ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 70 Questions
Question 1 of 5
A patient has a nursing diagnosis of disturbed sleep pattern related to difficulty maintaining sleep state. Which of the following actions should the nurse include in the plan of care?
Correct Answer: D
Rationale: Clustering nursing activities and providing uninterrupted rest periods will minimize sleep-cycle disruption. Sedative and opioid medications tend to decrease the amount of rapid eye movement (REM) sleep and can contribute to sleep disturbance and disturbed sensory perception. Silencing the alarms on the cardiac monitors would be unsafe in a critically ill patient, as would discontinuing assessments during the night.
Question 2 of 5
To determine the effectiveness of medications that a patient has received to reduce left ventricular afterload, which of the following hemodynamic parameters should the nurse monitor?
Correct Answer: B
Rationale: Systemic vascular resistance reflects the resistance to ventricular ejection, or afterload. The other parameters will be monitored, but do not reflect afterload as directly.
Question 3 of 5
While family members are visiting, a patient has a cardiac arrest and is being resuscitated. Which of the following actions by the nurse is best?
Correct Answer: A
Rationale: 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 patient.
Question 4 of 5
The nurse is caring for a patient following surgery whose central venous pressure (CVP) monitor indicates low pressures. Which of the following actions should the nurse anticipate implementing?
Correct Answer: A
Rationale: 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.
Question 5 of 5
The nurse is caring for a patient with pulmonary hypertension. Which of the following parameters should the nurse monitor as an index of right ventricular afterload?
Correct Answer: C
Rationale: Pulmonary vascular resistance and pulmonary artery pressure are indexes of right ventricular afterload. The other parameters do not directly assess for right ventricular afterload.