Chapter 65: Critical Care questions

The central venous oxygen saturation (ScvO2) is decreasing in a patient who has severe pancreatitis. To determine the possible cause of the decreased ScvO2, the nurse assesses the patient's a. lipase. b. temperature. c. urinary output. d.body mass index.

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

3. While close family members are visiting, a patient has a respiratory arrest, and resuscitation is started. Which action by the nurse is best? a. Tell the family members that watching the resuscitation will be very stressful. b. Ask family members if they wish to remain in the room during the resuscitation. c. Take the family members quickly out of the patient room and remain with them. d. Assign a staff member to wait with family members just outside the patient room.

ANS: B Evidence indicates that many family members want the option of remaining in the room during procedures such as cardiopulmonary resuscitation (CPR) and that this decreases anxiety and facilitates grieving. The other options may be appropriate if the family decides not to remain with the patient. DIF: Cognitive Level: Analyze (analysis) REF: 1558 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

6. The intensive care unit (ICU) nurse educator determines that teaching a new staff nurse about arterial pressure monitoring has been effective when the nurse a. balances and calibrates the monitoring equipment every 2 hours. b. positions the zero-reference stopcock line level with the phlebostatic axis. c. ensures that the patient is supine with the head of the bed flat for all readings. d. rechecks the location of the phlebostatic axis with changes in the patient's position.

ANS: B For accurate measurement of pressures, the zero-reference level should be at the phlebostatic axis. There is no need to rebalance and recalibrate monitoring equipment every 2 hours. Accurate hemodynamic readings are possible with the patient's head raised to 45 degrees or in the prone position. The anatomic position of the phlebostatic axis does not change when patients are repositioned. DIF: Cognitive Level: Apply (application) REF: 1560 TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment

24. The nurse is caring for a patient receiving a continuous norepinephrine IV infusion. Which patient assessment finding indicates that the infusion rate may need to be adjusted? a. Heart rate is slow at 58 beats/min. b. Mean arterial pressure (MAP) is 56 mm Hg. c. Systemic vascular resistance (SVR) is elevated. d. Pulmonary artery wedge pressure (PAWP) is low.

ANS: C Vasoconstrictors such as norepinephrine will increase SVR, and this will increase the work of the heart and decrease peripheral perfusion. The infusion rate may need to be decreased. Bradycardia, hypotension (MAP of 56 mm Hg), and low PAWP are not associated with norepinephrine infusion. DIF: Cognitive Level: Apply (application) REF: 1560 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

9. Which nursing action is needed when preparing to assist with the insertion of a pulmonary artery catheter? a. Determine if the cardiac troponin level is elevated. b. Auscultate heart sounds before and during insertion. c. Place the patient on NPO status before the procedure. d. Attach cardiac monitoring leads before the procedure.

ANS: D Dysrhythmias can occur as the catheter is floated through the right atrium and ventricle, and it is important for the nurse to monitor for these during insertion. Pulmonary artery catheter insertion does not require anesthesia, and the patient will not need to be NPO. Changes in cardiac troponin or heart and breath sounds are not expected during pulmonary artery catheter insertion. DIF: Cognitive Level: Apply (application) REF: 1564 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

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, 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 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.

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

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.

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 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, 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

LEWIS: End of Chapter Questions Critical Care 1. Certification in critical care nursing (CCRN) by the American Association of Critical-Care Nurses indicates that the nurse. a. is an advanced practice nurse who cares for acutely and critically ill patients. b. may practice independently to provide symptom management for the critically ill. c. has earned a master's degree in the field of advanced acute and critical care nursing. d. has practiced in critical care and successfully completed a test of critical care knowledge.

1. Correct answer: d Rationale: Certification in critical care nursing (CCRN) by the American Association of Critical-Care Nurses requires registered nurse licensure, practice experience in critical or progressive care nursing, and successful completion of a written test.

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

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

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.

