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The nurse is caring for a mechanically ventilated patient w ith a pulmonary artery catheter who is receiving continuous enteral tube feedings. When obtaining continuous hemodynamic monitoring measurements, what is the best nursing action?a birb.com/test
- A. Do not document hemodynamic values until the patient can be placed in the supine position.
- B. Level and zero reference the air-fluid interface of the t ransducer with the patient in the supine position and record hemodynamic values.
- C. Level and zero reference the air-fluid interface of the t ransducer with the patient’s head of bed elevated to 30 degrees and record hemodynamic values.
- D. Level and zero reference the air-fluid interface of the tarbainrbs.cdoumc/teers t with the patient supine in the side-lying position and record hemodynamic values.
Correct Answer: C
Rationale: Rationale: Option C is the correct answer because when caring for a patient with a pulmonary artery catheter receiving continuous enteral feedings, it is crucial to level and zero reference the transducer with the patient's head of bed elevated to 30 degrees. This position helps to ensure accurate hemodynamic measurements, as the head of bed elevation minimizes the impact of intra-abdominal pressure on the catheter readings. By referencing the transducer in this position, the nurse can obtain reliable and precise hemodynamic values.
Summary of Incorrect Choices:
A: This option is incorrect because delaying documentation until the patient is in the supine position can lead to inaccuracies in the hemodynamic readings due to changes in patient positioning.
B: Leveling and zero referencing the transducer with the patient in the supine position is not ideal as it does not account for the impact of intra-abdominal pressure on the catheter readings in patients receiving enteral feedings.
D: Leveling and zero referencing
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A critically ill patient who is intubated and agitated is restrained with soft wrist restraints. Based on research findings, what is the best nursing action?
- A. Maintain the restraints to protect patient safety.
- B. Remove the restraints periodically to check skin integrity.
- C. Remove the restraints periodically for range of motion.
- D. Assess and intervene for causes of agitation. Answer Key
Correct Answer: D
Rationale: The correct answer is D: Assess and intervene for causes of agitation. In a critically ill patient, agitation while intubated could indicate underlying issues like pain, delirium, or inadequate sedation. By assessing and addressing the root cause of agitation, the nurse can improve patient comfort and prevent potential harm from restraints. Removing restraints periodically for skin integrity (B) and range of motion (C) is important but should not be the primary focus when agitation is present. Maintaining restraints (A) without addressing the agitation could lead to increased distress and potential complications.
A patient who is receiving positive pressure ventilation is scheduled for a spontaneous breathing trial (SBT). Which finding by the nurse is most important to discuss with the health care provider before starting the SBT?
- A. New ST segment elevation is noted on the cardiac monitor.
- B. Enteral feedings are being given through an orogastric tube.
- C. Scattered rhonchi are heard when auscultating breath sounds.
- D. HYDROmorphone (Dilaudid) is being used to treat postoperative pain.
Correct Answer: A
Rationale: The correct answer is A: New ST segment elevation is noted on the cardiac monitor. This finding is concerning because it may indicate myocardial ischemia or infarction, which can be exacerbated by the physiological stress of weaning from mechanical ventilation. It is crucial to address any cardiac issues before initiating a spontaneous breathing trial to prevent potential cardiac complications during the weaning process.
Explanation for why the other choices are incorrect:
B: Enteral feedings being given through an orogastric tube are not contraindicated for starting a spontaneous breathing trial.
C: Scattered rhonchi heard when auscultating breath sounds may indicate retained secretions but are not a contraindication for a spontaneous breathing trial.
D: The use of HYDROmorphone to treat postoperative pain is not a contraindication for a spontaneous breathing trial unless it is causing respiratory depression, which would need to be addressed separately.
A nurse who has been recently hired to manage the nursing staff of the ICU is concerned at the lack of evidence-based practice she sees among the staff. Which of the following would be the best step for her to take to promote incorporating evidence into clinical practice?
- A. Only hire nurses certified in critical care nursing.
- B. Leave copies of several different nursing journals in the nurses lounge.
- C. Demonstrate to the staff the best nursing-related search terms to use in Google orYahoo!
- D. Introduce the staff to the PubMed search engine and assign them topics to researchon it.
Correct Answer: D
Rationale: The correct answer is D because introducing the staff to the PubMed search engine and assigning them topics to research on it is the most effective way to promote evidence-based practice. PubMed is a reputable database that contains a vast collection of peer-reviewed articles and research studies, making it a reliable source for evidence. By assigning specific topics, the nurse can ensure that the staff is focusing on relevant and current information, fostering a deeper understanding of evidence-based practice.
Choice A is incorrect because certification in critical care nursing does not guarantee a commitment to evidence-based practice. Choice B is not as effective as it relies on passive exposure to journals rather than active engagement with specific research topics. Choice C is not the best option as using general search terms on search engines like Google or Yahoo may lead to unreliable or outdated information.
What nursing delivery of care provides the nurse to plan and direct care of a group of clients over a 24-hour period?
- A. Case management.
- B. Team nursing.
- C. Primary nursing.
- D. Functional nursing.
Correct Answer: C
Rationale: The correct answer is C: Primary nursing. Primary nursing is a care delivery model where one nurse is responsible for the total care of a group of clients over a 24-hour period. This promotes continuity of care, individualized attention, and better nurse-client relationships. In primary nursing, the nurse plans and directs care, coordinates with other healthcare team members, and serves as the main point of contact for the clients.
A: Case management involves coordinating care across different healthcare providers and services, not necessarily focusing on a specific group of clients over a 24-hour period.
B: Team nursing involves a team of healthcare providers working together to deliver care, rather than one nurse being responsible for a specific group of clients over a 24-hour period.
D: Functional nursing divides tasks among different healthcare team members based on their specific skills, which may not provide the same level of continuity and individualized care as primary nursing.
The nurse is caring for a 70-kg patient in septic shock with a pulmonary artery catheter. Which hemodynamic value indicates an appropriate response to therapy aimed at enhancing oxygen delivery to the organs and tissues?
- A. Arterial lactate level of 1.0 mEq/L
- B. Cardiac output of 2.5 L/min
- C. Mixed venous (SvO ) of 40%
- D. Cardiac index of 1.5 L/min/m2
Correct Answer: C
Rationale: The correct answer is C: Mixed venous (SvO2) of 40%. In septic shock, improving oxygen delivery to tissues is vital. SvO2 reflects the balance between oxygen delivery and consumption. A value of 40% indicates adequate oxygen delivery to tissues.
A: Arterial lactate level of 1.0 mEq/L - Although a low lactate level is good, it does not directly indicate improved oxygen delivery.
B: Cardiac output of 2.5 L/min - Cardiac output should ideally increase to improve oxygen delivery, so 2.5 L/min is low for a 70-kg patient.
D: Cardiac index of 1.5 L/min/m2 - Cardiac index is cardiac output adjusted for body surface area. 1.5 L/min/m2 is low and indicates inadequate cardiac function for a patient in septic shock.