COMPLEX 2021 - Chapter 65 Critical Care

The nurse is caring for a patient who has an intraaortic balloon pump (IABP) after a massive heart attack. The nurse notices blood backing up into the IABP catheter. In which order should the nurse take the following actions? a. Confirm that the IABP console has turned off. b. Assess the patient's vital signs and orientation. c. Obtain supplies for insertion of a new IABP catheter. d. Notify the health care provider of the IABP malfunction.

ANS: A, B, D, C Blood in the IABP catheter indicates a possible tear in the balloon. The console should shut off automatically to prevent complications such as air embolism. Next, the nurse will assess the patient and communicate with the health care provider about the patient's assessment and the IABP problem. Finally, supplies for insertion of a new IABP catheter may be needed based on the patient assessment and the decision of the health care provider.

In which order will the nurse take these actions when assisting with oral intubation of a patient in respiratory distress? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Obtain a portable chest-x-ray. b. Position the patient in the supine position. c. Inflate the cuff of the endotracheal tube after insertion. d. Attach an end-tidal CO2 detector to the endotracheal tube. e. Oxygenate the patient with a bag-valve-mask device for several minutes.

ANS: E, B, C, D, A The patient is preoxygenated with a bag-valve-mask system for 3 to 5 minutes before intubation and then placed in a supine position. After the intubation, the cuff on the endotracheal tube is inflated to occlude and protect the airway. Tube placement is assessed first with an end-tidal CO2 sensor and then with chest x-ray examination.

Which finding by the nurse caring for a patient with a right radial arterial line indicates a need for the nurse to take immediate 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 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.

A patient with respiratory failure has arterial pressure-based cardiac output (APCO) monitoring and is receiving mechanical ventilation with peak end-expiratory pressure (PEEP) of 12 cm H2O. Which information indicates that a change in the ventilator settings may be required? a. The arterial pressure is 90/46. b. The heart rate is 58 beats/min. c. The stroke volume is increased. d. The stroke volume variation is 12%.

ANS: A The hypotension suggests that the high intrathoracic pressure caused by the PEEP may be decreasing venous return and (potentially) cardiac output. The other assessment data would not be a direct result of PEEP and mechanical ventilation.

The nurse observes that the patient's central venous catheter insertion site is red and tender to touch. 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.

A patient who is orally intubated and receiving mechanical ventilation is anxious and is "fighting" the ventilator. Which action should the nurse take next? a. Verbally coach the patient to breathe with the ventilator. b. Sedate the patient with the ordered PRN lorazepam (Ativan). c. Manually ventilate the patient with a bag-valve-mask device. d. Increase the rate for the ordered propofol (Diprivan) infusion.

ANS: A The initial response by the nurse should be to try to decrease the patient's anxiety by coaching the patient about how to coordinate respirations with the ventilator. The other actions may also be helpful if the verbal coaching is ineffective in reducing the patient's anxiety.

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

ANS: A The low pressure alarm indicates a drop in the patient's blood pressure, which may be caused by 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.

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.

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.

The central venous oxygen saturation (ScvO2) is decreasing in a patient who has severe pancreatitis. What would the nurse assess to determine the possible cause of the decreased ScvO2? 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.

What is the best initial action by the nurse to verify the correct placement of an oral endotracheal tube (ET) after insertion? a. Obtain a portable chest x-ray. b. Use an end-tidal CO2 monitor. c. Auscultate for bilateral breath sounds. d. Observe for symmetrical chest movement.

ANS: B End-tidal CO2 monitors are currently recommended for rapid verification of ET placement. Auscultation for bilateral breath sounds and checking chest expansion are also used, but they are not as accurate as end-tidal CO2 monitoring. A chest x-ray confirms the placement but is done after the tube is secured.

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.

What action by a new intensive care unit staff nurse would indicate that the nurse educator's teaching about arterial pressure monitoring has been effective? 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.

The nurse is caring for a patient who has an intraaortic balloon pump in place. Which action should be included in the plan of care? a. Avoid the use of anticoagulant medications. b. Measure the patient's urinary output every hour. c. Provide passive range of motion for all extremities. d. Position the patient supine with head flat at all times.

ANS: B Monitoring urine output will help determine whether the patient's cardiac output has improved. It also will help monitor for balloon displacement blocking the renal arteries. The head of the bed can be elevated up to 30 degrees. Heparin is used to prevent thrombus formation. Limited movement is allowed for the extremity with the balloon insertion site to prevent displacement of the balloon.

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.

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.

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. What should the nurse plan to do? 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.

The nurse educator is evaluating the performance of a new registered nurse (RN) who is providing care to a patient receiving mechanical ventilation with 15 cm H2O of peak end-expiratory pressure (PEEP). Which action indicates that the new RN is safe? a. The RN plans to suction the patient every 1 to 2 hours. b. The RN uses a closed-suction technique to suction the patient. c. The RN changes the ventilator circuit tubing routinely every 48 hours. d. The RN tapes the connection between the ventilator tubing and the ET.

ANS: B The closed-suction technique is used when patients require high levels of PEEP (>10 cm H2O) to prevent the loss of PEEP that occurs when disconnecting the patient from the ventilator. Suctioning should not be scheduled routinely, but it should be done only when patient assessment data indicate the need for suctioning. Taping connections between the ET and ventilator tubing would restrict the ability of the tubing to swivel in response to patient repositioning. Ventilator tubing changes increase the risk for ventilator-associated pneumonia and are not indicated routinely.

An intraaortic balloon pump (IABP) is being used for a patient who is in cardiogenic shock. Which data indicate to the nurse that the goals of treatment with the IABP are being met? a. Urine output of 25 mL/hr b. Heart rate of 110 beats/min c. Cardiac output (CO) of 5 L/min d. Stroke volume (SV) of 40 mL/beat

ANS: C A CO of 5 L/min is normal and indicates that the IABP has been successful in treating the shock. The low SV signifies continued cardiogenic shock. The tachycardia and low urine output also suggest continued cardiogenic shock.

The nurse notes thick, white secretions in the endotracheal tube (ET) of a patient who is receiving mechanical ventilation. Which intervention will most directly treat this finding? a. Reposition the patient every 1 to 2 hours. b. Increase suctioning frequency to every hour. c. Add additional water to the patient's enteral feedings. d. Instill 5 mL of sterile saline into the ET before suctioning.

ANS: C Because the patient's secretions are thick, better hydration is indicated. Suctioning every hour without any specific evidence for the need will increase the incidence of mucosal trauma and would not address the etiology of the ineffective airway clearance. Instillation of saline does not liquefy secretions and may decrease the SpO2. Repositioning the patient is appropriate but will not decrease the thickness of secretions.

