Solution Manual for Understanding the Essentials of Critical Care Nursing, 3rd Edition

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DECISION-MAKINGCASE SUMMARIESCASENAMEOVERVIEWMAJOR CASEDECISIONSJim EdgerlyMr. Jim Edgerly is a 28-year-oldman who presents to the EDfront desk with complaints ofheartpalpitations andlightheadedness. Symptomshave been present for aboutone hour, and Mr. Edgerlydrove himself to the ED. He hasno significant medical orsurgical history and currentlytakes only a daily multivitamin.Mr. Edgerly exercises regularly,doesnot use tobacco orrecreational drugs, andconsumes 2-3 alcoholic drinksper day.1.Identifying and responding todysrhythmias2.Prioritizing medicationadministration3.Monitoring for side effects oftreatments4.Identifyingand responding tochanges in patient condition5.Assessing for stabilization ofvital signs and hemodynamics6.Recognizing a need foradditional patient teachingEstimated Case Length:1 hourDifficulty Level:HighLearning Objectives:Describe thecharacteristics of supraventricular tachycardia (SVT).Prioritize the nursing interventions for stable SVT.Prioritize the nursing interventions for unstable SVT.Present pertinent patient education regarding the management of SVT.Providedischarge teaching for a patient who has experienced SVT.QuestionsCorrect Answers1.After obtaining vital signsand placing the patient on acontinuous cardiac monitor,what should your nextactions be?Select all thatapply.Obtain IV accessPerform a 12-lead EKG2.A 12-lead EKG is quicklyperformed. It reveals that theSudden onset and terminationCRITICAL CARENURSING#1:SUPRAVENTRICULAR TACHYCARDIA

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patient is experiencingsupraventricular tachycardia(SVT) with a heart rate of170 beats per minute. SVTis characterized by which ofthe following?Select all thatapply.Re-entry rhythmPossible palpitations and syncope3.The ER physicianconfirms that Mr. Edgerly isexperiencing SVT. Which ofthe following measures maythe physician choose as aninitial treatment option?Vasovagal maneuver4.The initialinterventionproves unsuccessful interminating Mr. Edgerly’sSVT, so the ED physiciandecides to administeradenosine (Adenocard).Which of the followingguidelines should you followwhen administering thismedication?Select all thatapply.Monitor the patient’s cardiac rhythm during administration forrun of asystole prior to conversion to sinus rhythm.Administer adenosine via rapid IV push, followed by 20 mlnormal saline via rapid IV push.Inform the patient that he may become flushed, experiencechest pain, and feel lightheaded following administration.5.Mr. Edgerly continues inSVT at 180 beats perminute. He begins to loseconsciousness. As the EDnurse, what is your nextstep?Prepare for synchronizedelectrocardioversion at 50 joules6.As the team prepares forelectrocardioversion, whichof the following nursingactions are appropriate?Place one defibrillator pad on the patient’s right upper chest andthe second either on the lower left chest orthe back under theleft shoulder blade.7.Mr. Edgerly converts tosinus rhythm on the monitorafter one shock. Whatshould be your first actionafter this successfulconversion?Palpate the carotid artery for a pulse8.Mr. Edgerly’s vital signsstabilize, with BP 113/60, PPharmacological rate control with either beta blockers orcalcium channel blockers

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80 sinus rhythm, RR 16, andO2sat 98% on room air. Mr.Edgerly is admitted forcardiology consult andobservation.Later, when you have theopportunity to obtain a morethorough health history, Mr.Edgerly reveals that he hasexperienced similarpalpitations andlightheadedness in the past,with approximately sixepisodes in the last threemonths.What potential futureinterventions should Mr.Edgerly anticipate for thisdysrhythmia?Select all thatapply.Ablation therapyOngoing outpatient management with a cardiologistPharmacological rate control with either beta blockers orcalcium channel blockers9.Mr.Edgerly is dischargedthe following day. Hisdischarge medications includea multivitamin and metoprolol(Toprol XL) 25 mg daily. Hehas a scheduled appointmentwith a cardiologist.Which of the following optionswould be considered essentialpatient education for Mr.Edgerly?Select all thatapply.Teaching Mr. Edgerly how to palpate and time his carotid orradial pulseTeaching Mr. Edgerly to hold metoprolol and notify his physicianif his pulse is less than 60 bpmTeaching Mr. Edgerly about thepotential triggers/etiologies ofSVTTeaching Mr. Edgerly vasovagal maneuversTeaching Mr. Edgerly to call 911 if he becomes lightheadedduring an episode of SVT

