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A Patient Is Admitted to the Cardiac Surgical Intensive Care

Question 31

Multiple Choice

A patient is admitted to the cardiac surgical intensive care unit after cardiac surgery.Four hours after admission to the surgical intensive care unit at 4 PM,the patient has stable vital signs and normal arterial blood gases (ABGs) ,and is placed on a T-piece for ventilatory weaning.The following information pertains to the 1900 assessment.
 Assessments and Vital Signs  Nursing Action  Restless  Performs complete assessment  Increased to 110 beats/min  Suctions patient for pink, frothy secretions  Respirations 36 breaths/min  Obtains prescriptions from provider for  ABGs, electrolyte levels, and portable  chest x-ray  Blood pressure 156/98 mmHg Sinus tachycardia 10PVCs/min Elevated pulmonary artery pressure  Loud crackles throughout  New ABGs: pH: 7.28PaCO2:46 mmHgBicarbonate:22mE/LPaO2:58 mmHgO2 saturation: 88%\begin{array}{|l|l|}\hline {\text { Assessments and Vital Signs }} & {\text { Nursing Action }} \\\hline \text { Restless } & \text { Performs complete assessment } \\\hline \text { Increased to } 110 \text { beats/min } & \text { Suctions patient for pink, frothy secretions } \\\hline \text { Respirations } 36 \text { breaths/min } & \begin{array}{l}\text { Obtains prescriptions from provider for } \\\text { ABGs, electrolyte levels, and portable } \\\text { chest x-ray }\end{array} \\\hline \text { Blood pressure } 156 / 98 \mathrm{~mm} \mathrm{Hg} & \\\hline \text { Sinus tachycardia } & \\\hline 10 \mathrm{PVCs} / \mathrm{min} & \\\hline \text { Elevated pulmonary artery pressure } & \\\hline \text { Loud crackles throughout } & \\\hline \begin{array}{l}\text { New } \mathrm{ABGs}: \\\text { pH: } 7.28\end{array} & \\\mathrm{PaCO}_{2}: 46 \mathrm{~mm} \mathrm{Hg} \\\mathrm{Bicarbonate:} 22 \mathrm{mE} / \mathrm{L} & \\\mathrm{PaO}_{2}: 58 \mathrm{~mm} \mathrm{Hg} \\\mathrm{O}_{2} \text { saturation: } 88 \%\\\hline\end{array}
What interdisciplinary staff member does the nurse notify to assist in the care of this patient while preparing to give this patient diuretics?


A) Respiratory therapist to adjust ventilator
B) Social worker to notify family
C) Phlebotomy to obtain another set of blood gasses
D) Nursing assistant to help reposition the patient

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