Medical Surgical Chapter 66 Critical Care

The nurse is having difficulty obtaining an accurate oxygen saturation of hemoglobin (SpO2) measurement on a patient. What should the nurse consider as the reason for this difficulty? 1 Body temperature 95.4° F 2 Receiving a cardiac glycoside 3 Blood pressure of 118/72 mm Hg 4 Heart rate of 72 beats/minute with occasional ectopy

1 Accurate oxygen saturation of hemoglobin (SpO2) measurements may be difficult to obtain on patients who are hypothermic, are 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 blood pressure of 118/72 mm Hg and heart rate of 72 with occasional ectopy are not manifestations of shock and would not cause this difficulty. Text Reference - p. 1609

A pulmonary artery catheter has just been inserted through a patient's internal jugular vein. What should be done before the catheter is used for fluid administration? 1 Obtain a chest x-ray 2 Draw a hemoglobin level 3 Evaluate electrolyte levels 4 Obtain a 12-lead electrocardiogram

1 After insertion and before using the PA catheter, a chest x-ray must be taken to confirm the catheter's position. A hemoglobin level is not needed before using the catheter for fluid administration. Electrolyte levels do not need to be evaluated before using the catheter for fluid administration. A 12-lead electrocardiogram is not needed before using the catheter for fluid administration. Text Reference - p. 1608

What is the similarity between negative pressure ventilation and positive pressure ventilation? 1 Both involve passive expiration. 2 Both require an artificial airway. 3 Both are routinely used for acutely ill patients. 4 Both raise intrathoracic pressure during lung inflation.

1 Both negative pressure ventilation and positive pressure ventilation involve passive expiration. Negative pressure ventilation does not require an artificial airway. Positive pressure ventilation may require invasive mechanical ventilation through an artificial airway. Positive pressure ventilation is primarily used with acutely ill patients; negative pressure ventilation is not routinely used for acutely ill patients. In positive pressure ventilation, intrathoracic pressure is raised during lung inflation but in negative pressure ventilation, intrathoracic pressure is decreased during lung inflation. Text Reference - p. 1618

Which neurologic complication may occur in a patient with a head injury who is on positive pressure ventilation? 1 Decrease in venous return 2 Compression of jugular vein 3 Reduction of cerebral volume 4 Reduction of intracranial pressure

1 In a patient with a head injury, positive pressure ventilation decreases the venous return because of the increase in intrathoracic pressure. Increased intrathoracic pressure causes jugular vein distension rather than compression. Positive pressure ventilation increases the cerebral volume. A decrease in venous return causes an increase in intracranial pressure. Text Reference - p. 1623

The nurse is concerned about a patient's stroke volume. What determines stroke volume? 1 Preload, afterload, and contractility 2 Cardiac output, heart rate, and body surface area 3 Afterload, cardiac output, and mean arterial pressure 4 Cardiac index, mean arterial pressure, and blood pressure

1 Preload, afterload, and contractility determine stroke volume (SV). Cardiac output and heart rate are used to determine stroke volume; however, body surface area is used to determine cardiac index. Mean arterial pressure is used to determine afterload, not stroke volume. Cardiac index is a more precise measurement of the efficiency of the heart's pumping action; it is not used to determine stroke volume. Text Reference - p. 1603

A nurse is attending a patient with acute respiratory distress syndrome (ARDS). Which position is best for this patient? 1 Prone 2 Sitting 3 Supine 4 Lateral

1 Prone positioning refers to the repositioning of a patient from a supine or lateral position to a prone position. This repositioning improves lung reexpansion through various mechanisms. Firstly, the gravity reverses the effects of fluid in the dependent parts of the lungs as the patient is moved from supine to prone. Secondly, in the prone position, the heart rests on the sternum, away from the lungs, contributing to an overall uniformity of pleural pressures. These two mechanisms help in better ventilation in the patient with respiratory failure. The prone position is a relatively safe supportive therapy used for critically ill patients with acute lung injury or ARDS and is used for improved oxygenation. Resting in other positions such as sitting, supine, or lateral may not help in oxygenation. Text Reference - p. 1622