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.

Which finding by the nurse should result in postponing the spontaneous breathing trial for a patient receiving positive pressure ventilation? a. Enteral nutrition is being given through an orogastric tube. b. Scattered rhonchi are heard when auscultating breath sounds. c. New ST segment elevation is observed on the cardiac monitor. d. Hydromorphone (Dilaudid) is being used to treat postoperative pain.

ANS: C Myocardial ischemia is a contraindication for ventilator weaning. The ST segment elevation is an indication that weaning should be postponed until further investigation and/or treatment for myocardial ischemia can be done. Ventilator weaning can proceed when opioids are used for pain management, abnormal lung sounds are present, or enteral nutrition is being delivered.

The nurse is weaning a 68-kg patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation. Which finding indicates that the weaning protocol should be stopped? a. The patient's heart rate is 97 beats/min. b. The patient's oxygen saturation is 93%. c. The patient respiratory rate is 32 breaths/min. d. The patient's spontaneous tidal volume is 450 mL.

ANS: C Tachypnea is a sign that the patient's work of breathing is too high to allow weaning to proceed. The patient's heart rate is within normal limits, but the nurse should continue to monitor it. An O2 saturation of 93% is acceptable for a patient with COPD. A spontaneous tidal volume of 450 mL is within the acceptable range.

After change-of-shift report on a ventilator weaning unit, which patient should the nurse assess first? a. Patient who failed a spontaneous breathing trial and has been placed in a rest mode on the ventilator b. Patient who is intubated and has continuous partial pressure end-tidal CO2 (PETCO2) monitoring c. Patient who was successfully weaned and extubated 4 hours ago and has no urine output for the last 6 hours d. Patient with a central venous O2 saturation (ScvO2) of 69% while on bilevel positive airway pressure (BiPAP)

ANS: C The decreased urine output may indicate acute kidney injury or that the patient's cardiac output and perfusion of vital organs have decreased. Any of these causes would require rapid action. The data about the other patients indicate that their conditions are stable and do not require immediate assessment or changes in their care. Continuous PETCO2 monitoring is frequently used when patients are intubated. The rest mode should be used to allow patient recovery after a failed SBT. A ScvO2 of 69% is within normal limits.

Which assessment finding by the nurse caring for a patient receiving mechanical ventilation indicates the need for suctioning? a. The patient was last suctioned 6 hours ago. b. The patient's oxygen saturation drops to 93%. c. The patient's respiratory rate is 32 breaths/min. d. The patient has occasional audible expiratory wheezes.

ANS: C The increase in respiratory rate indicates that the patient may have decreased airway clearance and requires suctioning. Suctioning is done when patient assessment data indicate that it is needed and not on a scheduled basis. Occasional expiratory wheezes do not indicate poor airway clearance. Suctioning the patient may induce bronchospasm and increase wheezing. An O2 saturation of 93% is acceptable and does not suggest that immediate suctioning is needed.

While waiting for heart transplantation, a patient with severe cardiomyopathy has a ventricular assist device (VAD) implanted. What should the nurse anticipate when planning care for this patient? a. Preparing the patient for a permanent VAD b. Teaching the patient the reason for bed rest c. Monitoring the incision for signs of infection d. Administering immunosuppressants medications

ANS: C The insertion site for the VAD provides a source for transmission of infection to the circulatory system and requires frequent monitoring. Patients with VADs can have some mobility and may not be on bed rest. The VAD is a bridge to transplantation, not a permanent device. Immunosuppression is not necessary for nonbiologic devices such as the VAD.

The nurse notes that a patient's endotracheal tube (ET), which was at the 22-cm mark, is now at the 25-cm mark, and the patient is anxious and restless. Which action should the nurse take next? a. Check the O2 saturation. b. Offer reassurance to the patient. c. Listen to the patient's breath sounds. d. Notify the patient's health care provider.

ANS: C The nurse should first determine whether the ET tube has been displaced into the right mainstem bronchus by listening for unilateral breath sounds. If so, assistance will be needed to reposition the tube immediately. The other actions are also appropriate, but detection and correction of tube malposition are the most critical actions.

The nurse is caring for a patient receiving a continuous norepinephrine IV infusion. Which 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. 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.

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.

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.

The nurse notes premature ventricular contractions (PVCs) while suctioning a patient's endotracheal tube. Which next action by the nurse is indicated? a. Plan to suction the patient more frequently. b. Decrease the suction pressure to 80 mm Hg. c. Give antidysrhythmic medications per protocol. d. Stop and ventilate the patient with 100% oxygen.

ANS: D Dysrhythmias during suctioning may indicate hypoxemia or sympathetic nervous system stimulation. The nurse should stop suctioning and ventilate the patient with 100% O2. There is no indication that more frequent suctioning is needed. Lowering the suction pressure will decrease the effectiveness of suctioning without improving the hypoxemia. Because the PVCs occurred during suctioning, there is no need for antidysrhythmic medications (which may have adverse effects) unless they recur when the suctioning is stopped, and patient is well oxygenated.

The nurse is caring for a patient with a subarachnoid hemorrhage who is intubated and placed on a mechanical ventilator with 10 cm H2O of peak end-expiratory pressure (PEEP). What new finding indicates that the nurse needs to notify the health care provider immediately? a. O2 saturation of 93% b. Respirations of 20 breaths/min c. Green nasogastric tube drainage d. Increased jugular venous distention

ANS: D Increases in jugular venous distention in a patient with a subarachnoid hemorrhage may indicate an increase in intracranial pressure (ICP) and that the PEEP setting is too high for this patient. A respiratory rate of 20, O2 saturation of 93%, and green nasogastric tube drainage are within normal limits.

When monitoring the effectiveness of treatment for a patient with a large anterior wall myocardial infarction, what is the most pertinent measurement for the nurse to obtain? 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.

The charge nurse is evaluating the care that a new registered nurse (RN) provides to a patient receiving mechanical ventilation. Which action by the new RN indicates the need for more education? a. The RN increases the FIO2 to 100% before suctioning. b. The RN secures a bite block in place using adhesive tape. c. The RN asks for assistance to resecure the endotracheal tube. d. The RN positions the patient with the head of bed at 10 degrees.

ANS: D The head of the patient's bed should be positioned at 30 to 45 degrees to prevent ventilator-associated pneumonia. The other actions by the new RN are appropriate.

