cuff leak is a standard component of respiratory assessment in mechanically ventilated clients. The presence of a cuff leak increases the risk of accidental extubation, impairs ventilation, and allows aspiration of secretions from the mouth and throat. (Option 3) Oral care with oral suctioning is performed every 2 hours to prevent ventilator-associated pneumonia (VAP). Secretions in the mouth and throat often contain bacteria that can cause pneumonia. (Option 4) Repositioning clients at least every 2 hours reduces the occurrence of VAP. Turning clients side-to-side promotes mobilization of secretions and prevents secretions from pooling in dependent areas of the lungs. Educational objective: Endotracheal suctioning in mechanically ventilated clients should be performed based on assessment findings such as adventitious breath sounds, elevated peak airway pressure, coughing, or acute respiratory distress. Suctioning should be performed only when needed to reduce the risk of lung trauma and hypoxia.

The nurse precepts a new nurse caring for a client showing signs of improvement from hypovolemic shock. Which action by the new nurse would cause the preceptor to immediately intervene? Click the exhibit button for additional information. Vital signs = Temperature 98.2 F (36.8 C); Blood pressure 103/55 mm Hg; Heart rate 91/min; Respirations 18/min; Oxygen saturation (SpO2)99% 1. Changes the oxygen mask to a nasal cannula 2. Delays requesting a new norepinephrine IV bag when the first is almost finished 3. Postpones giving IV antibiotics due to inadequate IV access 4. Questions prescription to change IV fluids from 0.9% to 0.45% normal saline

2 Hypovolemic shock, the most common type of shock, occurs when blood volume decreases through hemorrhage or movement of fluid from the intravascular compartment into the interstitial space (third-spacing). Treatment involves preventing additional fluid loss, restoring volume through IV fluids, and improving hemodynamic stability through vasoactive medications (eg, norepinephrine, dopamine). Norepinephrine causes vasoconstriction and improves heart contractility/output, but the effects end quickly. It should be tapered slowly and cautiously to avoid the progression or relapse of shock. (Option 1) Oxygen via facemask is used to improve tissue oxygenation during shock. With improvement, it would be appropriate to wean the client to a nasal cannula. This client has an oxygen saturation of 99%; therefore, weaning is appropriate. (Option 3) Postponing antibiotics would be a greater concern if the client were in septic, rather than hypovolemic, shock. It is more important to confirm that norepinephrine is available to ensure hemodynamic stability. (Option 4) 0.45% normal saline (½ NS) is a hypotonic fluid that decreases circulatory volume. Clients in hypovolemic shock require isotonic solutions (eg, 0.9% NS, lactated Ringer) to increase circulatory volume. Infusion of ½ NS is more appropriate for a client with hypertonic dehydration (eg, excessive perspiration). Educational objective: Hypovolemic shock occurs when blood volume decreases via hemorrhage or third-spacing. Stopping the source of blood loss, increasing blood volume through IV fluids, and improving blood pressure with vasoactive medications are the first steps in treating this condition. Abruptly discontinuing vasoactive medications can cause hemodynamic instability; these medications should always be tapered slowly.

The nurse is caring for a client who had a near-drowning accident in cold weather. Which assessment finding indicates the most severe injury? 1. Decreased body temperature 2. Toes pointed straight down 3. Weak and thready pulse 4. Wheezing on auscultation

2 Near-drowning occurs when a client is under water and unable to breathe for an extended period. In a matter of seconds, major body organs begin to shut down from lack of oxygen and permanent damage results. Decerebrate posturing is a sign of severe brain damage. During assessment, the nurse would observe arms and legs straight out, toes pointed down, and the head/neck arched back. These assessment findings indicate that severe injury has occurred. (Option 1) Hypothermia is generally seen in near-drowning victims. One of the first goals of treatment is to warm the client. This is done using warmed IV fluids, blankets, and air. Sustained hypothermia will eventually lead to organ failure, making this an urgent finding but not initially life-threatening. (Option 3) A weak and thready pulse is generally detected in near-drowning victims due to hypothermia. Once the client is properly warmed, the pulse generally returns to normal. Sometimes the client is so cold that a pulse cannot be detected; this is why a client is not dead until warm and dead. Such clients may require prolonged resuscitation. (Option 4) When wheezing is heard on auscultation after a near-drowning, the first observation would be that the client is still moving air and providing oxygen to the body. The wheezing may indicate that the client has bronchospasm. If the client has aspirated fluid, crackles would be heard. Most such clients will develop acute respiratory distress syndrome. Educational objective: Decerebrate posturing (arms and legs straight out, toes pointed down, head/neck arched back) usually indicates severe brain injury.

