Question 1

The nurse is caring for a client with sepsis and acute respiratory failure who was intubated and prescribed mechanical ventilation 3 days ago.  The nurse assesses for which adverse effect associated with the administration of positive pressure ventilation (PPV)?

Accepted Answer

Positive pressure ventilation (PPV) delivers positive pressure to the lungs using a mechanical ventilator (MV), either invasively through a tracheostomy or endotracheal tube or noninvasively through a nasal mask/facemask, nasal prongs, or a mouthpiece. The most common type used in the acute care setting for clients with acute respiratory failure is the volume cycled positive pressure MV, which delivers a preset volume and concentration of oxygen (eg, 21%-100%) with varying pressure. Positive pressure applied to the lungs compresses the thoracic vessels and increases intrathoracic pressure during inspiration. This leads to reduced venous return, ventricular preload, and cardiac output, which results in hypotension. The hypotensive effect of PPV is even greater in the presence of hypovolemia (eg, hemorrhage, hypovolemic shock) and decreased venous tone (eg, septic shock, neurogenic shock). (Option A) Fluid and/or sodium retention usually occurs about 48-72 hours after initiation of PPV due to: (1) increased intrathoracic pressure and decreased cardiac output that stimulate the kidneys to release renin; (2) physiologic stress that leads to the release of antidiuretic hormone and cortisol; and (3) breathing through the ventilator's closed circuitry, which decreases insensible loss associated with respiration. (Option B) Hypokalemia is not associated with PPV. (Option D) PPV increases intrathoracic pressure and reduces venous return to the right side of the heart, reducing preload and cardiac output as well. Educational objective: Positive pressure ventilation causes increased intrathoracic pressure and reduced venous return and cardiac output, which can result in hypotension.

Question 2

The charge nurse is evaluating the skills of a new registered nurse (RN) assigned to care for a client with shock. Which action taken by the new RN indicates a need for further education?

Accepted Answer

The nurse manager would intervene when the new RN places the HOB of a client with hypovolemic shock in high Fowler's (90 degrees) position. Raising the HOB causes blood pressure to decrease, especially in a client with hypovolemic shock and inadequate circulating vascular volume. (Option A) Furosemide (Lasix) is an appropriate drug for the nurse to administer to decrease left ventricular preload in a client in cardiogenic shock with a PAWP of 24 mm Hg (normal, 6-12 mm Hg). (Option B) Norepinephrine (Levophed) is a vasopressor used to increase stroke volume, cardiac output, and MAP. Titrating a norepinephrine infusion upward to maintain the MAP within normal limits (>65 mm Hg) is an appropriate nursing action for a client in anaphylactic shock. > (Option C) In clients with decreased peripheral tissue perfusion who are receiving vasopressors, pulse oximetry readings are usually more accurate when the sensor is placed on the forehead rather than on the finger. Therefore, moving the pulse oximeter sensor from the finger to the forehead is an appropriate action for the nurse to take for a client with septic shock. Educational objective: Norepinephrine is a vasopressor used to increase stroke volume, cardiac output, and MAP. MAP should be maintained at >65 mm Hg in septic or anaphylactic shock. Furosemide is an appropriate drug to decrease left ventricular preload in a client in cardiogenic shock. Normal PAWP is 6-12 mm Hg.

Question 3

The nurse in the intensive care unit is caring for a client who is postoperative from a cardiac surgery. The client has a mediastinal chest tube. During assessment, the nurse notes bubbling in the suction control chamber. Which nursing action is appropriate?

Accepted Answer

11ecbb05_cafe_cf88_b433_a94da8092978_MD0009_00 Gentle, continuous bubbling in the suction control chamber (section A) of a chest tube drainage unit indicates that suction is present and the unit is functioning appropriately. The nurse should document the finding and continue to monitor. (Option A) Subcutaneous emphysema is air that has leaked into the tissue surrounding the chest tube insertion site. A crackling sensation is felt when palpating the skin. It does not affect bubbling within the chest tube drainage unit. (Option B) An air leak would cause bubbling in the air leak gauge (section C) or water seal chamber not in the suction control chamber. (Option D) Turning down the wall suction would effectively negate the presence of suction in the chest tube drainage unit. Educational objective: Gentle, continuous bubbling in the suction control chamber of a chest tube drainage unit indicates the presence of suction in the system and is an expected finding.

