Critical Care

A client with massive trauma and possible spinal cord injury is admitted to the emergency department following a dirt bike accident. Which clinical manifestation does the nurse assess to help best confirm a diagnosis of neurogenic shock? 1. Apical heart rate 48/min 2. Blood pressure 186/92 mm Hg 3. Cool, clammy skin 4. Temperature 100 F (37.7 C) tympanic

1. Apical heart rate 48/min Educational objective:Neurogenic shock (a form of distributive shock) causes a disruption in the function of the sympathetic, but not parasympathetic, nervous system. Bradycardia, a characteristic manifestation of neurogenic shock, occurs as a result of this alteration in neural activity between the 2 systems.

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

2. "I will perform endotracheal suctioning routinely after oral care." Endotracheal suctioning in mechanically ventilated clients should be performed based on assessment findings such as adventitious breath sounds, elevated peak airway pressure, coughing, or acute respiratory distress. Suctioning should be performed only when needed to reduce the risk of lung trauma and hypoxia.

The nurse assesses diminished lung sounds and high-pitched wheezing in a client with acute asthma exacerbation. Arterial blood gas (ABG) findings are shown in the exhibit. Which acid-base imbalance does the nurse correctly identify? pH 7.49 PaCO 230 mm Hg (4 kPa) PaO 279 mm Hg (10.5 kPa) HCO 3-25 mEq/L (25 mmol/L) 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

4. Respiratory alkalosis

The client is brought to the emergency department after falling off a roof and landing on his back. A T1 spinal fracture is diagnosed. The client's blood pressure is 74/40 mm Hg, pulse is 50/min, and skin is pink and dry. What nursing action is a priority? 1. Administer IV normal saline 2. Determine if urinary occult blood is present 3. Perform a neurological assessment 4. Verify that there is no stool impaction

1. Administer IV normal saline This presentation is classic for neurogenic shock, a distributive shock. Vascular dilation with decreased venous return to the heart is present due to loss of innervation from the spine. Classic signs/symptoms are hypotension, bradycardia, and pink and dry skin from the vasodilation. Neurogenic shock usually occurs in cervical or high thoracic injuries (T6 or higher). Systolic blood pressure should remain at 80 mm Hg or above to adequately perfuse the kidneys. Administration of fluids is a priority to ensure adequate kidney and other organ perfusion. Educational objective:Neurogenic shock/distributive shock can occur from vasodilation soon after spinal injury. Classic symptoms are hypotension, bradycardia, and pink and dry skin. The hypotension must be treated with isotonic fluids to maintain vital organ perfusion.

An emergency department nurse is sent to the scene of a massive motor vehicle collision. A client there reports neck pain. Which actions should the nurse perform at this time? Select all that apply. 1. Apply a hard cervical collar 2. Assess neck range of motion 3. Inspect client's respiratory pattern 4. Position client flat on firm surface 5. Use logrolling technique if moving client

1. Apply a hard cervical collar 3. Inspect client's respiratory pattern 4. Position client flat on firm surface 5. Use logrolling technique if moving client The initial priorities for a client with a suspected cervical spine injury are to ensure a patent airway and immobilize the spine to prevent further injury. This includes applying a rigid hard collar, placing the client on a firm surface (eg, a backboard), and moving the client as a unit (logrolling) if required (Options 1, 4, and 5). A soft foam cervical collar does not provide immobilization. Further stabilization is achieved by taping down the client's head and using straps to immobilize the arms, especially if the client is not cooperating. After immobilizing the client, the nurse should obtain a baseline set of vital signs to monitor for neurogenic shock (eg, hypotension, bradycardia, poikilothermia [ie, inability to regulate body temperature]), a potential complication of spinal cord injury. The nurse should also assess the client's respiratory rate, pattern, and effort. Presence of abdominal breathing or increased work of breathing may indicate impending loss of airway and require prompt rapid-sequence intubation (Option 3). Educational objective:The priorities for a client with a suspected cervical spine injury are maintaining a patent airway and spinal immobilization. Interventions include application of a rigid hard collar, placing the client on a firm surface, logrolling the client during movement and transfers, and continued assessment of need for an advanced airway.

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

1. Apply defibrillator pads 2. Call out and look around to ensure that everyone is "all clear" 3. Continue chest compressions until ready to deliver shock Defibrillation is indicated in clients with ventricular fibrillation (Vfib) and pulseless ventricular tachycardia. Cardiopulmonary resuscitation (CPR) should be initiated and compressions continued until the shock is ready to be delivered (Option 3). Certain pulseless rhythms (asystole and pulseless electrical activity) do not need defibrillation. Steps to perform defibrillation are as follows: Turn on the defibrillator Place defibrillator pads on the client's chest (Option 1) Charge defibrillator. Chest compressions should continue until defibrillator has charged and is ready to deliver the shock. Before delivering the shock, ensure that the area is "all clear." Confirm that no personnel are touching the client, bed, or any equipment attached to the client (Option 2). Deliver the shock Immediately resume chest compressions Educational objective:The steps for defibrillation are as follows: Turn on the defibrillator, place pads on the client's chest, charge defibrillator, ensure the area is "all clear," deliver the shock, then resume compressions immediately.

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

1. Ask the client to bear down as if having a bowel movement Clients with paroxysmal supraventricular tachycardia (SVT) (regular, narrow QRS complex tachycardia) are initially treated with vagal maneuvers. The act of "bearing down" as if having a bowel movement (Valsalva) is an example of these maneuvers and may need to be attempted more than once. Vagal maneuvers work by increasing intra-thoracic pressure and stimulating the vagus nerve, which supplies parasympathetic nerve fibers to the heart, resulting in slowed electrical conduction through the atrioventricular node. Educational objective:Supraventricular tachycardia is a regular, narrow QRS complex tachycardia with a rate of around 150-220/min. The best treatment is vagal maneuvers and adenosine IV push.

An intoxicated client not wearing a seatbelt drives into a metal barricade near the entrance to the emergency department. The client's head has hit the windshield, and the client is unconscious. What nurse actions are appropriate? Select all that apply. 1. Assess the client for a carotid pulse 2. Determine the client's Glasgow Coma Scale score 3. Maintain airway with head-tilt/chin-lift maneuver 4. Place a hard cervical collar on the client 5. Remove the client from the car onto a backboard

1. Assess the client for a carotid pulse 2. Determine the client's Glasgow Coma Scale score 4. Place a hard cervical collar on the client 5. Remove the client from the car onto a backboard The transference of kinetic energy to the client's body from an opposing force during sudden deceleration (eg, fall, motor vehicle collision) causes bodily injury. If the client is not wearing a seatbelt during an automobile crash, the client may strike (or be propelled through) the windshield, causing blunt-force trauma to the head, neck, or spine. The unconscious client should first be assessed for adequate breathing and the presence of a pulse (using the rule of airway, breathing, and circulation [ABCs]) (Option 1). Using a rigid cervical collar, cervical spine immobilization must be maintained throughout the client assessment to minimize further injury (Option 4). The client should be removed and placed on a backboard after the cervical spine has been stabilized Educational objective:After sudden deceleration with blunt-force head injury, the nurse first checks if the client is breathing and has a pulse (using the rule of airway, breathing, and circulation [ABCs]). Spinal injury should be presumed, and the cervical spine should be stabilized (eg, cervical collar). The jaw-thrust maneuver may be used to open the airway.

