3 Answers to Core Review Test 3
3-1. (A) Extra heart sounds are heard in both right and left ventricular failure due to filling patterns in a noncompliant ventricle. Basilar crackles, orthopnea, and elevated pulmonary artery pressures are found in patients with left ventricular failure.
3-2. (C) The patient appears to be in status epilepticus. Status epilepticus is defined as seizure activity lasting longer than 5 to 10 minutes or repetitive seizures occurring without full recovery between ictal episodes. These may be generalized convulsive, nonconvulsive (without visible movement), or focal motor seizures. Benzodiazepines are commonly given to stop acute seizures (usually concurrently with an anticonvulsant drug such as phenytoin) and may be repeated after ten minutes if seizure activity persists. While an EEG (Option A) is helpful in diagnosis and treatment planning for patients with seizure disorders, a STAT EEG would not provide any additional information during the acute period. Although some electrolyte disturbances can cause seizures, the description of patient activity is characteristic for status epilepticus, so STAT labs (Option B) are not as high a priority as stopping the seizure activity. The longer a seizure lasts, the more difficult it is to control. Most commonly, seizures refractory to these treatments are stopped with barbiturate infusion. However, the above measures are attempted prior to treatment with barbiturates (Option D). Additionally, the barbiturate dose is twice the recommended dosing (10 mg/kg over 30 minutes followed by a continuous infusion at a lower rate).
3-3. (D) Up to 70% of houses built before 1960 have surfaces covered in lead-based paint. Lead poisoning does not produce a classic toxidrome that facilitates easy diagnosis. Lead is compartmentalized into three main areas: bones, soft tissue (including the brain), and blood. Organic lead is assimilated rapidly by the CNS and can produce a host of neuropsychiatric manifestations as described. Cyanide poisoning presents with signs and symptoms that are primarily cardiopulmonary in nature: dysrhythmias, asystole, hypotension, and cardiovascular collapse. Carbon monoxide (CO) exposure results in tissue hypoxia and cellular toxicity. CO binds with hemoglobin in place of oxygen. The organs with the greatest sensitivity to hypoxia—the CNS and cardiovascular system—are affected the most. In addition to neuropsychiatric manifestations, patients with CO poisoning will present with dyspnea, tachycardia, and cardiac ischemia. Pesticide exposure produces a cholinergic crisis. Signs and symptoms would include sweating, pupillary constriction, excessive salivation, bradycardia, and blurred vision.
3-4. (D) The left anterior descending coronary artery supplies the left ventricle (LV) and septum, including the bundle of His and bundle branches. Occlusion of the left anterior descending artery may cause LV failure, resulting in heart failure, pulmonary edema, and heart block. Bradycardia is associated with occlusion of the right coronary artery which supplies the SA and AV nodes. Left ventricular aneurysm is associated with circumflex artery occlusion and posterior myocardial infarction. Mitral regurgitation and papillary muscle dysfunction are associated with right coronary artery and circumflex artery occlusions.
3-5. (A) Many Mediterranean males have a glucose-6-phosphate dehydrogenase enzyme (G6PD) deficiency. This genetic variation increases the risk for hemolysis if the patient receives aspirin. Options B, C, and D are incorrect because the metabolism of these medications is not altered with G6PD deficiency.
Reference: Glucose-6-phosphate dehydrogenase deficiency. Available at www.nlm.nih.gov/medlineplus/ency/article/000528.htm. Retrieved on July 1, 2006.
3-6. (D) The incision in abdominal aortic aneurysm extends from thorax to umbilicus. Pain control is the most urgent problem for the hemodynamically stable patient in the immediate postoperative period. Return of circulation to the extremities after aneurysm repair is dependent upon the preoperative circulatory status. Coughing and deep breathing and use of incentive spirometry are required after extubation and may require premedication with analgesics to prevent incisional pain. The patient is usually extubated within 24 hours unless pre-existing pulmonary disease is present. Because the patient is NPO and may have had a preoperative bowel prep, a bowel protocol is usually instituted after 2 or more days after surgery.
Reference: Fahey, V. A. Vascular Nursing, 4th ed. St. Louis, Elsevier, 2004.
3-7. (B) Because this patient is minimally responsive, endotracheal intubation is indicated for acute respiratory failure. The diagnosis of acute respiratory failure is supported by the ABG findings of respiratory acidosis and hypoxemia. BiPAP may be used in respiratory failure patients who are responsive. Although low flow oxygen is frequently used in COPD, this patient is in acute respiratory failure, and the low flow delivery would not be beneficial in correcting the PaCO2. Correction of pH is best accomplished by decreasing the PaCO2. If the pH was lower than 7.20, sodium bicarbonate might also be indicated.
3-8. (B) Hepatitis B infections are prevalent in persons of Asian descent. Many individuals are infected at birth and remain unaware of the infection until they develop symptoms. Acute presentation includes jaundice, elevated transaminases, positive HBVsAg, and positive HBV DNA quantatitive level of virus. Hepatitis A (Option A) would be the diagnosis if the HAV IgM was positive and the HAV IgG was negative. This would indicate an acute infection with hepatitis A virus. The HAV IgG being positive in this case indicates a past infection with hepatitis A. Hepatitis C infection (Option C) is usually asymptomatic and noted in a lab result of HCV ab (antibody) that is positive. In this case, the antibody result is negative. Hepatitis D (Option D) is associated with hepatitis B but is not reflected in the laboratory results shown in the table on the next page.
| Hepatitis A Virus (HAV) | |
|---|---|
| HAV Total Antibody | Presence in serum confers lifelong immunity. |
| HAV IgM | Rises early during infection (detectable at 3-4 weeks after exposure and just before liver tests elevate); indicates acute infection; returns to normal in approximately 8 weeks. |
| HAV IgG | Rises slowly during infection (detectable at 6-12 weeks after exposure and persists for more than 10 years after infection). |
| Hepatitis B Virus (HBV) | |
|---|---|
| HBsAg | HBV surface antigen; most commonly used marker for HBV infection; detectable within 30 days of exposure and persists up to 3 months after jaundice unless a carrier state develops, in which case it will persist longer; presence in serum (seropositivity) indicates active hepatitis B infection. |
| HBsAb | Antibody to HBsAg; presence in serum (seropositivity) indicates HBV immunity due to HBV infection or vaccination; detectable 4-12 weeks after HBsAg disappears. |
| HBeAg | HBV e antigen; found only in sera positive for HBsAg; presence in serum (seropositivity) indicates high titer of HBV (extensive viral replication) and increased infectiousness (ongoing viral replication); detectable 4-6 weeks after exposure. Persistence of this marker in the blood predicts the development of chronic HBV infection. |
| HbeAb | HBV e antibody; indicates that an acute phase of HBV infection is over or almost over with reduced infectability. Appears at 4-6 weeks. |
| HBcAg | HBV core antigen; not detectable in serum, detectable only in hepatocytes. |
| HbcAb Total | Antibody to HBcAg; detectable 3-12 weeks after exposure during what is referred to as the “window phase” (after HBsAg disappears but before HBsAb appears). |
3-9. (D) Left ventricular strain pattern on the ECG indicates that myocardial end organ dysfunction has occurred. Blurred vision may be caused by vitreal hemorrhages or cotton-wool patches common in hypertensive crisis. These are usually reversible when hypertension is controlled. The BUN is normal and does not indicate renal end organ dysfunction. It is anticipated that patients will feel lethargic following blood pressure reduction for hypertensive crisis.
3-10. (D) Contralateral symptoms in the lower extremity usually relate to anterior cerebral artery circulation problems. All of these findings can occur after aneurysmal subarachnoid hemorrhage, but the clinical signs described are most commonly associated with vasospasm of the right anterior cerebral artery. Hyponatremia (Option A) does occur in this patient population but is not a likely cause of a focal deficit or acute change. Rebleed (Option B) as well as hydrocephalus (Option C) would likely cause deficits of a more global nature.
References: Greenberg, M. S. (ed.). Handbook of Neurosurgery, 6th ed. New York, Thieme Medical Publishers, 2006.
3-11. (A) Because the patient must undergo cardiopulmonary bypass and hypothermia, as well as receive multiple transfusions, this patient is at high risk for coagulopathy. Aneurysm development is associated with smoking and hypertension. Presence of an aneurysm may contribute to traumatic rupture but need not be present for rupture to occur. If the patient had a history of both hypertension and smoking, he may be at risk of difficulty in the weaning process. The large surgical incision could place the patient at risk of pain interference with weaning, but this may be controlled with adequate analgesic measures. Since hemodynamic instability is anticipated in the early postoperative period, weaning is generally deferred at that time. Postoperative myocardial infarction is associated with the presence of cardiac risk factors and may be related to the original cause of the motor vehicle crash. Cross-clamping of the aorta places the patient at high risk of spinal cord injury, but not stroke.
Reference: Leung, J. M. Cardiac and Vascular Anesthesia. Philadelphia, Elsevier, 2004.
3-12. (C) COPD patients can demonstrate isolated elevations in PA pressures because of compensatory hypoxemic vasoconstriction, which increases pressures in the pulmonary circulation. Option A shows elevation across all hemodynamic variables, a finding often associated with pericardial tamponade. Option B shows uniformly low hemodynamic pressures, a pattern that may be observed in patients with hypovolemia. Option D shows an isolated elevation in the PAOP, a finding associated with left ventricular failure.
3-13. (B) Ventricular septal rupture and papillary muscle rupture may occur abruptly after acute MI and are associated with loud systolic murmurs and left ventricular (LV) failure. Immediate treatment is aimed at reducing LV afterload using vasodilators and IABP therapy. If surgery was performed for this patient, CABG would not be the appropriate procedure because patency of the coronary arteries is not responsible for the clinical findings. PCI is ineffective to treat either ventricular septal rupture or papillary muscle rupture. Emergency valve or septal surgery is indicated in this case. Endovascular repair of septal defects may be performed. Administration of vasoconstricting agents may worsen failure.
3-14. (C) This patient has low levels in ability to participate in care related to her vision impairment. Data support that case management planning and coordination of care has the potential to reduce patient readmission rates. Option A is not correct at this time as all other options should be explored prior to removing the patient from her home. Option B is incorrect as it does not address the patient’s visual problem, though it would have been part of the solution if the patient were lacking understanding of how to administer insulin. Option D is not correct as there is no indication that family members can be relocated to care for the patient at home.
3-15. (D) Identification and treatment of the underlying source of inflammation or infection is the most important element in reducing mortality associated with SIRS/MODS. Medical and surgical interventions to remove sources of infection or contamination may limit the inflammatory response and improve the patient’s chances of recovery. Pain and associated anxiety can increase the patient’s oxygen consumption. For patients who are exhibiting signs of low tissue perfusion, pain management needs to be addressed. Maintenance of tissue oxygenation by focusing on interventions that decrease oxygen demand and increase oxygen delivery will preserve organ function until the underlying problem (infectious process or inflammatory condition) is corrected or resolved. Hypermetabolism in SIRS/MODS results in profound weight loss, cachexia, and loss of organ function. The goal of nutritional/metabolic support is to preserve organ structure and function. Nutrition will prevent generalized nutritional deficiencies and preserve gut integrity.
3-16. (A) If the balloon catheter advances too far caudally, it obstructs the subclavian artery, resulting in pallor and decreased pulses in the left upper extremity. If the balloon were obstructing the renal artery, urine output would decrease. Balloon timing is assessed by placing the patient on 1:2 timing and observing the balloon assisted systolic and diastolic waveforms with the patient’s arterial waveform and ECG. The patient described here does not evidence problems related to timing (e.g., suboptimal hemodynamics). Pulses in the lower balloon insertion extremity would be decreased when compared with the unaffected extremity if the balloon catheter was impeding flow to the insertion extremity.
