1 :

Mrs. Marsh, a 60-year-old female, arrived at the ER today via EMS with nausea and vomiting and left jaw pain. She stated that she has been feeling fatigued for over a week.

Hypertension

hyperlipidaemia

diabetes, and one pack/day smoker for 40 years.

EKG in the ER showed a STEMI, code "STEMI" called, and she was quickly taken to the Cath lab, She received four 81mg baby aspirin in the squad as well as 2 sublingual nitro-glycerine with pain relief, in the ER she received 180mg of Brilinta (Ticagrelor), a 4,000 unit bolus of heparin, and a heparin drip started at 12units/kg/hr. The patient weighs 80 kg Mrs.

Marsh underwent an emergent cardiac catheterization with stent placement to her left anterior descending (LAD) artery. During the procedure, the patient experienced a ventricular fibrillation (VF) arrest. The patient was defibrillated twice with 200 and 300 joules, 1 mg of epinephrine and 300 mg of amiodarone was administered, followed by an amiodarone drip at 1 mg/min and ROSC was achieved. She is now intubated, and a balloon pump was placed via the right femoral artery. Ejection Fraction (EF) estimated at 15-20%, M. Access includes pulmonary artery catheter via right internal jugular vein and a right radial arterial line.

Blood pressure: 80/50 mm Hg (MAP 60 mm Hg)

Heart rate: 110/min

Respiratory rate: 16/min

SpO₂: 94%

Temperature: 38.2°C

General Appearance and Neurological Status

The client is resting and pale. She opens her eyes to commands and can squeeze both hands and wiggle her toes on command.

RASS score: -1

Respiratory

Breath sounds are clear bilaterally in the upper lobes, with occasional wheezing noted. Bilateral rales are present in the lower lobes.

Endotracheal tube: Size 8, secured at 23 cm at the lip.

Current ventilator settings:

  • Mode: Assist-control (A/C)
  • Respiratory rate: 14/min
  • Tidal volume: 500 mL
  • PEEP: 5 cm H₂O
  • FiO₂: 100%

Cardiovascular

Heart sounds are audible. The cardiac monitor shows sinus tachycardia with occasional premature ventricular contractions (PVCs). The client's skin is cool, mottled, and clammy. Peripheral pulses are +1 in all four extremities.

Intra-Aortic Balloon Pump

The right groin balloon pump insertion site is dry and intact, with some bruising noted at the insertion site. The balloon pump is set at a 1:1 ratio.

The pulmonary artery catheter is secured in place with the following readings:

  • Pulmonary artery pressure: 45/20 mm Hg
  • Central venous pressure (CVP): 10 mm Hg
  • Pulmonary artery occlusion pressure (PAOP): 22 mm Hg
  • Cardiac output: 3 L/min
  • Cardiac index: 1.6 L/min/m²

Gastrointestinal

Nasogastric tube (NGT) placement is verified, and the tube is clamped. Bowel sounds are normoactive in all four quadrants.

Genitourinary

Foley catheter is in place. Urine is clear and yellow. Urine output is minimal at 20 mL/hr.

  • Heparin 12 units/kg/hr
  • Amiodarone 1 mg/min
  • Dobutamine 2.5 mcg/kg/min
  • Propofol 5 mcg/kg/min

Complete Blood Count (CBC)

White blood cell count (WBC): 16,000/mm³

Hemoglobin: 11 g/dL

Hematocrit: 34%

Platelets: 180,000/mm³

Chemistry

Blood urea nitrogen (BUN): 8 mg/dL

Creatinine: 1.2 mg/dL

Potassium: 5.0 mEq/L

Magnesium: 1.8 mEq/L

Troponin: 0.6 ng/mL

Lactate: 2.0 mmol/L

Based on the information in the client's assessment, select the assessment findings that are abnormal and require follow-up by the nurse.

Answer Options

Hint : 🔍Look for findings showing poor tissue perfusion.

Correct Answers:

  • Blood pressure 80/50 mm Hg (MAP 60 mm Hg)
  • Skin is cool, mottled, and clammy, with +1 pulses in all four extremities
  • Cardiac output of 3 L/min with a cardiac index of 1.6 L/min/m²
  • Urine output of 20 mL/hr

Rationale :

🫀Hypotension with MAP 60 indicates inadequate systemic perfusion.

🩸Cool, mottled skin and weak pulses indicate reduced peripheral circulation.

