A nurse is caring for a patient with shock of unknown etiology whose hemodynamic monitoring indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure.
Which collaborative intervention ordered by the health care provider should the nurse question?
a. Infuse normal saline at 250 mL/hr.
b. Keep head of bed elevated to 30 degrees.
c. Hold nitroprusside (Nipride) if systolic BP <90 mm hg.
d. Titrate dobutamine (Dobutrex) to keep systolic BP >90 mm Hg.
Question 2A 78-kg patient with septic shock has a urine output of 30 mL/hr for the past 3 hours. The pulse rate is 120/minute and the central venous pressure and pulmonary artery wedge pressure are low.
Which order by the health care provider will the nurse question?
a. Give PRN furosemide (Lasix) 40 mg IV.
b. Increase normal saline infusion to 250 mL/hr.
c. Administer hydrocortisone (Solu-Cortef) 100 mg IV.
d. Titrate norepinephrine (Levophed) to keep systolic BP >90 mm Hg.
Question 3The nurse is caring for a patient who has an intraortic balloon pump (IABP) following a massive heart attack. When assessing the patient, the nurse notices blood backing up into the IABP catheter.
In which order should the nurse take the following actions? (Put a comma and a space between each answer choice A, B, C, D.)
a. Ensure that the IABP console has turned off.
b. Assess the patient's vital signs and orientation.
c. Obtain supplies for insertion of a new IABP catheter.
d. Notify the health care provider of the IABP malfunction.
Question 4When assisting with oral intubation of a patient who is having respiratory distress, in which order will the nurse take these actions? (Put a comma and a space between each answer choice A, B, C, D, E.)
a. Obtain a portable chest-x-ray.
b. Position the patient in the supine position.
c. Inflate the cuff of the endotracheal tube after insertion.
d. Attach an end-tidal CO2 detector to the endotracheal tube.
e. Oxygenate the patient with a bag-valve-mask device for several minutes.
Question 5After change-of-shift report, which patient should the progressive care nurse assess first?
a. Patient who was extubated in the morning and has a temperature of 101.4 F (38.6 C)
b. Patient with bilevel positive airway pressure (BiPAP) for sleep apnea whose respiratory rate is 16
c. Patient with arterial pressure monitoring who is 2 hours postpercutaneous coronary intervention who needs to void
d. Patient who is receiving IV heparin for a venous thromboembolism and has a partial thromboplastin time (PTT) of 98 sec
Question 6After change-of-shift report on a ventilator weaning unit, which patient should the nurse assess first?
a. Patient who failed a spontaneous breathing trial and has been placed in a rest mode on the ventilator
b. Patient who is intubated and has continuous partial pressure end-tidal CO2 (PETCO2) monitoring
c. Patient with a central venous oxygen saturation (ScvO2) of 69 while on bilevel positive airway pressure (BiPAP)
d. Patient who was successfully weaned and extubated 4 hours ago and now has no urine output for the last 6 hours
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