ICU Exam 1
Advance Directives Act of 1999 (TADA)
This act outlines a clear process for resolving futility disputes when a patient or surrogate requests life-sustaining treatment that the treating physician or health care facility believes to be ineffective, inappropriate, or futile
allows unrestricted, spontaneous breaths throughout the ventilatory cycle; on inspiration the patient receives a preset level of continuous positive airway pressure, and pressure is periodically released to aid expiration
airway pressure release ventilation (APRV)
set # of breaths/min; pt can initiate own breaths delivered at set tidal volume
assist-control (AC) ventilation
Arterial lines
continual blood pressure measurements
completely controls the patient's ventilation; rarely used except in paralyzed or anesthetized patients
continuous mandatory ventilation (CMV)
positive pressure applied throughout the respiratory cycle to a spontaneously breathing patient to promote alveolar and airway stability; may be administered with endotracheal or tracheostomy tube or by mask
continuous positive airway pressure (CPAP)
How RR impacts the patient condition
incorrect respiratory rate can cause respiratory acidosis or alkalosis. It can also worsen the pH. Also a factor in determining tidal volume. If tidal volume is miscalculated, there will be a ventilation and perfusion mismatch (V/Q mismatch). Respiratory rate can be lowered to decrease the minute ventilation.
combination of mechanically assisted breaths and spontaneous breaths
intermittent mandatory ventilation (IMV)
medical futility
interventions that are unlikely to produce any significant benefit for the patient
Pulmonary Artery Pressure
monitors right atrial, pulmonary artery systolic and diastolic pressures, mean pulmonary MAP and pulmonary wedge pressures. Used to determine left ventricular fill pressures
CVP
monitors the pressure in the vena cava, right atrium, pre-load. Used to determine hydration status and right sided heart failure
When invasive ventilation is not enough to improve oxygenation, what other options does the team have to increase it?
- Positioning (Prone) - use gravity - Inhaled pulmonary vasodilator medications - vasodilates only in areas of the lung that receive adequate ventilation. - Administer bolus and/or drip of paralytic medication (vecuronium). The paralytic agent eliminates any muscular activity on the part of the patient which decreases oxygen consumption. It also eliminates any patient respiratory effort which might be contributing to dysynchrony with the ventilator and either ineffective ventilation or increased oxygen consumption.
HCP need to provide to respiratory therapy and nursing for ventilator management
- mode of mechanical ventilation, the tidal volume, respiratory rate, inspired oxygen concentration (FiO2) and level of Positive End Expiratory Pressure - Need a Foley catheter, feeding tube, OG - prevent aspiration and instill tube feeding/bypass the gag reflex, some type of sedation, - patient's IDEAL weight because tidal volume is based on the patient's IDEAL body weight in an assisted Control Method of ventilation.
2. A client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A nurse checks the client when the high pressure alarm on the ventilator sounds, and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of: a. Right pneumothorax b. Pulmonary Embolism c. Displaced EndoTracheal Tube d. Acute Respiratory distress syndrome (ARDS)
Answer: A Rationale: Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left main stem bronchi.
1. The low-pressure alarm sounds on a ventilator. A nurse assess the client and then attempts to determine the cause of the alarm. The nurse is unsuccessful in determining the cause of the alarm and takes what initial action? a. Administers oxygen b. Checks the clients vital signs c. Ventilates the client manually d. Starts cardiopulmonary resuscitation (CPR)
Answer: C Rationale: If at any time an alarm is sounding and the nurse cannot quickly ascertain the problem, the client is disconnected from the ventilator and manual resuscitation is used to support respirations until the problem can be corrected. No reason is given to begin CPR. Checking vital signs is not the initial action. Although oxygen is helpful, it will not provide ventilation to the client.
