Exam (elaborations)
NR 342: CRITICAL CARE COMPLEX TEST REVIEW ACCURATE AND VERIFIED- CHAMBERLAIN
- Course
- NR 342
- Institution
- Chamberlain College Of Nursing
NR 342: CRITICAL CARE COMPLEX TEST REVIEW ACCURATE AND VERIFIED- CHAMBERLAIN
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lOMoAR cPSD| 42091925lOMoAR cPSD| 42091925
NR 342: CRITICAL CARE COMPLEX TEST REVIEW ACCURATE AND VERIFIED-
CHAMBERLAIN
1. Different invasive lines for pt who is in ICU and just had a CABG, cardiac status, other vital functions.
- nurse should always assess vital signs and chest dressing first
POST-OP CABG (SATA)
- 1. hemodynamic monitoring (CO)
- 2. an arterial line for continuous BP monitoring
- 3. pleural and mediastinal chest tubes for chest drainage
- 4. continuous ECG monitoring
- 5. an endotracheal tube connected to mechanical ventilation
- 6. epicardial pacing wires for emergency pacing of the heart
- 7. urinary catheter to monitor urine output
2. NI for pts on ventilators to prevent complications. SATA. May develop peptic ulcers, NI and drugs to administer
– Administer pantoprazole, reposition endotracheal tube daily, raise HOB, monitor for skin irritations in the mouth.
Minimizing sedation, spontaneous awakening trials (SATS), early exercise and mobilization, use of ET tube with
subglottic secretion drainage ports for the pt likely to be intubated greater than 48-72 hrs, elevate HOB greater than
30-45 degrees, oral care with chlorhexidine and no routine changes of the patient ventilation circuit tubing, turn pt
Q2hrs.
1. Which actions should the nurse start to reduce the risk for ventilator-associated pneumonia
(VAP)? (Select all that apply.)
a. Obtain arterial blood gases daily.
b. Provide a “sedation holiday” daily.
c. Give prescribed pantoprazole (Protonix).
d. Elevate the head of the bed to at least 30 degrees.
e. Provide oral care daily with chlorhexidine (0.12%) solution.
ANS: B, C, D, E
All these interventions are part of the ventilator bundle that is recommended to prevent VAP. Arterial blood gases
may be done daily but are not always necessary and do not help prevent VAP.
3. Pt with COPD show signs of anxiety, what NI we perform. What do we do first
Elevate HOB 30 to 45
- interventions for COPD patient who is anxious (pg 572)
● Identify when level of anxiety changes to determine possible precipitating factors
● Use calm, reassuring approach to provide reassurance
● Stay w/ pt to promote safety and reduce fear
● Encourage verbalization of feelings, precipitations, and fears to identify problem areas so appropriate planning
can take place
● Provide factual info concerning diagnosis, treatment, and prognosis to help pt know what to expect
, lOMoAR cPSD| 42091925
● Instruct pt in the use of relaxation techniques to relieve and promote ease of respirations
- provide better comfort for COPD patient
-COPD – manifestations, chronic intermittent cough, dyspnea, wheezing, chest tightness, fatigue, weight loss,
anorexia
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nursing interventions/teaching, Stop smoking, avoid environmental pollutants, avoid others who are sick, practice
good HH, take meds as prescribed, exercise regularly, maintain a healthy weight.
Influenza and pneumococcal vaccines are recommended
Pursed lip breathing, huff breathing to clear secretions, chest physiotherapy, postural drainage, percussion vibration
medical interventions including medications: bronchodilators, O2 therapy complications: exacerbations from COPD,
cor pulmonale, acute respiratory failure.
The nurse observes a new onset of agitation and confusion in a patient with chronic obstructive pulmonary disease
(COPD). Which action should the nurse take first?
a. Observe for facial symmetry.
b. Notify the health care provider.
c. Attempt to calm and reorient the patient.
d. Assess oxygenation using pulse oximetry.
ANS: D
Because agitation and confusion are often the initial indicators of hypoxemia, the nurse’s initial action should be to
assess O2 saturation. The other actions are appropriate, but assessment of oxygenation takes priority over other
assessments and notification of the health care provider.
4. ABG
KNOW ABGs. Compensated VS uncompensated - ph will be normal or close to normal
ABG’s – interpretation and/or expected findings for a client condition/disease process
Normal Findings:
ph- 7.35-7.45 (hydrogen)
PaCO2 : (carbon dioxide) 35-45mmhg
HCO3 (bicarbonate) 22-26mmol/l
ROME -Respiratory opposite, metabolic equal.
Respiratory Acidosis: ph below 7.35, CO2 above 45, bicarb within range. treatment is 2-4L o2, lift head of the bed,
increase oral fluids, turn cough deep breath, maintain airway.
Respiratory Alkalosis: Ph above 7.35, CO2 below 35, bicarb within range. “paper bag” -rebreather, watch potassium
and calcium levels, monitor for overventilation.
Metabolic Acidosis: ph below 7.35, CO2 within range, HCO3 below 22. insulin to reduce ketones for DKA,
antidiarrheal, fall precautions, iv isotonic/hypertonic, sodium bicarb, hyperkalemia.
Metabolic alkalosis: ph above 7.45, CO2 within range, HCO2 above 26. Antiemetic, stop diuretics, watch for signs
avoid foods that cause gas(cabbage, beans, cauliflower_ of distress, watch potassium and calcium, hypokalemia.
5. Visitation policies for pts in ICU – EBP pg 1537 critical care ch 65
- lack of visitations causes mental complications
- individualized to the patient’s needs. (ICU is more restrictive)
● Evidence suggests several positive benefits of flexible visitations for the patient:
o decrease anxiety confusion and agitation
o fewer cardiovascular complications
o shorter ICU length of stay
The family members of a patient who has been admitted to the intensive care unit (ICU) with multiple traumatic
injuries have just arrived in the ICU waiting room. Which action should the nurse take first?
a. Explain ICU visitation policies and encourage family visits.
b. Escort the family from the waiting room to the patient’s bedside.
c. Describe the patient’s injuries and the care that is being provided.
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