Critical Care
The nurse, a LPN, and an UAP are caring for clients in a CCU. Which task would be most appropriate for the nurse to assign/delegate? A. Instruct the UAP to obtain the client's serum glucose level B. Request the LPN to change the central line dressing. C. Ask the LPN to bathe the client and change the bed linen D. Tell the UAP to obtain urine output for the 12-hour shift.
ANS: D. RATIONALE: The UAP can add up the urine output for the 12-hr shift, however, the nurse is responsible for evaluating whether the urine output is what is expected for the client. A - serum blood glucose requires venipuncture. B - this is a sterile dressing change and requires assessing the insertion site for infection C - the nurse should ask the UAP to bathe and change the linen.
6. The purpose of adding PEEP to positive pressure ventilation is to a. increase functional residual capacity and improve oxygenation. b. increase FIO2 in an attempt to wean the patient and avoid O2 toxicity. c. determine if the patient is in synchrony with the ventilator or needs to be paralyzed. d. determine if the patient is able to be weaned and avoid the risk of pneumomediastinum.
Rationale: Positive end-expiratory pressure (PEEP) is a ventilatory maneuver in which positive pressure is applied to the airway during exhalation. This increases functional residual capacity (FRC) and often improves oxygenation with restoration of lung volume that normally remains at the end of passive exhalation.
The nurse is caring for a client with cyclical vomiting. The client's ABG results are as follows: pH 7.48, pCO2 38, HCO3 27. The nurse knows the client is experiencing which of the following? A. Respiratory acidosis B. Metabolic acidosis C. Respiratory alkalosis D. Metabolic alkalosis
ANS: D RATIONALE: This client is experiencing metabolic alkalosis. The pH is acidic, the pCO2 is normal, and there is excess HCO3, which is the source of the alkalosis. The client's pCO2 is normal, so the client's imbalance does not have a respiratory source.
A nurse caring for a ventilated client reviews the alarm settings at the beginning of the shift. Which of the following are potential reasons for this? Select all that apply. 1. To avoid an alarm sounding continuously, contributing to alarm fatigue 2. To determine client readiness for a spontaneous breathing trial 3. To ensure the alarms are set according to the appropriate parameters 4. To assess whether the client is stable enough to turn off the alarms 5.To verify that the alarms are on and not disabled
ANS: 1, 3, 5 RATIONALE: The nurse makes sure the alarms follow set parameters in order to avoid continuous alarming. When an alarm sounds too frequently and the client is not in distress, the nurse can experience alarm fatigue, and fail to assess the client when there is an actual problem. Reviewing alarm settings is a standard practice for every nurse at the beginning of the shift. The nurse is responsible for the safety of the client, and ventilator alarms must be assessed by the nurse and documented in order to keep the ventilated client safe. There are instances where the alarms on a ventilator are disabled, which is a major client safety issue. A disabled alarm can lead to a sentinel event if something goes wrong with that ventilator, because it will not alert the nurse that there is a problem.
Which statement explains the scientific rationale for having emergency suction equipment available during resuscitation efforts? 1. Gastric distention can occur as a result of ventilation. 2. It is needed to assist when intubating the client. 3. This equipment will ensure a patent airway. 4. It keeps the vomitus away from the healthcare provider.
ANS: 1. Gastric distention occurs from overventilating clients. When compressions are performed, the pressure will cause vomiting, which may cause aspiration into the lungs. RATIONALES 2. The health-care provider does not require suctioning equipment to intubate. 3. Nothing ensures a patent airway, except a correctly inserted endotracheal tube, and suction is needed to clear the airway. 4. Suction equipment is for the client's needs, not the health-care provider's needs. TEST-TAKING HINT: Option "4" could be eliminated because the equipment is for the client, not for the nurse or health-care providers. The word "ensures" in option "3" is an absolute word, so the test taker should be cautious before selecting this option.
Which health-care team member referral should be made by the nurse when a code is being conducted on a client in a community hospital? 1. The hospital chaplain. 2. The social worker. 3. The respiratory therapist. 4. The director of nurses.
