NURSING 432 CHAPTER 66: NURSING MANAGEMENT: CRITICAL CARE TEST BANK WITH ANSWERS 100% CORR, Exams of Nursing

Download NURSING 432 CHAPTER 66: NURSING MANAGEMENT: CRITICAL CARE TEST BANK WITH ANSWERS 100% CORR and more Exams Nursing in PDF only on Docsity!

MANAGEMENT: CRITICAL CARE TEST

BANK WITH ANSWERS 100% CORRECT

RATED A+

Chapter 66: Nursing Management: Critical Care Test Bank

1. A 68-year-old patient has been in the intensive care unit for 4 days and has a nursing diagnosis of disturbed sensory perception related to sleep deprivation. Which action should the nurse include in the plan of care? a. Administer prescribed sedatives or opioids at bedtime to promote sleep. b. Cluster^ nursing^ activities^ so^ that^ the^ patient^ has^ uninterrupted^ rest^ periods. c. Silence^ the^ alarms^ on^ the^ cardiac monitors^ to^ allow^ 30-^ to^ 40-minute naps. d. Eliminate assessments between 0100 and 0600 to allow uninterrupted sleep. ANS: B 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

MANAGEMENT: CRITICAL CARE TEST

BANK WITH ANSWERS 100% CORRECT

RATED A+

discontinuing assessments during the night. DIF: Cognitive Level: Apply (application) REF: 1601 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

2. Which hemodynamic parameter is most appropriate for the nurse to monitor to determine the effectiveness of medications given to a patient to reduce left ventricular afterload? a. Mean arterial pressure (MAP)

MANAGEMENT: CRITICAL CARE TEST

BANK WITH ANSWERS 100% CORRECT

RATED A+

b. Systemic^ vascular^ resistance^ (SVR) c. Pulmonary vascular resistance (PVR) d. Pulmonary^ artery^ wedge^ pressure^ (PAWP) ANS: B Systemic vascular resistance reflects the resistance to ventricular ejection, or afterload. The other parameters will be monitored, but do not reflect afterload as directly. DIF: Cognitive Level: Apply (application) REF: 1604 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

3. While family members are visiting, a patient has a respiratory arrest and is being resuscitated. Which action by the nurse is best? a. Tell^ the^ family^ members^ that^ watching^ the^ resuscitation^ will^ be^ very^ stressful. b. Ask family members if they wish to remain in the room during the resuscitation.

MANAGEMENT: CRITICAL CARE TEST

BANK WITH ANSWERS 100% CORRECT

RATED A+

c. Take^ the^ family^ members^ quickly^ out^ of^ the^ patient^ room^ and^ remain^ with^ them. d. Assign a staff member to wait with family members just outside the patient room. ANS: B Research indicates that family members want the option of remaining in the room during procedures such as cardiopulmonary resuscitation (CPR) and that this decreases anxiety and facilitates grieving. The other options may be appropriate if the family decides not to remain with the patient.

MANAGEMENT: CRITICAL CARE TEST

BANK WITH ANSWERS 100% CORRECT

RATED A+

DIF: Cognitive Level: Apply (application) REF: 1602 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

4. Following surgery for an abdominal aortic aneurysm, a patient’s central venous pressure (CVP) monitor indicates low pressures. Which action is a priority for the nurse to take? a. Administer^ IV^ diuretic^ medications. b. Increase^ the IV^ fluid infusion^ per^ protocol. c. Document the CVP and continue to monitor. d. Elevate^ the^ head^ of^ the^ patient’s^ bed^ to^45 degrees. ANS: B 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. DIF: Cognitive Level: Apply (application) REF: 1609

MANAGEMENT: CRITICAL CARE TEST

BANK WITH ANSWERS 100% CORRECT

RATED A+

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

5. When caring for a patient with pulmonary hypertension, which parameter is most appropriate for the nurse to monitor to evaluate the effectiveness of the treatment? a. Central venous pressure (CVP) b. Systemic^ vascular^ resistance^ (SVR) c. Pulmonary vascular resistance (PVR)

