Practice Questions: Shock, Sepsis, Critical Care

A massive gastrointestinal bleed has resulted in hypovolemic shock in an older patient. What is a priority nursing diagnosis?

a. Acute pain

b. Impaired skin integrity

c. Decreased cardiac output

d. Ineffective tissue perfusion

d. Ineffective tissue perfusion

(The many deleterious effects of shock are all related to inadequate perfusion and oxygenation of every body system. This nursing diagnosis supersedes the other diagnoses.)

A 50-yr-old woman with a suspected brain tumor is scheduled for a CT scan with contrast media. The nurse notifies the physician that the patient reported an allergy to shellfish. Which response by the physician should the nurse question?

a. Infuse IV diphenhydramine before the procedure.

b. Administer lorazepam (Ativan) before the procedure.

c. Complete the CT scan without the use of contrast media.

d. Premedicate with hydrocortisone sodium succinate (Solu-Cortef).

b. Administer lorazepam (Ativan) before the procedure.

(An individual with an allergy to shellfish is at an increased risk to develop anaphylactic shock if contrast media is injected for a CT scan. To prevent anaphylactic shock, the nurse should always confirm the patient's allergies before diagnostic procedures (e.g., CT scan with contrast media). Appropriate interventions may include cancelling the procedure, completing the procedure without contrast media, or premedication with diphenhydramine or hydrocortisone. IV fluids may be given to promote renal clearance of the contrast media and prevent renal toxicity and acute kidney injury. The use of an antianxiety agent such as lorazepam would not be effective in preventing an allergic reaction to the contrast media.)

A 64-yr-old woman is admitted to the emergency department vomiting bright red blood. The patient's vital signs are blood pressure of 78/58 mm Hg, pulse of 124 beats/min, respirations of 28 breaths/min, and temperature of 97.2°F (36.2°C). Which physician order should the nurse complete first?

a. Obtain a 12-lead ECG and arterial blood gases.

b. Rapidly administer 1000 mL normal saline solution IV.

c. Administer norepinephrine (Levophed) by continuous IV infusion.

d. Carefully insert a nasogastric tube and an indwelling bladder catheter.

b. Rapidly administer 1000 mL normal saline solution IV.

(Isotonic crystalloids, such as normal saline solution, should be used in the initial resuscitation of hypovolemic shock. Vasopressor drugs (e.g., norepinephrine) may be considered if the patient does not respond to fluid resuscitation and blood products. Other orders (e.g., insertion of nasogastric tube and indwelling bladder catheter and obtaining the diagnostic studies) can be initiated after fluid resuscitation is initiated.)

The nurse would recognize which clinical manifestation as suggestive of sepsis?

a. Sudden diuresis unrelated to drug therapy

b. Hyperglycemia in the absence of diabetes

c. Respiratory rate of seven breaths per minute

d. Bradycardia with sudden increase in blood pressure

b. Hyperglycemia in the absence of diabetes

(Hyperglycemia in patients with no history of diabetes is a diagnostic criterion for sepsis. Oliguria, not diuresis, typically accompanies sepsis along with tachypnea and tachycardia.)

The nurse is caring for a 72-yr-old man in cardiogenic shock after an acute myocardial infarction. Which clinical manifestations would be most concerning?

a. Restlessness, heart rate of 124 beats/min, and hypoactive bowel sounds

b. Mean arterial pressure of 54 mm Hg; increased jaundice; and cold, clammy skin

c. PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and puncture site bleeding

d. Agitation, respiratory rate of 32 breaths/min, and serum creatinine of 2.6 mg/dL

c. PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and puncture site bleeding

(Severe hypoxemia, lactic acidosis, and bleeding are clinical manifestations of the irreversible state of shock. Recovery from this stage is not likely because of multiple organ system failure. Restlessness, tachycardia, and hypoactive bowel sounds are clinical manifestations that occur during the compensatory stage of shock. Decreased mean arterial pressure, jaundice, cold and clammy skin, agitation, tachypnea, and increased serum creatinine are clinical manifestations of the progressive stage of shock.)