ANS: 1. The chaplain should be called to help address the client's family or significant others. A small community hospital does not have a 24-hour on-duty pastoral service. A chaplain is part of the code team in large medical center hospitals. RATIONALE: 2. The social worker does not need to be notified of a code. 3. The respiratory therapist responds to the code automatically without a referral. The respiratory therapist is part of the code team and one (1) is on duty 24 hours a day, even in a small community hospital. 4. The director of nurses does not need to be notified of codes, but possibly the house supervisor should be notified. TEST-TAKING HINT: The test taker must know the roles of the multidisciplinary health-care team to make appropriate referrals. The words "community hospital" are an important phrase to help determine the correct answer.
The CPR instructor is discussing an automated external defibrillator (AED) during class. Which statement best describes an AED? 1. It analyzes the rhythm and shocks the client in ventricular fibrillation. 2. The client will be able to have synchronized cardioversion with the AED. 3. It will keep the health-care provider informed of the client's oxygen level. 4. The AED will perform cardiac compressions on the client.
ANS: 1. This is the correct statement explaining what an AED does when used in a code. RATIONALE: 2. The Life Pack on the crash cart must be used to perform synchronized cardioversion. 3. This is the explanation for a pulse oximeter. 4. This is not the function of the AED. TEST-TAKING HINT: The test taker must know equipment to be able to answer this question. The test taker may be able to eliminate options based on knowledge of what other equipment does.
Which equipment must be immediately brought to the client's bedside when a code is called for a client who has experienced a cardiac arrest? 1. A ventilator. 2. A crash cart. 3. A gurney. 4. Portable oxygen
ANS: 2. The crash cart is the mobile unit with the defibrillator and all the medications and supplies needed to conduct a code. RATIONALE: 1. A ventilator is not kept on the medicalsurgical floors and is not routinely brought to the bedside. The client is manually ventilated until arriving in the intensive care unit. 3. The gurney, a stretcher, may be needed when the client is being transferred to another unit, but it is not an immediate need, and in some hospitals the client is transferred in the bed. 4. Oxygen is available in the room and portable oxygen is on the crash cart, so it doesn't need to be brought separately. TEST-TAKING HINT: This is knowledge the test taker must have. The crash cart is the primary piece of equipment, and in most facilities there is a person assigned to bring the crash cart to the client's bedside.
The unlicensed assistive personnel (UAP) is performing cardiac compressions on an adult client during a code. Which behavior warrants immediate intervention by the nurse? 1. The UAP has hand placement on the lower half of the sternum. 2. The UAP performs cardiac compressions and allows for rescue breathing. 3. The UAP depresses the sternum 0.5 to one (1) inch during compressions. 4. The UAP asks to be relieved from performing compressions because of exhaustion.
ANS: 3. The sternum should be depressed one and one-half (1.5) to two (2) inches during compressions to ensure adequate circulation of blood to the body; therefore, the nurse needs to correct the UAP. RATIONALE: 1. This hand position will help prevent positioning the hand over the xiphoid process, which can break the ribs and lacerate the liver during compressions. 2. This is the correct two-rescuer CPR; therefore, no intervention is needed. 4. The UAP should request another healthcare provider to perform compressions when exhausted. TEST-TAKING HINT: The test taker must select which option is an incorrect procedure for cardiac compressions.
The nurse finds the client unresponsive on the floor of the bathroom. Which action should the nurse implement first? 1. Check the client for breathing. 2. Assess the carotid artery for a pulse. 3. Shake the client and shout. 4. Notify the rapid response team.
ANS: 3. This is the first intervention the nurse should implement after finding the client unresponsive on the floor. RATIONALE: 1. This is the third intervention based on the answer options available in this question. 2. This is the fourth intervention based on the options available in this question. 4. The rapid response team is called if the client is breathing; a code would be called if the client were not breathing. TEST-TAKING HINT: Options "1," "2," and "3" are all assessment interventions, which is the first step in the nursing process. Of these three (3) possible options, the test taker should select the intervention easiest and fastest to determine if the client is alert, which is to shake and shout at the client.
Which intervention is most important for the nurse to implement when participating in a code? 1. Elevate the arm after administering medication. 2. Maintain sterile technique throughout the code. 3. Treat the client's signs/symptoms; do not treat the monitor. 4. Provide accurate documentation of what happened during the code.
