Burn Injury Management: Multiple Choice Questions and Answers, Exams of Public Health

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Many variables influence the outcome of elderly burn patient mortality, including preinjury hydration status, nutrition status, and comorbid diseases, especially heart failure. Assessment questions should include, as a priority, information about the patient's cardiovascular status, including heart failure. Obtaining food or drug allergy information is also important along with other past medical history, including past surgeries. Information on the patient's living arrangements is an important safety consideration for discharge planning. - CORRECT ANSWERS The nurse is conducting an admission assessment of an 82-year-old patient who sustained a 12% burn from spilling hot coffee on the hand and arm. Which statement is of priority to assist in planning treatment?

a.

"Do you live alone?"

b.

"Do you have any drug or food allergies?"

c.

"Do you have a heart condition or heart failure?"

d.

"Have you had any surgeries?"

ANS: A

Patients with toxic epidermal necrolysis, Stevens-Johnson Syndrome (SJS), and erythema multiforme present with acute onset fever and flulike symptoms, with erythema and blisters developing within 24 to 96 hours, skin and mucous membranes slough, resulting in a significant and painful partial- thickness injury. Staphylococcal scalded skin syndrome presents predominantly in children. Necrotizing soft tissue infection results from rapidly invasive bacterial infections. Graft versus host disease is not logical given the clinical information provided. - CORRECT ANSWERS A 63-year-old patient is admitted with new onset fever; flulike symptoms; blisters over her arms, chest, and neck; and red, painful, oral mucous membranes. The patient should be further evaluated for which possible non-burn injured skin disorder?

a.

Toxic epidermal necrolysis

b.

Staphylococcal scalded skin syndrome

c.

Necrotizing soft tissue infection

d.

Graft versus host disease

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ANS: B

Tissue damage results from the conversion of electrical energy into heat. Monitor the patient for cardiac dysrhythmias. - CORRECT ANSWERS A(An) ____________________ often produces a superficial cutaneous injury but may cause cardiopulmonary arrest and transient but severe central nervous system deficits.

a.

chemical burn

b.

electrical burn

c.

heat burn

d.

infection

ANS: A, B, C

The rapid metabolism associated with burn injury may require additional pain medication. Many of the procedures associated with burn wounds are painful, such as dressing changes. Adequate pain medication should be given prior to the procedures. Edema in burned patients alters the absorption of medications that are injected intramuscularly; therefore, drugs must be administered by the IV route. - CORRECT ANSWERS Which of the following statements about the pain management of a burn victim are true? (Select all that apply.)

a.

Additional pain medication may be needed because of rapid body metabolism.

b.

Pain medication should be given before procedures such as debridement, dressing changes, and physical therapy.

c.

Patients with a history of drug and alcohol abuse will require higher doses of pain medication.

d.

The intramuscular route is preferred for pain medication administration.

ANS: B, C, E

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Venous thromboembolism (VTE) is a significant risk for patients who have thermal injury, venous stasis associated with immobility/bedrest, hypercoagulability seen with burn injuries greater than 10% TBSA, and hypovolemia associated with delayed fluid resuscitation. Burns to lower extremities will limit mobility and use of sequential compression devices, increasing the potential risk for VTE. Electrical burn injury may pose a risk for VTE; however, VTE is more closely associated with thermal injuries greater than 10% TBSA. - CORRECT ANSWERS Which of the following factors increase the burn patient's risk for venous thromboembolism? (Select all that apply.)

a.

Burn injury less than 10%

b.

Bedrest

c.

Burns to lower extremities

d.

Electrical burn injury

e.

Delayed fluid resuscitation

ANS: A, B, D

It is important to avoid immobility in patients with burns of the hands, feet, or major joints. Measures must be taken to maintain the function of the hands, feet, and major joints. Nursing interventions to maintain range of motion, applying splits to keep the extremities in a position of function, and individually wrapping fingers and toes are necessary to maintain function of the hands, feet, and joints. Effective pain management is necessary to encourage mobility. - CORRECT ANSWERS The nurse is caring for a patient with burns to the hands, feet, and major joints. The nurse plans care to include which of the following? (Select all that apply.)

a.

Applying splints that maintain the extremity in an extended position

b.

Implementing passive or active range-of-motion exercises

c.

Keeping the limbs as immobile as possible

d.

Wrapping fingers and toes individually with bandages

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ANS: A, C, E

Nurses can help reduce the risk of infection by using topical antibacterial wound ointments and dressings as prescribed, daily questioning the need for invasive devices such as central IV access and indwelling urinary catheters, and maintaining aseptic technique during all care provided to the patient. Changing the indwelling urinary catheter will not reduce the risk of infection; wound care is achieved by aseptic technique; and restricting family is not an intervention related to infection prevention. - CORRECT ANSWERS Which of the following infection control strategies should the nurse implement to decrease the risk of infection in the burn-injured patient? (Select all that apply.)

a.

Apply topical antibacterial wound ointments/dressings.

b.

Change indwelling urinary catheter every 7 days.

c.