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

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

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

1. Assess vital signs Third-spacing of fluids can occur 24-72 hours after extensive abdominal surgery as a result of increased capillary permeability due to tissue trauma. It occurs when too much fluid moves from the intravascular into the interstitial or third space, a place between cells where fluid does not normally collect (ie, injured site, peritoneal cavity). This fluid serves no physiologic purpose, cannot be measured, and leads to decreased circulating volume (hypovolemia) and cardiac output. The priority intervention is to assess vital signs as the manifestations associated with third-spacing include weight gain, decreased urinary output, and signs of hypovolemia, such as tachycardia and hypotension. If third-spacing is not recognized and corrected early on, postoperative hypotension can lead to decreased renal perfusion, prerenal failure, and hypovolemic shock (Option 1). Educational objective:Third-spacing can occur following extensive abdominal surgery and can lead to hypovolemia, decreased cardiac output, hypotension and tachycardia, and decreased urine output. Monitoring vital signs and urine output, and maintaining IV fluids are appropriate interventions to prevent prerenal failure and hypovolemic shock.

A client with hypothermia has just arrived in the emergency department via ambulance. The client is being rewarmed with blankets, and the IV fluids are being changed over to warmed fluids. What additional intervention is a priority? 1. Attaching the cardiac monitor 2. Covering the client's head 3. Drawing blood for electrolytes and glucose 4. Placing an additional large-bore IV catheter

1. Attaching the cardiac monitor Hypothermia occurs when the core temperature is below 95 F (35 C) and the body is unable to compensate for heat loss. As the core temperature decreases, the cold myocardium becomes extremely irritable and prone to dysrhythmias. The client should be handled gently as spontaneous ventricular fibrillation could develop when moved or touched. Therefore, placing the client on a cardiac monitor is a high priority; the nurse should anticipate defibrillation in these clients. Educational objective:Cardiac monitoring and gentle handling of the client are a high priority with hypothermia. The cold myocardium is extremely irritable and prone to dysrhythmias. The nurse should anticipate defibrillation in these clients.

The nurse is caring for an intubated client whose oxygen saturation begins to drop. What action should the nurse take first? 1. Auscultate lung sounds bilaterally 2. Hyper-oxygenate with 100% oxygen 3. Manually ventilate with bag valve mask 4. Suction the endotracheal tube

1. Auscultate lung sounds bilaterally A drop in oxygen saturation signifies a problem with ventilation. When an artificial airway is present, the nurse should assess the client to determine the cause of hypoventilation. Auscultating lung sounds is the first step and quickest intervention to confirm proper tube placement. It is not uncommon for the tube to become displaced in the hypopharynx, which would not allow proper ventilation. Another important complication is pneumothorax, which can cause hypotension and a drop in oxygen saturation. Lung auscultation would help diagnose this as well. Educational objective:Proper placement of the endotracheal tube is essential for adequate ventilation in intubated clients. If the tube becomes displaced in the hypopharynx, hypoxemia can result. Confirming the presence of equal breath sounds bilaterally via auscultation is an important initial nursing intervention.

The nurse is caring for a client on a mechanical ventilator. The settings on the ventilator have just been changed, and the standing prescription is to draw arterial blood gases 30 minutes after a ventilator change. In anticipation of this blood draw, what intervention should the nurse implement? 1. Avoid suctioning the client 2. Pre-oxygenate the client 3. Raise the head of the bed 4. Reduce the amount of sedation medication

1. Avoid suctioning the client Arterial blood gases (ABGs) indicate the acid-base balance in the body and how well oxygen is being carried to the tissues. It is common to measure ABGs after a ventilator change to assess how well the client has tolerated it. Factors such as changes in the client's activity level or oxygen settings, or suctioning within 20 minutes prior to the blood draw can cause inaccurate results. Unless the client's condition dictates otherwise, the nurse should avoid suctioning as it will deplete the client's oxygen level and cause inaccurate test results. Educational objective:If the client's condition allows, the nurse should avoid suctioning or changing activity or oxygenation levels prior to drawing of ABGs. These actions can result in inaccurate ABG results.

A client with acute respiratory distress syndrome is receiving positive pressure mechanical ventilation with 15 cm H2O (11 mm Hg) positive end-expiratory pressure (PEEP). The nurse should assess for which complication associated with PEEP? 1. Barotrauma 2. Decreased oxygen saturation 3. Hypertension 4. Oxygen toxicity

1. Barotrauma Positive end-expiratory pressure (PEEP) applies a given pressure at the end of expiration during mechanical ventilation. It counteracts small airway collapse and keeps alveoli open so that they can participate in gas exchange. PEEP is usually kept at 5 cm H2O (3.7 mm Hg). However, a higher level of PEEP is an effective treatment strategy for acute respiratory distress syndrome (ARDS), a type of progressive respiratory failure that causes damage to the type II surfactant-producing pneumocytes that then leads to atelectasis, noncompliant lungs, poor gas exchange, and refractory hypoxemia. High levels of PEEP (10-20 cm H2O [7.4-14.8 mm Hg]) can cause overdistension and rupture of the alveoli, resulting in barotrauma to the lung. Air from ruptured alveoli can escape into the pulmonary interstitial space or pleural space, resulting in a pneumothorax and/or subcutaneous emphysema. Educational objective:High PEEP is commonly used to prevent small airway/alveolar collapse in clients with ARDS. PEEP helps to reduce oxygen toxicity. However, high levels of PEEP (10-20 cm H2O [7.4-14.8 mm Hg]) can cause barotrauma to the lung, resulting in a pneumothorax, and decreased venous return causes hypotension.

The home health nurse is providing care for a 6-year-old client who has a tracheostomy and is being mechanically ventilated when the ventilator's apnea alarm sounds. The nurse finds the client to be unresponsive and pulseless, and there are no other caregivers present. Which action should the nurse take first? 1. Begin chest compressions 2. Deliver 2 breaths using a bag valve device connected to the tracheostomy 3. Locate and apply an automated external defibrillator 4. Use a phone to call 911

1. Begin chest compressions Cardiac arrest is the sudden cessation of cardiac output that is usually caused by an arrhythmia. Arrest can be precipitated by a variety of factors (eg, hypoxia, toxins, electrolyte imbalance) and is a medical emergency. In children, cardiac arrest is commonly caused by hypoxia and respiratory failure. If the nurse is a single rescuer in a witnessed cardiac arrest of a pediatric client, the first action is to promptly initiate CPR, starting with chest compressions (Option 1). For the pediatric client, initiating CPR before other interventions (eg, calling 911) helps minimize risk for end organ damage and brain injury. The nurse should provide 30 chest compressions and 2 rescue breaths in each cycle of CPR. Educational objective:Cardiac arrest, the sudden cessation of cardiac output, is a medical emergency. If a single rescuer witnesses cardiac arrest in a pediatric client, the rescuer should immediately begin CPR (starting with chest compressions) for 2 minutes (~5 cycles) before activating the emergency response system and obtaining an automated external defibrillator.