ANS: 3. This is the most important intervention. The nurse should always treat the client based on the nurse's assessment and data from the monitors; an intervention should not be based on data from the monitors without the nurse's assessment. RATIONALE: 1. This is an appropriate intervention, but it is not the most important. 2. Sterile technique should be maintained as much as possible, but the nurse can treat a live body with an infection without using sterile technique; however, the nurse cannot treat a dead body without an infection. 4. Documentation is important but not priority over treating the client. TEST-TAKING HINT: The phrase "most important" in the stem is the key to answering this question. All four (4) options are appropriate interventions for the question, but only one (1) is the most important. The test taker should remember to always select the option directly affecting the client, and this may mean not selecting an assessment intervention when the client is in distress.
The nurse is teaching CPR to a class. Which statement best explains the definition of sudden cardiac death? 1. Cardiac death occurs after being removed from a mechanical ventilator. 2. Cardiac death is the time the HCP officially declares the client dead. 3. Cardiac death occurs within one (1) hour of the onset of cardiovascular symptoms. 4. The death is caused by myocardial ischemia resulting from coronary artery disease.
ANS: 3. Unexpected death occurring within one (1) hour of the onset of cardiovascular symptoms is the definition of sudden cardiac death. TEST-TAKING HINT: If the test taker relates the word "sudden" in the stem with "unexpected," the best answer is option "3." The test taker must be aware of adjectives and adverbs.
The nurse is caring for clients on a medical floor. Which client is most likely to experience sudden cardiac death? 1. The 84-year-old client exhibiting uncontrolled atrial fibrillation. 2. The 60-year-old client exhibiting asymptomatic sinus bradycardia. 3. The 53-year-old client exhibiting ventricular fibrillation. 4. The 65-year-old client exhibiting supraventricular tachycardia.
ANS: 3. Ventricular fibrillation is the most common dysrhythmia associated with sudden cardiac death; ventricular fibrillation is responsible for 65% to 85% of sudden cardiac deaths. RATIONALE: 1. Atrial fibrillation is not a life-threatening dysrhythmia; it is chronic. 2. Asymptomatic sinus bradycardia may be normal for the client, especially for athletes or long-distance runners. 4. "Supraventricular" means "above the ventricle." The atrium is above the ventricle, and atrial dysrhythmias are not life threatening. TEST-TAKING HINT: The test taker should know the left ventricle is responsible for pumping blood to the body (heart muscle and brain) and could eliminate options "1" and "4" as correct answers. The word "asymptomatic" should cause the test taker to eliminate option "2" as the correct answer.
Which intervention is the most important for the intensive care unit nurse to implement when performing mouth-to-mouth resuscitation on a client who has pulseless ventricular fibrillation? 1. Perform the jaw thrust maneuver to open the airway. 2. Use the mouth to cover the client's mouth and nose. 3. Insert an oral airway prior to performing mouth to mouth. 4. Use a pocket mouth shield to cover the client's mouth.
ANS: 4. Nurses should protect themselves against possible communicable disease, such as HIV and hepatitis, and should be protected if the client vomits during CPR. RATIONALE: 1. A jaw thrust is used for a possible fractured neck. The nurse should use the head-tilt, chin-lift maneuver to open the airway. 2. The nurse should cover the client's mouth and nose with the nurse's mouth when giving mouth-to-mouth resuscitation to an infant but not when giving mouth-to-mouth resuscitation to an adult. According to the American Heart Association 2010 Guidelines mouth to mouth is only performed with a barrier device in place to protect the rescuer. 3. An oral airway is not mandatory to do effective breathing; therefore, it is not the most important intervention. TEST-TAKING HINT: Unless the stem provides an age for the client, the client is an adult client; therefore, the test taker could eliminate option "2" because it is for an infant.
The nursing administrator responds to a code situation. When assessing the situation, which role must the administrator ensure is performed for legal purposes and continuity of care of the client? 1. A person is ventilating with an Ambu bag. 2. A person is performing chest compressions correctly. 3. A person is administering medications as ordered. 4. A person is keeping an accurate record of the code.
ANS: 4. The chart is a legal document, and the code must be documented in the chart and provide information needed in the intensive care unit. RATIONALE 1. This is providing immediate direct care to the client and is not performed for legal purposes. 2. The key to answering the question is "legal," and direct care is not performed for legal purposes. 3. This is providing immediate direct care to the client and is not performed for legal purposes. This is an occasion where someone else is allowed to document another nurse's medication administration. TEST-TAKING HINT: Answer options "1," "2," and "3" have the nurse providing direct handson care. Option "4" is the only option addressing documentation and should be selected as the correct answer because it is different.
