Chapter 66: Nursing Management: Critical Care My Nursing Test Banks

Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 66: Nursing Management: Critical Care

Test Bank

MULTIPLE CHOICE

1. A patient has a nursing diagnosis of disturbed sensory perception related to sleep deprivation. Which action will the nurse include in the plan of care?

a.

Discontinue assessments during the night to allow uninterrupted sleep.

b.

Administer prescribed sedatives or opioids at bedtime to promote sleep.

c.

Silence the alarms on the cardiac monitors to allow 30- to 40-minute naps.

d.

Cluster nursing activities so that the patient has uninterrupted rest periods.

ANS: D

Clustering nursing activities and providing uninterrupted rest periods will minimize sleep-cycle 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.

DIF: Cognitive Level: Application REF: 1686 TOP: Nursing Process: Planning

MSC: NCLEX: Psychosocial Integrity

2. To determine the effectiveness of medications that a patient has received to reduce left ventricular afterload, which hemodynamic parameter will the nurse monitor?

a.

Central venous pressure (CVP)

b.

Systemic vascular resistance (SVR)

c.

Pulmonary vascular resistance (PVR)

d.

Pulmonary artery wedge pressure (PAWP)

ANS: B

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: Application REF: 1687-1689 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

3. While family members are visiting, a patient has a cardiac arrest and is being resuscitated. Which action by the nurse is best?

a.

Ask family members if they wish to remain in the room during the resuscitation.

b.

Explain to family members that watching the resuscitation will be very stressful.

c.

Assign a staff member to wait with family members just outside the patient room.

d.

Escort family members quickly out of the patient room and then remain with them.

ANS: A

Research indicates that family members want the option of remaining in the room during procedures such as 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.

DIF: Cognitive Level: Application REF: 1687

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

4. Following surgery, a patients central venous pressure (CVP) monitor indicates low pressures. Which action will the nurse anticipate taking?

a.

Increase the IV fluid infusion rate.

b.

Administer IV diuretic medications.

c.

Elevate the head of the patients bed to 45 degrees.

d.

Document the CVP and continue to monitor.

ANS: A

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.

DIF: Cognitive Level: Application REF: 1693-1695 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

5. When caring for a patient with pulmonary hypertension, which parameter will the nurse monitor to evaluate whether treatment has been effective?

a.

Mean arterial pressure (MAP)

b.

Central venous pressure (CVP)

c.

Pulmonary vascular resistance (PVR)

d.

Pulmonary artery wedge pressure (PAWP)

ANS: C

PVR is a major contributor to pulmonary hypertension, and a decrease would indicate that pulmonary hypertension was improving. The other parameters also may be monitored, but do not directly assess for pulmonary hypertension.

DIF: Cognitive Level: Application REF: 1687-1689 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

6. The intensive care unit (ICU) charge nurse will determine that teaching about hemodynamic monitoring for a new staff nurse has been effective when the new nurse

a.

positions the zero-reference stopcock line level with the phlebostatic axis.

b.

balances and calibrates the hemodynamic monitoring equipment every hour.

c.

rechecks the location of the phlebostatic axis when changing the patients position.

d.

ensures that the patient is lying supine with the head of the bed flat for all readings.

ANS: A

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 patients head raised to 45 degrees or in the prone position. The anatomic position of the phlebostatic axis does not change when patients are repositioned.

DIF: Cognitive Level: Application REF: 1687-1689 TOP: Nursing Process: Evaluation

MSC: NCLEX: Safe and Effective Care Environment

7. When monitoring for the effectiveness of treatment for a patient with left ventricular failure, the most important information for the nurse to obtain is

a.

mean arterial pressure (MAP).

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). Because the patient in left ventricular failure will have a high PAWP, a decrease in this value will be the best indicator of patient improvement. The other values would also provide useful information, but the most definitive measurement of improvement is a drop in PAWP.

DIF: Cognitive Level: Application REF: 1687-1689 | 1691-1692

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

8. Which action should the nurse take when the low pressure alarm sounds for a patient who has an arterial line in the right radial artery?

a.