A patient has the following device. Which port should be used to measure pulmonary artery pressure? 1. A 2. B 3. C 4. D

1 The distal lumen port (catheter tip), labeled A in the image, is within the pulmonary artery. This port is used to monitor pulmonary artery (PA) pressures. 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. Text Reference - p. 1607

A patient with an arterial invasive device has the following auscultated blood pressures. What setting should the nurse use for this patient's low pressure alarms? 1 Systolic 100; Diastolic 60 2 Systolic 120; Diastolic 80 3 Systolic 140; Diastolic 80 4 Systolic 150; Diastolic 90

1 The high- and low-pressure alarms are set based on the patient's current status. Since the patient's lowest auscultated systolic blood pressure was 118 mm Hg, the best setting to use would be systolic 100. Because the patient's lowest diastolic blood pressure 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. Text Reference - p. 1606

A patient with a pulmonary arterial catheter for systolic heart failure is diagnosed with a urinary tract infection (UTI). The last central venous oxygen saturation (ScvO2) mixed venous oxygen saturation (SvO2) measurement was 89%. What should the nurse suspect is occurring with this patient? 1 Sepsis 2 Decreased cardiac output 3 Increased oxygen demand 4 Balanced oxygen supply and deman

1 The patient has a urinary tract infection, which can lead to sepsis. In sepsis, oxygen is not extracted properly at the tissue level, resulting in increased central venous oxygen saturation (ScvO2) mixed venous oxygen saturation (SvO2) measurements. Central venous oxygen saturation (ScvO2) mixed venous oxygen saturation (SvO2) measurements would be low if the patient was experiencing decreased cardiac output or increased oxygen demand. Central venous oxygen saturation (ScvO2) mixed venous oxygen saturation (SvO2) measurements would be between 60% and 80% if the oxygen supply and demand was balanced. Text Reference - p. 1609

The nurse is caring for a patient receiving intraaortic balloon therapy. Which nursing interventions are appropriate for this patient? Select all that apply. 1 Monitoring oxygen deprivation levels 2 Monitoring hemodynamic parameters 3 Monitoring neurovascular complications 4 Including spinach in the patient's diet 5 Providing warfarin therapy

1, 2, 3 Intraaortic balloon therapy destroys platelets and may cause thrombocytopenia. Monitoring hemodynamic parameters helps estimate the loss of platelets and development of thrombus. Enlarged blood clots reduce blood flow to the tissues and result in hypoxemia. Therefore, measurement of oxygen deprivation levels assesses for thrombus formation in the patient. Peripheral neurovascular damage is generally observed as a result of intraaortic balloon therapy and should be monitored. Spinach is rich in vitamin K and increases the formation of clotting factors. Warfarin is an anticoagulant used to prevent future development of blood clots. Spinach and warfarin should be avoided for patients with thrombocytopenia. Text Reference - p. 1611

The nurse is evaluating a patient receiving intraaortic balloon pump (IABP) therapy. Which findings 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 Blood pressure 168/88 mm Hg 5 Oriented to person, place, and time

1, 2, 3, 5 Hemodynamic effects of intraaortic balloon pump therapy (IABP) 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 blood pressure regulation. Text Reference - p. 1611

A patient is placed on a ventilator for assisted ventilation. What precautions should a nurse take to prevent the patient from ventilator-assisted pneumonia (VAP)? Select all that apply. 1 Wash hands before and after suctioning. 2 Use an endotracheal (ET) tube with a dorsal lumen above the cuff. 3 Change the patient's ventilator circuit tubing every two to three hours. 4 Wear gloves when in contact with the patient, and change gloves between activities. 5 Maintain the head-of-bed elevation at a minimum of 90 degrees unless medically contraindicated.

