Medical Surgical Chapter 66 Critical Care

1 Prone positioning refers to the repositioning of a patient from a supine or lateral position to a prone position. This repositioning improves lung reexpansion through various mechanisms. Firstly, the gravity reverses the effects of fluid in the dependent parts of the lungs as the patient is moved from supine to prone. Secondly, in the prone position, the heart rests on the sternum, away from the lungs, contributing to an overall uniformity of pleural pressures. These two mechanisms help in better ventilation in the patient with respiratory failure. The prone position is a relatively safe supportive therapy used for critically ill patients with acute lung injury or ARDS and is used for improved oxygenation. Resting in other positions such as sitting, supine, or lateral may not help in oxygenation. Text Reference - p. 1622

A nurse is attending a patient with acute respiratory distress syndrome (ARDS). Which position is best for this patient? 1 Prone 2 Sitting 3 Supine 4 Lateral

1, 2, 5 It is extremely essential to monitor all ICU patients and prevent delirium. Sensory overload can lead to patient distress and anxiety. The nurse should limit noise in the ICU and help the patient to understand that some noises in the ICU cannot be prevented, for example, beeping of a cardiac monitor. The nurse can also limit noise levels by muting phones, setting alarms based on the patient's condition, and reducing unnecessary alarms. The use of clocks and calendars can help orient the patient to time and date. Regular assessment should be carried out using tools like the Confusion Assessment Method for the ICU and the Intensive Care Delirium Screening Checklist. Seeing a familiar face may make the patient comfortable; therefore, the presence of a caregiver is important. Giving regular sponge baths helps to maintain hygiene but doesn't affect delirium directly. Text Reference - p. 1601

A nurse is caring for a patient in ICU who is taking sedatives. What are the steps that a nurse should take in order to prevent delirium in this patient? Select all that apply. 1 Keep the noise in the ICU to a minimum. 2 Use clocks and a calendar to keep the patient oriented. 3 Ensure that there is minimal communication with the patient. 4 Give regular sponge baths to the patient, and monitor the urinary output. 5 Carry out frequent assessment for delirium by using the Confusion Assessment Method.

1, 2, 3 The primary goal of nutritional support is to prevent or correct nutritional deficiencies. This is usually done by the early provision of enteral nutrition or parenteral nutrition. Enteral nutrition preserves the structure and function of the gut mucosa and stops the movement of gut bacteria across the intestinal wall and into the bloodstream. In addition to this, early enteral nutrition is associated with fewer complications. Enteral feedings cannot be administered to all patients; in patients with paralytic ileus, intestinal obstruction, and GI ischemia, enteral feeding is contraindicated. In these patients, parenteral feeding is the best option. Text Reference - p. 1600

A nurse is starting enteral feeding through a nasogastric tube for a patient in ICU. What advantages of enteral feeding over parenteral feeding does the nurse identify in the patient? Select all that apply. 1 Preserves the structure and function of gut mucosa 2 Stops the movement of gut bacteria across the intestinal wall 3 Results in fewer complications 4 Prevents and corrects nutritional deficiencies 5 Can be administered to all patients

1, 3, 4 It is extremely important for a nurse to closely assess the patient before, during, and after the suctioning procedure. If the patient is unable to tolerate suctioning, stop the procedure and hyperoxygenate until equilibration occurs before attempting next suction pass. Decreased SpO2, increased or decreased BP, and development of dysrhythmias are indicators that the patient is not tolerating suction. Sustained coughing rather than absence of coughing also indicates that the patient is not tolerating suctioning. Presence of shivering and convulsions is not related to suctioning. Text Reference - p. 1616

A nurse is suctioning a patient. Which signs indicate that the patient is not tolerating suctioning? Select all that apply. 1 Decreased SpO2 2 Absence of coughing 3 Increased blood pressure (BP) 4 Development of dysrhythmias 5 Shivering and convulsions of the entire body

4 Central venous pressure (CVP) is a measure of the filling pressure of the right ventricle and is indicative of how the right side of the heart accommodates fluid load. A series of CVP measurements of 12 mm Hg or higher indicates failure of the right ventricle to handle venous return. A normal CVP measurement is 2 to 8 mm Hg. Cardiogenic shock and circulatory failure are late manifestations of heart failure in general and would likely show a decreased CVP and cardiac output. CVP may be increased with left ventricular failure; however, this is a late sign. It is possible to have both right and left failure at the same time. Text Reference - p. 1608

A nurse measures a patient's central venous pressure and recognizes a series of increased readings as directly indicative of: 1 Cardiogenic shock 2 Circulatory failure 3 Left ventricular failure 4 Right ventricular failure

2 Mechanical ventilation can cause pneumothorax as a result of excessive pressure applied to lung tissue. Hypertension is not a direct complication; however, a patient undergoing mechanical ventilation may be anxious and fearful, resulting in high blood pressure; sedation should be considered in this event. Electrolyte imbalance is not a related complication. Mechanical ventilation does increase intrathoracic pressure, which may then increase cardiac output, causing a beneficial secondary effect. Text Reference - p. 1615

A nurse should monitor a patient undergoing mechanical ventilation for which common complication? 1 Hypertension 2 Pneumothorax 3 Electrolyte imbalance 4 Increased cardiac output

1, 4, 5 It is important to remove the dentures of the patient during the process of oral intubation because the dentures can obstruct the airway. Inform the patient that brief restraint will be necessary for safety purposes. It is also necessary to brief the patient about the procedure to avoid any type of resistance during intubation. Metallic objects on the body do not interfere with the procedure of intubation, and, therefore, need not be removed. Before intubating, it is extremely important to preoxygenate the patient with 100% oxygen. This is because the patient will not get any oxygen supply during intubation for a short period. STUDY TIP: Avoid planning other activities that will add stress to your life between now and the time you take the licensure examination. Enough will happen spontaneously; do not plan to add to it. Text Reference - p. 1614

A patient admitted to the ICU is being intubated. What are the steps that a nurse should ensure for a safe intubation? Select all that apply. 1 Remove the dentures of the patient. 2 Ensure that the patient is not wearing any metallic objects. 3 Oxygenate the patient using a bag-valve-mask (BVM) and 95% oxygen before the procedure. 4 Inform the patient that brief restraint will be necessary. 5 Explain the procedure to the patient and also the patient's role in the procedure.

2, 3, 5 It is extremely important to follow aseptic measures to avoid infection following an IABP. Covering all the insertion sites with occlusive dressings avoids infections. Aseptic techniques should be followed during insertion and dressing changes to prevent infection. Prophylactic antibiotics prevent infections. Infection doesn't breed in the dressings if aseptic precautions are followed and the dressings are cleaned and replaced regularly. Replacing the lines every two hours is not necessary, but following aseptic conditions is. A culture swab helps to identify the presence of infection but d

A patient has received intraaortic balloon pump (IABP) therapy. In this case, what precautions should a nurse take to prevent any infection at the site? Select all that apply. 1 Replace the lines every two to three hours. 2 Cover all insertion sites with occlusive dressings. 3 Use strict aseptic technique line insertion and dressing changes. 4 Send culture swabs from the insertion site regularly. 5 Administer prophylactic antibiotics for the entire course of therapy

1 The distal lumen port (catheter tip), labeled A in the image, is within the pulmonary artery. This port is used to monitor pulmonary artery (PA) pressures. Choice B is the port used for infusions. Choice C is the port used for injecting medications. Choice D is the port used to inflate the balloon. Text Reference - p. 1607

A patient has the following device. Which port should be used to measure pulmonary artery pressure? 1. A 2. B 3. C 4. D

4 Indications for intraaortic balloon pump (IABP) therapy include acute myocardial infarction and cardiogenic shock. The use of the pump with this health problem allows time for emergent angiography. The pump is not used to reduce pressure in the pulmonary artery, improve coronary artery vessel perfusion, or to enhance the effectiveness of cardiac medications. Text Reference - p. 1610

A patient is experiencing cardiogenic shock after an acute myocardial infarction. Why would an intraaortic balloon pump (IABP) be beneficial for this patient? 1 Reduces pressure in the pulmonary artery 2 Improves coronary artery vessel perfusion 3 Enhances effectiveness of cardiac medications 4 Provides time for an emergency angiogram to be performed