MANAGEMENT: CRITICAL CARE TEST

BANK WITH ANSWERS 100% CORRECT

RATED A+

d. Pulmonary^ artery^ wedge^ pressure^ (PAWP) ANS: C PVR is a major contributor to pulmonary hypertension, and a decrease would indicate that pulmonary hypertension was improving. The other parameters also may be monitored but do not directly assess for pulmonary hypertension. DIF: Cognitive Level: Apply (application) REF: 1603- TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

6. The intensive care unit (ICU) nurse educator will determine that teaching about arterial pressure monitoring for a new staff nurse has been effective when the nurse a. balances^ and^ calibrates^ the^ monitoring^ equipment^ every^2 hours. b. positions the zero-reference stopcock line level with the phlebostatic axis. c. ensures^ that^ the patient^ is^ supine^ with the^ head of^ the^ bed flat for^ all^ readings.

MANAGEMENT: CRITICAL CARE TEST

BANK WITH ANSWERS 100% CORRECT

RATED A+

d. rechecks^ the^ location^ of^ the^ phlebostatic^ axis^ when^ changing^ the^ patient’s^ position. ANS: B 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. DIF: Cognitive Level: Apply (application) REF: 1605 TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment

7. When monitoring for the effectiveness of treatment for a patient with a large anterior wall myocardial infarction, the most important information for the nurse to obtain is

MANAGEMENT: CRITICAL CARE TEST

BANK WITH ANSWERS 100% CORRECT

RATED A+

a. central^ venous^ pressure^ (CVP). b. systemic vascular resistance (SVR). c. pulmonary^ vascular^ resistance^ (PVR). d. pulmonary^ artery^ wedge^ pressure^ (PAWP). ANS: D PAWP reflects left ventricular end diastolic pressure (or left ventricular preload) and is a sensitive indicator of cardiac function. Because the patient is high risk for left ventricular failure, the PAWP must be monitored. An increase will indicate left ventricular failure. The other values would also provide useful information, but the most definitive measurement of changes in cardiac function is the PAWP. DIF: Cognitive Level: Apply (application) REF: 1607 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

8. Which action is a priority for the nurse to take when the low pressure alarm sounds for a patient who has an arterial line in the left radial artery?

MANAGEMENT: CRITICAL CARE TEST

BANK WITH ANSWERS 100% CORRECT

RATED A+

a. Fast flush the arterial line. b. Check^ the^ left^ hand^ for^ pallor. c. Assess for cardiac dysrhythmias. d. Rezero^ the^ monitoring^ equipment.

MANAGEMENT: CRITICAL CARE TEST

BANK WITH ANSWERS 100% CORRECT

RATED A+

ANS: C

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 left 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. DIF: Cognitive Level: Apply (application) REF: 1606 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

9. Which action will the nurse need to do when preparing to assist with the insertion of a pulmonary artery catheter? a. Determine^ if^ the^ cardiac^ troponin^ level^ is^ elevated. b. Auscultate^ heart^ and^ breath^ sounds^ during^ insertion. c. Place the patient on NPO status before the procedure. d. Attach^ cardiac^ monitoring^ leads^ before^ the^ procedure.

MANAGEMENT: CRITICAL CARE TEST

BANK WITH ANSWERS 100% CORRECT

RATED A+

ANS: D

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 anesthesia, and the patient will not need to be NPO. Changes in cardiac troponin or heart and breath sounds are not expected during pulmonary artery catheter insertion. DIF: Cognitive Level: Apply (application) REF: 1608 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

10. When assisting with the placement of a pulmonary artery (PA) catheter, the nurse notes that the catheter is correctly placed when the monitor shows a

MANAGEMENT: CRITICAL CARE TEST

BANK WITH ANSWERS 100% CORRECT

RATED A+

a. typical^ PA^ pressure^ waveform. b. tracing of the systemic arterial pressure. c. tracing^ of^ the^ systemic^ vascular^ resistance. d. typical^ PA^ wedge^ pressure^ (PAWP)^ tracing. ANS: D The purpose of a PA line is to measure PAWP, so the catheter is floated through the pulmonary artery until the dilated balloon wedges in a distal branch of the pulmonary artery, and the PAWP 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 and the systemic vascular resistance is a calculated value, not a waveform. DIF: Cognitive Level: Understand (comprehension) REF: 1608 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

11. Which assessment finding obtained by the nurse when caring for a patient with a right radial arterial line indicates a need for the nurse to take immediate action?