Check the right hand for pallor.

b.

Assess for cardiac dysrhythmias.

c.

Flush the arterial line with saline.

d.

Rezero the monitoring equipment.

ANS: B

The low pressure alarm indicates a drop in the patients blood pressure, which may be caused by cardiac dysrhythmias. There is no indication to rezero the equipment. Pallor of the right 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.

DIF: Cognitive Level: Application REF: 1689-1691

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

9. When preparing to assist with the insertion of a pulmonary artery catheter, the nurse will plan to

a.

check cardiac enzymes before insertion.

b.

auscultate heart sounds during insertion.

c.

place the patient on NPO status before the procedure.

d.

attach cardiac monitoring leads before the procedure.

ANS: D

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 enzymes or heart sounds are not expected during pulmonary artery catheter insertion.

DIF: Cognitive Level: Application REF: 1691-1693 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

10. When assisting with insertion of a pulmonary artery (PA) catheter, the nurse identifies that the catheter is correctly placed when the

a.

monitor shows a typical PAWP tracing.

b.

PA waveform is observed on the monitor.

c.

systemic arterial pressure tracing appears on the monitor.

d.

catheter has been inserted to the 22-cm marking on the line.

ANS: A

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. The length of catheter needed for insertion will vary with patient size.

DIF: Cognitive Level: Comprehension REF: 1693

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

11. Which assessment data obtained by the nurse when caring for a patient with a left radial arterial line indicates a need for the nurse to take action?

a.

The left hand is cooler than the right hand.

b.

The mean arterial pressure (MAP) is 75 mm Hg.

c.

The system is delivering only 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 hemodynamic monitoring are set up to deliver 3 to 6 mL/hour of flush solution.

DIF: Cognitive Level: Application REF: 1691-1692

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

12. The mixed venous oxygen saturation (SvO2) is decreasing in a patient who has severe pancreatitis. To determine the possible cause of the decreased SvO2, the nurse assesses the patients

a.

weight.

b.

amylase.

c.

temperature.

d.

urinary output.

ANS: C

Elevated temperature increases metabolic demands and oxygen use by tissues, resulting in a drop in oxygen saturation of mixed venous blood. Information about the patients weight, urinary output, and amylase will not help in determining the cause of the patients drop in SvO2.

DIF: Cognitive Level: Application REF: 1695-1696

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

13. An intraaortic balloon pump (IABP) is being used for a patient who is in cardiogenic shock. An assessment finding indicating to the nurse that the goals of treatment with the IABP are being met is a

a.

heart rate of 110 beats/min.

b.

urine output of 20 mL/hr.

c.

cardiac output (CO) of 5 L/min.

d.

stroke volume (SV) of 40 mL/beat.

ANS: C

A CO of 5 L/min 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.

DIF: Cognitive Level: Application REF: 1688 | 1697-1701

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

14. When caring for a patient who has an intraaortic balloon pump in place, which action will be included in the plan of care?

a.

Avoid the use of anticoagulant medications.

b.

Keep the head of the bed elevated 45 degrees.

c.

Measure the patients urinary output every hour.

d.

Provide passive range of motion for all extremities.

ANS: C

Monitoring urine output will help determine whether the patients cardiac output has improved and also help monitor for balloon displacement. The head of the bed should be no higher than 30 degrees. Heparin is used to prevent thrombus formation. Limited movement is allowed for the extremity with the balloon insertion site to prevent displacement of the balloon.

DIF: Cognitive Level: Application REF: 1697-1699 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

15. While waiting for cardiac transplantation, a patient with severe heart failure has a ventricular assist device (VAD) implanted. When developing the plan of care, the nursing actions should include

a.

administration of immunosuppressive medications.

b.

monitoring the surgical incision for signs of infection.

c.

teaching the patient the reason for continuous bed rest.

d.

preparing the patient to have the VAD in place permanently.