Daily assess the need for central IV catheters.

d.

Restrict family visitation.

e.

Maintain strict aseptic technique during burn wound management.

ANS: A, B, D, E, G, H

Electrical injuries vary in severity of injury by the intensity of energy exposed to the body. Manifestations and complications may include cardiac dysrhythmias or cardiopulmonary arrest, hypoxia, deep tissue necrosis, rhabdomyolysis and acute kidney injury, compartment syndrome, long bone fractures, acute cataract formation, and neurological deficits (including seizures). Hypertension and peptic ulcer disease are not direct consequences of electrical burn injuries. - CORRECT ANSWERS Which complications may manifest after an electrical injury? (Select all that apply.)

a.

Long bone fractures

b.

Cardiac dysrhythmias

c.

Hypertension

d.

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Compartment syndrome of extremities

e.

Dark brown urine

f.

Peptic ulcer disease

g.

Acute cataract formation

h.

Seizures

ANS: A, B, D

Autograft skin will allow for faster healing with less scar formation and a shorter hospitalization. - CORRECT ANSWERS An autograft is used to optimally treat a partial- or full-thickness wound that: (Select all that apply.)

a.

involves a joint.

b.

involves the face, hands, or feet.

c.

is infected.

d.

requires more than 2 weeks for healing.

ANS:

D, A, B, C

Early care has a positive impact on recovery. The first priority is to stop the burning process and prevent further injury. At this point, you initiate the primary survey, which is to assess the ABCs and cervical spine. Oxygen therapy follows the ABCs. The secondary survey includes further assessment for additional injuries. - CORRECT ANSWERS The correct priority order of actions in prehospital primary survey for burn injuries is: _______________, _______________, _______________, _______________. (Put a comma and space between each answer choice.)

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a. Assess ABCs and cervical spine.

b. Provide oxygen therapy if smoke inhalation is suspected.

c. Make rapid head-to-toe assessment to rule out additional trauma.

d. Stop the burning process and prevent further injury.

ANS: A

Both hemodynamic parameters and the reported hematocrit value indicate hypovolemia and blood loss requiring volume resuscitation with blood products. Furosemide administration will worsen fluid volume status. Inotropic agents will not correct the underlying fluid volume deficit and anemia. Vasoconstrictors are contraindicated in a volume-depleted state. - CORRECT ANSWERS A patient is admitted to the hospital with multiple trauma and extensive blood loss. The nurse assesses vital signs to be BP 80/50 mm Hg, heart rate 135 beats/min, respirations 36 breaths/min, cardiac output (CO) of 2 L/min, systemic vascular resistance of 3000 dynes/sec/cm-5, and a hematocrit of 20%. The nurse anticipates administration of which the following therapies or medications?

a.

Blood transfusion

b.

Furosemide (Lasix)

c.

Dobutamine (Dobutrex) infusion

d.

Dopamine hydrochloride (Dopamine) infusion

ANS: C

The pulmonary pressures are higher than normal, indicating elevated preload, and the cardiac index and output values are low. The priority order for the nurse to implement is to begin a dobutamine (Dobutrex) infusion to improve cardiac output, possibly reducing pulmonary artery occlusion pressures. The other treatments are important, but the dobutamine infusion is the most important at this time. - CORRECT ANSWERS After pulmonary artery catheter insertion, the nurse assesses a pulmonary artery pressure of 45/25 mm Hg, a pulmonary artery occlusion pressure (PAOP) of 20 mm Hg, a cardiac output of 2.6 L/min and a cardiac index of 1.9 L/min/m2. Which physician order is of the highest priority?

a.

Apply 50% oxygen via venture mask.

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b.

Insert an indwelling urinary catheter.

c.

Begin a dobutamine (Dobutrex) infusion.

d.

Obtain stat cardiac enzymes and troponin.

ANS: B

Numbness and tingling in the left hand, which is the location of an arterial catheter, indicates possible neurovascular compromise and requires immediate action. A dampened waveform can indicate problems with arterial line patency but is not an emergent situation. Slight bloody drainage at the subclavian insertion site is not an unusual finding. Slight redness at the insertion site, while of concern, does not require immediate action. - CORRECT ANSWERS The nurse is caring for a patient with a left subclavian central venous catheter (CVC) and a left radial arterial line. Which assessment finding by the nurse requires immediate action?

a.

A dampened arterial line waveform

b.

Numbness and tingling in the left hand

c.

Slight bloody drainage at subclavian insertion site

d.

Slight redness at subclavian insertion site

ANS: B

Upon removal of an invasive arterial line, adequate pressure must be applied for at least 5 minutes to ensure adequate hemostasis. Application of an air occlusion dressing is not standard of care following removal of an arterial line. Elevation of the affected limb following removal of an arterial line is not a necessary intervention. Neutral wrist position is optimum while the catheter is in place and not necessary after catheter discontinuation. - CORRECT ANSWERS The physician writes an order to discontinue a patient's left radial arterial line. When discontinuing the patient's invasive line, what is the priority nursing action?

a.