Question 4

When caring for a client with a left radial artery catheter, which assessment data obtained by the nurse indicates the need to take immediate action?

Accepted Answer

Although the Allen's test is performed before cannulating the radial artery and determines the adequacy of ulnar artery blood flow, circulation to the extremity is monitored frequently. The nurse must assess color, capillary refill, sensation, temperature, and movement per institution policy. Impairment in any of these parameters must be reported immediately because it may indicate impaired circulation to the extremity, and removal of the catheter may be necessary. (Option A) Capillary refill of less than 3 seconds is an indicator of normal arterial circulation. (Option C) A mean arterial pressure of 65 mm Hg is adequate to perfuse the vital organs. (Option D) To maintain patency of the arterial blood pressure monitoring system, an intravenous bag of normal saline solution is placed in a pressure infuser device. The device is set to maintain continual pressure at 300 mm Hg. The pressure drops as the volume of solution in the bag decreases and can be pumped back up. This does not pose an immediate threat to the client. Educational objective: When caring for a client with a radial, brachial, or femoral arterial line in place, the nurse must be able to assess for complications. These include hemorrhage, infection, thrombus formation, and circulatory and neurovascular impairment.

Question 5

The emergency department nurse receives a client with extensive injuries to the head and upper back. The nurse will perform what action to allow the best visualization of the airway?

Accepted Answer

11ecbb05_caf8_66dd_b433_3fe9a032013a_MD0009_00 Clinical situations involving trauma should follow ABC: Airway, Breathing, and Circulation. Airway assessment is particularly critical in clients with injuries to the head, neck, and upper back. Injury to the upper back should be treated as spinal trauma until the client has been cleared by an Advanced Trauma Life Support-qualified health care provider. Until the spine is appropriately assessed, the client should be placed on a backboard and stabilized. The nurse should use the jaw-thrust maneuver to avoid movement of an unstable spine. One provider should stabilize the cervical vertebra allowing the second provider to articulate the jaw independently of the spinal column. (Option A) Although use of the backboard is appropriate, the head-tilt chin-lift should not be used as it involves manipulation of the neck without proper stabilization. If the cervical vertebrae are fractured, the spinal cord could be badly damaged. (Option B) The head-tilt chin-lift does not stabilize the alignment of the head and neck and can cause spinal cord damage. In addition, the Trendelenburg position causes the abdominal organs to shift toward the diaphragm, which increases the work of breathing. (Option C) The jaw-thrust maneuver is appropriate, but stabilization of the spine is best performed in the supine position, such as on the flat, hard surface of a backboard. Educational objective: If there is any suspicion of spinal injury, the jaw-thrust maneuver should be used for airway assessment to avoid any shifting of unstable vertebrae and subsequent spinal cord damage.

Question 6

A client is admitted to the intensive care unit with diabetic ketoacidosis. The client is most likely to exhibit which of the following arterial blood gas results?

Accepted Answer

11ecbb05_caf9_c66f_b433_adcbece354e3_MD0009_00 The arterial blood gas (ABG) result most consistent with the diagnosis of diabetic ketoacidosis (DKA) is metabolic acidosis or partially compensated metabolic acidosis (pH 7.30, PaCO₂ 30 mm Hg [4.0 kPa], HCO₃ 15 mEq/L [15 mmol/L]). DKA is a life-threatening complication of type 1 diabetes characterized by hyperglycemia (>250 mg/dL [13.9 mmol/L]) resulting in ketosis, a metabolic acidosis. Glucose cannot be taken out of the bloodstream and used for energy without insulin, which individuals with type 1 diabetes cannot produce. Similar to a state of starvation, the body begins to break down fat stores into ketones, causing a metabolic acidosis (low pH and low HCO3). As a compensatory mechanism, this client has deep and rapid respirations with fruity/acetone smell (Kussmaul respirations) in an attempt to reduce carbon dioxide levels by inducing a respiratory alkalosis to partially compensate for the ketoacidosis, which has nearly normalized the pH. (Option A) This is an example of respiratory acidosis (low pH and increased CO₂ levels). It is commonly seen in conditions that cause CO₂ retention (eg, chronic obstructive pulmonary disease, obesity hypoventilation syndrome, respiratory depression due to narcotics). (Option C) This is an example of normal ABG results. (Option D) This is an example of metabolic alkalosis (high pH and elevated HCO₃), which typically presents with prolonged vomiting and aggressive diuresis. Educational objective: The arterial blood gas result most consistent with the diagnosis of diabetic ketoacidosis is metabolic acidosis or partially compensated metabolic acidosis (pH ≤7.30 and HCO₃ ≤18 mEq/L [18 mmol/L]). Respiratory compensation may raise pH to near-normal values, but the PCO₂ will be dramatically lower than normal (PCO₂ ≤30 mm Hg [4.0 kPa]).

