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Critical Care Chapter 65 Questions and
Answers Rated A+
- A patient who has been in the intensive care unit for 4 days has disturbed sensory
perception from 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 2200 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 discontinuing all assessments
during the night.
- Which hemodynamic parameter best reflects the effectiveness of drugs that the nurse
gives to reduce a patient's left ventricular afterload?
a. Mean arterial pressure (MAP)
b. Systemic vascular resistance (SVR)
c. Pulmonary vascular resistance (PVR)
d. Pulmonary artery wedge pressure (PAWP) ✔✔ANS: B
SVR reflects the resistance to ventricular ejection, or afterload. The other parameters may be monitored
but do not reflect afterload as directly.
- While close family members are visiting, a patient has a respiratory arrest, and
resuscitation is started. 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.
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
Evidence indicates that many 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.
PVR is a major contributor to pulmonary hypertension, and a decrease would indicate that pulmonary
hypertension was improving. The other parameters may also be monitored but do not directly assess for
pulmonary hypertension.
- The intensive care unit (ICU) nurse educator determines that teaching a new staff nurse
about arterial pressure monitoring 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.
d. rechecks the location of the phlebostatic axis with changes in 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 every 2 hours. 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.
- When monitoring the effectiveness of treatment for a patient with a large anterior wall
myocardial infarction, the most pertinent measurement for the nurse to obtain is
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.
- Which action should the nurse take when the low pressure alarm sounds for a patient
who has an arterial line in the left radial artery?
a. Fast flush the arterial line.
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.
- While assisting with the placement of a pulmonary artery (PA) catheter, the nurse
notes that the catheter is correctly placed when the balloon is inflated and the monitor shows 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.
- 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 action?
a. The right hand feels 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 2 days previously. ✔✔ANS: A
The change in temperature of the right hand suggests that blood flow to the right 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/hr of flush solution.
- The central venous oxygen saturation (ScvO2) is decreasing in a patient who has severe pancreatitis. To determine the possible cause of the decreased ScvO
, the nurse assesses the patient's
a. lipase level. c. urinary output.
action should be included in the plan of care?
a. Avoid the use of anticoagulant medications.
b. Measure the patient's urinary output every hour.
c. Provide passive range of motion for all extremities.
d. Position the patient supine with head flat at all times. ✔✔ANS: B
Monitoring urine output will help determine whether the patient's cardiac output has improved and also
help monitor for balloon displacement blocking the renal arteries. 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.
- While waiting for heart transplantation, a patient with severe cardiomyopathy has a
ventricular assist device (VAD) implanted. When planning care for this patient, the nurse should
anticipate
a. preparing the patient for a permanent VAD.
b. administering immunosuppressive medications.
c. teaching the patient the reason for complete bed rest.
d. monitoring the surgical incision for signs of infection. ✔✔ANS: D
The insertion site for the VAD provides a source for transmission of infection to the circulatory system
and requires frequent monitoring. Patients 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 such as the VAD.
- To verify the correct placement of an oral endotracheal tube (ET) after insertion, the
best initial action by the nurse is to
a. obtain a portable chest x-ray.
b. use an end-tidal CO
monitor.
c. auscultate for bilateral breath sounds.
d. observe for symmetrical chest movement. ✔✔ANS: B
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
a. Plan to suction the patient more frequently.
b. Decrease the suction pressure to 80 mm Hg.
c. Give antidysrhythmic medications per protocol.
d. Stop and ventilate the patient with 100% oxygen. ✔✔ANS: D
Dysrhythmias during suctioning may indicate hypoxemia or sympathetic nervous system stimulation. The nurse should stop suctioning and ventilate the patient with 100% O
. There is no indication that more
frequent suctioning is needed. 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.
- Which assessment finding obtained by the nurse when caring for a patient receiving
mechanical ventilation indicates the need for suctioning?
a. The patient was last suctioned 6 hours ago.
b. The patient's oxygen saturation drops to 93%.
c. The patient's respiratory rate is 32 breaths/min.