The client in a code is now in ventricular bigeminy. The HCP orders a lidocaine drip at three (3) mg/min. The lidocaine comes prepackaged with two (2) grams of lidocaine in 500 mL of D5W. At which rate will the nurse set the infusion pump? _________
ANS: 45 mL/hr The test taker could remember the mnemonic, which is "For 1 mg, 2 mg, 3 mg, 4 mg the rate is 15 mL, 30 mL, 45 mL, 60 mL." If the test taker has not memorized it, it is too late to figure it out in an emergency situation. But for math purposes: First determine the number of milligrams of lidocaine in the 500 mL of D5W: 2 g × 1,000 mg = 2,000 mg per 500 mL Then determine how many milligrams per milliliters: 2,000 mg ÷ 500 mL = 4 mg/mL Then find out how many milliliters must be infused per minute to give the ordered dose of 3 mg/min. In algebraic terms: 4 mg : 1 mL = 3 mg : x mL Cross multiply and divide: x = 3/4 or 0.75 The number of milliliters to be infused in a minute is 3/4 mL or 0.75. The infusion pump is set at an hourly rate, so multiply 3/4 by 60 minutes: 3/4 × 60 = 45 The pump should be set at 45 mL/hr to infuse three (3) mg/min.
The nurse notes a client's ABGs are the following: pH 7.48, pCO2 28, HCO3 25. Which of the following could be the source of this client's imbalance? A. Hyperventilation B. Salicylate overdose C. Cyclical vomiting D. Clostridium difficile infection
ANS: A RATIONALE: The ABGs reveal respiratory alkalosis. This client is most likely experiencing hyperventilation. When a client hyperventilates, they blow off CO2, which is an acid. This increases blood pH, which is reflected in the high (alkaline) pH in this client's ABG results. Salicylate overdose would lead to metabolic acidosis from an accumulation of excess acids from the salicylates. Salicylate ingestion is not a respiratory source. C. diff can lead to metabolic acidosis as HCO3 is lost through the GI tract. Since this client's ABG results reflect respiratory alkalosis, a C. diff infection is not the cause. Excessive vomiting can lead to metabolic alkalosis due to a loss of HCl (hydrochloric acid) from the stomach. These ABG results do not reflect this.
A nurse is experiencing alarm fatigue toward the end of a 12-hour shift. Which of the following behaviors by the nurse most accurately demonstrates the concept of alarm fatigue? A. The nurse hears a ventilated client's low pressure alarm, and finishes up charting without having a sense of urgency to check the client B. The nurse is fatigued after a long shift in which a code blue occurred on the unit, and asks a family member to give a ride instead of driving home alone C. The nurse is sensitized to the sound of alarms and even hears the sound of alarms while dreaming D. The nurse describes feeling chronically exhausted and overworked, and continuously makes cynical statements throughout the shift
ANS: A RATIONALE: This accurately describes the behavior of a nurse with alarm fatigue. When alarms sound frequently throughout a shift, staff can become desensitized when an alarm sounds, and ignore them or even disable them. Alarm fatigue is the most common factor that contributes to alarm-related sentinel events. A low-pressure alarm means the client has self extubated, the tubing has become disconnected, or there is a leak in the tubing or air cuff. This client must be immediately assessed because they risk losing an airway. When the nurse is desensitized to sounding alarms and does not treat emergent alarms seriously, the nurse demonstrates alarm fatigue.
The nurse is evaluating the following ABG results: pH 7.3, PaCO2 38, HCO3 20. Which of the following is most likely occurring? A. Diarrhea B. NG tube Suction C. Hyperventilation D. Airway obstruction
ANS: A RATIONALE: This client is in metabolic acidosis. A pH of 7.3 is acidic. A PaCO2 of 38 is normal, and an HCO3 of 20 is low, which means this client is in acidosis with a metabolic source. Diarrhea is the only option listed with a metabolic source resulting in a gastrointestinal loss of HCO3, causing acidosis. Excess NG tube suction is not the source. An NG tube removes gastric secretions, including hydrochloric acid from the stomach. This means the client would have a loss of H+ ions, resulting in increased alkalinity. NG tube suctioning can lead to metabolic alkalosis rather than metabolic acidosis. Hyperventilation results in the client blowing off excess CO2, which results in respiratory alkalosis as the body's PaCO2 is lowered. Since this client has a normal PaCO2 but an abnormal HCO3, hyperventilation is not the cause. An airway obstruction results in an increased PaCO2 which leads to respiratory acidosis. This client's PaCO2 is normal (35-45), so an airway obstruction is not the cause of these ABG results.
