NUR 02 CRITICAL CARE 01

NUR 02 CRITICAL CARE 01 01 A client undergoing endotracheal intubation received IV sedation and succinylcholine. Shortly after respiratory status has been stabilized, the client becomes flushed, profusely diaphoretic, and has a rigid jaw. Which medication should the nurse prepare to administer? Click the exhibit button for more information. 1. IM epinephrine 2. IV atropine 3. IV dantrolene 4. IV glucagon Explanation: Malignant hyperthermia (MH) is a rare and life-threatening condition precipitated by general anesthetics (eg, succinylcholine). Skeletal muscles become unable to control calcium levels, leading to a hypermetabolic state manifested by contracture and increased temperature. Early signs of MH include tachypnea, tachycardia, and rigid jaw or generalized rigidity. As the condition progresses, the client develops a high fever. Muscle tissue is broken down, leading to hyperkalemia, cardiac dysrhythmias, and myoglobinuria. MH requires emergent treatment with IV dantrolene to reverse the process by slowing metabolism. Succinylcholine should be discontinued. Other interventions include applying cooling blankets to reduce temperature and treating high potassium levels. (Option 1) IM epinephrine is administered for cardiac arrest, anaphylactic reactions, or severe asthma attacks; it is not appropriate for MH. (Option 2) IV atropine, an anticholinergic agent, is used to treat bradycardia. It would worsen tachycardia in this client. (Option 4) Naturally produced by the pancreas, glucagon is given intramuscularly, subcutaneously, or intravenously for severe hypoglycemia. IV glucose is preferred for its immediate effect; however, if it is unavailable, glucagon can be given to stimulate glycogenolysis in the liver, thereby raising blood glucose. Educational objective: Malignant hyperthermia (MH) is a life-threatening hypermetabolic condition triggered by general anesthetics. Administration of IV dantrolene slows metabolism and is the priority nursing action for a client with MH. Other interventions include cooling the client and treating high potassium levels. 02 The nurse is admitting a client with a possible diagnosis of Guillain-Barré syndrome. When collecting data to develop a plan of care for the client, the nurse should give priority to which of the following items? 1. Orthostatic blood pressure changes 2. Presence or absence of knee reflexes 3. Pupil size and reaction to light 4. Rate and depth of respirations Explanation: Guillain-Barré syndrome (GBS) is an acute, immune-mediated polyneuropathy that is most often accompanied by ascending muscle paralysis and absence of reflexes. Lower-extremity weakness progresses over hours to days to involve the thorax, arms, and cranial nerves (CNs). Neuromuscular respiratory failure is the most life-threatening complication. The rate and depth of the respirations should be monitored (Option 4). Measurement of serial bedside forced vital capacity (spirometry) is the gold standard for assessing early ventilation failure. (Option 1) Autonomic dysfunction is common in GBS and usually results in orthostatic hypotension, paralytic ileus, urinary retention, and diaphoresis. These complications need to be assessed but are not a priority. (Option 2) Absence of knee reflexes is expected early in the course of GBS due to the ascending nature of the disease. Absence of gag reflex indicates GBS progression. (Option 3) PERRLA (pupils equal, round, reactive to light, accommodation) evaluation assesses CNs II, III, IV, and VI. CN abnormalities are expected after the thoracic muscles (respiratory) are involved due to the ascending nature of GBS. Educational objective: The most serious complication to monitor for in new-onset Guillain-Barré syndrome is respiratory compromise from the paralysis ascending into the thoracic region. Monitoring for rate/depth of respirations and measuring serial bedside vital capacity (spirometry) help to detect this early in the disease course. 