Following insertion of a pulmonary artery catheter (PAC),a bthirbe. cpohmy/tessitc ian orders the nurse to obtain a blood sample for mixed venous oxygen saturation (SvO ). Which action by the nurse best ensures the obtained value is accurate?

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Question 1 of 9

Following insertion of a pulmonary artery catheter (PAC),a bthirbe. cpohmy/tessitc ian orders the nurse to obtain a blood sample for mixed venous oxygen saturation (SvO ). Which action by the nurse best ensures the obtained value is accurate?

Correct Answer: B

Rationale: The correct answer is B because calibrating the system with central venous and arterial blood samples ensures accuracy of the mixed venous oxygen saturation (SvO2) measurement. This calibration allows for comparison of the values obtained from both sources to confirm the accuracy of the measurement. Choice A is incorrect because zero referencing the transducer at the level of the phlebostatic axis does not directly address the accuracy of the SvO2 measurement. Choice C is incorrect because ensuring patency of the catheter using normal saline pressurized at 300 mm Hg does not directly impact the accuracy of the SvO2 measurement. Choice D is incorrect because using noncompliant pressure tubing does not ensure the accuracy of the SvO2 measurement. The length of the tubing and the presence of stopcocks are not directly related to obtaining an accurate SvO2 value.

Question 2 of 9

The critical care environment is often stressful to a criticalalbyir bil.clo pma/tteiset nt. Identify stressors that are commonly stressful for the critically ill patient. (Select all that apply.)

Correct Answer: A

Rationale: The correct answer is A: Alarms that sound from various devices. In the critical care environment, alarms often indicate changes in the patient's condition, causing stress. Bright fluorescent lighting (B) may be bothersome but not directly related to patient stress. Lack of day-night cues (C) may disrupt sleep patterns but is not a direct stressor. Sounds from the mechanical ventilator (D) are essential for patient care and not inherently stressful.

Question 3 of 9

A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED). The nurse determines that discharge teaching has been effective when the patient makes which statement?

Correct Answer: C

Rationale: The correct answer is C: "I should drink sports drinks when working outside in hot weather." This statement is correct because hypotension and elevated temperature could indicate dehydration and electrolyte imbalance due to excessive sweating in hot weather. Drinking sports drinks can help replenish electrolytes lost through sweating and prevent dehydration. Incorrect choices: A: Taking salt tablets can lead to an imbalance in electrolytes and worsen the condition. B: Acetaminophen can lower fever but does not address dehydration or electrolyte imbalance. D: Moving to a cool environment when feeling confused is important but does not address the underlying issue of dehydration and electrolyte imbalance.

Question 4 of 9

The patient undergoes a cardiac catheterization that requires the use of contrast dyes during the procedure. To detect signs of contrast-induced kidney injury, the nurse should

Correct Answer: B

Rationale: The correct answer is B because evaluating the patient's serum creatinine for up to 72 hours after the procedure is crucial in detecting contrast-induced kidney injury. An increase in serum creatinine levels indicates impaired kidney function due to the contrast dye. This monitoring allows for early detection and intervention to prevent further kidney damage. Choice A is incorrect because a decrease in urine output is a late sign of kidney injury and may not be present in the early stages. Choice C is incorrect as a renal ultrasound is not typically used to detect contrast-induced kidney injury. Choice D is incorrect as postvoid residual volume assessment is not specific to detecting intrarenal injury related to contrast dye use.

Question 5 of 9

The vision of the American Association of Critical-Care N urses is a healthcare system driven by achieving what goal?

Correct Answer: D

Rationale: The correct answer is D because the vision of the American Association of Critical-Care Nurses focuses on creating respectful, healing, and humane environments. This aligns with the core values of nursing, emphasizing compassion, dignity, and patient-centered care. A is incorrect as the focus is not solely on the work environment. B is incorrect as it emphasizes the role of physicians over the collaborative approach advocated by the AACN. C is incorrect as it only addresses meeting patient needs, whereas the vision encompasses a broader scope of creating healing environments.

Question 6 of 9

A nurse is weaning a 68-kg male patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation. Which patient assessment finding indicates that the weaning protocol should be stopped?

Correct Answer: C

Rationale: The correct answer is C because a respiratory rate of 32 breaths/min indicates increased work of breathing, which could be a sign of respiratory distress. In a patient being weaned from mechanical ventilation, an elevated respiratory rate suggests that the patient may not be able to sustain adequate ventilation on their own. This warrants stopping the weaning protocol to prevent respiratory failure. Choice A is incorrect because a heart rate of 97 beats/min is within normal range for an adult. Choice B is incorrect because an oxygen saturation of 93% is acceptable for a patient with COPD. Choice D is incorrect because a tidal volume of 450 mL is adequate for a patient weaning from mechanical ventilation.

Question 7 of 9

The nurse manager is assisting a nurse with improving organizational skills and time management. Which nursing activity is the priority in pre-planning a schedule for selected nursing activities in the daily assignment?

Correct Answer: B

Rationale: The correct answer is B: Medication administration. This is the priority because medication administration is time-sensitive and crucial for patient safety. It requires precise timing and cannot be delayed. Tracheostomy tube suctioning (A), colostomy care instruction (C), and client personal hygiene (D) are important nursing activities but can be adjusted within the schedule based on patient needs and acuity levels. Prioritizing medication administration ensures that patients receive their medications on time, preventing adverse events and promoting optimal health outcomes.

Question 8 of 9

The nurse recognizes that which patient is likely to benefit most from patient-controlled analgesia?

Correct Answer: A

Rationale: The correct answer is A, the 21-year-old with a C4 fracture and quadriplegia. This patient is likely to benefit most from patient-controlled analgesia (PCA) due to the inability to self-administer traditional pain medications. With quadriplegia, the patient may have limited mobility and sensation, making it challenging to communicate pain levels effectively. PCA allows the patient to control their pain relief within preset limits, enhancing autonomy and optimizing pain management. Summary: - Choice B: The 45-year-old with femur fracture and closed head injury may benefit from PCA, but the severity of the head injury could affect their ability to use the device effectively. - Choice C: The 59-year-old postoperative elective bariatric surgery patient can typically manage pain with traditional methods postoperatively. - Choice D: The 70-year-old postoperative cardiac surgery patient with mild dementia may have the cognitive ability to use PCA but could potentially benefit more from other pain management strategies due

Question 9 of 9

The family of a critically ill patient has asked to discuss organ donation with the patient’s nurse. When preparing to answer the family’s questions, th e nurse understands which concern(s) most often influence a family’s decision to donate? (Select all that apply.)

Correct Answer: A

Rationale: Rationale for Correct Answer A: Donor disfigurement influences on funeral care. Families often consider the impact of organ donation on the appearance of their loved one during funeral arrangements. This concern can significantly influence their decision to donate. Incorrect Answers: B: Fear of inferior medical care provided to donor. This is not a common concern as medical care for donors is typically of high quality. C: Age and location of all possible organ recipients. While important, this is not a primary concern for families when deciding on organ donation. D: Concern that donated organs will not be used. Families are generally more concerned about the impact on their loved one's appearance post-donation rather than the utilization of organs.

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