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Flashcards in Critical Care NCLEX style questions Deck (40)
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1

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.

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.

2

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)

B
SVR reflects the resistance to ventricular ejection, or afterload. The other parameters may be monitored but do not reflect afterload as directly.

3

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.

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.

4

After surgery for an abdominal aortic aneurysm, a patient’s central venous pressure (CVP) monitor indicates low pressures. Which action should the nurse take?
a. Administer IV diuretic medications.
b. Increase the IV fluid infusion per protocol.
c. Increase the infusion rate of IV vasodilators.
d. Elevate the head of the patient’s bed to 45 degrees.

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 or increasing vasodilators may decrease cerebral perfusion.

5

When caring for a patient with pulmonary hypertension, which parameter will the nurse use to directly evaluate the effectiveness of the treatment?
a. Central venous pressure (CVP)
b. Systemic vascular resistance (SVR)
c. Pulmonary vascular resistance (PVR)
d. Pulmonary artery wedge pressure (PAWP)

C
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.

6

What action by a new intensive care unit staff nurse would indicate that the nurse educator’s teaching about arterial pressure monitoring has been effective?
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.

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.

7

When monitoring the effectiveness of treatment for a patient with a large anterior wall myocardial infarction, what is the most pertinent measurement for the nurse to obtain?
a. Central venous pressure (CVP)
b. Systemic vascular resistance (SVR)
c. Pulmonary vascular resistance (PVR)
d. Pulmonary artery wedge pressure (PAWP)

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.

8

Which action should the nurse take first when the low pressure alarm sounds for a patient who has an arterial line in the left radial artery?
a. Assess for dysrhythmias.
b. Fast flush the arterial line.
c. Check the left hand for pallor.
d. Re-zero the monitoring equipment.

A
The low pressure alarm indicates a drop in the patient’s blood pressure, which may be caused by dysrhythmias. There is no indication to re-zero 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.

9

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

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.

10

The nurse is assisting with the placement of a pulmonary artery (PA) catheter. What would the nurse expect to see on the monitor as an indication that the catheter with inflated balloon is placed correctly?
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

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.

11

Which finding by the nurse caring for a patient with a right radial arterial line indicates a need for the nurse to take immediate 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 changed 2 days previously.

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.

12

The central venous oxygen saturation (ScvO2) is decreasing in a patient who has severe pancreatitis. What would the nurse assess to determine the possible cause of the decreased ScvO2?
a. Lipase level
b. Temperature
c. Urinary output
d. Body mass index

B
Elevated temperature increases metabolic demands and O2 use by tissues, resulting in a drop in O2 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.

13

An intraaortic balloon pump (IABP) is being used for a patient who is in cardiogenic shock. Which 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/min
c. Cardiac output (CO) of 5 L/min
d. Stroke volume (SV) of 40 mL/beat

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.

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?
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.

B
Monitoring urine output will help determine whether the patient’s cardiac output has improved. It also will 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.

15

While waiting for heart transplantation, a patient with severe cardiomyopathy has a ventricular assist device (VAD) implanted. What should the nurse anticipate when planning care for this patient?
a. Preparing the patient for a permanent VAD
b. Teaching the patient the reason for bed rest
c. Monitoring the incision for signs of infection
d. Administering immunosuppressants medications

C
The insertion site for the VAD provides a source for transmission of infection to the circulatory system and requires frequent monitoring. Patients with VADs can 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

16

What is the best initial action by the nurse to verify the correct placement of an oral endotracheal tube (ET) after insertion?
a. Obtain a portable chest x-ray.
b. Use an end-tidal CO2 monitor.
c. Auscultate for bilateral breath sounds.
d. Observe for symmetrical chest movement.

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 not as accurate as end-tidal CO2 monitoring. A chest x-ray confirms the placement but is done after the tube is secured.

17

How should the nurse maintain proper cuff pressure of an endotracheal tube (ET) when the patient is on mechanical ventilation?
a. Inflate the cuff with a minimum of 10 mL of air.
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.

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 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.