03 The nurse performs admission assessments on 4 clients. Which client assessment information is most concerning and needs priority care? 17-year-old with suspected meningococcal meningitis who has a fever of 103 F (39.4 1. C), headache with photophobia, and stiff neck 36-year-old who is an IV drug user with cellulitis of the arm, a fever of 103.2 F (39.6 C), and 2. foul-smelling drainage from self-injection sites 45-year-old with diabetes mellitus and osteomyelitis of the foot who has a fever of 100.9 F 3. (38.3 C) and a serum glucose of 295 mg/dL (16.4 mmol/L) 76-year-old with chronic bronchitis who has a fever of 101 F (38.3 C) and a productive 4. cough of thick green mucus Explanation: Meningococcal meningitis is a highly contagious condition that involves inflammation and bacterial infection in the tissues covering the brain and spinal cord (meninges). It is transmitted through direct contact or by inhaling droplets from infected individuals (ie, upper respiratory tract infections) and is prevalent among those living in close proximity (eg, prisons, dormitories). Characteristic signs include fever, headache, nuchal rigidity (stiff neck), photophobia, nausea, vomiting, and changes in mental status. If any of these are present, prompt testing (eg, lumbar puncture [LP], cultures) and initiation of antibiotic therapy immediately following the LP are critical as this is a life-threatening medical emergency. (Option 2) Although this client has an infection, is at increased risk for septicemia, and needs to be treated with antibiotics and antipyretics, this situation is not immediately life-threatening. (Option 3) Fever and hyperglycemia are expected responses to infection, and this client needs to be treated with antibiotics and insulin. However, this situation is not immediately life-threatening. (Option 4) This client is at increased risk for pneumonia and needs to be treated with antibiotics, antipyretics, bronchodilators, and expectorants. This situation is not immediately life-threatening. Educational objective: Meningococcal meningitis is a highly contagious bacterial infection. Classic signs include fever, nuchal rigidity, headache, photophobia, nausea, vomiting, and changes in mental status. If meningococcal meningitis is suspected, diagnostic testing and immediate treatment with antibiotics are critical as it is a life-threatening medical emergency. 04 A client with a bowel obstruction has been treated with gastric suctioning for 4 days. The nurse notices an increase in nasogastric drainage. Which acid-base imbalance does the nurse correctly identify? Click the exhibit button for more information. 1. Metabolic alkalosis, compensated 2. Metabolic alkalosis, uncompensated 3. Respiratory alkalosis, compensated 4. Respiratory alkalosis, uncompensated Explanation: This client's ABG analysis shows uncompensated metabolic alkalosis. The most likely cause of this alkalosis is the loss of acidic gastric contents from prolonged gastric suctioning. Metabolic imbalances affect the bicarbonate level. This client's ABG is high in pH (alkalosis) and bicarbonate. Bicarbonate (HCO3-) is basic; therefore, an elevated bicarbonate level indicates a more basic (alkalotic) state due to a metabolic cause. The nurse recognizes that this is uncompensated alkalosis. The lungs compensate for metabolic imbalance by either blowing off acidic carbon dioxide (hyperventilating) or retaining it (hypoventilating). Hypoventilation raises the carbon dioxide level, making the blood more acidic. Compensation is complete once the pH returns to normal limits (Option 1). (Options 3 and 4) Respiratory alkalosis (pH >7.45) results from a decreased PaCO2 (<35 mm Hg [4.66 kPa]). The kidneys compensate for respiratory alkalosis by excreting HCO3-. Therefore, a decrease in HCO - (<22 mEq/L [22 mmol/L]) and normalized pH (7.35-7.45) would indicate compensated respiratory alkalosis. Educational objective: Loss of acid through suctioning of gastric contents creates a state of metabolic alkalosis. Compensatory hypoventilation may regulate the pH by retaining carbon dioxide (acid). 05 The emergency department nurse receives a client with extensive injuries to the head and upper back. The nurse will perform what action to allow the best visualization of the airway? 1. Head-tilt chin-lift in the supine position on a backboard 2. Head-tilt chin-lift in the Trendelenburg position 3. Jaw-thrust maneuver in semi-Fowler's position 4. Jaw-thrust maneuver in the supine position on a backboard Explanation: Clinical situations involving trauma should follow ABC: Airway, Breathing, and Circulation. Airway assessment is particularly critical in clients with injuries to the head, neck, and upper back. Injury to the upper back should be treated as spinal trauma until the client has been cleared by an Advanced Trauma Life Support-qualified health care provider. Until the spine is appropriately assessed, the client should be placed on a backboard and stabilized. The nurse should use the jaw-thrust