How should the nurse maintain proper cuff pressure of an endotracheal tube (ET) when the patient is on mechanical ventilation? a. Inflate the cuff with a minimum of 10 mL of air. b. Inflate the cuff until the pilot balloon is firm on palpation. c. Inject air into the cuff until a manometer shows 15 mm Hg pressure. d. Inject air into the cuff until a slight leak is heard only at peak inflation.

ANS: D The minimal occluding volume technique involves injecting air into the cuff until an air leak is present only at peak inflation. The volume to inflate the cuff varies with the ET and the patient's size. Cuff pressure should be maintained at 20 to 25 mm Hg. An accurate assessment of cuff pressure cannot be obtained by palpating the pilot balloon.

The nurse responding to a ventilator alarm finds the patient lying in bed gasping and the endotracheal tube on the floor. Which action should the nurse take next? a. Activate the rapid response team. b. Provide reassurance to the patient. c. Call the health care provider to reinsert the tube. d. Manually ventilate the patient with 100% oxygen.

ANS: D The nurse should ensure maximal patient oxygenation by manually ventilating with a bag-valve-mask system. Offering reassurance to the patient, notifying the health care provider about the need to reinsert the tube, and activating the rapid response team are also appropriate after the nurse has stabilized the patient's oxygenation.

After change-of-shift report, which patient should the progressive care nurse assess first? a. Patient who was extubated this morning and has a temperature of 101.4° F (38.6°C). b. Patient with bilevel positive airway pressure (BiPAP) for obstructive sleep apnea and a respiratory rate of 16. c. Patient with arterial pressure monitoring who is 2 hours post-percutaneous coronary intervention and needs to void. d. Patient who is receiving IV heparin for a venous thromboembolism and has a partial thromboplastin time (PTT) of 101 seconds.

ANS: D The patient the nurse must assess first has a high risk for bleeding from an elevated (nontherapeutic) PTT. The nurse needs to adjust the rate of the infusion (dose) per the health care provider's parameters. The patient with BiPAP for sleep apnea has a normal respiratory rate. The patient recovering from the percutaneous coronary intervention will need to be assisted with voiding and this task could be delegated to unlicensed assistive personnel. The patient with a fever may be developing ventilator-associated pneumonia but addressing the bleeding risk is a higher priority.

Four hours after mechanical ventilation is initiated, a patient's arterial blood gas (ABG) results include a pH of 7.51, PaO2 of 82 mm Hg, PaCO2 of 26 mm Hg, and HCO3 ?2-of 23 mEq/L (23 mmol/L). What change should the nurse anticipate to the ventilator settings? a. Increase the FIO2. b. Increase the tidal volume. c. Increase the respiratory rate. d. Decrease the respiratory rate.

ANS: D The patient's PaCO2 and pH indicate respiratory alkalosis caused by too high a respiratory rate. The PaO2 is appropriate for a patient with COPD and increasing the respiratory rate and tidal volume would further lower the PaCO2.

The nurse is assisting with the placement of a pulmonary artery (PA) catheter. What would the nurse expect to see on the monitor as an indication that the catheter with inflated balloon is placed correctly? 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.

When providing care for a patient requiring hemodynamic stability monitoring, which clinical manifestations would the nurse associate with the patient being hemodynamically unstable? Select all that apply. 1 Diarrhea 2 Absent bowel sounds 3 High body temperature 4 Reduced urinary output 5 Tiredness and exhaustion

Absent bowel sounds Reduced urinary output Tiredness and exhaustion The patient with diminished perfusion to the gastrointestinal (GI) tract may develop hypoactive or absent bowel sounds. Monitoring urine output is a method used to determine the adequacy of perfusion to the kidneys. Reduced urinary output indicates hemodynamic instability. The patient may be tired and exhausted if there is too little cardiac reserve to sustain even minimal activity. Diarrhea and high body temperature are not indications of hemodynamic instability.

When the health care prescriber determines that a patient with ventricular failure caused by a myocardial infarction needs a ventricular assist device (VAD), which actions would the nurse implement to prepare the patient? Begin preoperative preparation per protocol. Explain that this is an outpatient procedure to the patient. Schedule the procedure to occur within the next two weeks. Determine which laboratory personnel will insert the device.

Begin preoperative preparation per protocol. Direct cannulation of the atria and great vessels occurs in the operating room through a sternotomy; therefore the nurse begins preoperative preparation when the provider determines the need for a VAD. The patient has ventricular failure caused by a myocardial infarction and discharge for the procedure as an outpatient is not a viable option. The procedure entails a sternotomy in the operating room, not in a laboratory. The patient is acutely ill and not expected to wait several weeks for implantation of the device.

When orienting the patient's significant other to all the equipment, which explanation would the nurse use to explain the function of a transducer? Helps to locate the phlebostatic axis Transmits electronic signal as a pressure wave Converts pressure waves into an electronic signal Changes zero-reference point to atmospheric pressure

Converts pressure waves into an electronic signal The transducer takes pressure waves from catheters and converts them into an electronic signal displayed on the monitor from which the nurse collects readings. The transducer does not help to locate the phlebostatic axis; the nurse uses this landmark to level the transducer to the atria. The transducer does not transmit electronic signals as pressure waves; this is the opposite of a transducer's function. The transducer does not change zero reference point to atmospheric pressure. Zero-reference point is a landmark.

For the patient with an increasing afterload, which hemodynamic parameter would the nurse expect to reflect the afterload status? Decreased heart rate Decreased cardiac output Decreased BP Decreased carbon dioxide level

Decreased cardiac output Increased afterload often results in a decreased cardiac output. Decreasing afterload will reduce the heart rate and BP. Increased afterload increases oxygen needs of the heart. Increased afterload does not directly affect carbon dioxide level, which would affect the carbon dioxide level. The patient's respiratory status would determine carbon dioxide level.

For the patient on the intensive care unit (ICU), which condition would the nurse associate with a loss of recent memory, restlessness, lethargy, and daytime sleepiness with nighttime agitation? Pain Anxiety Delirium ICU psychosis

Delirium A patient in the ICU who is experiencing symptoms of loss of recent memory, restlessness, lethargy, and daytime sleepiness with nighttime agitation is likely suffering from delirium. Pain and anxiety may occur in the patient in the ICU and should be immediately addressed, but the symptoms described do not relate to either of these. ICU psychosis is a form of delirium marked by a break with reality.

For the patient receiving continuous arterial BP monitoring, which actions would the nurse implement to avoid thrombus formation and maintain line patency? Select all that apply. 1 Ensure that the flush bag contains a sufficient amount of fluid. 2 Change the pressure tubing to the flush bag every five hours. 3 Ensure the flush system is delivering a minimum of 3 to 6 mL/hr. 4 Ensure inflation of the flush system's pressure bag is 300 mm Hg. 5 Assess neurovascular status distal to insertion site every four hours.

