Critical Care Nursing Questions

Correct Answer: A

Rationale: The correct answer is A: Inflate the balloon for no more than 8 to 10 seconds while noting the waveform change. This is because inflating the balloon within this time frame allows for accurate measurement of PAOP without causing complications like pulmonary edema. Noting the waveform change helps in determining the accurate pressure reading. Explanation of why other choices are incorrect: B: Inflating the balloon with air and recording the volume necessary is not a recommended practice as it can lead to inaccurate readings and potential harm to the patient. C: Maintaining the balloon inflated for 8 hours following insertion is unnecessary and could lead to complications such as vascular damage or thrombosis. D: Zero referencing and leveling the transducer at the phlebostatic axis are important steps but not directly related to performing an initial PAOP measurement.

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.

Correct Answer: C

Rationale: The correct answer is C: Decrease the risk of bradycardia during surgery. Rationale: 1. Atropine is an anticholinergic medication that works by blocking the parasympathetic nervous system. 2. During surgery, the parasympathetic stimulation can lead to bradycardia (slow heart rate). 3. By administering atropine, the nurse can counteract the bradycardic effects and maintain a normal heart rate during the procedure. 4. Options A, B, and D are incorrect as atropine is not used for inducing anesthesia, relaxation, or minimizing postoperative analgesia.

Correct Answer: B

Rationale: The correct answer is B: Train-of-four yields two twitches. This assessment indicates a target level of paralysis because a train-of-four ratio of 2 twitches out of 4 suggests a 50% neuromuscular blockade, which is often the goal for patients receiving paralysis for procedures or ventilation. A: A Glasgow Coma Scale score of 3 assesses consciousness, not neuromuscular blockade. C: A Bispectral index of 60 measures depth of anesthesia, not paralysis level. D: CAM-ICU assesses delirium, not neuromuscular blockade.

Correct Answer: A

Rationale: The correct answer is A: Diminished breath sounds over the left lung field. This finding could indicate a pneumothorax, a serious complication of subclavian CVC insertion. Immediate action is required to prevent respiratory distress. Incorrect answers: B: Localized pain at insertion site is common post-procedure and may not indicate a serious issue. C: A central venous pressure of 5 mm Hg is within the normal range and does not require immediate action. D: Slight bloody drainage is expected initially and can be managed with routine care.