1, 4, 5 Following an intubation, it is important to confirm the placement of the endotracheal (ET) tube. This confirmation is obtained by x-ray after visualizing the ET tube correctly placed in the trachea. Auscultating lungs for breath sounds confirms that air is going into the lungs and not in the stomach. If the sounds are heard over the epigastrium, it indicates that the ET tube has gone in the stomach. Presence of carbon dioxide in exhaled air also confirms that the tube has gone into the lungs, and the breathing effort is normal. In this case, a CT scan is redundant. However, an x-ray is sufficient to confirm the placement of the ET tube. The patient may require a urinary catheter, but it is not an immediate intervention and can be done after intubation. Text Reference - p. 1614

A patient in ICU has been intubated for the relief of airway obstruction. What nursing actions should be performed to prevent complications after intubation? Select all that apply. 1 Obtain a chest x-ray to confirm the placement. 2 Obtain a computed tomography (CT) scan to note the placement. 3 Immediately catheterize the patient and check for urine output. 4 Auscultate lungs bilaterally and also epigastrium for breath sounds. 5 Use an end-tidal carbo

3 PaCO2 is the best indicator of alveolar hyperventilation or hypoventilation. Continuous PETCO2 monitoring can assess the patency of the airway and the presence of breathing. Continuous oxygen saturation (SpO2) provides objective data regarding tissue oxygenation. Central venous pressure (CVP) or pulmonary artery (PA) catheters with ScvO2 or SvO2 capability provide an indirect indication of the patient's tissue oxygenation status. Text Reference - p. 1615

A patient is admitted to the ICU and is on assisted ventilation. Which is the best indicator of inadequate alveolar oxygenation? 1 PETCO2 2 SpO2 3 PaCO2 4 ScvO2 or SvO2

1, 3, 4 Before PA catheter insertion, the patient is positioned supine and flat. The procedure is explained to the patient, and informed consent is obtained. The patient's electrolyte, acid-base, oxygenation, and coagulation status are noted. Imbalances such as hypokalemia, hypomagnesemia, hypoxemia, or acidosis can make the heart more irritable and increase the risk of ventricular dysrhythmia during catheter insertion. Coagulopathy increases the risk of hemorrhage. The procedure is never performed in a sitting position. The PA catheter is inserted through a sheath percutaneously into the internal jugular, subclavian, antecubital, or femoral vein using surgical asepsis. The insertion sites have to be dressed with occlusive dressings. Text Reference - p. 1608

A patient is advised to have a pulmonary artery (PA) catheter inserted for pulmonary artery pressure monitoring. What precautions are necessary prior to insertion of the catheter? Select all that apply. 1 Place the patient in the supine and flat position. 2 Position the patient sitting and with head turned laterally. 3 Explain the procedure to the patient and get consent. 4 Note the patient's electrolyte levels and oxygenation and coagulation status. 5 Do not cover the catheter insertion site with any dressings.

2, 4, 5 Appropriate patient selection for ventricular assist device (VAD) includes patients who are waiting for heart transplantation, who are diagnosed with Class IV heart disease, and have failed medical therapy, and who have failed to wean from cardiopulmonary bypass (CPB). Body surface area less than 1.3 m2 is a contraindication for ventricular assist device (VAD) therapy. Liver failure unrelated to a cardiac event is a contraindication for ventricular assist device (VAD) therapy. Text Reference - p. 1612

A patient is being considered for ventricular assist device (VAD) therapy. Which criteria indicate that this patient is an appropriate candidate for implantation of this device? Select all that apply. 1 Body surface area 1.1 m2 2 Placed on the heart transplantation list 3 Diagnosed with alcoholic liver failure 4 Diagnosed with Class IV heart disease 5 Unable to wean from the cardiopulmonary bypass (CPB) machine

3 Presence of condensate or water in tubing triggers a high-pressure ventilation alarm. Power failure triggers ventilator inoperative or low battery alarm. Insufficient gas flow and tracheotomy cuff leak triggers low tidal volume or minute ventilation alarm. Text Reference - p. 1620

A patient is being mechanically ventilated. A high-pressure ventilation alarm sounds. The nurse should assess for what cause of this type of alarm? 1 Power failure 2 Insufficient gas flow 3 Condensate in tubing 4 Tracheotomy cuff leak

3 Before inserting a line into the radial artery, an Allen test should be performed to confirm that ulnar circulation to the hand is adequate. In this test, pressure is applied to the radial and ulnar arteries simultaneously. The patient opens and closes the hand repeatedly until the hand blanches. When the pressure on the ulnar artery is released, the hand should return to a pink color within six seconds. If pinkness does not return within six seconds the ulnar artery is inadequate to maintain blood flow to the extremity and the radial artery should not be used for arterial line insertion. The phlebostatic axis is used to zero the arterial line, which would be done much later. Because of the risk of heparin-induced thrombocytopenia (HIT), heparinized saline should not be routinely used for the flush solution. The flush bag should be set to deliver 3 to 6 mL/hr. Text Reference - p. 1606

A patient is being prepared for insertion of an arterial measuring device. What should be done before the catheter is inserted into the patient's radial artery? 1 Locate the phlebostatic axis 2 Prepare a heparinized flush bag 3 Occlude the radial and ulnar arteries 4 Set an intravenous pump to deliver 15 mL/h

1, 3, 5 Nasal intubation is a blind procedure. There are chances that the tube may be misdirected. It may cause complications if there was a recent cranial surgery and fracture of the facial bones or the base of the skull. Suspected spinal fracture is a contraindication for oral intubation because it requires some movement of the neck and head. A deviated nasal septum can cause some difficulty in nasal intubation, although it is not a contraindication. STUDY TIP: Begin studying by setting goals. Make sure they are realistic. A goal of scoring 100% on all exams is not realistic, but scoring an 85% may be a better goal. Text Reference - p. 1614

A patient is being prepared for intubation using a nasal intubation technique. What absolute contraindications for nasal intubation should the nurse be aware of? Select all that apply. 1 Recent cranial surgery 2 Suspected spine injury 3 Fracture of facial bones 4 Deviated nasal septum 5 Fracture of the base of the skull

2 Benzodiazepines, such as lorazepam, have anxioloytic activity and help to alleviate symptoms of anxiety in patients. Propofol is an anesthetic, and fentanyl is an analgesic agent. These two medications do not help to treat anxiety but are used to relax intubated, ventilated patients. Esomeprazole is a proton pump inhibitor that helps to reduce symptoms of peptic ulcer. Text Reference - p. 1600

A patient is experiencing symptoms of anxiety. The nurse anticipates that which medication will be prescribed? 1 Propofol 2 Lorazepam 3 Fentanyl 4 Esomeprazole

3 An SBT is recommended in patients who demonstrate weaning readiness. An SBT should be at least 30 minutes but no more than 120 minutes. At least 15 minutes but no more than 30 minutes, at least 30 minutes but no more than 60 minutes, and at least 60 minutes but no more than 120 minutes are not recommended time frames to determine weaning readiness. Text Reference - p. 1626

A patient is intubated. The nurse has to perform a spontaneous breathing trial (SBT) on this patient. For how long should this trial be done? 1 At least 15 minutes but not more than 30 minutes 2 At least 30 minutes but not more than 60 minutes 3 At least 30 minutes but not more than 120 minutes 4 At least 60 minutes but not more than 120 minutes

1, 2, 4 Patients have a higher risk for hospital-acquired pneumonia when they require mechanical ventilation. This is because the ET or tracheostomy tube bypasses the normal upper airway defenses. Additionally, poor nutritional state, immobility, and the underlying disease process make the patient more prone to infection. VAP is pneumonia that occurs 48 hours or more post-ET intubation. To prevent VAP, the health care team should strictly wash their hands before and after suctioning. An ET tube with a dorsal lumen above the cuff should be used to allow continuous suctioning of secretions in the subglottic area. Gloves should be worn whenever the nurse is in contact with the patient, and the nurse should change them frequently between activities to avoid cross-infection. If the ventilator circuit tubing is changed frequently, there is more risk of exposing the patient to various infections. Therefore, there should be no routine changes in the patient's ventilator circuit tubing. In addition to this, the head-of-bed should be elevated at a minimum of 30 to 45 degrees, unless medically contraindicated, to prevent pooling of secretions and facilitate suctioning. Text Reference - p. 1623

A patient is placed on a ventilator for assisted ventilation. What precautions should a nurse take to prevent the patient from ventilator-assisted pneumonia (VAP)? Select all that apply. 1 Wash hands before and after suctioning. 2 Use an endotracheal (ET) tube with a dorsal lumen above the cuff. 3 Change the patient's ventilator circuit tubing every two to three hours. 4 Wear gloves when in contact with the patient, and change gloves between activities. 5 Maintain the head-of-bed elevation at a minimum of 90 degrees unless medically contraindicated.