ANS: B

The insertion site for the VAD provides a source for transmission of infection to the circulatory system and requires frequent monitoring. Patients 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: Application REF: 1700-1701 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

16. To verify the correct placement of an endotracheal tube (ET) after insertion, the best initial action by the nurse is to

a.

auscultate for the presence of bilateral breath sounds.

b.

obtain a portable chest radiograph to check tube placement.

c.

observe the chest for symmetrical movement with ventilation.

d.

use an end-tidal CO2 monitor to check for placement in the trachea.

ANS: D

End-tidal CO2 monitors are currently recommended for rapid verification of ET placement. Auscultation for bilateral breath sounds and checking chest expansion also are used, but they are not as accurate as end-tidal CO2monitoring. A chest x-ray confirms the placement but is done after the tube is secured.

DIF: Cognitive Level: Application REF: 1701-1702 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

17. To inflate the cuff of an endotracheal tube (ET) when the patient is on mechanical ventilation, the nurse

a.

inflates the cuff until the pilot balloon is firm.

b.

inflates the cuff with a minimum of 10 mL of air.

c.

injects air into the cuff until a manometer shows 15 mm Hg pressure.

d.

injects 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 patients 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.

DIF: Cognitive Level: Comprehension REF: 1701-1702

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

18. Premature ventricular contractions (PVCs) occur while the nurse is suctioning a patients endotracheal tube. Which action by the nurse is best?

a.

Decrease the suction pressure to 80 mm Hg.

b.

Stop and ventilate the patient with 100% oxygen.

c.

Document the dysrhythmia in the patients chart.

d.

Give prescribed PRN antidysrhythmic medications.

ANS: B

Dysrhythmias during suctioning may indicate hypoxemia or sympathetic nervous system stimulation, and 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 the PVCs occurred during suctioning, there is no need for antidysrhythmic medications (which may have adverse effects) unless they recur when the patient is well oxygenated.

DIF: Cognitive Level: Application REF: 1703-1704

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

19. Which assessment information obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning?

a.

The respiratory rate is 32 breaths/min.

b.

The pulse oximeter shows a SpO2 of 93%.

c.

The patient has not been suctioned for the last 6 hours.

d.

The lungs have occasional audible expiratory wheezes.

ANS: A

The increase in respiratory rate indicates that the patient may have decreased airway clearance and requires suctioning. Suctioning is done when patient assessment data indicate that it is needed, not on a scheduled basis. Occasional expiratory wheezes do not indicate poor airway clearance, and suctioning the patient may induce bronchospasm and increase wheezing. An SpO2 of 93% is acceptable and does not suggest that immediate suctioning is needed.

DIF: Cognitive Level: Application REF: 1702-1704

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

20. The nurse notes thick, white respiratory secretions for a patient who is receiving mechanical ventilation. Which intervention will be most effective in resolving this problem?

a.

Suction the patient every hour.

b.

Reposition the patient every 2 hours.

c.

Add additional water to the patients enteral feedings.

d.

Instill 5 mL of sterile saline into the endotracheal tube (ET) before suctioning.

ANS: C

Because the patients secretions are thick, better hydration is indicated. Suctioning every hour without any specific evidence for the need will increase the incidence of mucosal trauma and would not address the etiology of the ineffective airway clearance. Instillation of saline does not liquefy secretions and may decrease the SpO2. Repositioning the patient is appropriate but will not decrease the thickness of secretions.

DIF: Cognitive Level: Application REF: 1703-1704

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

21. Four hours after mechanical ventilation is initiated for a patient with chronic obstructive pulmonary disease (COPD), the patients arterial blood gas (ABG) results include a pH of 7.50, PaO2 of 80 mm Hg, PaCO2 of 29 mm Hg, and HCO3 of 23 mEq/L (23 mmol/L). The nurse will anticipate the need to

a.

increase the FIO2.

b.

decrease the respiratory rate.

c.

increase the tidal volume (VT).

d.

leave the ventilator at the current settings.

