The ICU charge nurse will evaluate that teaching about hemodynamic monitoring for a new staff nurse has been effective when the new nurse does which of the following?

Position the limb with the catheter insertion site at the level of the transducer.

Positions the transducer level with the phlebostatic axis.

Ensures that the patient is lying with the head of the bed flat for all readings.

Balances and calibrates the hemodynamic monitoring equipment every hour.

Answer and Explanation

The Correct Answer is B

Positioning the transducer level with the phlebostatic axis is a crucial step in accurate hemodynamic monitoring. The phlebostatic axis is an imaginary reference point located at the fourth intercostal space, mid-anterior/posterior chest. Placing the transducer at this level ensures that the pressure measurements obtained are reflective of the patient's true hemodynamic status.
A. Positioning the limb with the catheter insertion site at the level of the transducer in (option A) is incorrect because: While it is important to position the limb appropriately to avoid kinks or occlusions in the catheter tubing, this is not directly related to the accurate measurement of hemodynamic parameters.
C. Ensuring that the patient is lying with the head of the bed flat for all readings in (option C) is incorrect because The position of the patient's head does not directly impact the accuracy of hemodynamic monitoring unless it specifically relates to changes in preload or intracranial pressure monitoring.
D. Balancing and calibrating the hemodynamic monitoring equipment every hour in (option D) is incorrect because: While it is important to ensure that the monitoring equipment is calibrated and functioning properly, doing so every hour may not be necessary. Calibration frequency may vary based on institutional policies and patient stability.
Therefore, the correct action that demonstrates effective teaching about hemodynamic monitoring is positioning the transducer level with the phlebostatic axis.

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Correct Answer is C

Explanation

In septic shock, one of the key goals of management is to restore and maintain adequate intravascular volume. However, in this case, the patient's urine output is low (30 mL/hr for the past 3 hours), suggesting inadequate renal perfusion and potential fluid overload.
Administering additional normal saline at an increased rate (250 mL/hr) without addressing the low urine output could potentially exacerbate fluid overload and further compromise the patient's condition.
A. Administer hydrocortisone (Solu-Cortef) 100 mg IV in (option A) is incorrect because: Hydrocortisone is commonly used in septic shock to help stabilize blood pressure and modulate the inflammatory response.
B. Giving PRN furosemide (Lasix) 40 mg IV in (option B) is incorrect because Furosemide, a loop diuretic, can be administered as needed to address fluid overload or to increase urine output if there is evidence of volume overload.
D. Titrate norepinephrine (Levophed) to keep systolic BP >90 mm Hg in (option D) is incorrect because: Norepinephrine is a vasopressor commonly used in septic shock to increase systemic vascular resistance and maintain adequate blood pressure.

A. Assess the patient's tissue perfusion further. B. Ask if the patient needs pain medication. C. Document the findings in the patient's chart. D. Increase the rate of the patient's IV infusion.

Correct Answer is A

Explanation

The increased respiratory rate and pulse rate can be indicators of physiological changes or potential complications in the patient's condition. These changes may suggest alterations in tissue perfusion or other underlying issues that require further assessment.
Assessing the patient's tissue perfusion includes evaluating additional vital signs, such as blood pressure, oxygen saturation, and capillary refill time. Assessing skin color, temperature, and moisture, as well as peripheral pulses, can also provide important information regarding tissue perfusion.
B. Pain medication (option B) is incorrect because the increased respiratory and pulse rates could also indicate other factors that require assessment before administering pain medication.
C. Documenting the findings in the patient's chart (option C) is incorrect because it should not be the primary action at this point. Assessing the patient's condition and determining appropriate interventions take priority.
D. Increasing the rate of the patient's IV infusion (option D) is incorrect because may not be the most appropriate action without further assessment. The patient's increased respiratory and pulse rates may not necessarily be related to hydration status, and it is important to assess the patient comprehensively before making changes to the IV infusion rate.
Therefore, the best action by the nurse in this situation is to further assess the patient's tissue perfusion to gather more information and determine the appropriate course of action.

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The ICU charge nurse will evaluate that teaching about hemodynamic monitoring for a new staff nurse has been effective when the new nurse does which of the following?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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