A client is admitted to the intensive care unit with diabetic ketoacidosis. The client is most likely to exhibit which of the following arterial blood gas results? 1. pH 7.26, PaCO2 56 mm Hg (7.5 kPa), HCO3 23 mEq/L (23 mmol/L) 2. pH 7.30, PaCO2 30 mm Hg (4.0 kPa), HCO3 15 mEq/L (15 mmol/L) 3. pH 7.40, PaCO2 40 mm Hg (5.3 kPa), HCO3 24 mEq/L (24 mmol/L) 4. pH 7.58, PaCO2 48 mm Hg (6.4 kPa), HCO3 44 mEq/L (44 mmol/L)

2 The arterial blood gas (ABG) result most consistent with the diagnosis of diabetic ketoacidosis (DKA) is metabolic acidosis or partially compensated metabolic acidosis (pH 7.30, PaCO2 30 mm Hg [4.0 kPa], HCO3 15 mEq/L [15 mmol/L]). DKA is a life-threatening complication of type 1 diabetes characterized by hyperglycemia (>250 mg/dL [13.9 mmol/L]) resulting in ketosis, a metabolic acidosis. Glucose cannot be taken out of the bloodstream and used for energy without insulin, which individuals with type 1 diabetes cannot produce. Similar to a state of starvation, the body begins to break down fat stores into ketones, causing a metabolic acidosis (low pH and low HCO3). As a compensatory mechanism, this client has deep and rapid respirations with fruity/acetone smell (Kussmaul respirations) in an attempt to reduce carbon dioxide levels by inducing a respiratory alkalosis to partially compensate for the ketoacidosis, which has nearly normalized the pH. (Option 1) This is an example of respiratory acidosis (low pH and increased CO2 levels). It is commonly seen in conditions that cause CO2 retention (eg, chronic obstructive pulmonary disease, obesity hypoventilation syndrome, respiratory depression due to narcotics). (Option 3) This is an example of normal ABG results. (Option 4) This is an example of metabolic alkalosis (high pH and elevated HCO3), which typically presents with prolonged vomiting and aggressive diuresis. Educational objective: The arterial blood gas result most consistent with the diagnosis of diabetic ketoacidosis is metabolic acidosis or partially compensated metabolic acidosis (pH ≤7.30 and HCO3 ≤18 mEq/L [18 mmol/L]). Respiratory compensation may raise pH to near-normal values, but the PCO2 will be dramatically lower than normal (PCO2 ≤30 mm Hg [4.0 kPa]).

A nurse in the emergency department is caring for a homeless client just brought in with frostbite to the fingers and toes. The client is experiencing numbness, and assessment shows mottled skin. Which interventions should be included in the client's plan of care? Select all that apply. 1. Apply occlusive dressings after rewarming 2. Elevate affected extremities after rewarming 3. Massage the areas to increase circulation 4. Provide adequate analgesia 5. Provide continuous warm water soaks