Ensure that the flush bag contains a sufficient amount of fluid Ensure the flush system is delivering a minimum of 3 to 6 mL/hr. Ensure inflation of the flush system's pressure bag is 300 mm Hg. To maintain line patency and limit thrombus formation, assess the continuous flush system every one to four hours to determine the flush bag contains fluid for continuous flushing. The flush system should deliver 3 to 6 mL/hr for effective prevention of thrombus formation. The nurse should also ensure inflation of the pressure bag of the flush system is 300 mm Hg. Changing of the pressure tubing occurs approximately every 96 hours. The nurse should assess the neurovascular status distal to the insertion site every hour, not every four hours.

When determining a patient's phlebostatic axis to balance a pressure monitoring device, which landmarks would the nurse use to identify the axis? Midaxillary line and 4th intercostal space Midaxillary line and 2nd intercostal space Anterior chest wall and 5th intercostal space Posterior chest wall and 4th intercostal space

Midaxillary line and 4th intercostal space To determine the phlebostatic axis, the nurse should draw an imaginary horizontal line down from the axilla, midway between the anterior and posterior chest walls and an imaginary vertical line laterally through the fourth intercostal space along the chest wall. The phlebostatic axis is the intersection of the two imaginary lines. When identifying the landmarks for the phlebostatic axis, the nurse would not use the 2nd and 5th intercostal spaces, or anterior and posterior chest walls.

When the nurse, performing a dynamic response test, observes the depicted tracing, which response would the nurse implement? Flush the line. Reconfirm zeroing. No action is required. Reposition the wrist.

No action is required. The nurse would perform a dynamic response test every 8 to 12 hours, as well as when the system is opened to air or the accuracy of the measurements is questioned. The test involves activating the fast flush and checking that the equipment reproduces a distortion-free signal. A square wave indicates a normal response and requires no further action. This waveform does not indicate a need to flush the line, nor does the nurse need to reconfirm the waveform to indicate zero, nor does the wrist need repositioning.

Suspecting that a patient with an arterial invasive device has a catheter-related infection, which action would the nurse implement? 1 Conduct a dynamic response test. 2 Administer an antipyretic as prescribed. 3 Apply warm soaks to the catheter insertion site. 4 Notify the health care provider and prepare for reinsertion.

Notify the health care provider and prepare for reinsertion. If suspecting an infection, the nurse should notify the provider and remove the catheter and replace all equipment. Because the nurse does not insert or remove an arterial line, the nurse should notify the health care provider about the infection and then prepare for reinsertion by obtaining and preparing new equipment. A suspected catheter-related infection does not indicate the need for a dynamic response test. There is no evidence that the patient has a temperature elevation, so the nurse would not administer an antipyretic at this time. After removal of the infected catheter, warm soaks may be applicable.

When a patient with an arterial invasive device has a capillary refill of five seconds, which action would the nurse implement immediately? Elevate the limb on a pillow. Soak the hand in warm water. Notify the health care provider. Perform passive range of motion to the limb.

Notify the health care provider. Normal capillary refill is three seconds. A refill time of five seconds indicates compromised arterial flow, which is an emergency. The nurse should contact the health care provider immediately. Elevating the limb on a pillow may further compromise arterial blood flow. Soaking the hand in warm water will not improve arterial blood flow. Passive range of motion to the limb with the arterial line would be contraindicated because this could cause the catheter to dislodge.

After assisting with the insertion of a pulmonary artery catheter (PAC) via the patient's internal jugular vein, which action would the nurse implement prior to infusing prescribed fluids? 1 Evaluate current electrolyte levels. 2 Obtain a 12-lead electrocardiogram. 3 Draw a hemoglobin level for the PAC. 4 Obtain anterior and posterior chest x-ray.

Obtain anterior and posterior chest x-ray. After insertion and before using the PAC, the nurse would ensure completion of a chest x-ray to confirm the catheter's position. The nurse would not need a hemoglobin level before using the catheter for fluid administration. Electrolyte levels do not need evaluation before using the catheter for fluid administration. The nurse would not need a 12-lead electrocardiogram before using the catheter for fluid administration.

When determining a patient's stroke volume, which three concepts would the nurse identify? Heart rate, preload, and afterload Preload, afterload, and contractility Heart rate, preload, and contractility BP, afterload, and contractility

Preload, afterload, and contractility Preload, afterload, and contractility are three determinants of stroke volume. Preload is the amount of blood in the ventricle at the end of diastole. Afterload describes the forces opposing ventricular ejection, including systemic arterial pressure, the resistance of the aortic valve, and mass and density of blood to be moved. Contractility is the strength of the heart's contraction. Heart rate influences cardiac output but not stroke volume directly. BP is too broad of a term when referring to what influences stroke volume.

For the patient requiring monitoring after removal of a pulmonary arterial catheter (PAC), which clinical manifestation eliminated the need for impedance cardiography (ICG)? 1 Pulse deficit of 8 beats/minute 2 BP 198/120 mm Hg 3 Presence of generalized edema 4 Distant lung sounds in both bases

Presence of generalized edema Distant lung sounds in both bases The provider/nurse would not use ICG on patients who have generalized edema or third spacing because the excess volume interferes with accurate signals. This measuring approach is not contraindicated in cases of hypertension. Use the ICG measuring approach for early signs of pulmonary dysfunction, which could be occurring with distant lung sounds in both bases. Utilize this measuring approach for early signs of cardiac dysfunction, which could be occurring with a pulse deficit of 8 beats/minute.

When attempting to determine a patient's peripheral vascular resistance (PVR), which hemodynamic parameters would the nurse use? Systolic and diastolic BPs Stroke volume (SV) and right ventricular ejection fraction (RVEF) Mean arterial pressure (MAP), central venous pressure (CVP), and cardiac output (CO) Pulmonary artery mean pressure (PAMP), pulmonary artery wedge pressure (PAWP), and CO

Pulmonary artery mean pressure (PAMP), pulmonary artery wedge pressure (PAWP), and CO Calculate the PVR using the PAMP minus the PAWP, multiplying by 80 and dividing by the CO. Determine the MAP with systolic and diastolic BPs. Use SV and RVEF to determine right ventricular end-diastolic volume (RVEDV). Use the MAP, CVP, and CO to determine systemic vascular resistance (SVR).

For new admission on the intensive care unit (ICU), which patient condition would the nurse anticipate the need for intubation with an endotracheal tube (ET)? Select all that apply. The patient has a risk of aspiration. The patient has respiratory distress. The patient has a high risk of stroke. The patient has a fracture of the humerus. The patient has an upper airway obstruction.