1. What is hemodynamic monitoring? a. Use of pressure monitoring devices to directly measure cardiovascular function b. Invasive procedure used to measure cardiac chamber pressures and assess patency of coronary arteries c. Test used to evaluate functioning of the heart during a period of increased oxygen demand d. Process of continuous electrocardiographic monitoring by the transmission of radio waves from a battery-operated transmitter
Answer: a Rationale: -b. refers to cardiac catheterization -c. refers to cardiac stress test -d. refers to telemetry
2. A patient in the ICU has been orally incubated and on a mechanical ventilator for 2-weeks after having a severe stroke. What action does the nurse anticipate the physician will take now that the patient has been intubated for this length of time? a. The pt will have a tracheostomy tube inserted b. The pt will require manual ventilation hence forth c. The pt will be extubated & allowed to breathe on their own d. The pt will remain orally intubated and no action is necessary
Answer: a Rationale: Endotracheal intubation may be used for no longer than 14 to 21 days, by which time a tracheostomy must be considered to decrease irritation of and trauma to the tracheal lining, to reduce the incidence of vocal cord paralysis (secondary to laryngeal nerve damage), and to decrease the work of breathing.
4. Which is a potential complication of a low pressure in the endotracheal tube cuff? a. Aspiration pneumonia b. Tracheal bleeding c. Tracheal ischemia d. Pressure necrosis
Answer: a Rationale: Low pressure in the cuff can increase the risk for aspiration pneumonia. High pressure in the cuff can cause tracheal bleeding, ischemia or necrosis.
2. A patient's blood pressure is 81/54. What value would the nurse report to the doctor for the patient's MAP? Are we concerned with this Map value? a. 63, yes we are concerned. b. 63, no we are not concerned. c. 72, no we are not concerned. d. 72, yes we are concerned.
Answer: a Rationale: MAP means mean arterial pressure, with the equation being (2 X diastolic pressure + systolic pressure)/3. (54 X 2 + 81)/3 = 63. It is ideal for a MAP to be between 65 and 100, so it is concerning that the MAP is 63, therefore A is the correct answer.
4. The client with a diagnosis of heart failure reports frequently awakening during the night with the need to urinate. The nurse offers which explanation? a. edema is collected in dependent extremities during the day; at night when the client lays down, it is reabsorbed into the circulation and excreted by the kidneys. b. when the client is in the recumbent position, more pressure is put on the bladder with the result of increased need to urinate. c. the blood pressure is lower when the client is recumbent and this causes the kidneys to work harder; therefore, more urine is produced. d. fluid that is held in the lungs during the day becomes part of the circulation at night and the kidneys produce an increased amount of urine.
Answer: a Rationale: Nocturia is common in patients with heart failure. Fluid collected in dependent areas during the day is reabsorbed into the circulation at night when the client is recumbent. The kidneys excrete more urine with the increased circulating volume.
5. Dehydration, blood loss, severe vomiting or diarrhea can all cause hypovolemia which can lead to altered central venous pressure. What CVP value would cause the nurse to call the doctor with suspicions of hypovolemia? a. 1.9 b. 3.1 c. 5.6 d. 6.8
Answer: a Rationale: The ideal CVP should be between 2 and 6mmHg. -Hypovolemia would cause a decreased CVP, and a CVP below 2 would be concerning. -Hypervolemia would cause an increased CVP, and a value above 6 would be concerning.
4. The patient has a heart rate of 72 bpm with a regular rhythm. Where does the nurse determine the impulse arises from? a. Sinoatrial (SA) node b. Purkinje fibers c. Bundle of His d. Atrioventricular (AV) node
Answer: a Rationale: The sinoatrial node, the primary pacemaker of the heart, in a normal resting adult heart has an inherent firing rate of 60 to 100 impulses per minute; however, the rate changes in response to the metabolic demands of the body.
2) How can a mechanical ventilator affect the cardiac system? a. Delivers high levels of PEEP and increases the intra-thoracic pressure and the pressure in the chest can compress the heart b. Decreases intra-throacic pressure c. Delivers low levels of PEEP d. Delivers low levels of PEEP and decreases the intra-thoracic pressure and the pressure in the chest can compress the heart.
Answer: a Reasoning: Respiration has a hydraulic influence on cardiovascular function. The ventilator delivers high levels of PEEP and it increases the intra-thoracic pressure and pressure in the chest which can compress the heart.
