Final

The nurse is calculating the rate for a regular rhythm. There are 20 small boxes before each R wave. The nurse interprets the rate to be: 50 beats/min. 75 beats/min. 85 beats/min. 100 beats/min.

75 beats/min. Small box method: The small box method is used to calculate the exact rate of a regular rhythm. In this method, two consecutive P and QRS waves are located. The number of small boxes between the highest points of these consecutive P waves is counted, and that number is divided into 1500 to determine the atrial rate in beats per minute. The number of small boxes between the highest points of two consecutive QRS waves is counted, and that number is divided into 1500 to determine the ventricular rate. This method is accurate only if the rhythm is regular.

A patient is admitted to the hospital with multiple trauma and extensive blood loss. The nurse assesses vital signs to be BP 80/50 mm Hg, heart rate 135 beats/min, respirations 36 breaths/min, cardiac output (CO) of 2 L/min, systemic vascular resistance of 3000 dynes/sec/cm-5, and a hematocrit of 20%. The nurse anticipates administration of which the following therapies or medications? A. Blood transfusion B. Furosemide C. Dobutamine infusion D. Dopamine hydrochloride infusion

A

The charge nurse is supervising the care of four critical care patients being monitored using invasive hemodynamic modalities. Which patient should the charge nurse evaluate first? A. A patient in cardiogenic shock with a cardiac output (CO) of 2.0 L/min B. A patient with a pulmonary artery systolic pressure (PAP) of 20 mm Hg C. A hypovolemic patient with a central venous pressure (CVP) of 6 mm Hg D. A patient with a pulmonary artery occlusion pressure (PAOP) of 10 mm Hg

A

The nurse is caring for a 100-kg patient being monitored with a pulmonary artery catheter. The nurse assesses a blood pressure of 90/60 mm Hg, heart rate 110 beats/min, respirations 36/min, oxygen saturation of 89% on 3 L of oxygen via nasal cannula. Bilateral crackles are audible upon auscultation. Which hemodynamic value requires immediate action by the nurse? A. Cardiac index (CI) of 1.2 L/min/m3 B. Cardiac output (CO) of 4 L/min C. Pulmonary vascular resistance (PVR) of 80 dynes/sec/cm-5 D. Systemic vascular resistance (SVR) of 1400 dynes/sec/cm-5

A

The nurse is caring for a 70-kg patient in septic shock with a pulmonary artery catheter. Which hemodynamic value indicates an appropriate response to therapy aimed at enhancing oxygen delivery to the organs and tissues? A. Arterial lactate level of 1.0 mEq/L B. Cardiac output of 2.5 L/min C. Mixed venous (SvO2) of 40% D. Cardiac index of 1.5 L/min/m2

A

Poor patient outcomes after a traumatic injury are associated with a. chest tube placement for treatment of a hemothorax. b. immediate decompression of a tension pneumothorax. c. massive transfusions of blood products. d. intraosseous cannulation for intravenous fluid administration.

c. massive transfusions of blood products.

The nurse is caring for a patient with a left radial arterial line and a pulmonary artery catheter inserted into the right subclavian vein. Which action by the nurse best ensures the safety of the patient being monitored with invasive hemodynamic monitoring lines? A. Document all waveform values. B. Limit the pressure tubing length. C. Zero reference the system daily. D. Ensure alarm limits are turned on.

D

The nurse is caring for a patient who has positive end-expiratory pressure (PEEP) as an adjunct to the ventilation. When PEEP is increased, the nurse is prepared for which assessment finding? A decrease in cardiac output A decrease in inspiratory pressure An increase in tidal volume An increased work of breathing

A decrease in cardiac output Because PEEP increases intrathoracic pressure, cardiac output may decrease.

The nurse is caring for a patient with a diagnosis of acute myocardial infarction (AMI). Which medication should the nurse anticipate administering to the patient to reduce platelet aggregation? Aspirin Lidocaine Nitroglycerin Oxygen

Aspirin Aspirin blocks synthesis of thromboxane A2, thus inhibiting aggregation of platelets.

In a patient with increased intracranial pressure (ICP), which of the following cranial nerves should the nurse assess for consensual light response, elevation of the eyelids, and eye movement? I, IX, X II, V, VII II, VI, X III, IV, VI

III, IV, VI Cranial nerve III is responsible for the consensual light response, elevation of the eyelids, and eye movements. In addition, cranial nerves III, IV, and VI affect extraocular eye movements.

A 55-year-old trauma patient hit the steering wheel and has a cardiac contusion. Which are potential complications of the injury? (SATA) a. Flail chest b. Dysrhythmias c. Hypotension d. Myocardial ischemia

b, c, d

Prevention of hypothermia is crucial in caring for trauma patients. Which treatments are appropriate for preventing hypothermia? (SATA) a. Administer cool humidified oxygen. b. Cover the patient with an external warming device. c. Leave the patient's clothing on, even if wet. d. Warm fluids and blood products before or during administration. e. Warm the room in the emergency department and critical care unit.

b,d,e

A 67-year-old female is admitted to the emergency department complaining of midback pain and shortness of breath for the preceding 2 hours. She also complains of nausea and states that she vomited twice before coming to the hospital. She denies any chest discomfort or arm pain. The nurse prepares to the treat the patient for a diagnosis of: flu symptoms. anxiety attack. myocardial infarction (MI). osteoporosis.

myocardial infarction (MI). Women are more likely to have atypical signs and symptoms of acute myocardial infarction (AMI), such as shortness of breath, nausea and vomiting, and back or jaw pain.

The patient, who is being treated for hypercholesterolemia, complains of hot flashes and a metallic taste in the mouth. The nurse educates the patient that this is a side effect of: bile acid resins. clopidogrel. nicotinic acid. statins.

nicotinic acid. Common side effects of nicotinic acid include metallic taste in mouth, flushing, and increased feelings of warmth.

The patient presents to the emergency department with severe substernal chest discomfort. Cardiac enzymes are elevated, and his ECG shows ST-segment depression in V2 and V3. The nurse anticipates a diagnosis of: non-Q-wave myocardial infarction (MI). pulmonary embolism. Q-wave myocardial infarction (MI). right ventricular infarction.

non-Q-wave myocardial infarction (MI). The non-Q-wave MI usually results from a partially occluded coronary vessel, and it is associated with ST-segment depression in two or more leads, along with elevated cardiac enzymes.

The nurse is interpreting a patient's cardiac rhythm and notes that the PR interval is 0.16 seconds long. The nurse determines that this PR interval indicates: slower-than-normal conduction from the SA node through the AV node. normal conduction from the SA node through the AV node. faster-than-normal conduction from the SA node through the AV node. abnormally fast depolarization of the atria and ventricles.

normal conduction from the SA node through the AV node. The interval from the beginning of the P wave to the next deflection from the baseline is called the PR interval. The PR interval measures the time it takes for the impulse to depolarize the atria, travel to the AV node, and dwell there briefly before entering the bundle of His. The normal PR interval is 0.12 to 0.20 seconds, three to five small boxes wide. When the PR interval is longer than normal, the speed of conduction is delayed in the AV node. When the PR interval is shorter than normal, the speed of conduction is abnormally fast.

A 45-year-old male is visiting the wellness clinic and has been newly diagnosed as a stage I hypertensive patient. His blood pressure assessment over the past 6 months has consistently been 145/92 mm Hg. The patient asks, "What is blood pressure?" What is the best response by the nurse? "A complex measurement that should be discussed only with your physician." "A measurement that should be 120/80 mm Hg unless complications are present." "A measurement that takes into consideration the amount of blood your heart is pumping and the size of the vessel diameter the heart must pump against." "The amount of pressure exerted on the veins by the blood."

"A measurement that takes into consideration the amount of blood your heart is pumping and the size of the vessel diameter the heart must pump against." The contractile force of the heart is the driving pump behind blood flow through the cardiovascular system. The ease of blood flow is a measurement of diameter of the vessel (resistance) and the volume and viscosity of blood through the cardiovascular circuit. It is within the scope of practice of a nurse to educate the patient about blood pressure. Blood pressure values may have a wide range dependent upon the pumping action of the heart, vessel diameter, and blood volume. Variations can be tolerated, but trends that remain high should be evaluated further. Blood pressure measurement is a reflection of pumping action of the heart, vessel diameter, and blood volume.

The nurse explains to the new RN that angiotensin-converting enzyme inhibitors (ACE inhibitors) should be started within 24 hours of acute myocardial infarction (AMI). Which statement by the new RN indicates that teaching has been effective? "ACE inhibitors are started within 24 hours to prevent hibernating myocardium." "ACE inhibitors are started within 24 hours to prevent myocardial remodeling." "ACE inhibitors are started within 24 hours to prevent myocardial stunning." "ACE inhibitors are started within 24 hours to prevent tachycardia."

"ACE inhibitors are started within 24 hours to prevent myocardial remodeling." Myocardial remodeling is a process mediated by angiotensin II, aldosterone, catecholamine, adenosine, and inflammatory cytokines; it causes myocyte hypertrophy and loss of contractile function in the areas of the heart distant from the site of infarctions. ACE inhibitors should be ordered.

The nurse is listening to a lecture on the physiological consequences of acute respiratory distress syndrome (ARDS). Which statement indicates that teaching has been effective? "ARDS is associated with decreased compliance." "ARDS is associated with decreased physiological dead space." "ARDS is associated with increased resistance." "ARDS is associated with Pulmonary fibrosis."

"ARDS is associated with decreased compliance." ARDS is associated with decreased lung compliance.

The nurse is educating a new RN on the therapeutic effect of head-of-the-bed elevation and neutral head and neck alignment on a patient with increased intracranial pressure (ICP). Which statement by the new RN indicates that teaching has been effective? "Head-of-the-bed elevation lowers ICP by allowing for elevations in CO2 to dilate cerebral arteries." "Head-of-the-bed elevation lowers ICP by facilitating venous drainage and decreasing venous obstruction." "Head-of-the-bed elevation lowers ICP by maintaining an open airway." "Head-of-the-bed elevation lowers ICP by reducing the risk of snoring."

"Head-of-the-bed elevation lowers ICP by facilitating venous drainage and decreasing venous obstruction." Head-of-the-bed elevation and a neutral head position that avoids hyperextension or hyperflexion facilitate jugular venous drainage, helping to minimize increases in ICP. Elevated CO2 contributes to cerebral vessel vasodilation, which can increase cerebral blood volume and further elevate ICP. Maintaining an open airway alone does not minimize increases in ICP. Reducing the risk of snoring by maintaining an open airway alone does not minimize increases in ICP.