Apply an air occlusion dressing to insertion site.

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b.

Apply pressure to the insertion site for 5 minutes.

c.

Elevate the affected limb on pillows for 24 hours.

d.

Keep the patient's wrist in a neutral position.

ANS: C

X-ray results indicate proper position of the catheter. The tip of the central venous catheter should rest just above the right atrium in the superior vena cava. The central venous catheter is positioned correctly in the superior vena cava. Dysrhythmias occur if the catheter migrates to the right ventricle. Central venous catheters are placed into great vessels of the venous system and not advanced into the pulmonary artery. - CORRECT ANSWERS Following insertion of a central venous catheter, the nurse obtains a stat chest x-ray film to verify proper catheter placement. The radiologist reports to the nurse: "The tip of the catheter is located in the superior vena cava." What is the best interpretation of these results by the nurse?

a.

The catheter is not positioned correctly and should be removed.

b.

The catheter position increases the risk of ventricular dysrhythmias.

c.

The distal tip of the catheter is in the appropriate position.

d.

The physician should be called to advance the catheter into the pulmonary artery.

ANS: C

Balloon inflation should never be forced because the PAC may have migrated further into the pulmonary artery, creating resistance to balloon inflation. Verification of proper line placement is warranted to avoid pulmonary artery rupture. In addition, the PAC waveform should be observed to assist in identifying location of the tip of the PAC. In this scenario, adding additional air to the balloon will further risk pulmonary artery rupture.

Advancing a pulmonary artery catheter is not within the nurse's scope of practice.

Flushing the distal port with saline may be indicated to ensure patency; however, the balloon of the PAC should never be locked in the inflated position as rupture of the pulmonary artery may occur. - CORRECT ANSWERS 10. While inflating the balloon of a pulmonary artery catheter (PAC) with 1.0 mL

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of air to obtain a pulmonary artery occlusion pressure (PAOP), the nurse encounters resistance. What is the best nursing action?

a.

Add an additional 0.5 mL of air to the balloon and repeat the procedure.

b.

Advance the catheter with the balloon deflated and repeat the procedure.

c.

Deflate the balloon and obtain a chest x-ray study to determine line placement.

d.

Lock the balloon in the inflated position and flush the distal port of the PAC with normal saline.

ANS: A

Diminished breaths sounds over the lung field on the same side of the line insertion site may be indicative of a pneumothorax. A pneumothorax, which can develop slowly, is a major complication following insertion of central lines when the subclavian route is used. Localized pain at catheter insertion site is not the immediate priority in this scenario. A measured central venous pressure of 5 mm Hg is normal. Slight bloody drainage at the insertion site soon after the procedure does not require immediate action. - CORRECT ANSWERS The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which assessment finding 2 hours after insertion by the nurse warrants immediate action?

a.

Diminished breath sounds over left lung field

b.

Localized pain at catheter insertion site

c.

Measured central venous pressure of 5 mm Hg

d.

Slight bloody drainage around insertion site

ANS: C

Elevation of the head of bed is an important intervention to prevent aspiration and ventilator- associated pneumonia. Patients who require hemodynamic monitoring while receiving tube feedings should have the air-fluid interface of the transducer leveled with the phlebostatic axis while the head of bed is elevated to at least 30 degrees. Readings will be accurate. Supine positioning of a

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mechanically ventilated patient increases the risk of aspiration and ventilator-associated pneumonia and is contraindicated in this patient. Hemodynamic values can be accurately measured and trended in with the head of the bed elevated as high as 60 degrees. Even though hemodynamic values can be obtained in lateral positions, it is technically difficult and not accurate unless the positioning of the transducer is exact. Regardless, head of bed elevation is indicated for this patient. - CORRECT ANSWERS The nurse is caring for a mechanically ventilated patient with a pulmonary artery catheter who is receiving continuous enteral tube feedings. When obtaining continuous hemodynamic monitoring measurements, what is the best nursing action?

a.

Do not document hemodynamic values until the patient can be placed in the supine position.

b.

Level and zero reference the air-fluid interface of the transducer with the patient in the supine position and record hemodynamic values.

c.

Level and zero reference the air-fluid interface of the transducer with the patient's head of bed elevated to 30 degrees and record hemodynamic values.

d.

Level and zero reference the air-fluid interface of the transducer with the patient supine in the side- lying position and record hemodynamic values.

ANS: B

A pulmonary artery catheter provides hemodynamic measurements that guide interventions that include appropriate fluid therapy. Even though a pulmonary catheter provides multiple intravenous access sites, this is not the primary purpose of the catheter. Although the catheter is positioned in the pulmonary artery, positioning is not the purpose of the catheter. The primary purpose of the catheter is not to aid in the healing of the heart but to guide therapy. - CORRECT ANSWERS The nurse is educating a patient's family member about a pulmonary artery catheter (PAC). Which statement by the family member best indicates understanding of the purpose of the PAC?

a.

"The catheter will provide multiple sites to give intravenous fluid."

b.

