Chapter 5 My Nursing Test Banks

Perrin, Understanding the Essentials of Critical Care Nursing, 2/e
Chapter 5

Question 1

Type: MCSA

A patient has a blood pressure of 134/70 per blood pressure cuff and a blood pressure of 90/50 per arterial line. The nurse should:

1. Discontinue the arterial line immediately.

2. Check the level of the transducer and relevel and rezero the system.

3. Do nothing because this is a normal variation between the two methods of measurement.

4. Begin the infusion of a dopamine drip.

Correct Answer: 2

Rationale 1: The system needs to be assessed first.

Rationale 2: The placement of the transducer is essential for accurate measurement. It must be level with the phlebostatic axis in order for the monitoring system to be accurate.

Rationale 3: This is not a normal variation between the two methods of measurement.

Rationale 4: More information and data are needed before administering medication therapy.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5-3: Evaluate the accuracy of a pressure monitoring system.

Question 2

Type: MCSA

The nurse is monitoring a patients pulmonary vascular resistance. Which value is the normal value?

1. 100250 mm Hg

2. 10250 dynes/sec/cm2

3. 400800 mm Hg

4. 8001,400 dynes/sec/cm2

Correct Answer: 2

Rationale 1: A measurement in mm Hg is used to measure pressure only.

Rationale 2: The pulmonary system is a low-pressure system. The pressure of the vascular system is measured in dynes/sec/cm2 due to factors of flow, resistance, and time. This is the normal value for pulmonary vascular resistance.

Rationale 3: A measurement in mm Hg is used to measure pressure only.

Rationale 4: This is the value for SVR.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-1: Explain how preload, afterload, and contractility determine cardiac output.

Question 3

Type: MCSA

A patients systemic vascular resistance (SVR) has dangerously decreased. The nurse would expect to administer which medications?

1. Furosemide (Lasix) and dopamine

2. Nitroprusside and furosemide (Lasix)

3. Dopamine and norepinephrine (Levophed)

4. Nitroglycerin and digoxin (Lanoxin)

Correct Answer: 3

Rationale 1: Furosemide (Lasix) is a diuretic that reduces fluid volume and is a mild vasodilator. The systemic vascular resistance will be further decreased.

Rationale 2: Furosemide (Lasix) is a diuretic that reduces fluid volume and is a mild vasodilator. The systemic vascular resistance will be further decreased.

Rationale 3: If the SVR is low, there is massive peripheral vasodilation. These meds will increase vasomotor tone as well as increase blood pressure.

Rationale 4: Nitroglycerin is a potent vasodilator. The systemic vascular resistance will be further decreased.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-1: Explain how preload, afterload, and contractility determine cardiac output.

Question 4

Type: MCSA

A patient has mixed venous oxygen saturation (SVO2) of 52% with the following hemodynamic findings: CO of 4.8 L/min, SaO2 of 95%, and an unchanged hemoglobin level. The nurse should assess the patient for:

1. Excessive sedation

2. Position of the PA catheter

3. Hypothermia

4. Pain

Correct Answer: 4

Rationale 1: Excessive sedation contributes to a higher than normal SVO2 level due to a lower level of oxygen extracted by the tissues.

Rationale 2: This would not influence the patients blood levels of oxygen and carbon dioxide.

Rationale 3: Hypothermia contributes to a higher than normal SVO2 level due to a lower level of oxygen extracted by the tissues.

Rationale 4: Pain causes an increased consumption of oxygen; therefore, the SVO2 level will decrease.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-2: Describe how oxygen supply and demand can be evaluated.

Question 5

Type: MCSA

Which of the following actions has the highest priority for maintaining safety when caring for a patient with a PA catheter?

1. Obtain pressures per protocol.

2. Administer fluids and medications via pump.

3. Maintain asepsis when providing line care.

4. Obtain lab values as ordered.

Correct Answer: 3

Rationale 1: This is not of the highest priority for safety in a patient with a PA catheter.

Rationale 2: This is not of the highest priority for safety in a patient with a PA catheter.

Rationale 3: The presence of all invasive lines can lead to infection and sepsis. Preventing infection is the highest priority in maintaining patient safety.

Rationale 4: This is not of the highest priority for safety in a patient with a PA catheter.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5-4: Explain nursing responsibilities in the care of the patient with invasive pressure monitoring systems, including arterial, central venous, and pulmonary artery pressure lines.

