Nokea
The nurse is caring for a patient with a left radial arterial line. Which of the following assessments indicates a need for the nurse to take action?
- A. The left hand is cooler than the right hand.
- B. The mean arterial pressure (MAP) is 75 mm Hg.
- C. The system is delivering only 3 mL of flush solution per hour.
- D. The flush bag and tubing were last changed 3 days previously.
Correct Answer: A
Rationale: The change in temperature of the left hand suggests that blood flow to the left hand is impaired. The flush system needs to be changed every 96 hours or per agency policy. A mean arterial pressure (MAP) of 75 mm Hg is normal. Flush systems for hemodynamic monitoring are set up to deliver 3-6 mL/hour of flush solution.
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A patient has a nursing diagnosis of disturbed sleep pattern related to difficulty maintaining sleep state. Which of the following actions should the nurse include in the plan of care?
- A. Discontinue assessments during the night to allow uninterrupted sleep.
- B. Administer prescribed sedatives or opioids at bedtime to promote sleep.
- C. Silence monitor alarms to allow 30- to 40-minute rest periods.
- D. Cluster nursing activities so that the patient has uninterrupted rest periods.
Correct Answer: D
Rationale: Clustering nursing activities and providing uninterrupted rest periods will minimize sleep-cycle disruption. Sedative and opioid medications tend to decrease the amount of rapid eye movement (REM) sleep and can contribute to sleep disturbance and disturbed sensory perception. Silencing the alarms on the cardiac monitors would be unsafe in a critically ill patient, as would discontinuing assessments during the night.
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.
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.
Which of the following actions should the nurse take when the low-pressure alarm sounds for a patient who has an arterial line in the right radial artery?
- A. Check the right hand for pallor.
- B. Assess for cardiac dysrhythmias.
- C. Flush the arterial line with saline.
- D. Rezero the monitoring equipment.
Correct Answer: B
Rationale: The low-pressure alarm indicates a drop in the patient's blood pressure, which may be caused by cardiac dysrhythmias. There is no indication to rezero the equipment. Pallor of the right hand would be caused by occlusion of the radial artery by the arterial catheter, not by low pressure. There is no indication of a need for flushing the line.
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.