"The catheter will allow the physician to better manage fluid therapy."

c.

"The catheter tip comes to rest inside my brother's pulmonary artery."

d.

"The catheter will be in position until the heart has a chance to heal."

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ANS: D

Pressures are highest when measured at end exhalation in the spontaneously breathing patient. In mechanically ventilated patients, pressures increase with inhalation and decrease with exhalation. Measurements are obtained just before the increase in pressure during inhalation. Supine positioning is contraindicated in the mechanically ventilated patient. The head of bed should be elevated to 30 degrees. Pulmonary artery occlusion pressure is not averaged, but measured during inhalation in the mechanically ventilated patient while appropriate positioning is maintained. - CORRECT ANSWERS The nurse is preparing to obtain a pulmonary artery occlusion pressure (PAOP) reading for a patient who is mechanically ventilated. Ensuring that the air-fluid interface is at the level of the phlebostatic axis, what is the best nursing action?

a.

Place the patient in the supine position and record the PAOP immediately after exhalation.

b.

Place the patient in the supine position and document the average PAOP obtained after three measurements.

c.

Place the patient with the head of bed elevated 30 degrees and document the average PAOP pressure obtained.

d.

Place the patient with the head of bed elevated 30 degrees and record the PAOP just before the increase in pressures during inhalation.

ANS: A

A cardiac index of 1.2 L/min/m3 combined with the identified clinical assessment findings indicate a low cardiac output with fluid overload (bilateral crackles) requiring intervention. The remaining hemodynamic values are within normal limits: cardiac output of 4 L/min; pulmonary vascular resistance of 80 dynes/sec/cm-5; and the systemic vascular resistance of 1800 dynes/sec/cm-5. - CORRECT ANSWERS The nurse is caring for a 100-kg patient being monitored with a pulmonary artery catheter. The nurse assesses a blood pressure of 90/60 mm Hg, heart rate 110 beats/min, respirations 36/min, oxygen saturation of 89% on 3 L of oxygen via nasal cannula. Bilateral crackles are audible upon auscultation. Which hemodynamic value requires immediate action by the nurse?

a.

Cardiac index (CI) of 1.2 L/min/m

b.

Cardiac output (CO) of 4 L/min

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c.

Pulmonary vascular resistance (PVR) of 80 dynes/sec/cm-

d.

Systemic vascular resistance (SVR) of 1800 dynes/sec/cm-

ANS: B

Low pulmonary artery occlusion pressures usually indicate volume depletion, so intravenous fluids would be indicated. Administration of diuretics would worsen the patient's volume status. Negative inotropes would not improve the patient's volume status. Vasopressors will increase blood pressure but are contraindicated in a low volume state. - CORRECT ANSWERS While caring for a patient with a small bowel obstruction, the nurse assesses a pulmonary artery occlusion pressure (PAOP) of 1 mm Hg and hourly urine output of 5 mL. The nurse anticipates which therapeutic intervention?

a.

Diuretics

b.

Intravenous fluids

c.

Negative inotropic agents

d.

Vasopressors

ANS: B

Loose connections in hemodynamic monitoring tubing can lead to hemorrhage, a major complication of arterial pressure monitoring. Application of a pressure dressing is required only upon arterial line removal. Blood return is adequate confirmation of arterial line placement; x-ray studies are not performed to confirm arterial line placement. Neutral positioning of the extremity and use of an arm board, without limb restraint, is the standard of care. - CORRECT ANSWERS The nursing is caring for a patient who has had an arterial line inserted. To reduce the risk of complications, what is the priority nursing intervention?

a.

Apply a pressure dressing to the insertion site.

b.

Ensure all tubing connections are tightened.

c.

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Obtain a portable x-ray to confirm placement.

d.

Restrain the affected extremity for 24 hours.

ANS: D

A hemodynamic value not supported by clinical assessment should be treated as questionable. To ensure the accuracy of hemodynamic readings, the catheter transducer system must be leveled at the phlebostatic axis and zero referenced. In this example, the catheter transducer system may be lower than the phlebostatic axis, resulting in erroneously higher pressures. Clinical manifestations do not support increasing supplemental oxygen. Clinical manifestations do not warrant physician intervention; aberrant values should be investigated further. An aberrant value warrants further investigation, which includes zero referencing and checking the level as an initial measure. A chest x- ray study is not warranted at this time. - CORRECT ANSWERS While caring for a patient with a pulmonary artery catheter, 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 breaths/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 findings.

c.

Obtain a stat chest x-ray film to verify proper catheter placement.

d.

Zero reference and level the catheter at the phlebostatic axis.

ANS: C

A high pulmonary artery occlusion pressure of 25 mm Hg combined with low oxygen saturation is indicative of fluid volume overload and warrants priority action because the patient is at risk for hypoxemia. A CVP of 6 mm Hg with 40 mL of hourly urine output are acceptable assessment findings. A patient with a normal blood pressure and with a slightly dampened waveform does not require immediate action. A pulmonary artery pressure of 25/10 mmHg and a normal oxygen saturation does not require immediate treatment. - CORRECT ANSWERS The charge nurse is supervising care for a group of patients monitored with a variety of invasive hemodynamic devices. Which patient should the charge nurse evaluate first?

a.