3-17. (A) When providing care for bariatric patients, the nurse should expect to find a high incidence of low self-esteem. This population will likely benefit from clear and feasible goals established frequently with considerable amounts of encouragement distributed generously during the postoperative period. Although some bariatric patients may have needs related to dependence versus independence, personal autonomy, and trusting others, these have not been identified in the literature as characteristic of the bariatric patient.
3-18. (C) COPD is characterized by permanent impairment in airflow, so cessation of smoking will not restore “normal lungs” to this patient. Stopping smoking will, however, slow continuing COPD damage to the lungs, reduce the likelihood of exacerbations of COPD, and diminish the patient’s risk of developing both lung cancer and coronary heart disease. Smoking cessation is a major component in preventing progression and exacerbation of COPD. Alpha-1 related emphysema is caused by an inherited lack of the protective protein, alpha-1 antitrypsin. Cessation of smoking in patients with this disorder accrues comparable benefits as those with emphysema from other causes and, similarly, does not restore normal lungs.
3-19. (B) Hypovolemia is common in paralytic ileus due to fluid shifts from the distended bowel segments into the interstitial space. Sepsis would be associated with a subnormal or elevated temperature. GI hemorrhage would likely present as hemetemesis or melena. An SpO2 of 94% does not indicate impending respiratory failure.
3-20. (C) When contrast dye will be administered, it is recommended that administration of metformin be temporarily halted because it has been associated with nephrotoxicity and lactic acidosis. N-Acetylcysteine works directly in the kidney to vasodilate the tubule and scavenge oxygen free radicals; however, studies are inconclusive as to whether administration will prevent nephrotoxicity. All diuretics should be held on the day of the procedure to prevent volume depletion. Current literature cites that renal dose dopamine does not prevent the onset of acute renal failure, decrease the need for dialysis, or reduce mortality.
3-21. (B) The nurse is demonstrating caring practices with concern over adequacy of comfort measures. One of the main concerns of family members when a patient is at end of life is the comfort of their loved one. Assessing comfort can be challenging in an unresponsive patient. The Bispectral (BIS) Index Monitor can assist in the assessment and management of analgesic effectiveness. BIS monitoring provides information about the effects of pain medication and sedation. It involves placing an external sensor on a patient’s forehead. No internal wires are required. Option A is incorrect since BIS monitoring does not alarm when the patient is brain dead. Option C is incorrect as BIS monitoring does not measure ICP. Option D is incorrect as BIS monitoring is not used on all comatose patients.
3-22. (C) Pericardial effusion with friction rub predisposes the patient to development of pericardial tamponade. Chronic renal failure with delayed hemodialysis places the patient at risk of developing pericardial tamponade owing to uremic deposits in the pericardium. When renal failure is treated promptly with hemodialysis, this does not occur. Acute MI and thrombolytic therapy predispose to intracranial, genitourinary, and gastrointestinal bleeding, as well as oozing from gums and puncture sites, but not within the pericardium. Insertion of the aortic balloon pump does not cause cardiac tamponade; however, if the reason for insertion is to treat conditions such as myocarditis, the patient may be at risk of development of tamponade related to the underlying condition and administration of heparin.
3-23. (B) A number of different systems have been developed to help determine the severity and prognosis for patients with acute pancreatitis. Current consensus is that the 11 Ranson’s signs system should now be replaced by the more useful and predictive indicators afforded by the patient’s (Acute Physiology and Chronic Health Evaluation-II) APACHE-II score and C-reactive protein (CRP). An APACHE-II score of 24 or higher predicts a mortality of at least 80%. Neither serum amylase nor arterial oxygen is used as a prognostic indicator for pancreatitis. CRP is a highly sensitive but not specific marker for the inflammatory processes associated with acute pancreatitis.
References: Baillie, J. The importance of anatomic severity classifications in predicting complications. In AGA clinical symposium: problems and pitfalls of Atlanta Classification for Acute Pancreatitis. AGA, APA and IAP to revisit. Program and abstracts of Digestive Disease Week, May 20-25, 2006, Los Angeles. Accessed at Baillie, J. Emerging Issues in Pancreatic Disease: A Clinical Update. http://www.medscape.com/viewprogram/5452.
Parker, M. Acute pancreatitis. Emerg Nurse,11(10), 28, 2004.
3-24. (C) Higher levels of PEEP can elevate pulmonary pressures and escalate the risk for additional pneumothorax or air leaks, especially in single-lung ventilation. Prompt ventilator weaning and aggressive pulmonary toilet are essential for reducing the risk of ventilator-associated pneumonia and baro-/volutrauma. Adequate pain management enhances the patient’s ability to perform coughing, deep breathing, and incentive spirometry.
References: Alspach, J. G. (ed.). Core Curriculum for Critical Care Nursing, 6th ed. St. Louis, Elsevier, 2006.
3-25. (C) Continuous arterial venous hemofiltration (CAVH) uses the patient’s blood pressure to force fluid through a filter where it is removed. When diuretics fail to cause diuresis, either a change of diuretic or the use of CAVH, CVVH, or hemodialysis may be used to remove fluid and decrease pulmonary vascular congestion. Since furosemide (Lasix) and bumetanide (Bumex) did not produce diuresis, an alternate diuretic or hemofiltration is needed. Spironolactone (Aldactone) or thiazide diuretics may be tried. Dopamine infusion is not indicated in a hypertensive patient. Low- dose dopamine (below 5 mcg/kg/min) may improve renal perfusion and assist with diuresis.
3-26. (A) Disseminated intravascular coagulation (DIC) is a complex, consumptive coagulopathy that occurs in patients with a variety of disorders. It manifests as an overstimulation of the normal coagulation process and results in microvascular clotting and hemorrhage in organ systems that lead to thrombosis and fibrinolysis. Clotting factor derangements precipitate further inflammation and thrombosis and microvascular damage leads to additional organ injury. Cell injury and damage to the endothelium activate the intrinsic and extrinsic coagulation pathways. Low platelet counts and elevated D-dimer concentrations and fibrin degradation products are clinical indicators of DIC. A prothrombin time (PT) >12.5 seconds and an activated partial thromboplastin time (aPTT) >40 seconds are also key laboratory findings with DIC.
3-27. (D) The aPTT is approximately twice the normal value. Removal of the epicardial pacing wires with an elevated aPTT would place the patient at risk for bleeding and pericardial tamponade. Therefore, the nurse should obtain an order to defer removal of the epicardial pacing wires until the aPTT is within normal values. The patient does not have symptomatic bradycardia as indicated by the stable BP and therefore does not require pacing. Low-molecular-weight heparin has a longer half-life than unfractionated heparin, but it is generally accepted that a delay of 12 hours or more after administration of the last dose provides a safe margin for invasive interventions. The INR is within normal range so it would be appropriate to remove epidural pacing wires.
Reference: Davis, L. Cardiovascular Nursing Secrets. St. Louis, Elsevier, 2004.
3-28. (C) Ventricular assist devices are treatments, not cures. The mortality on device support is high. While most devices are used as a bridge to transplant, there is a portable VAD on the market that can be inserted so patients may then be discharged home. The pump is placed in the upper part of the abdomen. Another tube attached to the pump is brought out of the abdominal wall to the outside of the body and attached to the pump’s battery and control system. Patients with LVADs can be discharged from the hospital and have an acceptable quality of life while waiting for a donor heart to become available.
References: American Heart Association: Left ventricular assist device. Available at www.americanheart.org/presenter.jhtml?identifier=4599. Retrieved on September 2, 2006.
3-29. (C) In ethanol ablation, the septal perforator arteries are ablated, causing shrinkage of the tissues and decreased outflow obstruction in hypertrophic cardiomyopathy. Septal ablation may result in conduction problems such as heart blocks, so patients may require temporary or permanent pacing after the procedure. Although supraventricular dysrhythmias including atrial fibrillation are commonly seen in cardiomyopathy, their incidence is not increased by the ablation procedure. Medications for these dysrhythmias may be used, but only if the patient was on the medication prior to the procedure. Since ablation affects the myocardial tissues, elevation of cardiac biomarkers is anticipated.
3-30. (C) ITP is a deficiency of platelets with measurable amounts of antiplatelet antibodies resulting in bleeding into the skin and other organs. Acute ITP is generally a disease that affects children, while chronic ITP is generally experienced by adolescents and adults. Because of blood loss, replacing circulating blood volume is the primary goal when managing patients with idiopathic thrombocytopenic purpura. Changes in the airway and respiratory function arise only when volume replacement is not adequate and shock occurs. While coping with the bruises and purpura is a challenge for the patient, this is not a major focus of nursing interventions.
3-31. (C) Current guidelines for the prevention and management of CVC infection include effective handwashing, maximum sterile precautions during catheter insertion, skin prep antisepsis with 2% chlorhexidine, avoidance of routine replacement of CVCs, insertion of antiseptic/antibiotic-impregnated short-term catheter if infection rate is high, culture of blood and catheter to confirm clinical suspicion of infection, treatment of intravascular catheter infection with IV antimicrobial therapy, removal of CVC if infected, and adequate education of staff who insert and maintain CVCs. Prevention is the best defense against complications resulting from infections. Migration of skin organisms at the insertion site into the cutaneous catheter tract with colonization of the catheter tip has been designated as the primary mechanism in the pathogenesis of catheter-related infections. Current recommendations for insertion of a CVC include effective handwashing and use of sterile precautions and technique by the physician and staff during insertion of the catheter. Routine replacement of CVCs after a period of time to prevent infection showed no significant difference in rate of infection so the practice is no longer recommended. There is potential to promote fungal infections and antimicrobial resistance with the use of antibiotic ointment or cream at the insertion site. Use of either transparent dressing alone or gauze dressing with tape is recommended. If the patient is diaphoretic or if there is bleeding at the site, a gauze dressing is preferred. Otherwise, a transparent dressing is indicated to allow visual inspection of insertion site. Do not use multiple types of dressings simultaneously. A gauze dressing covered with a transparent dressing can harbor moisture and provide an environment for bacterial growth.
3-32. (B) The patient has pulmonary hemorrhage, which requires a return to the operating room for exploration and definitive treatment. Insertion of a second chest tube would help evacuate the blood, but stopping the hemorrhage is a higher priority than removing the blood from the pleural space and could add more trauma to the area. Dopamine is not needed at this time as this patient requires fluid resuscitation. Using a positively inotropic agent can increase myocardial workload and cause myocardial ischemia in patients with reduced preload. A bronchoscopy will not likely be helpful in identifying the source of this rapid bleeding, as it may exist outside the tracheobroncheal tree.
3-33. (C) Cerebral arterial vasospasm is the most common cause of neurologic deterioration 4 to 7 days after SAH in both operated and nonoperated patients. It can be definitively diagnosed with either CT or traditional angiography as well as by clinical examination and transcranial doppler ultrasonography. Transluminal balloon angioplasty (TBA) of the major affected intracerebral arteries can be performed during the same procedure as the diagnostic angiogram. It has led to successful resolution of refractory, angiographically demonstrated vasospasm and to successful reversal of delayed neurologic deficits. Nimodipine is the only medication shown to prevent vasospasm and improve patient outcome after aneurysmal SAH. Administration of this calcium channel blocking agent has become a standard practice for vasospasm prevention. Occasionally, the usual dose of 60 mg every 4 hours is changed to 30 mg every 2 hours if patients become relatively hypotensive with standard dosing. Increasing the dose to 60 mg every 2 hours (Option A), however, is not appropriate. Because of nimodipine’s vasodilator effect, BP should be carefully monitored. Triple-H therapy (hypertensive-hypervolemic hemodilution [HHH]) increases cardiac output and BP with aggressive intravascular volume loading and vasopressor medications. Fluid loading usually leads to hemodilution. Vasoactive drugs are administered to increase BP if intravascular volume expansion alone is inadequate. Filling pressures (CVP or PCWP) are also monitored to guide volume dosing. Fluid restriction (Option B) is contraindicated in this patient population. Lumbar puncture (Option D) is not indicated at this time, since cerebral vasospasm is the most likely cause of the patient’s symptoms. If the patient had other signs and/or symptoms of meningitis, then LP would be indicated.