What laboratory finding is consistent with a medical diagnosis of cardiogenic shock?

a. Decreased liver enzymes

b. Increased white blood cells

c. Decreased red blood cells, hemoglobin, and hematocrit

d. Increased blood urea nitrogen (BUN) and serum creatinine (Cr) levels

d. Increased blood urea nitrogen (BUN) and serum creatinine (Cr) levels

(The renal hypoperfusion that accompanies cardiogenic shock results in increased BUN and creatinine levels. Impaired perfusion of the liver results in increased liver enzymes, but white blood cell levels do not typically increase in cardiogenic shock. Red blood cell indices are typically normal because of relative hypovolemia.)

A patient's localized infection has become systemic and septic shock is suspected. What medication is expected to treat septic shock refractory to fluids?

a. Insulin infusion

b. Furosemide (Lasix) IV push

c. Norepinephrine administered by titration

d. Administration of nitrates and β-adrenergic blockers

c. Norepinephrine administered by titration

(If fluid resuscitation using crystalloids is not effective, vasopressor medications such as norepinephrine (Levophed) & dopamine are indicated to restore mean arterial pressure (MAP). Nitrates and β-adrenergic blockers are most often used in the treatment of patients in cardiogenic shock. Furosemide (Lasix) is indicated for patients with fluid volume overload. Insulin infusion may be administered to normalize blood sugar and improve overall outcomes, but it is not considered a medication used to treat shock.)

After coronary artery bypass graft surgery a patient has postoperative bleeding that requires returning to surgery for repair. During surgery, the patient has a myocardial infarction (MI). After restoring the patient's body temperature to normal, which patient parameter is the most important for planning nursing care?

a. Cardiac index (CI) of 5 L/min/m2

b. Central venous pressure of 8 mm Hg

c. Mean arterial pressure (MAP) of 86 mm Hg

d. Pulmonary artery pressure (PAP) of 28/14 mm Hg

d. Pulmonary artery pressure (PAP) of 28/14 mm Hg

(Pulmonary hypertension as indicated by an elevated PAP indicates impaired forward flow of blood because of left ventricular dysfunction or hypoxemia. Both can be a result of the MI. The CI, CVP, and MAP readings are normal.)

The nurse is caring for a 29-yr-old man who was admitted 1 week ago with multiple rib fractures, pulmonary contusions, and a left femur fracture from a motor vehicle crash. The attending physician states the patient has developed sepsis, and the family members have many questions. Which information should the nurse include when explaining the early stage of sepsis?

a. Antibiotics are not useful when an infection has progressed to sepsis.

b. Weaning the patient away from the ventilator is the top priority in sepsis.

c. Large amounts of IV fluid are required in sepsis to fill dilated blood vessels.

d. The patient has recovered from sepsis if he has warm skin and ruddy cheeks.

c. Large amounts of IV fluid are required in sepsis to fill dilated blood vessels.

(Patients with sepsis may be normovolemic, but because of acute vasodilation, relative hypovolemia and hypotension occur. Patients in septic shock require large amounts of fluid replacement and may require frequent fluid boluses to maintain circulation. Antibiotics are an important component of therapy for patients with septic shock. They should be started after cultures (e.g., blood, urine) are obtained and within the first hour of septic shock. Oxygenating the tissues is the top priority in sepsis, so efforts to wean septic patients from mechanical ventilation halt until sepsis is resolving. Additional respiratory support may be needed during sepsis. Although cool and clammy skin is present in other early shock states, the patient in early septic shock may feel warm and flushed because of a hyperdynamic state.)

When caring for a patient in acute septic shock, what should the nurse anticipate?

a. Infusing large amounts of IV fluids

b. Administering osmotic and/or loop diuretics

c. Administering IV diphenhydramine (Benadryl)

d. Assisting with insertion of a ventricular assist device (VAD)

a. Infusing large amounts of IV fluids

(Septic shock is characterized by a decreased circulating blood volume. Volume expansion with the administration of IV fluids is the cornerstone of therapy. The administration of diuretics is inappropriate. VADs are useful for cardiogenic shock not septic shock. Diphenhydramine may be used for anaphylactic shock but would not be helpful with septic shock.)

