CC practice Questions week 1.| LATEST SOLUTION

CC practice Questions week 1.| LATEST SOLUTION Week 1 Chapter 66 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. . ANS: B 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) . ANS: B 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. . ANS: B 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. . ANS: B 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) . ANS: C 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. . ANS: B 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). . ANS: D 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. . ANS: C 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. . ANS: D 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. . ANS: D 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 lef t 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. . 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. . 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 . 14. The nurse is caring for a patient who has an intraaortic balloon pump in place. Which action should be included in the plan of care? a Position the patient supine at all times. . b Avoid the use of anticoagulant medications. . c. Measure the patients urinary output every hour. d Provide passive range of motion for all extremities. . 15. While waiting for cardiac transplantation, a patient with severe cardiomyopathy has a ventricular assist device (VAD) implanted. When planning care for this patient, the nurse should anticipate a giving immunosuppressive medications. . b preparing the patient for a permanent VAD. . c. teaching the patient the reason for complete bed rest. d monitoring the surgical incision for signs of infection. . 16. To verify the correct placement of an oral endotracheal tube (ET) after insertion, the best initial action by the nurse is to a auscultate for the presence of bilateral breath sounds. . b obtain a portable chest x-ray to check tube placement. . c. observe the chest for symmetric chest movement with ventilation. d use an end-tidal CO2 monitor to check for placement in the trachea. . 17. To maintain proper cuff pressure of an endotracheal tube (ET) when the patient is on mechanical ventilation, the nurse should a inflate the cuff with a minimum of 10 mL of air. . b inflate the cuff until the pilot balloon is firm on palpation. . c. inject air into the cuff until a manometer shows 15 mm Hg pressure. d inject air into the cuff until a slight leak is heard only at peak inflation. . 18. The nurse notes premature ventricular contractions (PVCs) while suctioning a patients endotracheal tube. Which action by the nurse is a priority? a Decrease the suction pressure to 80 mm Hg. . b Document the dysrhythmia in the patients chart. . c. Stop and ventilate the patient with 100% oxygen. d Give antidysrhythmic medications per protocol. . 19. Which assessment finding obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning? a The patients oxygen saturation is 93%. . b The patient was last suctioned 6 hours ago. . c. The patients respiratory rate is 32 breaths/minute. d The patient has occasional audible expiratory wheezes. . 20. The nurse notes thick, white secretions in the endotracheal tube (ET) of a patient who is receiving mechanical ventilation. Which intervention will be most effective in addressing this problem? a Increase suctioning to every hour. . b Reposition the patient every 1 to 2 hours. . c. Add additional water to the patients enteral feedings. d Instill 5 mL of sterile saline into the ET before suctioning.