Question 6

Type: MCSA

A patient with a right subclavian triple lumen catheter has a CVP reading of 18 mm Hg. The nurse would further assess the patient for symptoms of:

1. Peripheral edema and jugular vein distention

2. Decreased peripheral pulses and cool extremities

3. Hypovolemia and hypotension

4. Orbital edema and disorientation

Correct Answer: 1

Rationale 1: An elevated CVP indicates hypervolemia and/or right ventricular failure because it is a direct measurement of pressure in the right side of the heart. This is manifested by jugular vein distention and peripheral edema.

Rationale 2: These are not symptoms associated with hypervolemia or right ventricular failure.

Rationale 3: An elevated CVP would not occur with hypovolemia or hypotension.

Rationale 4: These are not symptoms associated with hypervolemia or right ventricular failure.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-4: Explain nursing responsibilities in the care of the patient with invasive pressure monitoring systems, including arterial, central venous, and pulmonary artery pressure lines.

Question 7

Type: MCSA

The nurse is monitoring the PA pressure of a mechanically ventilated patient. In order to accurately measure this pressure, the nurse should obtain the measurement:

1. Whenever because the timing does not matter

2. At the last clear waveform before the baseline drops

3. At the last clear waveform before the baseline rises

4. With the patient off the ventilator

Correct Answer: 3

Rationale 1: Timing does matter because the measurement can be elevated because of the ventilator. Timing is crucial for accuracy.

Rationale 2: If it is measured before the baseline drops, this reading is high as the result of increased thoracic pressure in the chest from the positive pressure given by the ventilator.

Rationale 3: The positive pressure of the ventilator causes an abnormally high reading during inspiration. The accurate measurement is the reading seen before the baseline rises.

Rationale 4: Taking the patient off the ventilator is not an option.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5-4: Explain nursing responsibilities in the care of the patient with invasive pressure monitoring systems, including arterial, central venous, and pulmonary artery pressure lines.

Question 8

Type: MCSA

A patient with a PA catheter has an SVO2 of 90%. The nurse should assess the patient for:

1. Fever

2. Pain

3. Hypothermia

4. Anemia

Correct Answer: 3

Rationale 1: Fever causes a drop in the SVO2.

Rationale 2: Pain causes a drop in the SVO2.

Rationale 3: Normal SVO2 is 60% to 75%. This is a high SVO2, which means that there is not enough extraction of O2 from the hemoglobin to the tissues. This can occur with hypothermia.

Rationale 4: Anemia causes a drop in the SVO2.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-2: Describe how oxygen supply and demand can be evaluated.

Question 9

Type: MCSA

What should the nurse monitor in response to a change in SVO readings?

1. Potassium level

2. Glucose level

3. Sodium level

4. Hemoglobin level

Correct Answer: 4

Rationale 1: Potassium does not influence oxygen saturation of venous blood.

Rationale 2: Glucose does not influence oxygen saturation of venous blood.

Rationale 3: Sodium does not influence oxygen saturation of venous blood.

Rationale 4: Oxygen is carried by hemoglobin; this value can influence and is reflected by the SVO2 level.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-2: Describe how oxygen supply and demand can be evaluated.

Question 10

Type: MCSA

A patient asks the nurse, What is blood pressure? The nurse would most appropriately respond:

1. A measurement that should always be 120/80 unless complications are present.

2. The amount of pressure exerted on your veins by the blood.

3. A measurement that takes into consideration the amount of blood that your heart is pumping and the size of the vessel diameter the heart must pump against.

4. A complex measurement that should only be discussed with your health care provider.

Correct Answer: 3

Rationale 1: This is not an accurate statement.

Rationale 2: This is not the best response.

Rationale 3: This is understandable to the patient as well as accurate.

Rationale 4: This is not an accurate response.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5-2: Describe how oxygen supply and demand can be evaluated.

Question 11

Type: MCSA

The health care provider is preparing to insert a PA catheter. The nurse should ensure that:

1. The patient is in the Trendelenburg position to prevent air embolism.

2. The patient has received a dose of IV lidocaine.

3. The site has been cleaned with soap and water.

4. A tourniquet has been applied to the neck.

Correct Answer: 1

Rationale 1: The Trendelenburg position promotes venous filling in the upper body for easier catheter insertion and prevention of air embolism.

Rationale 2: This is not a part of the procedure.

Rationale 3: The site should be prepped with antiseptic solution according to agency protocol.

