Deck 68: Nursing Management Critical Care Environment

Question 1

The nurse is caring for a client with severe heart failure who has a ventricular assist device (VAD) implanted and is waiting for cardiac transplantation. Which of the following actions should the nurse include in the plan of care?

A)Administer of immuno-suppressive medications.
B)Monitor the surgical incision for signs of infection.
C)Teach the client the reason for continuous bed rest.
D)Prepare the client to have the VAD in place permanently.

Answer 1

Monitor the surgical incision for signs of infection.

Question 2

The nurse is caring for a client following surgery whose central venous pressure (CVP) monitor indicates low pressures. Which of the following actions should the nurse anticipate implementing?

A)Increase the IV fluid infusion rate.
B)Administer IV diuretic medications.
C)Elevate the head of the client's bed to 45 degrees.
D)Document the CVP and continue to monitor.

Answer 2

Increase the IV fluid infusion rate.

Question 3

Premature ventricular contractions (PVCs) occur while the nurse is suctioning a client's endotracheal tube. Which of the following actions by the nurse is best?

A)Decrease the suction pressure to 80 mm Hg.
B)Stop and ventilate the client with 100% oxygen.
C)Document the dysrhythmia in the client's chart.
D)Give prescribed PRN antidysrhythmic medications.

Answer 3

Stop and ventilate the client with 100% oxygen.

Question 4

The nurse is caring for a client who has an intra-aortic balloon pump in place. Which of the following actions should 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 client's urinary output every hour.
D)Provide passive range of motion for all extremities.

Question 5

The intensive care unit nurse educator is teaching a new staff nurse about hemodynamic monitoring. Which of the following actions indicates that the teaching has been effective?

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 client's position
D)Ensures that the client is lying supine with the head of the bed flat for all readings

Question 6

Which of the following actions should the nurse do to inflate the cuff of an endotracheal tube (ET) when the client is on mechanical ventilation?

A)Inflate the cuff until the pilot balloon is firm.
B)Inflate the cuff with a minimum of 10 mL of air.
C)Inject air into the cuff until a manometer shows 15 mm Hg pressure.
D)Inject air into the cuff until a slight leak is heard only at peak inflation.

Question 7

While family members are visiting, a client has a cardiac arrest and is being resuscitated. Which of the following actions 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 client room.
D)Escort family members quickly out of the client room and then remain with them.

Question 8

The nurse is assisting with insertion of a pulmonary artery (PA) catheter in a client. Which of the following data identifies that the catheter is correctly placed?

A)Monitor shows a typical PAOP 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.

Question 9

Which of the following information obtained by the nurse when caring for a client receiving mechanical ventilation indicates the need for suctioning?

A)The respiratory rate is 32 breaths/minute.
B)The pulse oximeter shows a SpO? of 93%.
C)The client has not been suctioned for the last 6 hours.
D)The lungs have occasional audible expiratory wheezes.

Question 10

Which of the following actions should the nurse take when the low-pressure alarm sounds for a client 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.

Question 11

The nurse is monitoring for the effectiveness of treatment for a client with left ventricular failure. Which of the following assessments is most important for the nurse to evaluate?

A)Mean arterial pressure (MAP)
B)Systemic vascular resistance (SVR)
C)Pulmonary vascular resistance (PVR)
D)Pulmonary artery occlusive pressure (PAOP)

Question 12

Which of the following actions should the nurse implement to verify the correct placement of an endotracheal tube (ET) after insertion?

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 CO? monitor to check for placement in the trachea.

Question 13

The nurse is caring for a client with pulmonary hypertension. Which of the following parameters should the nurse monitor as an index of right ventricular afterload?

A)Mean arterial pressure (MAP)
B)Central venous pressure (CVP)
C)Pulmonary vascular resistance (PVR)
D)Pulmonary artery wedge pressure (PAWP)

Question 14

The nurse is caring for a client who is in cardiogenic shock and has an intra-aortic balloon pump (IABP). Which of the following assessment findings indicates that the goals of treatment with the IABP are being met?

A)Heart rate of 110 beats/minute
B)Urine output of 20 mL/hour
C)Cardiac output (CO) of 5 L/minute
D)Stroke volume (SV) of 40 mL/beat

Question 15

The nurse is caring for a client with a left radial arterial line. Which of the following assessments 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.