ANS: B

The patients PaCO2 and pH indicate respiratory alkalosis caused by too high a respiratory rate. The PaO2 is appropriate for a patient with COPD, increasing the tidal volume would further lower the PaCO2, and the PaCO2 and pH indicate a need to make the ventilator changes.

DIF: Cognitive Level: Analysis REF: 1710-1711 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

22. A patient with respiratory failure has hemodynamic monitoring and is receiving mechanical ventilation with peak end-expiratory pressure (PEEP) of 10 cm H2O. Which information indicates that a change in the ventilator settings may be required?

a.

The arterial line shows a blood pressure of 90/46.

b.

The pulmonary artery pressure (PAP) is decreased.

c.

The cardiac monitor shows a heart rate of 58 beats/min.

d.

The pulmonary artery wedge pressure (PAWP) is increased.

ANS: A

The hypotension indicates that the high intrathoracic pressure caused by the PEEP may be decreasing venous return and cardiac output (CO). The other assessment data would not be caused by mechanical ventilation.

DIF: Cognitive Level: Application REF: 1710 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

23. When the nurse is weaning a patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation, which patient assessment indicates that the weaning protocol should be discontinued?

a.

The patient heart rate is 98 beats/min.

b.

The patients oxygen saturation is 93%.

c.

The patient respiratory rate is 32 breaths/min.

d.

The patients spontaneous tidal volume is 500 mL.

ANS: C

Tachypnea is a sign that the patients work of breathing is too high to allow weaning to proceed. The patients heart rate is within normal limits, although the nurse should continue to monitor it. An oxygen saturation of 93% is acceptable for a patient with COPD. A spontaneous tidal volume of 500 mL is within the acceptable range.

DIF: Cognitive Level: Application REF: 1713 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

24. The nurse is caring for a patient receiving a continuous norepinephrine (Levophed) IV infusion. Which patient assessment information indicates that the infusion rate may be too high?

a.

Heart rate is 58 beats/min.

b.

Mean arterial pressure is 55 mm Hg.

c.

Systemic vascular resistance (SVR) is elevated.

d.

Pulmonary artery wedge pressure (PAWP) is low.

ANS: C

Vasoconstrictors such as norepinephrine (Levophed) will increase SVR, and this will increase the work of the heart and decrease peripheral perfusion. Bradycardia, hypotension, and low PAWP are not associated with norepinephrine infusion.

DIF: Cognitive Level: Application REF: 1693-1695 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

25. When caring for the patient with a pulmonary artery pressure catheter, the nurse notes that the PA waveform indicates that the catheter is in the wedged position. Which action should the nurse take?

a.

Inflate the PA balloon.

b.

Change the flush system.

c.

Zero balance the transducer.

d.

Notify the health care provider.

ANS: D

When the catheter is in the wedge position, blood flow past the catheter is obstructed, placing the patient at risk for pulmonary infarction. A health care provider or specially trained nurse should be called to reposition the catheter. The other actions will not correct the wedging of the PA catheter.

DIF: Cognitive Level: Application REF: 1696

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

26. While assessing a patient with a central venous catheter, the nurse notes the catheter insertion site is red and tender and the patients temperature is 101.8 F. The nurse will plan to

a.

administer analgesics and antibiotics.

b.

check the site frequently for any swelling.

c.

discontinue the catheter and culture the tip.

d.

change the flush system and monitor the site.

ANS: C

The information indicates that the patient has a local and systemic infection caused by the catheter and the catheter should be discontinued. Changing the flush system, administration of analgesics, and continued monitoring will not help prevent or treat the infection. Administration of antibiotics is appropriate, but the line should still be discontinued to avoid further complications such as endocarditis.

DIF: Cognitive Level: Application REF: 1696 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

27. An elderly patient who has stabilized after being in the intensive care unit (ICU) for a week is preparing for transfer to the step down unit when the nurse notices that the patient has new onset confusion. The nurse will plan to

a.

inform the receiving nurse and then transfer the patient.

b.

notify the health care provider and postpone the transfer.

c.

administer PRN lorazepam (Ativan) and cancel the transfer.

d.

obtain an order for restraints as needed and transfer the patient.