The nurse is orienting a new RN in the care of a patient with respiratory distress due to emphysema. The patient is being treated with O2 via a Venturi mask with 35% oxygen. Which statement by the new RN indicates that teaching has been effective, when the nurse questions the new RN about the use of the Venturi mask? "A nasal cannula will dry the mucous membranes and cause an increased risk of infection." "Her alveoli cannot absorb higher levels of O2 because of the emphysema." "Her alveoli have been damaged and may rupture with higher doses of O2." "Her respiratory center requires low O2 concentration to stimulate breathing."

"Her respiratory center requires low O2 concentration to stimulate breathing." In patients with COPD, the respiratory drive is stimulated by hypoxemia, not increased levels of carbon dioxide. Administration of oxygen in high levels will impair the respiratory drive.

When checking a patient's pulmonary artery occlusion pressure, the nurse inflates the balloon as ordered, not inflating the balloon for more than 8 to 10 seconds. The patient asks the rationale behind the nurse's actions. Which statement should the nurse make? "Prolonged inflation can obstruct blood flow, resulting in ischemia." "Prolonged inflation increases the risk of catheter balloon rupture." "Prolonged inflation increases the likelihood of thermistor damage." "Prolonged inflation will reduce tension on the pulmonary artery wall."

"Prolonged inflation can obstruct blood flow, resulting in ischemia." Prolonged inflation of the pulmonary artery catheter balloon will compromise blood flow forward of the balloon, risking pulmonary infarction. Overinflation with a high volume of air in the balloon, rather than prolonged inflation, can lead to balloon rupture. Balloon inflation does not influence thermistor damage. Prolonged inflation will increase tension on the pulmonary artery wall.

The nurse is orienting a new RN to the ICU. The nurse begins to review orders recently entered by the cardiologist and to explain their rationale to the new RN. Medication orders include dobutamine (Dobutrex) 400 mg in 250 mL 5% dextrose in water titrated to keep cardiac index >2 L/min/m2. Which statement by the new RN indicates that teaching has been effective? "The cardiac index is the amount of blood pumped out by a ventricle per minute." "The cardiac index is the amount of blood ejected with each ventricular contraction." "The cardiac index is the pressure created by the volume of blood in the left heart." "The cardiac index is the measurement specific to the patient's size or body area."

"The cardiac index is the measurement specific to the patient's size or body area." Cardiac index is cardiac output individualized to a patient's body surface area or size. Cardiac output is the amount of blood pumped out by a ventricle per minute. The amount of blood ejected with each ventricular contraction is stroke volume. The pressure created by the volume of blood in the left heart is pulmonary artery occlusive pressure.

The nurse is educating a new RN on preparing a patient for assessment of cardiac output using an esophageal monitor. Which statement by the new RN indicates that teaching was effective? "The procedure involves a thin probe inserted into the esophagus." "Patients require deep sedation provided by an anesthesia provider." "The procedure immediately assesses right ventricular performance." "There are no absolute contraindications for the procedure."

"The procedure involves a thin probe inserted into the esophagus." The procedure involves insertion of a thin silicone probe into the distal esophagus. The probe is easily placed similarly to an orogastric or nasograstric tube, so patients require little to no sedation. The procedure provides an immediate assessment of left ventricular performance. There are several contraindications to the procedure, including esophageal stricture and esophagegeal varices (see Box 8-9).

The nurse is interpreting the rhythm strip of a patient and measures the QRS complex as being three small boxes in width. The nurse interprets this width as: 0.04 seconds. 0.10 seconds. 0.12 seconds. 0.16 seconds.

0.12 seconds. ECG paper contains a standardized grid in which the horizontal axis measures time and the vertical axis measures voltage or amplitude. Larger boxes are circumscribed by darker lines and the smaller boxes by lighter lines. The larger boxes contain 5 smaller boxes on the horizontal line and 5 on the vertical line for a total of 25 per large box. Horizontally, the smaller boxes denote 0.04 seconds each or 40 milliseconds; the larger box contains five smaller boxes and thus equals 0.20 seconds or 200 milliseconds. Along the uppermost aspect of the ECG paper are vertical hash marks that occur every 15 large boxes. The area between these marks equals 3 seconds.

The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which action by the nurse best reduces the risk of catheter-related bloodstream infection (CRBSI)? A. Review daily the necessity of the central venous catheter. B. Cleanse the insertion site daily with isopropyl alcohol. C. Change the pressurized tubing system and flush bag daily. D. Maintain a pressure of 300 mm Hg on the flush bag.

A

The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which assessment finding 2 hours after insertion by the nurse warrants immediate action? A. Diminished breath sounds over left lung field B. Localized pain at catheter insertion site C. Measured central venous pressure of 5 mm Hg D. Slight bloody drainage around insertion site

A

Upon entering the room of a patient with a right radial arterial line, the nurse assesses the waveform to be slightly dampened and notices blood to be backed up into the pressure tubing. What is the best action by the nurse? A. Check the inflation volume of the flush system pressure bag. B. Disconnect the flush system from the arterial line catheter. C. Zero reference the transducer system at the phlebostatic axis. D. Reduce the number of stopcocks in the flush system tubing.

A

The patient has a temporary transvenous, demand-type ventricular pacemaker. The rate on the pacemaker is set at 60 beats/min. Which of the following situations would be of concern? A paced rhythm of 60 beats/min is seen on the monitor; no other waveforms are seen. A pacemaker spike is seen on the T wave of the preceding beat. The patient's inherent (own) rate falls to 58 and the pacemaker fires. The patient's inherent rate is 70 beats/min; no pacemaker spikes are seen.

A pacemaker spike is seen on the T wave of the preceding beat. Failure to sense manifests as pacer spikes that fall earlier than the programmed rate. This can cause an artificial R-on-T phenomenon similar to when a PVC occurs during the T wave, and ventricular tachycardia may occur.

The nurse is preparing for insertion of a pulmonary artery catheter (PAC). During insertion of the catheter, what are the priority nursing actions? (Select all that apply.) A. Allay the patient's anxiety by providing information about the procedure. B. Ensure that a sterile field is maintained during the insertion procedure. C. Inflate the balloon during the procedure when indicated by the provider. D. Monitor the patient's cardiac rhythm throughout the procedure. E. Obtain informed consent by informing the patient of procedural risks.

A, B, C, D

Which nursing actions are most important for a patient with a right radial arterial line? (Select all that apply.) A. Checking the circulation to the right hand every 2 hours B. Maintaining a pressurized flush solution to the arterial line setup C. Monitoring the waveform on the monitor for dampening D. Restraining all four extremities with soft limb restraints E. Ensuring all junctions remain tightly connected

A, B, C, E

When performing an initial pulmonary artery occlusion pressure (PAOP), what are the best nursing actions? (Select all that apply.) A. Inflate the balloon for no more than 8 to 10 seconds while noting the waveform change. B. Inflate the balloon with air, recording the volume necessary to obtain a reading. C. Maintain the balloon in the inflated position for 8 hours following insertion. D. Zero reference and level the air-fluid interface of the transducer at the level of the phlebostatic axis. E. Inflate and deflate the balloon on an hourly schedule

A, B, D

The nurse is preparing to obtain a right atrial pressure (RAP/CVP) reading. What are the most appropriate nursing actions? (Select all that apply.) A. Compare measured pressures with other physiological parameters. B. Flush the central venous catheter with 20 mL of sterile saline. C. Inflate the balloon with 3 mL of air and record the pressure tracing. D. Obtain the right atrial pressure measurement during end exhalation. E. Zero reference the transducer system at the level of the phlebostatic axis.

A, D, E

The nurse has attended a lecture on pain and anxiety. Which statement by the nurse indicates that teaching has been effective? A. "Pain and anxiety are cyclical, with each exacerbating the other" B. "Pain and anxiety are easily controlled with pain medication" C. Pain and anxiety are mutually exclusive; only one can be experienced at a time" D. "Pain and anxiety are treated with sedative medications"

A. "Pain and anxiety are cyclical, with each exacerbating the other"

The nurse is caring for a nonverbal critically ill adult patient who cannot communicate. Which pain scale should the nurse select to use with this patient? A. Behavioral pain scale (BPS) B. Pain intensity (0-10) scale C. PQRST method D. Visual Analog Scale (VAS)

A. Behavioral pain scale (BPS)

To qualify as a living organ donor, several characteristics are required. Which statement(s) best reflect characteristics of living organ donors? (SATA) A. Between the ages of 18 and 60 B. Similar ethnicity as recipient C. No history of heart disease D. Blood type of recipient E. No history of diabetes

A. Between the ages of 18 and 60, C. No history of heart disease, D. Blood type of recipient, E. No history of diabetes

Which stressors should the nurse anticipate the patient to have during the critical care experience? (SATA) A. Difficult communication B. Pain C. Feelings of dread D. Difficulty sleeping E. Thoughts of death and dying

A. Difficult communication, B. Pain, C. Feelings of dread, E. Thoughts of death and dying

Which intervention is most helpful in preventing sensory overload in critically ill patients? A. Encourage family members to assist in the reorientation of the patient B. Increase the amount of noise from equipment in the patient's room C. Move the patient to a semiprivate room with another confused patient D. Place the patient nearer to the nurses' station for observation

A. Encourage family members to assist in the reorientation of the patient

Which of the following nonpharmacological approaches by the nurse may be useful in the management of pain and anxiety in the critically ill patient? (SATA) A. Encouraging family members to bring familiar items from home B. Guided imagery C. Involving family members in the patient's care D. Music therapy E. Patient-controlled analgesia

A. Encouraging family members to bring familiar items from home, B. Guided imagery, C. Involving family members in the patient's care, D. Music therapy

The nurse is caring for a patient experiencing pain, anxiety, and agitation. Which factors assist the nurse in creating a personalized care plan for this patient? (SATA) A. Extreme anxiety and pain may lead to agitation B. Many critically ill patients experience panic and fear C. Pain and anxiety stimulate the parasympathetic nervous system D. Patients may develop PTSD as a result of an ICU stay

A. Extreme anxiety and pain may lead to agitation, B. Many critically ill patients experience panic and fear, D. Patients may develop PTSD as a result of an ICU stay

The nurse is discussing organ donation with the family of a patient for whom death is imminent. Which common concern should the nurse anticipate? A. Having to pay for the donation process B. Organizing the funeral care C. Helping the patient's wife notify extended family D. Trying to wean the patient off the ventilator

A. Having to pay for the donation process

Which strategies should the nurse manager implement to improve collaboration in the critical care setting? (SATA) A. Initiate interdisciplinary rounds B. Create joint programs for continuing education C. Institute morning briefings D. Exclude family members from rounds

A. Initiate interdisciplinary rounds, B. Create joint programs for continuing education, C. Institute morning briefings

The nurse is assessing a patient for a possible pulmonary embolus. Assessment findings may include which of the following? Select all that apply. Acute onset of chest pain Hemoptysis Low oxygen saturation level Pleural friction rub

Acute onset of chest pain Hemoptysis Low oxygen saturation level Chest pain, hemoptysis, and a low oxygen saturation level are signs and symptoms of pulmonary embolus. A pleural friction rub is seen with disorders such as pleural effusion.