maneuver to avoid movement of an unstable spine. One provider should stabilize the cervical vertebra allowing the second provider to articulate the jaw independently of the spinal column. (Option 1) Although use of the backboard is appropriate, the head–tilt chin-lift should not be used as it involves manipulation of the neck without proper stabilization. If the cervical vertebrae are fractured, the spinal cord could be badly damaged. (Option 2) The head-tilt chin-lift does not stabilize the alignment of the head and neck and can cause spinal cord damage. In addition, the Trendelenburg position causes the abdominal organs to shift toward the diaphragm, which increases the work of breathing. (Option 3) The jaw-thrust maneuver is appropriate, but stabilization of the spine is best performed in the supine position, such as on the flat, hard surface of a backboard. Educational objective: If there is any suspicion of spinal injury, the jaw-thrust maneuver should be used for airway assessment to avoid any shifting of unstable vertebrae and subsequent spinal cord damage. 06 A client's wife is panic-stricken at the thought of withdrawing all life support from her husband, who is dying from end-stage chronic obstructive pulmonary disease and sepsis. She asks the nurse what he will experience when mechanical ventilation is stopped. Which statement made by the nurse is most appropriate at this time? "The healthcare provider will prescribe a continuous intravenous infusion of 1. morphine to make him more comfortable." "To maintain blood flow to his heart and lungs, we will continue norepinephrine, the 2. vasopressor, but discontinue all other medications." "To prevent aspiration, we will discontinue his feeding tube and begin total parenteral 3. nutrition to meet his nutritional needs." "We will continue basic care, such as monitoring his vital signs, giving nutrition, and 4. monitoring laboratory tests." Explanation: The nursing goals in end-of-life care are to comfort and support the client and family when death is imminent. Morphine is commonly used to manage the dyspnea, tachycardia, and restlessness associated with withdrawing mechanical ventilator support. Intravenous benzodiazepines, (eg, midazolam, lorazepam) may be administered for additional comfort. (Options 2 and 3) When a client is taken off life support, vasopressors, antibiotics, blood, hemodialysis, and nutritional support are commonly withheld. (Option 4) Vital signs, laboratory testing, and nutritional support are detrimental to client comfort and are usually discontinued after the decision has been made to withdraw life support. Educational objective: When withdrawing life support, the major goal is client comfort. The primary nursing responsibility is to assess and intervene appropriately for symptoms of pain and discomfort. 07 Which client incident would be classified as an adverse event that requires an incident/event/irregular occurrence/variance report? Select all that apply. Client admitted with white blood cell count of 28,000 mm3 (28.0 × 109/L) and dies from 1. sepsis Client receives 1 mg morphine instead of prescribed 0.5 mg morphine 2. Client refuses pneumonia vaccination and contracts pneumonia 3. Nurse did not report client's new hemoglobin result of 6 g/dL (60 g/L) to oncoming nurse 4. Provider was not notified of client's positive blood culture results 5. Explanation: An adverse event is an injury to a client caused by medical management rather than a client's underlying condition. It may or may not be preventable. The Institute of Medicine (2000) recognizes 4 types of errors. They are: • Diagnostic (delay in diagnosis, failure to employ indicated tests, failure to act on results of monitoring) • Treatment (error in performance of procedure, treatment, dose; avoidable delay) • Preventive (failure to provide prophylactic treatment, inadequate follow-up/monitoring of treatment) • Other (failure of communication, equipment failure, system failure) Option 2 is a treatment error. Option 4 is a communication error as well as inadequate follow-up. Option 5 is a communication error and a failure to respond to an abnormal test. Timely reporting of critical results of tests and diagnostic procedures is part of the Joint Commission Hospital National Patient Safety Goals. (Option 1) The client was admitted with signs of a severe infection and the death is likely a result of that process rather than a medical error. (Option 3) Under the ethical principle of autonomy, the client has the right to refuse anything even if it is not to the client's ultimate best interest. The pneumonia could be due to lack of vaccination, but there is no direct relationship. Educational objective: Adverse events are injuries caused by medical management rather than a client's underlying condition. Types of errors include diagnostic, treatment, preventive, and failure of communication, equipment, or other systems. 