2, 4, 5, 6 The possible causes for a high-pressure limit alarm to go off include secretions, coughing, or gagging. It may also be set off in case of ventilator asynchrony if the patient is fighting the ventilator. Decreased compliance due to conditions like pulmonary edema may also cause the setting off of the high-pressure alarm. It can also be due to kinked or compressed tubing, which usually happens when the patient is biting on the endotracheal tube. Oversedation and loss of airway cause an apnea alarm and can also set off the low-pressure limit alarm. Text Reference - p. 1620

A patient is placed on mechanical ventilation. A nurse notices that the alarm for the high-pressure limit has been set off. What are the possible conditions that could give rise to this alarm? Select all that apply. 1 Oversedation 2 Secretions, coughing, or gagging 3 Loss of airway through total or partial extubation 4 Patient fighting the ventilator 5 Decreased compliance due to pulmonary edema 6 Kinked or compressed tubing

1, 3 Milrinone is a vasodilator. Vasodilation decreases preload and afterload. This medication does not directly affect the heart rate. Vasodilators cause the blood pressure to decrease. Vasodilators will improve cardiac output. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation. Text Reference - p. 1604

A patient is prescribed milrinone. What effects on the patient's hemodynamic parameters should the nurse expect? Select all that apply. 1 Decreased preload 2 Increased heart rate 3 Decreased afterload 4 Increased blood pressure 5 Decreased cardiac output

2 The patient with a ventricular assist device (VAD) may be mobile and require an activity plan such as progressive ambulation. Complete bedrest is not required. The patient will be permitted to do more than move from the bed to a chair twice a day. Activity will be greater than bed rest with bathroom privileges. Text Reference - p. 1613

A patient is recovering from the implantation of a ventricular assist device (VAD). What should the nurse anticipate being prescribed for this patient's activity status? 1 Complete bedrest 2 Progressive ambulation 3 Moving out of bed to a chair twice a day 4 Bedrest with bathroom privileges

6 The patient's airway pressure during expiration is 6 cm H2O. Normally during exhalation, the airway pressure drops to zero and exhalation occurs passively. The pressure in CPAP is delivered continuously during spontaneous breathing to prevent the patient's airway pressure from falling to zero. Therefore, if CPAP is 6 cm H2O, airway pressure during expiration is 6 cm H2O. Text Reference - p. 1621

A patient on mechanical ventilation is receiving a continuous positive airway pressure (CPAP) of 6 cm H2O. What is the patient's airway pressure during expiration? Record your answer using a whole number. ___________________ cm H2O

4 Intrathoracic pressure changes associated with positive pressure ventilation cause a decrease in production of atrial natriuretic peptide. Positive pressure ventilation also decreases cardiac output, which further decreases renal perfusion. A decrease in renal perfusion increases the production of renin, angiotensin and aldosterone, which results in sodium retention. Text Reference - p. 1623

A patient on positive pressure ventilation has increased sodium retention in the body. A decrease in production of which biologic factor may have caused sodium retention in the patient? 1 Renin 2 Angiotensin 3 Aldosterone 4 Atrial natriuretic peptide

1 The patient has a urinary tract infection, which can lead to sepsis. In sepsis, oxygen is not extracted properly at the tissue level, resulting in increased central venous oxygen saturation (ScvO2) mixed venous oxygen saturation (SvO2) measurements. Central venous oxygen saturation (ScvO2) mixed venous oxygen saturation (SvO2) measurements would be low if the patient was experiencing decreased cardiac output or increased oxygen demand. Central venous oxygen saturation (ScvO2) mixed venous oxygen saturation (SvO2) measurements would be between 60% and 80% if the oxygen supply and demand was balanced. Text Reference - p. 1609

A patient with a pulmonary arterial catheter for systolic heart failure is diagnosed with a urinary tract infection (UTI). The last central venous oxygen saturation (ScvO2) mixed venous oxygen saturation (SvO2) measurement was 89%. What should the nurse suspect is occurring with this patient? 1 Sepsis 2 Decreased cardiac output 3 Increased oxygen demand 4 Balanced oxygen supply and deman

2, 4, 6 Negative pressure ventilation is similar to normal ventilation in that expiration is passive and decreased intrathoracic pressures produce inspiration. Negative pressure ventilation uses intermittent subatmospheric pressure around the chest wall. This pressure reduces the intrathoracic pressure during inspiration. Negative pressure ventilation is noninvasive because it does not require an artificial airway. During inspiration, the chest is pulled outward because of the intermittent negative pressure around the chest wall. Negative pressure ventilation uses chambers that encase the chest wall, but not the upper airway. Text Reference - p. 1618

A patient with a spinal cord injury requires negative pressure ventilation. What statements should the nurse say to the patient's caregiver about negative pressure ventilation? Select all that apply. 1 "It is a type of invasive ventilation." 2 "It is similar to the normal ventilation." 3 "It pulls the chest inward during inspiration." 4 "It uses intermittent subatmospheric pressure." 5 "It uses chambers that encase the upper airway." 6 "It reduces intrathoracic pressure during inspiration."

1 The high- and low-pressure alarms are set based on the patient's current status. Since the patient's lowest auscultated systolic blood pressure was 118 mm Hg, the best setting to use would be systolic 100. Because the patient's lowest diastolic blood pressure was 78, the best setting to use would be diastolic 60. The setting of systolic 120 and diastolic 80 may cause the low pressure alarm to go off frequently. The settings of systolic 140, diastolic 80 and systolic 150, diastolic 90 would not be appropriate for low-pressure settings. Text Reference - p. 1606

A patient with an arterial invasive device has the following auscultated blood pressures. What setting should the nurse use for this patient's low pressure alarms? 1 Systolic 100; Diastolic 60 2 Systolic 120; Diastolic 80 3 Systolic 140; Diastolic 80 4 Systolic 150; Diastolic 90

3 A β-adrenergic blocking medication decreases stroke volume. Contractility is reduced by negative inotropes. An example of a negative inotrope is a β-adrenergic blocker. Since an increase in contractility increases stroke volume (SV) and myocardial oxygen requirements, a negative inotrope such as a β-adrenergic blocker will decrease stroke volume (SV). A β-adrenergic blocking medication will decrease rather than increase oxygen use. This medication does not affect myocardial cellular metabolism. Text Reference - p. 1604

A patient with hypertension is prescribed a β-adrenergic blocking medication. What effect should the nurse expect this medication to have on the patient's heart? 1 Increased oxygen use 2 Increased stroke volume 3 Decreased stroke volume 4 Decreased cellular metabolism

3 A central venous oxygen saturation (ScvO2) mixed venous oxygen saturation (SvO2) measurement of 48% is low. Metabolic demand exceeds oxygen supply in conditions that increase muscle movement and metabolic rate, including physiologic states such as seizures. Central venous oxygen saturation (ScvO2) mixed venous oxygen saturation (SvO2) measurements greater than 80% are caused by increased oxygen supply. Even though a low central venous oxygen saturation (ScvO2) mixed venous oxygen saturation (SvO2) measurement is associated with a decreased cardiac output, the patient is not experiencing a health problem such as cardiogenic shock caused by left ventricular pump failure that supports decreased cardiac output as the reason for the low measurement. Central venous oxygen saturation (ScvO2) mixed venous oxygen saturation (SvO2) measurements greater than 80% are caused by decreased oxygen demand. Text Reference - p. 1609

A patient with meningitis and seizures has a pulmonary arterial catheter inserted. The most recent central venous oxygen saturation (ScvO2) mixed venous oxygen saturation (SvO2) measurement is 48%. What should the nurse realize is the reason for this patient's measurement? 1 Increased oxygen supply 2 Decreased cardiac output 3 Increased oxygen demand 4 Decreased oxygen demand

1, 2, 5 In RSI, a sedative and paralytic are administered to the patient. Usually a sedative-hypnotic-amnesic agent like midazolam is used to make the patient unconscious. A rapid-onset opioid like fentanyl is also given to blunt the pain of the procedure. A paralytic drug like succinylcholine is then given to produce skeletal muscle paralysis. Before this, the patient is 100% oxygenated. After intubation, the patient is again 100% oxygenated, and tube placement is confirmed. Auscultation of the chest bilaterally and x-ray are some of the methods of confirming the placement of the tube. During intubation, the endotracheal (ET) tube is inserted through the nose or mouth. While performing RSI, no opening is made in the throat. However, an opening in the throat is made in a procedure called tracheostomy. Text Reference - p. 1614

A patient with severe respiratory distress is brought to the medical facility. The health care provider prescribes rapid-sequence intubation (RSI) to be done. What information should the nurse include when explaining the procedure to the family members? Select all that apply. 1 A sedative and a paralytic medication is administered so that the patient sleeps and does not feel the pain. 2 After intubation, 100% oxygen is given to the patient, and placement of the tube is confirmed. 3 After giving paralytic, an opening is made in the throat through which a tube is introduced. 4 After establishing the opening in the throat, the tube is placed and dressed properly. 5 A tube will be introduced in the patient's throat through the mouth so that ventilation can be established.

