Test Bank - Priorities in Critical Care Nursing, 8th Edition
(Lough, 9780323531993), Chapter 1-27 | Rationals Included
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. - ANSWER: 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.
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) - ANSWER: ANS: B
Systemic vascular resistance reflects the resistance to ventricular ejection, or afterload. The other
parameters will be monitored, but do not reflect afterload as directly.
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. - ANSWER: 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.
Following surgery for an abdominal 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. - ANSWER: 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.
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) - ANSWER: 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.
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. - ANSWER:
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 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.
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). - ANSWER: 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 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. - ANSWER: 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.
Which action will 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. - ANSWER: 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.
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. - ANSWER: ANS: D
(Lough, 9780323531993), Chapter 1-27 | Rationals Included
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. - ANSWER: 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.
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) - ANSWER: ANS: B
Systemic vascular resistance reflects the resistance to ventricular ejection, or afterload. The other
parameters will be monitored, but do not reflect afterload as directly.
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. - ANSWER: 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.
Following surgery for an abdominal 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. - ANSWER: 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.
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) - ANSWER: 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.
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. - ANSWER:
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 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.
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). - ANSWER: 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 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. - ANSWER: 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.
Which action will 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. - ANSWER: 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.
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. - ANSWER: ANS: D