2, 4, 5 Frostbite involves tissue freezing, resulting in ice crystal formation in intracellular spaces that causes peripheral vasoconstriction, reduced blood flow, vascular stasis, and cell damage. Superficial frostbite can manifest as mottled, blue, or waxy yellow skin. Deeper frostbite may cause skin to appear white and hard and unable to sense touch. This can eventually progress to gangrene. Treatment of frostbite should include the following: - Remove clothing and jewelry to prevent constriction. - Do not massage, rub, or squeeze the area involved. Injured tissue is easily damaged (Option 3). - Immerse the affected area in water heated to 98.6-102.2 F (37-39 C), preferably in a whirlpool. Higher temperatures do not significantly decrease rewarming time but can intensify pain (Option 5). - Avoid heavy blankets or clothing to prevent tissue sloughing. - Provide analgesia as the rewarming procedure is extremely painful (Option 4). - As thawing occurs, the injured area will become edematous and may blister. Elevate the injured area after rewarming to reduce edema (Option 2). - Keep wounds open immediately after a water bath or whirlpool treatment and allow them to dry before applying loose, nonadherent, sterile dressings (Option 1). - Monitor for signs of compartment syndrome. Educational objective: Care of the client with frostbite focuses on preventing further injury and reducing pain. This includes removing items that can cause constriction or sloughing; no massaging or rubbing of the injured area; providing warm water soaks and analgesia; elevating injured areas; applying loose, nonadherent, sterile dressings; and monitoring for compartment syndrome.

A client is brought to the emergency department after his face slammed into a brick wall during a gang fight. Which client assessment finding is most important for the nurse to consider before inserting a nasogastric tube? 1. An ecchymotic area on the forehead 2. Frontal headache rated as 10 on a 1-10 scale 3. Nasal drainage on gauze has a red spot surrounded by serous fluid 4. Small amount of bright red blood oozing from cheek laceration

3 Cerebrospinal fluid (CSF) rhinorrhea (or CSF otorrhea) can confirm that a skull fracture has occurred and transversed the dura. If the drainage is clear, dextrose testing can determine if it is CSF. However, the presence of blood would make this test unreliable as blood also contains glucose. In this case, the halo/ring test should be performed by adding a few drops of the blood-tinged fluid to gauze and assessing for the characteristic pattern of coagulated blood surrounded by CSF. Identification of this pattern is very important as CSF leakage places the client at risk for infection. The client's nose should not be packed. No nasogastric or oral gastric tube should be inserted blindly when a basilar skull fracture is suspected as there is a risk of penetrating the skull through the fracture site and having the tube ascend into the brain. These tubes are placed under fluoroscopic guidance in clients with such fractures. (Option 1) A bruise is an expected finding after direct trauma. It would be a concern if the ecchymosis were around the eyes (periorbital, "raccoon eyes") or postauricular (Battle's sign) as this generally indicates a basilar skull fracture, a tear in the dura, and a potential CSF leak. (Option 2) A headache is an expected finding after trauma. It would be a concern if it were unrelieved by non-narcotic analgesics or accompanied by signs of increased intracranial pressure. (Option 4) The head is highly vascular and it is not unusual to have blood oozing after trauma. This is not as concerning as a potential CSF leak. However, it can become a problem if the nurse is unable to eventually stop the bleeding as substantial total blood loss is a concern. Educational objective: A nasogastric tube should not be inserted when a basilar skull fracture is suspected. CSF leakage is an indication of this and can be evidenced by a positive halo/ring test of the blood-tinged nasal drainage (coagulated blood surrounded by CSF).

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? 1. Assesses gastric residual volumes every 4 hours 2. Measures the number of centimeters the feeding tube is secured at the nare every 4 hours 3. Requests that the physician change the client from continual to bolus feedings 4. Uses a sedation scale to titrate down the sedation (if possible)

3 Critically ill clients are at increased risk for aspiration of oropharyngeal secretions and gastric content. It is common in clients who are intubated, sedated, on a mechanical ventilator, and receiving enteral feedings. The nurse must provide nursing interventions to prevent aspiration and monitor for its signs and symptoms. Clients are at increased risk when receiving bolus rather than continual enteral feedings. Bolus feedings should be avoided in critically ill clients, who are already at increased risk for aspiration. (Option 1) Assessing gastric residual volumes according to institution policy (at least every 4 hours) is standard for clients receiving continual enteral feedings. Increased volumes may indicate poor absorption and increase the risk of regurgitation and aspiration. (Option 2) Measuring the number of centimeters at the nare every 4 hours can help determine if the tube has moved, but it can increase aspiration risk. X-ray confirmation may be necessary if the tube has moved. (Option 4) A sedation scale such as the Ramsay Scale is used to assess level of sedation. It is preferable to keep the client minimally sedated (asleep but arousable). This helps decrease the risk of aspiration. Educational objective: Assessing gastric residual volumes and level of sedation at regular intervals, checking enteral feeding tube placement, and administering continual rather than bolus tube feeding are interventions that help prevent aspiration in critically ill high-risk clients.