3-34. (B) The process of weaning from mechanical ventilation can be challenging and complex, especially for older patients with numerous chronic comorbidities. Data suggest that improved outcomes can result when collaborative decision-making processes are used (e.g., by ventilator teams who focus on patients such as this who need extra support). Discharge to a long-term care facility may not be appropriate, particularly for a patient with compromised pulmonary status. The patient is not sufficiently strong for discharge home, and no family members are mentioned to provide this care. Although optimizing the patient’s nutritional status will surely benefit him, it does not afford a promising avenue for any near-term solution to the weaning problem.
3-35. (A) Stroke may occur during left heart catheterization as emboli are released from the left heart and travel to the aorta and cerebral arteries. Catheterization of the right heart releases thrombi to the pulmonary artery, causing pulmonary embolus. Right heart catheterization may irritate vagus nerve endings in the SA or AV node, causing vagal stimulation that results in bradycardia or hypotension. Flushing and nausea are side effects of contrast administration and are self limiting.
3-36. (D) Replacement of bicarbonate is the most appropriate intervention for the patient with diabetic ketoacidosis and a pH below 7.0 and should be repeated every 2 hours until the pH exceeds 7.0. Even though the patient’s admitting glucose is only 200 mg/dL, the patient is experiencing dehydration and an anion gap to have been admitted with a diagnosis of diabetic ketoacidosis, so administration of NPH insulin will not provide a timely reduction of serum glucose. Absorption of insulin via the subcutaneous route would be impaired owing to diminished circulation associated with hypovolemia. Oral fluids should also be discouraged, as they are unlikely to be absorbed and may result in nausea and emesis. Delaying treatment for a period of hours while a specimen is obtained and sent to the laboratory and the results reported could have potentially lethal consequences for this patient.
3-37. (A) An endotracheal tube cuff leak allows oral secretions above the cuff to leak into the bronchial tree, placing the patient at high risk of developing ventilator-associated pneumonia. Enteral feedings place the patient at risk of VAP if a semirecumbent position is not maintained or if residual volumes are increased. A diminished level of consciousness and obtundation are risk factors for hospital-acquired pneumonia (HAP) in a nonintubated patient. Nasogastric tubes place the nonintubated patient at risk of HAP.
3-38. (D) In the 12-lead ECG, QRS width greater than 0.12 seconds is indicative of both bundle branch block and ventricular initiated rhythms. Negative QRS concordance, or presence of QS complexes in all precordial leads, is a distinguishing feature of ventricular tachycardia. In bundle branch blocks, leads V1 and V6 are helpful to determine if LBBB or RBBB is present. In RBBB, the QS complex is seen in lead V6, while an upright rSR′ may be seen in lead V1. In LBBB, the QS complex is seen in lead V1 and an upright RS in lead V6. Pericarditis may present on ECG as ST segment elevation in precordial leads.
3-39. (D) Patients with the best outcome following a traumatic arrest are those who are promptly transported to a trauma care facility where appropriate interventions can be initiated. The focus of prehospital/hospital resuscitation should be to safely extricate and stabilize the patient and to minimize interventions that will delay transport to definitive care at a trauma center. The primary and secondary surveys, including exposure of the patient to determine the extent of injury, are performed within minutes of the patient arriving at the tertiary care facility. Aggressive fluid resuscitation is now recommended only for patients with isolated head or extremity trauma, either blunt or penetrating. It is not recommended for penetrating trauma, especially in the urban setting, because it is likely to increase blood pressure and accelerate the rate of blood loss.
3-40. (A) Troponins are specific to cardiac tissue and are not affected by skeletal muscle injury. Creatinine kinase is found in skeletal muscle and is therefore a nonspecific indicator of MI in the surgical patient. C-reactive protein is synthesized in the liver in response to inflammation and is used to determine risk of cardiovascular disease. C-reactive protein levels less than 1.0 mg/L indicate a patient has a low risk of developing cardiovascular disease, whereas a level higher than 3.0 mg/L identifies a patient at high risk of cardiovascular disease. Myoglobin levels increase in skeletal muscle injury and are therefore unreliable indicators of myocardial infarction in the surgical patient.
3-41. (B) Withholding antiretroviral treatment may result in increased resistance and increased immunosuppression owing to viral load rebound. When patients are admitted to the ICU and intubated, oftentimes oral medications are held. Many antiretroviral therapies are not available in intravenous form. Some medications, when given enterally, may be inadequately absorbed. This may lead to drug resistance. ICU nurses must also observe for serious toxicities of the agents prescribed, such as pancreatitis. Option D does not exhibit sensitivity to the patient’s concerns. Antiretroviral therapy has resulted in rare but potentially life-threatening toxic effects, such as hypersensitivity reactions, pancreatitis, and lactic acidosis, but these conditions are not related to the onset of critical illness, but rather to the medications themselves.
3-42. (D) ST segment depression indicates myocardial ischemia and is evident in lead I and lead V1. ST segment elevation indicates myocardial injury or ST segment elevation myocardial infarction (STEMI). Q waves indicate that myocardial necrosis has occurred and may resolve or persist as permanent ECG changes. New onset left bundle branch block suggests acute myocardial infarction, but is not evident in the ECG because the QRS duration is less than 0.12 seconds and lead V1 does not demonstrate the deep S waves commonly seen in LBBB.
3-43. (C) There are many approaches to problem solving, depending on the nature of the problem and the people involved, but most approaches involve clarifying the nature and extent of the problem, analyzing causes, identifying alternatives, assessing each alternative, choosing one, implementing it, and evaluating whether the problem was solved. The most effective approach to defuse this situation is to begin problem identification by asking the surgeon to explain what happened and describe the reason(s) underlying his comments. This fact finding will help to isolate the problem(s) and lend clarity to determining its possible causes and appropriate solutions. Option A delays dealing with the physician’s displeasure and defers problem solving to the nurse manager. Option B is inappropriate as there is no basis currently established to question the efficacy of existing unit standards. Option D applies an instructional solution to a problem yet to be identified.
McNamara, C. Problem solving. Available at www.managementhelp.org/prsn_prd/prob_slv.htm. Retrieved September 2, 2006.
3-44. (B) Maintaining activity levels is a key component of pulmonary rehabilitation because it prevents many of the physical and psychological complications common to patients with COPD. Bronchitis exacerbations may be associated with many environmental factors, only one of which is increased physical activity. Supplemental oxygen and bronchodilators are interventions that may make resumption of physical activity easier for the patient and should be considered, but only if indicated.
3-45. (A) Patients with severe diastolic dysfunction may benefit from resynchronization therapy achieved via implantation of a biventricular pacemaker. Synchronized right and left ventricular pacing with a programmed atrial rate provides adequate time for ventricular filling and preserves “atrial kick,” which enhances cardiac output. Biventricular pacing is not helpful in the patient with systolic dysfunction because there is no problem with diastolic filling. Atrial fibrillation refractory to pharmacologic therapy may be treated with radiofrequency ablation, cardioversion, or dual chamber (DVI/VVI) pacing. Patients with systolic dysfunction may present with tachydysrhythmias or heart blocks. If the patient has heart block, a dual chamber pacemaker may be implanted. If the patient has tachydysrhythmias, a combination ICD/pacemaker may be implanted.
3-46. (A) Studies have demonstrated that massage, music therapy, and therapeutic touch promote relaxation and comfort in critically ill patients. Environmental interventions are safe and logical interventions to use to help patients sleep. Options B and C are not recommended for sleep promotion in critically ill patients because the safety data related to aromatherapy and alternative sedatives (e.g., valerian, melatonin) are unclear. Progressive muscle relaxation has been extensively studied and shown to be effective in enhancing sleep in persons with insomnia, but it requires that patients consciously relax specific muscle groups and practice these techniques. This may be challenging for many critically ill patients and impossible for others.
3-47. (A) Ventricular septal rupture causes a left to right shunt of oxygenated blood from the left ventricle into the right ventricle as indicated by the flow of contrast from the left ventricle to the right ventricle and equal oxygen saturation levels in the ventricles. An atrial septal defect would cause flow from the left atrium to the right atrium and a step-up oxygen saturation in the right atrium. Papillary muscle rupture is a complication of acute myocardial infarction, which causes left ventricular failure and mitral valve regurgitation. Rupture of the free ventricular wall would cause signs of pericarditis, cardiogenic shock, and pulseless electrical activity.
3-48. (D) Selective serotonin reuptake inhibitors (SSRIs) are frequently prescribed to elderly patients for depression. Gastrointestinal bleeding has been described in patients taking these medications and may result in hospitalization. The patient’s hemoglobin and hematocrit values will afford a good initial estimate of possible bleeding. Because the patient is taking digoxin, the heart rate may not increase as a compensatory response to the bleeding. Signs of increased intracranial pressure include a widening pulse pressure and bradycardia. The patient’s pulse pressure is not widened, and the bradycardia is more likely attributable to taking digoxin. Since the bradycardia is medication induced, it does not require intervention. While the patient’s diet and nutritional support may need attention at some point, this is not currently a pressing need.
3-49. (C) Both the tricuspid and pulmonary valves are right heart structures. Emboli released from diseased valves would lodge in the pulmonary tree and cause ventilation/perfusion mismatch and potentially prevent adequate oxygenation. Endocarditis associated with right heart valves is frequently associated with intravenous drug abuse, but this patient is at low risk for seizures owing to administration of lorazepam. Antibiotic therapy reduces the risk of septicemia. Stroke would be a potential complication of endocarditis affecting left heart valves.
3-50. (C) Members of the Gypsy culture are usually not agreeable to organ donation because they believe the person’s soul remains active for a year following death, so the body must remain intact during that time. Option A is true for African American families, Option B is true for patients of Vietnamese descent, and Option D is true among Filipino families.
References: American Red Cross: Tissue donation. Statements from various religions. Available at www.redcross.org/donate/tissue/relgstmt.html. Retrieved July 10, 2006.
Pacquiao, D. F. People of Filipino heritage. In L. D. Purnell, B. J. Baulanka (eds.). Transcultural Health Care. A Culturally Competent Approach, 2nd ed. Philadelphia, F. A. Davis, 2005, pp 138-59.
3-51. (C) The patient is exhibiting signs of meningitis, which include headache, chills, fever, nausea, vomiting, photophobia, back pain, and generalized seizures. Signs of meningeal irritation may include stiff neck (nuchal rigidity), Brudzinski’s sign (adduction/flexion of legs as examiner flexes neck), and Kernig’s sign (after examiner adducts thigh against abdomen, examiner’s attempts to extend the leg are met with resistance). Common CSF findings in meningitis include high protein, low glucose, and elevated white blood cell count. Bacterial meningitis is most commonly caused by Staphylococcus and is most appropriately treated with antibiotics. Meningitis is diagnosed with lumbar puncture for CSF evaluation after head CT scan is obtained. CT is the preferred scan in this population and MRI (Option A) to rule out any intracranial pathology such as a mass lesion (e.g., brain tumor) is not indicated. Plasmaphoresis (Option B) is indicated for patients with Guillain-Barré syndrome when IV immune globulin (IVIG) is not used. It is generally used every other day for 10 to 15 days and works by removing detrimental immune factors. There is no basis for serial LPs (Option D) in this scenario. Typically, CSF findings for patients with meningitis include elevated protein and low glucose. Another population with clinical findings of meningeal irritation are patients who have had a subarachnoid hemorrhage (SAH). LP is typically done only if SAH is suspected but head CT is negative. LP in SAH commonly includes elevated cell count (particularly RBCs) and xanthochromia, but neither elevated protein nor low glucose.
