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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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The charge nurse is mentoring a new RN staff member providing care to a patient receiving mechanical ventilation. Which of the following actions by the new RN indicates the need for more education?
- A. The RN increases the FIO2 up to 100%.
- B. The RN secures a bite block in place using adhesive tape.
- C. The RN positions the patient with the head of bed at 10 degrees.
- D. The RN asks for assistance to turn the patient to the prone position.
Correct Answer: C
Rationale: The head of the patient's bed should be positioned at 30-45 degrees to prevent ventilator-acquired pneumonia. The other actions by the new RN are appropriate.
The nurse is caring for a patient with a left radial arterial line. Which of the following assessments indicates a need for the nurse to take action?
- A. The left hand is cooler than the right hand.
- B. The mean arterial pressure (MAP) is 75 mm Hg.
- C. The system is delivering only 3 mL of flush solution per hour.
- D. The flush bag and tubing were last changed 3 days previously.
Correct Answer: A
Rationale: The change in temperature of the left hand suggests that blood flow to the left hand is impaired. The flush system needs to be changed every 96 hours or per agency policy. A mean arterial pressure (MAP) of 75 mm Hg is normal. Flush systems for hemodynamic monitoring are set up to deliver 3-6 mL/hour of flush solution.
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.
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 assisting with insertion of a pulmonary artery (PA) catheter in a patient. Which of the following data identifies that the catheter is correctly placed?
- A. Monitor shows a typical PAOP tracing.
- B. PA waveform is observed on the monitor.
- C. Systemic arterial pressure tracing appears on the monitor.
- D. Catheter has been inserted to the 22-cm marking on the line.
Correct Answer: A
Rationale: One of the purposes of a PA line is to measure PAOP, so the catheter is floated through the pulmonary artery until the dilated balloon wedges in a distal branch of the pulmonary artery, and the PAOP readings are available. After insertion, the balloon is deflated and the PA waveform will be observed. Systemic arterial pressures are obtained using an arterial line. The length of catheter needed for insertion will vary with patient size.