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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?
Cluster nursing activities so that the patient has uninterrupted rest periods.
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.
To determine the effectiveness of medications that a patient has received to reduce left ventricular afterload, which hemodynamic parameter will the nurse monitor?
Systemic vascular resistance (SVR)
Systemic vascular resistance reflects the resistance to ventricular ejection, or afterload. The other parameters will be monitored, but do not reflect afterload as directly.
While family members are visiting, a patient has a cardiac arrest and is being resuscitated. Which action by the nurse is best?
Ask family members if they wish to remain in the room during the resuscitation.
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.
Following surgery, a patient's central venous pressure (CVP) monitor indicates low pressures. Which action will the nurse anticipate taking?
Increase the IV fluid infusion rate.
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.
When caring for a patient with pulmonary hypertension, which parameter will the nurse monitor to evaluate whether treatment has been effective?
Pulmonary vascular resistance (PVR)
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.
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 ______________
positions the zero-reference stopcock line level with the phlebostatic axis.
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.
When monitoring for the effectiveness of treatment for a patient with left ventricular failure, the most important information for the nurse to obtain is ______________
pulmonary artery wedge pressure (PAWP).
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.
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?
Assess for cardiac dysrhythmias.
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 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.
When preparing to assist with the insertion of a pulmonary artery catheter, the nurse will plan to ______________
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 enzymes or heart sounds are not expected during pulmonary artery catheter insertion.
When assisting with insertion of a pulmonary artery (PA) catheter, the nurse identifies that the catheter is correctly placed when the _______________
monitor shows a typical 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. The length of catheter needed for insertion will vary with patient size.
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?
The left hand is cooler than the right hand.
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.
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 patient's ____________
Elevated temperature increases metabolic demands and oxygen use by tissues, resulting in a drop in oxygen saturation of mixed venous blood. Information about the patient's weight, urinary output, and amylase will not help in determining the cause of the patient's drop in SvO2.
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 _________________
cardiac output (CO) of 5 L/min.
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.
When caring for a patient who has an intraaortic balloon pump in place, which action will be included in the plan of care?
Measure the patient's urinary output every hour.
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 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.
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 ___________
monitoring 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.
To verify the correct placement of an endotracheal tube (ET) after insertion, the best initial action by the nurse is to _______________
use an end-tidal CO2 monitor to check for placement in the trachea.
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 CO2 monitoring. A chest x-ray confirms the placement but is done after the tube is secured.
To inflate the cuff of an endotracheal tube (ET) when the patient is on mechanical ventilation, the nurse ______________
injects air into the cuff until a slight leak is heard only at peak inflation.
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.
Premature ventricular contractions (PVCs) occur while the nurse is suctioning a patient's endotracheal tube. Which action by the nurse is best?
Stop and ventilate the patient with 100% oxygen.
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.
Which assessment information obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning?
The respiratory rate is 32 breaths/min.
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.
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?
Add additional water to the patient's enteral feedings.
Because the patient's 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.
Four hours after mechanical ventilation is initiated for a patient with chronic obstructive pulmonary disease (COPD), the patient's 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 ____________
decrease the respiratory rate.
The patient's 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.
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?
The arterial line shows a blood pressure of 90/46.
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.
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?
The patient respiratory rate is 32 breaths/min.
Tachypnea is a sign that the patient's work of breathing is too high to allow weaning to proceed. The patient's 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.
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?
Systemic vascular resistance (SVR) is elevated.
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.
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?
Notify the health care provider.
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.
While assessing a patient with a central venous catheter, the nurse notes the catheter insertion site is red and tender and the patient's temperature is 101.8° F. The nurse will plan to _____________
discontinue the catheter and culture the tip.
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.
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 ________________
inform the receiving nurse and then transfer the patient.
The patient's 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.
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?
Describe the patient's injuries and the care that is being provided.
Lack of information is a major source of anxiety for family members and should be addressed first. Family members should be prepared for the patient's 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.
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?
There is redness at the catheter insertion site.
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.
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?
Manually ventilate the patient with 100% oxygen.
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 patient's oxygenation.
The nurse notes that a patient's 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?
Listen to the patient's lungs.
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.
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?
The RN positions the patient with the head of bed at 10 degrees.
The head of the patient's bed should be positioned at 30 to 45 degrees to prevent ventilator-acquired pneumonia. The other actions by the new RN are appropriate.
A patient who is receiving mechanical ventilation is anxious and is "fighting" the ventilator. Which action should the nurse take first?
Verbally coach the patient to breathe with the ventilator.
The initial response by the nurse should be to try to decrease the patient's 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 patient's anxiety.
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)?
The RN uses a closed-suction technique to suction the patient.
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.
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 _______________
increased jugular vein distention (JVD).
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.
A patient's 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 patient's stroke volume? ____________________
Stroke volume = cardiac output/heart rate
In which order will the nurse take these actions when assisting with oral intubation of a patient who is having respiratory distress?
e) Oxygenate the patient with a bag-valve-mask system for several minutes.
b) Place the patient in the supine position.
c) Inflate the cuff of the
d) Attach an end-tidal CO2 detector to the endotracheal
a) Obtain a portable chest-x-ray.tube.endotracheal tube.
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.
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