3-52. (D) Normal cardiac output is 4-8 L/min but is dependent on multiple factors such as stroke volume and heart rate. The normal mixed venous oxygen saturation (SVO2) is 60% to 80%. Decreased SVO2 indicates hypovolemia, decreased hemoglobin, or increased oxygen consumption by the tissues. Normal systemic vascular resistance (SVR) is 800 to 1200 dynes/sec/cm−5. Increased SVR indicates that peripheral vasoconstriction is occurring to support cardiac output, an indication that fluid resuscitation is not adequate. Increased SVR indicates the patient needs more volume to maintain cardiac output.
3-53. (D) Radiographic confirmation is the only reliable method to date of confirming enteral tube placement. An aspirate from a gastric tube often has a pH of 5 or less and is usually grass-green or clear and colorless, with off-white to tan mucus shreds. An aspirate from a small bowel tube often has a pH of 6 or greater and is usually bile stained (ranging in color from light to golden yellow or brownish-green). An aspirate from a tube inadvertently positioned in the tracheobronchial tree or the pleural space typically has a pH of 6 or greater. An aspirate from a tube in the pleural space is usually straw-colored and watery, possibly tinged with bright-red blood from perforation of the pleura by the tube. Option A is incorrect because there are numerous reports of tubes entering the respiratory tract undetected. In most of these cases, the auscultatory method falsely ensured that the tube was correctly positioned in the stomach. Options B and C are incorrect as they can cause harm to the patient if they provide a false-negative result despite incorrect positioning of the tube.
Reference: AACN Practice Alert. Verification of Feeding Tube Placement. Available at www.aacn.org/AACN/practiceAlert.nsf/Files/FTP/$file/Verification%20of%20Feeding%20Tube%20Placement.pdf Retrieved on July 1, 2006.
3-54. (C) Acute respiratory failure is defined by a PaO2 lower than 60 mm Hg and/or a PaCO2 higher than 50 mm Hg. The additional finding of respiratory acidosis indicates an acute respiratory condition. Patients with chronic respiratory conditions may compensate for their chronically low PaO2 and/or elevated PaCO2 with a pH greater than 7.45. These patients may benefit from low flow oxygen or noninvasive modes of ventilation. Metabolic acidosis is indicated by a low pH and low PaCO2.
3-55. (C) When administered within 2 weeks of exposure, gamma globulin will help provide antibodies to prevent active hepatitis B infection. Acetaminophin administration will stress the liver and, in large enough quantities, can produce chemical hepatitis or liver failure. It is too late for those contacts to build antibodies through the vaccination process, but vaccination would afford immunity to future exposures. Transfusions would not be useful, as the infected person would not acquire immunity, and transfusion would subject the recipient to unnecessary risks, including contracting viruses, circulatory overload, or even hemolytic reactions related to clerical and patient identity errors.
3-56. (B) CT scan of the head is useful for looking at bone and blood and is the best imaging study to view most intracranial processes, including trauma, intracerebral hemorrhage, and hydrocephalus. MRI (Option A) is useful for evaluating tumors, spinal pathology, spinal cord injury, and other processes. It is most helpful for looking at tissue, structures, and perfusion. MRI may also be used after the acute period following TBI has passed, when it can help identify injuries such as diffuse axonal injury and shearing injuries. An LP (Option C) is contraindicated until intracranial pathology has been ruled out and is not useful in the initial evaluation of TBI. An LP assists in detection of infection or increased ICP. Option D, cerebral angiography, is valuable for evaluating and managing cerebral aneurysms, arteriovenous malformations, and cerebral vasospasm. Angiography may also be used to identify carotid artery dissection in some traumatic cases.
3-57. (D) Reviewing relevant research findings related to the nature and scope of support that family members of ICU patients need can afford a sound and evidence-based approach to identifying family- and visitor-friendly features that should be incorporated into waiting areas. The nurse member of the design team can provide valuable input by gathering, compiling, and summarizing the findings of this research. Facilitating visitor comfort can then operate in conjunction with open visitation policies to provide additional elements in the patient support system. Summarizing these findings is well within the capability of a single nurse, so involvement of the nurse manager or another group of nurses is not necessary. Waiting until the next meeting to mention these concerns unnecessarily delays addressing the problem.
3-58. (D) Return of ST segments to baseline signifies return of coronary artery perfusion. CPK-MB and troponin levels may increase with evolving and extending acute MI. Serum troponin levels remain elevated for 7 to 10 days after myocardial injury. Dysrhythmias may be associated with reperfusion, but may also occur as a complication of acute MI.
3-59. (C) The patient is currently on hemodialysis, and it would be continued. Hemodialysis is the most effective of all of the renal replacement therapies and is considered the “gold standard” for the treatment of acute and chronic renal failure. Hemodialysis is contraindicated in patients with hemodynamic instability, hypovolemia, coagulation disorders, or vascular access problems. Slow continuous ultrafiltration is used for patients with fluid volume excess and some degree of renal function. It has minimal impact on urea and creatinine levels. Continuous venovenous hemodialysis is used for patients who are hemodynamically unstable and unable to tolerate the rapid fluid and electrolyte shifts that occur with hemodialysis. Peritoneal dialysis is slower and less effective than hemodialysis.
3-60. (B) Several changes in GI function normally occur in older adults and include a decrease in glucose tolerance, which is partly associated with an increase in insulin resistance. This may be modified with diet and exercise and does not require insulin (Option A). The incidence of diabetes increases by 0.5% to 1% in individuals age 65 years and older. Although motility, secretory function, and absorption capabilities may decrease with age, there is no significant impairment of function within the GI tract in healthy older adults, so Option C is not correct. Option A is not a true statement based on the information provided in the case; his hyperglycemia can be managed and resolved well before discharge. Option D is incorrect because there is no evidence of pre-existing diabetes, and the patient would very likely have manifested signs and symptoms of that disorder if it had existed.
3-61. (A) ST and T wave changes indicate myocardial ischemia. ST and T wave changes occur in dilated, restrictive, and hypertrophic cardiomyopathies that affect the left ventricle and are associated with inadequate coronary filling during diastole resulting in ischemia. Arrhythmogenic right ventricular cardiomyopathy causes right ventricular dilation and signs of right ventricular failure and is associated with right bundle branch block and ventricular tachycardia. Bundle branch blocks are associated with QRS, ST and T wave abnormalities that reflect altered conduction rather than ischemia. ST segment elevation in the precordial leads occurs in pericarditis, but does not reflect the severity of this disorder.
Reference: Bruce, J. Getting to the heart of cardiomyopathies. Nursing 2005, 35, 44-47, 2005.
3-62. (A) The focus should be on restoring circulating volume and preventing the complications of hypovolemia. Signs and symptoms of early hypovolemic shock include diminished level of consciousness, which can manifest as agitation or restlessness; cool, clammy skin; tachycardia; and vasoconstriction. The patient is having an acute deterioration in his cardiovascular status. After fluid resuscitation is instituted, the nurse can complete the abdominal assessment. Although the patient’s fever may be contributing to his tachycardia and vasodilation, it is not the cause of this acute change, so is of lesser importance now. Initiation of fluid resuscitation should be the first intervention with cultures and cooling measures following. It is important to identify the patient’s current medications; however, this can be delegated to another member of the nursing staff until cardiovascular stabilization is achieved.
Reference: Kelley, D. M. Hypovolemic shock: an overview. Critical Care Nurse Q, 28, 2-19, 2005.
3-63. (C) Pleuritic chest pain is a common occurrence with pneumococcal pneumonia (Option C) and needs to be treated in order to improve the patient’s ventilation. Pleural effusions, pneumothoraces, and pulmonary edema are not consistent with the patient’s clinical presentation (Options A, B, and D).
3-64. (A) Rebound pulmonary hypertension may occur when nitric oxide is discontinued. Patients on nitric oxide may develop methemoglobinemia, which prevents release of oxygen to tissues, falsely elevating SpO2 and thus making SpO2 an unreliable indicator of oxygenation status. Although hypotension is common with the administration of nitric oxide (since it causes vasodilation), it can be readily treated with vasopressors or by titration of nitric oxide delivery rates, so is not a major concern. Nitric oxide may cause coagulation defects, including thrombocytopenia and bleeding disorders.
3-65. (A) β-Blockers help to reduce mortality in acute myocardial ischemia and infarction owing to atherosclerosis. There are two contraindications, however, to the use of β-blockers in myocardial ischemia: one is when the ischemia is related to Prinzmetal’s angina, and the other is when it is due to cocaine. Cocaine stimulates both the α- and β- peripheral receptors. The administration of a β-blocker would leave the α- activity unopposed. This would enhance coronary vasoconstriction, systemic hypertension, and heart rate. For that reason, β-blockers are contraindicated in the management of MI related to cocaine use. Morphine is indicated to manage chest pain and anxiety, both of which could increase heart rate and myocardial oxygen consumption. Nitroglycerin is a vasodilator and reverses the cocaine-induced coronary artery vasospasm. Aspirin reduces clotting activity and is recommended to prevent the formation of thrombi.
References: Buchanan Keller, K. The cocaine-abused heart. Am J Crit Care 12(6), 562-566, 2003. Website: http://www.acc.org/clinical/guidelines/stemi/Guideline1/index.pdf. Accessed May 7, 2006.
3-66. (A) The approach that will best serve this patient’s needs is for the ICU team to collaborate with the perinatal team, with the perinatal CNS serving as the initial bridge between those patient care areas by providing immediate support in establishing priorities of care, particularly for aspects of maternal and fetal monitoring unfamiliar to the ICU nurse. Once the basic plan of care is developed and procedures are reviewed, the perinatal team may continue their consulting involvement less directly, on a more as-needed basis. Collaboration between perinatal and ICU teams in caring for critically ill pregnant women works best to promote the best possible outcomes for mothers and babies. Option B is not optimal because the ICU nurse likely does not have competency to initiate and manage fetal heart monitoring without more direct assistance and needs to know much more about this patient’s care than just fetal monitoring. Although both ED nurses and neurosurgical CNSs could lend some support to the ICU nurse, neither has the unique expertise and skills required for optimal care of this patient that the prenatal CNS has.
3-67. (D) ECG characteristics of left bundle branch block (LBB) include QRS duration greater than 0.12 seconds and a QS pattern in V1 and V2 with ST segment orientation opposite to the QRS deflection. LBBB is an indicator of acute MI if the block is new or if it is associated with elevated cardiac serum markers such as CPK-MB, myoglobin, or troponin. Since LBBB alters repolarization, ST segment elevation is commonly seen. Some studies indicate that markedly elevated ST segments may indicate acute MI in patients with LBBB; however, a diagnosis of acute MI in patients with LBBB by ECG alone is not conclusive. Acute anterior wall MI is indicated by ST segment elevation or Q waves in leads V3 and V4. Posterior wall MI is indicated by large R waves in leads V1 and V2. Anterolateral MI shows ST segment elevation in leads V3-V4 and V5-V6. In the presence of LBBB, ST segment elevation is not a reliable indicator of acute ischemia.