Question 7

The nurse is caring for a ventilator-dependent client with neuromuscular degenerative disease and observes the plethysmograph waveform in the image below. What is the nurse's immediate action?

Accepted Answer

11ecbb05_cafe_8167_b433_f30a4470db93_MD0009_00 The erratic pulse oximeter tracing is representative of an artifact plethysmograph waveform caused by motion. When an electronic assessment reading is questionable, the nurse should always assess the client first for possible etiology. The assessment includes the client's oxygenation and perfusion status (skin temperature, color), the level of consciousness (in sedated clients), and restlessness or agitation. This assessment data guides the nurse in the correct analysis of the tracing. (Option B) The artifact is most likely from movement or loose contact between the sensor and the area of the body to which it is attached. It is not an electrical artifact and does not require the device to be disconnected from this client. (Option C) The pulse oximeter reading is 95%. Unless there are audible or visual secretions, increased ventilator peak pressure readings, coughing, or rhonchi, this client does not require immediate endotracheal suctioning. (Option D) The reading on the device is 95% and the low alarm is set to 90%. Therefore, alarm parameters do not need to be reset. Educational objective: When the nurse assesses an erratic plethysmograph waveform, the first action is to assess the client's oxygenation/perfusion status and assess for a motion artifact. This assessment data guides the nurse in the correct analysis of the tracing.

Question 8

A client with massive trauma and possible spinal cord injury is admitted to the emergency department following a dirt bike accident.  Which clinical manifestation does the nurse assess to help best confirm a diagnosis of neurogenic shock?

Accepted Answer

11ecbb05_cafa_b0d1_b433_a5ee7e028e16_MD0009_00 Neurogenic shock belongs to the group of distributive (vasodilatory) shock. It affects the vasomotor center in the medulla and causes a disruption in the sympathetic nervous system (SNS); the parasympathetic nervous system (PNS) remains intact. The imbalance of activity between the SNS and PNS results in massive vasodilation and pooling of blood in the venous circulation, causing hypotension and bradycardia, the characteristic manifestations of neurogenic shock. (Option B) Hypotension, not hypertension, is characteristic of neurogenic shock. (Option C) Warm, dry skin is more likely to be present in neurogenic shock; cool, clammy skin is not a characteristic manifestation. (Option D) Although thermoregulation may be impaired (poikilothermia) in neurogenic shock, a low-grade temperature of 100 F (37.7 C) is not a characteristic manifestation. Educational objective: Neurogenic shock (a form of distributive shock) causes a disruption in the function of the sympathetic, but not parasympathetic, nervous system. Bradycardia, a characteristic manifestation of neurogenic shock, occurs as a result of this alteration in neural activity between the 2 systems.

Question 9

The nurse cares for an intubated client on mechanical ventilation with worsening cerebral edema from increased intracranial pressure (ICP). Which nursing interventions help reduce ICP? Select all that apply.