After receiving handoff report from the night shift, the nurse completes the morning assessment of a patient with severe sepsis. Vital sign assessment notes blood pressure 95/60 mm Hg, heart rate 110 beats/min, respirations 32 breaths/min, oxygen saturation (SpO2)96% on 45% oxygen via Venturi mask, temperature 101.5° F, central venous pressure (CVP/RAP) 2 mm Hg, and urine output of 10 mL for the last hour. Given this report, the nurse obtains orders for treatment that include which of the following? Select all that apply. Administer infusion of 500 mL 0.9% normal saline every 4 hours as needed if the CVP is <5 mm Hg. Increase supplemental oxygen therapy to 60% Venturi mask. Administer 40 mg furosemide (Lasix) intravenously as needed if the urine output is less than 30 mL/hr. Administer acetaminophen (Tylenol) 650 mg suppository per rectum as needed to treat temperature >101° F.

Administer infusion of 500 mL 0.9% normal saline every 4 hours as needed if the CVP is <5 mm Hg. Administer acetaminophen (Tylenol) 650 mg suppository per rectum as needed to treat temperature >101° F. Fluid volume resuscitation is a priority in patients with severe sepsis to maintain circulating blood volume and end organ perfusion and oxygenation. A 500-mL IV bolus of 0.9% normal saline is appropriate given the patient's CVP of 2 mm Hg and hourly urine output of 10 mL/hr. There is no evidence to support the need to increase supplemental oxygen. Administration of furosemide (Lasix) in the presence of a fluid volume deficit is contraindicated. The fever may need to be treated.

What is the best understanding of mixed venous oxygen saturation by the nurse? An overall picture of oxygen delivery and oxygen consumption The amount of oxygen attached to each hemoglobin molecule The amount of oxygen perfusion taking place within the myocardium The amount of oxygen the lungs are able to mix with the blood

An overall picture of oxygen delivery and oxygen consumption Clinical determination of mixed venous oxygen saturation can be measured hemodynamically and provides a picture of the overall oxygen utilization by organs and tissues. Mixed venous oxygen saturation is the percentage of hemoglobin saturation in the central venous circulation, and it provides an assessment of the amount of oxygen used by the tissues.

The nurse is caring for a patient at risk for respiratory failure. Which assessment findings would alert the nurse to potential respiratory failure? Anxiety and restlessness Cyanosis and hyperventilation Dyspnea and nasal flaring Hypertension and bradycardia

Anxiety and restlessness Neurological changes, such as anxiety and restlessness, are early signs of hypoxemia in respiratory failure. Other early signs are tachycardia and increased blood pressure. Cyanosis, dyspnea, and nasal flaring are later signs.

Following insertion of a pulmonary artery catheter (PAC), the provider requests the nurse obtain a blood sample for mixed venous oxygen saturation (SvO2). Which action by the nurse best ensures the obtained value is accurate? A. Zero referencing the transducer at the level of the phlebostatic axis following insertion B. Calibrating the system with a central venous blood sample and arterial blood gas value C. Ensuring patency of the catheter using a 0.9% normal saline solution pressurized at 300 mm Hg D. Using noncompliant pressure tubing that is no longer than 36 to 48 inches and has minimal stopcocks

B

The nurse is caring for a mechanically ventilated patient being monitored with a left radial arterial line. During the inspiratory phase of ventilation, the nurse assesses a 20 mm Hg decrease in arterial blood pressure. What is the best interpretation of this finding by the nurse? A. The mechanical ventilator is malfunctioning. B. The patient may require fluid resuscitation. C. The arterial line may need to be replaced. D. The left limb may have reduced perfusion.

B

The nurse is caring for a patient who has had an arterial line inserted. To reduce the risk of complications, what is the priority nursing intervention? A. Apply a pressure dressing to the insertion site. B. Ensure that all tubing connections are tightened. C. Obtain a portable x-ray to confirm placement. D. Restrain the affected extremity for 24 hours.

B

The nurse is caring for a patient with a left subclavian central venous catheter (CVC) and a left radial arterial line. Which assessment finding by the nurse requires immediate action? A. A dampened arterial line waveform B. Numbness and tingling in the left hand C. Slight bloody drainage at subclavian insertion site D. Slight redness at subclavian insertion site

B

The nurse is educating a patient's family member about a pulmonary artery catheter (PAC). Which statement by the family member best indicates understanding of the purpose of the PAC? A. "The catheter will provide multiple sites to give intravenous fluid." B. "The catheter will allow the provider to better manage fluid therapy." C. "The catheter tip comes to rest inside my brother's pulmonary artery." D. "The catheter will be in position until the heart has a chance to heal."

B

The nurse is preparing to measure the thermodilution cardiac output (TdCO) in a patient being monitored with a pulmonary artery catheter. Which action by the nurse best ensures the safety of the patient? A. Ensure the transducer system is zero referenced at the level of the phlebostatic axis. B. Avoid infusing vasoactive agents in the port used to obtain the TdCO measurement. C. Maintain a pressure of 300 mm Hg on the flush solution using a pressure bag. D. Limit the length of the noncompliant pressure tubing to a maximum 48 inches.

B

The nurse returns from the cardiac catheterization laboratory with a patient following insertion of a pulmonary artery catheter and assists in transferring the patient from the stretcher to the bed. Before obtaining a cardiac output, which action is most important for the nurse to complete? A. Document a pulmonary artery catheter occlusion pressure. B. Zero reference the transducer system at the phlebostatic axis. C. Inflate the pulmonary artery catheter balloon with 1 mL air. D. Inject 10 mL of 0.9% normal saline into the proximal port

B

The provider writes an order to discontinue a patient's left radial arterial line. When discontinuing the patient's invasive line, what is the priority nursing action? A. Apply an air occlusion dressing to insertion site. B. Apply pressure to the insertion site for 5 minutes. C. Elevate the affected limb on pillows for 24 hours. D. Keep the patient's wrist in a neutral position.

B

While caring for a patient with a small bowel obstruction, the nurse assesses a pulmonary artery occlusion pressure (PAOP) of 1 mm Hg and hourly urine output of 5 mL. The nurse anticipates which therapeutic intervention? A. Diuretics B. Intravenous fluids C. Negative inotropic agents D. Vasopressors

B

Which of the following situations may result in a low cardiac output and low cardiac index? (Select all that apply.) A. Exercise B. Hypovolemia C. Myocardial infarction D. Shock E. Fever

B, C, D

The nurse is listening to a lecture on increased-risk organ donors. Which statement by the nurse indicates that teaching has been effective? A. "Increased-risk donors are those who have been declared brain dead" B. "Increased-risk donors are those who have a recent history of illicit drug use" C. "Increased-risk donors are those who donate after withdrawal from life-support" D. "Increased-risk donors are those who have suffered intracranial hemorrhage"

B. "Increased-risk donors are those who have a recent history of illicit drug use"

The nurse has just listened to a lecture on how nociceptors differ from other nerve receptors in the body. Which statement by the nurse indicates that teaching has been effective? A. "Nociceptors adapt readily to the pain response to allow the body to adjust" B. "Nociceptors adapt very little to the pain response" C. "Nociceptors release histamine to help increase oxygenation" D. "Nociceptors secrete serotonin to help ease pain and inflammation"

B. "Nociceptors adapt very little to the pain response"

The nurse has attended a lecture on pain. Which statement by the nurse indicates that teaching has been effective? (SATA) A. "Pain is a state of apprehension" B. "Pain is a strictly physiological experience" C. "Pain is often exacerbated by anxiety" D. "Pain is whatever the experiencing person says it is"

B. "Pain is a strictly physiological experience" C. "Pain is often exacerbated by anxiety" D. "Pain is whatever the experiencing person says it is"

Following insertion of a central venous catheter, the nurse obtains a stat chest x-ray film to verify proper catheter placement. The radiologist reports to the nurse: "The tip of the catheter is located in the superior vena cava." What is the best interpretation of these results by the nurse? A. The catheter is not positioned correctly and should be removed. B. The catheter position increases the risk of ventricular dysrhythmias. C. The distal tip of the catheter is in the appropriate position. D. The physician should be called to advance the catheter into the pulmonary artery.

C

Which statements best describe functions of an organ procurement organization? (SATA) A. Declaration of brain death B. Consent for organ donation C. Management of organ donor D. Evaluation of transplant candidate E. Surgical retrieval of organs

B. Consent for organ donation, C. Management of organ donor, D. Evaluation of transplant candidate

The nurse is participating on a committee to remodel the critical care unit and recommends which features to enhance care delivery and the patient-family experience? (SATA) A. Headwall systems that look like regular furniture B. Designated space for staff, administration, and education C. Rooms at least 100 sq. ft. in area D. Space for the family within the patient room

B. Designated space for staff, administration, and education, D. Space for the family within the patient room

The nurse is on a committee related to family visitation in the critical care unit and discusses evidence to help in the planning. Which statement reflects evidence? A. Allowing children to visit is stressful for the patient and the child B. Family presence during procedures promotes adaptation C. Restricted visitation prevents family exhaustion D. Visitation shapes the critical care experience for the family but not the nurse

B. Family presence during procedures promotes adaptation

The nurse is caring for a client diagnosed with delirium. How should the nurse focus the patient assessment? A. Focus on keeping the patient medicated until transfer B. Focus on keeping the patient safe C. Focus on maintaining patency of the artificial airway D. Focus on maximizing conversations with health care providers

B. Focus on keeping the patient safe

The assessment of pain and anxiety is a continuous process. The first priority for treating pain and/or anxiety in the critical care setting is to: A. Ask the patient frequently if he or she needs pain/anxiety medication B. Identify and treat the underlying causes of pain and anxiety C. Medicate routinely with pain/antianxiety medications to keep the patient comfortable D. Wait for the patient to ask for medication and give it promptly

B. Identify and treat the underlying causes of pain and anxiety

After pulmonary artery catheter insertion, the nurse assesses a pulmonary artery pressure of 45/25 mm Hg, a pulmonary artery occlusion pressure (PAOP) of 20 mm Hg, a cardiac output of 2.6 L/min and a cardiac index of 1.9 L/min/m2. Which provider order is of the highest priority? A. Apply 50% oxygen via Venturi mask. B. Insert an indwelling urinary catheter. C. Begin a dobutamine infusion. D. Obtain stat cardiac enzymes and troponin.