3-68. (C) Ten jelly beans provide 15 grams of simple carbohydrate with a minimal fluid volume. While the orange juice and soft drink provide approximately 15 grams of carbohydrate, they also provide fluid and electrolytes that may affect the patient’s clinical findings related to renal failure. The breath mints contain simple sugars, but it is unlikely the patient will consume enough of them to increase the circulating glucose level.
3-69. (C) The behavior described in the visitors’ complaints is a comfort gesture between two people. Although some visitors may not personally like the gesture, there is nothing inherent in the behavior that warrants convening a team conference or moving the patient to a different cubicle. Option B puts visitors’ needs and preferences above those of a patient and does not support caring practices (i.e., creating a compassionate and therapeutic environment) toward that patient.
3-70. (B) In order to determine if this patient is experiencing acute rejection, preparation for liver biopsy is essential, as this provides definitive diagnosis of rejection. Later in the course of treatment, should rejection be ruled out, magnetic resonance imaging or a CT scan may be employed in an effort to detect lesions. Cardiovascular instability unresponsive to less invasive treatment is not mentioned, so neither a central nor a PA line requires insertion at this point. Abdominal girth measurement should have been performed with the admission assessment. There is no indication that this patient has ascites or other basis for intra-abdominal pressure monitoring.
3-71. (B) The critical care nurse should first administer free water because the patient is in a hyperosmolar state, as evidenced by his serum sodium and osmolality and urine SG values. The goal is to gradually normalize the serum sodium level over 48 to 72 hours. Older patients are at very high risk for osmolality disorders because with advanced age, the hypothalamus becomes less sensitive to changes in osmolality and less able to produce the physiologic adjustments necessary for maintaining a normal range of osmolality. In older patients, neurologic signs such as a change in mental status, disorientation, lethargy, and delusions, indicative of osmolality disorders, may be erroneously attributed to advanced age rather than osmolality imbalances. Hyperosmolar disorders can be caused by inadequate intake of water, excessive water loss, or conditions that cause an inhibition of antidiuretic hormone. The patient’s magnesium level is within normal limits. Potassium may be administered at a later time for the slightly low potassium level. The patient’s calcium level is within normal limits, and vitamin D is not indicated.
3-72. (A) The rhythm strip indicates a DDD pacemaker because atrial contraction is sensed and, when not sensed within the set limits, an atrial pacemaker spike is initiated. The ventricular pacemaker follows within the timeframe associated with a normal PR interval (0.20 sec or less). Complete capture is evidenced by the presence of P waves in the MCL1 strip below the lead II strip, even though the pacemaker spike is not evident. A VVI pacemaker would not sense or pace the atria. An AAI pacemaker would not pace the ventricles.
3-73. (D) Acute blood loss results in the development of hypovolemic shock, which occurs as a result of inadequate fluid volume in the intravascular space. When this occurs, the kidneys will increase retention of sodium, thereby conserving both sodium and body water and increasing circulating volume. The pulse pressure narrows when systolic pressure is low and the diastolic blood pressure is rising because of compensatory vasoconstriction. Arterial vasodilation would worsen the shock state and diminish oxygen delivery to tissues, while vasoconstriction increases systemic vascular resistance and systolic blood pressure, thereby improving tissue perfusion. The heart rate increases in response to increased sympathetic nervous system stimulation.
3-74. (B) Although pulmonary complications are a significant risk after esophageal surgery, pain control is essential in ensuring good pulmonary toilet. Pain control is key in the patient who has undergone an esophageal surgical procedure. Without optimal pain control, many of the other interventions to prevent complications (e.g., pulmonary toilet) cannot be performed effectively. Patients who undergo esophageal surgical procedures are susceptible to noncardiogenic pulmonary edema. Major fluid shifts occur in the first few days after surgery, however; because of the reduced clearance of lymph, patients are predisposed to interstitial pulmonary edema, so large volumes of IV fluid would not be appropriate. While a feeding tube is placed during surgery, these patients may not receive tube feedings for 2 to 3 days after surgery to allow sufficient time for peristalsis to redevelop.
Mackenzie, D. J. Care of patients after esophagectomy. Crit Care Nurse, 16-29, Feb 2004.
3-75. (A) Isolated, mild deficits (NIH Stroke Scale score of 1 or less) represent a contraindication to rt-PA therapy. While a seizure at the onset of stroke is a contraindication, a history of epilepsy or seizure disorder (Option B), in itself, would not constitute a contraindication. Another stroke, intracranial surgery, or serious head trauma within the past 3 months would exclude a patient from rt-PA use, but not a mild TBI 6 months prior (Option C). Current use of anticoagulants or an INR greater than 1.7 would qualify as a contraindication, but an INR of 1.3 (Option D) would be acceptable.
3-76. (A) The P/F ratio is obtained by dividing the PaO2 by the FiO2. For this patient, the P/F ratio is 68 ÷ 1.00, or 68. The P/F ratio is used to distinguish whether the patient has an acute lung injury or ARDS. A P/F ratio of less than 300 indicates acute lung injury, whereas a P/F ratio of 200 or less indicates ARDS.
3-77. (A) The MAP, PCWP, and SVR indicate afterload reduction is optimized for this patient. The primary effect of nitroglycerin infusion is to decrease preload. The CVP is elevated, and the patient would benefit from preload reduction to reduce pulmonary congestion and improve coronary artery perfusion. Option B, nitroprusside (Nipride), reduces preload but also reduces afterload. Dobutamine is an inotropic agent; increasing contractility (Option C) would increase cardiac workload and may worsen ischemia. Dopamine at low doses (Option D) may increase renal perfusion and myocardial contractility, but also contributes to tachycardia, which would increase myocardial work.
3-78. (C) The nurse should delegate tasks to ensure that priority patient care needs are met in a timely fashion and that staff needs for instruction are accommodated in accordance with patient care priorities. A nurse who must devote full attention to patient care needs to seek a colleague who may be in a better position to lend support to the new nurse. In deciding the best course of action, the nurse should consider that both patients would benefit from assessments performed by the same provider to ensure continuity of care. Hourly glucose checks on a young patient with DKA reflect a patient whose care requires close and frequent nursing supervision that should not be disrupted unnecessarily. Hourly neurological checks should be performed only by a skilled RN. A new nurse should not be asked to review a staffing schedule, as this requires considerable experience and knowledge of other staff members’ competency.
3-79. (B) The presence of fat in the pulmonary circulation injures the endothelial lining of the capillary, increasing capillary permeability and resulting in alveolar flooding. The skin rash, diminished level of consciousness, and reduction in platelet count are indications of fat emboli most likely associated with the femur fracture. A thrombus resulting from venous stasis or deep vein thrombosis is more likely to cause a pulmonary embolus. The bronchociliary clearance mechanisms are protective mechanisms usually affected in cases of aspiration or pneumonia. Although they could be affected in this patient, there is no evidence of this in the scenario described. The shunting of blood through poorly ventilated areas of pulmonary consolidation can produce hypoxia, but this scenario does not describe a patient who has aspirated or developed pneumonia.
3-80. (C) Surgery for atrial septal defect involves surgical incisions and scar development in the atrial septum leading to development of re-entry dysrhythmias and atrial fibrillation. These dysrhythmias are frequently successfully treated with radiofrequency ablation.
3-81. (A) Intravenous infusions of norepinephrine and dobutamine are indicated for this patient based on the provided hemodynamic parameters. Norepinephrine will increase the patient’s mean arterial pressure. Dobutamine is an inotropic agent that will increase myocardial contractility, cardiac output, and cardiac index. Both agents will increase tissue perfusion and subsequent oxygen delivery. Fluid administration with intravenous dopamine is not warranted for this patient because both the pulmonary artery pressure and the central venous pressure indicate adequate intravascular volume. There is no evidence that the patient is in metabolic acidosis, so sodium bicarbonate does not appear to be indicated.
3-82. (B) Leveling the transducer air-fluid interface to the left atrium corrects for changes in hydrostatic pressure in vessels above and below the heart. Data suggest that in the supine position, the external landmark for the left atrium is the phlebostatic axis (fourth ICS/half AP diameter of the chest). Option A is incorrect because a square wave test is only performed on the initial system setup, then at least once each shift, after opening the catheter system (e.g., for rezeroing, drawing blood, or changing tubing), and whenever the PAP waveform appears to be damped or distorted. Option C is not a requirement because data support that the head of the bed elevation can be at any angle from 0° (flat) to 60° for measurement. Accurate measurements require reading pressure waveforms during end expiration, so Option D is incorrect.
Reference: AACN Practice Alert. Pulmonary Artery Pressure Measurements. Available at www.aacn.org//AACN/practiceAlert.nsf/Files/PAPMonitoring4-7-04/$file/PAPMonitoring.pdf. Retrieved on July 1, 2006.
3-83. (C) In vasogenic shock, vasodilation may lead to a relative hypovolemia that causes hypotension. If the status of circulating volume is not known with certainty, crystalloids may be administered to support BP and correct hypovolemia. If circulating volume is adequate, vasopressor therapy such as norepinephrine may then be initiated and guided by CVP or PCWP pressures. Norepinephrine (Levophed) is an alpha stimulant that restores circulating volume via vasoconstriction. Milrinone (Primacor) causes vasodilation and increased myocardial contractility. Since the patient in vasogenic shock is already vasodilated, further vasodilation is contraindicated At high doses, dopamine exhibits alpha effects similar to norepinephrine and is also indicated after volume deficits have been corrected.
3-84. (C) Diagnostic studies are needed to evaluate for pulmonary embolism or bleeding from the aorta. Although the patient’s clinical picture has deteriorated, neither intubation (Option A) nor emergency surgery (Option D) is indicated without diagnostic evaluation. The patient may require sedation and analgesia (Option B), but further workup needs to precede administration of those agents so the cause of her acute decompensation can be determined.
McQuillan, K. A., et al. (eds.). Trauma Nursing, 3rd ed. St. Louis, Elsevier, 2002.
3-85. (B) The Kehr sign is characterized by severe left shoulder pain when in a supine position and is caused by diaphragmatic irritation typically owing to phrenic nerve irritation from the presence of intraperitoneal blood and air. The clinical significance of Kehr’s sign is its association with splenic injuries such as splenic laceration with bleeding, which will result in a reduction in bowel sounds and increased abdominal girth. Epigastric pain with belching is symptomatic of esophageal reflux. This is not an emergency condition. Decreased breath sounds bilaterally indicate atelectasis or consolidation. While over time this may adversely affect the patient’s condition, this is not an emergent condition. Pain and burning with hematuria are symptomatic of a urinary tract infection. Urinary tract infections can lead to septicemia; however, at this time this is not an emergent condition.
3-86. (B) Encephalopathy is not a disease itself but always occurs as the end result of another disease process. Evaluation for these disease processes—often infectious or metabolic—should be considered first. For example, diabetic ketoacidosis may precipitate encephalopathy and be evidenced by headache and lethargy, which suggest cerebral edema. A second disorder, water intoxication, may be ruled out by checking serum osmolarity, and a third, hepatic encephalopathy, can be determined by checking serum ammonia. Level of consciousness is most important in monitoring these patients. The nurse should look for signs of increased ICP (e.g., hypertension, increased muscle tone in extremities, hyperventilation, dilated pupils). ICP monitoring (Option A) would be indicated in stage III hepatic encephalopathy but would not be a first-line action in this patient. Lumbar puncture (LP) (Option C) is not indicated in this patient. If ICP were elevated, LP could be harmful. Immunoassay is not indicated for this patient, and a CT of the head would be a more appropriate diagnostic study than (Option D) cerebral angiography.
Greenberg, M. S. (ed.). Handbook of Neurosurgery, 6th ed. New York, Thieme, 2006.
