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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 patient’s potassium level is 7.0 mEq/L. Besides dialysis, which of the following actually reduces plasma potassium levels and total body potassium content safely in a patient with renal dysfunction?
- A. Sodium polystyrene sulfonate
- B. Sodium polystyrene sulfonate with sorbitol
- C. Regular insulin
- D. Calcium gluconate
Correct Answer: C
Rationale: Correct Answer: C - Regular insulin
Rationale:
1. Insulin promotes cellular uptake of potassium.
2. When insulin is administered, it moves potassium from extracellular to intracellular space.
3. This decreases plasma potassium levels safely.
4. Other options do not directly lower potassium levels in the same manner.
Summary of Other Choices:
A: Sodium polystyrene sulfonate - exchanges sodium for potassium in the intestines, not reducing total body potassium.
B: Sodium polystyrene sulfonate with sorbitol - similar to A, does not reduce total body potassium.
D: Calcium gluconate - does not directly lower potassium levels, used for treating hyperkalemia-induced cardiac toxicity.
The nurse is caring for a patient receiving continuous norepinephrine (Levophed) IV infusion. Which patient assessment finding indicates that the infusion rate may need to be adjusted?
- A. Heart rate is 58 beats/minute.
- B. Mean arterial pressure (MAP) is 56 mm Hg.
- C. Systemic vascular resistance (SVR) is elevated.
- D. Pulmonary artery wedge pressure (PAWP) is low.
Correct Answer: B
Rationale: The correct answer is B because a low Mean Arterial Pressure (MAP) indicates inadequate perfusion, which may require adjusting the norepinephrine infusion rate to increase blood pressure. A: A heart rate of 58 beats/minute is within a normal range and may not necessarily indicate a need for adjustment. C: Elevated Systemic Vascular Resistance (SVR) may be an expected response to norepinephrine and does not necessarily indicate a need for adjustment. D: A low Pulmonary Artery Wedge Pressure (PAWP) may indicate fluid volume deficit but does not directly relate to the need for adjusting norepinephrine infusion rate.
To prevent any unwanted resuscitation after life-sustaininga btirrbe.acotmm/teenstt s have been withdrawn, the nurse should ensure that what intervention has been im plemented?
- A. Do-not-resuscitate (DNR) orders are written before dis continuation of the treatments.
- B. The family is not allowed to visit until the death occur s.
- C. DNR orders are written as soon as possible after the di scontinuation of the treatments.
- D. The change-of-shift report includes the information thaatb irtbh.ceo pma/tetiset nt is not to be resuscitated.
Correct Answer: A
Rationale: The correct answer is A because writing DNR orders before discontinuation of life-sustaining treatments ensures clear communication and legal documentation of the patient's wishes. Choice B is incorrect as family support is essential in end-of-life care. Choice C is incorrect as DNR orders should be established before withdrawing treatment. Choice D is incorrect as the DNR order should be in place before shift change for immediate implementation if needed.
The nurse is caring for a patient who is mechanically ventilated. The nurse understands that what statement should be considered when determining apapbrirob.pcormia/ttees tn ursing interventions?
- A. Communication with intubated patients is often difficult.
- B. Controlled ventilation is the preferred mode for most p atients.
- C. Patients with chronic obstructive pulmonary disease w ean easily from mechanical ventilation.
- D. Wrist restraints are applied to all patients to avoid self- extubation.
Correct Answer: A
Rationale: The correct answer is A because communication with intubated patients is often challenging due to the presence of an artificial airway, which hinders speech. This understanding is crucial when determining appropriate nursing interventions to ensure effective patient care.
Choice B is incorrect because different patients may require different modes of ventilation based on their specific condition, and controlled ventilation may not always be the preferred mode for all patients.
Choice C is incorrect as patients with chronic obstructive pulmonary disease often have difficulty weaning from mechanical ventilation due to their underlying respiratory condition.
Choice D is incorrect as wrist restraints are not applied to all patients on mechanical ventilation unless absolutely necessary for safety concerns, such as preventing self-extubation.
The nurse is caring for a postoperative patient in the critica l care unit. The physician has ordered patient-controlled analgesia (PCA) for the patient. The nurse understands what facts about the PCA? (Select all that apply.)
- A. It is a safe and effective method for administering anal gesia.
- B. It has potentially fewer side effects than other routes of analgesic administration.
- C. It is an ideal method to provide critically ill patients so me control over their treatment.
- D. It does not work well without family assistance
Correct Answer: A
Rationale: Step-by-step rationale for why Answer A is correct:
1. Patient-controlled analgesia (PCA) allows patients to self-administer pain medication within preset limits, promoting pain management.
2. PCA is considered safe and effective as it provides better pain control, reduces the risk of overdose, and allows for individualized dosing.
3. Healthcare providers can monitor and adjust the PCA settings as needed to ensure optimal pain relief.
4. Studies have shown that PCA is a preferred method for postoperative pain management due to its efficacy and safety profile.
5. Overall, PCA is a reliable and beneficial approach to analgesia administration in postoperative patients.
Summary of why other choices are incorrect:
B: While PCA may have fewer side effects compared to some routes, this is not a defining characteristic of PCA.
C: While patients do have some control over their treatment with PCA, the primary focus is on pain management rather than giving control to critically ill patients.
D: PCA can be used effectively without family