A patient has a spinal cord injury at T4. Vital signs include falling blood pressure with bradycardia. The nurse recognizes that the patient is experiencing

a. a relative hypervolemia.

b. an absolute hypovolemia.

c. neurogenic shock from low blood flow.

d. neurogenic shock from massive vasodilation.

d. neurogenic shock from massive vasodilation.

(Neurogenic shock results in massive vasodilation without compensation as a result of the loss of sympathetic nervous system vasoconstrictor tone. Massive vasodilation leads to a pooling of blood in the blood vessels, tissue hypoperfusion, and, ultimately, impaired cellular metabolism. Clinical manifestations of neurogenic shock are hypotension (from the massive vasodilation) and bradycardia (from unopposed parasympathetic stimulation).)

A 78-yr-old man has confusion and temperature of 104°F (40°C). He is a diabetic with purulent drainage from his right heel. After an infusion of 3 L of normal saline solution, his assessment findings are BP 84/40; heart rate 110; respiratory rate 42 and shallow; CO 8 L/minute; and PAWP mm Hg. This patient's symptoms are most likely indicative of

a. sepsis.

b. septic shock.

c. multiple organ dysfunction syndrome.

d. systemic inflammatory response syndrome.

b. septic shock.

(Septic shock is the presence of sepsis with hypotension despite fluid resuscitation along with the presence of inadequate tissue perfusion. To meet the diagnostic criteria for sepsis, the patient's temp must be higher than 100.9° F (38.3° C), or the core temp must be lower than 97.0° F (36° C). Hemodynamic parameters for septic shock include elevated heart rate; decreased pulse pressure, blood pressure, systemic vascular resistance, central venous pressure, and pulmonary artery wedge pressure; normal or elevated pulmonary vascular resistance; and decreased, normal, or increased pulmonary artery pressure, cardiac output, and mixed venous O2 saturation.)

Appropriate treatment modalities for the management of cardiogenic shock include (select all that apply)

a. dobutamine to increase myocardial contractility.

b. vasopressors to increase systemic vascular resistance.

c. circulatory assist devices such as an intraaortic balloon pump.

d. corticosteroids to stabilize the cell wall in the infarcted myocardium.

e. Trendelenburg positioning to facilitate venous return and increase preload.

a. dobutamine to increase myocardial contractility.

c. circulatory assist devices such as an intraaortic balloon pump.

(Dobutamine (Dobutrex) is used in patients in cardiogenic shock with severe systolic dysfunction. Dobutamine increases myocardial contractility, decreases ventricular filling pressures, decreases systemic vascular resistance and pulmonary artery wedge pressure, and increases cardiac output, stroke volume, and central venous pressure. Dobutamine may increase or decrease the heart rate. The workload of the heart in cardiogenic shock may be reduced with the use of circulatory assist devices such as an intraaortic balloon pump or ventricular assist device.)

What is the key factor in describing any type of shock

a. hypoxemia

b. hypotension

c. vascular collapse

d. inadequate tissue perfusion

d. inadequate tissue perfusion

What physical problems could precipitate hypovolemic shock (select all)

a. burns

b. ascites

c. vaccines

d. insect bites

e. hemorrhage

f. ruptured spleen

a. burns

b. ascites

e. hemorrhage

f. ruptured spleen

A 70 year old pt is malnourished, has a history of type 2 diabetes mellitus, and is admitted from the nursing home w/ pneumonia. For which kind of shock should the nurse closely monitor this pt?

a. septic shock

b. neurogenic shock

c. cardiogenic shock

d. anaphylactic shock

a. septic shock

Which hemodynamic monitoring description of the identified shock is accurate?