Rationale 4: No tourniquet is necessary.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5-4: Explain nursing responsibilities in the care of the patient with invasive pressure monitoring systems, including arterial, central venous, and pulmonary artery pressure lines.

Question 12

Type: MCSA

In order to correctly calculate cardiac output, the nurse should:

1. Only take two measurements and then average the two readings.

2. Take one measurement to prevent fluid volume overload.

3. Obtain five measurements and record the highest reading.

4. Take three to five measurements and take the average of the three readings that are within 10% of one another.

Correct Answer: 4

Rationale 1: There could be inconsistency on both temperature and technique.

Rationale 2: This could cause an inaccurate measurement.

Rationale 3: There could be inconsistency on both temperature and technique.

Rationale 4: There could be inconsistency on both temperature and technique. The average of the three closest measurements is standard to reflect accuracy.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5-6: Interpret invasive pressure monitoring waveforms.

Question 13

Type: MCSA

The nurse identifies pulsus paradoxus on a patients arterial pressure waveform monitoring when:

1. The waveform has tall, tented waves.

2. The pulse pressure is above 20 mm Hg on exhalation.

3. There is a decrease of more than 10 mm Hg in the arterial waveform before inhalation.

4. There is a single, nonperfused beat.

Correct Answer: 3

Rationale 1: This does not indicate a change in intrathoracic pressure.

Rationale 2: This does not cause a change in intrathoracic pressure.

Rationale 3: There is a change in intrathoracic pressure that affects the filling of the ventricles, which is reflected in the arterial pressure.

Rationale 4: This does not cause a change in intrathoracic pressure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-2: Describe how oxygen supply and demand can be evaluated.

Question 14

Type: MCSA

How will the nurse calculate a patients mean arterial pressure (MAP)?

1. Dividing the systolic pressure by the diastolic pressure

2. Averaging three of the patients blood pressures over a 6-hour period

3. Dividing the diastolic pressure by the pulse pressure

4. Adding the systolic pressure and two diastolic pressures and then dividing by 3

Correct Answer: 4

Rationale 1: This is not the way to calculate mean arterial pressure.

Rationale 2: This is not the way to calculate mean arterial pressure.

Rationale 3: This is not the way to calculate mean arterial pressure.

Rationale 4: This is the gold standard for measuring MAP and it reflects the time the heart is in diastole during the cardiac cycle.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-2: Describe how oxygen supply and demand can be evaluated.

Question 15

Type: MCSA

What will the nurse use to measure the contractility of the left side of a patients heart?

1. Left atrial pressure

2. Pulmonary artery wedge pressure

3. Systemic vascular resistance

4. Left ventricular stroke work index

Correct Answer: 4

Rationale 1: This will not measure the contractility of the left heart.

Rationale 2: This will not measure the contractility of the left heart.

Rationale 3: This will not measure the contractility of the left heart

Rationale 4: This reflects the stretch and force of contraction of the heart muscle.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-5: Explain the indications for pressure monitoring systems.

Question 16

Type: MCSA

Which nursing intervention ensures an accurate cardiac output reading for a patient?

1. Administer the injectate within 4 seconds.

2. Use 5 cc of iced saline as the injectate.

3. Ensure that there is a difference of 10C between the injectate temperature and the patients body temperature.

4. Inject the fluid into the pulmonary artery distal port.

Correct Answer: 1

Rationale 1: This time frame is necessary to ensure accuracy because the injectate will be pumped out during one cardiac cycle.

Rationale 2: This will not ensure an accurate cardiac output reading.

Rationale 3: This will not ensure an accurate cardiac output reading.

Rationale 4: This will not ensure an accurate cardiac output reading.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5-4: Explain nursing responsibilities in the care of the patient with invasive pressure monitoring systems, including arterial, central venous, and pulmonary artery pressure lines.

Question 17

Type: MCSA

Before determining a patients cardiac output, the nurse reviews normal values and realizes the value for cardiac output is:

1. 69 L/min

2. 48 L/min

3. 810 L/min

4. 24 L/min

Correct Answer: 2

Rationale 1: This is not the normal cardiac output.

Rationale 2: The heart pumps the entire blood volume through the body in 1 minute. This is the normal cardiac output.

Rationale 3: This is not the normal cardiac output.

Rationale 4: This is not the normal cardiac output.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-1: Explain how preload, afterload, and contractility determine cardiac output.