C

The charge nurse is supervising care for a group of patients monitored with a variety of invasive hemodynamic devices. Which patient should the charge nurse evaluate first? A. A patient with a central venous pressure (RAP/CVP) of 6 mm Hg and 40 mL of urine output in the past hour B. A patient with a left radial arterial line with a BP of 110/60 mm Hg and slightly dampened arterial waveform C. A patient with a pulmonary artery occlusion pressure of 25 mm Hg and an oxygen saturation of 89% on 3 L of oxygen via nasal cannula D. A patient with a pulmonary artery pressure of 25/10 mm Hg and an oxygen saturation of 94% on 2 L of oxygen via nasal cannula

C

The nurse is caring for a mechanically ventilated patient with a pulmonary artery catheter who is receiving continuous enteral tube feedings. When obtaining continuous hemodynamic monitoring measurements, what is the best nursing action? A. Do not document hemodynamic values until the patient can be placed in the supine position. B. Level and zero reference the air-fluid interface of the transducer with the patient in the supine position and record hemodynamic values. C. Level and zero reference the air-fluid interface of the transducer with the patient's head of bed elevated to 30 degrees and record hemodynamic values. D. Level and zero reference the air-fluid interface of the transducer with the patient supine in the side-lying position and record hemodynamic values.

C

The nurse is caring for a patient with an arterial monitoring system. The nurse assesses the patient's noninvasive cuff blood pressure to be 70/40 mm Hg. The arterial blood pressure measurement via an intraarterial catheter in the same arm is assessed by the nurse to be 108/70 mm Hg. What is the best action by the nurse? A. Activate the rapid response system. B. Place the patient in Trendelenburg position. C. Assess the cuff for proper arm size. D. Administer 0.9% normal saline bolus.

C

The provider prescribes a pulmonary artery occlusive pressure reading (PAOP) for a patient being monitored with a pulmonary artery catheter. Immediately after obtaining an occlusive pressure, the nurse notes the change in waveform indicated on the strip below. What are the best actions by the nurse? A. Turn the patient to the left side; obtain a stat portable chest x-ray. B. Place the patient supine; repeat zero referencing of the system. C. Document the wedge pressure; continue to monitor the patient. D. Perform an immediate dynamic response test; obtain a chest x-ray.

C

While inflating the balloon of a pulmonary artery catheter (PAC) with 1.0 mL of air to obtain a pulmonary artery occlusion pressure (PAOP), the nurse encounters resistance. What is the best nursing action? A. Add an additional 0.5 mL of air to the balloon and repeat the procedure. B. Advance the catheter with the balloon deflated and repeat the procedure. C. Deflate the balloon and obtain a chest x-ray study to determine line placement. D. Lock the balloon in the inflated position, and flush the distal port of the PAC with normal saline.

C

The nurse is listening to a lecture on increasing organ donation. Which statement by the nurse indicates that teaching has been effective? A. "Each hospital individually determines if patients meet donation criteria" B. "Hospitals must notify the organ procurement organization of deaths within 48 hours" C. "Hospitals must have an agreement with an organ procurement organization" D. "Hospitals are not responsible for notifying family members of the option to donate organs"

C. "Hospitals must have an agreement with an organ procurement organization"

The nurse has listened to a lecture on the management of pain in patients with a history of substance abuse. Which of the following statements by the nurse indicates that teaching has been effective? A. "Folic acid and thiamine administration may potentiate the action of pain medications" B. "Pain medications should be withheld to avoid addiction to the medications" C. "Patients may have a higher-than-normal dosage threshold to achieve therapeutic effects" D. "Withdrawal symptoms from drugs or alcohol do not occur if the patient is mechanically ventilated"

C. "Patients may have a higher-than-normal dosage threshold to achieve therapeutic effects"

The nurse is meeting with family members of a critically ill patient. Which statement best addresses the psychological needs of the family members? A. "I'm adjusting the alarms on the monitor to reduce the noise level in the room" B. "It would help the patient if you can spend the night in the waiting room" C. "The team has just made rounds on the patient. We are going to begin weaning the patient from the ventilator today since the patient's oxygen is improving" D. "There are coffee and cookies in the waiting room. Why don't you take a short break?"

C. "The team has just made rounds on the patient. We are going to begin weaning the patient from the ventilator today since the patient's oxygen is improving"

Which assessment findings should the nurse anticipate in a client who has been declared brain dead? A. Pupils are PERRLA B. Presence of gag reflex C. Absence of ocular movement D. Intact corneal reflex

C. Absence of ocular movement

The nurse is making rounds on a busy orthopedic floor. Which statement about pain does the nurse use to guide in pain assessments of patients? A. Anxiety can cause an increase in pain level, whereas pain has no effect on anxiety B. Anxiety can occur without increasing pain C. Anxiety is not associated with tissue injury D. Pain can occur without increasing anxiety

C. Anxiety is not associated with tissue injury

Which intervention is important in meeting the needs of family members of critically ill patients? A. Allow a minister to meet with the family only in the waiting room B. Allow the family to visit the patient in large groups whenever they wish C. Encourage family members to participate in small activities of patient care, such as range-of-motion exercises D. Tell the family that "everything will be ok. The patient has the best team in the hospital"

C. Encourage family members to participate in small activities of patient care, such as range-of-motion exercises

As part of the nursing assessment, the nurse asks the family spokesperson, "Since you have such a large family, can you tell me how well everyone gets along?" This question is part of which assessment? A. Cultural assessment B. Developmental assessment C. Functional assessment D. Structural assessment

C. Functional assessment

Pleasant sensory stimuli in the critical care unit can be promoted by which interventions? (SATA) A. Conversing with another nurse about another patient's condition B. Discussing other patients' conditions within hearing range C. Moving the patient's bed to facilitate looking out the window D. Providing a clock, calendar, and family pictures in the room E. Asking, "Do you know what day it is?"

C. Moving the patient's bed to facilitate looking out the window, D. Providing a clock, calendar, and family pictures in the room

Which statement best represents immunosuppressant therapy in organ transplant recipients? A. Immunosuppressive therapy in renal transplant patients requires steroids B. Effective immunosuppressant therapy requires a minimum of four medications C. The use of an mTOR inhibitor is contraindicated in early postoperative lung transplants D. Medication trough levels provide information on immune system suppression

C. The use of an mTOR inhibitor is contraindicated in early postoperative lung transplants

Which statements related to the management of unstable angina are true? Select all that apply. Aspirin is given at the onset of each chest pain episode. Calcium channel blockers help to reduce symptoms. Early revascularization (e.g., angioplasty) may be helpful. It is best treated with rest and nitroglycerin.

Calcium channel blockers help to reduce symptoms. Early revascularization (e.g., angioplasty) may be helpful. It is best treated with rest and nitroglycerin. Unstable angina can be treated by conservative management or early intervention with percutaneous intervention or surgical revascularization. Conservative intervention for the patient experiencing angina includes the administration of nitrates, beta-adrenergic blocking agents, and/or calcium channel blocking agents. Angioplasty, stenting, and bypass surgery are approaches to revascularization. Rest and nitroglycerin are treatments for stable angina. Aspirin is not a typical treatment for unstable angina.

The nurse is monitoring a patient's intracranial pressuere (ICP). While the nurse is providing hygiene measures, she observes that the ICP reading is sustained at 18 mm Hg. What is the priority nursing action? Cease stimulating the patient. Continue with hygiene measures. Lower the head of the bed to 10 degrees. Open the ICP monitor to continuous drainage.

Cease stimulating the patient. Sustained increases in ICP should be avoided. Nursing care activities should be spaced to prevent an increase in ICP. Actions that cause a sustained elevation in ICP should be avoided until ICP returns to baseline resting values. Elevating the head of the bed to 30 degrees or more can help reduce ICP. Continuous drainage of CSF fluid will result in herniation.

Herniation syndromes can be life-threatening situations. Which syndrome causes the supratentorial contents to shift downward and compress vital centers of the brainstem? Central herniation Cingulate herniation Tonsillar herniation Uncal herniation

Central herniation A downward shift of the cerebral hemispheres, basal ganglia, and diencephalon through the tentorial notch causes central herniation, which compresses the vital centers of the brainstem. This results in a shift of one cerebral hemisphere under the falx cerebri to the other cerebral hemisphere. Cerebellar tonsils are displaced through the foramen magnum, causing fatal damage to the respiratory and cardiac centers. Uncal herniation compresses the midbrain, causing dysfunction of the ipsilateral third nerve, resulting in unilateral pupil dilation.

The nurse is caring for a patient admitted with severe sepsis. The physician orders include the administration of large volumes of isotonic saline solution as part of early goal-directed therapy. Which of the following best represents a therapeutic end point for goal-directed fluid therapy? Central venous pressure >8 mm Hg Heart rate >60 beats/min Mean arterial pressure >50 mm Hg Serum lactate level >6 mEq/L

Central venous pressure >8 mm Hg Early goal-directed therapy includes administration of IV fluids to keep the central venous pressure at 8 mm Hg or greater. Additional therapeutic end points include a heart rate at less than 110 beats/min and a mean arterial blood pressure at 65 mm Hg or greater. Serum lactate levels are elevated in sepsis; target levels should be <2.2 mEq/L.

The nurse is caring for a patient with a ruptured cerebral aneurysm. During initial assessment, the nurse notes that the cerebrospinal fluid draining into a ventriculostomy system is blood tinged. What is the best interpretation of this finding by the nurse? Cerebral aneurysms commonly rupture in the subarachnoid space. This assessment finding is indicative of developing cerebral meningitis. Patient movement has resulted in dislodgment of the catheter. Normal cerebral spinal fluid contains a small amount of visible blood.

Cerebral aneurysms commonly rupture in the subarachnoid space. Cerebral aneurysms commonly rupture in the subarachnoid space, resulting in cerebral spinal fluid that is blood tinged. Cerebral spinal fluid is cloudy in the presence of meningitis. Ventriculostomy drains are typically sutured into place; a change in ICP waveform would be indicative of dislodgment of the catheter. Normal cerebrospinal fluid is clear.

The nurse is managing the blood pressure of a patient with a traumatic brain injury. When planning the care of this patient, which statement best represents appropriate blood pressure management? Cerebral perfusion pressure (CPP) should be sustained at least 70 mm Hg. Hypertension greater than 160 mm Hg is necessary to achieve adequate perfusion. Nimodipine reduces blood pressure through its effect on cerebral vessels. Nitrates are the vasopressors of choice with increased ICP.

Cerebral perfusion pressure (CPP) should be sustained at least 70 mm Hg. To achieve adequate cerebral blood flow, cerebral perfusion pressure (CPP = MAP-ICP) should be at least 70 mm Hg. While hypotension may compromise cerebral blood flow, in the setting of increased intracranial pressure, hypertension (>160 mm Hg) can worsen cerebral edema by increasing microvascular pressure. Nimodipine is a calcium channel blocker that does not affect cerebral vasculature and is effective in providing quick, tight control of blood pressure.

