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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.
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)
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.
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.
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)
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.
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).
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.
When preparing to assist with the insertion of a pulmonary artery catheter, the nurse will plan to ______________
attach cardiac monitoring leads before the procedure.
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.
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 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 ____________
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.
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.
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.
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.
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.
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.
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 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.
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.
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.
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.
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.
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.
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.
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 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.
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.
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 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.
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.
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.
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.
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).
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.
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