1, 2, 4 Patients have a higher risk for hospital-acquired pneumonia when they require mechanical ventilation. This is because the ET or tracheostomy tube bypasses the normal upper airway defenses. Additionally, poor nutritional state, immobility, and the underlying disease process make the patient more prone to infection. VAP is pneumonia that occurs 48 hours or more post-ET intubation. To prevent VAP, the health care team should strictly wash their hands before and after suctioning. An ET tube with a dorsal lumen above the cuff should be used to allow continuous suctioning of secretions in the subglottic area. Gloves should be worn whenever the nurse is in contact with the patient, and the nurse should change them frequently between activities to avoid cross-infection. If the ventilator circuit tubing is changed frequently, there is more risk of exposing the patient to various infections. Therefore, there should be no routine changes in the patient's ventilator circuit tubing. In addition to this, the head-of-bed should be elevated at a minimum of 30 to 45 degrees, unless medically contraindicated, to prevent pooling of secretions and facilitate suctioning. Text Reference - p. 1623

A patient with severe respiratory distress is brought to the medical facility. The health care provider prescribes rapid-sequence intubation (RSI) to be done. What information should the nurse include when explaining the procedure to the family members? Select all that apply. 1 A sedative and a paralytic medication is administered so that the patient sleeps and does not feel the pain. 2 After intubation, 100% oxygen is given to the patient, and placement of the tube is confirmed. 3 After giving paralytic, an opening is made in the throat through which a tube is introduced. 4 After establishing the opening in the throat, the tube is placed and dressed properly. 5 A tube will be introduced in the patient's throat through the mouth so that ventilation can be established.

1, 2, 5 In RSI, a sedative and paralytic are administered to the patient. Usually a sedative-hypnotic-amnesic agent like midazolam is used to make the patient unconscious. A rapid-onset opioid like fentanyl is also given to blunt the pain of the procedure. A paralytic drug like succinylcholine is then given to produce skeletal muscle paralysis. Before this, the patient is 100% oxygenated. After intubation, the patient is again 100% oxygenated, and tube placement is confirmed. Auscultation of the chest bilaterally and x-ray are some of the methods of confirming the placement of the tube. During intubation, the endotracheal (ET) tube is inserted through the nose or mouth. While performing RSI, no opening is made in the throat. However, an opening in the throat is made in a procedure called tracheostomy. Text Reference - p. 1614

A patient is advised to have a pulmonary artery (PA) catheter inserted for pulmonary artery pressure monitoring. What precautions are necessary prior to insertion of the catheter? Select all that apply. 1 Place the patient in the supine and flat position. 2 Position the patient sitting and with head turned laterally. 3 Explain the procedure to the patient and get consent. 4 Note the patient's electrolyte levels and oxygenation and coagulation status. 5 Do not cover the catheter insertion site with any dressings.

1, 3, 4 Before PA catheter insertion, the patient is positioned supine and flat. The procedure is explained to the patient, and informed consent is obtained. The patient's electrolyte, acid-base, oxygenation, and coagulation status are noted. Imbalances such as hypokalemia, hypomagnesemia, hypoxemia, or acidosis can make the heart more irritable and increase the risk of ventricular dysrhythmia during catheter insertion. Coagulopathy increases the risk of hemorrhage. The procedure is never performed in a sitting position. The PA catheter is inserted through a sheath percutaneously into the internal jugular, subclavian, antecubital, or femoral vein using surgical asepsis. The insertion sites have to be dressed with occlusive dressings. Text Reference - p. 1608

The nurse identifies that pulmonary artery catheterization is contraindicated for patients with a history of what? Select all that apply. 1 Coagulopathy 2 Cardiogenic shock 3 Fulminant myocarditis 4 Endocardial pacemaker 5 Mechanical tricuspid valve

1, 4, 5 Pulmonary artery catheterization helps to monitor and manage the care of patients who are at high risk for hemodynamic compromise. Pulmonary artery catheterization may cause trauma in the blood vessels and worsen symptoms of coagulopathy. Pulmonary artery catheterization increases the risk of trauma in patients with mechanical tricuspid valves and endocardial pacemakers; therefore, it is contraindicated in the patient with coagulopathy, mechanical tricuspid valve, and transvenous pacemaker. Pulmonary artery catheterization is performed in patients with cardiogenic shock and fulminant myocarditis to detect the risk of heart failure. Text Reference - p. 1607