3-87. (B) Increasing the cardiac index to greater than 2.2 L/min/m2 will increase renal blood flow and enhance renal tissue perfusion. If MAP, PAOP, PAD, and CVP are within normal limits, then the patient has achieved outcome criteria. Other outcome criteria include electrolytes within normal limits, normalization of acid-base balance, lungs clear on auscultation, normal level of consciousness, BUN and creatinine within normal limits, urine output within normal limits or patient stable on dialysis, stable hemoglobin and hematocrit values. In Options A, C, and D, the patient’s CVP, MAP, and PAOP are low, indicating decreased renal blood flow and tissue perfusion.
3-88. (B) Junctional tachycardia is a non–life-threatening dysrhythmia often associated with digoxin toxicity. Withholding digoxin until sinus rhythm is restored is often the only treatment necessary. Overdrive pacing is not effective in junctional tachycardia due to enhanced AV nodal conduction. Administration of digoxin is contraindicated in heart block. Adenosine is not indicated for a tachycardia of only 110/min.
Reference: Blomstrom-Lundqvist, C., Scheinman, M. M., Aliot, E. M., et al. ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the European Society of Cardiology Committee for Practice Guidelines and the European Society of Cardiology Committee. 2003: http://www.acc.org/clinical/guidelines/arrythmias/sva_index.pdf.
3-89. (D) Overwedging is usually caused by migration of the PA catheter forward into the pulmonary capillaries. When that situation occurs, the waveform no longer pulsates with pulmonary artery pressure variations because the catheter tip is now obstructed in a small branch of the pulmonary artery. If the catheter is overwedged, the PCWP will be much higher than the RAP and the PAD.
Reference: Fawcett, J. A. Hemodynamic Monitoring Made Easy. St. Louis, Elsevier, 2006.
3-90. (C) By providing correct and appropriate information, the nurse is helping to promote a caring environment for the family during a potentially stressful time. A number of physiologic changes will likely be manifested by the patient following withdrawal of mechanical ventilation, some of which may be distressing to the family unless they know about them beforehand. The anticipated time frame to death is variable and cannot be predicted with any confidence. The name of the person performing the procedure will not likely be relevant to the family or contribute to promoting a caring environment to the family. Secretions associated with a “death rattle” do not cause discomfort to the patient. This fluid should not be suctioned, as suctioning can cause discomfort to the patient.
References: Bickel, K., Arnold, R. Fast fact and concept #109: death rattle and oral secretions. Available at www.eperc.mcw.edu/fastFact/ff_109.htm. Retrieved on September 2, 2006.
3-91. (C) Sputum aspirate with quantitative or semiquantitative cultures is a more sensitive test for diagnosing HAP than expectorated samples with Gram’s stain. Chest x-rays are useful in determining the location of a pneumonia (Option A). Blood cultures are a key component of distinguishing primary from secondary infections, particularly in pneumococcal pneumonia (Option B). All cultures should be drawn prior to antibiotic administration to avoid masking organisms (Option D).
3-92. (C) Some Hispanics, Appalachians, and Puerto Ricans believe that health is externally controlled and, as a result, are less likely to take personal responsibility for preventive actions. If the patient does not assume personal responsibility for his own health, teaching him about managing risk factors will not likely have any effect. Each of the other choices involves the patient taking measures to prevent a future cardiac event, which is inconsistent with this patient’s health beliefs.
3-93. (D) Tumor necrosis factor-α is released from macrophages and lymphocytes in response to endotoxin, tissue injury, viral agents, and interleukins. Cellular responses to TNF include increased formation of oxygen radicals; recruitment and activation of neutrophils, macrophages, and lymphocytes; increased cytokine production; initial hyperglycemia followed by hypoglycemia, hypotension, metabolic acidosis, and coagulopathy; fever and increased oxygen consumption; increased capillary permeability, vasodilation, microvascular vasoconstriction, and noncardiac pulmonary edema; activation of the coagulation cascade; and production of nitric oxide.
3-94. (C) Definitive treatment for a persistent air leak can include bronchoscopy to introduce endobronchial glue, obliteration of the pleural space with chemical irritants such as antibiotics, or surgical decortication with removal of the pleural lining. Progressive advancement of the chest tube would not be included among the treatments for air leak; that intervention is used to treat empyemas.
3-95. (B) Four hours of hemodialysis needs to be done daily because the patient is manifesting symptoms of uremic pericarditis. Management of this disorder includes increasing the duration and frequency of hemodialysis. Peritoneal dialysis would not be considered for management in this case, as the patient is already on hemodialysis.
3-96. (C) Patients with diabetes insipidus would be expected to be thirsty and produce large volumes of dilute urine. They will usually exhibit a decrease in blood pressure and increase in heart rate related to hypovolemia secondary to an increased urinary output. Alterations in potassium level will occur as electrolytes are lost in the urine; however, tachycardia is expected with hypovolemia, and numbness and tingling in the extremities would be expected with a magnesium imbalance. Widened pulse pressure, pupilary changes, and posturing are symptoms produced by elevated intracranial pressure, not diabetes insipidus.
3-97. (A) Initial management of pulmonary edema should follow the ABCs of resuscitation. Airway adequacy should be assessed and treated first. Oxygen should be administered and an arterial blood gas obtained to determine whether the patient requires intubation. When the airway is secure, further testing, intravenous access, and medications may be administered.
3-98. (A) Hemolytic uremic syndrome is a renal disorder with kidney failure, microangiopathic hemolytic anemia, and a platelet deficiency. Most children recover with dialysis and supportive care, while prognosis in adults varies with the patient’s health status. Because irreversible organ damage and death can occur from clots, the primary goal is to prevent ischemia through frequent repositioning and maintaining the airway while providing dialysis as needed. Hydration and platelet removal may be employed as treatments, but the goal of these interventions is to minimize the amount of ischemic damage that occurs from a clotted microvasculature. These medical interventions are secondary to vigilant nursing care. Since this syndrome generally involves an inadequate number of platelets, removal of platelets is contraindicated.
3-99. (A) According to the Surviving Sepsis Campaign guidelines, during the first 6 hours of treatment, the goal is to achieve and maintain a CVP of 8 to 12 mm Hg, or 12 to 15 mm Hg for patients receiving mechanical ventilation and a MAP of at least 65 mm Hg with fluid resuscitation. Options B, C, and D are inconsistent with the current evidence-based guidelines.
Reference: AACN Practice Alert. Severe Sepsis. Available at www.aacn.org/AACN/practiceAlert.nsf/Files/ss/$file/Severe%20Sepsis.pdf Retrieved on July 1, 2006
3-100. (C) Nitroglycerin may be administered orally, intravenously, transdermally, or topically to reduce both preload and afterload in the patient with pulmonary edema. Furosemide (Lasix), morphine sulfate, and captopril (Capoten) are weaker agents. Morphine sulfate has not been found to consistently decrease PCWP in patients with pulmonary edema, but it is effective in decreasing anxiety. Furosemide (Lasix) is not as rapid as nitroglycerin in decreasing preload as effects take longer than 30 minutes to produce diuresis. ACE inhibitors such as captopril (Capoten) reduce afterload and are weak diuretics.
3-101. (A) Rudolf Virchow described the triad of venous stasis, vein injury, and a hypercoagulable state as risk factors for the development of pulmonary emboli. Pelvic fractures require immobility; lower extremity trauma that results in swelling reduces blood flow, and the need for blood replacement products heightens this patient’s risk for thrombi. Recognition of these risks provides the greatest opportunity for prevention of the complication of pulmonary embolism. Intravascular cannulation can lead to vein injury, and dehydration can result in venous stasis, but this patient’s age is not a factor in the triad. Hypoxia and intersitital edema result from rather than cause development of pulmonary embolus. Right ventricular dysfunction, pulmonary artery hypertension, and atelectasis are complications seen in the critically ill patient but do not increase a patient’s risk for pulmonary embolism
3-102. (D) When the onset of atrial fibrillation cannot be determined, it is possible that a thrombus has developed. Rate control is an immediate concern, and diltiazem is the drug of choice to decrease the ventricular rate in atrial fibrillation. Cardioversion is performed if the patient is unstable or has failed to respond to chemical cardioversion with diltiazem or ibutelide. Dofetilide is used for atrial fibrillation that is refractory to other medical therapies and is not a first-line medication. In addition, dofetilide requires close assessment of the QT interval and creatinine clearance to determine dosage.
3-103. (A) The patient already demonstrates hypotension and tachycardia related to hypovolemia, so attaining the primary goal of replacing renal function via ultrafiltration while obtaining solute removal via convection that will not further compromise hypotension represents the rationale for selecting this mode of renal replacement therapy. Patients treated with CVVH are not less vulnerable to developing complications such as clotting and infection. This patient would be expected to benefit from CVVH because she is experiencing acute (rather than chronic) renal failure owing to perioperative hypotension associated with hypovolemia related to operative blood loss. In acute renal failure, the BUN level does not elevate to the same level as it does in chronic renal failure, when BUN is over 100 mg/dL.
3-104. (D) The nurse will advocate for the family by facilitating the wife’s request with the physician and then identifying the best location for the wife. The advantage to the wife’s staying is consistent with a holistic family-centered approach to care that sees the patient and family as the unit of care. Denying the request owing to unit policy (Option A) does not advocate for the family. Option B seems to approach refusal by attempting to intimidate the wife. Option C fails to advocate for the family and attempts to harness the notion of sterility as the reason the family should not stay.
3-105. (C) Decreasing the blood pressure too quickly can overwhelm the cerebral autoregulatory system. Blood pressure should be reduced by 25% to 30% each 2 hours to enable the cerebral autoregulation mechanisms to remain intact.
3-106. (B) Hypotension in the mechanically ventilated patient may be related to increased intrathoracic pressure from high PEEP levels that decrease venous return. Administration of fluid bolus is indicated to treat hypotension. High PEEP levels are indicated in ARDS to improve oxygenation, and lowering PEEP would likely cause a further decrease in PaO2. Norepinephrine may be administered if volume replacement is insufficient to increase blood pressure to acceptable levels but would not be given prior to the volume replenishment. Tidal volumes for patients with ARDS should be maintained at 5 to 8 mL/kg.
3-107. (A) Hypothermia decreases oxygen consumption due to reduced tissue metabolism as a result of the low body temperature. Therefore, the SVO2 would be higher than normal (60% to 80%). Continuous SVO2 monitoring allows the health care team to make a determination of the patient’s oxygen balance by looking at oxygen supply and demand at the tissue level. The four factors that determine this balance are cardiac output, hemoglobin, arterial saturation, and tissue metabolism. Cardiac output, hemoglobin, and arterial saturation all contribute to oxygen supply. Tissue metabolism is a major determinant of oxygen consumption at the tissue level. Both anemia and a low cardiac output would contribute to a lower SVO2 because both conditions reduce the supply of oxygen delivered to the tissues; as a result, the tissues would continue to extract oxygen despite its diminished supply. Atrial fibrillation would not have a specific bearing on the SVO2 unless it altered the patient’s cardiac output.
Urden, L. D., Stacy, K. M., Lough, M. E. Thelan’s Critical Care Nursing: Diagnosis and Management, 5th ed. St. Louis, Elsevier, 2006, pp 414-422.
3-108. (D) Nitroglycerin is routinely used when the radial artery is utilized for the graft in coronary artery bypass surgery to prevent spasm in the graft. The purpose of coronary bypass surgery is to revascularize the myocardium and resolve ischemia. Nitroglycerin may be used to decrease systemic vascular resistance or systolic blood pressure, but other agents such as nitroprusside may be utilized for these purposes.