In preparing a patient in the ICU for oral ET intubation, what should the nurse do that is MOST important for successful intubation? A. Place the pt supine with the head extended and the next flexed B. Tell the pt that the tongue must extruded while the tube is inserted C. Position the pt supine with the head hanging over the edge of the bed to align the mouth and trachea D. Inform the pt that while it will not possible to talk during insertion of the tube, speech will be possible after it is correctly placed.
ANS: A RATIONALE: Pt is positioned with head extended and the neck flexed in the "sniffing position".
While the nurse is caring for a client on a ventilator the ventilator alarm sounds. What is the first action taken by the nurse? A. Silence the ventilator alarm B. Notify the RT C. Assess the client's respiratory status D. Ventilate the client using a manual resuscitation bag
ANS: A RATIONALE: The ventilator should be checked to determine which alarm is sounding. This is the FIRST step in assessing the client's problem. The nurse should assess the ventilator and the client and then notify the RT if needed. The client should be assessed, but the nurse should assess the machine first because the machine is breathing for the client. The client should be manually ventilated if the nurse cannot determine the cause of the ventilator alarm. TEST TIP: The nurse must determine if the clietn is in distress. Remember, If in distress, do not assess. The nurse must INTERVENE to help the client. In most situations, the nurse should not select equipment over the client's body; however, when the equipment is breathing for the client, the equipment should be assessed first.
The client's ABG results are pH 7.34, PaCO2 50, HCO3 24, and PaO2 87. Which intervention should the nurse implement first? A. Have the client turn, cough, and deep breathe B. Place the client on o2 via nasal cannula C. Check the patient's pulse oximeter reading D. Notify the HCP of the ABG results
ANS: A RATIONALE: These blood gases indicate respiratory acidosis that could be caused by ineffective cough, with resulting air trapping. The nurse should encourage the client to turn, cough, and deep breathe. PaO2 is within normal limits. The ABG O2 value is an accurate test, the pulse ox is an approximate level. The nurse can intervene to treat the client before notifying the HCP.
What precautions should the nurse take during mouth care and repositioning of an oral ET tube to prevent and detect tube dislodgement? (Select all that apply) A. Confirm bilateral breath sounds after care. B. Use suction pressures less than 120 mm Hg C. Use humidified inspired gas to help thin secretions D. One staff members hold the tube and one performs care E. Move secretions into larger airways with turning every 2 hours.
ANS: A, D RATIONALE: To prevent dislodgement of the ET tube during care, two nurses work together: one holds the tube while the other performs care. After completion of care, confirm the presence of bilateral breath sounds to ensure that the position of the tube was not changed and reconfirm cuff pressure. Other answers: Suction pressure less than 120 will prevent tracheal mucosal damage. Humidified inspired gas will help thin secretions. Secretions are moved to larger airways with turning, postural drainage, and percussion; but none of these other actions will prevent or detect tube dislodgement.
Before taking hemodynamic measurements, how must the nurse reference the monitoring equipment? A. Position the stopcock nearest the transducer level with the phlebostatic axis B. Place the transducer on the left side of the chest at the fourth intercostal space C. Confirm that when pressure in the system is zero, the equipment is functioning D. Place the patient in a left lateral position with the transducer level with the top surface of the mattress
ANS: A. RATIONALE: Referencing hemodynamic monitoring equipment means positioning the equipment so that the zero reference point is at the vertical level of the left atrium of the heart. The stopcock nearest the transducer is placed as the phlebostatic axis, the external landmark of the left atrium.
The client has ABG values of pH 7.38, PaO2 77, PaCO2 40, HCO3 24. Which intervention should the critical care nurse implement? A. Administer O2 6L/min via nasal cannula B. Encourage the client to take deep breaths C. Administer intravenous sodium bicarbonate D. Assess the client's respiratory status.
ANS: A. RATIONALE: The client's PaO2 is below normal level of 80-100, therefore the nurse should administer O2. The client should take deep breaths if their PaCO2 is >45. The nurse should give bicarb if HCO3 is < 22. The pt needs oxygen due to the low arterial oxygen level, the client does NOT need a respiratory assessment.