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A patient with a central venous pressure (RAP/CVP) of 6 mm Hg and 40 mL of urine output in the past hour

b.

A patient with a left radial arterial line with a BP of 110/60 mm Hg and slightly dampened arterial waveform

c.

A patient with a pulmonary artery occlusion pressure of 25 mm Hg and an oxygen saturation of 89% on 3 L of oxygen via nasal cannula

d.

A patient with a pulmonary artery pressure of 25/10 mm Hg and an oxygen saturation of 94% on 2 L of oxygen via nasal cannula

ANS: A

Duration of the catheter is an independent risk factor for CRBSI, and removal of the catheter when not needed to guide treatment is associated with a reduction in mortality. Maintaining of the insertion site should be guided by institutional guidelines and is best accomplished with chlorhexidine skin antisepsis. Minimizing the number of times the flush system is opened by changing tubing no more frequently than every 72 to 96 hours reduces the risk of CRBSI. Maintaining a pressure of 300 mm Hg on the flush solution bag helps maintain the integrity of the invasive line and does not reduce the risk of infection. - CORRECT ANSWERS The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which action by the nurse best reduces the risk of catheter- related bloodstream infection (CRBSI)?

a.

Review daily the necessity of the central venous catheter.

b.

Cleanse the insertion site daily with isopropyl alcohol.

c.

Change the pressurized tubing system and flush bag daily.

d.

Maintain a pressure of 300 mm Hg on the flush bag.

ANS: D

During the insertion of the pulmonary artery catheter, ventricular dysrhythmias may occur as the catheter passes through the right ventricle. Treatment with lidocaine hydrochloride may be necessary to suppress the irritated ventricle and should be readily available. Withdrawing of the

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catheter is not within the scope of practice of the nurse and may not be necessary. Having the patient cough and deep-breathe will not correct the problem. The maximum volume of air necessary to inflate the balloon is 1.5 mL. Any additional volumes added may increase the risk of complications. - CORRECT ANSWERS During insertion of a pulmonary artery catheter, the physician asks the nurse to assist by inflating the balloon with 1.5 mL of air. As the physician advances the catheter, the nurse notices premature ventricular contractions on the monitor. What is the best action by the nurse?

a.

Deflate the balloon while slowly withdrawing the catheter.

b.

Instruct the patient to cough and deep-breathe forcefully.

c.

Inflate the catheter balloon with an additional 1 mL of air.

d.

Ensure lidocaine hydrochloride (IV) is immediately available.

ANS: B

To ensure that an accurate SvO2 is obtained, calibration of the invasive monitoring system (e.g., PAC) is accomplished upon insertion and requires both a central venous blood sample from the PAC and an arterial blood gas sample. This process is unique to the accuracy of venous oxygen saturation monitoring systems. Zero referencing the transducer at the level of the phlebostatic axis, ensuring patency of the catheter with a pressurized flush system, and using tubing of adequate length ensure accuracy of all hemodynamic monitoring systems. - CORRECT ANSWERS Following insertion of a pulmonary artery catheter (PAC), the physician orders the nurse to obtain a blood sample for mixed venous oxygen saturation (SvO2). Which action by the nurse best ensures the obtained value is accurate?

a.

Zero referencing the transducer at the level of the phlebostatic axis following insertion

b.

Calibrating the system with a central venous blood sample and arterial blood gas value

c.

Ensuring patency of the catheter using a 0.9% normal saline solution pressurized at 300 mm Hg

d.

Using noncompliant pressure tubing that is no longer than 36 to 48 inches and has minimal stopcocks

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ANS: A

An arterial lactate level of 1.0 mEq/L is within normal limits and is indicative of normal oxygen delivery to the tissues. The cardiac output, mixed venous saturation, and cardiac index values are all below normal limits indicating inadequate cardiac output sufficient to provide oxygen delivery to the organs and tissues. - CORRECT ANSWERS The nurse is caring for a 70-kg patient in septic shock with a pulmonary artery catheter. Which hemodynamic value indicates an appropriate response to therapy aimed at enhancing oxygen delivery to the organs and tissues?

a.

Arterial lactate level of 1.0 mEq/L

b.

Cardiac output of 2.5 L/min

c.

Mixed venous (SvO2 ) of 40%

d.