The emergency department nurse is caring for a client who requires gastric lavage for a drug overdose. Which action would be appropriate? 1. Lavage through a small-bore nasogastric tube 2. Place client in Trendelenburg position during lavage 3. Prepare intubation and suction supplies at the bedside 4. Wait an hour after gastric decompression to initiate lavage

3 Gastric lavage (GL) is performed through an orogastric tube to remove ingested toxins and irrigate the stomach. GL is rarely performed as it is associated with a high risk of complications (eg, aspiration, esophageal or gastric perforation, dysrhythmias). GL is only indicated if the overdose is potentially lethal and if GL can be initiated within one hour of the overdose. Activated charcoal administration is the standard treatment for overdose, but it is ineffective for some drugs (eg, lithium, iron, alcohol). Intubation and suction supplies should always be available at the bedside during GL in case the client develops aspiration or respiratory distress (Option 3). (Option 1) GL is usually performed through a large-bore (36 to 42 French) orogastric tube so that a large volume of water or saline can be instilled in and out of the tube. (Option 2) During GL, clients should be placed on their side or with the head of bed elevated to minimize aspiration risk. (Option 4) GL should be initiated within one hour of overdose ingestion to be effective. The client's stomach should be decompressed first, but lavage should be initiated as soon as possible afterwards. Educational objective: Gastric lavage is used to remove ingested toxins and irrigate the stomach after a drug overdose. It should be initiated within one hour of overdose. The nurse should position the client to prevent aspiration and have emergency respiratory equipment at the bedside.

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? 1. Assess the insertion site for presence of subcutaneous emphysema 2. Notify the surgeon of a large air leak 3. Take no action as the chest tube is functioning appropriately 4. Turn down the wall suction until the bubbling disappears

3 Gentle, continuous bubbling in the suction control chamber (section A) of a chest tube drainage unit indicates that suction is present and the unit is functioning appropriately. The nurse should document the finding and continue to monitor. (Option 1) Subcutaneous emphysema is air that has leaked into the tissue surrounding the chest tube insertion site. A crackling sensation is felt when palpating the skin. It does not affect bubbling within the chest tube drainage unit. (Option 2) An air leak would cause bubbling in the air leak gauge (section C) or water seal chamber not in the suction control chamber. (Option 4) Turning down the wall suction would effectively negate the presence of suction in the chest tube drainage unit. Educational objective: Gentle, continuous bubbling in the suction control chamber of a chest tube drainage unit indicates the presence of suction in the system and is an expected finding.

A client undergoing endotracheal intubation received IV sedation and succinylcholine. Shortly after respiratory status has been stabilized, the client becomes flushed and profusely diaphoretic and has a rigid jaw. Which medication should the nurse prepare to administer? Click the exhibit button for more information. Vital signs = Temperature 105 F (40.6 C); Blood pressure 140/90 mm Hg; Heart rate 150/min; Respirations 28/min; O2 saturation 98% 1. IM epinephrine 2. IV atropine 3. IV dantrolene 4. IV glucagon

3 Malignant hyperthermia (MH) is a rare and life-threatening condition precipitated by certain medications used for anesthesia, including inhaled anesthetics (eg, desflurane, isoflurane, halothane) and succinylcholine (a paralytic used adjunctively for intubation and general anesthesia). Skeletal muscles become unable to control calcium levels, leading to a hypermetabolic state manifested by contracture and increased temperature. Early signs of MH include tachypnea, tachycardia, and a rigid jaw or generalized rigidity. As the condition progresses, the client develops a high fever. Muscle tissue is broken down, leading to hyperkalemia, cardiac dysrhythmias, and myoglobinuria. MH requires emergent treatment with IV dantrolene to reverse the process by slowing metabolism. Succinylcholine should be discontinued. Other interventions include applying cooling blankets to reduce temperature and treating high potassium levels. (Option 1) IM epinephrine is administered for cardiac arrest, anaphylactic reactions, or severe asthma attacks; it is not appropriate for MH. (Option 2) IV atropine, an anticholinergic agent, is used to treat bradycardia. It would worsen tachycardia in this client. (Option 4) Naturally produced by the pancreas, glucagon is given intramuscularly, subcutaneously, or intravenously for severe hypoglycemia. IV glucose is preferred due to its immediate effect; however, if it is unavailable, glucagon can be given to stimulate glycogenolysis in the liver, thereby raising blood glucose. Educational objective: Malignant hyperthermia is a life-threatening hypermetabolic condition triggered by certain drugs used for general anesthesia. Prompt administration of IV dantrolene is critical. Other interventions include cooling the client and treating high potassium levels.