120 MAP is calculated by adding the systolic blood pressure to two times the diastolic blood pressure and dividing by three. For this patient that calculation would be 172 + 2(94)/3 = 120 mm Hg. Normal MAP is between 70 and 105 mm Hg. Text Reference - p. 1603

A patient's blood pressure is 172/94 mm Hg. What would the nurse calculate as being this patient's mean arterial pressure (MAP)? Record your answer using a whole number. ____________ mm Hg

4 SIMV stands for synchronized intermittent mandatory ventilation, a mode of ventilation in which the ventilator delivers a preset tidal volume at a preset frequency in synchrony with the patient's spontaneous breathing. Between ventilator-delivered breaths the patient is able to breathe spontaneously, receiving the preset FIO2, but self-regulates the rate and depth of those breaths. Pressure support ventilation (PSV) applies positive pressure only during inspiration. PSV is not used as a sole ventilator support during acute respiratory failure because of the risk of hypoventilation, but it does decrease the work of breathing. Pressure-control inverse ratio ventilation (PC-IRV) sets the ventilation pressure and the ratio of inspiration to expiration to control the patient's breathing. Assist-control ventilation (ACV) or assisted mandatory ventilation (AMV) delivers a preset rate of breaths, but allows the patient to breathe spontaneously, with a preset tidal volume. Text Reference - p. 1620

A patient's family member asks the nurse what SIMV means on the settings of the mechanical ventilator attached to the patient. Which statement best describes this mode of ventilation? 1 "SIMV provides additional inspiratory pressure so that your father does not have to work as hard to breathe, thus enabling better oxygenation and a quicker recovery with fewer complications." 2 "SIMV is a mode that allows the ventilator to totally control your father's breathing. It will prevent him from hyperventilating or hypoventilating, thus ensuring the best oxygenation." 3 "SIMV is a mode that allows your father to breathe on his own, but the ventilator will control how deep a breath he will receive. The ventilator can sense when he wants a breath and it will deliver it." 4 "SIMV is a mode that allows your father to breathe on his own while receiving a preset number of breaths from the ventilator. He can breathe as much or as little as he wants beyond what the ventilator will breathe for him."

1 After insertion and before using the PA catheter, a chest x-ray must be taken to confirm the catheter's position. A hemoglobin level is not needed before using the catheter for fluid administration. Electrolyte levels do not need to be evaluated before using the catheter for fluid administration. A 12-lead electrocardiogram is not needed before using the catheter for fluid administration. Text Reference - p. 1608

A pulmonary artery catheter has just been inserted through a patient's internal jugular vein. What should be done before the catheter is used for fluid administration? 1 Obtain a chest x-ray 2 Draw a hemoglobin level 3 Evaluate electrolyte levels 4 Obtain a 12-lead electrocardiogram

2 To ensure adequate tracheal perfusion, the nurse should maintain cuff pressure at 20 to 25 cm H2O. Excess cuff pressure can damage the tracheal mucosa. Lesser cuff pressure may cause the ET tube to become destabilized and extubate. Text Reference - p. 1615

An endotracheal (ET) tube is inserted in a patient. The nurse inflates the cuff to stabilize the tube. How much cuff pressure should be maintained to keep it inflated and ensure adequate tracheal perfusion? 1 10-15 cm H2O 2 20-25 cm H2O 3 30-35 cm H2O 4 40-45 cm H2O

1, 3, 4 Whenever a patient is intubated, repositioning and retaping the tube after 24 hours are essential. For the orally intubated patient, remove the bite block and the old tape or ties. Provide oral hygiene, and then reposition the ET tube to the opposite side of the mouth. There is no need to give anesthesia for maintaining oral care. There is no point in physically restraining the patient, because it will cause discomfort and anxiety. Text Reference - p. 1617

An endotracheal (ET) tube is placed for a patient. What interventions should the nurse perform to maintain oral hygiene and care? Select all that apply. 1 Reposition and retape the ET tube at least every 24 hours. 2 Keep the buccal cavity and nasal cavity anesthetized. 3 Replace the bite block and reconfirm proper cuff inflation and tube placement regularly. 4 Provide oral hygiene with repositioning of the ET tube to the opposite side of the mouth after care. 5 Keep the patient restrained to avoid dislodging the tube.

3 Auto-positive end-expiratory pressure (auto-PEEP) is caused by inadequate exhalation time. Barotrauma, hemodynamic instability and increased work of breathing are the results and not the causes of the auto-PEEP. Text Reference - p. 1621

Auto-positive end-expiratory pressure (PEEP) is the additional PEEP over what is set by the health care provider. What causes auto-PEEP during mechanical ventilation? 1 Barotrauma 2 Hemodynamic instability 3 Inadequate exhalation time 4 Increased work of breathing

3 Certification as an advance care nurse practitioner (ACNP) is available through the American Association of Critical Care Nurses (AACN). The National League of Nurses (NLN), the American Association of Nurse Practitioners (AANP), and the National Council of State Boards of Nursing (NCSBN) are all nursing organizations but they do not offer certification to the advance practice registered nurse (APRN) as an ACNP. Text Reference - p. 1600

The advance practice registered nurse (APRN) is seeking certification as an advance care nurse practitioner (ACNP). Which professional organization can grant this certification to the APRN? 1 National League of Nurses (NLN) 2 American Association of Nurse Practitioners (AANP) 3 American Association of Critical Care Nurses (AACN) 4 National Council of State Boards of Nursing (NCSBN

1, 3, 4 In order to achieve the designation as a pediatric critical care nurse (CCRN) the nurse will require registered nurse licensure, successful completion of a written test, and pediatric intensive care clinical experience. An advance practice degree and recommendation from a pediatric physician are not required to achieve CCRN certification. Text Reference - p. 1599

The critical care nurse is pursuing certification as a pediatric critical care nurse (CCRN). What will the nurse need to accomplish to achieve this certification? Select all that apply. 1 Registered nurse licensure 2 An advanced practice degree 3 Successful completion of a written test 4 Pediatric intensive care clinical experience 5 Recommendation from a pediatric physician

1 Patients requiring ventilation up to 3 days are said to have received short-term ventilation. More than 3 days (7, 14, and 20 days) denotes long-term ventilation. Text Reference - p. 1625

The health care provider advises short-term ventilation for a patient. How many days would be considered short-term ventilation? 1 Up to 3 days 2 Up to 7 days 3 Up to 14 days 4 Up to 20 days

4 Pulse oximetry is a noninvasive and continuous method of determining the oxygen saturation of SpO2. Monitoring SpO2 may reduce the frequency of arterial blood gas (ABG) sampling. SpO2 is normally 95% to 100%. A value less than that may indicate hypoperfusion. Text Reference - p. 1609

The health care provider requests constant hemoglobin (SpO2) monitoring for a patient. What is the normal range of SpO2, which indicates that the saturation pressure of oxygen in this patient is adequate? 1 80-85% 2 85-90% 3 90-95% 4 95-100%

4 Progressive care units (PCUs), also called intermediate care units, provide a transition between the intensive care unit (ICU) and the general care unit or discharge. Generally, PCU patients are at risk for serious complications, but their risk is lower than that of the ICU patient. Therefore, the nurse anticipates that the patient with a stable blood pressure on a stable dose of a vasoactive drug will be transferred to the PCU. A patient who required a new drip overnight for hypotension and a patient who crashed and required intubation and mechanical ventilation are unstable and the nurse does not anticipate their transfer to the PCU. A preoperative heart transplant patient is often admitted to the PCU. A patient who is 12 hours post transplantation is not expected to be transferred to the PCU at this time. Text Reference - p. 1599

The intensive care unit (ICU) charge nurse is reviewing patient medical records during the overnight shift. Which patient does the nurse anticipate will be transferred to the progressive care unit (PCU)? 1 The patient who required a new drip overnight for hypotension. 2 The patient who was intubated and ventilated after crashing overnight. 3 The patient who is 12 hours postop for a heart and lung transplantation. 4 The patient whose blood pressure is 100/70 mm Hg on a stable dose of a vasoactive drug.