A patient's blood pressure is 172/94 mm Hg. What would the nurse calculate as being this patient's mean arterial pressure (MAP)? Record your answer using a whole number. ____________ mm Hg

120 MAP is calculated by adding the systolic blood pressure to two times the diastolic blood pressure and dividing by three. For this patient that calculation would be 172 + 2(94)/3 = 120 mm Hg. Normal MAP is between 70 and 105 mm Hg. Text Reference - p. 1603

What data are used to calculate stroke volume (SV) for a patient with arterial pressure-based cardiac output (APCO) monitoring? 1 Height, BMR, age, gender 2 Gender, age, height, weight 3 BMI, BMR, blood pressure, heart rate 4 Age, gender, blood pressure, heart rate

2 Arterial pressure-based cardiac output (APCO) monitoring uses the arterial waveform characteristics along with patient demographic data including gender, age, height, and weight to calculate stroke volume (SV). Basal metabolic rate (BMR), body mass index (BMI), blood pressure, and heart rate are not used to calculate stroke volume with this measuring device. Heart rate is used to calculate continuous cardiac output (COO) and continuous cardiac index (CCI). Text Reference - p. 1607

The nurse educator is preparing a lecture on hemodynamic monitoring. What should the educator use to explain the effects of preload? 1 Cardiac index 2 Frank-Starling's law 3 Systemic vascular resistance 4 Pulmonary vascular resistance

2 Frank-Starling's law explains the effects of preload and states that the more a myocardial fiber is stretched during filling, the more it shortens 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. Text Reference - p. 1604

A nurse should monitor a patient undergoing mechanical ventilation for which common complication? 1 Hypertension 2 Pneumothorax 3 Electrolyte imbalance 4 Increased cardiac output

2 Mechanical ventilation can cause pneumothorax as a result of excessive pressure applied to lung tissue. Hypertension is not a direct complication; however, a patient undergoing mechanical ventilation may be anxious and fearful, resulting in high blood pressure; sedation should be considered in this event. Electrolyte imbalance is not a related complication. Mechanical ventilation does increase intrathoracic pressure, which may then increase cardiac output, causing a beneficial secondary effect. Text Reference - p. 1615

The nurse is monitoring a patient in ICU. Which ScvO2/SvO2reading is a cause of concern in the patient? 1. 68% 2. 54% 3. 72% 4. 78%

2 Normal central venous oxygen saturation or ScvO2/SvO2 is 60% to 80%. It denotes normal oxygen supply and metabolic demand. Any reading out of the normal range can cause danger to the patient. More than 80% denotes increased oxygen supply and decreased oxygen demand. Less than 60% denotes decreased oxygen supply and increased demand. Text Reference - p. 1609

What condition would the nurse infer that a patient undergoing positive end-expiratory pressure (PEEP) therapy has? 1 Hypovolemia 2 Pulmonary edema 3 Low cardiac output 4 Unilateral lung disease

2 Positive end-expiratory pressure (PEEP) therapy is given to patients with pulmonary edema to provide a counter pressure opposing fluid extravasation. PEEP is not used for patients with hypovolemia, low cardiac output and unilateral or nonuniform lung disease because in those patients, the adverse effects of PEEP may outweigh any benefits. Text Reference - p. 1621

A patient is recovering from the implantation of a ventricular assist device (VAD). What should the nurse anticipate being prescribed for this patient's activity status? 1 Complete bedrest 2 Progressive ambulation 3 Moving out of bed to a chair twice a day 4 Bedrest with bathroom privileges

2 The patient with a ventricular assist device (VAD) may be mobile and require an activity plan such as progressive ambulation. Complete bedrest is not required. The patient will be permitted to do more than move from the bed to a chair twice a day. Activity will be greater than bed rest with bathroom privileges. Text Reference - p. 1613