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)? 1. Dehydration 2. Hypokalemia 3. Hypotension 4. Increased cardiac output

3 Positive pressure ventilation (PPV) delivers positive pressure to the lungs using a mechanical ventilator (MV), either invasively through a tracheostomy or endotracheal tube or noninvasively through a nasal mask/facemask, nasal prongs, or a mouthpiece. The most common type used in the acute care setting for clients with acute respiratory failure is the volume cycled positive pressure MV, which delivers a preset volume and concentration of oxygen (eg, 21%-100%) with varying pressure. Positive pressure applied to the lungs compresses the thoracic vessels and increases intrathoracic pressure during inspiration. This leads to reduced venous return, ventricular preload, and cardiac output, which results in hypotension. The hypotensive effect of PPV is even greater in the presence of hypovolemia (eg, hemorrhage, hypovolemic shock) and decreased venous tone (eg, septic shock, neurogenic shock). (Option 1) Fluid and/or sodium retention usually occurs about 48-72 hours after initiation of PPV due to: (1) increased intrathoracic pressure and decreased cardiac output that stimulate the kidneys to release renin; (2) physiologic stress that leads to the release of antidiuretic hormone and cortisol; and (3) breathing through the ventilator's closed circuitry, which decreases insensible loss associated with respiration. (Option 2) Hypokalemia is not associated with PPV. (Option 4) PPV increases intrathoracic pressure and reduces venous return to the right side of the heart, reducing preload and cardiac output as well. Educational objective: Positive pressure ventilation causes increased intrathoracic pressure and reduced venous return and cardiac output, which can result in hypotension.

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? 1. Angle of Louis at 2nd intercostal space (ICS) to left of sternal border 2. Aortic area at 2nd ICS to right of sternal border 3. Level of atria at 4th ICS, ½ anterior-posterior (AP) diameter 4. 5th ICS at mid clavicular line (MCL)

3 To measure pressures accurately using continual arterial and/or pulmonary artery pressure monitoring, the zeroing stopcock of the transducer system must be placed at the phlebostatic axis. This anatomical location, with the client in the supine position, is at the 4th ICS, at the midway point of the AP diameter (½ AP)of the chest wall. If the transducer is placed too low, the reading will be falsely high; if placed too high, the reading will be falsely low. This concept is similar to the positioning of the arm in relation to the level of the heart when measuring blood pressure indirectly using a sphygmomanometer or noninvasive blood pressure-monitoring device. The upper arm should be at the level of the phlebostatic axis. (Option 1) The angle of Louis is 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. (Option 2) The aortic area is an auscultatory area located at the 2nd ICS to the right of the sternal border. (Option 4) The mitral area (apex), an auscultatory area, and the point of maximal impulse are located at the 5th ICS at the MCL. Educational objective: The anatomical location of the phlebostatic axis is 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.

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? 1. Insert a large-bore IV line and infuse normal saline 2. Obtain blood for type and crossmatch and hemoglobin 3. Remove constrictive clothing to enhance circulation 4. Stabilize the scissors with sterile bulky dressings