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

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

A client who is 2 hours post aortic valve replacement is in the intensive care unit (ICU). The low pressure alarm for the client's radial arterial line sounds. Which action should the nurse take first? 1. Check for bleeding at tube connection sites 2. Perform a fast flush of the arterial line system 3. Re-level the transducer to the phlebostatic axis 4. Zero and re-balance the monitor and system

1. Check for bleeding at tube connection sites The low pressure alarm could signal hypotension. The nurse's first action should be to check the client for evidence of hypotension and the cause. Arterial lines carry the risk of hemorrhage and are most likely to occur at connection sites of the tubing and catheter. A client can lose a large amount of arterial blood in a short period of time. The nurse should verify that these connections are tight on admission of the client to the ICU. Educational objective:A low pressure alarm for an arterial line can indicate the presence of hypotension or disconnected tubing. Hemorrhage can rapidly occur with a disconnected arterial catheter line. The nurse should check the client for the presence of hypotension and its causes before troubleshooting the system.

The charge nurse responds to a cardiac arrest with resuscitation in progress of an adult client. Which of the following actions by a resuscitation team member would cause the charge nurse to intervene? Select all that apply. 1. Chest compressions are performed at a rate of 70-80/min 2. Chest compressions are stopped for a 10-second pulse check every 2 minutes 3. Defibrillator pads are applied at the left and right sternal borders 4. Manual breaths are delivered at a rate of 2 breaths per 30 chest compressions 5. Resuscitation team is alerted to remain clear of client before defibrillation

1. Chest compressions are performed at a rate of 70-80/min 3. Defibrillator pads are applied at the left and right sternal borders All members of the health care team must follow basic life support guidelines to perform cardiopulmonary resuscitation (CPR) for clients experiencing cardiac arrest. Essential components of adult CPR include: Chest compressions are performed at a rate of 100-120/min and a depth of 2.0-2.4 inches (5-6 cm), allowing complete chest recoil between compressions (Option 1). Defibrillator pads are placed on the right upper chest, just below the clavicle, and on the left lateral chest, near the anterior axillary line below the nipple line (Option 3). Educational objective:During cardiopulmonary resuscitation, chest compressions are performed at a rate of 100-120/min. Defibrillator pads are placed on the right upper chest and on the left lateral chest.

The nurse is caring for a client in the immediate postoperative period following an exploratory laparotomy after sustaining a gunshot wound to the abdomen. Which assessment finding is most important for the nurse to report to the health care provider? 1. Cold and clammy skin 2. Oxygen saturation of 92% 3. Sinus tachycardia of 108/min 4. Urine output of 0.6 mL/kg/hr

1. Cold and clammy skin Hypovolemic (hemorrhagic) shock may occur after abdominal trauma or surgery as mesenteric edema resolves and previously compressed sites of bleeding reopen. The shock continuum is staged in severity from initial (I) to irreversible (IV). During the initial stage, there is inadequate oxygen to supply the demand at the cellular level and anaerobic metabolism develops. At this point, there may be no recognizable signs or symptoms. As shock progresses to the compensatory stage, sympathetic compensatory mechanisms are activated to maintain homeostasis (eg, oxygenation, cardiac output). Cold, clammy skin indicates failing compensatory mechanisms (ie, progressive stage), and immediate intervention is necessary to prevent irreversible shock and death (Option 1). Educational objective:Cold, clammy skin in a client with shock indicates that compensatory mechanisms are failing and that hypoperfusion is occurring. This should be reported promptly to the health care provider as immediate intervention is necessary to prevent irreversible shock.

Emergency medical service personnel are transporting a near-drowning victim who is currently hypothermic. Based on anticipated vital signs, the nurse needs to prepare for which interventions? Select all that apply. 1. Covering client with warm blankets 2. Logrolling the client from side to side frequently 3. Mechanical ventilation 4. Warmed blood administration 5. Warmed IV fluids

1. Covering client with warm blankets 3. Mechanical ventilation 5. Warmed IV fluid The initial management of a near-drowning victim focuses on airway management due to potential aspiration (leading to acute respiratory distress syndrome), pulmonary edema, or bronchospasm (leading to airway obstruction). Hypoxia is managed and prevented by ensuring a patent airway via intubation and mechanical ventilation as necessary (Option 3). Careful handling of the hypothermic client is important because as the core temperature decreases, the cold myocardium becomes extremely irritable. Frequent turning could cause spontaneous ventricular fibrillation and should not be performed during the acute stage of hypothermia. Continuous cardiac monitoring should be initiated (Option 2). There are passive, active external, and active internal rewarming methods. Passive rewarming methods include removing the client's wet clothing, providing dry clothing, and applying warm blankets. Active external rewarming involves using heating devices or a warm water immersion. Active internal rewarming is used for moderate to severe hypothermia and involves administering warmed IV fluids and warm humidified oxygen (Options 1 and 5). Educational objective:Emergency department care of near-drowning victims includes advanced airway management, aggressive oxygenation, establishing IV access and administering IV fluids (warmed if hypothermic), and monitoring for cardiac arrhythmias and fluid imbalances.

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

1. Deficient fluid volume This client is exhibiting symptoms of hypovolemia, which include hypotension, tachycardia, and decreased urinary output. Therefore, the priority ND is deficient fluid volume related to active intravascular loss that is secondary to hemorrhage, gastric suction, wound drainage, and possible third spacing as evidenced by decreased urine output, hypotension, and tachycardia. The adverse effects of the epidural anesthesia can contribute to hypotension as well. This ND poses the greatest threat to survival because if not corrected, it can lead to decreased cardiac output, acute renal failure, and hypovolemic shock. Educational objective:Deficient fluid volume, nausea, and risk for infection are appropriate NDs for a client who has undergone surgery for repair of a blunt trauma intraabdominal hemorrhagic injury. However, the priority ND addresses the highest level of risk to a client: airway, breathing, circulation (eg, hypovolemia, cardiac output), and vital signs (eg, hypotension, tachycardia).

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

1. Elevating the head of the bed 30-45 degrees 3. Practicing strict hand hygiene 4. Providing frequent oral care with chlorhexidine 5. Scheduling daily sedation vacations

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

1. Maintain the head of the bed at 30-45 degrees 3. Pause sedation daily to assess weaning readiness 4. Perform oral care with chlorhexidine solution 5. Place a manual resuscitation bag at the bedside Clients requiring mechanical ventilation are at risk for a variety of ventilator-associated complications (eg, aspiration, pneumonia). When caring for a client receiving mechanical ventilation, the nurse should: Monitor respiratory status (eg, lung sounds, breathing pattern), airway patency, and ventilator functionality (eg, settings, alarm parameters). Maintain the head of the bed at 30-45 degrees to reduce aspiration risk (Option 1). Use the minimum amount of sedation necessary for client comfort (eg, compliant with ventilator, opens eyes to voice). Continuous IV sedation should be paused daily for evaluation of spontaneous respiratory effort and appropriateness for weaning off the ventilator (Option 3). Perform oral care with chlorhexidine oral solution every 2 hours, or per facility policy (Option 4). Perform tracheal suctioning as needed. Monitor correct endotracheal tube placement by noting insertion depth. Place emergency equipment at bedside (eg, manual resuscitation bag) (Option 5). Educational objective:When caring for a client requiring mechanical ventilation, the nurse should monitor respiratory status and airway patency (eg, breath sounds, insertion depth of endotracheal tube), maintain an appropriate level of sedation, assess for weaning readiness, prevent ventilator-associated infection (eg, oral care with chlorhexidine, head of the bed at 30-45 degrees), and implement safety measures (eg, emergency equipment at bedside, ventilator alarms on).