ANS: A

The patients history and symptoms most likely indicate delirium associated with the sleep deprivation and sensory overload in the ICU environment, and informing the receiving nurse and transferring the patient is appropriate. Postponing the transfer is likely to prolong the delirium. Benzodiazepines and restraints contribute to delirium and agitation.

DIF: Cognitive Level: Application REF: 1686 TOP: Nursing Process: Planning

MSC: NCLEX: Psychosocial Integrity

28. The family members of a patient who has just been admitted to the intensive care unit (ICU) with multiple traumatic injuries have just arrived in the ICU waiting room. Which action should the nurse take first?

a.

Immediately take the family members to the patients room.

b.

Discuss ICU visitation policies and encourage family visits.

c.

Describe the patients injuries and the care that is being provided.

d.

Invite the family to participate in a multidisciplinary care conference.

ANS: C

Lack of information is a major source of anxiety for family members and should be addressed first. Family members should be prepared for the patients appearance and the ICU environment before visiting the patient for the first time. ICU visiting should be individualized to each patient and family rather than being dictated by rigid visitation policies. Inviting the family to participate in a multidisciplinary conference is appropriate but should not be the initial action by the nurse.

DIF: Cognitive Level: Application REF: 1686-1687

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Psychosocial Integrity

29. When caring for a patient who has an arterial catheter in the radial artery to monitor blood pressure, which information obtained by the nurse is most important to report to the health care provider?

a.

The patient has a positive Allen test.

b.

The mean arterial pressure (MAP) is 86 mm Hg.

c.

There is redness at the catheter insertion site.

d.

The dicrotic notch is visible in the waveform.

ANS: C

Redness at the catheter insertion site indicates possible infection. The Allen test is performed before arterial line insertion, and a positive test indicates normal ulnar artery perfusion. A MAP of 86 is normal and the dicrotic notch is normally present on the arterial waveform.

DIF: Cognitive Level: Application REF: 1690-1691

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

30. When the ventilator alarm sounds, the nurse finds the patient lying in bed holding the endotracheal tube (ET). Which action should the nurse take first?

a.

Offer reassurance to the patient.

b.

Activate the hospitals rapid response team.

c.

Call the health care provider to reinsert the tube.

d.

Manually ventilate the patient with 100% oxygen.

ANS: D

The nurse should ensure maximal patient oxygenation by manually ventilating with a bag-valve-mask system. Offering reassurance to the patient, notifying the health care provider about the need to reinsert the tube, and activating the rapid response team also are appropriate after the nurse has stabilized the patients oxygenation.

DIF: Cognitive Level: Application REF: 1704-1706

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

31. The nurse notes that a patients endotracheal tube (ET), which was at the 21-cm mark, is now at the 24-cm mark and the patient appears anxious and restless. Which action should the nurse take first?

a.

Listen to the patients lungs.

b.

Offer reassurance to the patient.

c.

Bag the patient at an FIO2 of 100%.

d.

Notify the patients health care provider.

ANS: A

The nurse should first determine whether the ET tube has been displaced into the right mainstem bronchus by listening for unilateral breath sounds. If so, assistance will be needed to reposition the tube immediately. The other actions also are appropriate, but detection and correction of tube malposition are the most critical actions.

DIF: Cognitive Level: Application REF: 1701-1702

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

32. When the charge nurse is evaluating the care that a new RN staff member provides to a patient receiving mechanical ventilation, which action by the new RN indicates the need for more education?

a.

The RN turns the FIO2 up to 100% before suctioning.

b.

The RN secures a bite block in place using adhesive tape.

c.

The RN positions the patient with the head of bed at 10 degrees.

d.

The RN asks for assistance to turn the patient to the prone position.

