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Clustering nursing activities and providing uninterrupted rest periods will minimize sleepcycle disruption. Sedative and opioid medications tend to decrease the amount of rapid eye movement (REM) sleep and can contribute to sleep disturbance and disturbed sensory perception. Silencing the alarms on the cardiac monitors would be unsafe in a critically ill patient, as would discontinuing assessments during the night. DIP: Cognitive Level: Apply (application) 1601 TOP: Nursing Process: Planning MSC: NCLEX: psychosocial Integrity 2.
Which hemodynamic parameter is most appropriate for the nurse to monitor to determine the ffectiveness of medications given to a patient to reduce left ventricular afterload? a. Mean arterial pressure (MAP) b. Systemic vascular resistance (SVR) c. Pulmonary vascular resistance (PVR) d. Pulmonary artery wedge pressure (PAWP) Systemic vascular resistance reflects the resistance to ventricular ejection, or afterload. The other parameters will be monitored, but do not reflect afterload as directly.
DIF: Cognitive Level: Apply (application) 1604 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 3. While family members are visiting a patient has a respiratory arrest and is eing resuscitated. Which action by the nurse is best? a. Tell the family members that watching the resuscitation will be very stressful. b. Ask family members if they wish to remain in the room during the resuscitation. c. Take the family members quickly out of the patient room and remain with them. d. Assign a staff member to wait with family members just outside the patient room.
ANS: B Research indicates that family members want the option of remaining in the room during procedures such as cardiopulmonary resuscitation (CPR) and that this decreases anxiety and facilitates grieving. The other options may be appropriate if the family decides not to remain with the patient. USTESTBANK. COM DIF: Cognitive Level: Apply (application) REFI 1602 TOP: Nursing Process: Implementation 4. Following surgery for an abdominal aortic aneurysm, a patients central venous pressure (CVP) monitor indicates low pressures. Which action is a priority for the nurse to take? a. Administer IV diuretic medications. b.
Increase the IV fluid infusion per protocol. c. Document the CVP and continue to monitor. d. Elevate the head of the patient’s bed to 45 degrees. A low CVP indicates hypovolemia and a need for an increase in the infusion rate. Diuretic administration will contribute to hypovolemia and elevation of the head may decrease cerebral perfusion. Documentation and continued monitoring is an inadequate response to the low CVP. 1609 TOP: Nursing Process: planning 5. When caring for a patient with pulmonary hypertension, which parameter is most appropriate for the nurse to monitor to evaluate the effectiveness of the treatment? a.
Central venous pressure (CVP) ANS: C PVR is a major contributor to pulmonary hypertension, and a decrease would ndicate that pulmonary hypertension was improving. The other parameters also may be monitored but do not directly assess for pulmonary hypertension. DIE: Cognitive Level: Apply (application) 1603-1604 6. The intensive care unit (ICU) nurse educator will determine that teaching about arterial pressure monitoring for a new staff nurse has been effective when the nurse a. balances and calibrates the monitoring equipment every 2 hours. b. positions the zero-reference stopcock line level with the phlebostatic axis. . ensures that the patient is supine with the head of the bed flat for all readings. d. echecks the location of the phlebostatic axis when changing the patients position. ANS: B For accurate measurement of pressures, the zero-reference level should be at the phlebostatic axis. There is no need to rebalance and recalibrate monitoring equipment hourly. Accurate hemodynamic readings are possible with the patient’s head raised to 45 degrees or in the prone position. The anatomic position of the phlebostatic axis does not change when patients are repositioned. 1605 MSC: NCI_EX: Safe and Effective Care Environment 7.
When monitoring for the effectiveness of treatment for a patient with a arge anterior wall myocardial infarction, the most important information for the nurse to obtain is a. central venous pressure (CVP). b. systemic vascular resistance (SVR). c. pulmonary vascular resistance (PVR). d. pulmonary artery wedge pressure (PAWP). ANS: D PAWP reflects left ventricular end diastolic pressure (or left ventricular preload) and is a sensitive indicator of cardiac function. Because the patient is high risk for left ventricular failure, the PAWP must be monitored. An increase will indicate left ventricular failure.
