nursing test banks8 graded A latest
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.
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.
DIF: Cognitive Level: Apply (application) REF: 1556
TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity
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)
ANS: B
SVR reflects the resistance to ventricular ejection, or afterload. The other parameters may
be monitored but do not reflect afterload as directly.
DIF: Cognitive Level: Apply (application) REF: 1560
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
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.
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.
DIF: Cognitive Level: Analyze (analysis) REF: 1558
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
,nursing test banks8 graded A latest
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.
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 or increasing
vasodilators may decrease cerebral perfusion.
DIF: Cognitive Level: Apply (application) REF: 1564
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
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)
ANS: 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.
DIF: Cognitive Level: Apply (application) REF: 1560
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
6. 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.
DIF: Cognitive Level: Apply (application) REF: 1560
TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment
7. 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).
, nursing test banks8 graded A latest
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: 1563
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
8. 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.
b. Check the left hand for pallor.
c. Assess for cardiac dysrhythmias.
d. Re-zero 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 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.
DIF: Cognitive Level: Apply (application) REF: 1564
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
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.
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: 1564
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
10. 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.
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.
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.
DIF: Cognitive Level: Apply (application) REF: 1556
TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity
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)
ANS: B
SVR reflects the resistance to ventricular ejection, or afterload. The other parameters may
be monitored but do not reflect afterload as directly.
DIF: Cognitive Level: Apply (application) REF: 1560
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
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.
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.
DIF: Cognitive Level: Analyze (analysis) REF: 1558
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
,nursing test banks8 graded A latest
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.
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 or increasing
vasodilators may decrease cerebral perfusion.
DIF: Cognitive Level: Apply (application) REF: 1564
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
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)
ANS: 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.
DIF: Cognitive Level: Apply (application) REF: 1560
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
6. 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.
DIF: Cognitive Level: Apply (application) REF: 1560
TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment
7. 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).
, nursing test banks8 graded A latest
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: 1563
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
8. 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.
b. Check the left hand for pallor.
c. Assess for cardiac dysrhythmias.
d. Re-zero 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 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.
DIF: Cognitive Level: Apply (application) REF: 1564
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
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.
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: 1564
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
10. 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.