ANS: C

The head of the patients bed should be positioned at 30 to 45 degrees to prevent ventilator-acquired pneumonia. The other actions by the new RN are appropriate.

DIF: Cognitive Level: Application REF: 1711

OBJ: Special Questions: Delegation TOP: Nursing Process: Evaluation

MSC: NCLEX: Safe and Effective Care Environment

33. A patient who is receiving mechanical ventilation is anxious and is fighting the ventilator. Which action should the nurse take first?

a.

Ventilate the patient with a manual resuscitation bag.

b.

Verbally coach the patient to breathe with the ventilator.

c.

Sedate the patient with the ordered PRN lorazepam (Ativan).

d.

Increase the rate for the ordered propofol (Diprivan) infusion.

ANS: B

The initial response by the nurse should be to try to decrease the patients anxiety by coaching the patient about how to coordinate respirations with the ventilator. The other actions also may be helpful if the verbal coaching is ineffective in reducing the patients anxiety.

DIF: Cognitive Level: Application REF: 1704-1705

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

34. When the nursing supervisor is evaluating the performance of a new RN, which action indicates that the new RN is safe in providing care to a patient who is receiving mechanical ventilation with 10 cm of peak end-expiratory pressure (PEEP)?

a.

The RN plans to suction the patient every 2 hours.

b.

The RN uses a closed-suction technique to suction the patient.

c.

The RN tapes connection between the ventilator tubing and the ET.

d.

The RN changes the ventilator circuit tubing routinely every 24 hours.

ANS: B

The closed-suction technique is suggested when patients require high levels of PEEP to prevent the loss of PEEP that occurs when disconnecting the patient from the ventilator. Suctioning should not be scheduled routinely, but it should be done only when patient assessment data indicate the need for suctioning. Taping connections between the ET and the ventilator tubing would restrict the ability of the tubing to swivel in response to patient repositioning. Ventilator tubing changes increase the risk for ventilator-associated pneumonia (VAP) and are not indicated routinely.

DIF: Cognitive Level: Application REF: 1703-1704

OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation

MSC: NCLEX: Safe and Effective Care Environment

35. A patient with a subarachnoid hemorrhage is intubated and placed on a mechanical ventilator. When monitoring the patient, the nurse will need to notify the health care provider if the patient develops

a.

oxygen saturation of 94%.

b.

respirations of 18 breaths/min.

c.

green nasogastric tube drainage.

d.

increased jugular vein distention (JVD).

ANS: D

Increases in JVD in a patient with a subarachnoid hemorrhage may indicate an increase in intra-cranial pressure (ICP) and that the PEEP setting is too high for this patient. A respiratory rate of 18, O2 saturation of 94%, and green nasogastric tube drainage are normal.

DIF: Cognitive Level: Application REF: 1711-1712

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

COMPLETION

1. A patients vital signs are pulse 80, respirations 24, and BP of 124/60 mm Hg and cardiac output is 4.8 L/min. What is the patients stroke volume? ____________________

ANS:

60 mL

Stroke volume = cardiac output/heart rate

DIF: Cognitive Level: Comprehension REF: 1688

OBJ: Special Questions: Alternate Item Format

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

2. In which order will the nurse take these actions when assisting with oral intubation of a patient who is having respiratory distress? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________

a. Obtain a portable chest-x-ray.

b. Place the patient in the supine position.

c. Inflate the cuff of the endotracheal tube.

d. Attach an end-tidal CO2 detector to the endotracheal tube.

e. Oxygenate the patient with a bag-valve-mask system for several minutes.

ANS:

E, B, C, D, A

The patient is pre-oxygenated with a bag-valve-mask system for 3 to 5 minutes before intubation and then placed in a supine position. Following the intubation, the cuff on the endotracheal tube is inflated to occlude and protect the airway. Tube placement is assessed first with an end-tidal CO2 sensor, then with a chest x-ray.

DIF: Cognitive Level: Analysis REF: 1701-1702

OBJ: Special Questions: Alternate Item Format, Prioritization

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

Leave a Reply