Cardiac index of 1.5 L/min/m

ANS: D

A central venous pressure of 1 mm Hg, pulmonary artery occlusion pressure of 1 mm Hg along with a blood pressure of 85/40 mm Hg and heart rate of 125 are indicative of a low volume state. Infusion of 500 mL of 0.9% normal saline will increase circulating fluid volume. Administration of furosemide (Lasix) is contraindicated and could further reduce circulating fluid volume. Titrating supplemental oxygen, obtaining serum blood gas and electrolyte samples, although not a priority, are appropriate interventions. - CORRECT ANSWERS The nurse is caring for a patient with a pulmonary artery catheter. Assessment findings include a blood pressure of 85/40 mm Hg, heart rate of 125 beats/min, respiratory rate 35 breaths/min, and arterial oxygen saturation (SpO2) of 90% on a 50% venturi mask. Hemodynamic values include a cardiac output (CO) of 1.0 L/min, central venous pressure (CVP) of 1 mm Hg, and a pulmonary artery occlusion pressure (PAOP) of 3 mm Hg. The nurse questions which of the following physician's order?

a.

Titrate supplemental oxygen to achieve a SpO2 > 94%.

b.

Infuse 500 mL 0.9% normal saline over 1 hour.

c.

Obtain arterial blood gas and serum electrolytes.

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d.

Administer furosemide (Lasix) 20 mg intravenously.

ANS: D

Pulse contour analysis systems provide stroke volume variation and pulse pressure variation data and are better predictors of fluid responsiveness in mechanically ventilated patients. A patient postoperative from repair of an acute bowel obstruction that is mechanically ventilated is an appropriate candidate for this method of monitoring.

Aortic insufficiency, intraaortic balloon pump therapy, and the presence of cardiac dysrhythmias are conditions in which pulse contour analysis systems are either inaccurate or contraindicated. - CORRECT ANSWERS The charge nurse has a Vigileo pulse contour cardiac output monitoring system available for use in the surgical intensive care unit. For which patient is use of this device most appropriate?

a.

A patient with a history of aortic insufficiency admitted with a postoperative myocardial infarction

b.

A mechanically ventilated patient with cardiogenic shock 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

ANS: C

Under normal circumstances, a difference of 10 to 20 mm Hg or more between invasive and noninvasive blood pressure is expected, with the invasive value being higher than the noninvasive value. The cuff used for noninvasive measurement should be assessed for proper cuff size. Given that the invasive value is substantially higher, before initiating corrective actions based on a single noninvasive measurement, such as activating the rapid response system, placing the patient in Trendelenburg position, or administering a fluid bolus, further assessment and troubleshooting are necessary. - CORRECT ANSWERS The nurse is caring for a patient with an arterial monitoring system. The nurse assesses the patient's noninvasive cuff blood pressure to be 70/40 mm Hg. The arterial blood pressure measurement via an intraarterial catheter in the same arm is assessed by the nurse to be 108/70 mm Hg. What is the best action by the nurse?

a.

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Activate the rapid response system.

b.

Place the patient in Trendelenburg position.

c.

Assess the cuff for proper arm size.

d.

Administer 0.9% normal saline bolus.

ANS: D

Hemodynamic parameters can be accurately measured and trended with the head of the bed elevated to 45 degrees as long as the zeroing stopcock is properly leveled to the phlebostatic axis. Elevating the head of the bed to 45 degrees would be the optimum position to obtain a pulmonary artery occlusion pressure for a patient that becomes anxious and tachypneic when flat. Administering anxiety medications is not standard of care for obtaining hemodynamic pressures. Encouraging slow deep breaths while supine may inappropriately alter hemodynamic readings by altering intrathoracic pressure. - CORRECT ANSWERS The nurse is caring for a patient with an admitting diagnosis of congestive failure. While attempting to obtain a pulmonary artery occlusion pressure in the supine position, the patient becomes anxious and tachypneic. What is the best action by the nurse?

a.

Limit the patient's supine position to no more than 10 seconds.

b.

Administer anxiety medications while recording the pressure.

c.

Encourage the patient to take slow deep breaths while supine.

d.

Elevate the head of the bed 45 degrees while recording pressures.

ANS: B

To ensure accurate measurement, zero referencing of the transducer system is a priority action after moving a patient and should be completed prior to injecting 10 mL of room temperature 0.9% normal saline. A pulmonary artery catheter occlusion pressure should be documented before obtaining a cardiac output, but without zero referencing the system following movement of a patient, the obtained value may be inaccurate. Inflating the pulmonary artery catheter balloon with 1 mL of air, while appropriate, is not a step required prior to obtaining a cardiac output. - CORRECT

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ANSWERS The nurse returns from the cardiac catheterization laboratory with a patient following insertion of a pulmonary artery catheter and assists in transferring the patient from the stretcher to the bed. Prior to obtaining a cardiac output, which action is most important for the nurse to complete?

a.

Document a pulmonary artery catheter occlusion pressure.

b.

Zero reference the transducer system at the phlebostatic axis.

c.

Inflate the pulmonary artery catheter balloon with 1 mL air.

d.

Inject 10 mL of 0.9% normal saline into the proximal port.

ANS: A

A cardiac output of 2.0 L/min in a patient with cardiogenic shock warrants immediate assessment. A PAP of 20 mm Hg, CVP of 6 mm Hg, and a PAOP of 10 mm Hg are all within normal limits. - CORRECT ANSWERS The charge nurse is supervising the care of four critical care patients being monitored using invasive hemodynamic modalities. Which patient should the charge nurse evaluate first?

a.

