COMPLEX 2021 - Chapter 65 Critical Care
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1. When providing care for Absent bowel sounds
a patient requiring hemo- Reduced urinary output
dynamic stability monitor- Tiredness and exhaustion
ing, which clinical manifes-
tations would the nurse as- The patient with diminished perfusion to the gastrointestinal (GI)
sociate with the patient be- tract may develop hypoactive or absent bowel sounds. Monitoring
ing hemodynamically un- urine output is a method used to determine the adequacy of
stable? Select all that apply. perfusion to the kidneys. Reduced urinary output indicates hemo-
dynamic instability. The patient may be tired and exhausted if there
1 Diarrhea is too little cardiac reserve to sustain even minimal activity. Diarrhea
2 Absent bowel sounds and high body temperature are not indications of hemodynamic
3 High body temperature instability.
4 Reduced urinary output
5 Tiredness and exhaustion
2. When assisting the health The nurse should closely monitor waveform 2.
care provider with inser-
tion of a pulmonary artery This waveform represents the right ventricle. The patient has a
catheter (PAC) for a patient low potassium and a history of cardiac issues, making the heart
with a history of heart fail- susceptible to increased irritability. While continuous monitoring
ure and a potassium level is important during all phases of pulmonary artery insertion, when
of 3.2 mEq/L, which wave- the balloon floats through the right ventricle, it may irritate the
form would the nurse close- ventricle and cause lethal ventricular dysrhythmias such as ventric-
ly monitor when floating ular tachycardia or ventricular fibrillation. Waveform 1 represents
the PAC balloon? the right atrium, waveform 3 represents the pulmonary artery, and
waveform 4 represents the pulmonary wedge pressure reading.
These areas do not typically cause lethal dysrhythmias.
, COMPLEX 2021 - Chapter 65 Critical Care
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3. Which factors would the 1 The patient's preload, afterload, and contractility
nurse consider when deter-
mining the patient's stroke Preload, afterload, and contractility determine SV. Use the cardiac
volume (SV)? output and heart rate to determine stroke volume; however, body
surface area assists to determine the cardiac index. Use the mean
1 The patient's preload, af- arterial pressure to determine afterload, not stroke volume. Cardiac
terload, and contractility index is a more precise measurement of the efficiency of the heart's
2 The patient's cardiac out- pumping action and is not used to determine stroke volume.
put, heart rate, and body
surface area
3 The patient's afterload,
cardiac output, and mean
arterial pressure
4 The patient's cardiac in-
dex, mean arterial pressure,
and BP
4. Which action would the 3 Check transducer placement.
nurse implement when a
patient's invasive BP mea- The nurse should check the placement of the transducer because
suring device reflects a transducers placed lower than the phlebostatic axis will produce
reading significantly higher falsely high readings. The line does not need require flushing.
than the one measured two Raising the head of the bed will not correct the falsely elevated
hours ago? reading. Performing a dynamic-response test may be necessary
if moving the transducer continues to produce falsely elevated
1 Flush the line and readings.
, COMPLEX 2021 - Chapter 65 Critical Care
Study online at https://quizlet.com/_a68ols
recheck.
2 Raise the head of the bed.
3 Check transducer place-
ment.
4 Perform a dynamic re-
sponse test.
5. When the patient has 1A
the pictured hemodynam-
ic monitoring device, which The distal lumen port (catheter tip), labelled A in the image, is
port would the nurse use within the pulmonary artery and is used to monitor PA pressure.
to measure a pulmonary Choice B is the port used for infusions. Choice C is the port used
artery (PA) pressure? for injecting medications. Choice D is the port used to inflate the
balloon.
1A
2B
3C
4D
6. Which value reflects the 1 6.8 L/min
patient's cardiac output
(CO) when heart rate (HR) Calculate the patient's CO by multiplying SV by HR. For this patient,
is 68 beats/min and the the nurse should multiply 100 mL/beat x 68 beats/min = 6800
stroke volume (SV) is 100 mL/min or 6.8 L/min. A normal cardiac output is between 4 and
mL/beat? 8 L/min.
1 6.8 L/min
2 2.4 L/min
3 9.2 L/min
4 10.3 L/min
, COMPLEX 2021 - Chapter 65 Critical Care
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7. When suctioning a patient, Decreased SpO2
the development of which Development of dysrhythmias
clinical manifestation indi- Increased BP
cates that the nurse would
discontinue suctioning im- Closely assessing the patient before, during, and after the suc-
mediately? Select all that tioning procedure is extremely important for the nurse to perform.
apply. If the patient is unable to tolerate suctioning, stop the procedure
and hyperoxygenate until equilibration occurs before attempting
1 Decreased SpO2 next suction pass. Decreased SpO2, increased or decreased BP,
2 Absence of coughing and development of dysrhythmias are indicators that the patient is
3 Development of dysrhyth- not tolerating suction. Sustained coughing rather than absence of
mias coughing also indicates the patient is not tolerating suctioning. The
4 Increased BP presence of shivering and convulsions is not related to suctioning.
5 Shivering and convulsions
of the entire body
8. For the patient receiving 4 T wave
intraaortic balloon pump
(IABP) therapy, which part The ECG is the trigger for the pump to start inflation on the T
of the electrocardiogram wave. Deflation occurs on the upstroke of the R wave (of the QRS)
(ECG) would the nurse ex- complex. The P and Q waves do not trigger the pump to either
pect the balloon inflation? inflate or deflate.