4. The nurse is caring for a man who was involved in an auto accident the previous day. The client has a double-lumen tracheostomy tube with a cuff. Which of the following actions should the nurse perform? a. Changing the tracheostomy dressing every 8 hours and PRN. b. Change the tracheostomy ties every 48 hours. c. Keep the inner cannula of the tracheostomy in place at all times. d. Push the outer cannula back in if it accidently "blows outs."
Answer: a a. CORRECT: Changing the tracheostomy dressing should be done every 8 hours and PRN to prevent infection; use pre-cut gauze pads. b. INCORRECT: Keep old ties on until new ties are in place; 1 finger space between tie and neck. c. INCORRECT: The tracheostomy tried should be removed and cleaned every 8 hours and PRN. d. INCORRECT: Do not reinsert the outer cannula, instead maintain open airway and contact the physician.
1. A patient is being mechanically ventilated with an oral endotracheal tube in place. The nurse observes that the cuff pressure is 25 mmHg. Which of the following is NOT a potential complication associated with this cuff pressure? a. Tracheal ischemia b. Aspiration pneumonia c. Tracheal bleeding d. Pressure necrosis
Answer: b Rationale: Complications can occur from pressure exerted by the cuff on the tracheal wall. Cuff pressures should be maintained between 15 and 20 mm Hg. -High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis -Low cuff pressure can increase the risk of aspiration pneumonia.
1. The cuff on an endotracheal tube should be inflated to what pressure? a. 5-10 psi b. 15-20 mm Hg c. 8-12 mm Hg d. 3-5 psi
Answer: b Rationale: If the cuff on an endotracheal tube is underinflated, hypoxia or aspiration become very real possibilities. An overinflated cuff can cause tracheal bleeding, ischemia, and pressure necrosis. Great care for the proper pressure must be taken in order for proper functioning and to avoid injury.
1. The nursing home nurse find a 92-year-old client on the floor during rounds. The client is not responsive. Vital signs have been taken by the certified nursing assistant: blood pressure 98/52, heart rate 120, respirations 28, and oxygen saturation 94%. The client has a history of falls, hypertension, and an extensive cardiac history. The client's chart indicated a signed physician order that states "Do not resuscitate" and "Do not intubate" (DNR/DNI). Which of the following should the nurse do? a. Stay with client and have another staff member call 911. b. Begin CPR and have another staff member call 911. c. Move the client into the bed and call the physician. d. Call the family and ask what they would like to have done for the client.
Answer: a a. CORRECT: the nurse should have another staff member call 911, gather paperwork, and contact the primary physician to notify of the answer while the nurse stays with the client to continue to assess for any change in condition. b. INCORRECT: The client has a pulse and is breathing spontaneously at this point, so initiation of CPR would be contraindicated. If the client would no longer have a pulse and/or stop breathing, CPR would not be initiated due to the DNR/DNI status of the client. Unless the client has advanced directives that indicate no emergency treatment or no hospitalization, the nurse should continue reasonable and necessary treatment and nursing care up to the point of resuscitation and intubation. This includes calling 911 for emergency assistance. c. INCORRECT: the nurse would not move the client from the floor because the client may have experienced a fracture or head trauma during the unwitnessed fall. d. INCORRECT: Family notification would take place after emergency services are requests (or ordered).
4. Which of the following are indications for the use of a small-volume nebulizer? Select all that apply: a. Secretions b. Ineffective breathing and coughing c. Decreased Sp02 d. Unsuccessful trials of other means of clearing airway
Answer: a, b, d Rationale: Indications for the use of a small-volume nebulizer include difficulty in clearing respiratory secretions, reduced vital capacity with ineffective deep breathing and coughing, and unsuccessful trials of simpler and less costly methods for clearing secretions, delivering aerosol, or expanding the lungs
1) Regarding PEEP (Positive End-Expiratory Pressure), which of the following are true: Select all that apply. a. it is the pressure maintained in the lungs at the end of expiration b. keeps the alveoli open at the end of expiration to maximize gas exchange c. PaCO2 values are greater than 50mmHg d. Normal value is 5-15 cm of H20 e. Normal value is 25-30cm of H20
Answer: a, b, d Reasoning: As we learned in class the above underlined answers are true. The PaCO2 answer does not apply to PEEP and the values in the last answer are incorrect. The normal value should be 5-15 cm of H20.
