Nokea
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.
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Premature ventricular contractions (PVCs) occur while the nurse is suctioning a patient'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 patient with 100% oxygen.
- C. Document the dysrhythmia in the patient's chart.
- D. Give prescribed PRN antidysrhythmic medications.
Correct Answer: B
Rationale: Dysrhythmias during suctioning may indicate hypoxemia or sympathetic nervous system stimulation, and the nurse should stop suctioning and ventilate the patient with 100% oxygen. Lowering the suction pressure will decrease the effectiveness of suctioning without improving the hypoxemia. Because the PVCs occurred during suctioning, there is no need for antidysrhythmic medications (which may have adverse effects) unless they recur when the patient is well oxygenated.
While family members are visiting, a patient 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 patient room.
- D. Escort family members quickly out of the patient room and then remain with them.
Correct Answer: A
Rationale: Research indicates that family members want the option of remaining in the room during procedures such as CPR and that this decreases anxiety and facilitates grieving. The other options may be appropriate if the family decides not to remain with the patient.
The nurse is caring for a patient 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 patient's bed to 45 degrees.
- D. Document the CVP and continue to monitor.
Correct Answer: A
Rationale: A low CVP indicates hypovolemia and a need for an increase in the infusion rate. Diuretic administration will contribute to hypovolemia and elevation of the head may decrease cerebral perfusion. Documentation and continued monitoring is an inadequate response to the low CVP.
The nurse is assisting with insertion of a pulmonary artery (PA) catheter in a patient. 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.
Correct Answer: A
Rationale: One of the purposes of a PA line is to measure PAOP, so the catheter is floated through the pulmonary artery until the dilated balloon wedges in a distal branch of the pulmonary artery, and the PAOP readings are available. After insertion, the balloon is deflated and the PA waveform will be observed. Systemic arterial pressures are obtained using an arterial line. The length of catheter needed for insertion will vary with patient size.
The nurse is caring for a patient with heart failure requiring 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 patient the reason for continuous bed rest.
- D. Prepare the patient to have the VAD in place permanently.
Correct Answer: B
Rationale: The insertion site for the VAD provides a source for transmission of infection to the circulatory system and requires frequent monitoring. Patients with VADs are able to have some mobility and may not be on bed rest. The VAD is a bridge to transplantation, not a permanent device. Immuno-suppression is not necessary for nonbiological devices like the VAD.