1, 2, 3 ICU patients often require intensive and complicated nursing support related to the use of IV polypharmacy and advanced technology. Prescriptions that are classified as IV polypharmacy include sedation, thrombolytics, and vasopressor titration. Mechanical ventilation and hemodynamic monitoring are advanced technology prescriptions. Text Reference - p. 1600

The intensive care unit (ICU) nurse is providing care to a patient requiring IV polypharmacy. Which prescriptions is this patient receiving? Select all that apply. 1 Sedation 2 Thrombolytics 3 Vasopressor titration 4 Mechanical ventilation 5 Hemodynamic monitoring

4 Negative inspiratory force (NIF) is the amount of negative pressure that a patient is able to generate to initiate spontaneous respirations. An NIF of less than -20 cm H2O is an indicator for weaning but the more negative the number, the better the indication for weaning. Therefore -60 cm H2O is the best indication for weaning. Text Reference - p. 1626

The negative inspiratory force (NIF) is measured in a patient who is on positive pressure ventilation. Among the values given, which NIF value is the best indication for weaning? 1 -30 cm H2O 2 -40 cm H2O 3 -50 cm H2O 4 -60 cm H2O

2 Frank-Starling's law explains the effects of preload and states that the more a myocardial fiber is stretched during filling, the more it shortens during systole and the greater the force of the contraction. Cardiac index (CI) is the measurement of the cardiac output adjusted for body surface area (BSA). It is a more precise measurement of the efficiency of the heart's pumping action. Systemic vascular resistance (SVR) is opposition encountered by the left ventricle to blood flow by the vessels. Pulmonary vascular resistance (PVR) is opposition encountered by the right ventricle to blood flow by the vessels. Text Reference - p. 1604

The nurse educator is preparing a lecture on hemodynamic monitoring. What should the educator use to explain the effects of preload? 1 Cardiac index 2 Frank-Starling's law 3 Systemic vascular resistance 4 Pulmonary vascular resistance

1 Critical care nursing is a specialty dealing with human responses to life-threatening problems. Medial surgical nursing is a specialty dealing with the care of adult patients in a variety of settings. Mental health nursing is a specialty dealing with people of all ages with mental illness or mental distress. Maternal newborn nursing is a specialty dealing with the care of women throughout their pregnancy and childbirth. Text Reference - p. 1598

The nurse educator is teaching a group of nursing students about critical care nursing. Which statement by a student indicates appropriate understanding of this nursing specialty? 1 "Critical care nursing is a specialty dealing with human responses to life-threatening problems." 2 "Critical care nursing is a specialty dealing with the care of adult patients in a variety of settings." 3 "Critical care nursing is a specialty dealing with people of all ages with mental illness or mental distress." 4 "Critical care nursing is a specialty dealing with the care of women throughout their pregnancy and childbirth."

1, 4, 5 Pulmonary artery catheterization helps to monitor and manage the care of patients who are at high risk for hemodynamic compromise. Pulmonary artery catheterization may cause trauma in the blood vessels and worsen symptoms of coagulopathy. Pulmonary artery catheterization increases the risk of trauma in patients with mechanical tricuspid valves and endocardial pacemakers; therefore, it is contraindicated in the patient with coagulopathy, mechanical tricuspid valve, and transvenous pacemaker. Pulmonary artery catheterization is performed in patients with cardiogenic shock and fulminant myocarditis to detect the risk of heart failure. Text Reference - p. 1607

The nurse identifies that pulmonary artery catheterization is contraindicated for patients with a history of what? Select all that apply. 1 Coagulopathy 2 Cardiogenic shock 3 Fulminant myocarditis 4 Endocardial pacemaker 5 Mechanical tricuspid valve

1 Critical care nurses will face ethical dilemmas related to the care of patients. This can occur over perceived issues of delivering futile or nonbeneficial care, such as attempting to resuscitate a neonate born at 21 weeks of gestation. This situation does not represent a societal, temporal, or sequential dilemma. Text Reference - p. 1599

The nurse in the newborn intensive care unit (NICU) is providing care to a neonate born at 21 weeks gestation who is being resuscitated in the delivery room. The standard gestation compatible with life is 23 to 24 weeks gestation. Which type of dilemma could the nurse be facing? 1 Ethical 2 Societal 3 Temporal 4 Sequential

2 Inadequate pain control is often linked with agitation and anxiety and is known to add to the stress response. Pain is associated with infection, but the patient is at the highest risk for developing anxiety. Dementia and depression are not associated with unrelieved pain. Text Reference - p. 1600

The nurse is assessing a patient in the intensive care unit (ICU). The patient is intubated and exhibiting symptoms of pain. Based on this data what condition is the patient at the highest risk for developing? 1 Anxiety 2 Infection 3 Dementia 4 Depression

1, 2, 3 Intraaortic balloon therapy destroys platelets and may cause thrombocytopenia. Monitoring hemodynamic parameters helps estimate the loss of platelets and development of thrombus. Enlarged blood clots reduce blood flow to the tissues and result in hypoxemia. Therefore, measurement of oxygen deprivation levels assesses for thrombus formation in the patient. Peripheral neurovascular damage is generally observed as a result of intraaortic balloon therapy and should be monitored. Spinach is rich in vitamin K and increases the formation of clotting factors. Warfarin is an anticoagulant used to prevent future development of blood clots. Spinach and warfarin should be avoided for patients with thrombocytopenia. Text Reference - p. 1611

The nurse is caring for a patient receiving intraaortic balloon therapy. Which nursing interventions are appropriate for this patient? Select all that apply. 1 Monitoring oxygen deprivation levels 2 Monitoring hemodynamic parameters 3 Monitoring neurovascular complications 4 Including spinach in the patient's diet 5 Providing warfarin therapy

4 Intraaortic balloon therapy has potential complications such as site infection, thromboembolism, arterial trauma, hematologic complications, and hemorrhage from the insertion site. Maintaining the head of the bed below 45 degrees helps to prevent breathlessness in the patient in the event of arterial trauma. Monitoring coagulation profiles, hematocrit, and platelet count is beneficial when the patient has a hematologic complication. An occlusive dressing prevents risk of surface infection but is not used to treat arterial trauma in the patient. Heparin helps to prevent thromboembolism but does not treat arterial trauma. Text Reference - p. 1612

The nurse is caring for a patient who has suffered arterial trauma during intraaortic balloon pump (IABP) therapy. What is the appropriate nursing action for this patient? 1 Monitor coagulation profiles 2 Apply an occlusive dressing 3 Administer prophylactic heparin 4 Maintain head of the bed below 45 degrees

1, 3, 4 Administering IV fluids helps thin respiratory secretions and facilitates suctioning. Postural drainage and percussion every two hours helps move secretions into larger airways and promotes the removal through suctioning. Supplemental humidification helps thin secretions and promotes suctioning. The patient has an endotracheal tube and will not be given an oral diet. Instilling normal saline into the endotracheal tube can cause asphyxia. Text Reference - p. 1617

The nurse is caring for a patient with an artificial airway. Which nursing interventions ensure endotracheal tube patency? Select all that apply. 1 Provide adequate hydration 2 Provide gluten rich food 3 Promote postural drainage 4 Provide supplemental humidification 5 Instilling normal saline into the endotracheal tube

1 Preload, afterload, and contractility determine stroke volume (SV). Cardiac output and heart rate are used to determine stroke volume; however, body surface area is used to determine cardiac index. Mean arterial pressure is used to determine afterload, not stroke volume. Cardiac index is a more precise measurement of the efficiency of the heart's pumping action; it is not used to determine stroke volume. Text Reference - p. 1603

