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When the ventilator alarm sounds, the nurse finds the patient lying in bed holding the endotracheal tube (ET). Which of the following actions should the nurse take first?
- A. Offer reassurance to the patient.
- B. Activate the hospital's rapid response team.
- C. Call the health care provider to reinsert the tube.
- D. Manually ventilate the patient with 100% oxygen.
Correct Answer: D
Rationale: The nurse should ensure maximal patient oxygenation by manually ventilating with a bag-valve-mask system. Offering reassurance to the patient, notifying the health care provider about the need to reinsert the tube, and activating the rapid response team also are appropriate after the nurse has stabilized the patient's oxygenation.
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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.
When a patient's pulmonary artery catheter becomes wedged and does not reflect pulmonary artery pressures, which of the following actions should the nurse take?
- A. Reposition the patient and check for a pulmonary artery tracing.
- B. Deflate the balloon and flush the catheter with saline.
- C. Notify a health care provider or specially trained nurse.
- D. Increase the volume in the balloon to open the catheter.
Correct Answer: C
Rationale: When the catheter is in the wedge position, blood flow past the catheter is obstructed, placing the patient at risk for pulmonary infarction. A health care provider or specially trained nurse should be called to reposition the catheter. The other actions will not correct the wedging of the PA catheter.
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 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.
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.