3. What parameters should the nurse make sure they receive from the Dr. when they order a patient to be placed on a respirator. Select all that apply. a. Respiratory rate b. PEEP c. Duration of ventilation d. Tidal volume e. mode of mechanical ventilation f. FiO2
Answer: a, b, d, e, f Rationale: These are all parameters that need to documented and ordered by the doctor, and should be asked for if not directly given. The duration of ventilation is unknown and will need to be determined as treatment progresses.
2. In addition to respiratory failure or a compromised airway, what are some clinical indications that would corroborate the need for endotracheal intubation and mechanical ventilation. Select all that apply. a. a continuous decrease in oxygenation (PaO2) b. a worsening of crackles in the lower lobes of the lungs c. an increase in arterial carbon dioxide levels (PaCO2) d. a persistent acidosis (decreased pH)
Answer: a, c, d Rationale: A decrease in PaO2 signifies poor oxygenation and perfusion. An increase in PaCO2 demonstrates that gas exchange in the lungs has become inefficient. A persistent acidosis (respiratory) indicates that the build up of CO2 in the lungs. All three of these scenarios are further evidence for the need to intubate. Worsening crackles in the lower lobes of the lungs could be involved in a case in which mechanical ventilation is needed, but it is not a strong indicator of the need for intubation.
5. What are the indications for hemodynamic monitoring? Select all that apply a. Decreased cardiac output b. Increased cardiac output c. Deficient fluid volume d. Excess fluid volume
Answer: a, c, d Rationale: Indications for hemodynamic monitoring are decreased cardiac output, deficient fluid volume and excess fluid volume. Ineffective tissue perfusion can also be an option but increased cardiac output is not a indication for use of hemodynamic monitoring.
1. What are some of the benefits of a tracheostomy tube vs endotracheal tube? Select all that apply: a. Decreased need for sedation b. Decreased oxygenation requirements c. Increased comfort d. Ease of taking patient on an off ventilator without risk e. Easier insertion
Answer: a, c, d Rationale: Patients who cannot be separated from the ventilator for prolonged periods of time eventually require tracheostomy placement in order to reduce the risk of complications from long-term use of an endotracheal tube. Tracheostomy tubes also offer the benefits of decreased sedation needs, increased patient comfort, increased chances for the patient to eat or speak, ease of patient transfer and ease of taking the patient on and off the ventilator without the need for reintubation and its associated risks if they fail a period of spontaneous breathing.
4. Nitroglycerin can be used to alleviate which of the following? Select all that apply: a. Angina b. Pericarditis c. Pulmonary Embolism d. Esophageal Disorders
Answer: a, d Rationale: a. nitro, rest, O2 b. sitting upright, analgesia, antiinflammatory meds c. treatment of underlying cause d. nitro, food, antacid
1. What type of assisted oxygenation promotes alveolar and airway stability? a. BiPAP (Bilevel Positive Airway Pressure) b. CPAP (Continuous Positive Airway Pressure) c. CMV (Continuous Mandatory Ventilation) d. PSV (Pressure Support Ventilation)
Answer: b Rationale: -CPAP provides a constant positive pressure throughout the respiratory cycle to a spontaneously breathing patient to promote alveolar and airway stability. -BiPAP only provides pressure when the patient inhales. -CMV completely controls the patient's ventilation and is rarely used except in patients who are paralyzed or anesthetized. -PSV is used to decrease the work of breathing.
3. A patient is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this patient? a. Endotracheal intubation b. Continuous positive airway pressure (CPAP) c. Bi-level positive airway pressure (Bi-PAP) d. Corticosteroid inhaler
Answer: b Rationale: CPAP is the most effective treatment for obstructive sleep apnea because the positive pressure acts as a splint, keeping the upper airway and trachea open during sleep.