The nurse is concerned about a patient's stroke volume. What determines stroke volume? 1 Preload, afterload, and contractility 2 Cardiac output, heart rate, and body surface area 3 Afterload, cardiac output, and mean arterial pressure 4 Cardiac index, mean arterial pressure, and blood pressure

1, 2, 3, 5 Hemodynamic effects of intraaortic balloon pump therapy (IABP) include increased stroke volume leading to warm skin and increased urine output. The decrease in afterload improves breath sounds. Improved stroke volume also improves mentation. The pump has no direct effect on blood pressure regulation. Text Reference - p. 1611

The nurse is evaluating a patient receiving intraaortic balloon pump (IABP) therapy. Which findings indicate that the pump is improving the patient's health status? Select all that apply. 1 Warm and dry skin 2 Urine output 50 mL/hr 3 Breath sounds clear bilaterally 4 Blood pressure 168/88 mm Hg 5 Oriented to person, place, and time

1 Accurate oxygen saturation of hemoglobin (SpO2) measurements may be difficult to obtain on patients who are hypothermic, are receiving vasopressor therapy, or experiencing shock. A body temperature of 95.4° F is hypothermic and is most likely the reason this measurement is difficult to obtain. A cardiac glycoside is not a vasopressor and would not cause this difficulty. A blood pressure of 118/72 mm Hg and heart rate of 72 with occasional ectopy are not manifestations of shock and would not cause this difficulty. Text Reference - p. 1609

The nurse is having difficulty obtaining an accurate oxygen saturation of hemoglobin (SpO2) measurement on a patient. What should the nurse consider as the reason for this difficulty? 1 Body temperature 95.4° F 2 Receiving a cardiac glycoside 3 Blood pressure of 118/72 mm Hg 4 Heart rate of 72 beats/minute with occasional ectopy

2 Normal central venous oxygen saturation or ScvO2/SvO2 is 60% to 80%. It denotes normal oxygen supply and metabolic demand. Any reading out of the normal range can cause danger to the patient. More than 80% denotes increased oxygen supply and decreased oxygen demand. Less than 60% denotes decreased oxygen supply and increased demand. Text Reference - p. 1609

The nurse is monitoring a patient in ICU. Which ScvO2/SvO2reading is a cause of concern in the patient? 1. 68% 2. 54% 3. 72% 4. 78%

10 The formula to calculate the minute ventilation (VE) is: VE = VTf. Therefore, VE = (20) (0.5) = 10 L/min. Text Reference - p. 1626

The nurse is performing a weaning assessment on a patient receiving mechanical ventilation. What is the value of minute ventilation (VE) if the patient's spontaneous respiratory rate (f) is 20 breaths/minute and spontaneous tidal volume (VT) is 0.5 L? Record your answer using a whole number. ___________________L/min

3, 4, 5 Interventions to reduce the risk of infection in a patient with an intraaortic balloon pump (IABP) include covering the site with an occlusive dressing, administering prophylactic antibiotics as prescribed, and using strict aseptic technique with dressing changes. Keeping the lower extremities extended would help prevent arterial trauma caused by insertion or displacement of the balloon. Turning and repositioning every two hours would help prevent the development of stasis pneumonia. Text Reference - p. 1612

The nurse is planning care for a patient receiving intraaortic balloon pump (IABP) therapy. What interventions should be included to reduce this patient's risk of developing an infection? Select all that apply. 1 Keep lower extremities extended 2 Turn and reposition every two hours 3 Cover the site with an occlusive dressing 4 Administer prophylactic antibiotics as prescribed 5 Use strict aseptic technique with dressing changes

3 Stroke volume variation (SVV) is the variation of the arterial pulsation caused by heart-lung interaction. It is a sensitive indicator of preload responsiveness when used on select patients. SVV is used only for patients on controlled mechanical ventilation with a fixed respiratory rate and a fixed tidal volume of 8 mL/kg. SVV is not used on patients who have spontaneous respirations even though an arterial line does need to be in place. The patient may have continuous cardiac monitoring but the patient needs to be intubated rather than provided with oxygen via a face mask. The patient needs to be intubated; however, nasal intubation is not identified as a requirement. It is not identified that the patient needs to be receiving positive end expiration pressure through the ventilator. Text Reference - p. 1607

The nurse is preparing a patient for arterial pressure-based cardiac output (APCO) measuring. What patient criteria must be met before this measuring device can be used to determine the patient's stroke volume variation (SVV)? 1 Spontaneous respirations and placement of an arterial line 2 Continuous cardiac monitoring and application of oxygen via face mask 3 Controlled mechanical ventilation and fixed respiratory rate and tidal volume 4 Nasal intubation and positive end expiration pressure setting on the ventilator

4 When an intensive care unit (ICU) patient exhibits manifestations of delirium it is the nurse's priority to address physiologic factors that could be contributing to the patient's symptoms. Correction of oxygenation by increasing the patient's oxygen is the priority intervention for this patient. Placing a clock in the room and updating the calendar in the room are important when providing care to a patient with delirium but these are not the priorities in the current situation. Administering an opioid pain medication is likely to enhance the clinical manifestations of delirium. Text Reference - p. 1601

The nurse is providing care for a patient who is receiving care in the intensive care unit (ICU). The patient is exhibiting symptoms of delirium. Which will the nurse address on priority when providing care to this patient? 1 Placing a clock in the room 2 Updating the calendar in the room 3 Administering opioid analgesics for pain 4 Administering increased oxygen, per order

1, 3, 4, 5 Allowing a patient's family to be present during resuscitative efforts during a cardiac arrest can help in the grieving process if the patient dies. It also reduces the fear and anxiety that the family is feeling, allows the patient's family to support their loved one, and helps the family overcome any doubts about the patient's condition. Allowing the family to be in the room during resuscitative efforts has not been shown to decrease the likelihood of malpractice lawsuits. Text Reference - p. 1602

The nurse is providing care to a patient in the intensive care unit (ICU) who is being coded due to cardiac arrest. Why would it be appropriate for the patient's family to be present in this situation? Select all that apply. 1 It aids in the grieving process if the patient dies. 2 It decreases the likelihood of malpractice lawsuits. 3 It may reduce the fear and anxiety the family is feeling. 4 It allows the patient's family to support their loved one. 5 It may help the family overcome doubts about the patient's condition.

2 Music therapy is a nonpharmacologic relaxation intervention that can be used to treat the patient anxiety that often occurs in the intensive care unit (ICU) environment. Lorazepam is an appropriate pharmacologic, not nonpharmacologic, intervention for anxiety. A sedation holiday is appropriate to conduct a neurologic exam that is often difficult due to the deep sedation required for intubation and mechanical ventilation. Range-of-motion exercises can help treat the physical manifestations of an injury, but are not relaxation interventions. Text Reference - p. 1601

The nurse is providing care to a patient in the intensive care unit (ICU) who is experiencing anxiety. Which nonpharmacologic relaxation intervention is appropriate for this patient? 1 Lorazepam 2 Music therapy 3 Sedation holiday 4 Range-of-motion exercises

2 Patients with preexisting dementia, such as Alzheimer's disease, are at an increased risk for developing delirium when receiving care in the intensive care unit (ICU). Diabetes mellitus, Parkinson's disease, and multiple sclerosis are not known risk factors for developing delirium. Text Reference - p. 1601

The nurse is providing care to a patient in the intensive care unit (ICU). The patient is currently sedated due to intubation and mechanical ventilation. Which finding in the patient's medical record would place this patient at an increased risk for delirium? 1 Diabetes mellitus 2 Alzheimer's disease 3 Parkinson's disease 4 Multiple sclerosi

3, 5 Medications that are appropriate to induce and maintain sleep for the patient in the intensive care unit (ICU) environment include zolpidem and tamazepam. Propofol is a medication that is used to induce sedation not sleep. Fentanyl and morphine are opioid medications used to treat pain and are not appropriate to induce and maintain sleep for this patient. Text Reference - p. 1601

The nurse is providing care to a patient in the intensive care unit (ICU). Which pharmacologic interventions are appropriate to induce and maintain sleep? Select all that apply. 1 Propofol 2 Fentanyl 3 Zolpidem 4 Morphine 5 Temazepam

