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Which action is a priority for the nurse to take when the low-pressure alarm sounds for a patient who has an arterial line in the left radial artery?
- A. Fast flush of the arterial line.
- B. Check the left hand for pallor.
- C. Assess for cardiac dysrhythmias.
- D. Rezero the monitoring equipment.
Correct Answer: C
Rationale: Rationale for Correct Answer (C): When the low-pressure alarm sounds for a patient with an arterial line, the nurse should assess for cardiac dysrhythmias first. This is because a sudden drop in pressure could indicate a serious issue affecting the heart's ability to pump effectively. Identifying and addressing any cardiac dysrhythmias promptly is crucial for patient safety.
Summary of Incorrect Choices:
A: Fast flush of the arterial line - This would not address the underlying cause of the low-pressure alarm and may not be necessary.
B: Check the left hand for pallor - While assessing perfusion is important, it is not the priority when the alarm indicates a potential cardiac issue.
D: Rezero the monitoring equipment - While important for accuracy, it is not the priority when the alarm indicates a potential cardiac concern.
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The charge nurse has a Vigileo pulse contour cardiac output monitoring system available for use in the surgical intensive care unit. For which patient isa buisrbe.c oomf /ttehsits device most appropriate?
- A. A patient with a history of aortic insufficiency admitte d with a postoperative myocardial infarction
- B. A mechanically ventilated patient with cardiogenic sho ck being treated with an intraaortic balloon pump
- C. A patient with a history of atrial fibrillation having frequent episodes of paroxysmal supraventricular tachycardia
- D. A mechanically ventilated patient admitted following repair of an acute bowel obstruction
Correct Answer: B
Rationale: The correct answer is B because a mechanically ventilated patient with cardiogenic shock being treated with an intra-aortic balloon pump would benefit most from having a Vigileo pulse contour cardiac output monitoring system. This device provides continuous cardiac output monitoring and can help guide hemodynamic management in critically ill patients, especially those with hemodynamic instability like cardiogenic shock. It allows for real-time adjustments of fluid and vasoactive medications to optimize cardiac output and tissue perfusion.
Choice A is incorrect because a patient with a history of aortic insufficiency and postoperative myocardial infarction may not require continuous cardiac output monitoring like the patient in choice B. Choice C is incorrect as the patient with atrial fibrillation and paroxysmal supraventricular tachycardia does not necessarily need cardiac output monitoring. Choice D is also incorrect as a mechanically ventilated patient following repair of an acute bowel obstruction may not require continuous cardiac output monitoring unless there are specific complications.
The nurse uses subtle measures of painful stimuli, such as nailbed pressure to elicit a response from a neurologically impaired patient. By using this meth od rather than nipple pinching, the nurse is exemplifying what ethical principle?
- A. Beneficence
- B. Fidelity
- C. Nonmaleficence
- D. Veracity
Correct Answer: C
Rationale: The correct answer is C: Nonmaleficence. The nurse is demonstrating nonmaleficence by choosing a less harmful method (nailbed pressure) to assess pain in a neurologically impaired patient, instead of a more painful method (nipple pinching). Nonmaleficence is the ethical principle of avoiding harm or minimizing harm to the patient. In this scenario, the nurse is prioritizing the well-being and comfort of the patient by using a less invasive and painful method to elicit a response. Choices A, B, and D are incorrect because beneficence refers to doing good for the patient, fidelity to being loyal and maintaining trust, and veracity to truthfulness and honesty, none of which directly apply in this situation.
What are the diagnostic criteria for acute respiratory distress syndrome (ARDS)? (Select all that apply.)
- A. Bilateral infiltrates on chest x-ray study
- B. Decreased cardiac output
- C. PaO /FiO ratio of less than 200 2 2
- D. Pulmonary artery occlusion pressure (PAOP) of more than 18 mm Hg
Correct Answer: A
Rationale: The correct answer is A: Bilateral infiltrates on chest x-ray study. ARDS diagnosis requires bilateral infiltrates on chest x-ray, indicative of non-cardiogenic pulmonary edema. Choice B, decreased cardiac output, is not a diagnostic criterion for ARDS. Choice C, PaO2/FiO2 ratio of less than 200, is a key diagnostic criteria for ARDS, indicating severe hypoxemia. Choice D, PAOP of more than 18 mm Hg, is used to differentiate between cardiogenic and non-cardiogenic causes of pulmonary edema, but it is not a direct diagnostic criterion for ARDS.
The assessment of pain and anxiety is a continuous proces s. When critically ill patients exhibit signs of anxiety, what is the nurse’s first priority?
- A. To administer antianxiety medications as ordered
- B. To administer pain medication as ordered
- C. To identify and treat the underlying cause
- D. To reassess the patient hourly to determine whether symptoms resolve on their own
Correct Answer: C
Rationale: The correct answer is C: To identify and treat the underlying cause. The first priority of the nurse when critically ill patients exhibit signs of anxiety is to determine the root cause of the anxiety. By identifying and addressing the underlying cause, the nurse can effectively manage the patient's anxiety and prevent further complications. Administering medications without understanding the cause can mask the symptoms and lead to ineffective treatment. Reassessing the patient hourly may not address the root cause and could delay appropriate intervention. Pain medication may not be necessary if the anxiety is not related to pain. Treating the underlying cause ensures holistic and effective care for the patient.
Which nursing actions are most important for a patient witahb irab .croigmh/tte srta dial arterial line? (Select all that apply.)
- A. Checking the circulation to the right hand every 2 hour s
- B. Maintaining a pressurized flush solution to the arterial line setup
- C. Monitoring the waveform on the monitor for dampenin g
- D. Restraining all four extremities with soft limb restraint s
Correct Answer: A
Rationale: Step 1: Checking circulation to the right hand is crucial for assessing perfusion and detecting potential complications.
Step 2: Arterial line placement can compromise blood flow, leading to ischemia if circulation is impaired.
Step 3: Monitoring circulation every 2 hours allows for early detection of issues and prompt intervention.
Step 4: This action ensures patient safety and prevents complications.
Summary:
- Choice B is incorrect as pressurized flush solution can increase the risk of complications.
- Choice C is incorrect as monitoring the waveform is important but not the most critical action.
- Choice D is incorrect as limb restraints can impede circulation and are unnecessary in this scenario.