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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.
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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 preparing to assist with the insertion of a pulmonary artery catheter in a patient. Which of the following actions will the nurse implement?
- A. Check cardiac enzymes before insertion.
- B. Auscultate heart sounds during insertion.
- C. Place the patient on NPO status before the procedure.
- D. Attach cardiac monitoring leads before the procedure.
Correct Answer: D
Rationale: Dysrhythmias can occur as the catheter is floated through the right atrium and ventricle, and it is important for the nurse to monitor for these during insertion. Pulmonary artery catheter insertion does not require anaesthesia, and the patient will not need to be NPO. Changes in cardiac enzymes or heart sounds are not expected during pulmonary artery catheter insertion.
The nurse is caring for a patient following surgery whose central venous pressure (CVP) monitor indicates low pressures. Which of the following actions should the nurse anticipate implementing?
- A. Increase the IV fluid infusion rate.
- B. Administer IV diuretic medications.
- C. Elevate the head of the patient's bed to 45 degrees.
- D. Document the CVP and continue to monitor.
Correct Answer: A
Rationale: A low CVP indicates hypovolemia and a need for an increase in the infusion rate. Diuretic administration will contribute to hypovolemia and elevation of the head may decrease cerebral perfusion. Documentation and continued monitoring is an inadequate response to the low CVP.
The nurse is monitoring for the effectiveness of treatment for a patient with left ventricular failure. Which of the following assessments is most important for the nurse to evaluate?
- A. Mean arterial pressure (MAP)
- B. Systemic vascular resistance (SVR)
- C. Pulmonary vascular resistance (PVR)
- D. Pulmonary artery occlusive pressure (PAOP)
Correct Answer: D
Rationale: PAOP reflects left ventricular end diastolic pressure (or left ventricular preload). Because the patient in left ventricular failure will have a high PAOP, a decrease in this value will be the best indicator of patient improvement. The other values would also provide useful information, but the most definitive measurement of improvement is a drop in PAOP.
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.