1. A patient on hemodynamic monitoring through her radial artery raises the head of the bed to 60 degrees. It is important for the nurse to: a. Lower the head of the bed to 0 degrees immediately. b. adjust the transducer to the new height of the phlebostatic axis. c. adjust the pressure bag to the new height of the phlebostatic axis. d. Nothing. The patient can move about freely with no adjustments necessary.
Answer: b Rationale: It is important to readjust the transducer to the height of the phlebostatic axis when a patient changes position. For hemodynamic monitoring using the radial artery it is fine for the patient to raise the HOB up to 60 degrees, as long as the transducer is readjusted. It would not be ok to do this with a femoral line. The pressure bag does not have to be at the phlebostatic axis, but it does need to be maintained at 300mmhg. Therefor, B is correct.
5. The nurse is caring for a patient with an endotracheal tube (ET). Which of the following nursing interventions is contraindicated? a. Deflating the cuff prior to tube removal b. Deflating the cuff routinely c. Checking the cuff pressure every 6 to 8 hours d. Ensuring that humidified oxygen is always introduced through the tube.
Answer: b Rationale: Routine cuff deflation is not recommended because of the increased risk for aspiration and hypoxia. The cuff is deflated before the ET is removed. Cuff pressures should be checked every 6 to 8 hours. Humidified oxygen should always be introduced through the tube.
5. (True or False) The cuff on the tracheostomy or endotracheal tube should be deflated when the patient is receiving mechanical ventilation a. True b. False
Answer: b Rationale: The cuff on an endotracheal or tracheostomy tube should be inflated if the patient requires mechanical ventilation or is at high risk for aspiration.
2. What is the term that is used to describe the intervention where an ET tube is inserted into a patient's airway? a. Intrusive ventilation b. Invasive ventilation c. Aggressive ventilation d. Internal ventilation
Answer: b Rationale: There are two forms of mechanical ventilation: -invasive mechanical ventilation, in which an endotracheal tube is inserted in the patient's airway -noninvasive ventilation
3. For a patient with an endotracheal tube, which nursing intervention is the most important? a. Provide frequent oral hygiene b. Auscultate lungs for bilateral breath sounds c. Reposition every 2 hours d. Monitoring ABG's every 4 hours
Answer: b Rationale: While all the other answers are correct, checking the patients lung sounds are the most important because adequate oxygenation is the primary goal.
2. Men typically develop coronary artery disease (CAD) later than women. a. True b. False
Answer: b Rationale: Women typically develop CAD 10 years later than men because women have the benefit of the female hormone estrogen which provides cardioprotective effects
4) With continuous mechanical ventilation (CMV), what happens if the inspiratory flow is inadequate? a. Decreased work of breathing b. Increased work of breathing c. Increased perfusion d. Increases P-peak
Answer: b Reasoning: If inspiratory flow is inadequate the patient will have to work more to breathe. All other options are incorrect.
2. The critical care nurse is caring for a client with an arterial line (A-line). The nurse can utilize this line for which of the following? a. Monitoring blood pressure and heart rate, and infusing medications. b. Monitoring blood pressure and heart rate and obtaining blood gases and other lab samples. c. Monitoring heart rate, obtaining blood gases and other lab samples, and infusing medications. d. Obtaining blood gases and other lab samples, and infusing medications.
Answer: b a. INCORRECT: Medications should never be infused through an arterial line. b. CORRECT: Arterial lines are used for monitoring blood pressure and heart rate, especially in clients requiring the use of vasopressor medications intravenously. They are also used for clients requiring frequent blood draws. The nurse may also draw arterial blood gases and other lab samples from the line, following the procedure. This saves the client from frequent arterial and venous draws. c. INCORRECT: Medications should never be infused through an arterial line. d. INCORRECT: Medications should never be infused through an arterial line.