18

The nurse notes premature ventricular contractions (PVCs) while suctioning a patient’s endotracheal tube. Which next action by the nurse is indicated?
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

D
Dysrhythmias during suctioning may indicate hypoxemia or sympathetic nervous system stimulation. The nurse should stop suctioning and ventilate the patient with 100% O2. 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

19

Which assessment finding by the nurse 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

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. Suctioning the patient may induce bronchospasm and increase wheezing. An O2 saturation of 93% is acceptable and does not suggest that immediate suctioning is needed.

20

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

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 etiology of the ineffective airway clearance. Instillation of saline does not liquefy secretions and may decrease the SpO2. Repositioning the patient is appropriate but will not decrease the thickness of secretions.

21

Four hours after mechanical ventilation is initiated, a patient’s arterial blood gas (ABG) results include a pH of 7.51, PaO2 of 82 mm Hg, PaCO2 of 26 mm Hg, and HCO3?2- of 23 mEq/L (23 mmol/L). What change should the nurse anticipate to the ventilator settings?
a. Increase the FIO2.
b. Increase the tidal volume.
c. Increase the respiratory rate.
d. Decrease the respiratory rate.

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 PaCO2.

22

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 heart rate is 58 beats/min.
c. The stroke volume is increased.
d. The stroke volume variation is 12%.

A
The hypotension suggests that the high intrathoracic pressure caused by the PEEP may be decreasing venous return and (potentially) cardiac output.

23

The nurse is weaning a 68-kg patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation. Which 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

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 O2 saturation of 93% is acceptable for a patient with COPD. A spontaneous tidal volume of 450 mL is within the acceptable range.

24

The nurse is caring for a patient receiving a continuous norepinephrine IV infusion. Which finding indicates that the infusion rate may need to be adjusted?
a. Heart rate is slow at 58 beats/min.
b. Mean arterial pressure (MAP) is 56 mm Hg.
c. Systemic vascular resistance (SVR) is elevated.
d. Pulmonary artery wedge pressure (PAWP) is low

C
Vasoconstrictors, such as norepinephrine, will increase SVR. This will increase the work of the heart and decrease peripheral perfusion. The infusion rate may need to be decreased. Bradycardia, hypotension (MAP of 56 mm Hg), and low PAWP are not associated with
norepinephrine infusion

25

The nurse observes that the patient’s central venous catheter insertion site is red and tender to touch. The patient’s temperature is 101.8° F. What should the nurse plan to do?
a. Discontinue the catheter and culture the tip.
b. Use the catheter only for fluid administration.
c. Change the flush system and monitor the site.
d. Check the site more frequently for any swelling.

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.

26

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. What should the nurse plan to do?
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.

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.

27

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.

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 being dictated by rigid visitation policies. Inviting the family to participate in a multidisciplinary conference is appropriate but should not be the initial action by the nurse.

28

The nurse is caring for a patient who has an arterial catheter in the left radial artery for arterial pressure–based cardiac output (APCO) monitoring. Which information obtained by the nurse requires a report to the health care provider?
a. The patient has a positive Allen test result.
b. There is redness at the catheter insertion site.
c. The mean arterial pressure (MAP) is 86 mm Hg.
d. The dicrotic notch is visible in the arterial waveform.

B
Redness at the catheter insertion site indicates possible infection. The Allen test is performed before arterial line insertion, and a positive test result indicates normal ulnar artery perfusion. A MAP of 86 mm Hg is normal, and the dicrotic notch is normally present on the arterial waveform

29

The nurse responding to a ventilator alarm finds the patient lying in bed gasping and the endotracheal tube on the floor. Which action should the nurse take next?
a. Activate the rapid response team.
b. Provide reassurance to the patient.
c. Call the health care provider to reinsert the tube.
d. Manually ventilate the patient with 100% oxygen.

D
The nurse should ensure maximal patient oxygenation by manually ventilating with a bag-valve-mask system. Offering reassurance to the patient, notifying the health care provider about the need to reinsert the tube, and activating the rapid response team are also appropriate after the nurse has stabilized the patient’s oxygenation.

30

The nurse notes that a patient’s endotracheal tube (ET), which was at the 22-cm mark, is now at the 25-cm mark, and the patient is anxious and restless. Which action should the nurse take next?
a. Check the O2 saturation.
b. Offer reassurance to the patient.
c. Listen to the patient’s breath sounds.
d. Notify the patient’s health care provider.

C
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 are also appropriate, but detection and correction of tube malposition are the most critical actions.