When caring for a critically ill patient on mechanical ventilation, what task must the registered nurses (RNs) perform by themselves and not delegate to unlicensed assistive personnel (UAP)? 1 Obtaining vital signs 2 Administering sedatives 3 Measuring urine output 4 Performing bedside glucose test

2 While caring for a patient requiring mechanical ventilation, the registered nurses (RNs) must administer sedatives by themselves; they should not delegate this task to unlicensed assistive personnel (UAP). UAP can be tasked with obtaining vital signs, measuring urine output, and performing bedside glucose tests. Text Reference - p. 1625

A patient has received intraaortic balloon pump (IABP) therapy. In this case, what precautions should a nurse take to prevent any infection at the site? Select all that apply. 1 Replace the lines every two to three hours. 2 Cover all insertion sites with occlusive dressings. 3 Use strict aseptic technique line insertion and dressing changes. 4 Send culture swabs from the insertion site regularly. 5 Administer prophylactic antibiotics for the entire course of therapy

2, 3, 5 It is extremely important to follow aseptic measures to avoid infection following an IABP. Covering all the insertion sites with occlusive dressings avoids infections. Aseptic techniques should be followed during insertion and dressing changes to prevent infection. Prophylactic antibiotics prevent infections. Infection doesn't breed in the dressings if aseptic precautions are followed and the dressings are cleaned and replaced regularly. Replacing the lines every two hours is not necessary, but following aseptic conditions is. A culture swab helps to identify the presence of infection but d

A patient is being considered for ventricular assist device (VAD) therapy. Which criteria indicate that this patient is an appropriate candidate for implantation of this device? Select all that apply. 1 Body surface area 1.1 m2 2 Placed on the heart transplantation list 3 Diagnosed with alcoholic liver failure 4 Diagnosed with Class IV heart disease 5 Unable to wean from the cardiopulmonary bypass (CPB) machine

2, 4, 5 Appropriate patient selection for ventricular assist device (VAD) includes patients who are waiting for heart transplantation, who are diagnosed with Class IV heart disease, and have failed medical therapy, and who have failed to wean from cardiopulmonary bypass (CPB). Body surface area less than 1.3 m2 is a contraindication for ventricular assist device (VAD) therapy. Liver failure unrelated to a cardiac event is a contraindication for ventricular assist device (VAD) therapy. Text Reference - p. 1612

A patient is placed on mechanical ventilation. A nurse notices that the alarm for the high-pressure limit has been set off. What are the possible conditions that could give rise to this alarm? Select all that apply. 1 Oversedation 2 Secretions, coughing, or gagging 3 Loss of airway through total or partial extubation 4 Patient fighting the ventilator 5 Decreased compliance due to pulmonary edema 6 Kinked or compressed tubing

2, 4, 5, 6 The possible causes for a high-pressure limit alarm to go off include secretions, coughing, or gagging. It may also be set off in case of ventilator asynchrony if the patient is fighting the ventilator. Decreased compliance due to conditions like pulmonary edema may also cause the setting off of the high-pressure alarm. It can also be due to kinked or compressed tubing, which usually happens when the patient is biting on the endotracheal tube. Oversedation and loss of airway cause an apnea alarm and can also set off the low-pressure limit alarm. Text Reference - p. 1620

A patient with a spinal cord injury requires negative pressure ventilation. What statements should the nurse say to the patient's caregiver about negative pressure ventilation? Select all that apply. 1 "It is a type of invasive ventilation." 2 "It is similar to the normal ventilation." 3 "It pulls the chest inward during inspiration." 4 "It uses intermittent subatmospheric pressure." 5 "It uses chambers that encase the upper airway." 6 "It reduces intrathoracic pressure during inspiration."

