Chapter 66 Nursing Management Critical Care

PSYCH 320 : Chapter 66: Nursing Management: Critical Care
Lewis: Medical-Surgical Nursing, 10th Edition WITH rationale
Chapter 66: Nursing Management: Critical Care
Test Bank
MULTIPLE CHOICE
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
discontinuing assessments during the night.
DIF: Cognitive Level: Apply (application) REFF: 1601
TOPIC: 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)
b. Systemic vascular resistance (SVR)
c. Pulmonary vascular resistance (PVR)
d. Pulmonary artery wedge pressure (PAWP)
ANS: B
Systemic vascular resistance REFFlects the resistance to ventricular ejection, or afterload. The
otherparameters will be monitored, but do not REFFlect afterload as directly.
TOPIC: 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.
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.
TOPIC: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
4. Following surgery for anabdominal 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.
TOPIC: 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)

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) REFF: 1603-1604
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-REFFerence sTOPICcock 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.
ANS: B
For accurate measurement of pressures, the zero-REFFerence 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.
TOPIC: 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
a. central venous pressure (CVP).
b. systemic vascular resistance (SVR).
c. pulmonary vascular resistance (PVR).
d. pulmonary artery wedge pressure (PAWP).
ANS: D
PAWP REFFlects 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 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?
a. Fast flush the arterial line.
b. Check the left hand for pallor.
c. Assess for cardiac dysrhythmias.
d. Rezero the monitoring equipment.

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.
OBJ: Special Questions: Prioritization TOPIC: Nursing Process:
ImplementationMSC: NCLEX: Physiological Integrity
9. Which actionwill 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.
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.
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
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) REFF: 1608
TOPIC: 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?
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.
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.
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.
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.
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

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

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.
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.
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
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.
TOPIC: 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. STOPIC 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 sTOPIC suctioning and ventilate the patient with 100% oxygen.
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 sTOPICped and patient is well oxygenated.
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%.

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.
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?
a. Increase suctioning to every hour.
b. Reposition the patient every 1 to 2 hours.
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 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 for a patient with chronic obstructive
pulmonary disease (COPD), the 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– of 23 mEq/L (23 mmol/L). The nurse
will anticipate the need to
a. increase the FIO2.
b. increase the tidal volume.
c. increase the respiratory rate.
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 PaCO2.
DIF: Cognitive Level: Analyze (analysis) REFF: 1615-1616
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/minute.
c. The stroke volume is increased.
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.
23. A
nurse is weaning a 68-kg male patient who has chronic obstructive pulmonary disease
(COPD) from mechanical ventilation. Which patient assessment finding indicates that the
weaning protocol should be sTOPICped?
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, although the nurse should continue to monitor it.
An oxygen 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 (Levophed) IV
infusion. Which patient assessment finding indicates that the infusion rate may need to be
adjusted?
a. Heart rate is 58 beats/minute.
b. Mean arterial pressure (MAP) is 56 mm Hg.
c. Systemic vascular resistance (SVR) is elevated.
d. Pulmonary artery wedge pressure (PAWP) is low.
ANS: C
Vasoconstrictors such as norepinephrine (Levophed) will increase SVR, and 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. When caring for the patient with a pulmonary artery (PA) pressure catheter, the nurse
observes that the PA waveform indicates that the catheter is in the wedged position. Which action
should the nurse take next?
a. Zero balance the transducer.

b. Activate the fast flush system.
c. Notify the health care provider.
d. Deflate and reinflate the PA balloon.
ANS: D
When the catheter is in the wedge position, blood flow past the catheter is obstructed, placing the
patient at risk for pulmonary infarction. A health care provider or advanced practice nurse should
be called to reposition the catheter. The other actions will not correct the wedging of the PA
catheter.
26. When evaluating a patient with a central venous catheter, the nurse observes that the insertion
site is red and tender to touch and the patient’s temperature is 101.8° F. What should the nurse
plan to do next?
a. Give analgesics and antibiotics as ordered.
b. Discontinue the catheter and culture the tip.
c. Change the flush system and monitor the site.
d. Check the site more frequently for any swelling.