The patient has a risk of aspiration. The patient has respiratory distress. The patient has an upper airway obstruction. Intubation occurs in cases where the person cannot breathe and ventilate normally. Indications for ET intubation include high risk of aspiration, respiratory distress, and upper airway obstruction. Being a high-risk patient for stroke is not an indication for intubation unless there is respiratory distress. Potential intubation occurs in bilateral femur fracture if there is massive bleeding. Humerus fracture does not involve considerable bleeding; therefore, in these cases, the patient does not require insertion of an ET.

When admitting a patient who is post cardiac arrest and receiving therapeutic hypothermia along with a paralytic agent, which explanation would the nurse associate with the patient's assessment data? The patient is beginning to shiver. An unwarranted change in ventilator settings occurred. The nurse used a bag-valve-mask device during the arrest. Decreased oxygen delivery occurred during transfer to the intensive care unit (ICU) setting.

The patient is beginning to shiver. The patient is beginning to shiver. When utilizing a paralytic, piloerection, a sign of shivering, may be the only clinical manifestation indicating shivering. Shivering increases the metabolic demand, oxygen consumption, and may lead to a decrease in ScvO2. Normal ScvO2 is 60% to 80%. A change in ventilator settings did not cause the decrease because the oxygen increased. Bagging utilizes 100% oxygen, so the use of a bag-valve-mask device during the arrest did not cause the decrease in ScvO2. The health care team should not have allowed a decreased oxygen delivery during transfer to the ICU setting and is not a plausible answer.

When the nurse evaluates a patient receiving intraaortic balloon pump (IABP) therapy, which finding would indicate that the pump is improving the patient's health status? Select all that apply. 1 Warm and dry skin 2 Urine output 50 mL/hr 3 Breath sounds clear bilaterally 4 BP 168/88 mm Hg 5 Oriented to person, place, and time 6 Development of hypoactive bowel sounds

Warm and dry skin Urine output 50 mL/hr Breath sounds clear bilaterally Oriented to person, place, and time Hemodynamic effects of IABP therapy include increased stroke volume leading to warm skin and increased urine output. The decrease in afterload improves breath sounds. Improved stroke volume also improves mentation. The pump has no direct effect on BP regulation. Hypoactive bowel sounds indicate decreased perfusion of the gastrointestinal system.

Which factors would the nurse consider when determining the patient's stroke volume (SV)? 1 The patient's preload, afterload, and contractility 2 The patient's cardiac output, heart rate, and body surface area 3 The patient's afterload, cardiac output, and mean arterial pressure 4 The patient's cardiac index, mean arterial pressure, and BP

1 The patient's preload, afterload, and contractility Preload, afterload, and contractility determine SV. Use the cardiac output and heart rate to determine stroke volume; however, body surface area assists to determine the cardiac index. Use the mean arterial pressure to determine afterload, not stroke volume. Cardiac index is a more precise measurement of the efficiency of the heart's pumping action and is not used to determine stroke volume.

In which order would the nurse perform the steps to obtain a patient's BP via an arterial line? 1. Document the pressures. 2. Verify the reference point of zero. 3. Perform a dynamic response test. 4. Review the process with the patient. 5. Place the patient in the flat supine position. 6. Analyze the pressures per the printout.

1. Review the process with the patient. 2.Place the patient in the flat supine position. 3.Verify the reference point of zero. 4.Perform a dynamic response test. 5.Analyze the pressures per the printout. 6.Document the pressures. When obtaining a BP measurement with an invasive line, the nurse should first explain the procedure to the patient. Then the patient is to be positioned supine and flat. The nurse should confirm the zero-reference point next, then perform a dynamic response text. The nurse should then perform an analysis of the tracing printout for the pressures. The last step is to document the pressures.

When the patient's BP is 172/94 mm Hg, which value would be the patient's mean arterial pressure (MAP)? 1 80 2 100 3 120 4 160

120 Calculate the MAP by adding the systolic BP to two times the diastolic BP and dividing by three. For this patient, that calculation would be 172 + 2(94)/3 = 120 mm Hg. Normal MAP is between 70 mm and 105 mm Hg.

Which finding would the nurse identify as the rationale for a patient's intraaortic balloon pump (IABP) to automatically shut off? 1 Occlusion of the renal arteries 2 Blood backed up into the catheter 3 Head of the bed at a 60-degree angle 4 Obstruction in a lower extremity vessel

2 Blood backed up into the catheter If the balloon develops a leak, then the pump will automatically stop. Signs of a leak include blood backing up into the catheter. Occlusion of the renal arteries will cause a reduction in urine output but will not cause the IABP to automatically turn off. Elevating the head of the bed greater than 45 degrees could cause arterial trauma but will not cause the IABP to automatically turn off. A thromboembolism may cause an obstruction in a lower extremity vessel, but this condition will not cause the IABP to automatically turn off.

Which action would the nurse implement when a patient's invasive BP measuring device reflects a reading significantly higher than the one measured two hours ago? 1 Flush the line and recheck. 2 Raise the head of the bed. 3 Check transducer placement. 4 Perform a dynamic response test.

3 Check transducer placement. The nurse should check the placement of the transducer because transducers placed lower than the phlebostatic axis will produce falsely high readings. The line does not need require flushing. Raising the head of the bed will not correct the falsely elevated reading. Performing a dynamic-response test may be necessary if moving the transducer continues to produce falsely elevated readings.

For the patient receiving intraaortic balloon pump (IABP) therapy, which part of the electrocardiogram (ECG) would the nurse expect the balloon inflation? 1 P wave 2 Q wave 3 R wave 4 T wave

4 T wave The ECG is the trigger for the pump to start inflation on the T wave. Deflation occurs on the upstroke of the R wave (of the QRS) complex. The P and Q waves do not trigger the pump to either inflate or deflate.

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.)

52 Stroke volume = Cardiac output/heart rate 52 mL = (4.7 L 1000 mL/L)/90

When monitoring patients on the intensive care unit (ICU), which central venous oxygen saturation (ScvO2/SvO2) reading would the nurse report to the health care provider immediately? 68% 54% 72% 78%

54 % Normal ScvO2/SvO2 is 60% to 80%. The diagnostic 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. The nurse should report the 54% immediately to the health provider, as this value means that the patient has a decrease in oxygen supply and an increased demand, requiring an immediate intervention. Values of 68%, 72%, and 78% are within the normal range.