MANAGEMENT: CRITICAL CARE TEST

BANK WITH ANSWERS 100% CORRECT

RATED A+

a. The right hand is cooler than the left hand. b. The^ mean arterial^ pressure^ (MAP)^ is^77 mm^ Hg. c. The system is delivering 3 mL of flush solution per hour. d. The^ flush^ bag^ and^ tubing^ were^ last^ changed^3 days^ previously.

MANAGEMENT: CRITICAL CARE TEST

BANK WITH ANSWERS 100% CORRECT

RATED A+

ANS: A

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. A mean arterial pressure (MAP) of 75 mm Hg is normal. Flush systems for hemodynamic monitoring are set up to deliver 3 to 6 mL/hour of flush solution. DIF: Cognitive Level: Apply (application) REF: 1606 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

12. The central venous oxygen saturation (ScvO2) is decreasing in a patient who has severe pancreatitis. To determine the possible cause of the decreased ScvO2, the nurse assesses the patient’s a. lipase. b. temperature. c. urinary output. d. body^ mass^ index.

MANAGEMENT: CRITICAL CARE TEST

BANK WITH ANSWERS 100% CORRECT

RATED A+

ANS: B

Elevated temperature increases metabolic demands and oxygen use by tissues, resulting in a drop in oxygen saturation of central venous blood. Information about the patient’s body mass index, urinary output, and lipase will not help in determining the cause of the patient’s drop in ScvO2. DIF: Cognitive Level: Apply (application) REF: 1609 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

13. An intraaortic 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

MANAGEMENT: CRITICAL CARE TEST

BANK WITH ANSWERS 100% CORRECT

RATED A+

b. Heart^ rate^ of^110 beats/minute c. Cardiac output (CO) of 5 L/min d. Stroke^ volume (SV)^ of^40 mL/beat ANS: C A CO of 5 L/min is normal 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. DIF: Cognitive Level: Apply (application) REF: 1603 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

14. The nurse is caring for a patient who has an intraaortic balloon pump in place. Which action should be included in the plan of care?

MANAGEMENT: CRITICAL CARE TEST

BANK WITH ANSWERS 100% CORRECT

RATED A+

a. Position the patient supine at all times. b. Avoid^ the^ use^ of^ anticoagulant^ medications. c. Measure the patient’s urinary output every hour. d. Provide^ passive range^ of^ motion^ for^ all^ extremities. ANS: C

MANAGEMENT: CRITICAL CARE TEST

BANK WITH ANSWERS 100% CORRECT

RATED A+

Monitoring urine output will help determine whether the patient’s cardiac output has improved and also help monitor for balloon displacement. The head of the bed can be elevated up to 30 degrees. Heparin is used to prevent thrombus formation. Limited movement is allowed for the extremity with the balloon insertion site to prevent displacement of the balloon. DIF: Cognitive Level: Apply (application) REF: 1613 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

15. While waiting for cardiac transplantation, a patient with severe cardiomyopathy has a ventricular assist device (VAD) implanted. When planning care for this patient, the nurse should anticipate a. giving immunosuppressive medications. b. preparing the patient for a permanent VAD. c. teaching^ the^ patient^ the^ reason^ for^ complete^ bed^ rest. d. monitoring the surgical incision for signs of infection. ANS: D

MANAGEMENT: CRITICAL CARE TEST

BANK WITH ANSWERS 100% CORRECT

RATED A+

The insertion site for the VAD provides a source for transmission of infection to the circulatory system and requires frequent monitoring. Patient’s with VADs are able to have some mobility and may not be on bed rest. The VAD is a bridge to transplantation, not a permanent device. Immunosuppression is not necessary for nonbiologic devices like the VAD. DIF: Cognitive Level: Apply (application) REF: 1613 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

16. To verify the correct placement of an oral endotracheal tube (ET) after insertion, the best initial action by the nurse is to a. auscultate for the presence of bilateral breath sounds.