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

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

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

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

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

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 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

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

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 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

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

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%

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 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

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

2. What are the appropriate nursing interventions for the patient with delirium in the ICU (select all that apply)> a. Use clocks and calendars to maintain orientation. b. Encourage round-the-clock presence of caregivers at the bedside. c. Silence all alarms reduce overhead paging, and avoid conversations around the patient. d. Sedate the patient with appropriate drugs to protect the patient from harmful behaviors. e. Identify physiologic factors that may be contributing to the patient's confusion and irritibility.

2. Correct answers: a, d, e Rationale: The use of clocks and calendars can help orient the patient with delirium in the intensive care unit (ICU). If the patient demonstrates hyperactivity, insomnia, or delusions, management with neuroleptic drugs (e.g., dexmed¬etomidine [Precedex]) may be considered. Physical conditions such as hemodynamic instability, hypoxemia, hypercarbia, electrolyte disturbances, and severe infections can precipitate delirium.

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

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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

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 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

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

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

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

3. The critical care nurse recognizes that an ideal plan for caregiver involvement includes: a. a caregiver at the bedside at all times. b. allowing caregivers at the bedside at preset, brief intervals c. and individually devised plan to involve caregivers with care and comfort measures. d. restriction of visiting in the ICU because the environment is overwhelming to caregivers

3. Correct answer: c Rationale: An individualized plan of care should be developed for each patient and the caregivers. Caregivers should be allowed to assist with care and comfort measures in the ICU if desired.

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

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

4. Correct answer: c Rationale: Referencing means positioning the transducer so that the zero reference point is at the level of the atria of the heart. The stopcock nearest the transducer is usually the zero reference for the transducer. To place this reference level with the atria, use an external landmark: the phlebostatic axis. The phlebostatic axis is the intersection between the fourth intercostal space at the sternum and the midpoint between the anterior and posterior aspects of the chest wall. Position the port of the stopcock nearest the transducer level with the phlebostatic axis.

Question 2 of 14 Which hematologic problem significantly increases the risks associated with pulmonary artery (PA) catheter insertion? A. Leukocytosis B. Hypovolemia C. Hemolytic anemia D. Thrombocytopenia

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

Question 10 of 14 A 70-yr-old patient in the intensive care unit (ICU) has become agitated and inattentive since his heart surgery. The nurse knows that ICU delirium frequently occurs in individuals with preexisting dementia, history of alcohol abuse, and severe disease. What interventions should the nurse provide to improve the patient's cognition (select all that apply.)? Select all that apply. A. Improve oxygenation. B. Initiate early mobilization. C. Provide a small amount of beer. D. Have the family stay with the patient. E. Enable the patient to sleep on a schedule with dim lights. F. Encourage conversation in the patient's room to help reorient.

A B D E ICU delirium is common in ICU patients. Improving oxygenation, enabling the patient to sleep, early mobilization, and decreasing sensory overload along with orientation is all helpful in improving the patient's cognition. The beer may or may not be allowed for this patient, and the nurse should not assume that it will help. Having a family member stay with the patient to reorient the patient is helpful, but the family group may increase sensory overload with conversations not involving the patient. INCORRECT--> Encourage conversation in the patient's room to help reorient.

A client receiving a transfusion of packed red blood cells begins to vomit. The client's blood pressure is 90/50 mm Hg from a baseline of 125/78 mm Hg. The client's temperature is 100.8 ° F orally from a baseline of 99.2 ° F. The nurse determines that the client may be experiencing which complication of a blood transfusion? A. Septicemia B. Hyperkalemia C. Circulatory overload D. Delayed transfusion reaction

A. Septicemia occurs with the transfusion of blood contaminated with microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, and the development of shock

COMPLETION 1. A patient's vital signs are pulse 90, respirations 24, and BP 128/64 mm Hg, and cardiac output is 4.7 L/min. The patient's stroke volume is _____ mL. (Round to the nearest whole number.)