2, 4, 6 Negative pressure ventilation is similar to normal ventilation in that expiration is passive and decreased intrathoracic pressures produce inspiration. Negative pressure ventilation uses intermittent subatmospheric pressure around the chest wall. This pressure reduces the intrathoracic pressure during inspiration. Negative pressure ventilation is noninvasive because it does not require an artificial airway. During inspiration, the chest is pulled outward because of the intermittent negative pressure around the chest wall. Negative pressure ventilation uses chambers that encase the chest wall, but not the upper airway. Text Reference - p. 1618

A patient is intubated. The nurse has to perform a spontaneous breathing trial (SBT) on this patient. For how long should this trial be done? 1 At least 15 minutes but not more than 30 minutes 2 At least 30 minutes but not more than 60 minutes 3 At least 30 minutes but not more than 120 minutes 4 At least 60 minutes but not more than 120 minutes

3 An SBT is recommended in patients who demonstrate weaning readiness. An SBT should be at least 30 minutes but no more than 120 minutes. At least 15 minutes but no more than 30 minutes, at least 30 minutes but no more than 60 minutes, and at least 60 minutes but no more than 120 minutes are not recommended time frames to determine weaning readiness. Text Reference - p. 1626

Auto-positive end-expiratory pressure (PEEP) is the additional PEEP over what is set by the health care provider. What causes auto-PEEP during mechanical ventilation? 1 Barotrauma 2 Hemodynamic instability 3 Inadequate exhalation time 4 Increased work of breathing

3 Auto-positive end-expiratory pressure (auto-PEEP) is caused by inadequate exhalation time. Barotrauma, hemodynamic instability and increased work of breathing are the results and not the causes of the auto-PEEP. Text Reference - p. 1621

A patient is being prepared for insertion of an arterial measuring device. What should be done before the catheter is inserted into the patient's radial artery? 1 Locate the phlebostatic axis 2 Prepare a heparinized flush bag 3 Occlude the radial and ulnar arteries 4 Set an intravenous pump to deliver 15 mL/h

3 Before inserting a line into the radial artery, an Allen test should be performed to confirm that ulnar circulation to the hand is adequate. In this test, pressure is applied to the radial and ulnar arteries simultaneously. The patient opens and closes the hand repeatedly until the hand blanches. When the pressure on the ulnar artery is released, the hand should return to a pink color within six seconds. If pinkness does not return within six seconds the ulnar artery is inadequate to maintain blood flow to the extremity and the radial artery should not be used for arterial line insertion. The phlebostatic axis is used to zero the arterial line, which would be done much later. Because of the risk of heparin-induced thrombocytopenia (HIT), heparinized saline should not be routinely used for the flush solution. The flush bag should be set to deliver 3 to 6 mL/hr. Text Reference - p. 1606

What measurement is used to assess muscle strength in a patient with positive pressure ventilation? 1 Vital capacity 2 Minute ventilation 3 Negative inspiratory force 4 Rapid shallow breathing index

3 Negative inspiratory force is used to assess the muscle strength in a patient with positive pressure ventilation. Vital capacity, minute ventilation and rapid shallow breathing index are used to assess the muscle endurance. Test-Taking Tip: Multiple-choice questions can be challenging because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response. Text Reference - p. 1626

A patient is admitted to the ICU and is on assisted ventilation. Which is the best indicator of inadequate alveolar oxygenation? 1 PETCO2 2 SpO2 3 PaCO2 4 ScvO2 or SvO2

3 PaCO2 is the best indicator of alveolar hyperventilation or hypoventilation. Continuous 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. Text Reference - p. 1615

A patient is being mechanically ventilated. A high-pressure ventilation alarm sounds. The nurse should assess for what cause of this type of alarm? 1 Power failure 2 Insufficient gas flow 3 Condensate in tubing 4 Tracheotomy cuff leak

3 Presence of condensate or water in tubing triggers a high-pressure ventilation alarm. Power failure triggers ventilator inoperative or low battery alarm. Insufficient gas flow and tracheotomy cuff leak triggers low tidal volume or minute ventilation alarm. Text Reference - p. 1620

The nurse is preparing a patient for arterial pressure-based cardiac output (APCO) measuring. What patient criteria must be met before this measuring device can be used to determine the patient's stroke volume variation (SVV)? 1 Spontaneous respirations and placement of an arterial line 2 Continuous cardiac monitoring and application of oxygen via face mask 3 Controlled mechanical ventilation and fixed respiratory rate and tidal volume 4 Nasal intubation and positive end expiration pressure setting on the ventilator