The charge nurse is reviewing the patients on the critical care floor. Which patients does the charge nurse anticipate as benefiting from noninvasive positive pressure ventilation? Select all that apply. Acute respiratory distress syndrome Chronic obstructive pulmonary disease exacerbation Obstructive sleep apnea Pulmonary edema

Chronic obstructive pulmonary disease exacerbation Obstructive sleep apnea Pulmonary edema Noninvasive ventilation is not appropriate for management of acute respiratory distress syndrome. The other conditions are often treated initially with noninvasive ventilation.

The nurse is caring for a patient admitted with a spinal cord injury. Upon assessment, the nurse notes a complete loss of motor and sensory function below the patient's nipple line. What is the best interpretation of this assessment finding by the nurse? Anterior cord lesion Central cord lesion Complete cord lesion Brown-Sequard syndrome

Complete cord lesion A complete cord lesion results in loss of motor and sensory function below the level of spinal cord injury. Assessment findings associated with anterior cord lesion include loss of motor function, pain, and temperature sensation while touch, proprioception, and sense of vibration remain intact. Assessment findings with central cord injury include impairment in the arms and hands and to a lesser extent in the legs. The brain's ability to send and receive signals to and from parts of the body below the site of injury is reduced but not entirely blocked. Assessment findings with Brown-Sequard syndrome include loss of motor function, proprioception, vibration, and light touch on the same side as the injury while on the side opposite the injury, there is a loss of pain, temperature, and crude touch sensations.

During insertion of a pulmonary artery catheter, the provider asks the nurse to assist by inflating the balloon with 1.5 mL of air. As the provider advances the catheter, the nurse notices premature ventricular contractions on the monitor. What is the best action by the nurse? A. Deflate the balloon while slowly withdrawing the catheter. B. Instruct the patient to cough and deep-breathe forcefully. C. Inflate the catheter balloon with an additional 1 mL of air. D. Ensure lidocaine hydrochloride (IV) is immediately available.

D

The charge nurse has a pulse contour cardiac output monitoring system available for use in the surgical intensive care unit. For which patient is use of this device most appropriate? A. A patient with a history of aortic insufficiency admitted with a postoperative myocardial infarction B. A mechanically ventilated patient with cardiogenic shock being treated with an intraaortic balloon pump C.A patient with a history of atrial fibrillation having frequent episodes of paroxysmal supraventricular tachycardia D. A mechanically ventilated patient admitted following repair of an acute bowel obstruction

D

The nurse is caring for a patient with a pulmonary artery catheter. Assessment findings include a blood pressure of 85/40 mm Hg, heart rate of 125 beats/min, respiratory rate 35 breaths/min, and arterial oxygen saturation (SpO2) of 90% on a 50% Venturi mask. Hemodynamic values include a cardiac output (CO) of 1.0 L/min, central venous pressure (CVP) of 1 mm Hg, and a pulmonary artery occlusion pressure (PAOP) of 3 mm Hg. The nurse questions which of the following physician's orders? A. Titrate supplemental oxygen to achieve a SpO2 ≥94%. B. Infuse 500 mL 0.9% normal saline over 1 hour. C. Obtain arterial blood gas and serum electrolytes. D. Administer furosemide (Lasix) 20 mg intravenously.

D

The nurse is caring for a patient with an admitting diagnosis of congestive heart failure. While attempting to obtain a pulmonary artery occlusion pressure in the supine position, the patient becomes anxious and tachypneic. What is the best action by the nurse? A. Limit the patient's supine position to no more than 10 seconds. B. Administer antianxiety medications while recording the pressure. C. Encourage the patient to take slow, deep breaths while supine. D. Elevate the head of the bed 45 degrees while recording pressures.

D

The nurse is preparing to obtain a pulmonary artery occlusion pressure (PAOP) reading for a patient who is mechanically ventilated. Ensuring that the air-fluid interface is at the level of the phlebostatic axis, what is the best nursing action? A. Place the patient in the supine position and record the PAOP immediately after exhalation. B. Place the patient in the supine position and document the average PAOP obtained after three measurements. C. Place the patient with the head of bed elevated 30 degrees and document the average PAOP pressure obtained. D. Place the patient with the head of bed elevated 30 degrees and record the PAOP just before the increase in pressures during inhalation.

D

While caring for a patient with a pulmonary artery catheter, the nurse notes the pulmonary artery occlusion pressure (PAOP) to be significantly higher than previously recorded values. The nurse assesses respirations to be unlabored at 16 breaths/min, oxygen saturation of 98% on 3 L of oxygen via nasal cannula, and lungs clear to auscultation bilaterally. What is the priority nursing action? A. Increase supplemental oxygen and notify respiratory therapy. B. Notify the provider immediately of the assessment findings. C. Obtain a stat chest x-ray film to verify proper catheter placement. D. Zero reference and level the catheter at the phlebostatic axis.

D

The nurse is caring for a patient who is dying. Which action can the nurse take to establish a relationship with the patient? A. Leave the family alone to grieve B. Ask family to hold questions for the doctor C. Avoid discussing religious perspectives D. Communicate honestly about the patient's prognosis

D. Communicate honestly about the patient's prognosis

The nurse manager is reviewing the World Health Organization's guidelines on noise in the critical care environment. How does the nurse manager interpret these guidelines? A. Noise can be eliminated with acoustic ceiling tiles B. Noise can be minimized by shutting off alarms C. Noise is something the nurse just has to deal with D. Noise levels often exceed recommended levels

D. Noise levels often exceed recommended levels

Which statement best describes the role of the acute care nurse in the organ donation process? A. Approach the family for consent for organ donation once brain death has been determined B. Implement donor management procedures once brain death has been determined C. Obtain consent from the next-of-kin for withdrawal of life support D. Notify the organ procurement organization (OPO) in cases of impending death

D. Notify the organ procurement organization (OPO) in cases of impending death

The nurse is caring for a patient in acute liver failure caused by an overdose of acetaminophen. The patient is not expected to survive the night. Which statement best reflects appropriate application of the MELD score in this situation? A. The patient's present situation reflects a MELD score of 22 B. Patient status indicates the patient is ineligible for transplant C. The MELD score indicates survival beyond 24 hours is unlikely D. Use of the MELD score is not applicable in this situation

D. Use of the MELD score is not applicable in this situation

Which interventions are components of the ventilator bundle of care? Select all that apply. Daily assess the readiness for weaning/extubation. Elevate the head of the bed at least 30 degrees. Provide prophylaxis for deep vein thrombosis. Provide stress ulcer prophylaxis. Provide therapeutic paralysis.

Daily assess the readiness for weaning/extubation. Elevate the head of the bed at least 30 degrees. Provide prophylaxis for deep vein thrombosis. Provide stress ulcer prophylaxis. Therapeutic paralysis is not part of the ventilator bundle. The other responses, along with oral care, are part of the ventilator bundle.

The nurse is caring for a mechanically ventilated patient with acute respiratory failure. Which intervention is most beneficial in reducing the duration of mechanical ventilation and its complications? Administration of neuromuscular blockade Daily interruption of sedation and assessment of readiness to wean/extubate Frequent turning and early mobility, including ambulation if possible Regular and frequent oral care

Daily interruption of sedation and assessment of readiness to wean/extubate Daily assessment of readiness to extubate is the best approach for determining readiness to wean and for assisting in decreased duration of mechanical ventilation. Neuromuscular blockade prolongs mechanical ventilation. Turning and mobility are important interventions to prevent complications, but they do not necessarily affect duration of ventilation.

The nurse admits a patient to the coronary care unit in cardiogenic shock. The nurse anticipates administering which medication in an effort to improve cardiac output by increasing the contractile force of the heart? Dopamine (Intropin) Phenylephrine (Neo-Synephrine) Dobutamine (Dobutrex) Nitroprusside (Nipride)

Dobutamine (Dobutrex) Positive inotropic agents such as dobutamine (Dobutrex) are given to increase the contractile force of the heart in cardiogenic shock. Dopamine (Intropin) is used primarily in low cardiac output states to restore vascular tone and increase blood pressure, but not in cardiogenic shock. Neo-Synephrine would be contraindicated in cardiogenic shock, as the vasoconstriction it produces would exacerbate cardiac ischemia. Nitroprusside (Nipride), used for preload and after load reduction, can improve cardiac performance in shock states by its reduction of systemic vascular resistance.

The patient presents to the emergency department after having crushing chest pain for the past 5 hours. The ECG and laboratory work confirm suspicions of an acute myocardial infarction (AMI). Which findings would be the most conclusive that the patient is having an AMI? Select all that apply. ECG changes with ST-elevation Elevated CK-MB isoenzymes Elevated serum troponin levels Elevated urinary myoglobin level

ECG changes with ST-elevation Elevated CK-MB isoenzymes Elevated serum troponin levels ST-segment elevation and elevated cardiac enzymes are seen in Q-wave MI. Serum Troponin may assist in diagnosis of AMI.

Which of the following are nursing interventions to prevent ventilator-associated pneumonia (VAP)? Select all that apply. Elevate the head of bed to at least 30 degrees. Intubate the patient with an endotracheal tube with continuous subglottic aspiration of secretions. Maintain a deep level of sedation. Provide regular oral care, including the use of chlorhexidine.

Elevate the head of bed to at least 30 degrees. Provide regular oral care, including the use of chlorhexidine. Maintaining the head of bed at 30 to 45 degrees and providing oral care are two interventions to prevent VAP that the nurse can implement. The special endotracheal tube reduces the risk for VAP; however, this is not a nursing intervention. The patient should be sedated based on specific targets. Deep sedation should be avoided because it prolongs time on mechanical ventilation, increasing the patient's risk for VAP.

The nurse needs to obtain a cardiac output measurement from a patient who has just had a pulmonary artery catheter inserted. What are important interventions for ensuring accurate pressure and cardiac output measurements? Select all that apply. Ensure rapid injection of fluid through the injectate port. Zero reference the transducer system at the phlebostatic axis. Inflate the pulmonary artery catheter balloon with 5 mL air. Use lactated Ringer's solution for the injectate.

Ensure rapid injection of fluid through the injectate port. Zero reference the transducer system at the phlebostatic axis. To ensure accurate measurement, zero referencing of the transducer system is a priority action. Rapid injection of the appropriate solution will ensure more accurate readings. Inflating the pulmonary artery catheter balloon with 5 mL of air is likely to result in rupture of the balloon, as this volume of air is too high. Normal saline or 5% dextrose in water solutions are used for obtaining thermodilution cardiac output measurements.

The nurse is caring for a patient with a head injury. If autoregulation is lost, what should the nurse be most concerned for? Occurrence of central venous engorgement. Unchanged cerebral blood flow. Hypertension increasing cerebral blood flow. Shunting of cerebrospinal fluid (CSF) blockage.