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

1. New-onset right-sided paralysis of extremities 4. Sudden inability to be aroused to an awake stat Rapid response teams are formed as a means to get critical care specialists to the bedside of clients who are not in a critical care unit when acute, significant changes occur in their condition. Each institution sets its own criteria, but it usually includes acute changes in heart rate, systolic blood pressure, respiratory rate, oxygen saturation, level of consciousness, and/or urine output. Although strokes occur more commonly in adults, they can occur in children. Symptoms found in both groups can be similar, such as unilateral paralysis, which is usually found with vessel abnormalities or a hematologic complication (eg, sickle cell, cancer) (Option 1). Just as in adults, emergency treatment for children should be activated. A sudden loss of consciousness is emergent in any client (Option 4). Educational objective:Rapid response teams are formed as a means to get critical care assistance to the bedside of clients (not in intensive care) with acute significant changes in their condition. Common criteria include sudden, significant changes in pulse rate, respiration rate, systolic blood pressure, oxygen saturation, level of consciousness, and/or urine output.

The intensive care nurse is caring for a client who has just been extubated. Which interventions are appropriate at this time? Select all that apply. 1. Administer prescribed oral narcotics for throat pain 2. Administer warmed, humidified oxygen via facemask 3. Give the client ice chips to moisten the mouth 4. Provide mouth care with oral sponges 5. Start the client on incentive spirometer

2. Administer warmed, humidified oxygen via facemask 4. Provide mouth care with oral sponges 5. Start the client on incentive spirometer Recently extubated clients are at high risk for aspiration, airway obstruction (laryngeal edema and/or spasm), and respiratory distress. To prevent complications, clients are placed in high Fowler position to maximize lung expansion and prevent aspiration of secretions. Warmed, humidified oxygen is administered immediately after extubation to provide high concentrations of supplemental oxygen without drying out the mucosa (Option 2). Oral care is provided to decrease bacteria and contaminants as well as promote comfort (Option 4). Clients are instructed to frequently cough, deep breathe, and use an incentive spirometer to expand alveoli and prevent atelectasis (Option 5). Educational objective:Recently extubated clients are immediately placed on humidified oxygen and monitored for aspiration, airway obstruction, and respiratory distress. Clients should remain NPO until swallowing function has been evaluated. In addition, clients should be given routine oral care as well as instructions on coughing, deep breathing, and use of incentive spirometry.

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

2. Delays requesting a new norepinephrine IV bag when the first is almost finished Hypovolemic shock, the most common type of shock, occurs when blood volume decreases through hemorrhage or movement of fluid from the intravascular compartment into the interstitial space (third-spacing). Treatment involves preventing additional fluid loss, restoring volume through IV fluids, and improving hemodynamic stability through vasoactive medications (eg, norepinephrine, dopamine). Norepinephrine causes vasoconstriction and improves heart contractility/output, but the effects end quickly. It should be tapered slowly and cautiously to avoid the progression or relapse of shock. Educational objective:Hypovolemic shock occurs when blood volume decreases via hemorrhage or third-spacing. Stopping the source of blood loss, increasing blood volume through IV fluids, and improving blood pressure with vasoactive medications are the first steps in treating this condition. Abruptly discontinuing vasoactive medications can cause hemodynamic instability; these medications should always be tapered slowly.

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

2. Disturbed sleep pattern Educational objective:Disturbed sleep pattern related to environmental factors, such as excessive noise and circadian rhythm disturbance, is an important ND for a critically ill client. Lack of adequate uninterrupted sleep can lead to negative physiologic (eg, decreased REM sleep, increased heart rate) and psychologic (eg, delirium, anxiety, powerlessness, acute confusion) consequences that can affect client outcomes.

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

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

Based on the progress note documentation, which priority intervention does the nurse anticipate? Click on the exhibit button for additional information. 2000 Client admitted to CCU #4, reporting vise-like chest pain and shortness of breath. Pulmonary artery (PA) catheter inserted by the health care provider via right internal jugular vein without difficulty. Central venous pressure (CVP) 18 mm Hg, pulmonary artery wedge pressure (PAWP) 25 mm Hg and coarse crackles auscultated bilaterally._________________, RN 1. 0.9% sodium chloride, 500 mL intravenous bolus 2. Furosemide, 40 mg intravenous push 3. Metoprolol, 5 mg intravenous push 4. Vancomycin, 1 g intravenously every 12 hours

2. Furosemide, 40 mg intravenous push The client's central venous pressure (CVP) is elevated (normal value 2-8 mm Hg), indicating increased systemic circulation volume and increased right ventricular preload. Pulmonary artery wedge pressure (PAWP) is also elevated (normal value 6-12 mm Hg), indicating increased left ventricular preload. In the presence of increased CVP and PAWP, coarse crackles indicate left-sided failure. The treatment goal is to decrease fluid volume and preload. Furosemide is a loop diuretic that will decrease both left- and right-sided preload. Educational objective:Loop diuretics (eg, furosemide, bumetanide, torsemide) are effective in decreasing both right ventricular preload and left ventricular preload.

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

2. Heart rate is 120/min Dopamine (Intropin) is a sympathomimetic inotropic medication used therapeutically to improve hemodynamic status in clients with shock and heart failure. It enhances cardiac output by increasing myocardial contractility, increasing heart rate, and elevating blood pressure through vasoconstriction. Renal perfusion is also improved, resulting in increased urine output. The lowest effective dose of dopamine should be used as dopamine administration leads to an increased cardiac workload. Significant adverse effects include tachycardia, dysrhythmias, and myocardial ischemia. A heart rate of 120/min may indicate that the dopamine infusion needs to be reduced (Option 2). Educational objective:Dopamine is a sympathomimetic inotropic agent that increases heart rate, blood pressure, cardiac output, and urine output. Vital signs should be monitored closely in these clients as a higher dose can result in dangerous tachycardia and tachyarrhythmias.

The nurse cares for an intubated client on mechanical ventilation with worsening cerebral edema from increased intracranial pressure (ICP). Which nursing interventions help reduce ICP? Select all that apply. 1. Clustering as many interventions as possible when providing care 2. Hyperventilating before suctioning 3. Maintaining a quiet, dark environment 4. Maintaining the head in a neutral midline position 5. Suctioning for 30 seconds to remove endotracheal tube secretions at regular intervals

2. Hyperventilating before suctioning 3. Maintaining a quiet, dark environment 4. Maintaining the head in a neutral midline position Most nursing activities increase intracranial pressure (ICP) in brain injuries. The goal is to reduce ICP while managing basic client needs. During interventions, ICP should not exceed 25 mm Hg and should return to baseline within a few minutes. Metabolic demands (eg, pain, straining, agitation, shivering, fever, hypoxia) increase brain blood supply and raise ICP. Nursing interventions to control ICP include: Elevating the head of the bed to 30 degrees with the head/neck in a neutral position to reduce venous congestion (Option 4) Administering stool softeners to reduce the risk of straining (eg, Valsalva maneuver) Managing pain well while monitoring sedation Managing fever (eg, cool sponges, ice, antipyretics) while preventing shivering Maintaining a calm environment with minimal noise (eg, alarms, television, hall noise) (Option 3) Ensuring adequate oxygenation Hyperventilating and preoxygenating the client before suctioning; reducing CO2 (a potent cerebral vasodilator) by hyperventilation induces vasoconstriction and reduces ICP (Option 2) Educational objective:Nursing activities can increase intracranial pressure (ICP) and should be limited and spread throughout the day. The goal is to reduce ICP while managing basic needs. Nursing interventions include elevating the head of the bed, administering stool softeners, managing pain and fever, and maintaining a calm environment.