A nurse is caring for a client who has an indwelling arterial line. The nurse notes that the waveform on the hemodynamic monitor appears flat and dampened. Which of the following would be the first step in troubleshooting this waveform? A. Clamp the line for 1 minute and then release and recheck the waveform B. Check the line for kinks or obstructions C. Ask the client to turn his head and cough D. Add extension tubing to the line
ANS: B RATIONALE: A dampened waveform is a pattern on the hemodynamic monitor that is flattened and not necessarily accurate. This can indicate that the line is positional, which would give an inaccurate reading. The nurse should check for kinks and obstructions, then flush the line to clear it of air or blood. Finally, attempt to reposition the line in order to correct the waveform. A 'square wave test' is then performed, and if it indicates the reading is accurate, the client should be treated for hypotension.
A nurse is preparing to assist the healthcare provider with insertion of an arterial line into a client's radial artery. Prior to insertion of this line, which intervention should the nurse perform? A. Test the tip of the catheter by inflating and then deflating the balloon B. Perform an Allen's test on the affected arm C. Withdraw 1 mL of blood from the radial artery D. Range-of-motion exercises on the affected arm
ANS: B RATIONALE: An arterial catheter can be placed into an artery to assess internal blood pressure. When placed in the radial artery of the wrist, the nurse should perform the Allen's test by compressing both the radial and ulnar arteries of the wrist and checking for restoration of blood flow after release. Performing this test checks the collateral circulation of the radial artery prior to catheterization.
The nurse is caring for a client in DKA. The nurse notes that the client's ABG results reflect a low pH, a low HCO3, and a low pCO2. What is occurring with this client? A. Fully compensated metabolic acidosis B. Partially compensated metabolic acidosis C. Partially compensated respiratory alkalosis D. Fully compensated respiratory alkalosis
ANS: B RATIONALE: DKA leads to metabolic acidosis. This client's pH and HCO3 reflect metabolic acidosis. Since the pCO2 is low, the client is partially compensating for the metabolic acidosis. If this were fully compensated metabolic acidosis, the client's pH would be within the normal range. Since it's low, this is considered partially compensated metabolic acidosis. While the pCO2 is low, since we know the client is in DKA, the source of this imbalance is not respiratory. Instead, the client is compensating with a low pCO2. This client has partially compensated metabolic acidosis. The pCO2 is abnormal in this scenario due to compensation, not because this client's imbalance is due to a respiratory source. Additionally, if the client was fully compensated, the pH would be normal.
What is a priority nursing intervention that is indicated for the patient in the ICU who has a nursing diagnosis of anxiety r/t the ICU environment and sensory overload? A. Provide flexible visiting schedules for caregivers B. Eliminate unnecessary alarms and overhead paging C. Administer sedatives or psychotropic drugs to promote rest D. Allow the patient to do as many self-care activities as possible.
ANS: B RATIONALE: Anxiety in the ICU patient may be r/t the environment, which has unfamiliar equipment, high noise and light levels, and an intense pace of activity that leads to sensory overload. The nurse should eliminate as much of this source of stress as possible by muting phones, limiting overhead paging, setting alarms appropriate to the patient's condition, and eliminating unnecessary alarms during care when possible. A & D are indicated when impaired communication and loss of control contribute to anxiety. Use of sedation to reduce anxiety should be carefully evaluated and implemented when nursing measures are not effective.
What task should the critical care nurse delegate to the UAP? A. Check the pulse oximeter reading for the client on a ventilator B. Take the client's sterile urine specimen to the lab C. Obtain vital signs for the client in an Addisonian crisis. D. Assist the HCP with performing a paracentesis at the bedside.
ANS: B. RATIONALE: The UAP can take specimens to the lab. A - the client on the ventilator is unstable, therefore, the nurse should not delegate any tasks to the UAP C - The client in Addisonian crisis is unstable, the nurse should not delegate any tasks to UAP D - the UAP cannot assist the HCP with an invasive procedure at the bedside
The nurse receives report on a client with active chest pain and a type B aortic dissection noted on CT. The client has an arterial line placed. Which is the most important vital sign to monitor? A. Respirations B. Blood pressure C. Heart rate D. Temperature
ANS: B. Blood pressure RATIONALE: A client with a dissection will have very strict blood pressure parameters which are usually on the lower side of normal. This is necessary because increased pressure in the vessels increases the bleeding.
