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The intensive care unit (ICU) nurse educator will determine that teaching arterial pressure monitoring to staff nurses has been effective when the nurse:
- A. Balances and calibrates the monitoring equipment every 2 hours.
- B. Positions the zero-reference stopcock line level with the hemostatic axis.
- C. Ensures that the patient is supine with the head of the bed flat for all readings.
- D. Rechecks the location of the hemostatic axis when changing the patient’s position.
Correct Answer: B
Rationale: The correct answer is B because positioning the zero-reference stopcock line level with the hemostatic axis ensures accurate arterial pressure monitoring. Placing the stopcock at the hemostatic axis allows for correct measurement of blood pressure without any errors due to height differences. This positioning helps in obtaining precise and reliable readings.
A: Balancing and calibrating the monitoring equipment every 2 hours is important for equipment maintenance but does not directly impact the accuracy of arterial pressure monitoring.
C: Ensuring the patient is supine with the head of the bed flat is a standard position for arterial pressure monitoring but does not specifically address the correct positioning of the stopcock.
D: Rechecking the location of the hemostatic axis when changing the patient's position is essential for maintaining accuracy, but it does not directly relate to the initial correct positioning of the stopcock.
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The constant noise of a ventilator, monitor alarms, and inf usion pumps predisposes the patient to what form of stress?
- A. Anxiety
- B. Pain
- C. Powerlessness
- D. Sensory overload
Correct Answer: D
Rationale: The correct answer is D: Sensory overload. Constant noise from medical equipment can overwhelm the patient's senses, leading to sensory overload. This can result in increased stress levels, difficulty concentrating, and overall discomfort. Anxiety (A) is related to worry and fear, but in this context, the primary stressor is sensory overload, not anxiety. Pain (B) is a physical sensation, not directly related to the sensory overload caused by noise. Powerlessness (C) refers to a lack of control or influence, which is not the primary form of stress induced by constant noise. Therefore, the correct choice is D as it directly correlates with the impact of the noise on the patient's sensory perception.
The nurse wishes to increase the use of evidence-based practice in the critical care unit where he works. What is a significant barrier to the implementation of evidence-based practice?
- A. Use of computerized records by the hospital
- B. Health Information Privacy and Portability Act (HIPPA)
- C. Lack of knowledge about literature searches
- D. Strong collaborative relationships in the work setting
Correct Answer: C
Rationale: Rationale:
The correct answer is C because lack of knowledge about literature searches hinders the ability to find and utilize evidence-based practice guidelines. Nurses need to be skilled in conducting literature searches to access relevant research. Choices A, B, and D are incorrect as they do not directly impede the implementation of evidence-based practice in the critical care unit.
The nurse is caring for a 70-kg patient in septic shock with a pulmonary artery catheter. Which hemodynamic value indicates an appropriate response to therapy aimed at enhancing oxygen delivery to the organs and tissues?
- A. Arterial lactate level of 1.0 mEq/L
- B. Cardiac output of 2.5 L/min
- C. Mixed venous (SvO ) of 40%
- D. Cardiac index of 1.5 L/min/m2
Correct Answer: C
Rationale: The correct answer is C: Mixed venous (SvO2) of 40%. In septic shock, improving oxygen delivery to tissues is vital. SvO2 reflects the balance between oxygen delivery and consumption. A value of 40% indicates adequate oxygen delivery to tissues.
A: Arterial lactate level of 1.0 mEq/L - Although a low lactate level is good, it does not directly indicate improved oxygen delivery.
B: Cardiac output of 2.5 L/min - Cardiac output should ideally increase to improve oxygen delivery, so 2.5 L/min is low for a 70-kg patient.
D: Cardiac index of 1.5 L/min/m2 - Cardiac index is cardiac output adjusted for body surface area. 1.5 L/min/m2 is low and indicates inadequate cardiac function for a patient in septic shock.
Which nursing intervention would need to be corrected on a care plan for a patient in order to be consistent with the principles of effective end-of-life ca re?
- A. Control of distressing symptoms such as dyspnea, naus ea, and pain through use of pharmacological and nonpharmacological interventions
- B. Limitation of visitation to reduce the emotional distresasb ierbx.cpoemr/iteesnt ced by family members
- C. Patient and family education on anticipated patient res ponses to withdrawal of therapy
- D. Provision of spiritual care resources as desired by the p atient and family
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Limiting visitation to reduce emotional distress contradicts the principles of effective end-of-life care, which emphasize holistic support for the patient and family.
2. Effective end-of-life care encourages open communication and emotional support from loved ones.
3. Limiting visitation may hinder emotional closure and support for both the patient and family.
4. Options A, C, and D align with effective end-of-life care by focusing on symptom management, education, and spiritual support for the patient and family.
The patient is in a progressive care unit following arteriovenous fistula implantation in his left upper arm, and is due to have blood drawn with his next set of vital signs and assessment. When the nurse assesses the patient, the nurse should
- A. draw blood from the left arm.
- B. take blood pressures from the left arm.
- C. start a new intravenous line in the left lower arm.
- D. auscultate the left arm for a bruit and palpate for a thrill.
Correct Answer: D
Rationale: The correct answer is D because after arteriovenous fistula implantation, it is essential to assess for the presence of a bruit (audible sound caused by turbulent blood flow) and thrill (vibratory sensation) in the access site, which indicates proper functioning of the fistula. This assessment ensures that blood is flowing adequately through the newly created access for dialysis or other procedures. Drawing blood or taking blood pressures from the fistula arm can lead to complications such as clot formation or damage to the fistula. Starting a new IV line in the same arm is contraindicated to avoid compromising the newly created fistula. Thus, auscultating for a bruit and palpating for a thrill are the appropriate nursing actions in this scenario.