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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.
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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.
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.
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.
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.
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.