ANS: 52 Stroke volume = Cardiac output/heart rate 52 mL = (4.7 L x 1000 mL/L)/90 DIF: Cognitive Level: Understand (comprehension) REF: 1559 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

11. Which assessment finding obtained by the nurse when caring for a patient with a right radial arterial line indicates a need for the nurse to take action? a. The right hand feels cooler than the left hand. b. The mean arterial pressure (MAP) is 77 mm Hg. c. The system is delivering 3 mL of flush solution per hour. d. The flush bag and tubing were last changed 2 days previously.

ANS: A The change in temperature of the right hand suggests that blood flow to the right hand is impaired. The flush system needs to be changed every 96 hours. A mean arterial pressure (MAP) of 75 mm Hg is normal. Flush systems for hemodynamic monitoring are set up to deliver 3 to 6 mL/hr of flush solution. DIF: Cognitive Level: Apply (application) REF: 1565 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

25. When evaluating a patient with a central venous catheter, the nurse observes that the insertion site is red and tender to touch and the patient's temperature is 101.8° F. What should the nurse plan to do? a. Discontinue the catheter and culture the tip. b. Use the catheter only for fluid administration. c. Change the flush system and monitor the site. d. Check the site more frequently for any swelling.

ANS: A The information indicates that the patient has a local and systemic infection caused by the catheter, and the catheter should be discontinued to avoid further complications such as endocarditis. Changing the flush system, continued monitoring, or using the line for fluids will not help prevent or treat the infection. DIF: Cognitive Level: Apply (application) REF: 1562 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

4. After surgery for an abdominal aortic aneurysm, a patient's central venous pressure (CVP) monitor indicates low pressures. Which action should the nurse take? a. Administer IV diuretic medications. b. Increase the IV fluid infusion per protocol. c. Increase the infusion rate of IV vasodilators. d. Elevate the head of the patient's bed to 45 degrees.

ANS: B A low CVP indicates hypovolemia and a need for an increase in the infusion rate. Diuretic administration will contribute to hypovolemia and elevation of the head or increasing vasodilators may decrease cerebral perfusion. DIF: Cognitive Level: Apply (application) REF: 1564 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

1. A patient who has been in the intensive care unit for 4 days has disturbed sensory perception from sleep deprivation. Which action should the nurse include in the plan of care? a. Administer prescribed sedatives or opioids at bedtime to promote sleep. b. Cluster nursing activities so that the patient has uninterrupted rest periods. c. Silence the alarms on the cardiac monitors to allow 30- to 40-minute naps. d. Eliminate assessments between 2200 and 0600 to allow uninterrupted sleep.

ANS: B Clustering nursing activities and providing uninterrupted rest periods will minimize sleep-cycle disruption. Sedative and opioid medications tend to decrease the amount of rapid eye movement (REM) sleep and can contribute to sleep disturbance and disturbed sensory perception. Silencing the alarms on the cardiac monitors would be unsafe in a critically ill patient, as would discontinuing all assessments during the night. DIF: Cognitive Level: Apply (application) REF: 1556 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

12. The central venous oxygen saturation (ScvO2) is decreasing in a patient who has severe pancreatitis. To determine the possible cause of the decreased ScvO2, the nurse assesses the patient's a. lipase level. b. temperature. c. urinary output. d. body mass index.

ANS: B Elevated temperature increases metabolic demands and O2 use by tissues, resulting in a drop in O2 saturation of central venous blood. Information about the patient's body mass index, urinary output, and lipase will not help in determining the cause of the patient's drop in ScvO2. DIF: Cognitive Level: Apply (application) REF: 1565 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

28. The nurse is caring for a patient who has an arterial catheter in the left radial artery for arterial pressure-based cardiac output (APCO) monitoring. Which information obtained by the nurse requires a report to the health care provider? a. The patient has a positive Allen test result. b. There is redness at the catheter insertion site. c. The mean arterial pressure (MAP) is 86 mm Hg. d. The dicrotic notch is visible in the arterial waveform.

