Critical care TESTBANK exam 2 correct questions and answers 2021 latest edition

1. The nurse is caring for a 100-kg patient being monitored with a pulmonary artery catheter. The nurse assesses a blood pressure of 90/60 mm Hg, heart rate 110 beats/min, respirations 36/min, oxygen saturation of 89% on 3 L of oxygen via nasal cannula. Bilateral crackles are audible upon auscultation. Which hemodynamic value requires immediate action by the nurse? a. Cardiac index (CI) of 1.2 L/min/m3 b. Cardiac output (CO) of 4 L/min c. Pulmonary vascular resistance (PVR) of 80 dynes/sec/cm–5 d. Systemic vascular resistance (SVR) of 1400 dynes/sec/cm–5 A cardiac index of 1.2 L/min/m3 combined with the identified clinical assessment findings indicate a low cardiac output with fluid overload (bilateral crackles), requiring intervention. The remaining hemodynamic values are within normal limits: cardiac output of 4 L/min; pulmonary vascular resistance of 80 dynes/sec/cm–5; and the systemic vascular resistance of 1400 dynes/sec/cm–5. 2. While caring for a patient with a small bowel obstruction, the nurse assesses a pulmonary artery occlusion pressure (PAOP) of 1 mm Hg and hourly urine output of 5 mL. The nurse anticipates which therapeutic intervention? Low pulmonary artery occlusion pressures usually indicate volume depletion, so intravenous fluids would be indicated. A normal hourly urine output is 1 mL/kg or at least 30 mL/hour, so this is another indication that the patient is volume depleted. Administration of diuretics would worsen the patient’s volume status. Negative inotropes would not improve the patient’s volume status. Vasopressors will increase blood pressure but are contraindicated in a low volume state. 3. The nurse is caring for a patient who has had an arterial line inserted. To reduce the risk of complications, what is the priority nursing intervention? Loose connections in hemodynamic monitoring tubing can lead to hemorrhage, a major complication of arterial pressure monitoring. Application of a pressure dressing is required only upon arterial line removal. Blood return is adequate confirmation of arterial line placement; radiography is not performed to confirm arterial line placement. Neutral positioning of the extremity and use of an arm board, without limb restraint, is the standard of care. 4. While caring for a patient with a pulmonary artery catheter, the nurse notes the pulmonary artery occlusion pressure (PAOP) to be significantly higher than previously recorded values. The nurse assesses respirations to be unlabored at 16 breaths/min, oxygen saturation of 98% on 3 L of oxygen via nasal cannula, and lungs clear to auscultation bilaterally. What is the priority nursing action? A hemodynamic value not supported by clinical assessment should be treated as questionable. To ensure the accuracy of hemodynamic readings, the catheter transducer system must be leveled at the phlebostatic axis and zero referenced. In this example, the catheter transducer system may be lower than the phlebostatic axis, resulting in erroneously higher pressures. Clinical manifestations do not support increasing supplemental oxygen. Clinical manifestations do not warrant provider intervention; aberrant values should be investigated further. An aberrant value warrants further investigation, which includes zero referencing and checking the level as an initial measure. A chest x-ray study is not warranted at this time. 5. A patient is admitted to the hospital with multiple trauma and extensive blood loss. The nurse assesses vital signs to be BP 80/50 mm Hg, heart rate 135 beats/min, respirations 36 breaths/min, cardiac output (CO) of 2 L/min, systemic vascular resistance of 3000 dynes/sec/cm–5, and a hematocrit of 20%. The nurse anticipates administration of which the following therapies or medications? Both hemodynamic parameters and the reported hematocrit value indicate hypovolemia and blood loss requiring volume resuscitation with blood products. Furosemide administration will worsen fluid volume status. Inotropic agents will not correct the underlying fluid volume deficit and anemia. Vasoconstrictors are contraindicated in a volume-depleted state. 6. After pulmonary artery catheter insertion, the nurse assesses a pulmonary artery pressure of 45/25 mm Hg, a pulmonary artery occlusion pressure (PAOP) of 20 mm Hg, a cardiac output of 2.6 L/min and a cardiac index of 1.9 L/min/m2. Which provider order is of the highest priority? The pulmonary pressures are higher than normal, indicating elevated preload, and the cardiac index and output values are low. The priority order for the nurse to implement is to begin a dobutamine infusion to improve cardiac output, possibly reducing pulmonary artery occlusion pressures. The other treatments may be important, depending on other patient data, but the dobutamine infusion is the most important at this time. 7. The nurse is caring for a patient with a left subclavian central venous catheter (CVC) and a left radial arterial line. Which assessment finding by the nurse requires immediate action? Numbness and tingling in the left hand, which is the location of an arterial catheter, indicates possible neurovascular compromise and requires immediate action. A dampened waveform can indicate problems with arterial line patency but is not an emergent situation. Slight bloody drainage at the subclavian insertion site is not an unusual finding. Slight redness at the insertion site, while of concern, does not require immediate action. 