The other values would also provide useful nformation, but the most definitive measurement of changes in cardiac function is the PAWP. DIR Cognitive Level: Apply (application) REF: 1607 8. Which action is a priority for the nurse to take when the low pressure alarm sounds for a patient who has an arterial line in the left radial artery? a. Fast flush the arterial line. b. Check the left hand for pallor. c. Assess for cardiac dysrhythmias. d. Rezero the monitoring equipment. The low pressure alarm indicates a drop in the patient’s blood pressure, which may be caused by cardiac dysrhythmias.
There is no indication to rezero the equipment. Pallor of the left hand would be caused by occlusion of the radial artery by the arterial catheter, not by low pressure. There is no indication of a need for flushing the line. DIE Cognitive Level: Apply 1606 OBJ: Special Questions: Prioritization 9. Which action will the nurse need to do when preparing to assist with the insertion of a pulmonary artery catheter? a. Determine if the cardiac troponin level is elevated. b. Auscultate heart and breath sounds during insertion. c. Place the patient on NPO status before the procedure. d.
Attach cardiac monitoring leads before the procedure. Dysrhythmias can occur as the catheter is floated through the right atrium and ventricle, and it is important for the nurse to monitor for these during insertion. Pulmonary artery catheter insertion does not require anesthesia, and the patient will not need to be NPO. Changes in cardiac troponin or heart and breath sounds are not expected during pulmonary artery catheter insertion. 1608 10. When assisting with the placement of a pulmonary artery (PA) catheter, the nurse notes that the catheter is correctly placed when the monitor shows a a. ypical PA pressure waveform. b. tracing of the systemic arterial pressure. . tracing of the systemic vascular resistance. d. typical PA wedge pressure (PAWP) tracing. The purpose of a PA line is to measure PAWP, so the catheter is floated through the pulmonary artery until the dilated balloon wedges in a distal branch of the pulmonary artery, and the PAWP readings are available. After insertion, the balloon is deflated and the PA waveform will be observed. Systemic arterial pressures are obtained using an arterial line and the systemic vascular resistance is a calculated value, not a waveform.
DIF: Cognitive Level: Understand (comprehension) REF: 1608 TOP: Nursing Process: Assessment 1. Which assessment finding obtained by the nurse when caring for a patient with a right radial arterial line indicates a need for the nurse to take immediate action? a. The right hand is cooler than the left hand. b. The mean arterial pressure (MAP) is 77 mm Hg. c. The system is delivering 3 mL of flush solution per hour. d. The flush bag and tubing were last changed 3 days previously. ANS: A The change in temperature of the left hand suggests that blood flow to the left hand is impaired.
The flush system needs to be changed every 96 hours. A mean arterial pressure (MAP) of 75 mm Hg is normal. Flush systems for emodynamic monitoring are set up to deliver 3 to 6 mlJhour of flush solution. 12. The central venous oxygen saturation (Scv02) is decreasing in a patient who has severe pancreatitis. To determine the possible cause of the decreased Scv02, the nurse assesses the patient’s a. lipase. b. temperature. c. urinary output. d. body mass index. Elevated temperature increases metabolic demands and oxygen use by tissues, resulting in a drop in oxygen saturation of central venous blood.
Information about the patient’s body mass index, urinary output, and lipase will not help in determining the cause of the patient’s drop in Scv02. 3. An intraaortic balloon pump (IABP) is being used for a patient who is in cardiogenic shock. Which assessment data indicate to the nurse that the goals of treatment with the IABP are being met? a. IJrine output of 25 ml_/hr b. Heart rate of 1 10 beats/minute c. Cardiac output (CO) of 5 L/min d. Stroke volume (SV) of 40 mL/beat A CO of 5 Umin is normal and indicates that the IABP has been successful in treating the shock. The low SV signifies continued cardiogenic shock.