Question 18

Type: MCMA

A patient is experiencing reduced afterload. The nurse realizes that causes of reduced afterload include:

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Sepsis

2. Mitral stenosis

3. Reduced circulating blood volume

4. Vasodilator medications

5. Myocarditis

Correct Answer: 1,4

Rationale 1: Sepsis causes vasodilation due to the release of endotoxins.

Rationale 2: Mitral stenosis causes increased preload.

Rationale 3: Reduced circulating blood volume contributes to decreased preload.

Rationale 4: Vasodilators enlarge the vessels and reduce resistance.

Rationale 5: Myocarditis contributes to elevated preload.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-1: Explain how preload, afterload, and contractility determine cardiac output.

Question 19

Type: MCSA

A patient has a lactate level of 8 mmol/L. The nurse realizes that this finding indicates:

1. Carbon dioxide exchange

2. Underuse of oxygen

3. Glucose metabolism

4. Tissue hypoxia

Correct Answer: 4

Rationale 1: Lactate level does not indicate carbon dioxide exchange.

Rationale 2: Lactate level does not indicate the underuse of oxygen.

Rationale 3: Lactate level does not indicate glucose metabolism.

Rationale 4: When cells become oxygen deprived, anaerobic metabolism of glucose occurs, causing lactate formation instead of carbon dioxide and water. Elevated levels of lactate are a reliable indicator of tissue hypoxia.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-2: Describe how oxygen supply and demand can be evaluated.

Question 20

Type: MCSA

The nurse notices that a patient with an arterial line has an elevated partial thromboplastin time (PTT) and is not on anticoagulation therapy. The nurse would:

1. Take the patient for an immediate V/Q scan.

2. Assess for the presence of a deep vein thrombosis.

3. Change the heparinized saline solution in the pressure bag for the arterial line to a normal saline solution.

4. Ask for an order to begin Lovenox therapy.

Correct Answer: 3

Rationale 1: This does not need to be done.

Rationale 2: The elevated partial thromboplastin time would be desired for this situation.

Rationale 3: Heparinized solutions are contraindicated in patients with coagulation deficiencies or heparin-induced thrombocytopenia.

Rationale 4: This does not need to be done.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5-3: Evaluate the accuracy of a pressure monitoring system.

Question 21

Type: MCSA

Prior to the insertion of an arterial line in the radial artery, which assessment would the nurse perform?

1. Homans test

2. Kernigs test

3. Allens test

4. Leopolds maneuver

Correct Answer: 3

Rationale 1: This is not done prior to inserting an arterial line in the radial artery.

Rationale 2: This is not done prior to inserting an arterial line in the radial artery.

Rationale 3: The Allens test detects the patency of the ulnar artery. This is to ensure that there is adequate blood flow to the hand in the event the radial artery becomes occluded.

Rationale 4: This is not done prior to inserting an arterial line in the radial artery.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-4: Explain nursing responsibilities in the care of the patient with invasive pressure monitoring systems, including arterial, central venous, and pulmonary artery pressure lines.

Question 22

Type: MCSA

When observing the waveform of an arterial line, the nurse notes the presence of a dicrotic notch. The nurse knows this due to:

1. Pulmonic valve opening

2. Mitral valve closure

3. Aortic valve closure

4. Tricuspid valve closure

Correct Answer: 3

Rationale 1: This is not the cause for the dicrotic notch.

Rationale 2: This is not the cause for the dicrotic notch.

Rationale 3: The aortic valve closes and the mitral and tricuspid valves open in preparation for ventricular filling. The pulmonic valve closes at the same time as the aortic valve.

Rationale 4: This is not the cause for the dicrotic notch.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-6: Interpret invasive pressure monitoring waveforms.

Question 23

Type: MCSA

The nurse suspects that a patient is experiencing cardiogenic shock. Which parameter indicates that the nurses suspicion is correct?

1. Cardiac output of 8.9 L/min

2. Pulmonary artery wedge pressure (PAWP) of 8 mm Hg

3. Central venous pressure (CVP) of 5 mm Hg

4. Cardiac index (CI) of 1.8 L/min/m2

Correct Answer: 4

Rationale 1: This cardiac output is elevated and is not consistent with cardiogenic shock.

Rationale 2: The PAWP will be elevated in cardiogenic shock.

Rationale 3: This is a normal central venous pressure reading.