a. tachycardia w/ HTN is characteristic of neurogenic shock

b. in cardiogenic shock the pt will have increased pulmonary artery wedge pressure and a decreased cardiac output

c. anaphylactic shock is characterized by increased systemic vascular resistance, decreased cardiac output, and decreased PAWP

d. in septic shock, bacterial endotoxins cause vascular changes that result in increased systemic vascular resistance and decreased CO

b. in cardiogenic shock the pt will have increased pulmonary artery wedge pressure and a decreased cardiac output

In the compensatory stage of hypovolemic shock, to what organs does blood flow decrease after the sympathetic nervous system activates the alpha-adrenergic stimulation (select all)

a. skin

b. brain

c. heart

d. kidneys

e. gastrointestinal tract

a. skin

d. kidneys

e. gastrointestinal tract

As the body continues to try to compensate for hypovolemic shock, there is increased angiotensin II from the activation of the renin-angiotensin-aldosterone system. What physiologic change occurs r/t the increased angiotensin II?

a. vasodilation

b. decreased BP and CO

c. aldosterone release results in sodium and water excretion

d. ADH release increases water reabsorption

d. ADH release increases water reabsorption

The pt is in compensatory stage of shock, what manifestations indicate this to the nurse (select all)

a. pale and cool

b. unresponsive

c. lower BP than baseline

d. moist crackles in the lungs

e. hyperactive bowel sounds

f. tachypnea and tachycardia

a. pale and cool

c. lower BP than baseline

f. tachypnea and tachycardia

The nurse suspects sepsis as a cause of shock when the laboratory test results indicate

a. hypokalemia

b. thrombocytopenia

c. decreased hemoglobin

d. increased blood urea nitrogen (BUN)

b. thrombocytopenia

Progressive tissue hypoxia leading to anaerobic metabolism and metabolic acidosis is characteristic of the progressive stage of shock. What changes in the heart contribute to this increasing tissue hypoxia?

a. arterial constriction causes decreased perfusion

b. vasoconstriction decreases blood flow to pulmonary capillaries

c. increased capillary permeability and profound vasoconstriction cause increased hydrostatic pressure

d. decreased perfusion occurs, leading to dysrhythmias, decreased CO, and decreased oxygen delivery to cells

d. decreased perfusion occurs, leading to dysrhythmias, decreased CO, and decreased oxygen delivery to cells

A pt w/ acute pancreatitis is experiencing hypovolemic shock. which initial orders for the pt will the nurse implement first?

a. start 1000 mL of NS at 500 ml/hr

b. obtain blood cultures before starting IV antibiotics

c. draw blood for hematology and coagulation factors

d. administer high-flow oxygen w/ a non-rebreather mask

d. administer high-flow oxygen w/ a non-rebreather mask

What abnormal finding should the nurse expect to find in early compensatory shock?

a. metabolic acidosis

b. increased serum sodium

c. decreased BG

d. increased serum potassum

b. increased serum sodium

A pt w/ hypovolemic shock is receiving LR solution for fluid replacement therapy. During this therapy, which laboratory result is the most important for the nurse to monitor?

a. serum pH

b. serum sodium

c. serum potassium

d. Hgb and Hct

a. serum pH

The nurse determines that a large amount of crystalloid fluids administered to a pt on septic shock is effective when hemodynamic monitoring reveals what?

a. CO of 2.6 L/min

b. CVP of 15 mm Hg

c. PAWP of 4 mm Hg

d. HR of 106

b. CVP of 15 mm Hg

When caring for a pt in cardiogenic shock, the nurse recognizes that the metabolic demands of turning and moving the pt exceed the O2 supply when what change is revealed in hemodynamic monitoring?

a. SvO2 from 62% to 54%

b. CO from 4.2 L/min to 4.8 L/min

c. SV from 52 to 68 mL/beat

d. SVR from 1300 dyne/sec/cm5 to 1120 dyne/sec/cm5

a. SvO2 from 62% to 54%

During administration of IV norepinephrine (Levophed), what should the nurse assess the patient for?