Accepted Answer

Most nursing activities increase intracranial pressure (ICP) in brain injuries. The goal is to reduce ICP while managing basic client needs. During interventions, ICP should not exceed 25 mm Hg and should return to baseline within a few minutes. Metabolic demands (eg, pain, straining, agitation, shivering, fever, hypoxia) increase brain blood supply and raise ICP. Nursing interventions to control ICP include: Elevating the head of the bed to 30 degrees with the head/neck in a neutral position to reduce venous congestion (Option D) Administering stool softeners to reduce the risk of straining (eg, Valsalva maneuver) Managing pain well while monitoring sedation Managing fever (eg, cool sponges, ice, antipyretics) while preventing shivering Maintaining a calm environment with minimal noise (eg, alarms, television, hall noise) (Option C) Ensuring adequate oxygenation Hyperventilating and preoxygenating the client before suctioning; reducing CO₂ (a potent cerebral vasodilator) by hyperventilation induces vasoconstriction and reduces ICP (Option B) (Option A) Stimulation increases oxygen metabolism within the brain, increasing the risk for irreversible brain damage in increased ICP. Limit performing interventions unless absolutely necessary and avoid performing interventions in clusters. (Option E) The nurse should suction a maximum of 10 seconds and only as necessary to remove secretions. Prolonged suctioning increases ICP. Educational objective: Nursing activities can increase intracranial pressure (ICP) and should be limited and spread throughout the day. The goal is to reduce ICP while managing basic needs. Nursing interventions include elevating the head of the bed, administering stool softeners, managing pain and fever, and maintaining a calm environment.

Question 10

A client with acute respiratory distress syndrome is receiving positive pressure mechanical ventilation with 15 cm H₂O (11 mm Hg) positive end-expiratory pressure (PEEP). The nurse should assess for which complication associated with PEEP?

Accepted Answer

Positive end-expiratory pressure (PEEP) applies a given pressure at the end of expiration during mechanical ventilation. It counteracts small airway collapse and keeps alveoli open so that they can participate in gas exchange. PEEP is usually kept at 5 cm H₂O (3.7 mm Hg). However, a higher level of PEEP is an effective treatment strategy for acute respiratory distress syndrome (ARDS), a type of progressive respiratory failure that causes damage to the type II surfactant-producing pneumocytes that then leads to atelectasis, noncompliant lungs, poor gas exchange, and refractory hypoxemia. High levels of PEEP (10-20 cm H₂O [7.4-14.8 mm Hg]) can cause overdistension and rupture of the alveoli, resulting in barotrauma to the lung. Air from ruptured alveoli can escape into the pulmonary interstitial space or pleural space, resulting in a pneumothorax and/or subcutaneous emphysema. (Option B) PEEP opens up collapsed alveoli and improves gas exchange at a lower fraction of inspired oxygen (FiO₂), resulting in increased, not decreased, oxygen saturation. (Option C) Hemodynamic effects of PEEP include increased intrathoracic pressure, which leads to reduced venous return, decreased preload and cardiac output, and hypotension, not hypertension. (Option D) Keeping the alveoli open between breaths with PEEP improves gas exchange across the alveolar-capillary membrane, reduces hypoxemia, and allows for the use of a lower FiO2, which can reduce the risk for oxygen toxicity. Educational objective: High PEEP is commonly used to prevent small airway/alveolar collapse in clients with ARDS. PEEP helps to reduce oxygen toxicity. However, high levels of PEEP (10-20 cm H₂O [7.4-14.8 mm Hg]) can cause barotrauma to the lung, resulting in a pneumothorax, and decreased venous return causes hypotension.

Question 11

The nurse is supervising a graduate nurse (GN) on a telemetry unit. An assigned client develops asystole with no pulse, and emergency care interventions are initiated. Which action by the GN would cause the supervising nurse to intervene?

Accepted Answer

11ecbb05_cafc_8595_b433_2388185fb1fb_MD0009_00 The client in asystole has a total absence of ventricular electrical activity and is pulseless, apneic, and unresponsive. The nurse should first verify the monitor reading by assessing the client and palpating for a pulse, and then call for help and initiate emergency care (ie, CPR, oxygenated ventilation). Defibrillation is not indicated when there is no electrical activity present (ie, asystole) or when the heart muscle is not contracting despite an organized rhythm (ie, pulseless electrical activity [PEA]). Defibrillation attempts to convert lethal ventricular dysrhythmias (ie, ventricular fibrillation and pulseless ventricular tachycardia) into an organized rhythm by passing an electric shock through the heart. Defibrillation cannot create an organized rhythm if there is no electrical activity in the heart (Option D). (Options A, B, and C) Immediate interventions for asystole and PEA include CPR and oxygenated ventilation. Advanced cardiovascular life-support measures include epinephrine IV, placement of advanced airway (ie, intubation), and treatment of reversible causes (eg, hypovolemia, hyperkalemia). When treating asystole or PEA, the absolute priority is providing continuous, high-quality CPR and oxygenated ventilation until circulation spontaneously returns or the client enters into a shockable rhythm. Unfortunately, restoration of circulation may not be possible, and clients in asystole often cannot be resuscitated. Educational objective: Asystole is characterized by a total absence of ventricular electrical activity. The client is pulseless, apneic, and unresponsive. Treatment includes CPR, oxygenated ventilation, and advanced cardiovascular life-support measures (eg, epinephrine IV, advanced airway). Defibrillation is not effective for treatment of asystole or pulseless electrical activity.