ANS: B Redness at the catheter insertion site indicates possible infection. The Allen test is performed before arterial line insertion, and a positive test result indicates normal ulnar artery perfusion. A MAP of 86 mm Hg is normal, and the dicrotic notch is normally present on the arterial waveform. DIF: Cognitive Level: Apply (application) REF: 1562 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

2. Which hemodynamic parameter best reflects the effectiveness of drugs that the nurse gives to reduce a patient's left ventricular afterload? a. Mean arterial pressure (MAP) b. Systemic vascular resistance (SVR) c. Pulmonary vascular resistance (PVR) d. Pulmonary artery wedge pressure (PAWP)

ANS: B SVR reflects the resistance to ventricular ejection, or afterload. The other parameters may be monitored but do not reflect afterload as directly. DIF: Cognitive Level: Apply (application) REF: 1560 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

26. An 81-yr-old patient who has been in the intensive care unit (ICU) for a week is now stable and transfer to the progressive care unit is planned. On rounds, the nurse notices that the patient has new onset confusion. The nurse will plan to a. give PRN lorazepam (Ativan) and cancel the transfer. b. inform the receiving nurse and then transfer the patient. c. notify the health care provider and postpone the transfer. d. obtain an order for restraints as needed and transfer the patient.

ANS: B The patient's history and symptoms most likely indicate delirium associated with the sleep deprivation and sensory overload in the ICU environment. Informing the receiving nurse and transferring the patient is appropriate. Postponing the transfer is likely to prolong the delirium. Benzodiazepines and restraints contribute to delirium and agitation. DIF: Cognitive Level: Apply (application) REF: 1557 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

27. The family members of a patient who has been admitted to the intensive care unit (ICU) with multiple traumatic injuries have just arrived in the ICU waiting room. Which action should the nurse take first? a. Explain ICU visitation policies and encourage family visits. b. Escort the family from the waiting room to the patient's bedside. c. Describe the patient's injuries and the care that is being provided. d. Invite the family to participate in an interprofessional care conference.

ANS: C Lack of information is a major source of anxiety for family members and should be addressed first. Family members should be prepared for the patient's appearance and the ICU environment before visiting the patient for the first time. ICU visiting should be individualized to each patient and family rather than being dictated by rigid visitation policies. Inviting the family to participate in a multidisciplinary conference is appropriate but should not be the initial action by the nurse. DIF: Cognitive Level: Analyze (analysis) REF: 1558 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

5. When caring for a patient with pulmonary hypertension, which parameter will the nurse use to directly evaluate the effectiveness of the treatment? a. Central venous pressure (CVP) b. Systemic vascular resistance (SVR) c. Pulmonary vascular resistance (PVR) d. Pulmonary artery wedge pressure (PAWP)

ANS: C PVR is a major contributor to pulmonary hypertension, and a decrease would indicate that pulmonary hypertension was improving. The other parameters may also be monitored but do not directly assess for pulmonary hypertension. DIF: Cognitive Level: Apply (application) REF: 1560 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

8. Which action should the nurse take when the low pressure alarm sounds for a patient who has an arterial line in the left radial artery? a. Fast flush the arterial line. b. Check the left hand for pallor. c. Assess for cardiac dysrhythmias. d. Re-zero the monitoring equipment.

ANS: C The low pressure alarm indicates a drop in the patient's blood pressure, which may be caused by cardiac dysrhythmias. There is no indication to re-zero the equipment. Pallor of the left hand would be caused by occlusion of the radial artery by the arterial catheter, not by low pressure. There is no indication of a need for flushing the line. DIF: Cognitive Level: Apply (application) REF: 1564 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

7. When monitoring the effectiveness of treatment for a patient with a large anterior wall myocardial infarction, the most pertinent measurement for the nurse to obtain is a. central venous pressure (CVP). b. systemic vascular resistance (SVR). c. pulmonary vascular resistance (PVR). d. pulmonary artery wedge pressure (PAWP).