📉A cardiac index of 1.6 reflects significantly impaired cardiac output.

🚽Urine output of 20 mL/hr indicates decreased renal perfusion.

📌Core Message

Findings of hypotension, low cardiac output, weak peripheral perfusion, and oliguria require immediate follow-up.

2 :

Mrs. Marsh, a 60-year-old female, arrived at the emergency department (ED) today via EMS with nausea, vomiting, and left jaw pain. She stated that she has been feeling fatigued for over a week.

Hypertension

Hyperlipidemia

Diabetes mellitus

Smokes 1 pack of cigarettes per day for 40 years

An ECG in the emergency department showed a STEMI. A STEMI alert was initiated, and the client was quickly taken to the cardiac catheterization laboratory. She received four 81-mg chewable aspirin tablets from EMS, as well as 2 doses of sublingual nitroglycerin, with pain relief. In the emergency department, she received ticagrelor (Brilinta) 180 mg, a 4,000-unit bolus of heparin, and a heparin infusion initiated at 12 units/kg/hr. The client weighs 80 kg.

Mrs. Marsh underwent emergent cardiac catheterization with stent placement in the left anterior descending (LAD) coronary artery. During the procedure, the client experienced a ventricular fibrillation (VF) cardiac arrest. The client was defibrillated twice at 200 J and 300 J. Epinephrine 1 mg and amiodarone 300 mg were administered, followed by an amiodarone infusion at 1 mg/min. Return of spontaneous circulation (ROSC) was achieved.

The client is now intubated, and an intra-aortic balloon pump (IABP) was inserted via the right femoral artery. The ejection fraction (EF) is estimated at 15% to 20%. Additional invasive monitoring includes a pulmonary artery catheter inserted via the right internal jugular vein and a right radial arterial line.

Blood pressure: 80/50 mm Hg (MAP 60 mm Hg)

Heart rate: 110/min

Respiratory rate: 16/min

SpO₂: 94%

Temperature: 38.2°C

General Appearance and Neurological Status

The client is resting and pale. She opens her eyes to commands and can squeeze both hands and wiggle her toes on command.

RASS score: -1

Respiratory

Breath sounds are clear bilaterally in the upper lobes, with occasional wheezing noted. Bilateral rales are present in the lower lobes.

Endotracheal tube: Size 8, secured at 23 cm at the lip.

Current ventilator settings:

Mode: Assist-control (A/C)

Respiratory rate: 14/min

Tidal volume: 500 mL

PEEP: 5 cm H₂O

FiO₂: 100%

Cardiovascular

Heart sounds are audible. The cardiac monitor shows sinus tachycardia with occasional premature ventricular contractions (PVCs). The client's skin is cool, mottled, and clammy. Peripheral pulses are +1 in all four extremities.

Intra-Aortic Balloon Pump

The right groin balloon pump insertion site is dry and intact, with some bruising noted at the insertion site. The balloon pump is set at a 1:1 ratio.

The pulmonary artery catheter is secured in place with the following readings:

Pulmonary artery pressure: 45/20 mm Hg

Central venous pressure (CVP): 10 mm Hg

Pulmonary artery occlusion pressure (PAOP): 22 mm Hg

Cardiac output: 3 L/min

Cardiac index: 1.6 L/min/m²

Gastrointestinal

Nasogastric tube (NGT) placement is verified, and the tube is clamped. Bowel sounds are normoactive in all four quadrants.

Genitourinary

Foley catheter is in place. Urine is clear and yellow. Urine output is minimal at 20 mL/hr.

Heparin 12 units/kg/hr

Amiodarone 1 mg/min

Dobutamine 2.5 mcg/kg/min

Propofol 5 mcg/kg/min

Complete Blood Count (CBC)

White blood cell count (WBC): 16,000/mm³

Hemoglobin: 34 g/dL

Hematocrit: 11%

Platelets: 180,000/mm³

Coagulation Studies

Prothrombin time (PT): 11 seconds

Partial thromboplastin time (PTT): 25 seconds (baseline)

International normalized ratio (INR): 0.9

Chemistry

Blood urea nitrogen (BUN): 8 mg/dL

Creatinine: 1.2 mg/dL

Potassium: 5.0 mEq/L

Magnesium: 1.8 mEq/L

Troponin: 0.6 ng/mL

Lactate: 2.0 mmol/L

The nurse is reviewing the client's assessment findings. Which assessment findings should the nurse identify as abnormal and requiring follow-up?

