Lewis's Medical Surgical Nursing Test Bank 11th Edition [Harding]
Chapter 65 - Critical Care
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.
Answer: B
Explanation: Clustering care minimizes sleep disruption, which can help reduce sensory
perception disturbances. Sedatives and opioids can decrease REM sleep and worsen sensory
issues. Silencing alarms or skipping assessments compromises patient safety.
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)
Answer: B
Explanation: SVR reflects left ventricular afterload. A reduction in SVR indicates decreased
resistance against which the left ventricle pumps. MAP reflects perfusion pressure, PVR
relates to right ventricle afterload, and PAWP indicates left ventricular preload.
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.
Answer: B
,Explanation: Offering the option to stay respects family preferences and can reduce anxiety
and facilitate grieving. Forcing them out or making assumptions about their stress levels is
less supportive.
4. Following surgery for an abdominal aortic aneurysm, a patients 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 patients bed to 45 degrees.
Answer: B
Explanation: Low CVP suggests hypovolemia, which requires fluid resuscitation. Diuretics
would worsen hypovolemia, and elevating the head could reduce cerebral perfusion.
Documentation alone is insufficient.
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)
Answer: C
Explanation: PVR is a key factor in pulmonary hypertension. A decrease indicates improved
pulmonary vascular resistance. CVP, SVR, and PAWP do not directly reflect pulmonary
artery pressure changes.
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-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 patients position.
Answer: B
Explanation: Accurate pressure readings require the transducer to be leveled at the
phlebostatic axis. Recalibration every 2 hours is unnecessary; patients can be repositioned
without changing the phlebostatic axis location.
,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).
Answer: D
Explanation: PAWP reflects left ventricular end-diastolic pressure and is a sensitive indicator
of left ventricular function, which is critical after an anterior MI. CVP, SVR, and PVR are
less specific to left heart function.
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.
Answer: C
Explanation: A low pressure alarm may indicate hypotension, possibly due to dysrhythmias.
Flushing, checking for pallor, or rezeroing are not initial responses to a low pressure alarm.
9. 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: D
Explanation: Dysrhythmias can occur during PA catheter insertion, so cardiac monitoring is
essential. NPO status, troponin levels, and auscultation are not required for this procedure.
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.
Answer: D
Explanation: A PAWP tracing confirms the catheter is wedged in a distal pulmonary artery
branch, allowing for left ventricular preload measurement. PA pressure waveforms are seen
before wedging; systemic pressures and SVR are not directly displayed.
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.
Answer: A
Explanation: A cooler hand suggests impaired perfusion, possibly due to arterial occlusion. A
MAP of 77 is normal, a 3 mL/hr flush rate is standard, and flush systems are typically
changed every 96 hours.
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 patients
A. lipase.
B. temperature.
C. urinary output.
D. body mass index.
Answer: B
Explanation: Fever increases metabolic demand and oxygen consumption, lowering ScvO₂.
Lipase, urinary output, and BMI are not directly related to oxygen saturation changes.
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
Answer: C
Chapter 65 - Critical Care
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.
Answer: B
Explanation: Clustering care minimizes sleep disruption, which can help reduce sensory
perception disturbances. Sedatives and opioids can decrease REM sleep and worsen sensory
issues. Silencing alarms or skipping assessments compromises patient safety.
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)
Answer: B
Explanation: SVR reflects left ventricular afterload. A reduction in SVR indicates decreased
resistance against which the left ventricle pumps. MAP reflects perfusion pressure, PVR
relates to right ventricle afterload, and PAWP indicates left ventricular preload.
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.
Answer: B
,Explanation: Offering the option to stay respects family preferences and can reduce anxiety
and facilitate grieving. Forcing them out or making assumptions about their stress levels is
less supportive.
4. Following surgery for an abdominal aortic aneurysm, a patients 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 patients bed to 45 degrees.
Answer: B
Explanation: Low CVP suggests hypovolemia, which requires fluid resuscitation. Diuretics
would worsen hypovolemia, and elevating the head could reduce cerebral perfusion.
Documentation alone is insufficient.
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)
Answer: C
Explanation: PVR is a key factor in pulmonary hypertension. A decrease indicates improved
pulmonary vascular resistance. CVP, SVR, and PAWP do not directly reflect pulmonary
artery pressure changes.
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-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 patients position.
Answer: B
Explanation: Accurate pressure readings require the transducer to be leveled at the
phlebostatic axis. Recalibration every 2 hours is unnecessary; patients can be repositioned
without changing the phlebostatic axis location.
,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).
Answer: D
Explanation: PAWP reflects left ventricular end-diastolic pressure and is a sensitive indicator
of left ventricular function, which is critical after an anterior MI. CVP, SVR, and PVR are
less specific to left heart function.
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.
Answer: C
Explanation: A low pressure alarm may indicate hypotension, possibly due to dysrhythmias.
Flushing, checking for pallor, or rezeroing are not initial responses to a low pressure alarm.
9. 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: D
Explanation: Dysrhythmias can occur during PA catheter insertion, so cardiac monitoring is
essential. NPO status, troponin levels, and auscultation are not required for this procedure.
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.
Answer: D
Explanation: A PAWP tracing confirms the catheter is wedged in a distal pulmonary artery
branch, allowing for left ventricular preload measurement. PA pressure waveforms are seen
before wedging; systemic pressures and SVR are not directly displayed.
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.
Answer: A
Explanation: A cooler hand suggests impaired perfusion, possibly due to arterial occlusion. A
MAP of 77 is normal, a 3 mL/hr flush rate is standard, and flush systems are typically
changed every 96 hours.
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 patients
A. lipase.
B. temperature.
C. urinary output.
D. body mass index.
Answer: B
Explanation: Fever increases metabolic demand and oxygen consumption, lowering ScvO₂.
Lipase, urinary output, and BMI are not directly related to oxygen saturation changes.
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
Answer: C