Hypertension increasing cerebral blood flow. Autoregulation is the ability of the cerebral vessels to adjust their diameter in response to arterial pressure changes within the brain. If mean arterial blood pressure rises, cerebral vessels will constrict to prevent excessive distension of the cerebral arteries. When autoregulation is lost, cerebral vessels are no longer able to regulate diameter and as a result hypertension increases cerebral perfusion pressure. Cerebral vessels may become engorged as a result of the loss of autoregulation. Cerebral blood flow is affected with the loss of autoregulation. Loss of autoregulation does not block CSF flow.

The nurse is caring for a patient with status asthmaticus in the emergency department. The nurse anticipates what therapies to be ordered? Select all that apply. Inhaled anticholinergic agent Inhaled rapid-acting beta-2 agonists Oxygen administration Systemic corticosteroids

Inhaled anticholinergic agent Inhaled rapid-acting beta-2 agonists Oxygen administration Systemic corticosteroids All are treatment of severe asthma exacerbation (Table 15-2).

If the sinus node were diseased or ischemic and no longer firing as the heart's primary pacemaker, the nurse would anticipate which normal compensatory mechanism? Premature junctional beats Junctional escape rhythm, rate of 45 Junctional tachycardia, rate of 100 Accelerated junctional rhythm, rate of 75

Junctional escape rhythm, rate of 45 Junctional escape rhythm occurs when the dominant pacemaker, the SA node, fails to fire. The escape rhythm may consist of many successive beats, or it may occur as a single escape beat that follows a pause, such as a sinus pause. The normal intrinsic rate for the AV node and junctional tissue is 40 to 60 beats/min. An accelerated junctional rhythm has a rate between 60 and 100 beats/min, and the rate for junctional tachycardia is greater than 100 beats/min. Irritable areas in the AV node and junctional tissue can generate premature beats that are earlier than the next expected beat.

The nurse prepares to suction the endotracheal tube of an intubated patient. Which action is important for the nurse to take? Set the suction vacuum as high as possible. Instill normal saline before the procedure. Avoid hyperoxygenation during the procedure. Keep suction time to less than 10 to 15 seconds.

Keep suction time to less than 10 to 15 seconds. To prevent hypoxemia, suction time must not exceed 10 to 15 seconds. The vacuum is set between 80 and 120 mm Hg. Normal saline is not recommended. To prevent hypoxemia, all patients should be hyperoxygenated before suctioning.

The nurse is caring for a patient with hypovolemia. Which large volume crystalloid solution should the nurse anticipate the health care provider to order? Select all that apply. 5% dextrose Albumin Lactated Ringer's (LR) Normal saline

Lactated Ringer's (LR) Normal saline LR solution and 0.9% normal saline are isotonic solutions that are commonly infused to treat hypovolemia. Solutions of 5% dextrose in water and 0.45% normal saline are hypotonic and are not used for fluid resuscitation. Hypotonic solutions rapidly leave the intravascular space, causing interstitial and intracellular edema. A systematic review of 30 randomized controlled trials found no benefit in giving colloids (e.g., albumin) over crystalloids and recommended against the administration of colloids in most patient populations.

The nurse educator is presenting a lecture on crystalloid fluid replacement therapy in shock states. Which statement by a nurse indicates that the teaching has been effective? Lactated Ringer's should not be infused if lactic acidosis is severe. 3 mL of crystalloid is administered to replace 10 mL of blood loss. Administration of colloids is preferred over crystalloids. Solutions of 0.45% normal saline are used routinely in shock.

Lactated Ringer's should not be infused if lactic acidosis is severe. LR solutions contain lactate, which the liver converts to bicarbonate. If liver function is normal, this will counteract lactic acidosis. However, LR should not be infused if lactic acidosis is severe. To replace every 1 mL of blood loss, 3 mL of crystalloid is administered. There is no evidence to support colloid administration being more beneficial than crystalloid administration in shock states. Hypotonic solutions such as 0.45% normal saline are not administered in shock states as these solutions rapidly leave the intravascular space, causing interstitial and intracellular edema.

Lung-protective strategies for mechanical ventilation to treat acute respiratory distress syndrome while also preventing complications include which of the following? High levels of sedation Low tidal volume of 6 mL/kg ideal body weight Oxygen levels (FiO2) 0.80-1.00 Positive end-expiratory pressure (PEEP) 25 cm H2O or higher

Low tidal volume of 6 mL/kg ideal body weight The target tidal volume is 6 mL/kg. High levels of sedation may be needed but are not a protective strategy. The target lung-protective oxygen level is 0.6. Lower levels of PEEP are desirable as the risk for barotrauma increases with higher levels of PEEP.

The nurse is caring for a patient in shock. Which is a priority action by the nurse? Ensure adequate cellular hydration. Maintain adequate tissue perfusion. Prevent third-spacing of fluids. Support mechanical ventilation.

Maintain adequate tissue perfusion. Care of a patient in shock is directed toward correcting or reversing the altered circulatory component and reversing tissue hypoxia. Restoring circulating intravascular volume is the priority in improving tissue perfusion and oxygen delivery.

The nurse is caring for a patient who has blood pooling in the capillary bed and arterial blood pressure too low to support perfusion of vital organs. Which symptoms should the nurse assess for? Acute respiratory distress syndrome (ARDS) Disseminated intravascular coagulation (DIC) Increased cerebral perfusion pressure Multisystem organ failure and/or dysfunction

Multisystem organ failure and/or dysfunction Maldistribution of blood flow refers to the uneven distribution of flow to various organs and pooling of blood in the capillary beds. This impaired blood flow leads to impaired tissue perfusion and a decreased oxygen supply to the cells, all of which contribute to multiple organ failure. Damage to the type II pneumocytes leads to ARDS. Consumption of clotting factors may cause DIC. Low arterial blood pressure leads to decreased cerebral perfusion pressure.

A patient is complaining of midsternal chest discomfort radiating down the right arm. The discomfort has been present for about 5 minutes. The patient is also asthmatic and allergic to calcium channel blockers. The nurse anticipates an order from the health care provider for which medication? Isoptin Metoprolol Nifedipine Nitroglycerin sublingual

Nitroglycerin sublingual These are symptoms of angina. Administration of nitrates is indicated as a first-line treatment.

Which statements best represent optimal fluid administration for the management of increased intracranial pressure? Select all that apply. Normal saline (0.9%) is recommended for fluid volume resuscitation. The goal is to keep serum osmolality greater than 320 mOsm/L. 0.45% saline solution is acceptable for fluid volume resuscitation. Hypotonic solutions are avoided to prevent an increase in cerebral edema.

Normal saline (0.9%) is recommended for fluid volume resuscitation. Hypotonic solutions are avoided to prevent an increase in cerebral edema. Normal saline solution is recommended for fluid volume resuscitation because isotonic fluids do not increase cerebral edema. The goal is to keep serum osmolality less than 320 mOsm/L. Hypotonic solutions, such as 0.45% saline solution, are avoided because they increase cellular swelling and cerebral edema.

Which of the following treatments should the nurse anticipate administering to a hypoxic patient admitted with exacerbation of COPD? Bag-valve-mask ventilation with oxygen at 15 L/min Continuous positive airway pressure (CPAP) via face mask Non-rebreather mask with 80% oxygen Oxygen via Venturi mask at 40% oxygen

Oxygen via Venturi mask at 40% oxygen The initial treatment of hypoxemia is delivery of oxygen at a low flow rate. The Venturimask allows a designated percentage of oxygen to be delivered. The initial treatment is low-flow oxygen. If the patient fails to respond to this treatment, noninvasive ventilation (CPAP or BiPAP) may be indicated. A non-rebreather mask at 80% delivers a high percentage of oxygen, which may impair the patient's respiratory drive. Bag-valve-mask ventilation is not indicated.

The patient is admitted with the diagnosis of "Junctional Rhythm." The nurse places the patient on the cardiac monitor expecting to see: Select all that apply. P waves with a PR interval of 0.16 seconds. P waves with a PR interval less than 0.12 seconds. no P waves but a narrow QRS complex. P waves coming after the QRS complex. no P waves but a wide QRS complex.

P waves with a PR interval less than 0.12 seconds. no P waves but a narrow QRS complex P waves coming after the QRS complex Because of the location of the AV node—in the center of the heart—impulses generated may be conducted forward, backward, or both, creating three different P waveforms that may be associated with junctional rhythms: When the AV node impulse moves forward, P waves may be absent because the impulse enters the ventricle first. The atria receive the wave of depolarization at the same time as the ventricles; thus, because of the larger muscle mass of the ventricles, there is no P wave. QRS complex is normal. When the AV node impulse is conducted backward, the impulse enters the atria first. Conduction back toward the atria allows for at least partial depolarization of the atria. A short PR interval (<0.12 second) is noted. When the impulse is conducted both forward and backward, P waves may be present after the QRS complex. In this type of conduction, the impulse first moves into the ventricles, depolarizing them and creating a QRS complex. Because the impulse is also conducted backward, some atrial depolarization occurs, and a late P wave is noted after the QRS complex. In normal sinus rhythm, the PR interval is 0.12 to 0.20 seconds. Ventricular dysrhythmias arise from ectopic foci in the ventricles. Because the stimulus depolarizes the ventricles in a slower, abnormal way, the QRS complex appears widened and has a bizarre shape. The QRS complex is wider than 0.12 seconds and often wider than 0.16 seconds. Depolarization from abnormal ventricular beats rarely activates the atria in a retrograde fashion. Therefore, most ventricular dysrhythmias have no apparent P waves.

The nurse is drawing labs on a patient with COPD in the critical care unit. Which baseline arterial blood gases (ABGs) should the nurse expect for this patient? PaO2 50 mm Hg and PaCO2 35 mm Hg PaO2 55 mm Hg and PaCO2 55 mm Hg PaO2 80 mm Hg and PaCO2 50 mm Hg PaO2 75 mm Hg and PaCO2 40 mm Hg

PaO2 55 mm Hg and PaCO2 55 mm Hg The patient with COPD typically has hypoxemia and an elevated carbon dioxide level.

The nurse is preparing to admit a patient from the ED who has sustained a complete spinal cord lesion at the C5 level. When planning the patient's care, which nursing intervention is most important? Perform hourly incentive spirometry. Apply warming devices as needed. Give small, frequent feedings. Assist with passive range-of-motion.

Perform hourly incentive spirometry. A patient with a C5 spinal cord injury will have intact diaphragmatic breathing with varying impairment of intercostal and abdominal muscle function. It is most important for the nurse to perform hourly incentive spirometry to ensure the patient's lungs adequately expand, optimizing oxygenation. Applying warming devices, providing frequent feedings, and assisting with passive range-of-motion are all a part of the care of a patient with spinal cord injury; however, in a patient with C5 injury, interventions that support oxygenation, airway patency, and pulmonary toilet are of the highest priority.