Answer Options

Hint : 🧠Think about findings associated with circulatory instability after severe myocardial injury.

Correct Answers:

  • Hypotension
  • Irregular pulses
  • Weak pulses
  • Dysrhythmia
  • Mottling of the skin

Rationale :

💓Hypotension indicates that the cardiovascular system is not maintaining adequate systemic perfusion.

⚡Dysrhythmias and irregular pulses indicate cardiac electrical instability after the client's STEMI and ventricular fibrillation.

🤲Weak pulses reflect decreased stroke volume and reduced blood flow to the extremities.

🎨Skin mottling indicates impaired peripheral circulation caused by poor cardiac output.

📌Core Message

Hypotension, dysrhythmias, weak pulses, and mottled skin indicate cardiovascular instability and impaired circulation.

3 :

Mrs. Marsh, a 60-year-old female, arrived at the emergency department (ED) today via EMS with nausea, vomiting, and left jaw pain. She stated that she has been feeling fatigued for over a week.

Hypertension

Hyperlipidemia

Diabetes mellitus

Smokes 1 pack of cigarettes per day for 40 years

An ECG in the emergency department showed a STEMI. A STEMI alert was initiated, and the client was quickly taken to the cardiac catheterization laboratory. She received four 81-mg chewable aspirin tablets from EMS, as well as 2 doses of sublingual nitroglycerin, with pain relief. In the emergency department, she received ticagrelor (Brilinta) 180 mg, a 4,000-unit bolus of heparin, and a heparin infusion initiated at 12 units/kg/hr. The client weighs 80 kg.

Mrs. Marsh underwent emergent cardiac catheterization with stent placement in the left anterior descending (LAD) coronary artery. During the procedure, the client experienced a ventricular fibrillation (VF) cardiac arrest. The client was defibrillated twice at 200 J and 300 J. Epinephrine 1 mg and amiodarone 300 mg were administered, followed by an amiodarone infusion at 1 mg/min. Return of spontaneous circulation (ROSC) was achieved.

The client is now intubated, and an intra-aortic balloon pump (IABP) was inserted via the right femoral artery. The ejection fraction (EF) is estimated at 15% to 20%. Additional invasive monitoring includes a pulmonary artery catheter inserted via the right internal jugular vein and a right radial arterial line.

Blood pressure: 80/50 mm Hg (MAP 60 mm Hg)

Heart rate: 110/min

Respiratory rate: 16/min

SpO₂: 94%

Temperature: 38.2°C

General Appearance and Neurological Status

The client is resting and pale. She opens her eyes to commands and can squeeze both hands and wiggle her toes on command.

RASS score: -1

Respiratory

Breath sounds are clear bilaterally in the upper lobes, with occasional wheezing noted. Bilateral rales are present in the lower lobes.

Endotracheal tube: Size 8, secured at 23 cm at the lip.

Current ventilator settings:

Mode: Assist-control (A/C)

Respiratory rate: 14/min

Tidal volume: 500 mL

PEEP: 5 cm H₂O

FiO₂: 100%

Cardiovascular

Heart sounds are audible. The cardiac monitor shows sinus tachycardia with occasional premature ventricular contractions (PVCs). The client's skin is cool, mottled, and clammy. Peripheral pulses are +1 in all four extremities.

Intra-Aortic Balloon Pump

The right groin balloon pump insertion site is dry and intact, with some bruising noted at the insertion site. The balloon pump is set at a 1:1 ratio.

The pulmonary artery catheter is secured in place with the following readings:

Pulmonary artery pressure: 45/20 mm Hg

Central venous pressure (CVP): 10 mm Hg

Pulmonary artery occlusion pressure (PAOP): 22 mm Hg

Cardiac output: 3 L/min

Cardiac index: 1.6 L/min/m²

Gastrointestinal

Nasogastric tube (NGT) placement is verified, and the tube is clamped.

Bowel sounds are normoactive in all four quadrants.

Genitourinary

Foley catheter is in place. Urine is clear and yellow. Urine output is minimal at 20 mL/hr.

