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While caring for a patient with a pulmonary artery cathete r, the nurse notes the pulmonary artery occlusion pressure (PAOP) to be significantly higher than previously recorded values. The nurse assesses respirations to be unlabored at 16 breat hs/min, oxygen saturation of 98% on 3 L of oxygen via nasal cannula, and lungs clear to auscultation bilaterally. What is the priority nursing action?
- A. Increase supplemental oxygen and notify respiratory therapy.
- B. Notify the physician immediately of the assessment fin dings.
- C. Obtain a stat chest x-ray film to verify proper catheter placement.
- D. Zero reference and level the catheter at the phlebostati
Correct Answer: B
Rationale: The correct answer is B: Notify the physician immediately of the assessment findings. The significantly higher PAOP could indicate a potential complication or a change in the patient's condition that needs immediate medical attention. By notifying the physician, further assessment and interventions can be initiated promptly to address the underlying cause. Increasing supplemental oxygen (choice A) may not directly address the elevated PAOP, obtaining a chest x-ray (choice C) may delay urgent intervention, and zero referencing the catheter (choice D) is not a priority in this situation. Notifying the physician ensures timely and appropriate management of the patient's condition.
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A patient who is undergoing withdrawal of mechanical ventilation appears anxious and agitated. The patient is on a continuous morphine infusion and has an additional order for lorazepam 1 to 2 mg IV as needed (prn). The patient has received no lorazepam during this course of illness. What is the most appropriate nursing intearbvirbe.ncotmio/tnes tt o control agitation?
- A. Administer fentanyl (Duragesic) 25 mg IV bolus.
- B. Administer midazolam 2 mg IV now.
- C. Increase the rate of the morphine infusion by 50%.
- D. Request an order for a paralytic agent.
Correct Answer: B
Rationale: Step-by-step rationale for why choice B is correct:
1. Midazolam is a benzodiazepine used for sedation and anxiolysis.
2. It acts quickly and has a short duration of action, suitable for acute agitation.
3. Lorazepam (also a benzodiazepine) is in the same drug class, ensuring compatibility.
4. Lorazepam is specifically ordered for this patient, indicating its appropriateness.
5. Administering midazolam addresses the patient's agitation efficiently and safely.
Summary of why other choices are incorrect:
A: Fentanyl is an opioid analgesic, not ideal for managing agitation.
C: Increasing morphine infusion can exacerbate sedation or respiratory depression.
D: Paralytic agents are used for neuromuscular blockade, not agitation control.
Which statement about family assessment is false?
- A. Assessment of structure (who comprises the family) is the last step in assessment.
- B. Interaction among family members is assessed.
- C. It is important to assess communication among family members to understand roles.
- D. Ongoing assessment is important, because family funcatbioirbn.cinomg/ tmesat y change during the course of illness.
Correct Answer: A
Rationale: The correct answer is A because assessing the structure of the family (who comprises the family) is not the last step in family assessment. The rationale is that understanding the family structure is essential at the beginning of the assessment process to identify key relationships and support systems. Assessing interaction among family members helps to understand dynamics and relationships within the family. Assessing communication is crucial to identify roles and patterns of interaction. Ongoing assessment is necessary as family dynamics can evolve throughout the illness. Therefore, A is false as family structure assessment is an important initial step, not the last step.
The critical care unit environment is very stressful for patients, families, and staff. What nursing action is directed at reducing environmental stress?
- A. Constant evaluation of patient status
- B. Limiting visits to immediate family
- C. Bathing all patients during hours of sleep
- D. Maintaining quiet during hours of sleep
Correct Answer: D
Rationale: The correct answer is D: Maintaining quiet during hours of sleep. This action is essential in reducing environmental stress in the critical care unit as it promotes a restful environment for patients and allows for better sleep quality. Noise can disrupt sleep patterns and increase stress levels. Constant evaluation of patient status (A) is important but does not directly address environmental stress. Limiting visits to immediate family (B) can be beneficial in some cases but may not always reduce environmental stress. Bathing all patients during hours of sleep (C) may actually increase stress as it can be disruptive and uncomfortable for patients. Overall, maintaining a quiet environment during sleep hours is the most effective nursing action to reduce environmental stress in the critical care unit.
An intra-aortic balloon pump (IABP) is being used for a patient who is in cardiogenic shock. Which assessment data indicate to the nurse that the goals of treatment with the IABP are being met?
- A. Urine output of 25 mL/hr.
- B. Heart rate of 110 beats/minute.
- C. Cardiac output (CO) of 5 L/min.
- D. Stroke volume (SV) of 40 mL/beat.
Correct Answer: C
Rationale: The correct answer is C: Cardiac output (CO) of 5 L/min. In cardiogenic shock, the primary goal of using an IABP is to improve cardiac output to ensure adequate perfusion to vital organs. A cardiac output of 5 L/min indicates adequate blood flow and perfusion.
Choice A is incorrect as urine output is not a direct indicator of cardiac function. Choice B is incorrect as a heart rate of 110 beats/minute alone does not provide information on the effectiveness of the IABP in improving cardiac output. Choice D is incorrect as stroke volume alone does not provide a comprehensive assessment of overall cardiac function.
The nurse caring for a mechanically ventilated patient prepares to include which strategies to prevent ventilator-associated pneumonia should be into the patient’s plan of care? (Select all that apply.)
- A. Drain condensate from the ventilator tubing away from the patient.
- B. Elevate the head of the bed 30 to 45 degrees.
- C. Instill normal saline as part of the suctioning procedure.
- D. Perform regular oral care with chlorhexidine.
Correct Answer: A
Rationale: The correct answer is A: Drain condensate from the ventilator tubing away from the patient. This is crucial to prevent ventilator-associated pneumonia as stagnant condensate can harbor harmful bacteria. By draining it away from the patient, the risk of bacterial growth and subsequent aspiration is minimized. Elevating the head of the bed (choice B) helps prevent aspiration but is not specific to preventing ventilator-associated pneumonia. Instilling normal saline during suctioning (choice C) can increase the risk of infection. Performing regular oral care with chlorhexidine (choice D) is important for oral hygiene but not directly related to preventing ventilator-associated pneumonia.