8. The provider writes an order to discontinue a patient’s left radial arterial line. When discontinuing the patient’s invasive line, what is the priority nursing action? Upon removal of an invasive arterial line, adequate pressure must be applied for at least 5 minutes to ensure adequate hemostasis. Application of an air occlusion dressing is not the standard of care following removal of an arterial line. Elevation of the affected limb following removal of an arterial line is not a necessary intervention. Neutral wrist position is optimum while the catheter is in place but unnecessary after catheter discontinuation. 9. Following insertion of a central venous catheter, the nurse obtains a stat chest x-ray film to verify proper catheter placement. The radiologist reports to the nurse: “The tip of the catheter is located in the superior vena cava.” What is the best interpretation of these results by the nurse? X-ray results indicate proper position of the catheter. The tip of the central venous catheter should rest just above the right atrium in the superior vena cava. The central venous catheter is positioned correctly in the superior vena cava. Dysrhythmias occur if the catheter migrates to the right ventricle. Central venous catheters are placed into great vessels of the venous system and not advanced into the pulmonary artery. 10. While inflating the balloon of a pulmonary artery catheter (PAC) with 1.0 mL of air to obtain a pulmonary artery occlusion pressure (PAOP), the nurse encounters resistance. What is the best nursing action? Balloon inflation should never be forced because the PAC may have migrated farther into the pulmonary artery, creating resistance to balloon inflation. Verification of proper line placement is warranted to avoid pulmonary artery rupture. In addition, the PAC waveform should be observed to assist in identifying location of the tip of the PAC. In this scenario, adding additional air to the balloon will further risk pulmonary artery rupture. Advancing a pulmonary artery catheter is not within the nurse’s scope of practice. Flushing the distal port with saline may be indicated to ensure patency; however, the balloon of the PAC should never be locked in the inflated position as rupture of the pulmonary artery may occur. 11. The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which assessment finding 2 hours after insertion by the nurse warrants immediate action? Diminished breaths sounds over the lung field on the same side of the line insertion site may be indicative of a pneumothorax. A pneumothorax, which can develop slowly, is a major complication following insertion of central lines when the subclavian route is used. Localized pain at catheter insertion site is not the immediate priority in this scenario. A measured central venous pressure of 5 mm Hg is normal. Slight bloody drainage at the insertion site soon after the procedure does not require immediate action. 12. The nurse is caring for a mechanically ventilated patient with a pulmonary artery catheter who is receiving continuous enteral tube feedings. When obtaining continuous hemodynamic monitoring measurements, what is the best nursing action? Elevation of the head of bed is an important intervention to prevent aspiration and ventilator-associated pneumonia. Patients who require hemodynamic monitoring while receiving tube feedings should have the air-fluid interface of the transducer leveled with the phlebostatic axis while the head of bed is elevated to at least 30 degrees. Readings will be accurate. Supine positioning of a mechanically ventilated patient increases the risk of aspiration and ventilator-associated pneumonia and aspiration of tube feeding, and is contraindicated in this patient. Hemodynamic values can be accurately measured and trended in with the head of the bed elevated as high as 60 degrees. Even though hemodynamic values can be obtained in lateral positions, it is technically difficult and not accurate unless the positioning of the transducer is exact. Regardless, head of bed elevation is indicated for this patient. 13. The nurse is educating a patient’s family member about a pulmonary artery catheter (PAC). Which statement by the family member best indicates understanding of the purpose of the PAC? A pulmonary artery catheter provides hemodynamic measurements that guide interventions that include appropriate fluid therapy. Even though a pulmonary catheter provides multiple intravenous access sites, this is not the primary purpose of the catheter. Although the catheter is positioned in the pulmonary artery, positioning is not the purpose of the catheter. The primary purpose of the catheter is not to aid in the healing of the heart but to guide therapy. 14. The nurse is preparing to obtain a pulmonary artery occlusion pressure (PAOP) reading for a patient who is mechanically ventilated. Ensuring that the air-fluid interface is at the level of the phlebostatic axis, what is the best nursing action? Pressures are highest when measured at end exhalation in the spontaneously breathing patient. In mechanically ventilated patients, pressures increase with inhalation and decrease with exhalation. Measurements are obtained just before the increase in pressure during inhalation. Supine positioning is contraindicated in the mechanically ventilated patient. The head of bed should be elevated to 30 degrees. Pulmonary artery occlusion pressure is not averaged, but measured during inhalation in the mechanically ventilated patient while appropriate positioning is maintained. 