3 Stroke volume variation (SVV) is the variation of the arterial pulsation caused by heart-lung interaction. It is a sensitive indicator of preload responsiveness when used on select patients. SVV is used only for patients on controlled mechanical ventilation with a fixed respiratory rate and a fixed tidal volume of 8 mL/kg. SVV is not used 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 needs to be intubated rather than provided with oxygen via a face mask. The patient needs to be intubated; however, nasal intubation is not identified as a requirement. It is not identified that the patient needs to be receiving positive end expiration pressure through the ventilator. Text Reference - p. 1607

Which hemodynamic value should the nurse use to determine a patient's left ventricular afterload? 1 Central venous pressure 2 Pulmonary arterial pressure 3 Systemic vascular resistance 4 Peripheral vascular resistance

3 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. Text Reference - p. 1604

The patient has developed cardiogenic shock after a left anterior descending myocardial infection. Which circulatory assist device should the nurse expect to use for this patient? 1 Cardiopulmonary bypass 2 Impedance cardiography (ICG) 3 Intraaortic balloon pump (IABP) 4 Central venous pressure (CVP) measuremen

3 The most commonly used mechanical circulatory assist device is the IABP, and it is used to decrease ventricular workload, increase myocardial perfusion, and augment circulation. Cardiopulmonary bypass provides circulation during open heart surgery. It is not used as an assist device after surgery. ICG is a noninvasive method to obtain cardiac output and assess thoracic fluid status. CVP measurement is an invasive measurement of right ventricular preload and reflects fluid volume problems. Text Reference - p. 1611

To obtain an accurate central venous pressure reading with a central venous catheter, a nurse should place the patient in what position? 1 Left side-lying 2 Right side-lying 3 Supine and horizontal 4 Supine with head of bed elevated 45 degrees

3 To obtain an accurate central venous pressure (CVP) reading, the nurse should ensure that the patient is supine and in horizontal position so the zero reference point at the level of the right atrium (also known as the phlebostatic axis) is level with the zero mark on the manometer. If a patient is unable to lie flat, the manometer should be positioned so the zero reference is at the level of the right atrium and the degree of head elevation noted so there is consistency across measurements. Right or left side-lying and supine positions with the head of the bed elevated 45 degrees are all incorrect for obtaining a CVP reading. Text Reference - p. 1605

The nurse is planning care for a patient receiving intraaortic balloon pump (IABP) therapy. What interventions should be included to reduce this patient's risk of developing an infection? Select all that apply. 1 Keep lower extremities extended 2 Turn and reposition every two hours 3 Cover the site with an occlusive dressing 4 Administer prophylactic antibiotics as prescribed 5 Use strict aseptic technique with dressing changes

3, 4, 5 Interventions to reduce the risk of infection in a patient with an intraaortic balloon pump (IABP) include covering the site with an occlusive dressing, administering prophylactic antibiotics as prescribed, and using strict aseptic technique with dressing changes. Keeping the lower extremities extended would help prevent arterial trauma caused by insertion or displacement of the balloon. Turning and repositioning every two hours would help prevent the development of stasis pneumonia. Text Reference - p. 1612

What is the rapid shallow breathing index of a patient whose spontaneous respiratory rate (f) is 15 breaths/min and spontaneous tidal volume (VT) is 0.4 L? Record your answer using one decimal place. ___________________breaths/min/L

37.5 The formula to calculate the rapid shallow breathing index is f/VT. Therefore, rapid shallow breathing index = 15/0.4 = 37.5 breaths/min/L. Text Reference - p. 1626

A nurse measures a patient's central venous pressure and recognizes a series of increased readings as directly indicative of: 1 Cardiogenic shock 2 Circulatory failure 3 Left ventricular failure 4 Right ventricular failure