ANS: B
The information indicates that the patient has a local and systemic infection caused by the
catheter, and the catheter should be discontinued. Changing the flush system, giving analgesics,
and continued monitoring will not help prevent or treat the infection. Administration of
antibiotics is appropriate, but the line should still be discontinued to avoid further complications
such as endocarditis.
27. An 81-year-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.
TOPIC: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity
28. The family members of a patient who has just 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 next?
a. Explain ICU visitation policies and encourage family visits.
b. Immediately take the family members 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 a multidisciplinary 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 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.
ImplementationMSC: NCLEX: Psychosocial Integrity
29. When 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
is most important to report to the health care provider?
a. The patient has a positive Allen test.
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.
ANS: B
Redness at the catheter insertion site indicates possible infection. The Allen test is performed
before arterial line insertion, and a positive test indicates normal ulnar artery perfusion. A MAP
of 86 is normal and the dicrotic notch is normally present on the arterial waveform.
OBJ: Special Questions: Prioritization TOPIC: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
30. The nurse respondsto a ventilator alarm and finds the patient lying in bed holding the
endotracheal tube (ET). 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.
ANS: 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.

a patient’s endotracheal tube (ET), which was at the 22-cm mark, is now
31. The nurse notes that
at the 25-cm mark and the patient is anxious and restless. Which action should the nurse
take next?
a. Offer reassurance to the patient.
b. Bag the patient at an FIO2 of 100%.
c. Listen to the patient’s breath sounds.
d. Notify the patient’s health care provider.
ANS: 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.
32. The nurse educatoris evaluating the care that a new registered nurse (RN) provides to a
patient receiving mechanical ventilation. Which action by the new RN indicates the need for
more education?
a. The RN increases the FIO2 to 100% before suctioning.
b. The RN secures a bite block in place using adhesive tape.
c. The RN asks for assistance to reposition the endotracheal tube.

d. The RN positions the patient with the head of bed at 10 degrees.
ANS: D
The head of the patient’s bed should be positioned at 30 to 45 degrees to prevent ventilator-
associated pneumonia. The other actions by the new RN are appropriate.
OBJ: Special Questions: Delegation TOPIC: Nursing Process: Evaluation
MSC: NCLEX: Safe and Effective Care Environment
33. A patient who is orally intubated and receiving mechanical ventilation is anxious and is
“fighting” the ventilator. Which action should the nurse take next?
a. Verbally coach the patient to breathe with the ventilator.
b. Sedate the patient with the ordered PRN lorazepam (Ativan).
c. Manually ventilate the patient with a bag-valve-mask device.
d. Increase the rate for the ordered propofol (Diprivan) infusion.
ANS: A
The initial response by the nurse should be to try to decrease the patient’s anxiety by coaching
the patient about how to coordinate respirations with the ventilator. The other actions may also
be helpful if the verbal coaching is ineffective in reducing the patient’s anxiety.
OBJ: Special Questions: Prioritization TOPIC: Nursing Process: Implementation

34. The nurse educator is evaluating the performance of a new registered nurse (RN) who is
providing care to a patient who is receiving mechanical ventilation with 15 cm H2O of peak end-
expiratory pressure (PEEP). Which action indicates that the new RN is safe?
a. The RN plans to suction the patient every 1 to 2 hours.
b. The RN uses a closed-suction technique to suction the patient.
c. The RN tapes connection between the ventilator tubing and the ET.
d. The RN changes the ventilator circuit tubing routinely every 48 hours.
ANS: B
The closed-suction technique is used when patients require high levels of PEEP (>10 cm H2O) to
prevent the loss of PEEP that occurs when disconnecting the patient from the ventilator.
Suctioning should not be scheduled routinely, but it should be done only when patient
assessment data indicate the need for suctioning. Taping connections between the ET and the
ventilator tubing would restrict the ability of the tubing to swivel in response to patient
repositioning. Ventilator tubing changes increase the risk for ventilator-associated pneumonia
(VAP) and are not indicated routinely.
OBJ: Special Questions: Delegation TOPIC: Nursing Process: Implementation
35. The nurse is caring for a patient with

a subarachnoid hemorrhage who is intubated and placed
on a mechanical ventilator with 10 cm H2O of peak end-expiratory pressure (PEEP). When
monitoring the patient, the nurse will need to notify the health care provider immediately if the
patient develops
a. oxygen saturation of 93%.

