Nokea
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.
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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.
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 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.
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.
The nurse is assisting with insertion of a pulmonary artery (PA) catheter in a patient. Which of the following data identifies that the catheter is correctly placed?
- A. Monitor shows a typical PAOP tracing.
- B. PA waveform is observed on the monitor.
- C. Systemic arterial pressure tracing appears on the monitor.
- D. Catheter has been inserted to the 22-cm marking on the line.
Correct Answer: A
Rationale: One of the purposes of a PA line is to measure PAOP, so the catheter is floated through the pulmonary artery until the dilated balloon wedges in a distal branch of the pulmonary artery, and the PAOP readings are available. After insertion, the balloon is deflated and the PA waveform will be observed. Systemic arterial pressures are obtained using an arterial line. The length of catheter needed for insertion will vary with patient size.