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 and 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 O
saturation of 93% is acceptable and does not suggest that immediate suctioning is needed.
- The nurse notes thick, white secretions in the endotracheal tube (ET) of a patient who
is receiving mechanical ventilation. Which intervention will most directly treat this finding?
a. Reposition the patient every 1 to 2 hours.
b. Increase suctioning frequency to every hour.
c. Add additional water to the patient's enteral feedings.
d. Instill 5 mL of sterile saline into the ET before suctioning. ✔✔ANS: C
Because the patient's secretions are thick, better hydration is indicated. Suctioning every hour without any
specific evidence for the need will increase the incidence of mucosal trauma and would not address the
. c. increase the respiratory rate.
b. increase the tidal volume. d. decrease the respiratory rate. ✔✔ANS: D
The patient's PaCO2 and pH indicate respiratory alkalosis caused by too high a respiratory rate. The PaO2 is appropriate for a patient with COPD and increasing the respiratory rate and tidal volume would further lower the PaCO
.
- A patient with respiratory failure has arterial pressure-based cardiac output (APCO)
monitoring and is receiving mechanical ventilation with peak end-expiratory pressure (PEEP) of 12
cm H2O. Which information indicates that a change in the ventilator settings may be required?
a. The arterial pressure is 90/46.
b. The stroke volume is increased.
c. The heart rate is 58 beats/minute.
d. The stroke volume variation is 12%. ✔✔ANS: A
The hypotension suggests that the high intrathoracic pressure caused by the PEEP may be decreasing
venous return and (potentially) cardiac output. The other assessment data would not be a direct result of
PEEP and mechanical ventilation.
- A nurse is weaning a 68-kg patient who has chronic obstructive pulmonary disease
(COPD) from mechanical ventilation. Which patient assessment finding indicates that the weaning
protocol should be stopped?
a. The patient's heart rate is 97 beats/min.
b. The patient's oxygen saturation is 93%.
c. The patient respiratory rate is 32 breaths/min.
d. The patient's spontaneous tidal volume is 450 mL. ✔✔ANS: C
Tachypnea is a sign that the patient's work of breathing is too high to allow weaning to proceed. The
patient's heart rate is within normal limits, but the nurse should continue to monitor it. An O
saturation
of 93% is acceptable for a patient with COPD. A spontaneous tidal volume of 450 mL is within the
c. Change the flush system and monitor the site.
d. Check the site more frequently for any swelling. ✔✔ANS: A
The information indicates that the patient has a local and systemic infection caused by the catheter, and
the catheter should be discontinued to avoid further complications such as endocarditis. Changing the
flush system, continued monitoring, or using the line for fluids will not help prevent or treat the infection.
- An 81-yr-old patient who has been in the intensive care unit (ICU) for a week is now
stable and transfer to the progressive care unit is planned. On rounds, the nurse notices that the
patient has new onset confusion. The nurse will plan to
a. give PRN lorazepam (Ativan) and cancel the transfer.
b. inform the receiving nurse and then transfer the patient.
c. notify the health care provider and postpone the transfer.
d. obtain an order for restraints as needed and transfer the patient. ✔✔ANS: B
The patient's history and symptoms most likely indicate delirium associated with the sleep deprivation
and sensory overload in the ICU environment. Informing the receiving nurse and transferring the patient
is appropriate. Postponing the transfer is likely to prolong the delirium. Benzodiazepines and restraints
contribute to delirium and agitation.
- The family members of a patient who has been admitted to the intensive care unit
(ICU) with multiple traumatic injuries have just arrived in the ICU waiting room. Which action
should the nurse take first?
a. Explain ICU visitation policies and encourage family visits.
b. Escort the family from the waiting room to the patient's bedside.
c. Describe the patient's injuries and the care that is being provided.
d. Invite the family to participate in an interprofessional care conference. ✔✔ANS: C
Lack of information is a major source of anxiety for family members and should be addressed first.
Family members should be prepared for the patient's appearance and the ICU environment before visiting
the patient for the first time. ICU visiting should be individualized to each patient and family rather than