3-109. (A) For patients with COPD, goals of care related to ABGs are based on the patient’s baseline values, not on textbook definitions of normal values. Some environmental or situational triggers that lead to exacerbations may be identifiable but not avoidable, and others may be unknown. Antibiotics may be used for these patients but would not be arbitrarily based on WBC counts since these are less reliable indicators in older patients. Bronchodilators are commonly used early in the care of these patients to relax the airways and reduce the work of breathing.
3-110. (A) Data suggest that maintaining the head-of-bed elevation at 30 to 45 degrees decreases the risk of ventilator-associated pneumonia. There are no supportive data to suggest that any of the other interventions decreases the risk of this complication.
Reference: AACN Practice Alert. Ventilator Associated Pneumonia. Available at www.aacn.org/AACN/practiceAlert.nsf/Files/VAPPP/ Retrieved on July 1, 2006.
3-111. (C) The patient is exhibiting anxiousness, irritability, and confusion, all of which could be a sign of hypoglycemia; therefore, assessment of capillary glucose levels would be the first intervention the nurse should perform. Assessing for the concentration of urine may help distinguish between hyperglycemia and diabetes insipidus, but there is no mention of polyuria in this scenario. Medication with an analgesic is inappropriate before the reason for the pain and confusion is established. Use of restraints without thoroughly assessing the patient would delay appropriate treatment and could increase the patient’s agitation.
3-112. (C) As the patient’s natural immunity declines, his or her own normal body flora and fauna become the major source of opportunistic infections. While all of the other choices may contribute to the development of illness, they pose danger to the patient transiently and episodically rather than continually.
3-113. (B) Pericardial tamponade may occur in radiofrequency ablation from coronary artery perforation or dissection. Pericardial tamponade restricts myocardial pumping and may result in cardiogenic shock or pulseless electrical activity. Second-degree AV block is not life threatening unless the rate is so slow it is considered to be symptomatic bradycardia. Second-degree block may become life threatening if it progresses to third-degree AV block. Cardiac valve damage is generally not severe enough from the ablation catheter to cause immediate threat to life. Microemboli may cause TIA or CVA.
Reference: Blomstrom-Lundqvist, C., Scheinman, M. M., Aliot, E. M., et al. ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the European Society of Cardiology Committee for Practice Guidelines and the European Society of Cardiology Committee. 2003: http://www.acc.org/clinical/guidelines/arrythmias/sva_index.pdf.
3-114. (B) This question illustrates the nurse’s competency for response to diversity. Members of some cultures, such as Native Americans and Asians, look down when they are thinking or paying attention. They believe that it is rude to have prolonged eye contact. Since Asians often speak in a soft voice, nurses may be viewed as rude if they speak too loudly. Option A fails to recognize the nature of the communication problem at issue here. Options C and D appear to either neglect or disregard the cultural implications operating in this situation. Option D, in particular, demonstrates a lack of respect for cultural differences when this behavior is in direct opposition to the husband’s cultural background.
3-115. (C) Initial treatment for non–ST segment myocardial infarction (NSTEMI) includes administration of aspirin, nitroglycerin, and oxygen. Percutaneous intervention is performed within 24 hours for NSTEMI and within 90 minutes for acute myocardial infarction. Thrombolytics are administered within 30 minutes for acute ST segment elevation myocardial infarction. Delay of percutaneous intervention for NSTEMI greater than 24 hours is associated with poor outcomes.
3-116. (D) Immediate intubation is warranted for this patient due to the low SpO2 on high-flow oxygen. The WBC level is within normal limits, indicating that there is no infectious process warranting antibiotic coverage. The RBC and Hgb levels are low but not sufficiently low to warrant administration of blood products or to produce the patient’s low SpO2. Patchy infiltrates in one lobe do not warrant administration of a diuretic and do not reflect pneumonia that requires antibiotic coverage.
3-117. (A) The patient needs an immediate IV administration of insulin and glucose because he is demonstrating clinical signs of acute hyperkalemia. Clinical manifestations of hyperkalemia include irritability, restlessness, anxiety, nausea, vomiting, abdominal cramps, weakness, numbness, tingling, and cardiac irregularities. The presence of insulin forces potassium out of the serum and into the cells on a temporary basis, thereby protecting the heart from the effects of elevated serum potassium. In the patient with ESRD, potassium levels rise quickly owing to the complete loss of kidney function. Sodium polystyrene sulfonate (Kayexalate) is an ion resin that exchanges sodium for potassium in the bowel so that excessive amounts of potassium can be excreted via the feces. Although this is an effective means of ridding the body of excess potassium, its effects take longer to produce, making it a later option for management of hyperkalemia. Lidocaine and amiodarone are used to treat ventricular dysrhythmias and play no role in treating hyperkalemia.
3-118. (A) Acute coronary syndrome encompasses both non ST segment elevation MI (NSTEMI) and unstable angina. Physical findings may be normal or nonspecific. ECG findings may be nonspecific. Pulmonary rales, mitral regurgitation murmur, tachycardia, and hypotension may reflect heart failure or acute myocardial infarction. Patients with pain of any kind may have tachycardia. Hypotension may result from use of diuretics or use of nitrates to relieve chest pain.
3-119. (B) Data suggest that the patient must be in a supine position with the head of the bed (HOB) elevated no more than 30 to 45 degrees when ST segment analysis is performed. Option A is incorrect because if the ST alarm sounds and the patient is in a side-lying position, the patient should be returned to the supine position; only if the ST segment deviation persists with the patient supine should this finding be considered indicative of myocardial ischemia. Neither the completely flat (Option C) nor high Fowler’s position (Option D) affords ST segment monitoring as accurately as the supine position with HOB elevated.
Reference: AACN Practice Alert. ST Segment Monitoring. Available at www.aacn.org//AACN/practiceAlert.nsf/Files/ECG%20ST%20Segment/ Retrieved on July 1, 2006.
3-120. (A) HOB elevation of 30-45 degrees is associated with a lower incidence of aspiration of gastric contents. The current best practices for preventing VAP call for daily sedation vacations to avoid oversedation (Option B), frequent oral care (Option C), and early enteral rather than parenteral nutrition (Option D).
3-121. (B) In aortic stenosis, the left ventricle hypertrophies and requires higher filling pressures postoperatively to maintain adequate cardiac output. The filling pressure is demonstrated by the PCWP, which is generally maintained at 15 mm Hg or greater, so this patient needs the fluid bolus to raise filling pressure. Since nitroglycerin decreases preload, it would prevent adequate filling of the LV in the patient with aortic valve repair. Dobutamine is an inotropic agent, which would not be beneficial in this patient unless the volume status of the left ventricle was adequate. The patient requires nursing intervention to optimize cardiac output.
3-122. (C) Persons receiving enteral nutrition are at increased risk for developing hyperglycemic, hyperosmolar, non-ketotic coma because these solutions provide high carbohydrate nourishment. Assessment findings indicate polyuria resulting in dehydration. Without a history of diabetes, it is unlikely the patient has developed ketoacidosis. No bruising or other signs of trauma have been found, so there is little possibility the patient has developed diabetes insipidus.
3-123. (C) Vasodilators such as nitrates and ACE inhibitors decrease vasoconstriction, which decreases afterload. In addition, ACE inhibitors have a mild diuretic effect that is beneficial in congestive failure. Beta-blockers control atrial dysrhythmias and improve diastolic filling but do not decrease afterload. Digoxin improves myocardial contractility and controls atrial fibrillation but does not affect afterload. Nesiritide vasodilates to decrease afterload and promote diuresis.
3-124. (D) Data suggest that the two leads of choice for distinguishing ventricular tachycardia from supraventricular tachycardia with aberrant conduction are V1 and V6. Either lead II (Option A) or lead III is recommended to monitor atrial activity. Neither Option B nor Option C is recommended for specific monitoring purposes. Other data suggest that nurses use a standard monitoring lead irrespective of patient diagnosis.
Reference: AACN Practice Alert. Dysrhythmia Monitoring. Available at www.aacn.org/AACN/practiceAlert.nsf/Files/ECG%20Dysrhythmia/$file/ECG%20Dysrhythmia.pdf Retrieved on July 1, 2006.
3-125. (B) Chemotherapy regimens for colorectal cancer can have the side effect of gastrointestinal bleeding. Gastrointestinal perforation can occur. Dark-colored stools, fatigue, and the development of hypotension are sympyomatic of a gastrointestinal bleed. While malnutrition is a possibility in patients receiving chemotherapy, this patient does not exhibit evidence of that condition. The patient experiencing bleeding may well experience anemia, but stopping this patient’s bleeding is a higher priority need than treating the anemia. Patients on chemotherapy will incur immunosuppression, but that is not a pressing concern at this time.
3-126. (B) A patient who is breathing shallowly does not move air effectively in and out of the lungs. Diminished ventilation increases the volume of dead space, or air that does not contribute to gas exchange. The patient with increased dead space effectively rebreathes carbon dioxide, causing a rise in PaCO2. The amount of dead space affects the PaCO2 value. Administration of oxygen to a hypercapneic patient may actually increase PaCO2 because the higher amount of oxygen diminishes respiratory drive, thereby slowing the respiratory rate, which increases the PaCO2. Oxygen administration does not increase the work of breathing, but administration of 100% oxygen in a patient relying on hypoxia for respiratory drive should be avoided. Not all hypercapneic patients require hypoxia to stimulate ventilation; that response pattern is usually seen in patients with chronic rather than acute pulmonary disease. Decreased hemoglobin levels in anemia do not change the ratio of oxygen to carbon dioxide and therefore will not affect PaCO2. The A-a gradient is the difference in partial pressure of oxygen between arterial and alveolar blood. The normal value is 5 to 25 mm Hg or (age + 10) ÷ 4. High A-a gradients result from impaired diffusion or the presence of shunting. The higher the A-a gradient, the worse the diffusion defect. The A-a gradient reflects oxygenation and is independent of CO2 levels.
3-127. (D) Chest pain unrelieved by nitroglycerin or rest suggests that an atherosclerotic plaque has ruptured and embolized, causing occlusion of a coronary artery. Chest pain relieved by nitroglycerin or rest indicates that an atherosclerotic placque is stable and has not ruptured, causing distal occlusion. Chest pain associated with deep inspiration is characterized as pleuritic in nature.
3-128. (C) Patients with sudden-onset neurologic deficiencies and persistent focal neurologic deficits should be considered for rt-PA therapy. Patients with persistent symptoms after 1 hour have an 85% risk of stroke with only a 15% chance of full recovery. Patients whose symptoms resolve rapidly are most likely having a TIA and should not receive rt-PA. It is essential to identify the time of the onset of symptoms or at least the last time the patient was seen without deficits. For therapy to be effective, it must begin within 3 hours of symptom onset, not arrival to the hospital (Option A). Patient allergies are important to identify (Option B) but are not the most important factor. The time window of treatment options is the primary limiting factor in treatment of these patients. Bleeding at a noncompressible site such as a central vein (Option D) should be avoided, so a peripheral IV line is preferred to a central line.
3-129. (D) Signs of peripheral edema occur when shock has progressed and compensatory mechanisms are failing Peripheral edema, especially in dependent regions, occurs when increased capillary permeability allows plasma proteins to move from the vascular tree into the interstitial space. Tachycardia greater than 120 beats/min reflects progressive shock with cardiac compensation. Urine output less than 30 mL/hr may indicate early shock when renal vasoconstriction occurs. Increased capillary refill time occurs with vasoconstriction and may be present in early and progressive shock as well as during late shock.