08. The charge nurse is evaluating the skills of a new registered nurse (RN) assigned to care for a client with shock. Which action taken by the new RN indicates a need for further education? Administers furosemide to a client with pulmonary artery wedge pressure (PAWP) of 24 mm 1. Hg with cardiogenic shock Increases norepinephrine infusion rate to maintain mean arterial pressure (MAP) ≥65 mm 2. Hg in a client with anaphylactic shock Moves pulse oximeter sensor from the finger to the forehead of a client with septic shock 3. Places the head of the bed (HOB) for a client with hypovolemic shock in high 4. Fowler's position Explanation: The nurse manager would intervene when the new RN places the HOB of a client with hypovolemic shock in high Fowler's (90 degrees) position. Raising the HOB causes blood pressure to decrease, especially in a client with hypovolemic shock and inadequate circulating vascular volume. (Option 1) Furosemide (Lasix) is an appropriate drug for the nurse to administer to decrease left ventricular preload in a client in cardiogenic shock with a PAWP of 24 mm Hg (normal, 6-12 mm Hg). (Option 2) Norepinephrine (Levophed) is a vasopressor used to increase stroke volume, cardiac output, and MAP. Titrating a norepinephrine infusion upward to maintain the MAP within normal limits (≥65 mm Hg) is an appropriate nursing action for a client in anaphylactic shock. (Option 3) In clients with decreased peripheral tissue perfusion who are receiving vasopressors, pulse oximetry readings are usually more accurate when the sensor is placed on the forehead rather than on the finger. Therefore, moving the pulse oximeter sensor from the finger to the forehead is an appropriate action for the nurse to take for a client with septic shock. Educational objective: Norepinephrine is a vasopressor used to increase stroke volume, cardiac output, and MAP. MAP should be maintained at >65 mm Hg in septic or anaphylactic shock. Furosemide is an appropriate drug to decrease left ventricular preload in a client in cardiogenic shock. Normal PAWP is 6-12 mm Hg. 09. The nurse is caring for a client with sepsis and acute respiratory failure who was intubated and prescribed mechanical ventilation 3 days ago. The nurse assesses for which adverse effect associated with the administration of positive pressure ventilation (PPV)? 1. Dehydration 2. Hypokalemia 3. Hypotension 4. Increased cardiac output Explanation: Positive pressure ventilation (PPV) delivers positive pressure to the lungs using a mechanical ventilator (MV), either invasively through a tracheostomy or endotracheal tube or noninvasively through a nasal mask/facemask, nasal prongs, or a mouthpiece. The most common type used in the acute care setting for clients with acute respiratory failure is the volume cycled positive pressure MV, which delivers a preset volume and concentration of oxygen (eg, 21%-100%) with varying pressure. Positive pressure applied to the lungs compresses the thoracic vessels and increases intrathoracic pressure during inspiration. This leads to reduced venous return, ventricular preload, and cardiac output, which results in hypotension. The hypotensive effect of PPV is even greater in the presence of hypovolemia (eg, hemorrhage, hypovolemic shock) and decreased venous tone (eg, septic shock, neurogenic shock). (Option 1) Fluid and/or sodium retention usually occurs about 48-72 hours after initiation of PPV due to: (1) increased intrathoracic pressure and decreased cardiac output that stimulate the kidneys to release renin; (2) physiologic stress that leads to the release of antidiuretic hormone and cortisol; and (3) breathing through the ventilator's closed circuitry, which decreases insensible loss associated with respiration. (Option 2) Hypokalemia is not associated with PPV. (Option 4) PPV increases intrathoracic pressure and reduces venous return to the right side of the heart, reducing preload and cardiac output as well. Educational objective: Positive pressure ventilation causes increased intrathoracic pressure and reduced venous return and cardiac output, which can result in hypotension. 