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DECISION-MAKINGCASE SUMMARIESCASENAMEOVERVIEWMAJOR CASEDECISIONSDuncanMcLaughlinMr.Duncan McLaughlinis a64-year-old man who presents tothe ED front desk withdiaphoresis, nausea, and chestdiscomfort extending down hisleft arm and into his jaw.Symptoms have been presentfor about one hour, and Mr.McLaughlindrove himself to theED. He hasa history ofhypertension, hyperlipidemia,GERD, hypothyroidism, andType II diabetes. Mr.McLaughlinis a 40-pack yearsmoker and consumes 1-2beers on weekdays and 6-8beers on weekend days.1.Identifying and responding tosymptoms of MI2.Monitoring for side effects ofmedication3.Assessing forand respondingto complications of a medicalprocedure4.Responding to patientquestions5.Identifying and responding tochanges in patient condition6.Recognizing a need foradditional patient teachingEstimated Case Length:1 hourDifficulty Level:HighLearning Objectives:Prioritize nursing actions for the care of a patient with myocardial infarction.Identify and describe diagnostic findings associated with an ST elevation myocardialinfarction.Discuss the nurse’sresponsibilities when caring for a patient following cardiaccatheterization.Identify essential discharge teaching for a client who has undergone coronaryintervention.QuestionsCorrect Answers1.As Mr. McLaughlin’striage nurse, which of thefollowing actions should beyour priority?Select all thatapply.Place Mr. McLaughlin on the continuous cardiac monitorStart oxygen via nasal cannula2.Which of the followingdiagnostic tests will mostaccurately and quicklyTroponin and CPKCRITICAL CARENURSING#2:MYOCARDIALINFARCTION

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determine whether acutecoronary syndrome is thecause of Mr. McLaughlin’ssymptoms?3.The 12-lead ECG revealsST segment elevations inleads I, aVL, and V2–V5.The ER physician writes thefollowing order:“Nitroglycerin 0.4 mg SL forchest pain. May repeat q5minutes x 3. Notify MD forongoing chest discomfort.”What are the appropriatenursing actions for thismedication?Check the patient’s BP before and after medicationadministration4.Which of the followingstatements istrueregardingST elevation myocardialinfarction (STEMI)?STEMI is considered a transmural infarction.5.Mr. McLaughlin’s BPdrops to 85/49 after the firstdose of SL nitroglycerin. Mr.McLaughlin also continuesto have chest pain. Giventhese circumstances, whatshould be your next courseof action?Notify the healthcare provider and prepare to administer IVfluids6.Which of the followingdiagnostic tests would beessential to obtain beforecardiac catheterization?PT/INR/PTT, CBC, and basic metabolic profile7.During the initial post-catheterization exam, younote that the fingers on Mr.McLaughlin’s right hand arecool and capillary refill is >3.0 seconds. Mr.McLaughlin’s compressionband has been inplace for 1hour. What is the prioritynursing action?Notify the healthcare provider

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8.The day after his cardiaccatheterization, Mr.McLaughlin’s urine output is10 ml/h and his creatinine is2.4 (baseline 1.3). When toldabout these results, Mr.McLaughlin says, “Mykidneys have always beenfine. What happened?” Whatis your best response?“The dye from a cardiac catheterization can sometimes affectthe kidneys.”9.Which type of rhythm isMr. McLaughlinexperiencing?Atrial fibrillation10.What should be thehealthcare team’s immediateaction to treat this unstablerhythm?Synchronized electrocardioversion11.What specificinformation regardingclopidogrel (Plavix) shouldbe reinforced with thispatient?Select all thatapply.You should not take omeprazole with this medication.You should take this medication with a baby aspirin.12.As part of dischargeeducation, you note that Mr.McLaughlin had not beentaking his preadmissionprescribed medications.What is the best way foryouto address this situation withMr. McLaughlin?“Could you share with me why you were not taking themedications that were prescribed for you?”