3. The nurse is caring for a client who is taking Digoxin (Lanoxin) and wants to monitor for adverse effects. Which findings are characteristics of digoxin toxicity? Select all that apply. a. Tremors b. Diarrhea c. Irritability d. Blurred vision e. Nausea and vomiting
Answer: b, d, e Rationale: Digoxin is a cardiac glycoside. The risk of toxicity can occur with the use of this medication. Toxicity can lead to life-threatening events and the nurse needs to monitor the client closely for signs of toxicity. Early signs of toxicity include gastrointestinal problems such as anorexia, nausea, vomiting and diarrhea. Subsequent manifestations include headache, visual disturbances like diplopia, blurred vision, halos, drowsiness, fatigue and weakness. Cardiac rhythm abnormalities can also occur. The nurse also monitor the digoxin level. Therapeutic levels for digoxin range from 0.5 to 2 mg/ml.
5. What is the difference between thoracotomy and tracheotomy? a. Thoracotomy is a surgical opening into the chest cavity; tracheotomy is the insertion of a breathing tube through the nose or mouth b. Thoracotomy is the insertion of a chest tube; tracheotomy is the insertion of a breathing tube into the nose or mouth c. Thoracotomy is a surgical opening into the chest cavity; tracheotomy is a surgical opening into the trachea d. Tracheotomy is invasive; thoracotomy is non-invasive
Answer: c
3. What does decreased pulse pressure reflect? a. tachycardia b. reduced distensibility of the arteries c. reduced stroke volume d. elevated stroke volume
Answer: c Rationale: Decreased pulse pressure reflects reduced stroke volume and ejection velocity or obstruction to blood flow during systole. Increased pulse pressure would indicate reduced distensibility of the arteries, along with bradycardia.
3. Which of the following is NOT a common sign/symptom of cardio vascular disease (CVD)? a. Chest pain or discomfort b. Palpitations c. Nausea and vomiting d. Fatigue
Answer: c Rationale: Nausea and vomiting are not common signs or symptoms of CVD
4. When planning care for a patient on a mechanical ventilator, the nurse understands that the application of positive end-expiratory pressure (PEEP) to the ventilator settings has which therapeutic effect? a. Increased inflation of the lungs b. Prevention of barotrauma to the lung tissue c. Prevention of alveolar collapse during expiration d. Increased fraction of inspired oxygen concentration (FIO2) administration
Answer: c Rationale: PEEP is positive pressure that is applied to the airway during exhalation. This positive pressure prevents the alveoli from collapsing, improving oxygenation and enabling a reduced FIO2 requirement. PEEP does not cause increased inflation of the lungs or prevent barotrauma. Actually auto-PEEP resulting from inadequate exhalation overtime may contribute to barotrauma.
5) If about 4/5 of the blood is left in the ventricle after the contraction of the heart, what is the most likely ejection fraction (EF)? a. 70% b. 50% c. 20% d. 87%
Answer: c Reasoning: Ejection fraction in a healthy heart is 70%. If the ejection fraction is under 50% it means that there is a larger volume of blood left in the ventricle after the contraction. This means that there is less room for "new" blood in the ventricle and less blood is going out to perfuse the body. An ejection fraction of 20% is not good!
5. The nurse is preparing a female client for a cardiac catheterization with the femoral approach. The nurse should do which of the following when the client returns to her room after the procedure? a. Elevate the head of the bed 45 degrees. b. Keep the client's arm immobilized for the first 24 hours. c. Keep the client's leg immobilized for the first 12 hours. d. Tell the client to lie on the procedural side for 2 hours.
Answer: c a. INCORRECT: The head of the bed should be elevated to no more than 30 degrees to reduce the risk of bleeding and promote healing. b. INCORRECT: The arm is immobilized if the brachial approach is used. c. CORRECT: The affected leg is immobilized for the first 12 hours to prevent hemorrhage. d. INCORRECT: The client should be instructed to lie on her back for the first 12 hours to reduce the risk of bleeding and promote healing.
3. The intensive care nurse is caring for a client requiring mechanical ventilation. Which intervention should the nurse take to help prevent ventilator-associated pneumonia (VAP)? a. Reposition the client at least every 4 hours and maintain the head of the bed upright at 30-45 degrees. b. Promoted nutrition with the use of an NG tube and high-calorie feedings. c. Suction oral and pharynx secretions and provide thorough oral care at least every 2 hours. d. Perform hand hygiene before and after care of the client and implement prophylactic intravenous antibiotic therapy.