After explaining intraaortic balloon pump (IABP) therapy to the family of a patient with an acute mitral valve dysfunction, which statement indicates that a family member understood the nurse's teachings? "The pump inflates when the heart is resting between beats." "The pump increases the heart rate to provide the body oxygen." "The pump causes extra blood to be kept in the heart after each beat." "The pump inflates when the heart is ejecting blood into the body system."

"The pump inflates when the heart is resting between beats." IABP therapy is known as counterpulsation because the timing of balloon inflation is opposite to ventricular contraction. The pump inflates during diastole or when the heart is resting between beats. The pump decreases rather than increases the heart rate. The pump reduces rather than increases the amount of afterload, or the amount of blood remaining in the heart after each beat. The pump deflates rather than inflates during systole, or when the heart is ejecting blood into the body system.

When the certified critical care registered nurse (CCRN), precepting a novice nurse on the critical care unit (CCU), teaches the role of critical care nursing, which statement would the preceptor utilize? "We care for patients with acute problems who are stable." "We care for patients with chronic problems who are stable." "We care for patients with acute problems who are unstable." "We care for patients with chronic problems who are unstable."

"We care for patients with acute problems who are unstable." Critical care nurses provide care for patients with acute problems who are unstable. Stable patients with acute problems receive their care on a medical-surgical unit, not the CCU. Patients with chronic problems receive their care in the community setting. Unstable patients with chronic problems may require care in a rehabilitation or medical-surgical setting.

Which value reflects the patient's cardiac output (CO) when heart rate (HR) is 68 beats/min and the stroke volume (SV) is 100 mL/beat? 1 6.8 L/min 2 2.4 L/min 3 9.2 L/min 4 10.3 L/min

1 6.8 L/min Calculate the patient's CO by multiplying SV by HR. For this patient, the nurse should multiply 100 mL/beat x 68 beats/min = 6800 mL/min or 6.8 L/min. A normal cardiac output is between 4 and 8 L/min.

When the patient has the pictured hemodynamic monitoring device, which port would the nurse use to measure a pulmonary artery (PA) pressure? 1 A 2 B 3 C 4 D

1 A The distal lumen port (catheter tip), labelled A in the image, is within the pulmonary artery and is used to monitor PA pressure. Choice B is the port used for infusions. Choice C is the port used for injecting medications. Choice D is the port used to inflate the balloon.

To calculate a patient's cardiac output (CO) when the stroke volume is 60 mL and the heart rate is 70 beats/minute, the nurse would use the formula: CO = stroke volume × heart rate. Which value would the nurse document as the patient's CO? 1 4.2 L 2 6.8 L 3 14.5 L 4 22.16 L

4.2 L

When monitoring a patient's blood oxygen saturation (SpO2) levels, which range of values would the nurse associate with the normal saturation pressure of oxygen? 80% to 85% 85% to 90% 90% to 95% 95% to 100%

95% to 100% Pulse oximetry is a noninvasive and continuous method of determining the oxygen saturation of the blood. Monitoring SpO2 may reduce the frequency of arterial blood gas (ABG) sampling. SpO2 is normally 95% to 100%. A value less than that, such as 80%, 85%, or 90%, may indicate hypoperfusion.

For the patient receiving intraaortic balloon pump (IABP) therapy, which clinical manifestation would the nurse identify as the development of a therapy complication? 1 Cool, dry skin 2 Increased thirst 3 +1 pedal edema 4 Absent bowel sounds

Absent bowel sounds Movement of the balloon can block the mesenteric arteries, which can result in reduced or absent bowel sounds. Cool, dry skin, increased thirst, and +1 pedal edema are not complications of IABP therapy.

When assigning rooms for new admissions, which patients would the nurse place on the intensive care unit (ICU)? Select all that apply. An 82-year-old patient with respiratory failure A 27-year-old patient with diabetic ketoacidosis A 76-year-old patient with congestive heart failure A 15-year-old patient with a urinary tract infection A 58-year-old patient who underwent a bowel resection

An 82-year-old patient with respiratory failure A 27-year-old patient with diabetic ketoacidosis A 76-year-old patient with congestive heart failure Patients who have a high risk of life-threatening conditions should receive treatment in the ICU. Therefore admit the patient with diabetic ketoacidosis, congestive heart failure, or respiratory failure to the ICU for further medical management. The medical unit can safely manage the patient who underwent bowel resection without complications. The medical unit is able to safely manage the patient with a urinary tract infection.

When a patient with severe left ventricular failure considers artificial heart transplantation, which information would the nurse provide the patient as a long-term treatment requirement? β-blockers Anticoagulation Antibiotic therapy Immunosuppressive agents

Anticoagulation Patients require lifelong anticoagulation with an artificial heart. The device does not require patient use of β-blockers, antibiotic therapy, or immunosuppressive agents.

To ensure the safety of the patient with an implanted ventricular assist device (VAD) being prepared for discharge, of which intervention would the nurse verify completion prior to the patient leaving the hospital? Home care referral initiated Diet and activity teaching completed Battery charger available in the home Oxygen condenser delivered to the home

Battery charger available in the home In some cases, patients with VADs may go home. Preparation for discharge is complex and requires in-depth teaching about the device and the need to have a battery charger in the home. A home care referral can occur after the patient discharge, although this is not optimal. Diet and activity teaching should occur before the patient's discharge; however, this is not directly related to the safety and functioning of the device. There is no information to suggest that the patient requires or is prescribed oxygen therapy at home.

For the patient in which the nurse has difficulty obtaining an accurate oxygen saturation of hemoglobin (SpO2) measurement, which clinical manifestation would the nurse consider rational? 1 Body temperature 95.4° F 2 Reception of a cardiac glycoside 3 BP of 118/72 mm Hg 4 Heart rate of 72 beats/minute with occasional ectopy

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

When reviewing the electronic medical record of a patient scheduled for insertion of a pulmonary artery catheter (PAC), which conditions would the nurse recognize as contraindications for catheter insertion? Select all that apply. Coagulopathy Cardiogenic shock Fulminant myocarditis Endocardial pacemaker Mechanical tricuspid valve

Coagulopathy Endocardial pacemaker Mechanical tricuspid valve PAC helps to monitor and manage the care of patients who are at high risk for hemodynamic compromise. PAC may cause trauma in the blood vessels and worsen symptoms of coagulopathy. PAC increases the risk for 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. Insertion of a PAC occurs in patients with cardiogenic shock and fulminant myocarditis to detect the risk for heart failure.

