Nokea
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.
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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 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.
Which of the following actions should the nurse do to inflate the cuff of an endotracheal tube (ET) when the patient is on mechanical ventilation?
- A. Inflate the cuff until the pilot balloon is firm.
- B. Inflate the cuff with a minimum of 10 mL of air.
- C. Inject air into the cuff until a manometer shows 15 mm Hg pressure.
- D. Inject air into the cuff until a slight leak is heard only at peak inflation.
Correct Answer: D
Rationale: The minimal occluding volume technique involves injecting air into the cuff until an air leak is present only at peak inflation. The volume to inflate the cuff varies with the ET and the patient's size. Cuff pressure should be maintained at 20-25 mm Hg. An accurate assessment of cuff pressure cannot be obtained by palpating the pilot balloon.
The nurse notes that a patient's endotracheal tube (ET), which was at the 21-cm mark, is now at the 24-cm mark and the patient appears anxious and restless. Which of the following actions should the nurse take first?
- A. Listen to the patient's lungs.
- B. Offer reassurance to the patient.
- C. Bag the patient at an FIO2 of 100%.
- D. Notify the patient's health care provider.
Correct Answer: A
Rationale: The nurse should first determine whether the ET tube has been displaced into the right mainstem bronchus by listening for unilateral breath sounds. If so, assistance will be needed to reposition the tube immediately. The other actions also are appropriate, but detection and correction of tube malposition are the most critical actions.
The nurse is caring for a patient who requires medication to increase the contractility of the heart. Which of the following medications should the nurse anticipate administering for this patient?
- A. Metoprolol
- B. Procainamide
- C. Secobarbital
- D. Dopamine
Correct Answer: D
Rationale: Epinephrine, norepinephrine, isoproterenol, dopamine, dobutamine, digitalis-like drugs, calcium, and milrinone increase contractility. These agents are termed positive inotropes. Contractility is diminished by negative inotropes, such as acidosis and certain drugs (e.g., barbiturates [secobarbital], alcohol, procainamide, calcium channel blockers, β-adrenergic blockers [metoprolol]).