Rationale 4: The cardiac index (CI) is a measure of cardiac output and tissue perfusion in relation to the patients body surface area. This reading would be consistent with cardiogenic shock.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-1: Explain how preload, afterload, and contractility determine cardiac output.

Question 24

Type: MCSA

A patients hemodynamic parameters include the following: right atrial pressure (RAP) of 13 mm Hg, pulmonary artery wedge pressure (PAWP) of 8 mm Hg, systemic vascular resistance (SVR) of 1,000 dynes/sec/cm2, cardiac output (CO) of 4.9 L/min, cardiac index (CI) of 3.5 L/min, and pulmonary vascular resistance (PVR) of 280 dynes/sec/cm2. Which heart function should cause the nurse concern?

1. Afterload

2. Left heart contractility

3. Right heart contractility

4. Heart rate

Correct Answer: 3

Rationale 1: The CO, CI, and SVR are within normal limits and are indicators of left ventricular function.

Rationale 2: The CO, CI, and SVR are within normal limits and are indicators of left ventricular function.

Rationale 3: The RAP reflects the amount of blood returning to the right atrium and is a measurement of preload. The elevated PVR is a reflection of the pressure within the right ventricle and is the amount of pressure needed for the right ventricle to eject blood into the PA. The elevated RAP and PVR indicate a problem with right heart contractility and is most likely related to right heart failure.

Rationale 4: No data is available about the patients heart rate.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 5-1: Explain how preload, afterload, and contractility determine cardiac output.

Question 25

Type: MCMA

After assessing a patients hemodynamic parameters the nurse determines that preload and afterload are both elevated. These findings are consistent with which health problems?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Pericardial tamponade

2. Constrictive pericarditis

3. Hypovolemia

4. Neurogenic shock

5. Mitral stenosis

Correct Answer: 1,2

Rationale 1: Both right and left preload are elevated in conditions that cause increases in pericardial pressures such as pericardial tamponade.

Rationale 2: Both right and left preload are elevated in conditions that cause increases in pericardial pressures such as constrictive pericarditis.

Rationale 3: Preload is decreased in hypovolemia.

Rationale 4: Afterload is decreased in neurogenic shock.

Rationale 5: Preload is elevated in mitral stenosis.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-1: Explain how preload, afterload, and contractility determine cardiac output.

Question 26

Type: MCMA

The nurse wants to assess the oxygenation status of a patient who has been experiencing a gastrointestinal bleed. How will the nurse complete this assessment?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Use pulse oximetry

2. Send a blood sample for arterial blood gas analysis

3. Auscultate lung sounds

4. Evaluate cardiac rhythm strip

5. Calculate mean arterial pressure

Correct Answer: 1,2

Rationale 1: At the bedside the arterial oxygen saturation can be estimated by pulse oximetry.

Rationale 2: At the bedside the arterial oxygen saturation can be measured via an arterial blood gas analysis.

Rationale 3: Auscultating lung sounds will not provide information about a patients oxygenation status.

Rationale 4: The cardiac rhythm strip will not provide information about a patients oxygenation status.

Rationale 5: The mean arterial pressure will not provide information about a patients oxygenation status.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-2: Describe how oxygen supply and demand can be evaluated.

Question 27

Type: MCMA

The nurse is planning to assess the blood pressure of a patient with a BMI of 40. Which approaches will the nurse use to correctly obtain this patients blood pressure?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Use a cuff with a bladder that is 80% of the patients arm circumference.

2. Use a thigh cuff.

3. Use an adult cuff on the patients forearm.

4. Assess the blood pressure using the same approach each time.

5. Use an adult cuff on the patients thigh.

Correct Answer: 1,2,3,4

Rationale 1: A cuff with a bladder that is 80% of the patients arm circumference should be chosen.

Rationale 2: A thigh cuff can be used.

Rationale 3: An adult cuff may be used on the patients forearm.

Rationale 4: The blood pressure should be taken in the same way each time.

Rationale 5: This is not a recommended approach to obtain the blood pressure on an obese patient.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-3: Evaluate the accuracy of a pressure monitoring system.

Question 28

Type: MCMA

While caring for a patient in the intensive care unit, when would the nurse plan to conduct the square wave test on the patients arterial pressure monitoring system?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. At the beginning of the shift

2. After drawing blood

3. When the arterial tracing is not consistent with an auscultated blood pressure

4. When the monitoring cable is disconnected from the flush system

5. Any time the patients position is changed

Correct Answer: 1,2,3

Rationale 1: The square wave test should be performed during every shift.