Question 12

The flight nurse assesses an alert and oriented client at an industrial accident scene who was impaled in the abdomen by a pair of scissors. Which nursing action is the immediate priority on arrival at the scene?

Accepted Answer

A sharp object that pierces the skin and lodges in the body may result in penetrating trauma to nearby tissue and organs. Common types of impaled (embedded) objects include bullets or blast fragments from firearms as well as sharp objects such as scissors, nails, or knives. The embedded object creates a puncture wound and then controls potential bleeding by putting pressure on the wound. First responders should not manipulate or remove the impaled object. Manipulation or removal may cause further trauma and bleeding; therefore, stabilization of the object is the first priority to prevent it from moving during initial client assessment (Option D) and later during transport to a health care facility where skilled trauma care is available. Exception to the rule: First responders (EMS providers) may remove the impaled object if it obstructs the airway and prevents effective cardiopulmonary resuscitation. (Option A) An IV line may be inserted and fluids begun on scene after stabilization of the object and initial assessment. (Option B) Blood may be drawn after stabilization of the object and initial assessment. (Option C) Clothing may be removed on scene after stabilization of the object and initial assessment. Educational objective: An impaled object should not be manipulated or removed at the scene as further trauma and bleeding of soft tissue and surrounding organs may occur. The embedded object is stabilized on scene to allow for initial client assessment and later transport to a health care facility where skilled trauma care is available.

Question 13

A registered nurse is precepting a new nurse in the intensive care unit.  The client is sedated with propofol, on a mechanical ventilator, and is receiving enteral feeding via nasogastric tube.  The new nurse performs interventions to prevent aspiration.  The preceptor should intervene if the new nurse performs which of the following actions?

Accepted Answer

Critically ill clients are at increased risk for aspiration of oropharyngeal secretions and gastric content. It is common in clients who are intubated, sedated, on a mechanical ventilator, and receiving enteral feedings. The nurse must provide nursing interventions to prevent aspiration and monitor for its signs and symptoms. Clients are at increased risk when receiving bolus rather than continual enteral feedings. Bolus feedings should be avoided in critically ill clients, who are already at increased risk for aspiration. (Option A) Assessing gastric residual volumes according to institution policy (at least every 4 hours) is standard for clients receiving continual enteral feedings. Increased volumes may indicate poor absorption and increase the risk of regurgitation and aspiration. (Option B) Measuring the number of centimeters at the nare every 4 hours can help determine if the tube has moved, but it can increase aspiration risk. X-ray confirmation may be necessary if the tube has moved. (Option D) A sedation scale such as the Ramsay Scale is used to assess level of sedation. It is preferable to keep the client minimally sedated (asleep but arousable). This helps decrease the risk of aspiration. Educational objective: Assessing gastric residual volumes and level of sedation at regular intervals, checking enteral feeding tube placement, and administering continual rather than bolus tube feeding are interventions that help prevent aspiration in critically ill high-risk clients.

Question 14

A client who is 2 hours post aortic valve replacement is in the intensive care unit (ICU). The low pressure alarm for the client's radial arterial line sounds. Which action should the nurse take first?

Accepted Answer

The low pressure alarm could signal hypotension. The nurse's first action should be to check the client for evidence of hypotension and the cause. Arterial lines carry the risk of hemorrhage and are most likely to occur at connection sites of the tubing and catheter. A client can lose a large amount of arterial blood in a short period of time. The nurse should verify that these connections are tight on admission of the client to the ICU. (Option B) A fast flush of the arterial line system (square wave test) should be performed after the nurse has ruled out a physiological cause of the low pressure alarm. This test helps to verify if the arterial line is functioning correctly. (Option C) The transducer should be leveled to the client's phlebostatic axis to measure arterial pressure correctly. However, this should be done after the client has been checked for a physiological cause of the alarm. (Option D) Zeroing the monitor should be done if measurement accuracy is questioned. However, this should be done after the client has been taken care of. Educational objective: A low pressure alarm for an arterial line can indicate the presence of hypotension or disconnected tubing. Hemorrhage can rapidly occur with a disconnected arterial catheter line. The nurse should check the client for the presence of hypotension and its causes before troubleshooting the system.