When caring for a client with a left radial artery catheter, which assessment data obtained by the nurse indicates the need to take immediate action? 1. Capillary refill of less than 3 seconds 2. Left hand cooler than right 3. Mean arterial pressure of 65 mm Hg 4. Pressure bag at 300 mm Hg

2. Left hand cooler than right Although the Allen's test is performed before cannulating the radial artery and determines the adequacy of ulnar artery blood flow, circulation to the extremity is monitored frequently. The nurse must assess color, capillary refill, sensation, temperature, and movement per institution policy. Impairment in any of these parameters must be reported immediately because it may indicate impaired circulation to the extremity, and removal of the catheter may be necessary. Educational objective:When caring for a client with a radial, brachial, or femoral arterial line in place, the nurse must be able to assess for complications. These include hemorrhage, infection, thrombus formation, and circulatory and neurovascular impairment.

A client with a bowel obstruction has been treated with gastric suctioning for 4 days. The nurse notices an increase in nasogastric drainage. Which acid-base imbalance does the nurse correctly identify? pH7.50 PaCO245 mm Hg (5.98 kPa) PaO290 mm Hg (12 kPa) HCO332 mEq/L (32 mmol/L) 1. Metabolic alkalosis, compensated 2. Metabolic alkalosis, uncompensated 3. Respiratory alkalosis, compensated 4. Respiratory alkalosis, uncompensated

2. Metabolic alkalosis, uncompensated Educational objective:Loss of acid through suctioning of gastric contents creates a state of metabolic alkalosis. Compensatory hypoventilation may regulate the pH by retaining carbon dioxide (acid).

Upon arrival in the post-anesthesia care unit, the nurse performs the initial assessment of a client who had surgery under general anesthesia. Which assessment finding prompts the nurse to notify the health care provider immediately? 1. Difficult to arouse 2. Muscle stiffness 3. Pinpoint pupils 4. Temperature 94 F (34.4 C)

2. Muscle stiffness Malignant hyperthermia (MH) is a rare, life-threatening inherited muscle abnormality that is triggered by certain drugs used to induce general anesthesia in susceptible clients. The triggering agent leads to excessive release of calcium from the muscles, leading to sustained muscle contraction and rigidity. It can occur in the operating room or in the post-anesthesia care unit (PACU). The most specific characteristic signs and symptoms of MH include hypercapnia (earliest sign), generalized muscle rigidity (eg, jaw, trunk, extremities), and hyperthermia. Hyperthermia is a later sign and can confirm a suspicion of MH. The nurse monitors the temperature as it can rise 1 degree Celsius every 5 minutes and can exceed 105 F (40.6 C). The nurse would notify the health care provider, indicating the need for immediate treatment (eg, dantrolene, cooling blanket, fluid resuscitation) (Option 2). Educational objective:Malignant hyperthermia (MH) is a rare, life-threatening inherited muscle abnormality that is triggered by certain drugs used to induce general anesthesia. The most specific characteristic signs and symptoms of MH include hypercapnia, muscle rigidity, and hyperthermia.

A client at 32 weeks gestation goes into cardiac arrest. What is the nurse's best action while performing cardiopulmonary resuscitation for this client? 1. Compress chest at second intercostal space, right sternal border 2. Perform chest compressions slightly higher on the sternum 3. Place hands just below the diaphragm to perform chest compressions 4. Position client in the supine position for optimal compressions

2. Perform chest compressions slightly higher on the sternum Common causes of sudden cardiac arrest in pregnant clients include embolism, eclampsia, magnesium overdoses, and uterine rupture. If cardiopulmonary resuscitation (CPR) is required, several modifications must be made to ensure efficacy of the rescue efforts. During pregnancy, the heart is displaced toward the left because the growing uterus pushes upward on the diaphragm, particularly in the third trimester. To accommodate this displacement, the hands should be placed on the sternum slightly higher than usual for chest compressions during CPR Educational objective:Two important modifications for cardiopulmonary resuscitation of a pregnant client include performing chest compressions slightly higher on the sternum and displacing the uterus to the client's left side.

A 2-year-old at an outpatient clinic stops breathing and does not have a pulse. CPR is initiated. When the automated external defibrillator (AED) arrives, the nurse notes that it has only adult AED pads. What is the appropriate action at this time? 1. Continue CPR without using the automated external defibrillator (AED) until paramedics arrive 2. Place one AED pad on the chest and the other on the back 3. Place one AED pad on the upper right chest and the other on the lower left side 4. Place one AED pad on the upper right chest and dispose of the other

2. Place one AED pad on the chest and the other on the back An automated external defibrillator (AED) should be used as soon as it is available. Pediatric AED pads or a pediatric dose attenuator should be used for children age birth to 8 years if available. Standard adult pads can be used as long as they do not overlap or touch. If adult AED pads are used, one should be placed on the chest and the other on the back ("sandwiching the heart"). Educational objective:An automated external defibrillator (AED) should be used as soon as it is available. Adult AED pads can be used on a pediatric client if pediatric pads are unavailable. One pad is placed on the chest and the other is placed on the back ("sandwiching the heart").

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

2. Toes pointed straight down Near-drowning occurs when a client is under water and unable to breathe for an extended period. In a matter of seconds, major body organs begin to shut down from lack of oxygen and permanent damage results. Decerebrate posturing is a sign of severe brain damage. During assessment, the nurse would observe arms and legs straight out, toes pointed down, and the head/neck arched back. These assessment findings indicate that severe injury has occurred. Educational objective:Decerebrate posturing (arms and legs straight out, toes pointed down, head/neck arched back) usually indicates severe brain injury.

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

2. pH 7.30, PaCO2 30 mm Hg (4.0 kPa), HCO3 15 mEq/L (15 mmol/L) The arterial blood gas (ABG) result most consistent with the diagnosis of diabetic ketoacidosis (DKA) is metabolic acidosis or partially compensated metabolic acidosis (pH 7.30, PaCO2 30 mm Hg [4.0 kPa], HCO3 15 mEq/L [15 mmol/L]). DKA is a life-threatening complication of type 1 diabetes characterized by hyperglycemia (>250 mg/dL [13.9 mmol/L]) resulting in ketosis, a metabolic acidosis. Glucose cannot be taken out of the bloodstream and used for energy without insulin, which individuals with type 1 diabetes cannot produce. Similar to a state of starvation, the body begins to break down fat stores into ketones, causing a metabolic acidosis (low pH and low HCO3). As a compensatory mechanism, this client has deep and rapid respirations with fruity/acetone smell (Kussmaul respirations) in an attempt to reduce carbon dioxide levels by inducing a respiratory alkalosis to partially compensate for the ketoacidosis, which has nearly normalized the pH. Educational objective:The arterial blood gas result most consistent with the diagnosis of diabetic ketoacidosis is metabolic acidosis or partially compensated metabolic acidosis (pH ≤7.30 and HCO3 ≤18 mEq/L [18 mmol/L]). Respiratory compensation may raise pH to near-normal values, but the PCO2 will be dramatically lower than normal (PCO2 ≤30 mm Hg [4.0 kPa]).

The student nurse observes the respiratory therapist (RT) preparing to draw an arterial blood gas from the radial artery. The RT performs the Allen's test and the student asks why this test performed before the blood sample is drawn. Which statement made by the RT is most accurate? 1. "The Allen's test is done to determine if capillary refill is adequate." 2. "The Allen's test is done to determine if the radial pulse is palpable." 3. "The Allen's test is done to determine the patency of the ulnar artery." 4. "The Allen's test is done to determine the presence of a neurologic deficit."