4 A sharp object that pierces the skin and lodges in the body may result in penetrating trauma to nearby tissue and organs. Common types of impaled (embedded) objects include bullets or blast fragments from firearms as well as sharp objects such as scissors, nails, or knives. The embedded object creates a puncture wound and then controls potential bleeding by putting pressure on the wound. First responders should not manipulate or remove the impaled object. Manipulation or removal may cause further trauma and bleeding; therefore, stabilization of the object is the first priority to prevent it from moving during initial client assessment (Option 4) and later during transport to a health care facility where skilled trauma care is available. Exception to the rule: First responders (EMS providers) may remove the impaled object if it obstructs the airway and prevents effective cardiopulmonary resuscitation. (Option 1) An IV line may be inserted and fluids begun on scene after stabilization of the object and initial assessment. (Option 2) Blood may be drawn after stabilization of the object and initial assessment. (Option 3) Clothing may be removed on scene after stabilization of the object and initial assessment. Educational objective: An impaled object should not be manipulated or removed at the scene as further trauma and bleeding of soft tissue and surrounding organs may occur. The embedded object is stabilized on scene to allow for initial client assessment and later transport to a health care facility where skilled trauma care is available.

A 75-year-old client is hospitalized with chronic obstructive pulmonary disease (COPD) exacerbation. The health care provider (HCP) initiates noninvasive positive airway pressure ventilation (NIPPV) with a bilevel positive airway pressure (BIPAP) device. Prescribed medications are shown in the exhibit. Which parameter is most important for the nurse to monitor frequently in this client? Click on the exhibit button for additional information. Medication prescription: Albuterol and ipratropium: nebulizer, every 4 hours as needed Levofloxacin: 750 mg IV, once daily Methylprednisolone: 40 mg IV, every 8 hours Enoxaparin: 40 mg subcutaneously, once daily 1. Blood glucose level 2. Capillary refill time 3. Extremity swelling 4. Mental status

4 An exacerbation of COPD is characterized by the acute worsening of a client's baseline symptoms (eg, dyspnea, cough, sputum color and production). NIPPV is often prescribed short-term to support gas exchange in clients who have moderate to severe COPD exacerbations and acidosis (pH <7.3) or hypercapnia (PaCO2 >45 mm Hg). NIPPV can prevent the need for tracheal intubation and is administered until the underlying cause of the ventilatory failure is reversed with pharmacologic therapy (eg, corticosteroids, bronchodilators, antibiotics). BIPAP involves the use of a mechanical device and facemask in a conscious client who is breathing spontaneously. BIPAP delivers oxygen to the lungs and then removes carbon dioxide (CO2). CO2 retention causes mental status changes. If the client becomes drowsy or confused, it is likely that more CO2 is being retained than what BIPAP can remove; this should be reported to the HCP. Arterial blood gas evaluation should be obtained to determine CO2 level and BIPAP effectiveness. Altered mental status poses the greatest threat to a client's survival as it can lead to decreased protective reflexes (eg, gag, swallow, cough), periods of apnea, and airway compromise (Option 4). (Option 1) The nurse should monitor the blood glucose level because the client was prescribed the corticosteroid methylprednisolone (Solu-Medrol), which can cause hyperglycemia, especially in clients with diabetes mellitus. However, blood glucose is not the most important parameter to monitor frequently in this client. (Option 2) Capillary refill time is indicated to assess poor perfusion states, and a value of >3 seconds (delayed refill time) is seen in conditions such as dehydration, shock, and peripheral vascular disease. (Option 3) Unilateral extremity swelling is concerning for deep venous thrombosis (DVT) in a hospitalized client. Bilateral swelling indicates volume overload or venous stasis. This client was started on enoxaparin (blood thinner) to prevent DVT. Volume overload is unlikely as the client is not receiving IV fluids. Educational objective: In a client with COPD exacerbation, it is most important for the nurse to monitor mental status frequently and report changes such as restlessness, decreased level of consciousness, somnolence, difficult arousal, and confusion to the HCP. These signs may indicate increased CO2 retention and worsening hypercapnia, which would necessitate an immediate change in therapy.