3-130. (D) Positioning the patient with the injured side down and administering pain medication in the form of intercostal nerve blocks may be temporarily beneficial. The patient’s ABG results indicate that the high-flow mask in ineffective in providing adequate ventilation and oxygenation, so intubation with mechanical ventilation is needed. Positioning the patient with the uninjured side up helps to improve the ratio of ventilation to perfusion. Care must be taken in administration of IV fluids owing to this patient’s pulmonary contusion and the potential development of acute respiratory distress syndrome. The blood pressure is stable at this time, so inotropic support is unnecessary and would further compound existing significant tachycardia. The use of a CPAP mask would be less effective than intubation and pronation will increase the difficulty in management of the airway which is critically needed at this time. Trendelenberg positioning may impair ventilation without stabilization of the floating rib segment. Without a chest x-ray, it is difficult to know the extent of injury or whether a chest tube is warranted.
3-131. (C) Critically ill older patients exhibit delayed resolution of swallowing impairment post extubation. A fiberoptic endoscopic evaluation of swallowing should be considered in older patients following prolonged endotracheal intubation. While other consults (Options A and B) may be required, they can be delayed until the patient’s respiratory status is assured. Option D is incorrect because presence of laryngeal edema will be assessed prior to extubating the patient. Evaluation of the patient’s ability to swallow is essential to help prevent post-extubation aspiration.
3-132. (C) Aortic regurgitation results in dilation and noncompliance of the left ventricle. Vasopressor support with alpha-adrenergic agents such as norepinephrine (Levophed) increases the force of contraction and compliance of the left ventricle and constricts peripheral vessels to improve blood pressure. Volume boluses are often insufficient to improve BP and CO in a dilated, noncompliant left ventricle. In addition, PCWP and urine output indicate intravascular volume is adequate. Although dobutamine’s beta-adrenergic effects on the myocardium would increase LV contractility and heart rate, its beta-2 effects may dilate the peripheral vasculature, thereby lowering BP. Increasing the pacing rate without enhancing circulating volume would add further myocardial work.
3-133. (D) Most signs and symptoms of alcohol withdrawal are caused by rapid removal of the depressant effects of alcohol in the central nervous system. Alcohol withdrawal syndrome (AWS) usually occurs within 24 hours of the last drink and results in autonomic hyperreactivity (tremors, nausea, vomiting, sweating) and neuropsychiatric alterations (agitation, anxiety, auditory disturbances, clouding of sensorium, disturbances in visual or tactile senses). The worst form of AWS is called alcohol withdrawal delirium or delirium tremens, a life-threatening medical emergency that typically occurs 48 to 72 hours after the last drink. The autonomic hypersensitivity symptoms of delirium include hypertension, tachycardia, tachypnea, and tremors. Neuropsychiatric indications of delirium include hallucination, disorientation, and impaired attention. The cornerstone of pharmacologic management to halt progression of AWS and prevent DTs is administration of benzodiazepines, which provide CNS depression. Haldol is not indicated for the management of neuropsychiatric alterations associated with AWS. Restraints should not be applied, as they may intensify the neuropsychiatric alterations. The visual and auditory images associated with television may contribute to a patient’s confusion and hallucinations.
3-134. (A) Weight gain greater than 2 kg or 5 lb in 24 hours indicates failure of diuretic therapy and potential to develop pulmonary edema in the heart failure patient. This requires immediate contact to the primary care provider to adjust diuretic therapy or other lifestyle changes such as diet or fluid intake. Cough is a common side effect seen with ACE inhibitors and may be irritating but is not as life threatening as pulmonary edema. Leg edema is a common sign of right heart failure and may be diminished by leg elevation. Increased fatigue and exercise intolerance are signs of worsening heart failure or the development of co-existing problems such as flu or infection. Exercise tolerance in patients with heart failure waxes and wanes and does not warrant immediate physician notification.
3-135. (C) By seeking clarification and not readily implementing the order, the nurse is acting as an advocate for the patient. This is indicated as the patient’s family has not agreed to a do-not-resuscitate order and the ordered ventilator change is not clinically indicated. Option B could place the family in the middle between the patient and the physician and does not reflect caring practices. The nurse should recognize that to change a patient from receiving maximal ventilator support to a room-air level of oxygen support (Option A) when the patient’s oxygen saturation is low is not physiologically sound and could cause discomfort to the patient. The nurse will need to perform an ongoing patient assessment for presence of pain and discomfort and administer the medications based on that assessment. Administration of medications, as suggested in Option D, is not indicated until an assessment is made.
3-136. (A) This patient shows evidence of severe respiratory compromise, including respiratory acidosis, significant hypoxemia, and desaturation. This degree of pulmonary deterioration warrants intubation and mechanical ventilation (i.e., treatment considerably more aggressive than NIV or raising the FiO2). Although Heliox has been suggested for use in COPD as an adjunct to NIV, it is primarily used in treatment of status asthmaticus.
3-137. (A) Elevation of a pulseless extremity will decrease perfusion and is therefore contraindicated. Reverse Trendelenberg places the foot in a dependent position that would increase blood flow. Heparin could aid in resolving a clot which could be causing occlusion. Vasodilator medications would assist in promoting circulation to the foot and toe.
Reference: Fahey, V. A. Vascular Nursing, 4th ed. St. Louis, Elsevier, 2004.
3-138. (C). In general, southern Europeans (e.g., Spain) find frequent touching to be reassuring and comforting. Conversely, northern Europeans and Asians prefer little or no touching. This patient may be exhibiting restlessness and resistance to treatments because of the touching that is involved.
3-139. (C) The most likely cause of these findings is a pneumothorax, and the physician will assess the situation and probably insert a chest tube. To do nothing and continue with the bath will delay management of a recognizable condition that requires treatment and could pose some risk to the patient. Application of an occlusive dressing could convert this pneumothorax into a potential tension pneumothorax, a serious and possibly lethal problem that could result in cardiac arrest. At this time, the patient does not appear to be in any pulmonary distress, so intubation is not warranted.
3-140. (B) CT scan is used for patients with nonpenetrating trauma to determine the location and extent of renal parenchymal damage. A CT scan can assess the extent of parenchymal laceration, urine extravasation, surrounding hemorrhage, and presence of vascular injury. Ultrasound has minimal value for nonpenetrating injury, although it can help evaluate renal parenchymal injury and locate a hematoma. Renal scan is used to evaluate renal blood flow and possible parenchymal injury. Renal angiography is done if the injury is not clearly defined by other radiologic studies.
3-141. (C) Patients who have undergone major open abdominal procedures and are receiving postoperative opioids can develop a postoperative ileus. The complication is usually transient, and early recognition is key to expedient and effective management. Although the patient has a low-grade fever, no other signs of an intra-abdominal infection or wound infection are present, and the elevated white blood cell count that would be expected with infection is not evident. There is no evidence of an intra-abdominal hemorrhage, as the patient’s hemoglobin and vital signs are stable.
3-142. (C) This patient has pauses reflecting a heart rate of 19 beats/min followed by tachycardia. This is indicative of sick sinus syndrome and indicates need for a permanent pacemaker. A transcutaneous pacemaker could be used when the heart rate slows, but would not be effective when tachycardia appears. Atropine is not an appropriate treatment for a dysrhythmia which alternates between bradycardia and tachycardia. Continuous monitoring is indicated for this patient but is not sufficient for management and places the patient at risk for syncopal episodes which may result in patient injury.
3-143. (A) Hemoperfusion is a process used to clear blood of substances that bind to plasma proteins or are lipid soluble. When blood is pumped through a cartridge that contains activated charcoal and/or carbon, those two substances compete with plasma proteins to absorb drugs and poisons. Phenytoin is a highly protein bound substance, and hemoperfusion is the most effective treatment for removal. Lithium, salicylate, and ethanol are low-molecular-weight substances and, therefore, hemodialysis would be the preferred method for removal. The semipermeable membrane used during dialysis allows the movement of small molecules and middle-weight molecules from the blood into the dialysate. It is impermeable to larger molecules like phenytoin.
3-144. (C) In this situation, advocating for the patient occurs through preventing the transfer of infections between patients. The CDC recommends washing with either nonantimicrobial or antimicrobial soap; hence, any soap is effective. According to the CDC, alcohol-based hand rubs are not for visibly soiled hands; therefore, Option A is incorrect. Option B is incorrect because hands should be washed both after the removal of gloves and before the donning of gloves. A 10-minute scrub time is not recommended even for surgical hand antisepsis.
3-145. (A) A narrowed pulse pressure, tachycardia, location of the stab wound, and chest x-ray demonstrating an enlarged cardiac silhouette strongly suggest pericardial tamponade is present. A 10% pneumothorax is not sufficient to cause hypotension, and the condition is treated appropriately with chest tube placement. At least 250 mL of blood is needed in most cases to be visible as a hemothorax on chest x-ray; however, even a 250 mL loss would have been treated appropriately by the 500 mL bolus in the ED. There is no apparent source of excessive bleeding causing hypovolemia on chest x-ray, wound dressing, or in the chest tube collection chamber. Hypovolemia would cause hypotension and tachycardia, but not an enlarged cardiac silhouette.
3-146. (A) Part of the pathophysiology of emphysema involves the destruction of alveolar walls with resulting development of large, air-filled structures called “blebs.” These areas are at risk for rupturing, which will lead to the development of a pneumothorax. As a result, patient management includes careful monitoring of airway pressures and use of low- to normal-sized tidal volumes. Patients with emphysemia do not demonstrate alveolar/arterial diffusion defects as seen in ARDS, so they typically will respond to increases in FiO2. There are no standardized strategies for mode of ventilatory management in this patient population.
3-147. (B) Administration of insulin will help to correct the hyperglycemia associated with steroid administration and stress. This intervention should be followed by administration of IV fluids and electrolytes, as the patient has likely been experiencing polyuria. Low-dose insulin drip will require a greater period of time to correct the metabolic alterations but may be desirable at a later time. While the bicarbonate level is slightly decreased, administration of bicarbonate is not appropriate at this time, as this value will return to normal as fluids and electrolytes are replaced. This level of carbon dioxide may be a normal value for this patient, whose underlying respiratory disease may result in carbon dioxide retention.
3-148. (C) Although it is common to maintain CSF pressure at 10 mm Hg after thoracic aortic aneurysm repair, there is only about 150 mL of CSF in the system at one time. If CSF is drained too rapidly or in too large a volume, the patient is at risk of subarachnoid hemorrhage. Fluid administration may be used to maintain blood pressure after TAA repair and is used in conjunction with nitroglycerin administration to decrease systolic BP because many of these patients have pre-existing hypertension. FFP and platelets are commonly administered to these patients to replace coagulation factors and prevent coagulopathy.
3-149. (C) NPPV works by increasing inspiratory pressure to expand tidal volume. Increased tidal volume, in turn, enhances alveolar recruitment and diminishes the atelectasis caused by hypoventilation. Care must be exercised in use of NPPV, however, to avoid inadvertently increasing expiratory pressures as well. This is a particular concern for patients with COPD, who already have excessively high expiratory pressures owing to airway collapse on expiration with air-trapping in distal alveoli. Further increases in expiratory pressure from NPPV would then magnify one of the fundamental pathophysiologic effects of COPD. NPPV has minimal effects on V/Q matching and has no effect on mucous production in distal airways.
3-150. (D) Forced expiratory volume (FEV1) in 1 second, as an indication of flow, drops a minimum of 20 mL per year after age 25 years. Option A is incorrect because pulmonary changes observed in older adults include a decrease in maximal inspiratory and expiratory capacity, work capacity, and chest wall compliance secondary to rib cage calcification. Lungs become stiff, and compliance decreases owing to decreased elastic recoil. Options B and C are incorrect because older persons experience a decrease in alveolar surface area and a decline in surfactant production that lead to higher residual lung volumes and air trapping. Auscultation of breath sounds in an older individual reveals decreased air exchange in the lung bases that result from air trapping and decreased lung expansion.
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