3. "The Allen's test is done to determine the patency of the ulnar artery." The radial artery site at the wrist is preferred for collecting an arterial blood gas sample because it is near the surface, is easy to palpate and stabilize, and has good collateral supply from the ulnar artery. The patency of the ulnar artery can be confirmed with a positive modified Allen's test. The modified Allen's test includes the following steps: Instruct the client to make a tight fist (if possible) Occlude the radial and ulnar arteries using firm pressure Instruct the client to open the fist; the palm will be white if both arteries are sufficiently occluded Release the pressure on the ulnar artery; the palm should turn pink within 15 seconds as circulation is restored to the hand, indicating patency of the ulnar artery (positive Allen's test) If the Allen's test is positive, the arterial blood gas can be drawn; if negative and the palm does not return to a pink color, an alternate site (eg, brachial artery, femoral artery) must be used. Educational objective:The radial artery site at the wrist is preferred for collecting an arterial blood gas sample because it is near the surface, easy to palpate and stabilize, and has good collateral supply from the ulnar artery. The patency of the ulnar artery must be confirmed by performing a modified Allen's test to assure adequate circulation to the hand before proceeding with the arterial blood gas collection.

The nurse is caring for a client with surgical complications who requires continuous total parenteral nutrition (TPN). The nurse assists the health care provider with the insertion of a subclavian triple lumen central venous access device. What is the nurse's priority action before initiating the TPN infusion? 1. Attach a filter to the IV tubing 2. Check baseline fingerstick glucose levels 3. Check the results of the portable chest x-ray 4. Program the electronic infusion pump

3. Check the results of the portable chest x-ray The priority action after placing a subclavian central venous catheter is to check the results of the chest x-ray to ensure that the catheter tip is placed correctly in the superior vena cava. Obtain verification before using the catheter as perforation of the visceral pleura can occur during insertion and lead to an iatrogenic pneumothorax or hemothorax. Although these complications are rare, due to the use of ultrasound to guide insertion, if present, the TPN would infuse into the pleural space. Educational objective:Incorrect placement of a subclavian central venous catheter can result in an iatrogenic pneumothorax or hemothorax. The priority is to check the results of the chest x-ray to verify that the catheter tip has been placed correctly in the superior vena cava. Other appropriate actions include attaching a filter to the IV tubing, monitoring baseline and fingerstick BG levels every 6 hours, and programming the electronic infusion device to ensure an accurate and consistent hourly infusion rate.

The nurse is caring for a client with sepsis and acute respiratory failure who was intubated and prescribed mechanical ventilation 3 days ago. The nurse assesses for which adverse effect associated with the administration of positive pressure ventilation (PPV)? 1. Dehydration 2. Hypokalemia 3. Hypotension 4. Increased cardiac output

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

A client undergoing endotracheal intubation received IV sedation and succinylcholine. Shortly after respiratory status has been stabilized, the client becomes flushed and profusely diaphoretic and has a rigid jaw. Which medication should the nurse prepare to administer? Click the exhibit button for more information. Vital signs Temperature105 F (40.6 C) Blood pressure140/90 mm Hg Heart rate150/min Respirations28/minO2 saturation98% 1. IM epinephrine 2. IV atropine 3. IV dantrolene 4. IV glucagon

3. IV dantrolene Malignant hyperthermia (MH) is a rare and life-threatening condition precipitated by certain medications used for anesthesia, including inhaled anesthetics (eg, desflurane, isoflurane, halothane) and succinylcholine (a paralytic used adjunctively for intubation and general anesthesia). Skeletal muscles become unable to control calcium levels, leading to a hypermetabolic state manifested by contracture and increased temperature. Early signs of MH include tachypnea, tachycardia, and a rigid jaw or generalized rigidity. As the condition progresses, the client develops a high fever. Muscle tissue is broken down, leading to hyperkalemia, cardiac dysrhythmias, and myoglobinuria. MH requires emergent treatment with IV dantrolene to reverse the process by slowing metabolism. Succinylcholine should be discontinued. Other interventions include applying cooling blankets to reduce temperature and treating high potassium levels. Educational objective: Malignant hyperthermia is a life-threatening hypermetabolic condition triggered by certain drugs used for general anesthesia. Prompt administration of IV dantrolene is critical. Other interventions include cooling the client and treating high potassium levels.

The nurse is caring for a client with an implantable cardioverter defibrillator (ICD). The client goes into ventricular tachycardia and is pulseless. The ICD has fired twice. What action should the nurse take? 1. Administer epinephrine 1 mg IV push 2. Deactivate the ICD with a magnet 3. Initiate chest compressions 4. Take no action and let the ICD work

3. Initiate chest compressions tion Explanation: The client with an ICD that is firing is receiving electrical shocks from the internal defibrillator to interrupt the dysrhythmia. It is still imperative that the client receive chest compressions in the form of cardiopulmonary resuscitation (CPR) to provide circulation of blood to the vital organs. The nurse should implement the pulseless arrest algorithm, allowing 30-60 seconds for the ICD to complete its therapy cycle before applying external defibrillation pads/paddles. Educational objective:The ICD is designed to defibrillate potentially life-threatening dysrhythmias. Although the device is able to sense electrical activity of the heart and respond, it is unable to sense or treat pulselessness. CPR should be initiated in the pulseless client with an ICD.

To obtain accurate continuous blood pressure readings via a radial arterial catheter, the nurse places the air-filled interface of the stopcock at the phlebostatic axis. Where is it located? 1. Angle of Louis at 2nd intercostal space (ICS) to left of sternal border 2. Aortic area at 2nd ICS to right of sternal borde 3. Level of atria at 4th ICS, ½ anterior-posterior (AP) diameter 4. 5th ICS at mid clavicular line (MCL)

3. Level of atria at 4th ICS, ½ anterior-posterior (AP) diameter To measure pressures accurately using continual arterial and/or pulmonary artery pressure monitoring, the zeroing stopcock of the transducer system must be placed at the phlebostatic axis. This anatomical location, with the client in the supine position, is at the 4th ICS, at the midway point of the AP diameter (½ AP)of the chest wall. If the transducer is placed too low, the reading will be falsely high; if placed too high, the reading will be falsely low. This concept is similar to the positioning of the arm in relation to the level of the heart when measuring blood pressure indirectly using a sphygmomanometer or noninvasive blood pressure-monitoring device. The upper arm should be at the level of the phlebostatic axis. Educational objective:The anatomical location of the phlebostatic axis is the 4th ICS, at the midway point of the AP diameter (½ AP) of the chest wall. The stopcock nearest the transducer is placed here to assure accurate pressure measurements.

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

3. Nasal drainage on gauze has a red spot surrounded by serous fluid Cerebrospinal fluid (CSF) rhinorrhea (or CSF otorrhea) can confirm that a skull fracture has occurred and transversed the dura. If the drainage is clear, dextrose testing can determine if it is CSF. However, the presence of blood would make this test unreliable as blood also contains glucose. In this case, the halo/ring test should be performed by adding a few drops of the blood-tinged fluid to gauze and assessing for the characteristic pattern of coagulated blood surrounded by CSF. Identification of this pattern is very important as CSF leakage places the client at risk for infection. The client's nose should not be packed. No nasogastric or oral gastric tube should be inserted blindly when a basilar skull fracture is suspected as there is a risk of penetrating the skull through the fracture site and having the tube ascend into the brain. These tubes are placed under fluoroscopic guidance in clients with such fractures. Educational objective:A nasogastric tube should not be inserted when a basilar skull fracture is suspected. CSF leakage is an indication of this and can be evidenced by a positive halo/ring test of the blood-tinged nasal drainage (coagulated blood surrounded by CSF).