15. The charge nurse is supervising care for a group of patients monitored with a variety of invasive hemodynamic devices. Which patient should the charge nurse evaluate first? A high pulmonary artery occlusion pressure of 25 mm Hg combined with low oxygen saturation is indicative of fluid volume overload and warrants priority action because the patient is at risk for hypoxemia. A CVP of 6 mm Hg and 40 mL of hourly urine output are acceptable assessment findings. A patient with a normal blood pressure and with a slightly dampened waveform does not require immediate action. A pulmonary artery pressure of 25/10 mm Hg and a normal oxygen saturation does not require immediate treatment. 16. The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which action by the nurse best reduces the risk of catheter-related bloodstream infection (CRBSI)? Duration of the catheter is an independent risk factor for CRBSI, and removal of the catheter when not needed to guide treatment is associated with a reduction in mortality. Cleansing the insertion site should be guided by institutional guidelines and is best accomplished with chlorhexidine skin antisepsis. Minimizing the number of times the flush system is opened by changing tubing no more frequently than every 72 to 96 hours reduces the risk of CRBSI. Maintaining a pressure of 300 mm Hg on the flush solution bag helps maintain the integrity of the invasive line but does not reduce the risk of infection. 17. During insertion of a pulmonary artery catheter, the provider asks the nurse to assist by inflating the balloon with 1.5 mL of air. As the provider advances the catheter, the nurse notices premature ventricular contractions on the monitor. What is the best action by the nurse? During the insertion of the pulmonary artery catheter, ventricular dysrhythmias may occur as the catheter passes through the right ventricle. Treatment with lidocaine hydrochloride (or amiodarone) may be necessary to suppress the irritated ventricle and should be readily available. Withdrawal of the catheter is not within the scope of practice of the nurse and may not be necessary. Having the patient cough and deep-breathe will not correct the problem. The maximum volume of air necessary to inflate the balloon is 1.5 mL. Any additional volumes added may increase the risk of complications. 18. Following insertion of a pulmonary artery catheter (PAC), the provider requests the nurse obtain a blood sample for mixed venous oxygen saturation (SvO2). Which action by the nurse best ensures the obtained value is accurate? To ensure that an accurate SvO2 is obtained, calibration of the invasive monitoring system (e.g., PAC) is accomplished upon insertion and requires both a central venous blood sample from the PAC and an arterial blood gas sample. This process is unique to the accuracy of venous oxygen saturation monitoring systems. Zero referencing the transducer at the level of the phlebostatic axis, ensuring patency of the catheter with a pressurized flush system, and using tubing of adequate length ensure accuracy of all hemodynamic monitoring systems. 19. The nurse is caring for a 70-kg patient in septic shock with a pulmonary artery catheter. Which hemodynamic value indicates an appropriate response to therapy aimed at enhancing oxygen delivery to the organs and tissues? An arterial lactate level of 1.0 mEq/L is within normal limits and is indicative of normal oxygen delivery to the tissues. The cardiac output, mixed venous saturation, and cardiac index values are all below normal limits, indicating inadequate cardiac output sufficient to provide oxygen delivery to the organs and tissues. 20. The nurse is caring for a patient with a pulmonary artery catheter. Assessment findings include a blood pressure of 85/40 mm Hg, heart rate of 125 beats/min, respiratory rate 35 breaths/min, and arterial oxygen saturation (SpO2) of 90% on a 50% Venturi mask. Hemodynamic values include a cardiac output (CO) of 1.0 L/min, central venous pressure (CVP) of 1 mm Hg, and a pulmonary artery occlusion pressure (PAOP) of 3 mm Hg. The nurse questions which of the following physician’s orders? A central venous pressure of 1 mm Hg, pulmonary artery occlusion pressure of 3 mm Hg along with a blood pressure of 85/40 mm Hg and heart rate of 125 are indicative of a low volume state. Infusion of 500 mL of 0.9% normal saline will increase circulating fluid volume. Administration of furosemide (Lasix) is contraindicated and could further reduce circulating fluid volume. Titrating supplemental oxygen and obtaining serum blood gas and electrolyte samples, although not a priority, are appropriate interventions. 21. The charge nurse has a pulse contour cardiac output monitoring system available for use in the surgical intensive care unit. For which patient is use of this device most appropriate? Pulse contour analysis systems provide stroke volume variation and pulse pressure variation data and are better predictors of fluid responsiveness in mechanically ventilated patients. A patient postoperative from repair of an acute bowel obstruction that is mechanically ventilated is an appropriate candidate for this method of monitoring. Aortic insufficiency, intraaortic balloon pump therapy, and the presence of cardiac dysrhythmias are conditions in which pulse contour analysis systems are either inaccurate or contraindicated. 