2 Tachypnea and disorientation are early and subtle signs of deterioration. The rapid response team (RRT) brings rapid and immediate care to unstable patients in non-critical care units. While assessing pain, documenting the data in the medical record, and administering prescribed medications such as antihypertensive medications are all appropriate actions, they are not the priority nursing actions in this situation. Text Reference - p. 1599

The nurse is providing care to a postoperative patient on a medical-surgical unit. The patient is experiencing tachypnea and becomes disoriented at times. Which is the priority action by the nurse in this situation? 1 Assessing the current level of pain 2 Activating the rapid response team 3 Documenting the data in the medical record 4 Administering the prescribed antihypertensive medication

1 Nonverbal communication is important when providing care to an unresponsive patient in the intensive care unit (ICU). High levels of procedure-related touch and lower levels of comfort-related touch often characterize the ICU environment. The nurse would encourage the patient's spouse to touch and talk with her husband even if he is unresponsive. There is no way of knowing how aware the patient is of the surrounding when sedated. While bringing items from home for comfort are important, this is not the most appropriate statement by the nurse. Telling the spouse to sit where she will not be in the way of providing care is not therapeutic. Text Reference - p. 1601

The nurse is providing care to an unresponsive patient in the intensive care unit (ICU). The patient's spouse is at the bedside and states, "I just want him to know that I am here with him." Which statement by the nurse is most appropriate? 1 "You should talk and touch you husband whenever you visit." 2 "Your husband is so sedated he is not aware of his surroundings." 3 "You can bring items from home to make your husband more comfortable." 4 "Please sit where you will not be in the way as we provide care to your husband."

4 The patient with a collapsed lung and multiple injuries sustained in a car accident would be admitted to the trauma intensive care unit (ICU). Patients with minor acute injuries or those who are not expected to recover from an illness is usually not admitted to an ICU. Therefore, the ICU is not used to manage a fractured wrist; to prolong the natural process of death such as the patient with stage IV metastatic breast cancer; or for the patient in a persistent coma or vegetative state. Text Reference - p. 1600

The nurse is providing care to several patients in the emergency department (ED). Which patient does the nurse anticipate will be admitted to the intensive care unit (ICU)? 1 A patient with a fractured wrist 2 A patient with stage IV metastatic breast cancer 3 A patient in a permanent vegetative state who has a urinary tract infection 4 The patient with a collapsed lung and multiple injuries sustained in a car accident

4 The nurse should advise the caregiver to avoid external rotation of the patient's hip; this movement can be avoided by properly positioning the patient and by the use of specialized mattresses and beds. Simple maneuvers such as arm circles, knee bends and quadriceps setting should be performed, because they maintain the muscle tone in the upper and lower extremities of the patient. Text Reference - p. 1624

The nurse is teaching the patient's caregiver about receiving positive pressure ventilation. What movements should the nurse tell the caregiver to avoid doing to the patient? 1 Arm circles 2 Knee bends 3 Quadriceps setting 4 External rotation of the hip

2, 3, 4 When enteral nutrition is contraindicated in patients, the primary health care provider would prescribe parenteral nutrition to provide adequate nutrients to the patients. Patients with gastrointestinal disorders such as pancreatitis, paralytic ileus, and severe diarrhea will receive parenteral nutrition. Enteral nutrition is not contraindicated in the patient with arthritis and hypothyroidism. Text Reference - p. 1600

The nurse reviews medical records of several patient and concludes that which patients are appropriate candidates for parenteral nutrition? Select all that apply. 1 A patient with arthritis 2 A patient with pancreatitis 3 A patient with paralytic ileus 4 A patient with severe diarrhea 5 A patient with hypothyroidism

2, 3 Providing culturally competent care to critically ill patients and caregivers is challenging. The nurse who wants to provide culturally competent care to critically ill patients in the intensive care unit (ICU) should ask the patient or family members who is wanted in the room at the time of death. The nurse should also ask the patient or family members about cultural traditions regarding death and dying. The nurse should not prioritize cultural needs over physiologic needs. Often physiologic needs are the priority in the ICU. The nurse should not assume that the patient follows cultural customs for the documented ethnicity. The nurse should not tell the family that last rites are not possible and should advocate for the patient to receive last rites if this is the patient's wish. Text Reference - p. 1602

The nurse wants to provide culturally competent care to patients requiring care in the intensive care unit (ICU). Which actions by the nurse are appropriate? Select all that apply. 1 Prioritizing cultural needs over physiologic needs 2 Asking the patient who he or she wants in the room at the time of death 3 Asking the family about cultural traditions regarding death and dying 4 Assuming that the patient follows cultural customs for the documented ethnicity 5 Telling the family members it is not possible for last rites to be administered

2 Tidal volume is the volume of gas delivered to a patient during each ventilator breath. The number of breaths the ventilator delivers per minute is called the respiratory rate. The positive pressure used to augment the patient's inspiratory pressure is called pressure support. The positive pressure applied at the end of expiration of ventilator breaths is called positive end-expiratory pressure. Text Reference - p. 1619

The nurse working in a critical care unit understands that tidal volume is an important setting in a mechanical ventilator. Which statement appropriately describes tidal volume? 1 Number of breaths the ventilator delivers per minute 2 Volume of gas delivered to patient during each ventilator breath 3 Positive pressure used to augment patient's inspiratory pressure 4 Positive pressure applied at the end of expiration of ventilator breaths

3 The most commonly used mechanical circulatory assist device is the IABP, and it is used to decrease ventricular workload, increase myocardial perfusion, and augment circulation. Cardiopulmonary bypass provides circulation during open heart surgery. It is not used as an assist device after surgery. ICG is a noninvasive method to obtain cardiac output and assess thoracic fluid status. CVP measurement is an invasive measurement of right ventricular preload and reflects fluid volume problems. Text Reference - p. 1611

The patient has developed cardiogenic shock after a left anterior descending myocardial infection. Which circulatory assist device should the nurse expect to use for this patient? 1 Cardiopulmonary bypass 2 Impedance cardiography (ICG) 3 Intraaortic balloon pump (IABP) 4 Central venous pressure (CVP) measuremen

3 Critical care nurses provide care for patients with acute problems who are unstable. Patients with acute problems who are stable are often cared for on a medical-surgical unit versus the critical care unit. Patients with chronic problems who are stable may be cared for in the community setting. Patients with chronic problems who are unstable may require care in a rehabilitation or medical-surgical setting. Text Reference - p. 1598

The seasoned nurse is orienting a novice nurse to the critical care unit. When teaching the novice nurse about critical care nursing, which statement is most appropriate by the seasoned nurse? 1 "We care for patients with acute problems who are stable." 2 "We care for patients with chronic problems who are stable." 3 "We care for patients with acute problems who are unstable." 4 "We care for patients with chronic problems who are unstable."

4 Pulmonary vascular resistance (PVR) is calculated using the pulmonary artery mean pressure (PAMR) minus the pulmonary artery wedge pressure (PAWP), multiplying by 80 and dividing by the cardiac output (CO). Systolic and diastolic blood pressures are used to determine mean arterial pressure (MAP). Stroke volume (SV) and right ventricular ejection fraction (RVEF) are used to determine right ventricular end-diastolic volume (RVEDV). Mean arterial pressure (MAP), central venous pressure (CVP), and cardiac output (CO) are used to determine systemic vascular resistance (SVR). Text Reference - p. 1603

To determine a patient's peripheral vascular resistance (PVR) what hemodynamic parameters should the nurse use? 1 Systolic and diastolic blood pressures 2 Stroke volume and right ventricular ejection fraction 3 Mean arterial pressure, central venous pressure, and cardiac output 4 Pulmonary artery mean pressure, pulmonary artery wedge pressure, and cardiac output

3 To obtain an accurate central venous pressure (CVP) reading, the nurse should ensure that the patient is supine and in horizontal position so the zero reference point at the level of the right atrium (also known as the phlebostatic axis) is level with the zero mark on the manometer. If a patient is unable to lie flat, the manometer should be positioned so the zero reference is at the level of the right atrium and the degree of head elevation noted so there is consistency across measurements. Right or left side-lying and supine positions with the head of the bed elevated 45 degrees are all incorrect for obtaining a CVP reading. Text Reference - p. 1605

To obtain an accurate central venous pressure reading with a central venous catheter, a nurse should place the patient in what position? 1 Left side-lying 2 Right side-lying 3 Supine and horizontal 4 Supine with head of bed elevated 45 degrees