ANS: D PAWP reflects left ventricular end diastolic pressure (or left ventricular preload) and is a sensitive indicator of cardiac function. Because the patient is high risk for left ventricular failure, the PAWP must be monitored. An increase will indicate left ventricular failure. The other values would also provide useful information, but the most definitive measurement of changes in cardiac function is the PAWP. DIF: Cognitive Level: Apply (application) REF: 1563 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

10. While assisting with the placement of a pulmonary artery (PA) catheter, the nurse notes that the catheter is correctly placed when the balloon is inflated and the monitor shows a a. typical PA pressure waveform. b. tracing of the systemic arterial pressure. c. tracing of the systemic vascular resistance. d. typical PA wedge pressure (PAWP) tracing.

ANS: D The purpose of a PA line is to measure PAWP, so the catheter is floated through the pulmonary artery until the dilated balloon wedges in a distal branch of the pulmonary artery, and the PAWP readings are available. After insertion, the balloon is deflated and the PA waveform will be observed. Systemic arterial pressures are obtained using an arterial line, and the systemic vascular resistance is a calculated value, not a waveform. DIF: Cognitive Level: Understand (comprehension) REF: 1564 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Question 1 of 14 A 64-yr-old male patient admitted to the critical care unit for gastrointestinal hemorrhage complains of feeling tense and nervous. He appears restless with increased blood pressure and pulse. If the physical assessment shows no other changes, it is most important for the critical care nurse to take which action? A. Administer prescribed IV dose of lorazepam (Ativan). B. Stay with the patient and encourage expression of concerns. C. Ask a family member to remain at the bedside with the patient. D. Teach the patient how to use guided imagery to reduce anxiety.

B. Stay with the patient and encourage expression of concerns. Anxiety is a common problem for critically ill patients. The nurse should first stay with the patient and encourage the patient to express concerns and needs. After expression of feelings, the nurse should determine the appropriate intervention if needed (e.g., lorazepam, guided imagery, family presence). In addition, staying with the patient will allow the nurse to continue to assess for physiologic changes associated with recurrent gastrointestinal bleeding. INCORRECT-->Administer prescribed IV dose of lorazepam (Ativan).

Question 5 of 14 The nurse is caring for a 34-yr-old woman with acute decompensated heart failure who has a pulmonary artery catheter. Which assessment indicates the patient's condition is improving? A. Cardiac output (CO) is 3.5 L/min. B. Central venous pressure (CVP) is 10 mm Hg. C. Pulmonary artery wedge pressure (PAWP) is 10 mm Hg. D. Systemic vascular resistance (SVR) is 1500 dynes/sec/cm-5.

C. Pulmonary artery wedge pressure (PAWP) is 10 mm Hg. PAWP is the most sensitive indicator of cardiac function and fluid volume status. Normal range for PAWP is 6 to 12 mm Hg. PAWP is increased in heart failure. Normal range for CVP is 2 to 8 mm Hg. An elevated CVP indicates right-sided heart failure or volume overload. CO is decreased in heart failure. Normal cardiac output is 4 to 8 L/minute. SVR is increased in left-sided heart failure. Normal SVR is 800 to 1200 dynes/sec/cm-5. INCORRECT-->Cardiac output (CO) is 3.5 L/min.

The critical care nurse recognizes that an ideal plan for caregiver involvement includes A. allowing caregivers at the bedside at preset, brief intervals. B. a caregiver at the bedside at all times. C. restriction of visiting in the ICU because the environment is overwhelming to caregivers. D. an individually devised plan to involve caregivers with care and comfort measures.

D. An individually devised plan to involve caregivers with care and comfort measures. Rationale: An individualized plan of care should be developed for each patient and the caregivers. Caregivers should be allowed to assist with care and comfort measures in the ICU if desired.

Question 6 of 14 The nurse is caring for a 55-yr-old man who has a catheter in the right radial artery for invasive arterial blood pressure monitoring after abdominal aortic aneurysm surgery. Which observation by the nurse would require an emergency intervention? A. Arterial pressure bag is inflated to 250 mm Hg. B. Calculated mean arterial pressure is 74 mm Hg. C. Patient's head of bed elevation is at 30 degrees. D. Capillary refill time in the right hand is 5 seconds.

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