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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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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.
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 is caring for a patient who has an arterial catheter in the radial artery to monitor blood pressure. Which of the following information obtained by the nurse is most important to report to the health care provider?
- A. The patient has a positive Allen test.
- B. The mean arterial pressure (MAP) is 86 mm Hg.
- C. There is redness at the catheter insertion site.
- D. The dicrotic notch is visible in the waveform.
Correct Answer: C
Rationale: Redness at the catheter insertion site indicates possible infection. The Allen test is performed before arterial line insertion, and a positive test indicates normal ulnar artery perfusion. An MAP of 86 is normal and the dicrotic notch is normally present on the arterial waveform.
Which of the following actions should the nurse implement to verify the correct placement of an endotracheal tube (ET) after insertion?
- A. Auscultate for the presence of bilateral breath sounds.
- B. Obtain a portable chest radiograph to check tube placement.
- C. Observe the chest for symmetrical movement with ventilation.
- D. Use an end-tidal CO2 monitor to check for placement in the trachea.
Correct Answer: D
Rationale: End-tidal CO2 monitors are currently recommended for rapid verification of ET placement. Auscultation for bilateral breath sounds and checking chest expansion also are used, but they are not as accurate as end-tidal CO2 monitoring. A chest x-ray confirms the placement but is done after the tube is secured.
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.