A patient in cardiogenic shock with a cardiac output (CO) of 2.0 L/min

b.

A patient with a pulmonary artery systolic pressure (PAP) of 20 mm Hg

c.

A hypovolemic patient with a central venous pressure (CVP) of 6 mm Hg

d.

A patient with a pulmonary artery occlusion pressure (PAOP) of 10 mm Hg

ANS: B

The increase in thoracic pressure that occurs during the inspiration phase of positive pressure ventilation decreases venous return, decreasing systolic blood pressure.

A systolic blood pressure variation or decrease of more than 10 mm Hg in a mechanically ventilated patient is indicative of a patient who would respond to fluid resuscitation and improve tissue perfusion. There is no evidence to indicate the ventilator is malfunctioning, the arterial line needs to be replaced, or that the left limb may have reduced perfusion - CORRECT ANSWERS The nurse is

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caring for a mechanically ventilated patient being monitored with a left radial arterial line. During the inspiratory phase of ventilation, the nurse assesses a 20 mm Hg decrease in arterial blood pressure. What is the best interpretation of this finding by the nurse?

a.

The mechanical ventilator is malfunctioning.

b.

The patient may require fluid resuscitation.

c.

The arterial line may need to be replaced.

d.

The left limb may have reduced perfusion.

ANS: A

To maintain the patency of the arterial line, the inflation volume of the flush system pressure bag should be inflated to 300 mm Hg to ensure a constant flow of fluid through the system, preventing backward flow of blood into the system tubing. Disconnecting the flush system from the arterial line is not appropriate and could increase the risk of infection to the patient. Zero referencing the system will not help clear the blood from the system tubing. Reducing the number of stopcocks helps reduce the risk of a disconnection that could lead to excessive blood loss. - CORRECT ANSWERS Upon entering the room of a patient with a right radial arterial line, the nurse assesses the waveform to be slightly dampened and notices blood to be backed up into the pressure tubing. What is the best action by the nurse?

a.

Check the inflation volume of the flush system pressure bag.

b.

Disconnect the flush system from the arterial line catheter.

c.

Zero reference the transducer system at the phlebostatic axis.

d.

Reduce the number of stopcocks in the flush system tubing.

ANS: D

When hemodynamic monitoring is being done, it is important to set alarm limits to alert the nurse to changes in the patient's condition. Hemodyanamic values and waveforms are recorded at scheduled

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intervals and it is important that the tubing not be too long; however, alarm alerts are of highest priority. The lines are zero referenced per hospital policy, more frequently than daily. - CORRECT ANSWERS The nurse is caring for a patient with a left radial arterial line, and a pulmonary artery catheter inserted into the right subclavian vein. Which action by the nurse best ensures the safety of the patient being monitored with invasive hemodynamic monitoring lines?

a.

Document all waveform values.

b.

Limit the pressure tubing length.

c.

Zero reference the system daily.

d.

Ensure alarm limits are turned on.

ANS: B

Avoiding infusing vasoactive agents into the port used to obtain the thermodilution cardiac output (TdCO) measurement prevents the patient from receiving a bolus of these agents during rapid infusion of the injectate solution. Ensuring zero referencing of the transducer, maintaining 300 mm Hg pressure of the system pressure bag, and limiting the length of the pressure tubing help to ensure the obtained measures are accurate and do not influence safety. - CORRECT ANSWERS The nurse is preparing to measure the thermodilution cardiac output (TdCO) in a patient being monitored with a pulmonary artery catheter. Which action by the nurse best ensures the safety of the patient?

a.

Ensure the transducer system is zero referenced at the level of the phlebostatic axis.

b.

Avoid infusing vasoactive agents in the port used to obtain the TdCO measurement.

c.

Maintain a pressure of 300 mm Hg on the flush solution using a pressure bag.

d.

Limit the length of the noncompliant pressure tubing to a maximum 48 inches.

ANS: A, B, D

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To obtain an accurate pulmonary artery occlusion pressure (PAOP), the transducer system should be zero referenced and leveled to ensure accurate readings, and the balloon should be inflated with enough air, for no more than 8 to 10 seconds until a change in waveform is noted. The volume of air necessary to inflate the balloon should be documented. Maintaining the balloon in the inflated position can lead to pulmonary infarction. - CORRECT ANSWERS When performing an initial pulmonary artery occlusion pressure (PAOP), what are the best nursing actions? (Select all that apply.)

a.

Inflate the balloon for no more than 8 to 10 seconds while noting the waveform change.

b.

Inflate the balloon with air, recording the volume necessary to obtain a reading.

c.

Maintain the balloon in the inflated position for 8 hours following insertion.

d.

Zero reference and level the air-fluid interface of the transducer at the level of the phlebostatic axis.