a. hypotension

b. marked diuresis

c. metabolic alkalosis

d. decreased tissue perfusion

d. decreased tissue perfusion

When administering any vasoactive drug during the treatment of shock, the nurse should know that what is the goal of therapy?

a. increasing urine output to 50 mL/day

b. constriction of vessels to maintain BP

c. maintaining a MAP of at least 65 mm Hg

d. dilating vessels to improve tissue perfusion

c. maintaining a MAP of at least 65 mm Hg

What is the priority nursing responsibility in the prevention of shock?

a. frequently monitoring all pts vital signs

b. using aseptic technique for all invasive procedures

c. being aware of the potential for shock in all pts at risk

d. teaching pts health promotion activities to prevent shock

c. being aware of the potential for shock in all pts at risk

Which indicators of tissue perfusion should be monitored in critically ill patients by the nurse? SATA

a. skin

b. urine output

c. level of consciousness

d. ADLs

e. vital signs, including pulse oximetry

f. peripheral pulses w/ cap refil

a. skin

b. urine output

c. level of consciousness

e. vital signs, including pulse oximetry

f. peripheral pulses w/ cap refil

A pt in shock has a nursing diagnosis of fear r/t severity of condition and perceived threat of death as manifested by verbalization of anxiety about condition and fear of death. What is an appropriate nursing intervention for the pt?

a. administer antianxeity agents

b. allow caregivers to visit as much as possible

c. call a member of the clergy to visit the pt

d. inform the pt of the current plan of care and its rationale

d. inform the pt of the current plan of care and its rationale

1. A patient who has been in the intensive care unit for 4 days has disturbed sensory perception from 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 2200 and 0600 to allow uninterrupted sleep.

ANS: B

Clustering nursing activities and providing uninterrupted rest periods will minimize sleep-cycle

disruption. Sedative and opioid medications tend to decrease the amount of rapid eye movement (REM)

sleep and can contribute to sleep disturbance and disturbed sensory perception. Silencing the alarms on

the cardiac monitors would be unsafe in a critically ill patient, as would discontinuing all assessments

during the night.

2. Which hemodynamic parameter best reflects the effectiveness of drugs that the nurse gives to reduce a patient's 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

SVR reflects the resistance to ventricular ejection, or afterload. The other parameters may be monitored

but do not reflect afterload as directly.

3. While close family members are visiting, a patient has a respiratory arrest, and resuscitation is started. 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

Evidence indicates that many family members want the option of remaining in the room during

procedures such as cardiopulmonary resuscitation (CPR) and that this decreases anxiety and facilitates

grieving. The other options may be appropriate if the family decides not to remain with the patient.

4. After surgery for an abdominal aortic aneurysm, a patient's central venous pressure (CVP) monitor indicates low pressures. Which action should the nurse take?

a. Administer IV diuretic medications.

b. Increase the IV fluid infusion per protocol.

c. Increase the infusion rate of IV vasodilators.

d. Elevate the head of the patient's bed to 45 degrees.

ANS: B

A low CVP indicates hypovolemia and a need for an increase in the infusion rate. Diuretic administration

will contribute to hypovolemia and elevation of the head or increasing vasodilators may decrease cerebral

perfusion.

5. When caring for a patient with pulmonary hypertension, which parameter will the nurse use to directly 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

PVR is a major contributor to pulmonary hypertension, and a decrease would indicate that pulmonary

hypertension was improving. The other parameters may also be monitored but do not directly assess for

pulmonary hypertension.

6. The intensive care unit (ICU) nurse educator determines that teaching a new staff nurse about arterial pressure monitoring 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 with changes in the patient's position.

ANS: B

For accurate measurement of pressures, the zero-reference level should be at the phlebostatic axis. There

is no need to rebalance and recalibrate monitoring equipment every 2 hours. Accurate hemodynamic

readings are possible with the patient's head raised to 45 degrees or in the prone position. The anatomic

position of the phlebostatic axis does not change when patients are repositioned.