The emergency department nurse receives a client with extensive injuries to the head and upper back. The nurse will perform what action to allow the best visualization of the airway? 1. Head-tilt chin-lift in the supine position on a backboard 2. Head-tilt chin-lift in the Trendelenburg position 3. Jaw-thrust maneuver in semi-Fowler's position 4. Jaw-thrust maneuver in the supine position on a backboard

4 Clinical situations involving trauma should follow ABC: Airway, Breathing, and Circulation. Airway assessment is particularly critical in clients with injuries to the head, neck, and upper back. Injury to the upper back should be treated as spinal trauma until the client has been cleared by an Advanced Trauma Life Support-qualified health care provider. Until the spine is appropriately assessed, the client should be placed on a backboard and stabilized. The nurse should use the jaw-thrust maneuver to avoid movement of an unstable spine. One provider should stabilize the cervical vertebra allowing the second provider to articulate the jaw independently of the spinal column. (Option 1) Although use of the backboard is appropriate, the head-tilt chin-lift should not be used as it involves manipulation of the neck without proper stabilization. If the cervical vertebrae are fractured, the spinal cord could be badly damaged. (Option 2) The head-tilt chin-lift does not stabilize the alignment of the head and neck and can cause spinal cord damage. In addition, the Trendelenburg position causes the abdominal organs to shift toward the diaphragm, which increases the work of breathing. (Option 3) The jaw-thrust maneuver is appropriate, but stabilization of the spine is best performed in the supine position, such as on the flat, hard surface of a backboard. Educational objective: If there is any suspicion of spinal injury, the jaw-thrust maneuver should be used for airway assessment to avoid any shifting of unstable vertebrae and subsequent spinal cord damage.

The nurse is admitting a client with a possible diagnosis of Guillain-Barré syndrome. When collecting data to develop a plan of care for the client, the nurse should give priority to which of the following items? 1. Orthostatic blood pressure changes 2. Presence or absence of knee reflexes 3. Pupil size and reaction to light 4. Rate and depth of respirations

4 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). Neuromuscular respiratory failure is the most life-threatening complication. The rate and depth of the respirations should be monitored (Option 4). Measurement of serial bedside forced vital capacity (spirometry) is the gold standard for assessing early ventilation failure. (Option 1) Autonomic dysfunction is common in GBS and usually results in orthostatic hypotension, paralytic ileus, urinary retention, and diaphoresis. These complications need to be assessed but are not a priority. (Option 2) Absence of knee reflexes is expected early in the course of GBS due to the ascending nature of the disease. Absence of gag reflex indicates GBS progression. (Option 3) PERRLA (pupils equal, round, reactive to light, accommodation) evaluation assesses CNs II, III, IV, and VI. CN abnormalities are expected after the thoracic muscles (respiratory) are involved due to the ascending nature of GBS. Educational objective: The most serious complication to monitor for in new-onset Guillain-Barré syndrome is 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.

A nurse in the intensive care unit is caring for a client in the immediate postoperative period following abdominal surgery. The nurse receives several prescriptions. Which prescription should the nurse initiate first? Click on the exhibit button for additional information. Assessment data = Temperature 99.1 F (37.3 C); Blood pressure 82/58 mm Hg; Pulse 115/min; Respirations 22/min; Central venous pressure 1 mm Hg 1. Acetaminophen 1000 mg IVPB every 8 hours 2. Cefazolin 2 g IVPB once, now 3. Norepinephrine 0.02-2.0 mcg/kg/min titrated IV 4. Normal saline 2 L via rapid IV bolus

4 Hypotension, tachycardia, and low central venous pressure (normal: 2-8 mm Hg) may indicate hypovolemic shock. Central venous pressure is a measurement of right ventricular preload (volume within the ventricle at the end of diastole) and reflects the client's fluid volume status. This client is recovering from major abdominal surgery and has a low-grade fever, placing the client at risk for fluid volume losses (eg, blood loss during surgery, insensible losses [sweating]). This client should be treated with isotonic fluids (eg, normal saline, lactated Ringer solution) to restore adequate fluid volume status. IV boluses of isotonic fluids (ie, fluid resuscitation) increase intravascular volume, which increases blood pressure and end-organ perfusion (Option 4). (Option 1) Acetaminophen is an analgesic and antipyretic that reduces fever and pain; however, the client's hemodynamic stability should be addressed first. (Option 2) Cefazolin, a cephalosporin antibiotic, may be prescribed prophylactically to prevent intra-abdominal infection after major abdominal surgery. Medications timed "now" should be administered within 90 minutes. This intervention should be performed after stabilizing the client's hemodynamic status. (Option 3) If the client remains hypotensive following a fluid bolus, vasopressor or inotropic medications (eg, norepinephrine, dopamine) should be initiated. However, vasopressor medications are not effective without first restoring circulatory fluid volume as there is insufficient volume to compress within the vascular space. Educational objective:Hypotension, tachycardia, and decreased central venous pressure (normal: 2-8 mm Hg) may indicate hypovolemic shock. IV boluses of isotonic fluids (ie, fluid resuscitation) increase intravascular volume, which increases blood pressure and perfusion.