Question 15

The student nurse observes the respiratory therapist (RT) preparing to draw an arterial blood gas from the radial artery.  The RT performs the Allen's test and the student asks why this test performed before the blood sample is drawn.  Which statement made by the RT is most accurate?

Accepted Answer

11ecbb05_cafc_1064_b433_c5ac5cd95a3d_MD0009_00 The radial artery site at the wrist is preferred for collecting an arterial blood gas sample because it is near the surface, is easy to palpate and stabilize, and has good collateral supply from the ulnar artery. The patency of the ulnar artery can be confirmed with a positive modified Allen's test. The modified Allen's test includes the following steps: Instruct the client to make a tight fist (if possible) Occlude the radial and ulnar arteries using firm pressure Instruct the client to open the fist; the palm will be white if both arteries are sufficiently occluded Release the pressure on the ulnar artery; the palm should turn pink within 15 seconds as circulation is restored to the hand, indicating patency of the ulnar artery (positive Allen's test) If the Allen's test is positive, the arterial blood gas can be drawn; if negative and the palm does not return to a pink color, an alternate site (eg, brachial artery, femoral artery) must be used. (Option A) Capillary refill is tested by applying pressure to the fingernail bed to cause blanching. If refill is adequate, the nail bed should become pink in less than 3 seconds after pressure is released. (Option B) The radial artery is palpated with the fingertips to determine the presence of the radial pulse. (Option D) A neurologic deficit is assessed by monitoring color, sensation, and movement of the hand. Educational objective: The radial artery site at the wrist is preferred for collecting an arterial blood gas sample because it is near the surface, easy to palpate and stabilize, and has good collateral supply from the ulnar artery. The patency of the ulnar artery must be confirmed by performing a modified Allen's test to assure adequate circulation to the hand before proceeding with the arterial blood gas collection.

Question 16

To obtain accurate continuous blood pressure readings via a radial arterial catheter, the nurse places the air-filled interface of the stopcock at the phlebostatic axis.  Where is it located?

Accepted Answer

11ecbb05_caf9_2a2e_b433_bbcc7c823f8e_MD0009_00 To measure pressures accurately using continual arterial and/or pulmonary artery pressure monitoring, the zeroing stopcock of the transducer system must be placed at the phlebostatic axis. This anatomical location, with the client in the supine position, is at the 4th ICS, at the midway point of the AP diameter (½ AP)of the chest wall. If the transducer is placed too low, the reading will be falsely high; if placed too high, the reading will be falsely low. This concept is similar to the positioning of the arm in relation to the level of the heart when measuring blood pressure indirectly using a sphygmomanometer or noninvasive blood pressure-monitoring device. The upper arm should be at the level of the phlebostatic axis. (Option A) The angle of Louis is the palpable raised notch where the manubrium and sternum are joined. This anatomical location is useful in counting the ICSs and in finding auscultatory areas. (Option B) The aortic area is an auscultatory area located at the 2nd ICS to the right of the sternal border. (Option D) The mitral area (apex), an auscultatory area, and the point of maximal impulse are located at the 5th ICS at the MCL. Educational objective: The anatomical location of the phlebostatic axis is the 4th ICS, at the midway point of the AP diameter (½ AP) of the chest wall. The stopcock nearest the transducer is placed here to assure accurate pressure measurements.

Question 17

The nurse is caring for a client with an implantable cardioverter defibrillator (ICD).  The client goes into ventricular tachycardia and is pulseless.  The ICD has fired twice.  What action should the nurse take?

