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Chapter 68: Nursing Management: Critical Care EnvironmentLewis: Medical-Surgical Nursing in Canada 4th Canadian Edition
MULTIPLE CHOICE
1. A client has a nursing diagnosis of disturbed sleep pattern related to difficulty maintaing
sleep state. Which of the following actions should the nurse include in the plan of care?
a. Discontinue assessments during the night to allow uninterrupted sleep.
b. Administer prescribed sedatives or opioids at bedtime to promote sleep.
c. Silence the alarms on the cardiac monitors to allow 30- to 40-minute naps.
d. Cluster nursing activities so that the client has uninterrupted rest periods.
ANS: D
Clustering nursing activities and providing uninterrupted rest periods will minimize
sleep-cycle disruption. Sedative and opioid medications tend to decrease the amount of
rapid eye movement (REM) sleep and can contribute to sleep disturbance and disturbed
sensory perception. Silencing the alarms on the cardiac monitors would be unsafe in a
critically ill client, as would discontinuing assessments during the night.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
MSC: NCLEX: Psychosocial Integrity
2. To determine the effectiveness of medications that a client has received to reduce left
ventricular afterload, which of the following hemodynamic parameters should the nurse
monitor?
a. Central venous pressure (CVP)
b. Systemic vascular resistance (SVR)
c. Pulmonary vascular resistance (PVR)
d. Pulmonary artery wedge pressure (PAWP)
ANS: B
Systemic vascular resistance reflects the resistance to ventricular ejection, or afterload.
The other parameters will be monitored, but do not reflect afterload as directly.
DIF: Cognitive Level: Application TOP: Nursing Process: Evaluation
MSC: NCLEX: Physiological Integrity
3. While family members are visiting, a client has a cardiac arrest and is being resuscitated.
Which of the following actions by the nurse is best?
a. Ask family members if they wish to remain in the room during the resuscitation.
b. Explain to family members that watching the resuscitation will be very stressful.
c. Assign a staff member to wait with family members just outside the client room.
d. Escort family members quickly out of the client room and then remain with them.
ANS: A
Research indicates that family members want the option of remaining in the room during
procedures such as CPR and that this decreases anxiety and facilitates grieving. The other
options may be appropriate if the family decides not to remain with the client.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity
, 4. The nurse is caring for a client following surgery whose central venous pressure (CVP)
monitor indicates low pressures. Which of the following actions should the nurse
anticipate implementing?
a. Increase the IV fluid infusion rate.
b. Administer IV diuretic medications.
c. Elevate the head of the client’s bed to 45 degrees.
d. Document the CVP and continue to monitor.
ANS: A
A low CVP indicates hypovolemia and a need for an increase in the infusion rate. Diuretic
administration will contribute to hypovolemia and elevation of the head may decrease
cerebral perfusion. Documentation and continued monitoring is an inadequate response to
the low CVP.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
5. The nurse is caring for a client with pulmonary hypertension. Which of the following
parameters should the nurse monitor as an index of right ventricular afterload?
a. Mean arterial pressure (MAP)
b. Central venous pressure (CVP)
c. Pulmonary vascular resistance (PVR)
d. Pulmonary artery wedge pressure (PAWP)
ANS: C
Pulmonary vascular resistance and pulmonary artery pressure are indexes of right
ventricular afterload. The other parameters do not directly assess for right ventricular
afterload.
DIF: Cognitive Level: Application TOP: Nursing Process: Evaluation
MSC: NCLEX: Physiological Integrity
6. The intensive care unit nurse educator is teaching a new staff nurse about hemodynamic
monitoring. Which of the following actions indicates that the teaching has been effective?
a. Positions the zero-reference stopcock line level with the phlebostatic axis
b. Balances and calibrates the hemodynamic monitoring equipment every hour
c. Rechecks the location of the phlebostatic axis when changing the client’s position
d. Ensures that the client is lying supine with the head of the bed flat for all readings
ANS: A
For accurate measurement of pressures, the zero-reference level should be at the
phlebostatic axis. There is no need to rebalance and recalibrate monitoring equipment
hourly. Accurate hemodynamic readings are possible with the client’s head raised to 45
degrees or in the prone position. The anatomic position of the phlebostatic axis does not
change when clients are repositioned.
DIF: Cognitive Level: Application TOP: Nursing Process: Evaluation
MSC: NCLEX: Safe and Effective Care Environment
7. The nurse is monitoring for the effectiveness of treatment for a client with left ventricular
failure. Which of the following assessments is most important for the nurse to evaluate?
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