What is the best action by the nurse to level and zero a hemodynamic monitoring system transducer? Level the air-fluid interface of the zeroing transducer at the height of the patient's mattress. Position the air-fluid interface of the zeroing transducer at the fifth intercostal space,midclavicular line. Position the air-fluid interface of the zeroing transducer at the phlebostatic axis (fourth intercostal space, midaxillary line). Level the air-fluid interface of the zeroing transducer at the second intercostal space, anterior-axillary line.

Position the air-fluid interface of the zeroing transducer at the phlebostatic axis (fourth intercostal space, midaxillary line). To obtain accurate hemodynamic values, the transducer system must be positioned at the level of the atria and pulmonary artery, commonly termed the phlebostatic axis (fourth intercostal space, midaxillary line). The transducer must be leveled at the phlebostatic axis. The transducer must be placed at the level of the fourth intercostal space, midaxillary line.

What is the best action by the nurse to accurately record a thermodilution cardiac output (CO)? Place the patient prone, enter the computation constant, and obtain four successive measurements. Place the patient prone, elevate the backrest 30 degrees, and obtain three successive measurements. Place the patient supine, enter the computation constant, and obtain one value with the head of the bed elevated at 45 degrees. Position the patient supine, obtain three values within 10% of each other, and calculate the average cardiac output.

Position the patient supine, obtain three values within 10% of each other, and calculate the average cardiac output. The average of three cardiac output measurements, all within 10% of each other, is obtained to accurately assess a cardiac output. To obtain accurate cardiac output measurements, a patient must be in the supine position with a backrest elevation of 0 to 30 degrees. Three successive measurements are taken and the average cardiac output calculated.

The nurse is caring for a patient who is being monitored with a central venous catheter. In preparing to record a right atrial pressure reading, what is most important for the nurse to keep in mind when recording an accurate value? Record the pressure at the end of expiration. Low pressures indicate ventricular dysfunction. High pressures are likely to indicate hypovolemia. Zero referencing is not needed before every recording.

Record the pressure at the end of expiration. Right atrial pressures are measured at the end of expiration to ensure that pleural pressure changes do not skew the numerical value. Low pressures are generally indicative of hypovolemia, while high pressures are likely to indicate right ventricular dysfunction. Zero referencing is necessary to ensure accurate measurement and should be performed after any position change.

The nurse is caring for a patient in the ICU. Lab results show a PaCO2 greater than 45 mm Hg. How should the nurse interpret this? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Respiratory acidosis An elevated PaCO2 is seen in respiratory acidosis.

A patient in acute respiratory failure is experiencing carbon dioxide narcosis secondary to increased CO2 retention. What assessment finding should the nurse expect? Nasal flaring Paradoxical respirations Somnolence Suprasternal muscle retractions

Somnolence Somnolence, lethargy, and coma are seen with CO2 retention. Nasal flaring, paradoxical respirations, and muscle retracts are seen with respiratory muscle fatigue (clinical alert).

A patient presents to the emergency department in acute respiratory distress. She has a long-standing history of COPD. Which of the following positions should the nurse place this patient in for optimal tissue perfusion? Prone on a stretcher In a recliner, leaning back as far as it will go Side-lying with head of bed at 15 degrees Stretcher with head of bed as high as it will go

Stretcher with head of bed as high as it will go A patient with COPD will be most comfortable in an upright position that facilitates lung expansion. Proning will not be tolerated, and a 15-degree elevation is not high enough. A recliner is sometimes helpful, but not leaning back as far as it will go.

What is the best position for the nurse to place the patient in to obtain a right atrial pressure measurement? Left side-lying with the head of the bed elevated 30 degrees Prone, lying on the abdomen with slight head elevation Right side-lying with the head of the bed elevated 30 degrees Supine, either flat or with the head of the bed no more than 60 degrees

Supine, either flat or with the head of the bed no more than 60 degrees Accurate assessment of a hemodynamic measure is best accomplished with the patient in a supine position with the head of the bed elevated slightly but no more than 60 degrees. The measurement can be obtained in the lateral position, but it is technically difficult because the patient must be positioned at a 30-degree lateral position for this method to be accurate. Hemodynamic measurements are not assessed in the prone position.

The nurse is caring for a patient with an assessed Glasgow Coma Scale score of 3. What is the best interpretation of this finding? Coma scale score is a direct result of dysfunction of the cerebellum. Damage to the patient's corpus callosum has led to a comatose state. A Glasgow Coma Scale score of less than 3 indicates a semicomatose state. There is impairment of the reticular activating system (RAS), resulting in coma.

There is impairment of the reticular activating system (RAS), resulting in coma. The reticular activating system (RAS) controls arousal, the sleep-wake cycle, selective attention, and perceptual awareness. The patient with a Glasgow Coma Scale score of 3 has an impaired RAS system. Dysfunction of the cerebellum results in alteration of fine motor movement, muscle tone, balance, and coordination. The corpus callosum consists of fibers that provide connections between the two cerebral hemispheres. A Glasgow Coma Scale score of less than 8 is consistent with coma.

The nurse is caring for a patient who has symptoms of an acute myocardial infarction (AMI). Which lab should the nurse prepare to draw in order to detect myocardial necrosis? CK CK-MB Potassium Troponin I

Troponin I Troponin I has a greater specificity than other tests in the diagnosis of acute myocardial infarction (AMI) at 7 to 14 hours after the onset of chest pain.

In caring for a patient who is intubated with an endotracheal tube, which complication should the nurse assess for? Community-acquired pneumonia Oxygen toxicity Tension pneumothorax Tube placed in the right mainstem bronchus

Tube placed in the right mainstem bronchus Right mainstem bronchus intubation is common; breath sounds are assessed after intubation and a chest x-ray is done to verify placement. Ventilator-associated pneumonia is a common complication of mechanical ventilation. Oxygen toxicity is associated with mechanical ventilation with high oxygen levels. A tension pneumothorax is a rare, but life-threatening, complication of mechanical ventilation.

Assess and interpret the following arterial blood gases: pH 7.48, PaCO2 33 mm Hg, HCO2 20 mEq/L, PaO2 85 mm Hg. Fully compensated metabolic acidosis; normal oxygenation Normal ventilation and oxygenation Partly compensated respiratory acidosis with hypoxemia Uncompensated respiratory alkalosis; normal oxygenation

Uncompensated respiratory alkalosis; normal oxygenation The high pH, low PaCO2, normal bicarbonate, and normal oxygen levels indicate uncompensated respiratory alkalosis.

The patient is admitted with an anterior wall myocardial infarction. With this diagnosis, the nurse would expect to see Q waves in which leads? Select all that apply. II III V3 V4 aVF

V3 V4 Pathological Q waves are found on ECGs of individuals who have had myocardial infarctions, and they represent myocardial muscle death. Anatomical regions are described as septal, anterior, lateral, inferior, and posterior. Septal leads are V1 and V2; anterior leads are V3 and V4; lateral leads are V5, V6, I, and aVL; and inferior leads are II, III, and aVF.

The nurse is caring for a patient in neurogenic shock. Which should the nurse assess for? Tachycardia Hypertension Hypoventilation Vasodilation

Vasodilation In neurogenic shock, there is an interruption of impulse transmission or blockage of sympathetic outflow, resulting in vasodilation, inhibition of baroreceptor response, and impaired thermoregulation. Interruption of sympathetic nerve innervation would result in bradycardia. Interruption of sympathetic nerve innervation would result in hypotension. Hypoventilation is not a physiological mechanism.

The nurse is caring for a patient with possible distributive shock. Which should the nurse look for on assessment? Blood loss and actual hypovolemia. Decreased cardiac output. Third-spacing of fluids into peritoneal space. Vasodilation and relative hypovolemia.

Vasodilation and relative hypovolemia. Distributive shock presents with widespread vasodilation and decreased systemic vascular resistance that result in a relative hypovolemia. Blood loss is associated with hypovolemic shock. Decreased cardiac output is a primary cause of cardiogenic shock. Primary internal sequestration of fluids that causes internal fluid loss is associated with hypovolemic shock.

The nurse is assisting in weaning a patient from long-term mechanical ventilation. Which action should the nurse be prepared to take? Slowly wean over several hours using a T-piece. Expect that the patient will not be affected by fever or abdominal distension. Wean the patient by protocol-driven methods. Wean the patient while the patient's family is present in the room.

Wean the patient by protocol-driven methods. Research has shown that protocol-driven methods for weaning facilitate the process and shorten weaning time. T-piece trials are sometimes done as part of the weaning process; however, it is not always an easy process. Fever and abdominal distension are factors that impede weaning attempts. Family members may be able to provide psychological support during the weaning process.

When obtaining report on a trauma pateint, which question would be helpful in determining potential injuries associated with the mechanism of injury? (SATA) a. Was the patient wearing a seat belt? b. Where was the patient in the car? c. Where are the family members? d. Was fluid resuscitation initiated?

a, b

Which interventions are appropriate to consider in the management of the geriatric trauma patient? (SATA) a. Ask the patient if he or she has fallen recently. b. Obtain a detailed medical history. c. Administer intravenous fluids rapidly to maintain blood pressure. d. Frequently assess for signs of acute delirium. e. Observe for signs of infection, primarily elevated temperature. f. Obtain a detailed list of current medications.

a, b, d, f

The nurse is assessing a patient for suspected alcohol withdrawal and identifies which signs and symptoms as suspicious? (SATA) a.Irritable, confused, hallucinations b. Nausea, vomiting, diarrhea c. Hypotension and tachycardia d. Low body temperature e. Seizures f. Somnolent, difficult to arouse

a, b, e

To maintain the patient's airway, which interventions are appropriate to implement with a trauma patient who sustained a spinal cord injury? (SATA) a. Avoid hyperextension of the neck. b. Observe respiratory pattern. c. Insert an oral airway if patient is alert. d. Elevate the head of bed 30 degrees. e. Observe depth of ventilation. f. Maintain complete spinal immobilization.

a, b, e, f

A restrained patient's status after a motor vehicle crash includes dyspnea, dysphagia, hoarseness, and complaints of severe chest pain. Upon assessment you note that the patient has weak femoral pulses. Which of the following complications and related diagnostic test should be considered? a. Aortic dissection and aortogram b. Cardiac tamponade and pericardiocentesis c. Liver laceration and focused assessment with sonography for trauma (FAST) d. Pulmonary contusion and chest x-ray

a. Aortic dissection and aortogram

A trauma patient with a fractured forearm complains of extreme, throbbing pain at the fracture site and paresthesia in the fingers. Upon further assessment, you note that the forearm is extremely edematous, and you are now having difficulty palpating a radial pulse. You notify the physician immediately because you suspect: a. compartment syndrome b. fat emboli. c. Hypothermia. d. rhabdomyolysis.

a. compartment syndrome.