The nurse is caring for a client who was just resuscitated following an out-of-hospital cardiac arrest. The client does not follow commands and remains comatose. What intervention does the nurse anticipate being added to the client's plan of care? 1. Assisting the health care provider in discussing a do-not-resuscitate order with the family 2. Obtaining equipment and cold fluids for induction of therapeutic hypothermia 3. Placing a small-bore nasogastric feeding tube for enteral nutrition 4. Planning for passive range-of-motion exercises to prevent contractures

3. Placing a small-bore nasogastric feeding tube for enteral nutrition Neurologic injury is the most common cause of mortality in clients who have had cardiac arrest, particularly ventricular fibrillation or pulseless ventricular tachycardia. Inducing therapeutic hypothermia in these clients within 6 hours of arrest and maintaining it for 24 hours has been shown to decrease mortality rates and improve neurologic outcomes. It is indicated in all clients who are comatose or do not follow commands after resuscitation. The client is cooled to 89.6-93.2 F (32-34 C) for 24 hours before rewarming. Cooling is accomplished by cooling blankets; ice placed in the groin, axillae, and sides of the neck; and cold IV fluids. The nurse must closely assess the cardiac monitor (bradycardia is common), core body temperature, blood pressure (mean arterial pressure to be kept >80 mm Hg), and skin for thermal injury. The nurse must also apply neuroprotective strategies such as keeping the head of the bed elevated to 30 degrees. After 24 hours, the client is slowly rewarmed. Educational objective:Following return of spontaneous circulation in an out-of-hospital cardiac arrest, therapeutic hypothermia should be implemented for 24 hours in clients who are comatose or do not follow commands. Therapeutic hypothermia has been shown to improve neurologic outcomes and decrease mortality in these clients.

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

3. Prepare intubation and suction supplies at the bedside Gastric lavage (GL) is performed through an orogastric tube to remove ingested toxins and irrigate the stomach. GL is rarely performed as it is associated with a high risk of complications (eg, aspiration, esophageal or gastric perforation, dysrhythmias). GL is only indicated if the overdose is potentially lethal and if GL can be initiated within one hour of the overdose. Activated charcoal administration is the standard treatment for overdose, but it is ineffective for some drugs (eg, lithium, iron, alcohol). Intubation and suction supplies should always be available at the bedside during GL in case the client develops aspiration or respiratory distress (Option 3). Educational objective:Gastric lavage is used to remove ingested toxins and irrigate the stomach after a drug overdose. It should be initiated within one hour of overdose. The nurse should position the client to prevent aspiration and have emergency respiratory equipment at the bedside.

A registered nurse is precepting a new nurse in the intensive care unit. The client is sedated with propofol, on a mechanical ventilator, and is receiving enteral feeding via nasogastric tube. The new nurse performs interventions to prevent aspiration. The preceptor should intervene if the new nurse performs which of the following actions? 1. Assesses gastric residual volumes every 4 hours 2. Measures the number of centimeters the feeding tube is secured at the nare every 4 hours 3. Requests that the physician change the client from continual to bolus feedings 4. Uses a sedation scale to titrate down the sedation (if possible)

3. Requests that the physician change the client from continual to bolus feedings Critically ill clients are at increased risk for aspiration of oropharyngeal secretions and gastric content. It is common in clients who are intubated, sedated, on a mechanical ventilator, and receiving enteral feedings. The nurse must provide nursing interventions to prevent aspiration and monitor for its signs and symptoms. Clients are at increased risk when receiving bolus rather than continual enteral feedings. Bolus feedings should be avoided in critically ill clients, who are already at increased risk for aspiration. (Option 1) Assessing gastric residual volumes according to institution policy (at least every 4 hours) is standard for clients receiving continual enteral feedings. Increased volumes may indicate poor absorption and increase the risk of regurgitation and aspiration. Educational objective:Assessing gastric residual volumes and level of sedation at regular intervals, checking enteral feeding tube placement, and administering continual rather than bolus tube feeding are interventions that help prevent aspiration in critically ill high-risk clients.

The nurse is caring for a client with a pulmonary contusion. Assessment reveals restlessness, chest pain on inspiration, diminished breath sounds, and oxygen saturation of 86%. Which acid-base imbalance does the nurse correctly identify?Laboratory results pH7.31 PaO276 mm Hg (10.11 kPa) PaCO254 mm Hg (7.18 kPa) HCO3⁻24 mEq/L (24 mmol/L) 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

3. Respiratory acidosis

The nurse in the intensive care unit is caring for a client who is postoperative from a cardiac surgery. The client has a mediastinal chest tube. During assessment, the nurse notes bubbling in the suction control chamber. Which nursing action is appropriate? 1. Assess the insertion site for presence of subcutaneous emphysema 2. Notify the surgeon of a large air leak 3. Take no action as the chest tube is functioning appropriately 4. Turn down the wall suction until the bubbling disappears

3. Take no action as the chest tube is functioning appropriately Gentle, continuous bubbling in the suction control chamber (section A) of a chest tube drainage unit indicates that suction is present and the unit is functioning appropriately. The nurse should document the finding and continue to monitor. Educational objective:Gentle, continuous bubbling in the suction control chamber of a chest tube drainage unit indicates the presence of suction in the system and is an expected finding.

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

4. Jaw-thrust maneuver in the supine position on a backboard Clinical situations involving trauma should follow ABC: Airway, Breathing, and Circulation. Airway assessment is particularly critical in clients with injuries to the head, neck, and upper back. Injury to the upper back should be treated as spinal trauma until the client has been cleared by an Advanced Trauma Life Support-qualified health care provider. Until the spine is appropriately assessed, the client should be placed on a backboard and stabilized. The nurse should use the jaw-thrust maneuver to avoid movement of an unstable spine. One provider should stabilize the cervical vertebra allowing the second provider to articulate the jaw independently of the spinal column. Educational objective:If there is any suspicion of spinal injury, the jaw-thrust maneuver should be used for airway assessment to avoid any shifting of unstable vertebrae and subsequent spinal cord damage.

A nurse is caring for a client on a mechanical ventilator. The ventilator is sounding an alarm and displaying an alert about low tidal volumes. The nurse has checked all connections and the endotracheal tube, but the alarm persists and the client's oxygen saturation is dropping. What should the nurse do next? 1. Call the respiratory therapist to the bedside to troubleshoot 2. Elevate the head of the bed and apply a nonrebreather mask 3. Increase the oxygen delivery on the ventilator to 100% 4. Manually ventilate with a resuscitation bag device attached to the endotracheal tube

4. Manually ventilate with a resuscitation bag device attached to the endotracheal tube A low tidal volume alarm indicates that the volume of air the ventilator is delivering is lower than the set volume. This is most often due to a disconnection, loose connection, or leak in the circuit. The nurse should troubleshoot the most common causes of the alarm, but if the client's condition is deteriorating clinically (eg, decreasing oxygen saturation), then the nurse should disconnect the ventilator and manually ventilate the client's lungs with a resuscitation bag device at 10-15 L/min oxygen until the ventilator alarm state can be resolved. Educational objective:Ventilators may sound an alarm when set parameters are not being met (eg, low tidal volumes, high peak pressures). These alarms may indicate a client condition or ventilator malfunction. If a ventilator alarm cannot be readily resolved, the nurse should manually ventilate the client's lungs with a resuscitation bag device.

