Nokea
The nurse is concerned that the patient will pull out the en dotracheal tube. As part of the nursing management, the nurse should obtain an order for what intervention?
- A. A Posey-type vest
- B. A higher dosage of lorazepam
- C. Propofol
- D. Soft wrist restraints
Correct Answer: A
Rationale: The correct answer is A. A Posey-type vest is a restraint designed to prevent patients from pulling out medical devices like endotracheal tubes, ensuring their safety. It is a less restrictive option compared to wrist restraints and sedatives (B and C), which can have adverse effects and may not directly address the concern of tube removal. Using a Posey-type vest promotes patient autonomy by allowing some movement while still providing the necessary protection.
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The nurse wishes to increase the use of evidence-based practice in the critical care unit where he works. What is a significant barrier to the implementation of evidence-based practice?
- A. Use of computerized records by the hospital
- B. Health Information Privacy and Portability Act (HIPPA)
- C. Lack of knowledge about literature searches
- D. Strong collaborative relationships in the work setting
Correct Answer: C
Rationale: Rationale:
The correct answer is C because lack of knowledge about literature searches hinders the ability to find and utilize evidence-based practice guidelines. Nurses need to be skilled in conducting literature searches to access relevant research. Choices A, B, and D are incorrect as they do not directly impede the implementation of evidence-based practice in the critical care unit.
The charge nurse is supervising the care of four critical ca re patients being monitored using invasive hemodynamic modalities. Which patient should t he charge nurse evaluate first?
- A. A patient in cardiogenic shock with a cardiac output (CabOirb). coofm 2/te.0st L/min
- B. A patient with a pulmonary artery systolic pressure (PA P) of 20 mm Hg
- C. A hypovolemic patient with a central venous pressure (CVP) of 6 mm Hg
- D. A patient with a pulmonary artery occlusion pressure (PAOP) of 10 mm Hg
Correct Answer: A
Rationale: The correct answer is A because the patient in cardiogenic shock with a cardiac output of 2.0 L/min is experiencing a life-threatening condition that requires immediate evaluation. Cardiogenic shock indicates poor cardiac function, which can lead to multi-organ failure. Monitoring cardiac output is crucial in managing these patients.
Choice B is incorrect because a pulmonary artery systolic pressure of 20 mm Hg is within normal range and does not indicate an immediate life-threatening condition.
Choice C is incorrect because a CVP of 6 mm Hg in a hypovolemic patient may indicate volume depletion, but it is not as urgent as the patient in cardiogenic shock.
Choice D is incorrect because a PAOP of 10 mm Hg is within normal range and does not suggest an immediate critical condition.
The nurse responds to a ventilator alarm and finds the patient lying in bed holding the endotracheal tube (ET). Which action should the nurse take next?
- A. Activate the rapid response team.
- B. Provide reassurance to the patient.
- C. Call the health care provider to reinsert the tube.
- D. Manually ventilate the patient with 100% oxygen.
Correct Answer: D
Rationale: The correct action is D: Manually ventilate the patient with 100% oxygen. This is crucial to ensure adequate oxygenation and prevent hypoxia. Holding the ET tube can lead to extubation and airway compromise. Activating the rapid response team (A) may delay immediate intervention. Providing reassurance (B) is important but not the priority in this situation. Calling the health care provider (C) to reinsert the tube would also lead to a delay in providing essential respiratory support.
The nurse notes premature ventricular contractions (PVCs) while suctioning a patient’s endotracheal tube. Which action by the nurse is a priority?
- A. Decrease the suction pressure to 80 mm Hg.
- B. Document the dysrhythmia in the patient’s chart.
- C. Stop and ventilate the patient with 100% oxygen.
- D. Give antidysrhythmic medications per protocol.
Correct Answer: C
Rationale: The correct answer is C: Stop and ventilate the patient with 100% oxygen. This is the priority action because PVCs can lead to life-threatening arrhythmias and inadequate oxygenation. By stopping suctioning and providing 100% oxygen, the nurse ensures proper oxygenation and ventilation, which takes precedence over addressing the dysrhythmia itself. Decreasing suction pressure (choice A) may not address the underlying issue and could potentially harm the patient. Documenting the dysrhythmia (choice B) is important but not as urgent as ensuring adequate oxygenation. Giving antidysrhythmic medications (choice D) should be done under the direction of a healthcare provider and is not the first-line intervention in this situation.
The nursing is caring for a patient who has had an arterial line inserted. To reduce the risk of complications, what is the priority nursing intervention?
- A. Apply a pressure dressing to the insertion site.
- B. Ensure all tubing connections are tightened.
- C. Obtain a portable x-ray to confirm placement.
- D. Restrain the affected extremity for 24 hours.
Correct Answer: C
Rationale: The correct answer is C: Obtain a portable x-ray to confirm placement. This is the priority intervention because it ensures the arterial line is correctly positioned, reducing the risk of complications such as dislodgement or improper placement. Applying a pressure dressing (choice A) may be necessary but is not the priority. Ensuring tubing connections are tightened (choice B) is important for preventing leaks but does not address placement. Restraining the affected extremity (choice D) is unnecessary and can lead to complications. The x-ray confirms correct placement, ensuring accurate monitoring and treatment.