2 Positive end-expiratory pressure (PEEP) therapy is given to patients with pulmonary edema to provide a counter pressure opposing fluid extravasation. PEEP is not used for patients with hypovolemia, low cardiac output and unilateral or nonuniform lung disease because in those patients, the adverse effects of PEEP may outweigh any benefits. Text Reference - p. 1621

What condition would the nurse infer that a patient undergoing positive end-expiratory pressure (PEEP) therapy has? 1 Hypovolemia 2 Pulmonary edema 3 Low cardiac output 4 Unilateral lung disease

2 Arterial pressure-based cardiac output (APCO) monitoring uses the arterial waveform characteristics along with patient demographic data including gender, age, height, and weight to calculate stroke volume (SV). Basal metabolic rate (BMR), body mass index (BMI), blood pressure, and heart rate are not used to calculate stroke volume with this measuring device. Heart rate is used to calculate continuous cardiac output (COO) and continuous cardiac index (CCI). Text Reference - p. 1607

What data are used to calculate stroke volume (SV) for a patient with arterial pressure-based cardiac output (APCO) monitoring? 1 Height, BMR, age, gender 2 Gender, age, height, weight 3 BMI, BMR, blood pressure, heart rate 4 Age, gender, blood pressure, heart rate

37.5 The formula to calculate the rapid shallow breathing index is f/VT. Therefore, rapid shallow breathing index = 15/0.4 = 37.5 breaths/min/L. Text Reference - p. 1626

What is the rapid shallow breathing index of a patient whose spontaneous respiratory rate (f) is 15 breaths/min and spontaneous tidal volume (VT) is 0.4 L? Record your answer using one decimal place. ___________________breaths/min/L

1 Both negative pressure ventilation and positive pressure ventilation involve passive expiration. Negative pressure ventilation does not require an artificial airway. Positive pressure ventilation may require invasive mechanical ventilation through an artificial airway. Positive pressure ventilation is primarily used with acutely ill patients; negative pressure ventilation is not routinely used for acutely ill patients. In positive pressure ventilation, intrathoracic pressure is raised during lung inflation but in negative pressure ventilation, intrathoracic pressure is decreased during lung inflation. Text Reference - p. 1618

What is the similarity between negative pressure ventilation and positive pressure ventilation? 1 Both involve passive expiration. 2 Both require an artificial airway. 3 Both are routinely used for acutely ill patients. 4 Both raise intrathoracic pressure during lung inflation.

3 Negative inspiratory force is used to assess the muscle strength in a patient with positive pressure ventilation. Vital capacity, minute ventilation and rapid shallow breathing index are used to assess the muscle endurance. Test-Taking Tip: Multiple-choice questions can be challenging because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response. Text Reference - p. 1626

What measurement is used to assess muscle strength in a patient with positive pressure ventilation? 1 Vital capacity 2 Minute ventilation 3 Negative inspiratory force 4 Rapid shallow breathing index

75 Rapid shallow breathing index is equal to respiratory rate/tidal volume; therefore, 30/0.4 = 75. Text Reference - p. 1626

What will be the rapid shallow breathing index for a patient with a tidal volume of 0.4 L and respiratory rate of 30/minute? Record your answer using a whole number. ___ L

2 While caring for a patient requiring mechanical ventilation, the registered nurses (RNs) must administer sedatives by themselves; they should not delegate this task to unlicensed assistive personnel (UAP). UAP can be tasked with obtaining vital signs, measuring urine output, and performing bedside glucose tests. Text Reference - p. 1625

When caring for a critically ill patient on mechanical ventilation, what task must the registered nurses (RNs) perform by themselves and not delegate to unlicensed assistive personnel (UAP)? 1 Obtaining vital signs 2 Administering sedatives 3 Measuring urine output 4 Performing bedside glucose test

3 A dynamic response test is performed every 8 to 12 hours, as well as when the system is opened to air or the accuracy of the measurements is questioned. It involves activating the fast flush and checking that the equipment reproduces a distortion-free signal. A square wave indicates a normal response and requires no further action. This waveform does not indicate that the line needs to be flushed. Nor does it indicate that zero needs to be reconfirmed or that the wrist needs to be repositioned. Text Reference - p. 1605

When performing a dynamic response test, the nurse observes the following tracing. What action should the nurse perform based on this tracing?

1 Prior to the family entering the intensive care unit (ICU) to visit a family member who is critically ill the nurse should provide the family with a description of what to expect regarding the patient's appearance and the equipment that is being used to provide care to their family member. The nurse should accompany the family into the patient's room; it is not appropriate for the nurse to ask the physician to do this, nor is it appropriate for the family to enter the room alone. Although it is important to instruct the family on what to expect, the family should be encouraged to touch and speak to the patient. Text Reference - p. 1602

Which action by the nurse is most appropriate when bringing a family member of a critically ill patient into the intensive care unit (ICU) for the first time? 1 Give a description of what to expect 2 Ask the physician to accompany the family 3 Allow the family member to enter the room alone 4 Instruct the family not to touch and speak to the patient

1, 2, 3, 4 Caregivers play a valuable role in the intensive care unit (ICU) patient's recovery because they provide the patient with support. They are also a link to the patient's personal life, help the patient with activities of daily living, and function as the decision maker during the hospitalization. Although the caregiver may make financial decision for the patient during the hospitalization, this is not an important role the caregiver plays in the patient's recovery. Text Reference - p. 1601

Which are the reasons why caregivers play a valuable role in the intensive care unit (ICU) patient's recovery? Select all that apply. 1 They provide loving support for the patient. 2 They provide a link to the patient's personal life. 3 They help the patient with activities of daily living. 4 They function as the patient's decision-maker during the hospitalization. 5 They make the financial decision for the patient during the hospitalization.

3 Systemic vascular resistance is an index of left ventricular afterload. Central venous pressure is an index of preload. Pulmonary arterial pressure and peripheral vascular resistance are indices of right ventricular afterload. Text Reference - p. 1604

Which hemodynamic value should the nurse use to determine a patient's left ventricular afterload? 1 Central venous pressure 2 Pulmonary arterial pressure 3 Systemic vascular resistance 4 Peripheral vascular resistance

3, 4 Suctioning is preceded by a thorough assessment and hyperoxygenation for 30 seconds. Sterile, not clean, gloves are necessary and it is not necessary to administer a bronchodilator. Instillation of normal saline into the ET tube is not an accepted standard practice. Text Reference - p. 1616

Which interventions should the nurse perform before suctioning a patient who has an endotracheal (ET) tube using open-suction technique? Select all that apply. 1 Put on clean gloves. 2 Administer a bronchodilator. 3 Perform a cardiopulmonary assessment. 4 Hyperoxygenate the patient for 30 seconds. 5 Insert a few drops of normal saline into the ET to break up secretions.

1 Patients with preexisting dementia, such as Alzheimer's disease, are at an increased risk for developing delirium when receiving care in the intensive care unit (ICU). Diabetes mellitus, Parkinson's disease, and multiple sclerosis are not known risk factors for developing delirium. Text Reference - p. 1601

Which is the recommendation from the American Association of Critical Care Nursing (AACN) regarding family visitation in the intensive care unit (ICU)? 1 Individualized visitation 2 Visitation on the evening shift 3 Visitation as prescribed by the physician 4 Hourly visitations occurring on each shift

1 In a patient with a head injury, positive pressure ventilation decreases the venous return because of the increase in intrathoracic pressure. Increased intrathoracic pressure causes jugular vein distension rather than compression. Positive pressure ventilation increases the cerebral volume. A decrease in venous return causes an increase in intracranial pressure. Text Reference - p. 1623

Which neurologic complication may occur in a patient with a head injury who is on positive pressure ventilation? 1 Decrease in venous return 2 Compression of jugular vein 3 Reduction of cerebral volume 4 Reduction of intracranial pressure

4 The electronic or teleICU assists the bedside ICU team by monitoring the patient from a remote location using informatics. The ICU, CCU, and PICU are traditional critical care units. Text Reference - p. 1599

Which type of critical care unit uses informatics to monitor a critically ill patient from a remote location? 1 Intensive care unit (ICU) 2 Coronary care unit (CCU) 3 Pediatric intensive care unit (PICU) 4 Electronic intensive care unit (teleICU)