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A patient has a nursing diagnosis of disturbed sleep pattern related to difficulty maintaining 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 monitor alarms to allow 30- to 40-minute rest periods.
- D. Cluster nursing activities so that the patient has uninterrupted rest periods.
Correct Answer: D
Rationale: Clustering nursing activities and providing uninterrupted rest periods will minimize sleep-cycle disruption. Sedative and opioid medications tend to decrease the amount of rapid eye movement (REM) sleep and can contribute to sleep disturbance and disturbed sensory perception. Silencing the alarms on the cardiac monitors would be unsafe in a critically ill patient, as would discontinuing assessments during the night.
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The nurse is caring for a patient 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 patient 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.
Correct Answer: C
Rationale: 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.
When a patient's pulmonary artery catheter becomes wedged and does not reflect pulmonary artery pressures, which of the following actions should the nurse take?
- A. Reposition the patient and check for a pulmonary artery tracing.
- B. Deflate the balloon and flush the catheter with saline.
- C. Notify a health care provider or specially trained nurse.
- D. Increase the volume in the balloon to open the catheter.
Correct Answer: C
Rationale: When the catheter is in the wedge position, blood flow past the catheter is obstructed, placing the patient 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.
The nurse is caring for a patient 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)
Correct Answer: C
Rationale: Pulmonary vascular resistance and pulmonary artery pressure are indexes of right ventricular afterload. The other parameters do not directly assess for right ventricular afterload.
The nurse is monitoring for the effectiveness of treatment for a patient 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)
Correct Answer: D
Rationale: PAOP reflects left ventricular end diastolic pressure (or left ventricular preload). Because the patient in left ventricular failure will have a high PAOP, a decrease in this value will be the best indicator of patient improvement. The other values would also provide useful information, but the most definitive measurement of improvement is a drop in PAOP.
The charge nurse is mentoring a new RN staff member providing care to a patient receiving mechanical ventilation. Which of the following actions by the new RN indicates the need for more education?
- A. The RN increases the FIO2 up to 100%.
- B. The RN secures a bite block in place using adhesive tape.
- C. The RN positions the patient with the head of bed at 10 degrees.
- D. The RN asks for assistance to turn the patient to the prone position.
Correct Answer: C
Rationale: The head of the patient's bed should be positioned at 30-45 degrees to prevent ventilator-acquired pneumonia. The other actions by the new RN are appropriate.