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The nurse is assessing a patient with a central venous catheter notes the catheter insertion site is red and tender with the patient's temperature 38.8°C (101.8°F). Which of the following actions should the nurse implement?
- A. Administer analgesics and antibiotics.
- B. Check the site frequently for any swelling.
- C. Discontinue the catheter and culture the tip.
- D. Change the flush system and monitor the site.
Correct Answer: C
Rationale: The information indicates that the patient has a local and systemic infection caused by the catheter and the catheter should be discontinued. Changing the flush system, administration of analgesics, and continued monitoring will not help prevent or treat the infection. Administration of antibiotics is appropriate, but the line should still be discontinued to avoid further complications such as endocarditis.
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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.
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.
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 caring for an older-adult patient who has stabilized after being in the intensive care unit (ICU) for a week and is preparing for transfer to the step-down unit when the nurse notices that the patient has new onset confusion. Which of the following actions should the nurse implement?
- A. Inform the receiving nurse and then transfer the patient.
- B. Notify the health care provider and postpone the transfer.
- C. Administer PRN lorazepam and cancel the transfer.
- D. Obtain an order for restraints as needed and transfer the patient.
Correct Answer: A
Rationale: The patient's history and symptoms most likely indicate delirium associated with the sleep deprivation with sensory overload in the ICU environment. Informing the receiving nurse and transferring the patient is appropriate. Postponing the transfer is likely to prolong the delirium. Benzodiazepines and restraints contribute to delirium and agitation.
When assisting with oral intubation of a patient who is receiving mechanical ventilation, place the following actions in the correct order.
- A. Preoxygenate with a bag-valve-mask system for 3-5 minutes.
- B. Place the patient in a supine position.
- C. Perform a chest x-ray to verify tube placement.
- D. Inflate the cuff on the endotracheal tube.
- E. Use an end-tidal CO2 sensor to check tube placement.
Correct Answer: B,E,C,D,A
Rationale: The patient is placed in a supine position and preoxygenated with a bag-valve-mask system for 3-5 minutes before intubation. Following the intubation, the cuff on the endotracheal tube is inflated to occlude and protect the airway. Tube placement is assessed first with an end-tidal CO2 sensor, and then with a chest x-ray.