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The intensive care unit nurse educator is teaching a new staff nurse about hemodynamic monitoring. Which of the following actions indicates that the teaching has been effective?
- A. Positions the zero-reference stopcock line level with the phlebostatic axis.
- B. Balances and calibrates the hemodynamic monitoring equipment every hour.
- C. Rechecks the location of the phlebostatic axis when changing the patient's position.
- D. Ensures that the patient is lying supine with the head of the bed flat for all readings.
Correct Answer: A
Rationale: For accurate measurement of pressures, the zero-reference level should be at the phlebostatic axis. There is no need to rebalance and recalibrate monitoring equipment hourly. Accurate hemodynamic readings are possible with the patient's head raised to 45 degrees or in the prone position. The anatomic position of the phlebostatic axis does not change when patients are repositioned.
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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.
When the ventilator alarm sounds, the nurse finds the patient lying in bed holding the endotracheal tube (ET). Which of the following actions should the nurse take first?
- A. Offer reassurance to the patient.
- B. Activate the hospital's rapid response team.
- C. Call the health care provider to reinsert the tube.
- D. Manually ventilate the patient with 100% oxygen.
Correct Answer: D
Rationale: The nurse should ensure maximal patient oxygenation by manually ventilating with a bag-valve-mask system. Offering reassurance to the patient, notifying the health care provider about the need to reinsert the tube, and activating the rapid response team also are appropriate after the nurse has stabilized the patient's oxygenation.
The nurse is weaning a patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation. Which of the following patient assessments indicates that the weaning protocol should be discontinued?
- A. The patient heart rate is 98 beats/minute.
- B. The patient's oxygen saturation is 93%.
- C. The patient respiratory rate is 32 breaths/minute.
- D. The patient's spontaneous tidal volume is 500 mL.
Correct Answer: C
Rationale: A respiratory rate of 32 breaths/minute indicates respiratory distress and suggests that the patient is not tolerating the weaning process, necessitating discontinuation of the weaning protocol. A heart rate of 98 beats/minute, oxygen saturation of 93%, and spontaneous tidal volume of 500 mL are within acceptable ranges for weaning.
The nurse is caring for a patient who has an intra-aortic balloon pump in place. Which of the following actions should be included in the plan of care?
- A. Avoid the use of anticoagulant medications.
- B. Keep the head of the bed elevated 45 degrees.
- C. Measure the patient's urinary output every hour.
- D. Provide passive range of motion for all extremities.
Correct Answer: C
Rationale: Monitoring urine output will help determine whether the patient's cardiac output has improved and also help monitor for balloon displacement. The head of the bed should be no higher than 30 degrees. Heparin is used to prevent thrombus formation. Limited movement is allowed for the extremity with the balloon insertion site to prevent displacement of the balloon.
Four hours after mechanical ventilation is initiated for a patient with chronic obstructive pulmonary disease (COPD), the patient's arterial blood gas (ABG) results include a pH of 7.50, PaO2 of 80 mm Hg, PaCO2 of 29 mm Hg, and HCO3 of 23 mmol/L. The nurse will anticipate the need to do which of the following actions based upon these findings?
- A. Increase the FIO2.
- B. Decrease the respiratory rate.
- C. Increase the tidal volume (VT).
- D. Leave the ventilator at the current settings.
Correct Answer: B
Rationale: The patient's PaCO2 and pH indicate respiratory alkalosis caused by too high a respiratory rate. The PaO2 is appropriate for a patient with COPD, increasing the tidal volume would further lower the PaCO2, and the PaCO2 and pH indicate a need to make the ventilator changes.