Your patient was a passenger in a motor vehicle crash yesterday and suffered an open fracture of the femur. His condition was stable until an hour ago, when he began to complain of shortness of breath. His heart rate is 104 beats/min, respiratory rate is 30 breaths/min, BP is 90/60 mm Hg, and temperature is now 38.4°C. You suspect that he: a. has a fat embolism. b. has developed metabolic acidosis. c. is developing systemic inflammatory response syndrome (SIRS). d. is experiencing early multiple organ dysfunction syndrome (MODS).

a. has a fat embolism.

The nurse is speaking with the patient when the monitor shows that the patient is in ventricular fibrillation (VF). The nurse should: immediately defibrillate the patient. initiate basic life-support protocols and call for help. assess the patient and check the patient's monitor leads. initiate advanced life-support protocols as soon as possible.

assess the patient and check the patient's monitor leads. Ventricular fibrillation (VF) is a chaotic rhythm characterized by a quivering of the ventricles, which results in total loss of cardiac output and pulse. Because this patient was in the process of speaking with the nurse, there is evidence of cardiac output being present, which would not be the case with VF. Because a loose lead or electrical interference can produce a waveform similar to VF, it is always important to immediately assess the patient for pulse and consciousness. The issue here is more likely a loose lead. Immediate BLS and ACLS interventions would only be required if the patient was truly in VF.

The nurse is caring for an individual who is admitted for chest pain and shortness of breath. The patient states, "I can't believe I'm having chest pain. I'm a marathon runner and in good shape." During the night, the patient develops a sinus bradycardia with a heart rate of 40 beats/min. The nurse should: ignore this rate since the patient is an athlete. assess the patient for signs of decreased cardiac output. take the patient's temperature and expect to find hyperthermia. perform carotid massage (a maneuver to stimulate a vasovagal response).

assess the patient for signs of decreased cardiac output. Bradycardia is defined as a heart rate less than 60 beats/min. Sinus bradycardia may be a normal heart rhythm for some individuals such as athletes, or it may occur during sleep. Although sinus bradycardia may be asymptomatic, it may cause instability in some individuals if it results in a decrease in cardiac output. The key is to assess the patient and determine if the bradycardia is accompanied by signs of instability. Vasovagal response can occur due to: medications such as digoxin or AV nodal blocking agents, including calcium channel blockers and beta blockers; myocardial infarction; normal physiological variant in the athlete; disease of the sinus node; increased intracranial pressure; hypoxemia; and hypothermia. The nurse would not want to perform a vasovagal response, as this would lower the heart rate more.

If the low-exhaled volume alarm is sounding on a mechanical ventilator, the nurse should: assess to see that the ventilator is attached to the endotracheal tube. contact the respiratory therapist to set the tidal volume at a higher level. extubate the patient and ventilate with a bag-valve device. see whether the patient is biting the endotracheal tube.

assess to see that the ventilator is attached to the endotracheal tube. A low-exhaled volume alarm indicates the patient did not get the prescribed tidal volume. Connection of the ventilator tubing to the endotracheal tube should be checked quickly. The nurse should check the patient quickly; the therapist is contacted quickly if the cause of the alarm is not detected. Setting the tidal volume at a higher level will not correct the underlying problem. The patient is extubated only if the tube is in the esophagus. Biting the endotracheal tube results in a high-pressure alarm.

Autonomic dysreflexia is characterized by an exaggerated response of the sympathetic nervous system to a variety of stimuli. Common causes of autonomic dysreflexia include: Select all that apply. bladder distension. fecal impaction. sinus bradycardia. urinary tract infection.

bladder distension. fecal impaction. Causes of autonomic dysreflexia include bladder distension, stimulation to the bladder by a kinked Foley catheter, stimulation to the bowel by fecal impaction, rectal examination, or suppository insertion. Sinus bradycardia is a symptom of autonomic dysreflexia. Urinary tract infection is not a cause of autonomic dysreflexia; urinary retention is a cause.

A 72-year-old patient fractured his pelvis in a motor vehicle crash 2 days ago. He suddenly becomes anxious and short of breath. His respiratory rate is 34 breaths/min, and he is complaining of midsternal chest pain. His oxygen saturation drops to 75%. You suspect a. cardiac tamponade. b. myocardial infarction. c. pulmonary embolus. d. tension pneumothorax.

c. pulmonary embolus.

The patient complains of being lightheaded and feeling a "fluttering" in his chest. The nurse places the patient on the heart monitor and notices an atrial tachycardia at a rate of 160 beats/min. The patient's blood pressure has dropped from 128/76 mm Hg to 92/46 mm Hg but appears stable at the lower pressure. The nurse should: prepare the patient for asynchronized defibrillation. give the patient digitalis IV and then call the provider. call the provider and prepare the patient for medical or electrical cardioversion. withhold beta blockers and calcium channel blockers.

call the provider and prepare the patient for medical or electrical cardioversion. Atrial tachycardia is a rapid rhythm that arises from an ectopic focus in the atria. Because of the fast rate, atrial tachycardia can be a life-threatening dysrhythmia. Causes include digitalis toxicity, electrolyte imbalances, lung disease, ischemic heart disease, and cardiac valvular abnormalities. Treatment is directed at assessing the patient's tolerance of the tachycardia. If the rate is over 150 beats/min and the patient is symptomatic, emergent cardioversion is considered. Cardioversion is the delivery of a synchronized electrical shock to the heart by an external defibrillator. Medications that may be used include adenosine, beta blockers, calcium channel blockers, and amiodarone.

The patient is complaining of midsternal chest discomfort and nausea. The nurse calls for a 12-lead ECG and notices that the ST segment is newly elevated in two related leads. The nurse should: call the provider because the ST segment may indicate myocardial injury. continue to monitor the patient, as the ST segment is nondiagnostic. monitor the patient for increased signs of GI upset. assure the patient that the ST elevations are normal and of no concern.

call the provider because the ST segment may indicate myocardial injury. A displacement in the ST segment can indicate myocardial ischemia or injury. If ST displacement is noted and is a new finding, a 12-lead ECG is performed and the provider notified. The patient is assessed for signs and symptoms of myocardial ischemia.

The primary priority for the critical care nurse with regard to the trauma patient is which of the following? a. Decrease the patient's risk for multiple organ dysfunction syndrome. b. Ensure adequate fluid resuscitation. c. Increase the physiological reserve of the trauma patient. d. Provide adequate oxygenation and tissue perfusion.

d. Provide adequate oxygenation and tissue perfusion.

The nurse is working in the emergency department when a patient arrives who has experienced chest trauma. Which condition should the nurse be the most concerned with for this patient? a. Cardiac tamponade b. Flail chest c. Hemothorax d. Pulmonary contusion

d. Pulmonary contusion

Spinal cord injury causes a loss of sympathetic output, resulting in distributive shock with hypotension and bradycardia. Although blood pressure may respond to fluid resuscitation, what other therapy may be required to compensate for loss of sympathetic innervation? a. Colloids b. Glucocorticoids c. Proton pump inhibitors d. Vasopressors

d. Vasopressors

The trauma patient presenting with left lower rib fractures develops left upper quadrant tenderness, hypotension, and referred pain to the left shoulder. You suspect: a. bowel obstruction. b. cardiac tamponade. c. pulmonary contusion. d. splenic injury

d. splenic injury

The etiology of pulmonary edema in acute respiratory distress syndrome is related to: damage to the alveolar-capillary membrane. decreased cardiac output. tension pneumothorax. volutrauma and hypoxemia.

damage to the alveolar-capillary membrane. Noncardiogenic pulmonary edema is seen in ARDS secondary to damage to the alveolar-capillary membrane. Decreased cardiac output, tension pneumothorax, volutrauma, and hypoxemia are not causes.

The patient is admitted with a heart rate of 144 beats/min and a blood pressure of 88/42 mm Hg. The patient complains of generalized weakness and fatigue. He states, "Just let me sleep." The nurse determines that the presence of the patient's symptoms is due to: decreased cardiac output. the absence of ischemic heart disease. improved cardiac filling time, allowing the patient to relax. increased coronary artery filling time.

decreased cardiac output. The fast heart rhythm may cause a decrease in cardiac output because of the shorter filling time for the ventricles. Vulnerable populations are those with ischemic heart disease who are adversely affected by the shorter time for coronary filling during diastole.

The nurse notices ventricular tachycardia on the heart monitor. The nurse's first action should be to: determine patient responsiveness and presence of a pulse. immediately defibrillate the patient and provide CPR. administer intravenous amiodarone or lidocaine. cardiovert electrically into a more sustainable rhythm.

determine patient responsiveness and presence of a pulse. Determine whether the patient has a pulse. If no pulse is present, provide emergent basic and advanced life-support interventions, including defibrillation. If a pulse is present and the blood pressure is stable, the patient can be treated with intravenous amiodarone or lidocaine. Cardioversion is used as an emergency measure in patients who become hemodynamically unstable but continue to have a pulse. It may also be used in nonemergency situations, such as when a patient has asymptomatic VT.

The patient with a pacemaker shows pacemaker spikes that are not followed by a QRS. The nurse interprets this as: failure to capture. failure to pace. failure to sense. demand mode.

failure to capture. When the pacemaker generates an electrical impulse (pacer spike) and no depolarization is noted, it is described as failure to capture. Failure to pace or fire occurs when the pacemaker fails to initiate an electrical stimulus when it should fire. The problem is noted by absence of pacer spikes on the rhythm strip. Failure to sense manifests as pacer spikes that fall too closely to the patient's own rhythm, earlier than the programmed rate. The demand mode paces the heart when no intrinsic or native beat is sensed.

An adult patient suffered an anterior wall myocardial infarction (MI) 4 days ago. Today the patient is experiencing dyspnea and sitting straight up in bed. The nurse's assessment includes bibasilar crackles, an S3 heart sound with a heart rate of 125 beats/min. The nurse anticipates a diagnosis of: heart failure. papillary muscle rupture. pericarditis. pulmonary embolism.

heart failure. These are classic signs of fluid overload and heart failure. Presence of a heart murmur, not the S3, might alert the nurse to a papillary muscle rupture. The patient with pericarditis may have chest pain and a pericardial friction rub. The patient with a pulmonary embolism has symptoms including difficulty in breathing, cyanosis, chest pain and possibly death.

When an electrical signal in the heart is aimed directly at the positive electrode, the nurse interprets that the deflection seen on the 12-lead ECG or rhythm strip will be: equiphasic. negative. positive. invisible.

positive. When assessing the 12-lead ECG or a rhythm strip, it is helpful to understand that the electrical activity is viewed in relation to the positive electrode of that particular lead. The positive electrode is the "viewing eye" of the camera. When an electrical signal is aimed directly at the positive electrode, an upright inflection is visualized. If the impulse is going away from the positive electrode, a negative deflection is seen, and if the signal is perpendicular to the imaginary line between the positive and negative poles of the lead, the tracing is equiphasic, with equally positive and negative deflection.