Question 1

When the ventilator alarm sounds, the nurse finds the client lying in bed holdingthe endotracheal tube (ET). Which of the following actions should the nurse take first?

Accepted Answer

The nurse should ensure maximal client oxygenation by manually ventilating with a bag-valve-mask system. Offering reassurance to the client, 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 client's oxygenation.

Question 2

The nurse is caring for the client with a pulmonary artery pressure catheter and notes that the PA waveform indicates that the catheter is in the wedged position. Which of the following actions should the nurse take?

Accepted Answer

When the catheter is in the wedge position, blood flow past the catheter is obstructed, placing the client 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.

Question 3

The nurse notes that a client's endotracheal tube (ET), which was at the 21-cm mark, is now at the 24-cm mark and the client appears anxious and restless. Which of the following actions should the nurse take first?

Accepted Answer

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.

Question 4

The nurse is caring for a client who requires medication to increase the contractility of the heart. Which of the following medications should the nurse anticipate administering for this client?

Accepted Answer

Epinephrine, norepinephrine, isoproterenol, dopamine, dobutamine, digitalis-like drugs, calcium, and milrinone increase contractility. These agents are termed positive inotropes. Contractility is diminished by negative inotropes, such as acidosis and certain drugs (e.g., barbiturates [secobarbital], alcohol, procainamide, calcium channel blockers, ?-adrenergic blockers [metoprolol]).

Question 5

The nurse is caring for an older-adult client who has stabilized after being in the intensive care unit (ICU) for a week and is preparing for transfer to the step down unit when the nurse notices that the client has new onset confusion. Which of the followingactions should the nurse implement?

Accepted Answer

The client'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 client is appropriate. Postponing the transfer is likely to prolong the delirium. Benzodiazepines and restraints contribute to delirium and agitation.

Question 6

Four hours after mechanical ventilation is initiated for a client with chronic obstructive pulmonary disease (COPD), the client'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 mmol/L. The nursewill anticipate the need to do which of the following actions based upon these findings?

Accepted Answer

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

Question 7

The nurse is caring for a client receiving a continuous norepinephrine IV infusion. Which of the following client assessment information indicates that the infusion rate may be too high?

Accepted Answer

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.

Question 8

The nurse is caring for a client receiving mechanical ventilation who is anxious and is "fighting" the ventilator. Which of the following actions should the nurse take first?

Accepted Answer

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

Question 9

In which order will the nurse take these actions when assisting with oral intubation of a client who is having respiratory distress? A)Obtain a portable chest-x-ray. B)Place the client 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 client with a bag-valve-mask system for several minutes.

Accepted Answer

The answer of In which order will the nurse take...

Question 10

The charge nurse is evaluating the care that a new RN staff member provides to a client receiving mechanical ventilation. Which of the following actions by the new RN indicates the need for more education?

Accepted Answer

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

Question 11

The nurse is weaning a client who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation. Which of the following client assessments indicates that the weaning protocol should be discontinued?

Accepted Answer

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

Question 12

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

Accepted Answer

Lack of information is a major source of anxiety for family members and should be addressed first. Family members should be prepared for the client's appearance and the ICU environment before visiting the client for the first time. ICU visiting should be individualized to each client 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.

Question 13

The nurse is caring for a client with a head injury intubated and placed on a mechanical ventilator. When monitoring the client, which of the following findings should the nurse report to the health care provider?

Accepted Answer

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

Question 14

The nurse is caring for a client who has an arterial catheter in the radial artery to monitor blood pressure. Which of the following information obtained by the nurse is most important to report to the health care provider?

Accepted Answer

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. An MAP of 86 is normal and the dicrotic notch is normally present on the arterial waveform.

Question 15

The nursing supervisor is evaluating the performance of a new RN who is caring for a client receiving mechanical ventilation with 10 cm of positive end-expiratory pressure (PEEP). Which of the following actions indicates that the new RN is practising safely?

Accepted Answer

The closed-suction technique is suggested when clients require high levels of PEEP to prevent the loss of PEEP that occurs when disconnecting the client from the ventilator. Suctioning should not be scheduled routinely, but it should be done only when client 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 client repositioning. Ventilator tubing changes increase the risk for ventilator-associated pneumonia (VAP) and are not indicated routinely.

Question 16

A client's vital signs are pulse 80, respirations 24, BP of 124/60 mm Hg, and cardiac output is 4.8 L/minute. What is the client's stroke volume?

Accepted Answer

The answer of A client's vital signs are pulse 80,...

Question 17

The nurse is assessing a client with a central venous catheter and notes the catheter insertion site is red and tender and the client's temperature is 38.8°C (101.8°F). Which of the following actions should the nurse implement?

Accepted Answer

The information indicates that the client 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.

Quiz 68: Nursing Management Critical Care Environment

When the ventilator alarm sounds, the nurse finds the client lying in bed holdingthe endotracheal tube (ET) . Which of the following actions should the nurse take first?