1 P wave
2 Q wave
3 R wave
4 T wave
9. When the patient's BP 120
is 172/94 mm Hg, which
value would be the pa- Calculate the MAP by adding the systolic BP to two times the
tient's mean arterial pres- diastolic BP and dividing by three. For this patient, that calculation
Study online at https://quizlet.com/_a68ols
1. When providing care for Absent bowel sounds
a patient requiring hemo- Reduced urinary output
dynamic stability monitor- Tiredness and exhaustion
ing, which clinical manifes-
tations would the nurse as- The patient with diminished perfusion to the gastrointestinal (GI)
sociate with the patient be- tract may develop hypoactive or absent bowel sounds. Monitoring
ing hemodynamically un- urine output is a method used to determine the adequacy of
stable? Select all that apply. perfusion to the kidneys. Reduced urinary output indicates hemo-
dynamic instability. The patient may be tired and exhausted if there
1 Diarrhea is too little cardiac reserve to sustain even minimal activity. Diarrhea
2 Absent bowel sounds and high body temperature are not indications of hemodynamic
3 High body temperature instability.
4 Reduced urinary output
5 Tiredness and exhaustion
2. When assisting the health The nurse should closely monitor waveform 2.
care provider with inser-
tion of a pulmonary artery This waveform represents the right ventricle. The patient has a
catheter (PAC) for a patient low potassium and a history of cardiac issues, making the heart
with a history of heart fail- susceptible to increased irritability. While continuous monitoring
ure and a potassium level is important during all phases of pulmonary artery insertion, when
of 3.2 mEq/L, which wave- the balloon floats through the right ventricle, it may irritate the
form would the nurse close- ventricle and cause lethal ventricular dysrhythmias such as ventric-
ly monitor when floating ular tachycardia or ventricular fibrillation. Waveform 1 represents
the PAC balloon? the right atrium, waveform 3 represents the pulmonary artery, and
waveform 4 represents the pulmonary wedge pressure reading.
These areas do not typically cause lethal dysrhythmias.
, COMPLEX 2021 - Chapter 65 Critical Care
Study online at https://quizlet.com/_a68ols
3. Which factors would the 1 The patient's preload, afterload, and contractility
nurse consider when deter-
mining the patient's stroke Preload, afterload, and contractility determine SV. Use the cardiac
volume (SV)? output and heart rate to determine stroke volume; however, body
surface area assists to determine the cardiac index. Use the mean
1 The patient's preload, af- arterial pressure to determine afterload, not stroke volume. Cardiac
terload, and contractility index is a more precise measurement of the efficiency of the heart's
2 The patient's cardiac out- pumping action and is not used to determine stroke volume.
put, heart rate, and body
surface area
3 The patient's afterload,
cardiac output, and mean
arterial pressure
4 The patient's cardiac in-
dex, mean arterial pressure,
and BP
4. Which action would the 3 Check transducer placement.
nurse implement when a
patient's invasive BP mea- The nurse should check the placement of the transducer because
suring device reflects a transducers placed lower than the phlebostatic axis will produce
reading significantly higher falsely high readings. The line does not need require flushing.
than the one measured two Raising the head of the bed will not correct the falsely elevated
hours ago? reading. Performing a dynamic-response test may be necessary
if moving the transducer continues to produce falsely elevated
1 Flush the line and readings.
, COMPLEX 2021 - Chapter 65 Critical Care
Study online at https://quizlet.com/_a68ols
recheck.
2 Raise the head of the bed.
3 Check transducer place-
ment.
4 Perform a dynamic re-
sponse test.
5. When the patient has 1A
the pictured hemodynam-
ic monitoring device, which The distal lumen port (catheter tip), labelled A in the image, is
port would the nurse use within the pulmonary artery and is used to monitor PA pressure.
to measure a pulmonary Choice B is the port used for infusions. Choice C is the port used
artery (PA) pressure? for injecting medications. Choice D is the port used to inflate the
balloon.
1A
2B
3C
4D
6. Which value reflects the 1 6.8 L/min
patient's cardiac output
(CO) when heart rate (HR) Calculate the patient's CO by multiplying SV by HR. For this patient,
is 68 beats/min and the the nurse should multiply 100 mL/beat x 68 beats/min = 6800
stroke volume (SV) is 100 mL/min or 6.8 L/min. A normal cardiac output is between 4 and
mL/beat? 8 L/min.
1 6.8 L/min
2 2.4 L/min
3 9.2 L/min
4 10.3 L/min
, COMPLEX 2021 - Chapter 65 Critical Care
Study online at https://quizlet.com/_a68ols
7. When suctioning a patient, Decreased SpO2
the development of which Development of dysrhythmias
clinical manifestation indi- Increased BP
cates that the nurse would
discontinue suctioning im- Closely assessing the patient before, during, and after the suc-
mediately? Select all that tioning procedure is extremely important for the nurse to perform.
apply. If the patient is unable to tolerate suctioning, stop the procedure
and hyperoxygenate until equilibration occurs before attempting
1 Decreased SpO2 next suction pass. Decreased SpO2, increased or decreased BP,
2 Absence of coughing and development of dysrhythmias are indicators that the patient is
3 Development of dysrhyth- not tolerating suction. Sustained coughing rather than absence of
mias coughing also indicates the patient is not tolerating suctioning. The
4 Increased BP presence of shivering and convulsions is not related to suctioning.
5 Shivering and convulsions
of the entire body
8. For the patient receiving 4 T wave
intraaortic balloon pump
(IABP) therapy, which part The ECG is the trigger for the pump to start inflation on the T
of the electrocardiogram wave. Deflation occurs on the upstroke of the R wave (of the QRS)
(ECG) would the nurse ex- complex. The P and Q waves do not trigger the pump to either
pect the balloon inflation? inflate or deflate.
1 P wave
2 Q wave
3 R wave
4 T wave
9. When the patient's BP 120
is 172/94 mm Hg, which
value would be the pa- Calculate the MAP by adding the systolic BP to two times the
tient's mean arterial pres- diastolic BP and dividing by three. For this patient, that calculation