b. respirations of 20 breaths/minute.
c. green nasogastric tube drainage.
d. increased jugular venous distention.
ANS: D
Increases in jugular venous distention in a patient with a subarachnoid hemorrhage may indicate
an increase in intracranial pressure (ICP) and that the PEEP setting is too high for this patient. A
respiratory rate of 20, O2saturation of 93%, and green nasogastric tube drainage are within
normal limits.
36. A patient who is receiving positive pressure ventilation is scheduled for a spontaneous
breathing trial (SBT). Which finding by the nurse is most important to discuss with the health
care provider before starting the SBT?
a. New ST segment elevation is noted on the cardiac monitor.
b. Enteral feedings are being given through an orogastric tube.
c. Scattered rhonchi are heard when auscultating breath sounds.
d. HYDROmorphone (Dilaudid) is being used to treat posTOPICerative pain.
ANS: A
Myocardial ischemia is a contraindication for ventilator weaning. The ST segment elevation is an

indication that weaning should be postponed until further investigation and/or treatment for
myocardial ischemia can be done. The other information will also be shared with the health care
provider, but ventilator weaning can proceed when opioids are used for pain management,
abnormal lung sounds are present, or enteral feedings are being used.
OBJ: Special Questions: Prioritization TOPIC: Nursing Process: Assessment
37. After change-of-shift report on a ventilator weaning unit, which patient should the nurse
assess first?
Patient who failed a spontaneous breathing trial and has been placed in a rest mode on the
a. ventilator
Patient who is intubated and has continuous partial pressure end-tidal CO2 (PETCO2)
b. monitoring
Patient with a central venous oxygen saturation (ScvO2) of 69% while on bilevel positive
c. airway pressure (BiPAP)
Patient who was successfully weaned and extubated 4 hours ago and now has no urine
d. output for the last 6 hours
ANS: D
The decreased urine output may indicate acute kidney injury or that the patient’s cardiac output
and perfusion of vital organs have decreased. Any of these causes would require rapid action.
The data about the other patients indicate that their conditions are stable and do not require
immediate assessment or changes in their care. Continuous PETCO2 monitoring is frequently
used when patients are intubated. The rest mode should be used to allow patient recovery after a
failed SBT, and an ScvO2 of 69% is within normal limits.
DIF: Cognitive Level: Analyze (analysis) REFF: 1625 | 1627
OBJ: Special Questions: Prioritization; Multiple Patients TOPIC: Nursing Process: Planning

38. After change-of-shift report, which patient should the progressive care nurse assess first?
a. Patient who was extubated in the morning and has a temperature of 101.4° F (38.6° C)
Patient with bilevel positive airway pressure (BiPAP) for sleep apnea whose respiratory rate
b. is 16
Patient with arterial pressure monitoring who is 2 hours post–percutaneous coronary

c. intervention who needs to void
Patient who is receiving IV heparin for a venous thromboembolism and has a partial
d. thromboplastin time (PTT) of 98 sec
ANS: D
The findings for this patient indicate high risk for bleeding from an elevated (nontherapeutic)
PTT. The nurse needs to adjust the rate of the infusion (dose) per the health care provider’s
parameters. The patient with BiPAP for sleep apnea has a normal respiratory rate. The patient
recovering from the percutaneous coronary intervention will need to be assisted with voiding and
this task could be delegated to unlicensed assistive personnel. The patient with a fever may be
developing ventilator-associated pneumonia, but addressing the bleeding risk is a higher priority.
DIF: Cognitive Level: Analyze (analysis) REFF: 1600
OBJ: Special Questions: Prioritization; Multiple Patients TOPIC: Nursing Process: Planning
COMPLETION
1. Apatient’s vital signs are pulse 87, respirations 24, and BP of 128/64 mm Hg and cardiac
output is 4.7 L/min. The patient’s stroke volume is mL. (Round to the nearest whole
number.)
ANS:
54
Stroke volume = cardiac output/heart rate