4 Central venous pressure (CVP) is a measure of the filling pressure of the right ventricle and is indicative of how the right side of the heart accommodates fluid load. A series of CVP measurements of 12 mm Hg or higher indicates failure of the right ventricle to handle venous return. A normal CVP measurement is 2 to 8 mm Hg. Cardiogenic shock and circulatory failure are late manifestations of heart failure in general and would likely show a decreased CVP and cardiac output. CVP may be increased with left ventricular failure; however, this is a late sign. It is possible to have both right and left failure at the same time. Text Reference - p. 1608

A patient is experiencing cardiogenic shock after an acute myocardial infarction. Why would an intraaortic balloon pump (IABP) be beneficial for this patient? 1 Reduces pressure in the pulmonary artery 2 Improves coronary artery vessel perfusion 3 Enhances effectiveness of cardiac medications 4 Provides time for an emergency angiogram to be performed

4 Indications for intraaortic balloon pump (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 is not used to reduce pressure in the pulmonary artery, improve coronary artery vessel perfusion, or to enhance the effectiveness of cardiac medications. Text Reference - p. 1610

The nurse is caring for a patient who has suffered arterial trauma during intraaortic balloon pump (IABP) therapy. What is the appropriate nursing action for this patient? 1 Monitor coagulation profiles 2 Apply an occlusive dressing 3 Administer prophylactic heparin 4 Maintain head of the bed below 45 degrees

4 Intraaortic balloon therapy has potential complications such as site infection, thromboembolism, arterial trauma, hematologic complications, and hemorrhage from the insertion site. Maintaining the head of the bed below 45 degrees helps to prevent breathlessness in the patient in the event of arterial trauma. Monitoring coagulation profiles, hematocrit, and platelet count is beneficial when the patient has a hematologic complication. An occlusive dressing prevents risk of surface infection but is not used to treat arterial trauma in the patient. Heparin helps to prevent thromboembolism but does not treat arterial trauma. Text Reference - p. 1612

A patient on positive pressure ventilation has increased sodium retention in the body. A decrease in production of which biologic factor may have caused sodium retention in the patient? 1 Renin 2 Angiotensin 3 Aldosterone 4 Atrial natriuretic peptide

4 Intrathoracic pressure changes associated with positive pressure ventilation cause a decrease in production of atrial natriuretic peptide. Positive pressure ventilation also decreases cardiac output, which further decreases renal perfusion. A decrease in renal perfusion increases the production of renin, angiotensin and aldosterone, which results in sodium retention. Text Reference - p. 1623

The negative inspiratory force (NIF) is measured in a patient who is on positive pressure ventilation. Among the values given, which NIF value is the best indication for weaning? 1 -30 cm H2O 2 -40 cm H2O 3 -50 cm H2O 4 -60 cm H2O

4 Negative inspiratory force (NIF) is the amount of negative pressure that a patient is able to generate to initiate spontaneous respirations. An NIF of less than -20 cm H2O is an indicator for weaning but the more negative the number, the better the indication for weaning. Therefore -60 cm H2O is the best indication for weaning. Text Reference - p. 1626

The health care provider requests constant hemoglobin (SpO2) monitoring for a patient. What is the normal range of SpO2, which indicates that the saturation pressure of oxygen in this patient is adequate? 1 80-85% 2 85-90% 3 90-95% 4 95-100%

4 Pulse oximetry is a noninvasive and continuous method of determining the oxygen saturation of SpO2. Monitoring SpO2 may reduce the frequency of arterial blood gas (ABG) sampling. SpO2 is normally 95% to 100%. A value less than that may indicate hypoperfusion. Text Reference - p. 1609

The nurse is teaching the patient's caregiver about receiving positive pressure ventilation. What movements should the nurse tell the caregiver to avoid doing to the patient? 1 Arm circles 2 Knee bends 3 Quadriceps setting 4 External rotation of the hip

4 The nurse should advise the caregiver to avoid external rotation of the patient's hip; this movement can be avoided by properly positioning the patient and by the use of specialized mattresses and beds. Simple maneuvers such as arm circles, knee bends and quadriceps setting should be performed, because they maintain the muscle tone in the upper and lower extremities of the patient. Text Reference - p. 1624