For the patient scheduled for an arterial pressure-based cardiac output (APCO) measurement, which patient criteria would the nurse ensure compliance prior to using the measuring device to determine the patient's stroke volume variation (SVV)? Spontaneous respirations and placement of an arterial line Continuous cardiac monitoring and application of oxygen via face mask Controlled mechanical ventilation and fixed respiratory rate and tidal volume Nasal intubation and positive end expiration pressure setting on the ventilator

Controlled mechanical ventilation and fixed respiratory rate and tidal volume SVV is the variation of the arterial pulsation caused by heart-lung interaction. The measurement is a sensitive indicator of preload responsiveness when used on selected patients. Only use the SVV for patients on controlled mechanical ventilation with a fixed respiratory rate and a fixed tidal volume of 8 mL/kg. Do not use the SVV on patients who have spontaneous respirations, even though an arterial line does need to be in place. The patient may have continuous cardiac monitoring, but the patient requires rather than oxygen via a face mask. The requirements include intubation of the patient; however, nasal intubation is not identified as a requirement. The criteria do not include the patient receiving positive end expiration pressure through the ventilator.

Which skill would the nurse need to utilize the most when providing family-centered care for the patient admitted to the intensive care unit (ICU)? Assessment Communication Crisis intervention Case management

Crisis intervention To provide family-centered care for a patient admitted to the ICU, the most important skill for the nurse to implement is crisis intervention. Assessment, communication, and case management are all important skills, but crisis intervention is the skill most important to provide family-centered care to a patient in the ICU.

When suctioning a patient, the development of which clinical manifestation indicates that the nurse would discontinue suctioning immediately? Select all that apply. 1 Decreased SpO2 2 Absence of coughing 3 Development of dysrhythmias 4 Increased BP 5 Shivering and convulsions of the entire body

Decreased SpO2 Development of dysrhythmias Increased BP Closely assessing the patient before, during, and after the suctioning procedure is extremely important for the nurse to perform. If the patient is unable to tolerate suctioning, stop the procedure and hyperoxygenate until equilibration occurs before attempting next suction pass. Decreased SpO2, increased or decreased BP, and development of dysrhythmias are indicators that the patient is not tolerating suction. Sustained coughing rather than absence of coughing also indicates the patient is not tolerating suctioning. The presence of shivering and convulsions is not related to suctioning.

For the patient with an increased preload, which medication class would the nurse expect to administer to decrease the preload? Select all that apply. Diuretic Vasodilator Pain medication Cardiac glycoside IV fluids

Diuretic Vasodilator Diuresis and vasodilation decrease preload. Pain medication and cardiac glycosides do not affect preload. Fluid administration increases preload.

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

Electronic intensive care unit (teleICU) The electronic or teleICU assists the bedside ICU team by monitoring the patient from a remote location using informatics. The ICU, CCU, and PICU are traditional critical care units.

When preparing content on hemodynamic monitoring, which element would the nurse educator utilize to explain the effects of preload? 1 Cardiac index 2 Frank-Starling's law 3 Systemic vascular resistance 4 Pulmonary vascular resistance

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

Which data would the nurse use to calculate the stroke volume (SV) for a patient with arterial pressure-based cardiac output (APCO) monitoring? Height, basal metabolic rate (BMR), age, gender Gender, age, height, weight Body mass index (BMI), BMR, BP, heart rate Age, gender, BP, heart rate

Gender, age, height, weight APCO monitoring uses the arterial waveform characteristics along with patient demographic data including gender, age, height, and weight to calculate SV. The calculations do not require use of BMR, BMI, BP, and heart rate with this measuring device. The nurse would use the heart rate to calculate continuous cardiac output (CCO) and continuous cardiac index (CCI).

For the patient with meningitis and seizures, which problem would the nurse associate with the most recent central venous oxygen saturation (ScvO2) mixed venous oxygen saturation (SvO2) measurement of 48%? Increased oxygen supply Decreased cardiac output Increased oxygen demand Decreased oxygen demand

Increased oxygen demand An ScvO2 mixed 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. The cause of a ScvO2 mixed SvO2 measurement greater than 80% is an increased oxygen supply. Even though a low ScvO2 mixed 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. The cause of a ScvO2 mixed SvO2 measurement greater than 80% is a decreased oxygen demand.

For the patient with a pulmonary arterial catheter for systolic heart failure and a urinary tract infection (UTI), which problem would the nurse associate with the patient's last central venous oxygen saturation (ScvO2) mixed venous oxygen saturation (SvO2) measurement of 89%? Manifestation of sepsis Decreased cardiac output Increased oxygen demand Balanced oxygen supply and demand

Manifestation of sepsis The patient has a urinary tract infection, which can lead to sepsis. In sepsis, the tissues do not extract oxygen properly, resulting in increased ScvO2 mixed SvO 2 measurements. ScvO2 mixed SvO2 measurements would be low if the patient was experiencing decreased cardiac output or increased oxygen demand. ScvO mixed SvO2 measurements would be between 60% and 80% if there were a balance of the oxygen supply and demand.

For the patient admitted to the intensive care unit (ICU) receiving assisted ventilation, which indicator best reflects the patient's alveolar oxygenation status? 1 SpO2 2 PaCO2 3 PETCO2 4 ScvO2 or SvO2

PaCO2 Partial pressure of carbon dioxide (PaCO2) is the best indicator of alveolar hyperventilation or hypoventilation. Continuous partial pressure of EtCO2 (PETCO2) monitoring can assess the patency of the airway and the presence of breathing. Continuous oxygen saturation (SpO2) provides objective data regarding tissue oxygenation. Central venous pressure (CVP) or pulmonary artery (PA) catheters with ScvO2 or SvO2 capability provide an indirect indication of the patient's tissue oxygenation status.

For the patient recovering from implantation of a ventricular assist device (VAD), which intervention would the nurse anticipate as the patient's prescribed activity? Complete bed rest Progressive ambulation Move out of bed to a chair twice a day Bed rest with bathroom privileges

Progressive ambulation The patient with a VAD may be mobile and require an activity plan such as progressive ambulation. Prescribed activity does not include complete bed rest. The patient's prescribed activity includes more than move from the bed to a chair twice a day. Activity will be greater than bed rest with bathroom privileges.

For the patient experiencing cardiogenic shock after an acute myocardial infarction, which rationale would the nurse associate with use of intraaortic balloon pump (IABP) therapy? Improves coronary artery vessel perfusion Reduces pressure in the pulmonary artery Enhances the effectiveness of cardiac medications Provides time to perform an emergency angiogram

Provides time to perform an emergency angiogram Indications for IABP therapy include acute myocardial infarction and cardiogenic shock. The use of the pump with this health problem allows time for emergent angiography. The pump does not reduce pressure in the pulmonary artery, improve coronary artery vessel perfusion, or enhance the effectiveness of cardiac medications.