OTHER
1. When assisting with oral intubation of a patient who is having respiratory distress, in which
order will the nurse take these actions? (Put a comma and a space between
eachSelectedSelected answerwerwer choice[A, B, C, D, E].)
a. Obtain a portable chest-x-ray.
b. Position the patient in the supine position.
c. Inflate the cuff of the endotracheal tube after insertion.
d. Attach an end-tidal CO2 detector to the endotracheal tube.
e. Oxygenate the patient with a bag-valve-mask device for several minutes.
ANS:
E, B, C, D, A
The patient is pre-oxygenated with a bag-valve-mask system for 3 to 5 minutes before intubation
and then placed in a supine position. Following the intubation, the cuff on the endotracheal tube
is inflated to occlude and protect the airway. Tube placement is assessed first with an end-tidal
CO2 sensor, then with a chest x-ray.
2. The nurse iscaring for a patient who has an intraortic balloon pump (IABP) following a
massive heart attack. When assessing the patient, the nurse notices blood backing up into the
IABP catheter. In which order should the nurse take the following actions? (Put a comma and a
space between eachSelectedSelected answerwerwer choice [A, B, C, D].)
a. Ensure that the IABP console has turned off.
b. Assess the patient’s vital signs and orientation.
c. Obtain supplies for insertion of a new IABP catheter.
d. Notify the health care provider of the IABP malfunction.

ANS:
A, B, D, C
Blood in the IABP catheter indicates a possible tear in the balloon. The console will shut off
automatically to prevent complications such as air embolism. Next, the nurse will assess the
patient and communicate with the health care provider about the patient’s assessment and the
IABP problem. Finally, supplies for insertion of a new IABP catheter may be needed, based on
the patient assessment and the decision of the health care provider.
OBJ: Special Questions: Prioritization TOPIC: Nursing Process: Planning
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PSYCH 320 : Chapter 66: Nursing Management: Critical Care

Lewis: Medical-Surgical Nursing, 10th Edition WITH rationale

Chapter 66: Nursing Management: Critical Care

a. Administer prescribed sedatives or opioids at bedtime to promote sleep.

d. Eliminate assessments between 0100 and 0600 to allow uninterrupted sleep.

DIF: Cognitive Level: Apply (application) REFF: 1601

TOPIC: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

c. Pulmonary vascular resistance (PVR)

d. Pulmonary artery wedge pressure (PAWP)

DIF: Cognitive Level: Apply (application) REFF: 1604

TOPIC: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

TOPIC: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

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.

DIF: Cognitive Level: Apply (application) REFF: 1609

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

a. Central venous pressure (CVP)

b. Systemic vascular resistance (SVR)

c. Pulmonary vascular resistance (PVR)

DIF: Cognitive Level: Apply (application) REFF: 1603-1604

TOPIC: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

a. balances and calibrates the monitoring equipment every 2 hours.

DIF: Cognitive Level: Apply (application) REFF: 1605

b. systemic vascular resistance (SVR).

c. pulmonary vascular resistance (PVR).

d. pulmonary artery wedge pressure (PAWP).

DIF: Cognitive Level: Apply (application) REFF: 1607

TOPIC: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

a. Fast flush the arterial line.

b. Check the left hand for pallor.

c. Assess for cardiac dysrhythmias.

d. Rezero the monitoring equipment.

DIF: Cognitive Level: Apply (application) REFF: 1606

OBJ: Special Questions: Prioritization TOPIC: Nursing Process:

ImplementationMSC: NCLEX: Physiological Integrity

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.

DIF: Cognitive Level: Apply (application) REFF: 1608

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

b. tracing of the systemic arterial pressure.

c. tracing of the systemic vascular resistance.

d. typical PA wedge pressure (PAWP) tracing.

DIF: Cognitive Level: Understand (comprehension) REFF: 1608

TOPIC: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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.

DIF: Cognitive Level: Apply (application) REFF: 1606

TOPIC: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

d. body mass index.

DIF: Cognitive Level: Apply (application) REFF: 1609

TOPIC: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

a. Urine output of 25 mL/hr

c. Cardiac output (CO) of 5 L/min

d. Stroke volume (SV) of 40 mL/beat