A 75-year-old client is hospitalized with chronic obstructive pulmonary disease (COPD) exacerbation. The health care provider (HCP) initiates noninvasive positive airway pressure ventilation (NIPPV) with a bilevel positive airway pressure (BIPAP) device. Prescribed medications are shown in the exhibit. Which parameter is most important for the nurse to monitor frequently in this client? Click on the exhibit button for additional information. 1. Blood glucose level 2. Capillary refill time 3. Extremity swelling 4. Mental status

4. Mental status Educational objective:In a client with COPD exacerbation, it is most important for the nurse to monitor mental status frequently and report changes such as restlessness, decreased level of consciousness, somnolence, difficult arousal, and confusion to the HCP. These signs may indicate increased CO2 retention and worsening hypercapnia, which would necessitate an immediate change in therapy.

A nurse in the intensive care unit is caring for a client in the immediate postoperative period following abdominal surgery. The nurse receives several prescriptions. Which prescription should the nurse initiate first? Click on the exhibit button for additional information. 1. Acetaminophen 1000 mg IVPB every 8 hours 2. Cefazolin 2 g IVPB once, now 3. Norepinephrine 0.02-2.0 mcg/kg/min titrated IV 4. Normal saline 2 L via rapid IV bolus

4. Normal saline 2 L via rapid IV bolus Educational objective:Hypotension, tachycardia, and decreased central venous pressure (normal: 2-8 mm Hg) may indicate hypovolemic shock. IV boluses of isotonic fluids (ie, fluid resuscitation) increase intravascular volume, which increases blood pressure and perfusion

The charge nurse is evaluating the skills of a new registered nurse (RN) assigned to care for a client with shock. Which action taken by the new RN indicates a need for further education? 1. Administers furosemide to a client with pulmonary artery wedge pressure (PAWP) of 24 mm Hg with cardiogenic shock 2. Increases norepinephrine infusion rate to maintain mean arterial pressure (MAP) >65 mm Hg in a client with anaphylactic shock 3. Moves pulse oximeter sensor from the finger to the forehead of a client with septic shock 4. Places the head of the bed (HOB) for a client with hypovolemic shock in high Fowler's position

4. Places the head of the bed (HOB) for a client with hypovolemic shock in high Fowler's position The nurse manager would intervene when the new RN places the HOB of a client with hypovolemic shock in high Fowler's (90 degrees) position. Raising the HOB causes blood pressure to decrease, especially in a client with hypovolemic shock and inadequate circulating vascular volume. Educational objective:Norepinephrine is a vasopressor used to increase stroke volume, cardiac output, and MAP. MAP should be maintained at >65 mm Hg in septic or anaphylactic shock. Furosemide is an appropriate drug to decrease left ventricular preload in a client in cardiogenic shock. Normal PAWP is 6-12 mm Hg.

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

4. Provides defibrillator shock Educational objective: Asystole is characterized by a total absence of ventricular electrical activity. The client is pulseless, apneic, and unresponsive. Treatment includes CPR, oxygenated ventilation, and advanced cardiovascular life-support measures (eg, epinephrine IV, advanced airway). Defibrillation is not effective for treatment of asystole or pulseless electrical activity.

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

4. Providing compressions at a rate of at least 80-100/min The primary goal of cardiopulmonary resuscitation (CPR) is adequate perfusion to the brain and vital organs. High-quality chest compressions for adults are at least 2 in (5 cm) deep to adequately pump blood but no more than 2.4 in (6 cm) deep to prevent unnecessary client injury (Option 1). The chest should recoil completely after each compression to allow complete refilling of the heart chambers, which promotes effective perfusion. Educational objective:For high-quality adult cardiopulmonary resuscitation, compressions should be in the center of the chest; at a rate of 100-120/min; and at least 2 in (5 cm) but no more than 2.4 in (6 cm) deep for adequate perfusion without unnecessary client injury. Compression interruption should be minimized (eg, 30 compressions to 2 rescue breaths).

The flight nurse assesses an alert and oriented client at an industrial accident scene who was impaled in the abdomen by a pair of scissors. Which nursing action is the immediate priority on arrival at the scene? 1. Insert a large-bore IV line and infuse normal saline 2. Obtain blood for type and crossmatch and hemoglobin 3. Remove constrictive clothing to enhance circulation 4. Stabilize the scissors with sterile bulky dressings

4. Stabilize the scissors with sterile bulky dressings A sharp object that pierces the skin and lodges in the body may result in penetrating trauma to nearby tissue and organs. Common types of impaled (embedded) objects include bullets or blast fragments from firearms as well as sharp objects such as scissors, nails, or knives. The embedded object creates a puncture wound and then controls potential bleeding by putting pressure on the wound. First responders should not manipulate or remove the impaled object. Manipulation or removal may cause further trauma and bleeding; therefore, stabilization of the object is the first priority to prevent it from moving during initial client assessment (Option 4) and later during transport to a health care facility where skilled trauma care is available. Exception to the rule: First responders (EMS providers) may remove the impaled object if it obstructs the airway and prevents effective cardiopulmonary resuscitation.

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

4. Rate and depth of respirations Guillain-Barré syndrome (GBS) is an acute, immune-mediated polyneuropathy that is most often accompanied by ascending muscle paralysis and absence of reflexes. Lower-extremity weakness progresses over hours to days to involve the thorax, arms, and cranial nerves (CNs). Neuromuscular respiratory failure is the most life-threatening complication. The rate and depth of the respirations should be monitored (Option 4). Measurement of serial bedside forced vital capacity (spirometry) is the gold standard for assessing early ventilation failure. Educational objective:The most serious complication to monitor for in new-onset Guillain-Barré syndrome is respiratory compromise from the paralysis ascending into the thoracic region. Monitoring for rate/depth of respirations and measuring serial bedside vital capacity (spirometry) help to detect this early in the disease course.

Which would be the appropriate client criteria for activating a rapid response team at the hospital? Select all that apply. 1. Glasgow coma scale (GCS) score of 9 throughout shift 2. Heart rate remaining at 58 beats/min for more than 1 hour 3. Postoperative pain rated at 10 4. Respiratory rate maintaining an increase to 30 breaths/min 5. Sustained change in level of consciousness for 10 minutes

4. Respiratory rate maintaining an increase to 30 breaths/min 5. Sustained change in level of consciousness for 10 minutes The rapid response team is activated to marshal additional experienced and specialized resources for an acute need to try to prevent a client from deterioration into a code/arrest situation. The team has critical care expertise to provide immediate attention to unstable clients in noncritical care units and usually consists of a respiratory therapist, a critical care nurse, and a physician or advanced practice registered nurse. Recommended criteria to consider according to the Institute for Healthcare Improvement include the following: Any provider worried about the client's condition OR An acute change in any of the following:Heart rate <40 or >130/minSystolic blood pressure <90 mm HgRespiratory rate <8 or >28/min (Option 4)Oxygen saturation <90 despite oxygenUrine output <50 mL/4 hrLevel of consciousness (Option 5) Educational objective:Rapid response criteria for unstable clients in a nonacute care setting usually include sudden, significant changes that do not respond to treatment.