7. When monitoring the effectiveness of treatment for a patient with a large anterior wall myocardial infarction, the most pertinent measurement 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

PAWP reflects left ventricular end diastolic pressure (or left ventricular preload) and is a sensitive

indicator of cardiac function. Because the patient is high risk for left ventricular failure, the PAWP must

be monitored. An increase will indicate left ventricular failure. The other values would also provide

useful information, but the most definitive measurement of changes in cardiac function is the PAWP.

8. Which action should the nurse 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. Re-zero the monitoring equipment.

ANS: C

The low pressure alarm indicates a drop in the patient's blood pressure, which may be caused by cardiac

dysrhythmias. There is no indication to re-zero the equipment. Pallor of the left hand would be caused by

occlusion of the radial artery by the arterial catheter, not by low pressure. There is no indication of a need

for flushing the line.

9. Which nursing action is needed when preparing to assist with the insertion of a pulmonary artery catheter?

a. Determine if the cardiac troponin level is elevated.

b. Auscultate heart sounds before and during insertion.

c. Place the patient on NPO status before the procedure.

d. Attach cardiac monitoring leads before the procedure.

ANS: D

Dysrhythmias can occur as the catheter is floated through the right atrium and ventricle, and it is

important for the nurse to monitor for these during insertion. Pulmonary artery catheter insertion does not

require anesthesia, and the patient will not need to be NPO. Changes in cardiac troponin or heart and

breath sounds are not expected during pulmonary artery catheter insertion.

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 action?

a. The right hand feels 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 2 days previously.

ANS: A

The change in temperature of the right hand suggests that blood flow to the right hand is impaired. The

flush system needs to be changed every 96 hours. A mean arterial pressure (MAP) of 75 mm Hg is

normal. Flush systems for hemodynamic monitoring are set up to deliver 3 to 6 mL/hr of flush solution.

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

ANS: C

A CO of 5 L/min is normal and indicates that the IABP has been successful in treating the shock. The low

SV signifies continued cardiogenic shock. The tachycardia and low urine output also suggest continued

cardiogenic shock.

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. Avoid the use of anticoagulant medications.

b. Measure the patient's urinary output every hour.

c. Provide passive range of motion for all extremities.

d. Position the patient supine with head flat at all times.

ANS: B

Monitoring urine output will help determine whether the patient's cardiac output has improved and also

help monitor for balloon displacement blocking the renal arteries. The head of the bed can be elevated up

to 30 degrees. Heparin is used to prevent thrombus formation. Limited movement is allowed for the

extremity with the balloon insertion site to prevent displacement of the balloon.

15. While waiting for heart transplantation, a patient with severe cardiomyopathy has a ventricular assist device (VAD) implanted. When planning care for this patient, the nurse should anticipate

a. preparing the patient for a permanent VAD.

b. administering immunosuppressive medications.

c. teaching the patient the reason for complete bed rest.

d. monitoring the surgical incision for signs of infection.

ANS: D

The insertion site for the VAD provides a source for transmission of infection to the circulatory system

and requires frequent monitoring. Patients with VADs are able to have some mobility and may not be on

bed rest. The VAD is a bridge to transplantation, not a permanent device. Immunosuppression is not

necessary for nonbiologic devices such as the VAD.

24. The nurse is caring for a patient receiving a continuous norepinephrine IV infusion. Which patient assessment finding indicates that the infusion rate may need to be adjusted?

a. Heart rate is slow at 58 beats/min.

b. Mean arterial pressure (MAP) is 56 mm Hg.

c. Systemic vascular resistance (SVR) is elevated.

d. Pulmonary artery wedge pressure (PAWP) is low.

ANS: C

Vasoconstrictors such as norepinephrine will increase SVR, and this will increase the work of the heart

and decrease peripheral perfusion. The infusion rate may need to be decreased. Bradycardia, hypotension

(MAP of 56 mm Hg), and low PAWP are not associated with norepinephrine infusion.