When providing care for a patient with a pulmonary arterial catheter (PAC), which port would the nurse use to monitor the patient's central venous pressure (CVP)? Distal lumen Balloon valve Proximal lumen Thermistor connector

Proximal lumen CVP is a measurement of right ventricular preload and reflects fluid volume problems. A central venous catheter placed in the internal jugular or subclavian vein measures the CVP most often. Using the proximal lumen of the PAC, located in the right atrium, reflects the patient's CVP. Use the distal lumen to measure the pulmonary artery pressure. Use the balloon valve to inflate the balloon in the pulmonary artery. Use the thermistor connector to monitor blood or core temperature and for the thermodilution method of measuring cardiac output (CO).

When preparing to balance a patient's pressure monitoring device, identify and mark the component the nurse would use as the zero-reference point.

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.

For the patient on the intensive care unit (ICU), which problem would the nurse associate with a series of increased central venous pressure (CVP) readings? Cardiogenic shock Circulatory failure Left ventricular failure Right ventricular failure

Right ventricular failure 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. An increased CVP may reading may occur with left ventricular failure; however, this finding is a late sign. Having both right and left failure at the same time is possible.

When attempting to determine the patient's left ventricular afterload, which hemodynamic value would the nurse use? 1 Central venous pressure 2 Pulmonary arterial pressure 3 Systemic vascular resistance 4 Peripheral vascular resistance

Systemic vascular resistance Systemic vascular resistance is an index of left ventricular afterload. Central venous pressure is an index of preload. Pulmonary arterial pressure and peripheral vascular resistance are indices of right ventricular afterload.

For the patient with an arterial invasive device and the auscultated BPs depicted in the chart, which setting would the nurse use as the patient's low-pressure alarm? Systolic 100; Diastolic 60 Systolic 120; Diastolic 80 Systolic 140; Diastolic 80 Systolic 150; Diastolic 90

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

For the patient with a functioning pulmonary artery catheter (PAC), mark the location at which the nurse would identify the tip of the catheter's resting point.

The marked area indicates the proper location for the tip of the pulmonary artery (Swan-Ganz) catheter. If the catheter tip backs into the right ventricle, then it can irritate the ventricular wall and cause ventricular dysrhythmias. The tip of the catheter should migrate only into the pulmonary artery capillary bed for a few seconds when the balloon located at the tip is inflated to obtain a capillary bed wedge pressure. Prolonged wedging of the inflated catheter tip can cause pulmonary artery infarction.

When assisting the health care provider with insertion of a pulmonary artery catheter (PAC) for a patient with a history of heart failure and a potassium level of 3.2 mEq/L, which waveform would the nurse closely monitor when floating the PAC balloon?

The nurse should closely monitor waveform 2. This waveform represents the right ventricle. The patient has a low potassium and a history of cardiac issues, making the heart susceptible to increased irritability. While continuous monitoring is important during all phases of pulmonary artery insertion, when the balloon floats through the right ventricle, it may irritate the ventricle and cause lethal ventricular dysrhythmias such as ventricular tachycardia or ventricular fibrillation. Waveform 1 represents the right atrium, waveform 3 represents the pulmonary artery, and waveform 4 represents the pulmonary wedge pressure reading. These areas do not typically cause lethal dysrhythmias.

For the patient receiving intraaortic balloon pump (IABP) therapy, which action would the nurse ensure occurs when the health care provider removes the IABP catheter? The nurse would ensure that the pump is in the "off" position. The nurse would ensure that the pump remains in the "on" position. The nurse positions the patient on the side of the catheter's insertion site. The nurse would ensure the reduction of IV fluids to keep vein-open status.

The nurse would ensure that the pump remains in the "on" position. The nurse should continue the pumping until removal of the line, even if the patient is stable. This reduces the risk of thrombus formation around the catheter. The nurse should not turn the pump off. The patient does not need to be in the side-lying position for catheter removal. The nurse should not reduce the IV fluids to keep vein in open status for catheter removal.

Which clinical judgments would the nurse associate with a patient's increase in central venous O2 saturation (ScvO2)/mixed venous O2 saturation (SvO2) values? Select all that apply. The patient sustained a stroke. The values indicate improved perfusion. An occlusion of the catheter occurred. There has been a decrease in the patient's metabolic rate. The patient has an increased level of arterial oxygen saturation.

The values indicate improved perfusion. There has been a decrease in the patient's metabolic rate. The patient has an increased level of arterial oxygen saturation. Increased ScvO2/SvO2 is clinically significant and may indicate a clinical improvement in terms of increased arterial oxygen saturation, improved perfusion, and decreased metabolic rate. It may also indicate problems like sepsis. In sepsis, oxygen is not extracted properly at the tissue level, resulting in increased Scv2/SvO2. Stroke or occlusion of the catheter does not increase the ScvO2/SvO2.

After drawing blood from the patient's arterial line, which action would the nurse perform immediately when observing that the arterial line waveform has a flat line? Reboot the patient's monitor by performing a hard shut-off. Change the transducer setup to ensure functioning equipment. Verify the stopcock is open from the patient to the transducer. Notify the on-call provider of the absence of a visible dicrotic notch.

Verify the stopcock is open from the patient to the transducer. The nurse should verify the stopcock is open from the patient to the transducer, ensuring the status of the stopcock and that it was not inadvertently left off after drawing the blood. By turning the stopcock to the correct position, the nurse should see an arterial line waveform on the monitor. The nurse does not need to reboot the monitor by performing a hard shut-off. The problem is with the arterial line setup and transducer, not the monitor. The nurse should not notify the physician on call of an absent dicrotic notch; the nurse should troubleshoot the equipment prior to notifying the physician. The nurse does not need to change the transducer setup to ensure patent equipment. Implement this step after verifying the stopcock is in the correct position.

When the nurse evaluates a patient receiving intraaortic balloon pump (IABP) therapy, which finding would indicate that the pump is improving the patient's health status? Select all that apply. Warm and dry skin Urine output 50 mL/hr Breath sounds clear bilaterally BP 168/88 mm Hg Oriented to person, place, and time Development of hypoactive bowel sounds

Warm and dry skin Urine output 50 mL/hr Breath sounds clear bilaterally Oriented to person, place, and time Hemodynamic effects of IABP therapy include increased stroke volume leading to warm skin and increased urine output. The decrease in afterload improves breath sounds. Improved stroke volume also improves mentation. The pump has no direct effect on BP regulation. Hypoactive bowel sounds indicate decreased perfusion of the gastrointestinal system.