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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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.
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.
While family members are visiting, a patient has a cardiac arrest and is being resuscitated. Which of the following actions by the nurse is best?
- A. Ask family members if they wish to remain in the room during the resuscitation.
- B. Explain to family members that watching the resuscitation will be very stressful.
- C. Assign a staff member to wait with family members just outside the patient room.
- D. Escort family members quickly out of the patient room and then remain with them.
Correct Answer: A
Rationale: Research indicates that family members want the option of remaining in the room during procedures such as CPR and that this decreases anxiety and facilitates grieving. The other options may be appropriate if the family decides not to remain with the patient.
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.
To determine the effectiveness of medications that a patient has received to reduce left ventricular afterload, which of the following hemodynamic parameters should the nurse monitor?
- A. Central venous pressure (CVP)
- B. Systemic vascular resistance (SVR)
- C. Pulmonary vascular resistance (PVR)
- D. Pulmonary artery wedge pressure (PAWP)
Correct Answer: B
Rationale: Systemic vascular resistance reflects the resistance to ventricular ejection, or afterload. The other parameters will be monitored, but do not reflect afterload as directly.