ICU3

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1.

The critical care nurse recognizes that an ideal plan for caregiver involvement includes:
A. Allowing caregivers at the bedside at preset, brief intervals.
B. A caregiver at the bedside at all times.
C. Restriction of visiting in the ICU because the environment is overwhelming to
caregivers.
D. An individually devised plan to involve caregivers with care and comfort measures.

Rationale: An individualized plan of care should be developed for each patient and the
caregivers. Caregivers should be allowed to assist with care and comfort measures in the ICU if
desired.

2. The nurse wants to assess the oxygenation status of a patient who has been experiencing a
gastrointestinal bleed. How will the nurse complete this assessment? Select all that apply.
A. Use pulse oximetry
B. Send a blood sample for arterial blood gas analysis
C. Auscultate lung sound
D. Evaluate cardiac rhythm strip
E. Calculate mean arterial pressure

Rationale: At the bedside the arterial oxygen saturation can be estimated by pulse oximetry
and can be measured via an arterial blood gas analysis. Evaluating the cardiac rhythm strip,
calculating mean arterial pressure, and auscultating lung sounds will not provide information
about a patient's oxygenation status.

3. 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.
D. Rechecks the location of the phlebostatic axis when changing the patient's position.

Rationale: 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.

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