Nokea
Which of the following actions should the nurse take when the low-pressure alarm sounds for a patient who has an arterial line in the right radial artery?
- A. Check the right hand for pallor.
- B. Assess for cardiac dysrhythmias.
- C. Flush the arterial line with saline.
- D. Rezero the monitoring equipment.
Correct Answer: B
Rationale: The low-pressure alarm indicates a drop in the patient's blood pressure, which may be caused by cardiac dysrhythmias. There is no indication to rezero the equipment. Pallor of the right hand would be caused by occlusion of the radial artery by the arterial catheter, not by low pressure. There is no indication of a need for flushing the line.
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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 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.
A patient has a nursing diagnosis of disturbed sleep pattern related to difficulty maintaining sleep state. Which of the following actions should the nurse include in the plan of care?
- A. Discontinue assessments during the night to allow uninterrupted sleep.
- B. Administer prescribed sedatives or opioids at bedtime to promote sleep.
- C. Silence monitor alarms to allow 30- to 40-minute rest periods.
- D. Cluster nursing activities so that the patient has uninterrupted rest periods.
Correct Answer: D
Rationale: Clustering nursing activities and providing uninterrupted rest periods will minimize sleep-cycle disruption. Sedative and opioid medications tend to decrease the amount of rapid eye movement (REM) sleep and can contribute to sleep disturbance and disturbed sensory perception. Silencing the alarms on the cardiac monitors would be unsafe in a critically ill patient, as would discontinuing assessments during the night.
The nurse is caring for a patient who requires medication to increase the contractility of the heart. Which of the following medications should the nurse anticipate administering for this patient?
- A. Metoprolol
- B. Procainamide
- C. Secobarbital
- D. Dopamine
Correct Answer: D
Rationale: Epinephrine, norepinephrine, isoproterenol, dopamine, dobutamine, digitalis-like drugs, calcium, and milrinone increase contractility. These agents are termed positive inotropes. Contractility is diminished by negative inotropes, such as acidosis and certain drugs (e.g., barbiturates [secobarbital], alcohol, procainamide, calcium channel blockers, β-adrenergic blockers [metoprolol]).
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.