25. When evaluating a patient with a central venous catheter, the nurse observes that the insertion site is red and tender to touch and the patient's temperature is 101.8° F. What should the nurse plan to do?

a. Discontinue the catheter and culture the tip.

b. Use the catheter only for fluid administration.

c. Change the flush system and monitor the site.

d. Check the site more frequently for any swelling.

ANS: A

The information indicates that the patient has a local and systemic infection caused by the catheter, and

the catheter should be discontinued to avoid further complications such as endocarditis. Changing the

flush system, continued monitoring, or using the line for fluids will not help prevent or treat the infection.

26. An 81-yr-old patient who has been in the intensive care unit (ICU) for a week is now stable and transfer to the progressive care unit is planned. On rounds, the nurse notices that the patient has new onset confusion. The nurse will plan to

a. give PRN lorazepam (Ativan) and cancel the transfer.

b. inform the receiving nurse and then transfer the patient.

c. notify the health care provider and postpone the transfer.

d. obtain an order for restraints as needed and transfer the patient.

ANS: B

The patient's history and symptoms most likely indicate delirium associated with the sleep deprivation

and sensory overload in the ICU environment. Informing the receiving nurse and transferring the patient

is appropriate. Postponing the transfer is likely to prolong the delirium. Benzodiazepines and restraints

contribute to delirium and agitation.

27. The family members of a patient who has been admitted to the intensive care unit (ICU) with multiple traumatic injuries have just arrived in the ICU waiting room. Which action should the nurse take first?

a. Explain ICU visitation policies and encourage family visits.

b. Escort the family from the waiting room to the patient's bedside.

c. Describe the patient's injuries and the care that is being provided.

d. Invite the family to participate in an interprofessional care conference.

ANS: C

Lack of information is a major source of anxiety for family members and should be addressed first.

Family members should be prepared for the patient's appearance and the ICU environment before visiting

the patient for the first time. ICU visiting should be individualized to each patient and family rather than

being dictated by rigid visitation policies. Inviting the family to participate in a multidisciplinary

conference is appropriate but should not be the initial action by the nurse.

28. The nurse is caring for a patient who has an arterial catheter in the left radial artery for arterial pressure-based cardiac output (APCO) monitoring. Which information obtained by the nurse requires a report to the health care provider?

a. The patient has a positive Allen test result.

b. There is redness at the catheter insertion site.

c. The mean arterial pressure (MAP) is 86 mm Hg.

d. The dicrotic notch is visible in the arterial waveform.

ANS: B

Redness at the catheter insertion site indicates possible infection. The Allen test is performed before

arterial line insertion, and a positive test result indicates normal ulnar artery perfusion. A MAP of 86 mm

Hg is normal, and the dicrotic notch is normally present on the arterial waveform.

29. The nurse responds to a ventilator alarm and finds the patient lying in bed gasping and holding the endotracheal tube (ET) in her hand. Which action should the nurse take next?

a. Activate the rapid response team.

b. Provide reassurance to the patient.

c. Call the health care provider to reinsert the tube.

d. Manually ventilate the patient with 100% oxygen.

ANS: D

The nurse should ensure maximal patient oxygenation by manually ventilating with a bag-valve-mask

system. Offering reassurance to the patient, notifying the health care provider about the need to reinsert

the tube, and activating the rapid response team are also appropriate after the nurse has stabilized the

patient's oxygenation.

30. The nurse notes that a patient's endotracheal tube (ET), which was at the 22-cm mark, is now at the 25-cm mark, and the patient is anxious and restless. Which action should the nurse take next?

a. Check the O2 saturation.

b. Offer reassurance to the patient.

c. Listen to the patient's breath sounds.

d. Notify the patient's health care provider.

ANS: C

The nurse should first determine whether the ET tube has been displaced into the right mainstem

bronchus by listening for unilateral breath sounds. If so, assistance will be needed to reposition the tube

immediately. The other actions are also appropriate, but detection and correction of tube malposition are

the most critical actions.