Answer: c a. INCORRECT: The standard of care is to reposition the client at least every 2 hours using lateral and horizontal position techniques. It is correct to leave the head of raised to 30-45 degrees unless contraindicated. This helps reduce aspiration of both secretions and gastric contents. b. INCORRECT: An NG tube can lead to sinusitis, which increased the likelihood of the client developing VAP. The use of an orogastric tube to aid in feeding and/or gastric decompression is recommended over the use of an NG tube. c. CORRECT: Oral care should be done at least every 2 hours. The removal of excess secretions is also important element in the reduction of VAP. These secretions can cause aspiration and can also be perfect moist breeding ground for infection. d. INCORRECT: Although proper hand hygiene and the use of gloves have been shown to reduce the risk of VAP, prophylactic intravenous antibiotic therapy is not recommended. A broad-spectrum antibacterial oral rinse (chlorhexidine) has been used in conjunction with thorough oral care with good results.
3. Which of the following is not involved in the ethics advisory committee when determining whether a case of continued life-sustaining therapy is inappropriate or harmful? a. Physician b. Clergy c. Friends d. All of the above can be involved
Answer: d Rationale: A 3-phase review process by the institution's ethics advisory committee to determine whether a case of continued life-sustaining therapy is inappropriate or harmful: -Review by members of the committee -Review including the care team -Review including patient and/or supporting individuals, including surrogate and possibly clergy, friends, etc.
5. The nurse is reviewing the results of the patient's echocardiogram and observes that the ejection fraction is 35%. The nurse anticipates that the patient will receive treatment for what condition? a. pulmonary embolism b. myocardial infarction c. pericarditis d. heart failure
Answer: d Rationale: An ejection fraction of less than 40% indicates that the patient has decreased left ventricular function and likely requires treatment for heart failure.
5. A patient has a high magnesium level. Identify how hypermagnesemia affects cardiac function. a. Causes atrial tachycardia b. Causes ventricular tachycardia c. Increases myocardial contractility d. Decreases myocardial contractility
Answer: d Rationale: Hypermagnesemia can cause depression of myocardial contractility and excitability heart block and asystole. Hypomagnesemia predisposes patient to atrial or ventricular tachycardias.
2. A Nurse caring for a patient believes they are ready to be weaned off a ventilator. What is an indication that the patient is NOT ready? a. Patient maintains adequate oxygenation with minimal support b. Can maintain acid-base balances c. Can successfully breath on their own d. Needs frequent suctioning
Answer: d Rationale: If the patient continues to need frequent suctioning, they are not ready to be weaned from the vent. All the other options support the Nurse's belief that the patient can begin to be weaned off the ventilator.
4. What is the first thing you do if you enter a pt room and the patient has removed their own ET tube and is no longer receiving ventilatory support? a. apply oxygen via nasal canula b. check vitals c. re-intubate the patient immediately d. call for help/call a rapid response
Answer: d Rationale: You need help to manage this situation, so you need to call for help immediately, and then the correct course of action can be taken. The nurse should not ever attempt to re-intubate a patient. The patient will possibly need to be bagged, or may be able to breathe on their own, but you need help there immediately in case not, therefor the priority is to call for help first.
3) You are the nurse on duty and walk into Mr. Jensen's room. You notice that he has a trachea tube. He has mucous-like secretions hanging off the end of the trachea tube. What else are indications for suctioning the patient? a. increase in tidal volume, patient lungs sound clear b. decrease in tidal volume, hypoxia, and can hear rhonchi, mucus, cough c. good oxygen saturation with increased tidal volume d. patient can clear their own airway, and you hear rhonchi, see mucus, and they have a cough
Asnwer: b Reasoning: Indications for suction include a decrease in tidal volume, hypoxia, hearing rhonchi, the presence of mucous, patient coughing and unable to clear their airway. If tidal volume increases and the patient can clear their own airway there is no need for suction.