22. The provider prescribes a pulmonary artery occlusive pressure reading (PAOP) for a patient being monitored with a pulmonary artery catheter. Immediately after obtaining an occlusive pressure, the nurse notes the change in waveform indicated on the strip below. What are the best actions by the nurse? After obtaining a pulmonary artery occlusive pressure and deflating the balloon, the monitor tracing indicates the waveform has returned to a normal pulmonary artery waveform. The nurse should document the occlusive value and continue to monitor the patient. Turning the patient to the left side, zero referencing the system, and performing a dynamic response test are not necessary as the waveform displayed is normal. 23. The nurse is caring for a patient with an arterial monitoring system. The nurse assesses the patient’s noninvasive cuff blood pressure to be 70/40 mm Hg. The arterial blood pressure measurement via an intraarterial catheter in the same arm is assessed by the nurse to be 108/70 mm Hg. What is the best action by the nurse? Under normal circumstances, a difference of 10 to 20 mm Hg or more between invasive and noninvasive blood pressure is expected, with the invasive value being higher than the noninvasive value. The cuff used for noninvasive measurement should be assessed for proper cuff size. Given that the invasive value is substantially higher, before initiating corrective actions based on a single noninvasive measurement, such as activating the rapid response system, placing the patient in Trendelenburg position, or administering a fluid bolus, further assessment and troubleshooting are necessary. 24. The nurse is caring for a patient with an admitting diagnosis of congestive heart failure. While attempting to obtain a pulmonary artery occlusion pressure in the supine position, the patient becomes anxious and tachypneic. What is the best action by the nurse? Hemodynamic parameters can be accurately measured and trended with the head of the bed elevated to 45 degrees as long as the zeroing stopcock is properly leveled to the phlebostatic axis. Elevating the head of the bed to 45 degrees would be the optimum position to obtain a pulmonary artery occlusion pressure for a patient who becomes anxious and tachypneic when flat. Administering antianxiety medications is not standard of care for obtaining hemodynamic pressures. Encouraging slow, deep breaths while supine may inappropriately alter hemodynamic readings by altering intrathoracic pressure. 25. The nurse returns from the cardiac catheterization laboratory with a patient following insertion of a pulmonary artery catheter and assists in transferring the patient from the stretcher to the bed. Before obtaining a cardiac output, which action is most important for the nurse to complete? To ensure accurate measurement, zero referencing of the transducer system is a priority action after moving a patient and should be completed before obtaining readings. A pulmonary artery catheter occlusion pressure should be documented before obtaining a cardiac output, but without zero referencing the system following movement of a patient, the obtained value may be inaccurate. Inflating the pulmonary artery catheter balloon with 1 mL of air, while appropriate, is not a step required before obtaining a cardiac output. The nurse injects 5-10 mL of normal saline into the proximal port in order to measure the cardiac output; this is not a step done before obtaining the measurement. 26. The charge nurse is supervising the care of four critical care patients being monitored using invasive hemodynamic modalities. Which patient should the charge nurse evaluate first? A cardiac output of 2.0 L/min in a patient with cardiogenic shock warrants immediate assessment. A PAP of 20 mm Hg, CVP of 6 mm Hg, and a PAOP of 10 mm Hg are all within normal limits. 27. The nurse is caring for a mechanically ventilated patient being monitored with a left radial arterial line. During the inspiratory phase of ventilation, the nurse assesses a 20 mm Hg decrease in arterial blood pressure. What is the best interpretation of this finding by the nurse? The increase in thoracic pressure that occurs during the inspiration phase of positive pressure ventilation decreases venous return, decreasing systolic blood pressure. A systolic blood pressure variation or decrease of more than 10 mm Hg in a mechanically ventilated patient is indicative of a patient who would respond to fluid resuscitation and improve tissue perfusion. There is no evidence to indicate the ventilator is malfunctioning, the arterial line needs to be replaced, or that the left limb may have reduced perfusion. 28. Upon entering the room of a patient with a right radial arterial line, the nurse assesses the waveform to be slightly dampened and notices blood to be backed up into the pressure tubing. What is the best action by the nurse? To maintain the patency of the arterial line, the inflation volume of the flush system pressure bag should be inflated to 300 mm Hg to ensure a constant flow of fluid through the system, preventing backward flow of blood into the system tubing. Disconnecting the flush system from the arterial line is inappropriate and could increase the risk of infection to the patient. Zero referencing the system will not help clear the blood from the system tubing. Reducing the number of stopcocks helps reduce the risk of a disconnection that could lead to excessive blood loss. 29. The nurse is caring for a patient with a left radial arterial line and a pulmonary artery catheter inserted into the right subclavian vein. Which action by the nurse best ensures the safety of the patient