Rationale 2: The square wave test should be performed after opening the system, such as when drawing blood.

Rationale 3: The square wave test should be performed when values are suspected to be inaccurate.

Rationale 4: Zeroing should be done when the monitoring cable is disconnected from the flush system.

Rationale 5: Releveling is to be done any time the patients position is changed.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5-3: Evaluate the accuracy of a pressure monitoring system.

Question 29

Type: MCMA

The nurse is concerned that the hand with an arterial line in the wrist is becoming ischemic. What did the nurse assess in this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Delayed capillary refill

2. Pale skin color of the wrist and hand

3. Reduced pulses in the brachial artery

4. Hand cold to touch

5. Blood pressure discrepancy of 15 mm Hg

Correct Answer: 1,2,4

Rationale 1: Evidence of tissue ischemia in the cannulated extremity includes delayed capillary refill.

Rationale 2: Evidence of tissue ischemia in the cannulated extremity includes pallor.

Rationale 3: Evidence of tissue ischemia in the cannulated extremity includes a reduction in pulses distal to the cannula.

Rationale 4: Evidence of tissue ischemia in the cannulated extremity includes cool temperature.

Rationale 5: This is not evidence of tissue ischemia in the cannulated extremity.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-4: Explain nursing responsibilities in the care of the patient with invasive pressure monitoring systems, including arterial, central venous, and pulmonary artery pressure lines.

Question 30

Type: MCMA

The health care provider is planning to insert a pulmonary artery catheter into a patient. The nurse realizes this monitoring device is used to:

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Determine hemodynamic stability in heart failure

2. Monitor the effects of vasodilator administration

3. Monitor cardiac function during vascular surgical procedures

4. Assess cardiac output

5. Continuously monitor blood pressure

Correct Answer: 1,2,3,4

Rationale 1: A pulmonary artery is used to determine hemodynamic stability in cardiac disorders such as heart failure.

Rationale 2: The pulmonary artery catheter is used to guide medication effects such as vasodilators.

Rationale 3: The pulmonary artery catheter is used to monitor cardiac function during vascular procedures such as abdominal aneurysm repair.

Rationale 4: The pulmonary artery catheter is used to assess cardiac output.

Rationale 5: The pulmonary artery catheter is not used to continuously monitor blood pressure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-5: Explain the indications for pressure monitoring systems.

Question 31

Type: MCMA

The nurse is concerned that a patients pulmonary artery has slipped into the right ventricle. What are the hallmarks of the waveform that the nurse observes on the monitor?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Low diastolic pressure

2. No dicrotic notch

3. Continuous wedge waveform

4. Sharp upstroke, a plateau, and a rapid downstroke extending below the baseline

5. Smooth upstroke followed by a gradual downslope to the baseline

Correct Answer: 1,2

Rationale 1: One hallmark of right ventricular pressure is low diastolic pressure.

Rationale 2: One hallmark of right ventricular pressure is a lack of dicrotic notch.

Rationale 3: A continuous wedge waveform indicates the catheter is wedged in a pulmonary vessel.

Rationale 4: This describes the waveform caused by the square wave test.

Rationale 5: This describes a cardiac output curve.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-6: Interpret invasive pressure monitoring waveforms.

Question 32

Type: MCMA

A patient has a central line for fluid management and antibiotic therapy. What interventions will the nurse utilize to reduce the risk of infection in the access site?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Practice thorough hand hygiene.

2. Use chlorhexidine skin asepsis.

3. Review the continued need for the line daily.

4. Cover the insertion site with an opaque gauze dressing.

5. Change the dressing over the insertion site using clean technique.

Correct Answer: 1,2,3

Rationale 1: This is a best practice within the central line bundle to prevent central line infections.

Rationale 2: This is a best practice within the central line bundle to prevent central line infections.

Rationale 3: This is a best practice within the central line bundle to prevent central line infections.

Rationale 4: This approach would restrict the nurses ability to observe the insertion site for infection and should not be done.

Rationale 5: Central line dressings should be changed using sterile technique to reduce the risk of infection.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5-4: Explain nursing responsibilities in the care of the patient with invasive pressure monitoring systems, including arterial, central venous, and pulmonary artery pressure lines.

Perrin, Understanding the Essentials of Critical Care Nursing, 2/e Test Bank

Copyright 2012 by Pearson Education, Inc.

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