Question 16

To determine the effectiveness of medications that a client has received to reduce left ventricular afterload, which of the following hemodynamic parameters should the nurse monitor?

A)Central venous pressure (CVP)
B)Systemic vascular resistance (SVR)
C)Pulmonary vascular resistance (PVR)
D)Pulmonary artery wedge pressure (PAWP)

Question 17

The nurse notes thick, white respiratory secretions from a client who is receiving mechanical ventilation. Which of the following interventions will be most effective in resolving this problem?

A)Suction the client every hour.
B)Reposition the client every 2 hours.
C)Add additional water to the client's enteral feedings.
D)Instill 5 mL of sterile saline into the endotracheal tube (ET) before suctioning.

Question 18

Aclient has a nursing diagnosis of disturbed sleep pattern related to difficulty maintaing sleep state. Which of the following actions should 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 client has uninterrupted rest periods.

Question 19

The nurse is preparing to assist with the insertion of a pulmonary artery catheter in a client. Which of the following actions will the nurse implement?

A)Check cardiac enzymes before insertion.
B)Auscultate heart sounds during insertion.
C)Place the client on NPO status before the procedure.
D)Attach cardiac monitoring leads before the procedure.

Question 20

The nurse is caring for a client who has severe pancreatitis and the mixed venous oxygen saturation (SvO2) is decreasing. Which of the following parameters should the nurse assess to determine the possible cause of the decreased SvO2?

A)Weight
B)Amylase
C)Temperature
D)Urinary output

Question 21

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?

A)Offer reassurance to the client.
B)Activate the hospital's rapid response team.
C)Call the health care provider to reinsert the tube.
D)Manually ventilate the client with 100% oxygen.

Question 22

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?

A)Inflate the PA balloon.
B)Change the flush system.
C)Zero balance the transducer.
D)Notify the health care provider.

Question 23

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?

A)Listen to the client's lungs.
B)Offer reassurance to the client.
C)Bag the client at an FIO2 of 100%.
D)Notify the client's health care provider.

Question 24

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?

A)Metoprolol
B)Procainamide
C)Secobarbital
D)Dopamine

Question 25

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?

A)Inform the receiving nurse and then transfer the client.
B)Notify the health care provider and postpone the transfer.
C)Administer PRN lorazepam and cancel the transfer.
D)Obtain an order for restraints as needed and transfer the client.

Question 26

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, PaO? of 80 mm Hg, PaCO? 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?

A)Increase the FIO?.
B)Decrease the respiratory rate.
C)Increase the tidal volume (VT).
D)Leave the ventilator at the current settings.

Question 27

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?

A)Heart rate is 58 beats/minute.
B)Mean arterial pressure is 55 mm Hg.
C)Systemic vascular resistance (SVR) is elevated.
D)Pulmonary artery wedge pressure (PAWP) is low.

Question 28

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?

A)Ventilate the client with a manual resuscitation bag.
B)Verbally coach the client to breathe with the ventilator.
C)Sedate the client with the ordered PRN lorazepam.
D)Increase the rate for the ordered propofol infusion.

Question 29

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.

Question 30

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?

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 client with the head of bed at 10 degrees.
D)The RN asks for assistance to turn the client to the prone position.

Question 31

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?

A)The client heart rate is 98 beats/minute.
B)The client's oxygen saturation is 93%.
C)The client respiratory rate is 32 breaths/minute.
D)The client's spontaneous tidal volume is 500 mL.

Question 32

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?

A)Immediately take the family members to the client's room.
B)Discuss ICU visitation policies and encourage family visits.
C)Describe the client's injuries and the care that is being provided.
D)Invite the family to participate in a multidisciplinary care conference.

Question 33

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?

A)Oxygen saturation of 94%
B)Respirations of 18 breaths/minute
C)Green nasogastric tube drainage
D)Increased jugular venous distention

Question 34

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?

A)The client 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.

Question 35

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?

A)The RN plans to suction the client every 2 hours.
B)The RN uses a closed-suction technique to suction the client.
C)The RN tapes connection between the ventilator tubing and the ET.
D)The RN changes the ventilator circuit tubing routinely every 24 hours.

Question 36

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?

Question 37

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?

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.