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The family members of a patient 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 patient's room.
- B. Discuss ICU visitation policies and encourage family visits.
- C. Describe the patient's injuries and the care that is being provided.
- D. Invite the family to participate in a multidisciplinary care conference.
Correct Answer: C
Rationale: Lack of information is a major source of anxiety for family members and should be addressed first. Family members should be prepared for the patient's appearance and the ICU environment before visiting the patient for the first time. ICU visiting should be individualized to each patient and family rather than being dictated by rigid visitation policies. Inviting the family to participate in a multidisciplinary conference is appropriate but should not be the initial action by the nurse.
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The nurse notes thick, white respiratory secretions from a patient who is receiving mechanical ventilation. Which of the following interventions will be most effective in resolving this problem?
- A. Suction the patient every hour.
- B. Reposition the patient every 2 hours.
- C. Add additional water to the patient's enteral feedings.
- D. Instill 5 ml of sterile saline into the endotracheal tube (ET) before suctioning.
Correct Answer: C
Rationale: Because the patient's secretions are thick, better hydration is indicated. Suctioning every hour without any specific evidence for the need will increase the incidence of mucosal trauma and would not address the etiology of the ineffective airway clearance. Instillation of saline does not liquefy secretions and may decrease the SpO2. Repositioning the patient is appropriate but will not decrease the thickness of secretions.
To determine the effectiveness of medications that a patient 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)
Correct Answer: B
Rationale: Systemic vascular resistance reflects the resistance to ventricular ejection, or afterload. The other parameters will be monitored, but do not reflect afterload as directly.
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 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.
The nurse is caring for a patient with a head injury intubated and placed on a mechanical ventilator. When monitoring the patient, 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.
Correct Answer: D
Rationale: Increases in JVD in a patient with head injury may indicate an increase in intra-cranial pressure (ICP) and that the PEEP setting is too high for this patient. A respiratory rate of 18, saturation of 94%, and green nasogastric tube drainage are normal.