MANAGEMENT: CRITICAL CARE TEST

BANK WITH ANSWERS 100% CORRECT

RATED A+

b. obtain^ a^ portable^ chest^ x-ray^ to^ check^ tube^ placement. c. observe the chest for symmetric chest movement with ventilation. d. use^ an^ end-tidal^ CO2^ monitor^ to^ check for^ placement^ in^ the trachea. ANS: D End-tidal CO2 monitors are currently recommended for rapid verification of ET placement. Auscultation for bilateral breath sounds and checking chest expansion are also used, but they are not as accurate as end-tidal CO2monitoring. A chest x-ray confirms the placement but is done after the tube is secured. DIF: Cognitive Level: Apply (application) REF: 1614-1615 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

17. To maintain proper cuff pressure of an endotracheal tube (ET) when the patient is on mechanical ventilation, the nurse should a. inflate the cuff with a minimum of 10 mL of air.

MANAGEMENT: CRITICAL CARE TEST

BANK WITH ANSWERS 100% CORRECT

RATED A+

b. inflate^ the^ cuff^ until^ the^ pilot^ balloon^ is^ firm^ on^ palpation. c. inject air into the cuff until a manometer shows 15 mm Hg pressure. d. inject^ air^ into^ the^ cuff^ until^ a^ slight^ leak^ is^ heard^ only^ at^ peak^ inflation. ANS: D The minimal occluding volume technique involves injecting air into the cuff until an air leak is present only at peak inflation. The volume to inflate the cuff varies with the ET and the patient’s

MANAGEMENT: CRITICAL CARE TEST

BANK WITH ANSWERS 100% CORRECT

RATED A+

size. Cuff pressure should be maintained at 20 to 25 mm Hg. An accurate assessment of cuff pressure cannot be obtained by palpating the pilot balloon. DIF: Cognitive Level: Understand (comprehension) REF: 1615 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

18. The nurse notes premature ventricular contractions (PVCs) while suctioning a patient’s endotracheal tube. Which action by the nurse is a priority? a. Decrease the suction pressure to 80 mm Hg. b. Document^ the^ dysrhythmia^ in^ the^ patient’s^ chart. c. Stop^ and ventilate^ the^ patient^ with^ 100%^ oxygen. d. Give antidysrhythmic medications per protocol. ANS: C Dysrhythmias during suctioning may indicate hypoxemia or sympathetic nervous system stimulation. The nurse should stop suctioning and ventilate the patient with 100% oxygen.

MANAGEMENT: CRITICAL CARE TEST

BANK WITH ANSWERS 100% CORRECT

RATED A+

Lowering the suction pressure will decrease the effectiveness of suctioning without improving the hypoxemia. Because the PVCs occurred during suctioning, there is no need for antidysrhythmic medications (which may have adverse effects) unless they recur when the suctioning is stopped and patient is well oxygenated. DIF: Cognitive Level: Apply (application) REF: 1616 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

19. Which assessment finding obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning? a. The patient’s oxygen saturation is 93%.

MANAGEMENT: CRITICAL CARE TEST

BANK WITH ANSWERS 100% CORRECT

RATED A+

b. The^ patient^ was^ last^ suctioned^6 hours^ ago. c. The patient’s respiratory rate is 32 breaths/minute. d. The^ patient^ has^ occasional^ audible^ expiratory^ wheezes. ANS: C The increase in respiratory rate indicates that the patient may have decreased airway clearance and requires suctioning. Suctioning is done when patient assessment data indicate that it is needed, not on a scheduled basis. Occasional expiratory wheezes do not indicate poor airway clearance, and suctioning the patient may induce bronchospasm and increase wheezing. An oxygen saturation of 93% is acceptable and does not suggest that immediate suctioning is needed. DIF: Cognitive Level: Apply (application) REF: 1616 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

20. The nurse notes thick, white secretions in the endotracheal tube (ET) of a patient who is receiving mechanical ventilation. Which intervention will be most effective in addressing this problem?