5. The nurse knows that electrophysiologic testing is done primarily to: a. Determine the size, contour, and position of the heart b. Diagnose and determine the source of dysrhythmias c. Produce an image of the heart d. Evaluate myocardial blood flow and perfusion
Correct Answer: b. Rationale: The electrophysiology study (EPS) is an invasive procedure that plays a major role in the diagnosis and management of serious dysrhythmias. EPS may be indicated for patients with syncope, palpitations, or both, and for survivors of cardiac arrest from ventricular fibrillation. EPS does not determine the size, contour, and position of the heart; produce an image of the heart; or evaluate myocardial blood flow and perfusion.
1. Which of the following is NOT an indication for the nurse to start a pt on mechanical ventilation? a. If the pt is in hypercarbic or hypoxemic respiratory failure b. To prevent or reverse atelectasis c. If the pt has aspirated or is at risk for aspiration d. To prevent or reverse respiratory muscle fatigue
Correct Answer: c. Rationale: A patient should not be intubated and put on mechanical ventilation simply because of aspiration or a risk for aspiration. To treat aspiration, clear the airway of whatever is causing the aspiration, provide extra oxygen if necessary, and take antibiotics if a resulting infection has occurred. All other choices are indications for starting a patient on mechanical ventilation.
3. The nurse suspects hypoxemia in her patient when she notices the following signs and symptoms. Select all that apply. a. Confusion b. Increase in blood pressure c. Warm extremities d. Dysrhythmias or a change in heart rate e. A lack of sweating
Correct Answers: a, b, d. Rational: Hypoxemia, a decrease in the arterial oxygen tension in the blood, is manifested by changed in mental status (progressing through impaired judgment, agitation, disorientation, confusion, lethargy, and coma), dyspnea, increase in blood pressure, changes in heart rate, dysrhythmias, central cyanosis (late sign), diaphoresis, and cool extremities. Hypoxemia can lead to hypoxia, a decrease in oxygen supply to the tissues and cells, which can be life threatening if left untreated.
2. Which of the following evidence-based strategies used by the nurse best support the family members of ICU patients at high risk of dying? Select all that apply. a. Building rapport b. Communicating with the family infrequently c. Demonstrating no concern d. Demonstrating professionalism e. Supporting decision-making
Correct Answers: a, d, e. Rationale: Strategies such as building rapport, demonstrating professionalism, and supporting decision-making have shown to help family members cope; to have hope, confidence, and trust; to prepare for and accept impending death; and to make decisions. Other strategies that work include frequent communication, demonstrating concern, and providing factual information.
4. The nurse knows that one of the following blood chemistry values is NOT essential to monitoring heart function: a. Phosphate (2.5-4.5 mg/dL) b. Calcium (8.6-10.2 mg/dL) c. Magnesium (1.3-2.3 mEq/dL) d. Potassium (3.5-5 mEq/dL)
Correct Answers: a. Rationale: Phosphate plays no role in cardiac function. -Calcium is necessary for blood coagulability, neuromuscular activity, and automaticity of the nodal cells (sinus and atrioventricular nodes). -Magnesium is necessary for the absorption of calcium, maintenance of potassium stores, and metabolism of adenosine triphosphate. -Potassium has a major role in cardiac electrophysiologic function.
sets the peak inflation pressure and respiratory rate but doesn't specify the tidal volume.
Pressure control ventilation - tidal volume received by the pt varies based on the compliance of the respiratory system and the level of airway resistance.
FiO2
fraction of inspired oxygen. - ideal FiO2 = 0.21 - FiO2 is typically kept below 0.5 (50%) to avoid oxygen toxicity
preset positive pressure is delivered with spontaneous breaths to decrease work of breathing
pressure support ventilation (PSV)
partial ventilatory support in proportion to the patient's inspiratory efforts; decreases the work of breathing
proportional assist ventilation (PAV)
receive set # of breaths/minute. Pt can initiate own breaths, but on the extra breaths, the pt only gets as much tidal volume as they are capable of taking in on their own;
synchronized intermittent mandatory ventilation (SIMV)