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DECISION-MAKINGCASE SUMMARIESCASENAMEOVERVIEWMAJOR CASEDECISIONSRobertBarnesMr.Robert Barnes is a 70-year-old male who was admitted tothe ICU from the emergencydepartment for community-acquired pneumonia.One weekprior to admission he begancomplaining of feeling tired anda dull ache in his right chestwhen coughing. His wifebrought him to the ED todaybecause he did not seem toknow where he was, had afever, was coughing repeatedlyand breathing rapidly.1.Administering medications2.Selecting oxygen therapy3.Implementing priority nursingactions4.Interpreting and responding tolaboratory results5.Assisting with emergencyintubation6.Responding to questions fromthe patient’s family7.Responding to ventilator alarms8.Communicating with anintubated patient9.Implementing nutritionstrategies10.Recognizing risk factors forextubation11.Extubating the patientEstimated Case Length:1 hourDifficulty Level:HighLearning Objectives:Identify the manifestations of acute respiratory failure.Describe indications for the use of noninvasive ventilation.Explain the indications for andcomplications associated with mechanical ventilation.Discuss nursing responsibilities when caring for a patient receiving mechanicalventilation.Identify readiness to wean in the ventilated patient.QuestionsCorrect Answers1.Theantibiotics for Mr.Barnes arrive from thepharmacy. You see that hehas been prescribed bothceftriaxone andazithromycin. What is yourbest course of action?Plan to administer the ceftriaxone over 30 minutes, immediatelyfollowed by the azithromycinCRITICAL CARENURSING#3:RESPIRATORYFAILURE

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2.Mr. Barnes is receivinghigh-flow oxygen therapywith an FiO2of 80% at 60L/min. Which of the followingare reasons why high-flowtherapy would be moreappropriate for Mr. Barnesthan lower flow rate therapyby mask?Select all thatapply.High-flow therapy may also provide some positive end-expiratory pressure (PEEP).High-flow oxygen can be delivered by nasal cannula and maybe more comfortable.Oxygen delivery is more variable with low-flow therapy becauseroom air is mixed with theinspired gas.Patients receiving high-flow oxygen can often cough and speakmore easily than patients receiving low-flow mask therapy.3.When you assess Mr.Barnes 15 minutes after thehigh-flow oxygen has beeninstituted, he has arespiratory rate of 36 and anoxygen saturation of 88%.He is restless andcomplaining that someone ishammering on his roof.Which of the following is theappropriate course ofaction?Notify the physician of these findings4.The physician is notifiedof Mr.Barnes’s status andrequests that ABGs bedrawn.When the ABG resultsarrive, they are as follows:pH 7.28, PCO250, PO260,and HCO325. How shouldyou respond?Inform the physician and team of the ABG results and anticipatepossible intubation5.The physician decidesthat Mr. Barnes requiresimmediate intubation andmechanical ventilation.Which of the following is anursing responsibility prior toand during emergentintubation of Mr. Barnes?Verify that a CO2detector is used to determine placement of theendotracheal tube6.Following intubation, Mr.Barnes is placed on aventilator. When his wife“Theventilator will help your husband breathe until theantibiotics begin to work.”

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arrives at his bedside andsees the ventilator, sheasks, “How is that machinegoing to make my husbandbetter?” What is your bestresponse?7.The low pressure/lowminute volume alarm on themechanical ventilator beginsto sound. What should beyour first response to thealarm?Check the ventilator tubing fordisconnection8.After Mr. Barnes begins toawaken from the intubation,he looks at you and is tryingto say something whilepointing at his mouth andpumping his fist. Whatshould you do?Select allthat apply.Explain to Mr. Barnes that there is a tube in his throat that ishelping him breatheTell Mr. Barnes to blink once for yes and twice for no, then askhim yes-or-no questions9.Mr. Barnes remainsawake, anxious, and tryingto speak while reaching forthe endotracheal tube in hismouth. Thegoal for Mr.Barnes following intubationis light sedation. Currently,he is receiving IV propofol at20 mcg/kg/min. What shouldyou do next?Increase the rate of the propofol to 30 mcg/kg/min10.The morning followingMr. Barnes’s admission, themultidisciplinary team isreviewing his care to decidewhether he should beginenteral feeding. Sinceadmission, Mr. Barnes’sorogastric tube has beenattached to low continuoussuction. Which of thefollowing findings related tothe orogastric tube shouldyou mention to the teambecause it will likelyPlacement of the orogastric tube has not been verified by x-ray.

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influence the decision ofwhen to begin feedings?11.Three days later, Mr.Barnes is showing clinicalresponse to his antibioticsand the team is consideringweaning then extubatinghim. Which of the followingwould indicate that Mr.Barnes is at high risk forfailure to successfully weanfrom ventilation atthis time?He is 70 years old and has a maximum inspiratory pressure of–25 cm H2O.12.The healthcare teamdetermines that Mr. Barnesis ready to be extubated.Which of the followingactions should you take priorto and following hisextubation?Select all thatapply.Turn off theorogastric tube feeding prior to extubationNotify the physician and respiratory therapist immediately if Mr.Barnes develops stridor

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