ANS: A, D, E

To obtain an accurate right atrial pressure (RAP/CVP) reading, the transducer system should be zero referenced and leveled with the phlebostatic axis to ensure accurate readings; the value should be obtained during end exhalation, and any obtained measure should be evaluated in light of the patient's physiological parameters and physical assessment. The catheter does not need to be flushed before measurement because continuous saline flush is part of the RAP system. There is no balloon with a right atrial pressure (RAP/CVP) catheter. - CORRECT ANSWERS The nurse is preparing to obtain a right atrial pressure (RAP/CVP) reading. What are the most appropriate nursing actions? (Select all that apply.)

a.

Compare measured pressures with other physiological parameters.

b.

Flush the central venous catheter with 20 mL of sterile saline.

c.

Inflate the balloon with 3 mL of air and record the pressure tracing.

d.

Obtain the right atrial pressure measurement during end exhalation.

e.

Zero reference the transducer system at the level of the phlebostatic axis.

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ANS: A, B, C, D

During insertion of a pulmonary artery catheter (PAC/Swan-Ganz), the nurse should allay the patient's anxiety, ensure that the sterile field is maintained to decrease the risk of infection, inflate the balloon upon request of the physician to assist in catheter placement, and monitor for dysrhythmias that may occur as the catheter passes through the right ventricle. Informed consent may be witnessed by the nurse, but it is obtained by the physician and should occur before the procedure begins. - CORRECT ANSWERS The nurse is preparing for insertion of a pulmonary artery catheter (PAC). During insertion of the catheter, what are the priority nursing actions? (Select all that apply.)

a.

Allay the patient's anxiety by providing information about the procedure.

b.

Ensure that a sterile field is maintained during the insertion procedure.

c.

Inflate the balloon during the procedure when indicated by the physician.

d.

Monitor the patient's cardiac rhythm throughout the entire procedure.

e.

Obtain informed consent by informing the patient of procedural risks.

ANS: A, B, C

Options A, B, and C are required to ensure proper functioning of the arterial line.

There is no need to restrain all extremities. Depending on the patient's level of sedation, the right hand may need gentle restraint. - CORRECT ANSWERS Which nursing actions are most important for a patient with a right radial arterial line? (Select all that apply.)

a.

Checking the circulation to the right hand every 2 hours

b.

Maintaining a pressurized flush solution to the arterial line setup

c.

Monitoring the waveform on the monitor for dampening

d.

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Restraining all four extremities with soft limb restraints

ANS: B, C, D

Hypovolemia, myocardial infarction, and shock often result in a decreased cardiac output. Cardiac output is usually increased with exercise. - CORRECT ANSWERS Which of the following situations may result in a low cardiac output and low cardiac index? (Select all that apply.)

a.

Exercise

b.

Hypovolemia

c.

Myocardial infarction

d.

Shock

ANS: D

The high PaO2 level reflects hyperoxygenation; the PaCO2 and pH levels show respiratory acidosis. The respiratory acidosis is uncompensated as indicated by a pH of 7.31 (acidosis) and a normal bicarbonate level. No metabolic compensation has occurred. - CORRECT ANSWERS A patient has coronary artery bypass graft surgery and is transported to the surgical intensive care unit at noon. He is placed on mechanical ventilation. Interpret his initial arterial blood gas levels:

pH 7.31

PaCO2 48 mm Hg

Bicarbonate 22 mEq/L

PaO2 115 mm Hg

O2 saturation 99%

a.

Normal arterial blood gas levels with a high oxygen level

b.

Partly compensated respiratory acidosis, normal oxygen

c.

Uncompensated metabolic acidosis with high oxygen levels

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d.

Uncompensated respiratory acidosis; hyperoxygenated

ANS: D

Assist/control ventilation may result in respiratory alkalosis, especially when the

patient is breathing at a high rate. Each time the patient initiates a spontaneous breath—in this case 22 times per minute—the ventilator will deliver 600 mL of volume. - CORRECT ANSWERS The physician orders the following mechanical ventilation settings for a patient who weighs 75 kg. The patient's spontaneous respiratory rate is 22 breaths/min. What arterial blood gas abnormality may occur if the patient continues to be tachypneic at these ventilator settings?

Settings:

Tidal volume: 600 mL (8 mL per kg)

FiO2: 0.5

Respiratory rate: 14 breaths/min

Mode assist/control

Positive end-expiratory pressure: 10 cm H2O

a.

Metabolic acidosis

b.

Metabolic alkalosis

c.

Respiratory acidosis

d.

Respiratory alkalosis

ANS: A

Positive end-expiratory pressure increases intrathoracic pressure and may result in decreased venous return. Cardiac output decreases as a result, and is reflected in the lower blood pressure. It is essential to assess the patient to identify optimal positive end-expiratory pressure—the highest amount that can be applied without compromising cardiac output. Although hypovolemia can result in a decrease in blood pressure, there is no indication that this patient has hypovolemia. As noted, higher levels of positive end-expiratory pressure may cause a decrease, not an increase, in venous return. Oxygen toxicity can occur in this case secondary to the high levels of oxygen needed to maintain gas exchange; however, oxygen toxicity is manifested in damage to the alveoli. - CORRECT