10. A client with a blood pressure (BP) of 250/145 mm Hg is admitted for hypertensive crisis. The health care provider prescribes a continuous IV infusion of nitroprusside sodium. Which of these is the priority goal in initial management of hypertensive crisis? 1. Decrease mean arterial pressure (MAP) by no more than 25% 2. Keep blood pressure at or below 120/80 mm Hg 3. Maintain heart rate (HR) of 60-100/min 4. Maintain urine output of at least 30 mL/hr Explanation: Hypertensive crisis is a life-threatening emergency due to the possibility of severe organ damage. If not treated promptly, complications such as intracranial hemorrhage, heart failure, myocardial infarction (MI), renal failure, aortic dissection, or retinopathy may occur. Emergency treatment includes IV vasodilators such as nitroprusside sodium. It is important to lower the blood pressure slowly, as too rapid a drop may cause decreased perfusion to the brain, heart, and kidneys. This may result in stroke, renal failure, or MI. The initial goal is usually to decrease the MAP by no more than 25% or to maintain MAP at 110-115 mm Hg. The pressure can then be lowered further over a period of 24 hours. MAP is calculated by adding the systolic blood pressure (SBP) and double the diastolic blood pressure (DBP), and then dividing the resulting value by 3. MAP = (2 x DBP + SBP) / 3 (Option 2) A blood pressure of 120/80 mm Hg (MAP 93 mm Hg) is too low for an initial goal. This rapid drop from the client's initial pressure of 250/145 mm Hg (MAP 180 mm Hg) is a decrease of greater than 25% and could cause organ damage. However, it may be necessary to lower the SBP below 120 mm Hg if the client is experiencing an aortic dissection, as a higher BP can cause rupture. (Option 3) The nurse should monitor HR and rhythm for signs of MI or heart failure. However, the priority goal for this client is to achieve a therapeutic blood pressure, not HR. (Option 4) The nurse should carefully monitor urine output as an indicator of renal function. Output should be greater than 30 mL/hr, but this is not the priority goal in management of hypertensive crisis. Educational objective: Hypertensive crisis may require continuous infusion of an IV vasodilator. BP should be lowered slowly to prevent organ damage. The initial goal is to lower MAP by 25% or less or to maintain MAP of 110-115 mm Hg. 11. While caring for a postoperative client with an invasive arterial line, the nurse identifies a large discrepancy between the arterial line reading and the manual cuff pressure. Arterial line reading: 100/62 mm Hg; manual cuff reading: 120/76 mm Hg. What interventions should the nurse take to facilitate accurate functioning of the arterial line? Select all that apply. 1. Perform a square wave test on the monitor 2. Position the client flat for all blood pressure (BP) readings 3. Recheck and compare with an automatic BP machine 4. Verify that the zero reference stopcock is leveled with the client's phlebostatic axis 5. Zero balance the system Explanation: Invasive arterial line and manual cuff readings measure BP via 2 different methods. The arterial line measures flow of the blood past a catheter, and the manual cuff measures pressure based on compression of the artery. Because of the differences, the 2 pressures may not match. The arterial line can be highly useful to the clinician as it gives a continuous measurement of accurate BP. The manual cuff will give a reading of the pressure only at the moment the pressure is measured. The following steps should be instituted to ensure accuracy of invasive pressure readings: 1. Position the client supine, flat, prone, or with the head of the bed <45 degrees 2. Confirm zero reference stopcock (port of the stopcock nearest to the transducer) to be at the level of the phlebostatic axis (4th intercostal space, midaxillary line), which approximates the level of the atria of the heart 3. Zero the system after initial setup, with disconnection of the transducer or when accuracy of the measurements is questioned 4. Perform a dynamic response test (square wave test) every 8-12 hours, when the system is opened to air or when accuracy of measurements is questioned 5. Measure pressures at the end of expiration (Option 2) The client does not need to be flat for all pressure readings. As long as the zero reference stopcock is level with the phlebostatic axis, the position can be supine, flat, prone, or with the head of the bed <45 degrees.