A nurse enters a ventilated client's room to assess the client. The client's low pressure alarm is sounding. Which of the following actions should the nurse perform first? A. Immediately begin CPR B. Carefully examine the tubing for kinks C. Assess the client, then the ventilator D. Ensure the client is breathing spontaneously, then disable the alarm
ANS: C RATIONALE: When a nurse is caring for a ventilated client and an alarm sounds, the first thing the nurse should do is assess the client, then assess the ventilator. The nurse will be able to quickly determine whether the client is in distress by assessing the client's ABC's - airway, respiratory status, and vital signs. Is the ET tube in place? Is the client spontaneously breathing? What is the client's oxygen level? After assessing ABCs, the nurse can check the ventilator for a circuit disconnect or air leak. Kinks in the ventilator tubing cause a high-pressure alarm, not a low-pressure alarm.
What nursing care is included for the patient with an ET tube? A. Check the cuff pressure every hour B. Keep a tracheostomy tray at the bedside C. Hyperoxygenate before and after suctioning D. Reuse the suction catheter at the bedside for 24 hours.
ANS: C RATIONALE: The nurse should hyperoxygenate the pt before and after suctioning. Also keep suctioning equipment and an Ambu bag at the bedside. Also, us one-time sterile suction catheters for open suction technique, or a suction catheter that is enclosed in a plastic sleeve connected directly to the pt ventilator circuit, which is changed per facility protocol for the closed suction technique. Trach trays and used catheters are not left at the bedside.
A patient has an oral ET tube inserted to relieve upper airway obstruction and the facilitate secretion removal. Number the following responsibilities of the nurse immediately following placement of the tube in order of priority with 1 being the FIRST priority: A. Suction the tube to remove secretions B. X-ray confirmation of the ET tube placement C. Place an end tidal CO2 detector on the ET tube D. Secure the ET tube to the face with adhesive tape E. Assess for bilateral breath sounds and symmetrical chest movement
ANS: C, E, D, B, A RATIONALE: The FIRST action of hte nurse is to use an end tidal CO2 detector. If no CO2 is detected, the tube is in the esophagus. The second action after ET intubation is to auscultate the chest to confirm bilateral breath sounds and observe to confirm bilateral chest expansion. If this evidence is presence, the tube is secured and connected to an O2 source. Then the placement is confirmed immediately with an x-ray, and the tube is marked where it exits the mouth. The pt should be suctioned as needed.
A client presents to the emergency room with CNS depression due to narcotic overdose. The ABG results are as follows: pH 7.35, pCO2 48, HCO3 35. The nurse knows that the client is experiencing which of the following? A. Fully compensated metabolic acidosis B. Partially compensated metabolic acidosis C. Partially compensated respiratory acidosis D. Fully compensated respiratory acidosis
ANS: D RATIONALE: This client is in respiratory acidosis. They have a build-up of CO2 (acid) due to hypoventilation from CNS depression, but the body has fully compensated by increasing HCO3, bringing the pH into a normal range. The client is fully compensated because the pH is normal. The client has CNS depression which leads to hypoventilation. The cause of this client's imbalance is respiratory, not metabolic. Since the pH is normal, the client is fully compensated rather than only partially compensated. Additionally, since the HCO3 is high, this figure represents an excess base, not acid.
In preparing the patient for insertion of a pulmonary artery catheter, what should the nurse do? A. place the patient in high Fowler's position B. Obtain informed consent from the patient C. Perform an Allen test to confirm adequate ulnar artery perfusion D. Ensure that the patient has continuous ECG monitoring
ANS: D RATIONALE: During insertion of a pulmonary artery catheter, it is necessary to monitor the ECG continuously because of the risk for dysrhythmias, particularly when the catheter reaches the right ventricle. The RN also notes the patient's electrolyte, acid-base, oxygenation, and coag status. During the catheter insertion, the patient is place suprine with the head of the bed flat. It is the HCPs responsibility to obtain consent. An Allen test is perform before insertion of an arterial line in the radial artery.
The client is admitted to the critical care unit after a MVA. The client asks the nurse, "Do you know if the person in the other car is all right?" The nurse knows the patient died. Which statement supports the ethical principle of veracity? A. "I am not sure how the other person is doing." B. "I will try to find out how the other person is doing." C. "You should rest now and try not to worry about it." D. "I am sorry to have to tell you, but the person died."