Accepted Answer

11ecbb05_cafb_c243_b433_333ebea01aee_MD0009_00 The client with an ICD that is firing is receiving electrical shocks from the internal defibrillator to interrupt the dysrhythmia. It is still imperative that the client receive chest compressions in the form of cardiopulmonary resuscitation (CPR) to provide circulation of blood to the vital organs. The nurse should implement the pulseless arrest algorithm, allowing 30-60 seconds for the ICD to complete its therapy cycle before applying external defibrillation pads/paddles. (Option A) Epinephrine should be administered after CPR and defibrillation. (Option B) The ICD is firing as it was programmed to do. It should not be deactivated. (Option D) The nurse should let the ICD work but needs to implement CPR in addition. Educational objective: The ICD is designed to defibrillate potentially life-threatening dysrhythmias. Although the device is able to sense electrical activity of the heart and respond, it is unable to sense or treat pulselessness. CPR should be initiated in the pulseless client with an ICD.

Question 18

A nurse is caring for an intubated client receiving a continuous sedative infusion. Which interventions by the nurse reflect correct understanding of preventing ventilator-acquired pneumonia? Select all that apply.

Accepted Answer

11ecbb05_cafa_3ba0_b433_5fa24710aeee_MD0009_00 Mechanically ventilated clients are at risk for developing ventilator-associated pneumonia (VAP) due to sedation and impairment of natural defenses (eg, coughing) by artificial airways. Interventions to reduce the risk of VAP include: Elevating the head of the bed 30-45 degrees (ie, semi-Fowler position) (Option A) Providing oral care with antiseptic solutions (eg, chlorhexidine mouthwash) and suctioning subglottic secretions (Option D) Performing scheduled daily sedation vacations and maintaining appropriate client sedation levels (Option E) Practicing strict hand hygiene (Option C) (Option B) Endotracheal suctioning should be performed only when clinically indicated (eg, adventitious breath sounds, coughing, elevated peak airway pressure). Frequent suctioning increases the risk for tracheal and bronchial trauma, bleeding, and hypoxia. Educational objective: Mechanically ventilated clients are at risk for developing ventilator-associated pneumonia (VAP) due to sedation and use of an artificial airway. VAP prevention includes elevating the head of the bed 30-45 degrees, providing regular oral hygiene with chlorhexidine solution, practicing strict hand hygiene, and performing daily sedation vacations.

Question 19

The nurse is caring for a client in the immediate postoperative period following an exploratory laparotomy after sustaining a gunshot wound to the abdomen. Which assessment finding is most important for the nurse to report to the health care provider?

Accepted Answer

11ecbb05_cafb_2602_b433_0dd32aafa056_MD0009_00 Hypovolemic (hemorrhagic) shock may occur after abdominal trauma or surgery as mesenteric edema resolves and previously compressed sites of bleeding reopen. The shock continuum is staged in severity from initial (I) to irreversible (IV). During the initial stage, there is inadequate oxygen to supply the demand at the cellular level and anaerobic metabolism develops. At this point, there may be no recognizable signs or symptoms. As shock progresses to the compensatory stage, sympathetic compensatory mechanisms are activated to maintain homeostasis (eg, oxygenation, cardiac output). Cold, clammy skin indicates failing compensatory mechanisms (ie, progressive stage), and immediate intervention is necessary to prevent irreversible shock and death (Option A). (Option B) Slightly low oxygen saturation may occur when there is inadequate oxygen supply and increased metabolic demand. It is not the most important finding to report. (Option C) Sinus tachycardia is part of the compensatory response to maintain cardiac output and oxygen demand. It is not the most important finding to report. (Option D) As shock continues, the kidneys decrease filtration and increase reabsorption to maintain blood pressure, eventually resulting in decreased urinary output. Normal urine output is 0.5-1 mL/kg/hr or >30 mL/hr. Educational objective: Cold, clammy skin in a client with shock indicates that compensatory mechanisms are failing and that hypoperfusion is occurring. This should be reported promptly to the health care provider as immediate intervention is necessary to prevent irreversible shock.

Question 20

In the intensive care unit, the nurse cares for a client who is being treated for hypotension with a continuous infusion of dopamine.  Which assessment finding indicates that the infusion rate may need to be adjusted?

