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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 nurse is preparing to assist with the insertion of a pulmonary artery catheter in a patient. Which of the following actions will the nurse implement?
- A. Check cardiac enzymes before insertion.
- B. Auscultate heart sounds during insertion.
- C. Place the patient on NPO status before the procedure.
- D. Attach cardiac monitoring leads before the procedure.
Correct Answer: D
Rationale: Dysrhythmias can occur as the catheter is floated through the right atrium and ventricle, and it is important for the nurse to monitor for these during insertion. Pulmonary artery catheter insertion does not require anaesthesia, and the patient will not need to be NPO. Changes in cardiac enzymes or heart sounds are not expected during pulmonary artery catheter insertion.
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.
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.
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.
The nurse is caring for a patient who is in cardiogenic shock requiring an intra-aortic balloon pump (IABP). Which of the following assessment findings indicates that the goals of treatment with the IABP are being met?
- A. Heart rate of 110 beats/minute
- B. Urine output of 20 mL/hour
- C. Cardiac output (CO) of 5 L/minute
- D. Stroke volume (SV) of 40 mL/beat
Correct Answer: C
Rationale: A CO of 5 L/minute is normal (range is 4-8 L/minute) and indicates that the IABP has been successful in treating the shock. The low SV signifies continued cardiogenic shock. The tachycardia and low urine output also suggest continued cardiogenic shock.