The nurse is supervising a graduate nurse (GN) on a telemetry unit. An assigned client develops asystole with no pulse, and emergency care interventions are initiated. Which action by the GN would cause the supervising nurse to intervene? 1. Administers IV epinephrine 2. Applies oxygen with bag-mask 3. Initiates chest compressions 4. Provides defibrillator shock

4 The client in asystole has a total absence of ventricular electrical activity and is pulseless, apneic, and unresponsive. The nurse should first verify the monitor reading by assessing the client and palpating for a pulse, and then call for help and initiate emergency care (ie, CPR, oxygenated ventilation). Defibrillation is not indicated when there is no electrical activity present (ie, asystole) or when the heart muscle is not contracting despite an organized rhythm (ie, pulseless electrical activity [PEA]). Defibrillation attempts to convert lethal ventricular dysrhythmias (ie, ventricular fibrillation and pulseless ventricular tachycardia) into an organized rhythm by passing an electric shock through the heart. Defibrillation cannot create an organized rhythm if there is no electrical activity in the heart (Option 4). (Options 1, 2, and 3) Immediate interventions for asystole and PEA include CPR and oxygenated ventilation. Advanced cardiovascular life-support measures include epinephrine IV, placement of advanced airway (ie, intubation), and treatment of reversible causes (eg, hypovolemia, hyperkalemia). When treating asystole or PEA, the absolute priority is providing continuous, high-quality CPR and oxygenated ventilation until circulation spontaneously returns or the client enters into a shockable rhythm. Unfortunately, restoration of circulation may not be possible, and clients in asystole often cannot be resuscitated. Educational objective: Asystole is characterized by a total absence of ventricular electrical activity. The client is pulseless, apneic, and unresponsive. Treatment includes CPR, oxygenated ventilation, and advanced cardiovascular life-support measures (eg, epinephrine IV, advanced airway). Defibrillation is not effective for treatment of asystole or pulseless electrical activity.

A critically ill client receiving vasopressor therapy for hypotension requires continuous blood pressure monitoring via an arterial catheter. The nurse sets up the pressure monitoring system and correctly places the transducer at the phlebostatic axis. Where on the chest does the nurse mark this reference point?

The phlebostatic axis is an external anatomical point on the chest at the level of the atria of the heart (fourth intercostal space at the midaxillary line or midway point of the anterior posterior diameter of the chest). It is used as a reference point for correct placement of the zeroing point of the transducer when measuring continual arterial blood pressure (BP), central venous pressure (CVP) using a central line, and/or cardiopulmonary pressures via a pulmonary artery (Swan-Ganz) catheter. The nurse places the transducer and marks the chest at the phlebostatic axis, which helps to assure accuracy of measurement. After it is placed, the zero reference stopcock of the transducer is "leveled," or aligned with the level of the atrium, using a ruler or carpenter's level. If the zeroing stopcock is placed below this level, falsely high readings occur; if it is too high, falsely low readings are obtained. The phlebostatic axis is also used as a reference point for the upper arm when measuring BP indirectly using a noninvasive BP device or the auscultatory method with sphygmomanometer and stethoscope. If the upper arm is above or below this level, the BP reading will be inaccurate. Educational objective: The phlebostatic axis (fourth intercostal space at the midaxillary line or midway point of the anterior posterior diameter of the chest) is an external reference point on the thorax used to determine proper placement of the pressure monitoring system transducer when measuring direct BP, CVP, and/or cardiopulmonary pressures invasively. It is also used as a reference point for the upper arm when measuring BP indirectly.