ANS: D RATIONALE: This statement supports the ethical principle of veracity, which is duty to tell the truth. This statement will probably further upset the patient and cause psychological distress, which may hinder the recovery period. Answers A and B support the ethical principle of beneficence which is the ethical principal to do good actively for the patient. Because the client is in the ICU, he does not need any type of news that will further upset him. This statement supports beneficence.
The nurse observes a PAWP waveform on the monitor when the balloon of the patient's pulmonary artery catheter is deflated. What should the nurse recognize about this situation? A. The pt is at risk for embolism because of occlusion of the catheter with a thrombus B. The pt is developing pulmonary edema that has increased the pulmonary artery pressure C. The pt is at risk for an air embolus because the injected air cannot be withdrawn into the syringe D. The catheter must be immediately repositioned to prevent pulmonary infarction or pulmonary artery rupture.
ANS: D RATIONALE: When a pulmonary artery pressure tracing indicates a wedged waveform when the balloon is deflated, this indicates that the catheter has advanced and has become spontaneously wedged. If the catheter is not repositioned immediately, a pulmonary infarction or a rupture of a pulmonary artery may occur. If the catheter is becoming occluded, the pressure tracing becomes blunted. Pulmonary edema and increased pulmonary congestion increase the pulmonary artery waveform. Balloon leaks found when injected air does not flow back into the syringe do not alter waveforms.
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. an 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.
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 monitors the patient with positive pressure mechanical ventilation for a. paralytic ileus because pressure on the abdominal contents affects bowel motility. b. diuresis and sodium depletion because of increased release of atrial natriuretic peptide. c. signs of cardiovascular insufficiency because pressure in the chest impedes venous return. d. respiratory acidosis in a patient with COPD because of alveolar hyperventilation and increased PaO2 levels.
Correct answer: c Rationale: Positive pressure ventilation affects circulation by transmission of increased mean airway pressure to the thoracic cavity. With increased intrathoracic pressure, thoracic vessels are compressed. Such compression results in decreased venous return to the heart, decreased left ventricular end-diastolic volume (preload), decreased cardiac output, and hypotension.
7. The nursing management of a patient with an artificial airway includes a. maintaining ET tube cuff pressure at 30 cm H2O. b. routine suctioning of the tube at least every 2 hours. c. observing for cardiac dysrhythmias during suctioning. d. preventing tube dislodgment by limiting mouth care to lubrication of the lips.
Correct answer: c Rationale: Potential complications associated with suctioning include hypoxemia, bronchospasm, increased intracranial pressure, dysrhythmias, hypertension, hypotension, mucosal damage, pulmonary bleeding, pain, and infection. Closely assess the patient before, during, and after the suctioning procedure. If the patient does not tolerate suctioning (e.g., decreased arterial oxygenation, increased or decreased blood pressure, sustained coughing, development of dysrhythmias), stop the procedure, and manually hyperventilate the patient with a bag valve mask and 100% oxygen.
4. To establish hemodynamic monitoring for a patient, the nurse zeros 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 midclavicular line.
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.
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.
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.
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 irritability.
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., dexmedetomidine [Precedex]) may be considered. Physical conditions such as hemodynamic instability, hypoxemia, hypercarbia, electrolyte disturbances, and severe infections can precipitate delirium.
5. The hemodynamic changes the nurse expects to find after successful initiation of intraaortic balloon pump therapy in a patient with cardiogenic shock include (select all that apply) a. decreased SV. b. decreased SVR. c. decreased PAWP. d. increased diastolic BP. e. decreased myocardial O2 consumption.
Correct answers: b, c, d, e Rationale: The hemodynamic effects of intraaortic balloon inflation during diastole include increased diastolic blood pressure (BP), increased pressure in the aortic root, increased coronary artery perfusion pressure, and improved oxygen delivery to the myocardium. The hemodynamic effects of intraaortic balloon inflation during systole include decreased afterload (i.e., systemic vascular resistance [SVR]), decreased peak systolic pressure, decreased myocardial oxygen consumption, increased stroke volume (SV), and decreased preload (i.e., decreased pulmonary artery [PA] pressures), including decreased pulmonary artery wedge pressure (PAWP).