Accepted Answer

Dopamine (Intropin) is a sympathomimetic inotropic medication used therapeutically to improve hemodynamic status in clients with shock and heart failure. It enhances cardiac output by increasing myocardial contractility, increasing heart rate, and elevating blood pressure through vasoconstriction. Renal perfusion is also improved, resulting in increased urine output. The lowest effective dose of dopamine should be used as dopamine administration leads to an increased cardiac workload. Significant adverse effects include tachycardia, dysrhythmias, and myocardial ischemia. A heart rate of 120/min may indicate that the dopamine infusion needs to be reduced (Option B). (Options A, C, and D) These measurements fall within the respective reference ranges and do not indicate a need to adjust dopamine administration. Normal central venous pressure is 2-8 mm Hg; normal mean arterial pressure ([systolic blood pressure + (2 x diastolic blood pressure)]/3) is 70-105 mm Hg; and normal systemic vascular resistance is 800-1200 dynes/sec/cm^-5. Educational objective: Dopamine is a sympathomimetic inotropic agent that increases heart rate, blood pressure, cardiac output, and urine output. Vital signs should be monitored closely in these clients as a higher dose can result in dangerous tachycardia and tachyarrhythmias.

Exam 3: Critical Care

The nurse is caring for a client with sepsis and acute respiratory failure who was intubated and prescribed mechanical ventilation 3 days ago. The nurse assesses for which adverse effect associated with the administration of positive pressure ventilation (PPV) ?

The charge nurse is evaluating the skills of a new registered nurse (RN) assigned to care for a client with shock. Which action taken by the new RN indicates a need for further education?

The nurse in the intensive care unit is caring for a client who is postoperative from a cardiac surgery. The client has a mediastinal chest tube. During assessment, the nurse notes bubbling in the suction control chamber. Which nursing action is appropriate?

When caring for a client with a left radial artery catheter, which assessment data obtained by the nurse indicates the need to take immediate action?

The emergency department nurse receives a client with extensive injuries to the head and upper back. The nurse will perform what action to allow the best visualization of the airway?

A client is admitted to the intensive care unit with diabetic ketoacidosis. The client is most likely to exhibit which of the following arterial blood gas results?

The nurse is caring for a ventilator-dependent client with neuromuscular degenerative disease and observes the plethysmograph waveform in the image below. What is the nurse's immediate action?

A client with massive trauma and possible spinal cord injury is admitted to the emergency department following a dirt bike accident. Which clinical manifestation does the nurse assess to help best confirm a diagnosis of neurogenic shock?

The nurse cares for an intubated client on mechanical ventilation with worsening cerebral edema from increased intracranial pressure (ICP) . Which nursing interventions help reduce ICP? Select all that apply.

A client with acute respiratory distress syndrome is receiving positive pressure mechanical ventilation with 15 cm H₂O (11 mm Hg) positive end-expiratory pressure (PEEP) . The nurse should assess for which complication associated with PEEP?

The nurse is supervising a graduate nurse (GN) on a telemetry unit. An assigned client develops asystole with no pulse, and emergency care interventions are initiated. Which action by the GN would cause the supervising nurse to intervene?

The flight nurse assesses an alert and oriented client at an industrial accident scene who was impaled in the abdomen by a pair of scissors. Which nursing action is the immediate priority on arrival at the scene?

A client who is 2 hours post aortic valve replacement is in the intensive care unit (ICU) . The low pressure alarm for the client's radial arterial line sounds. Which action should the nurse take first?

The student nurse observes the respiratory therapist (RT) preparing to draw an arterial blood gas from the radial artery. The RT performs the Allen's test and the student asks why this test performed before the blood sample is drawn. Which statement made by the RT is most accurate?

To obtain accurate continuous blood pressure readings via a radial arterial catheter, the nurse places the air-filled interface of the stopcock at the phlebostatic axis. Where is it located?

The nurse is caring for a client with an implantable cardioverter defibrillator (ICD) . The client goes into ventricular tachycardia and is pulseless. The ICD has fired twice. What action should the nurse take?

A nurse is caring for an intubated client receiving a continuous sedative infusion. Which interventions by the nurse reflect correct understanding of preventing ventilator-acquired pneumonia? Select all that apply.

The nurse is caring for a client in the immediate postoperative period following an exploratory laparotomy after sustaining a gunshot wound to the abdomen. Which assessment finding is most important for the nurse to report to the health care provider?

In the intensive care unit, the nurse cares for a client who is being treated for hypotension with a continuous infusion of dopamine. Which assessment finding indicates that the infusion rate may need to be adjusted?