The tachycardia and low urine output also suggest continued cardiogenic shock. 1603 MSC: NCI_EX: Physiological Integrity 14. The nurse is caring for a patient who has an intraaortic balloon pump in place. Which action should be included in the plan of care? a. Position the patient supine at all times. b. Avoid the use of anticoagulant medications. c. Measure the patient’s urinary output every hour. d. Provide passive range of motion for all extremities. Monitoring urine output will help determine whether the patient’s cardiac output has improved and also help monitor for balloon displacement.
The head of the bed can be elevated up to 30 degrees. Heparin is used to prevent thrombus formation. Limited movement is allowed for the extremity with the alloon insertion site to prevent displacement of the balloon. 1613 15. While waiting for cardiac transplantation, a patient with severe cardiomyopathy has a ventricular assist device (VAD) implanted. When planning care for this patient, the nurse should anticipate a. giving immunosuppressive medications. b. preparing the patient for a permanent VAD. c. teaching the patient the reason for complete bed rest. d. onitoring the surgical incision for signs of infection. The insertion site for the VAD provides a source for transmission of infection to the circulatory system and requires frequent monitoring. Patient’s with VADs are able to have some mobility and may not be on bed rest. The VAD is a bridge to transplantation, not a permanent device. Immunosuppression is not necessary for nonbiologic devices like the VAD. DIF: Cognitive Level: Apply 16. To verify the correct placement of an oral endotracheal tube (ET) after insertion, the best initial action by the nurse is to b. . auscultate for the presence of bilateral breath sounds. obtain a portable chest X-ray to check tube placement. observe the chest for symmetric chest movement with ventilation. use an end-tidal C02 monitor to check for placement in the trachea. End-tidal C02 monitors are currently recommended for rapid verification of ET placement. Auscultation for bilateral breath sounds and checking chest expansion are also used, but they are not as accurate as end-tidal C02 monitoring. A chest x-ray confirms the placement but is done after the tube is secured. 614-1615 17. To maintain proper cuff pressure of an endotracheal tube (ET) when the patient is on mechanical ventilation, the nurse should a. inflate the cuff with a minimum of 10 mL of air. b. inflate the cuff until the pilot balloon is firm on palpation. c. inject air into he cuff until a manometer shows 15 mm Hg pressure. d. inject air into the cuff until a slight leak is heard only at peak inflation. ANS: D The minimal occluding volume technique involves injecting air into the cuff until an air leak is present only at peak inflation.
The volume to inflate the cuff varies with the ET and the patient’s size. Cuff pressure should be maintained at 20 to 25 mm Hg- An accurate assessment of cuff pressure cannot be obtained by palpating the pilot balloon. DIP: Cognitive Level: Understand (comprehension) 1615 18. The nurse notes premature ventricular contractions (PVCs) while uctioning a patient’s endotracheal tube. Which action by the nurse is a priority? a. Decrease the suction pressure to 80 mm Hg. b. Document the dysrhythmia in the patient’s chart. c. Stop and ventilate the patient with 100% oxygen. . Give antidysrhythmic medications per protocol. Dysrhythmias during suctioning may indicate hypoxemia or sympathetic nervous system stimulation. The nurse should stop suctioning and ventilate the patient with 100% oxygen. Lowering the suction pressure will decrease the effectiveness of suctioning without improving the hypoxemia. Because he PVCs occurred during suctioning, there is no need for antidysrhythmic medications (which may have adverse effects) unless they recur when the suctioning is stopped and patient is well oxygenated. 1616 19.
Which assessment finding obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning? a. The patients oxygen saturation is 93%. b. The patient was last suctioned 6 hours ago. c. The patient’s respiratory rate is 32 breaths/minute. d. The patient has occasional audible expiratory wheezes. The increase in respiratory rate indicates that the patient may have ecreased airway clearance and requires suctioning. Suctioning is done when patient assessment data indicate that it is needed, not on a scheduled basis.