ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 70 Questions
Question 1 of 5
The nurse is caring for a patient with a left radial arterial line. Which of the following assessments indicates a need for the nurse to take action?
Correct Answer: A
Rationale: The change in temperature of the left hand suggests that blood flow to the left hand is impaired. The flush system needs to be changed every 96 hours or per agency policy. A mean arterial pressure (MAP) of 75 mm Hg is normal. Flush systems for hemodynamic monitoring are set up to deliver 3-6 mL/hour of flush solution.
Question 2 of 5
Four hours after mechanical ventilation is initiated for a patient with chronic obstructive pulmonary disease (COPD), the patient's arterial blood gas (ABG) results include a pH of 7.50, PaO2 of 80 mm Hg, PaCO2 of 29 mm Hg, and HCO3 of 23 mmol/L. The nurse will anticipate the need to do which of the following actions based upon these findings?
Correct Answer: B
Rationale: The patient's PaCO2 and pH indicate respiratory alkalosis caused by too high a respiratory rate. The PaO2 is appropriate for a patient with COPD, increasing the tidal volume would further lower the PaCO2, and the PaCO2 and pH indicate a need to make the ventilator changes.
Question 3 of 5
The charge nurse is mentoring a new RN staff member providing care to a patient receiving mechanical ventilation. Which of the following actions by the new RN indicates the need for more education?
Correct Answer: C
Rationale: The head of the patient's bed should be positioned at 30-45 degrees to prevent ventilator-acquired pneumonia. The other actions by the new RN are appropriate.
Question 4 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 5 of 5
The nurse is assisting with insertion of a pulmonary artery (PA) catheter in a patient. Which of the following data identifies that the catheter is correctly placed?
Correct Answer: A
Rationale: One of the purposes of a PA line is to measure PAOP, so the catheter is floated through the pulmonary artery until the dilated balloon wedges in a distal branch of the pulmonary artery, and the PAOP readings are available. After insertion, the balloon is deflated and the PA waveform will be observed. Systemic arterial pressures are obtained using an arterial line. The length of catheter needed for insertion will vary with patient size.