Heparin 12 units/kg/hr

Amiodarone 1 mg/min

Dobutamine 2.5 mcg/kg/min

Propofol 5 mcg/kg/min

Complete Blood Count (CBC)

White blood cell count (WBC): 16,000/mm³

Hemoglobin: 11 g/dL

Hematocrit: 34%

Platelets: 180,000/mm³

Coagulation Studies

Prothrombin time (PT): 11 seconds

Partial thromboplastin time (PTT): 25 seconds (baseline)

International normalized ratio (INR): 0.9

Chemistry

Blood urea nitrogen (BUN): 8 mg/dL

Creatinine: 1.2 mg/dL

Potassium: 5.0 mEq/L

Magnesium: 1.8 mEq/L

Troponin: 0.6 ng/mL

Lactate: 2.0 mmol/L

The nurse is caring for this client in cardiogenic shock with an intra-aortic balloon pump. For each of the following prescriptions, indicate whether the prescription is anticipated or not anticipated for the client.

Possible Orders Anticipated Not Anticipated
Monitor hourly urine output
Strict intake and output (I&O) measurement
Neurovascular checks every 1 hr
D5 0.45% normal saline at 150 mL/hr
Norepinephrine (Levophed) infusion, start at 0.1 mcg/kg/min and titrate by 0.1 mcg/kg/min every 1 min for a MAP of 65–70 mm Hg
Metoprolol 5 mg IV
Out of bed to chair every shift

Hint : 🧐Consider which orders improve perfusion while protecting the femoral balloon-pump site.

Correct Answers

  • Monitor hourly urine output [ Anticipated ]
  • Strict intake and output (I&O) measurement [ Anticipated ]
  • Neurovascular checks every 1 hr [ Anticipated ]
  • D5 0.45% normal saline at 150 mL/hr [ Not Anticipated ]
  • Norepinephrine (Levophed) infusion, start at 0.1 mcg/kg/min and titrate by 0.1 mcg/kg/min every 1 min for a MAP of 65–70 mm Hg [ Anticipated ]
  • Metoprolol 5 mg IV [ Not Anticipated ]
  • Out of bed to chair every shift [ Not Anticipated ]
Rationale :

🚰Hourly urine output and strict I&O help evaluate renal perfusion and overall fluid status.

🦵Hourly neurovascular checks are essential because femoral IABP placement can compromise blood flow to the affected extremity.

💉Norepinephrine increases vascular tone and helps maintain an adequate MAP during severe hypotension.

🛡️The client requires careful hemodynamic support and restricted mobility while the femoral balloon pump remains in place.

📌Core Message

Clients with an IABP and cardiogenic shock require close perfusion monitoring, vasopressor support, and restricted mobility.

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4 :

Mrs. Marsh, a 60-year-old female, arrived at the emergency department (ED) today via EMS with nausea, vomiting, and left jaw pain. She stated that she has been feeling fatigued for over a week.

Hypertension

Hyperlipidemia

Diabetes mellitus

Smokes 1 pack of cigarettes per day for 40 years

An ECG in the emergency department showed a STEMI. A STEMI alert was initiated, and the client was quickly taken to the cardiac catheterization laboratory. She received four 81-mg chewable aspirin tablets from EMS, as well as 2 doses of sublingual nitroglycerin, with pain relief. In the emergency department, she received ticagrelor (Brilinta) 180 mg, a 4,000-unit bolus of heparin, and a heparin infusion initiated at 12 units/kg/hr. The client weighs 80 kg.

Mrs. Marsh underwent emergent cardiac catheterization with stent placement in the left anterior descending (LAD) coronary artery. During the procedure, the client experienced a ventricular fibrillation (VF) cardiac arrest. The client was defibrillated twice at 200 J and 300 J. Epinephrine 1 mg and amiodarone 300 mg were administered, followed by an amiodarone infusion at 1 mg/min. Return of spontaneous circulation (ROSC) was achieved.

The client is now intubated, and an intra-aortic balloon pump (IABP) was inserted via the right femoral artery. The ejection fraction (EF) is estimated at 15% to 20%. Additional invasive monitoring includes a pulmonary artery catheter inserted via the right internal jugular vein and a right radial arterial line.

Blood pressure: 80/50 mm Hg (MAP 60 mm Hg)

Heart rate: 110/min

Respiratory rate: 16/min

SpO₂: 94%

Temperature: 38.2°C

General Appearance and Neurological Status

The client is resting and pale. She opens her eyes to commands and can squeeze both hands and wiggle her toes on command.

RASS score: -1

Respiratory

Breath sounds are clear bilaterally in the upper lobes, with occasional wheezing noted. Bilateral rales are present in the lower lobes.

Endotracheal tube: Size 8, secured at 23 cm at the lip.

Current ventilator settings:

Mode: Assist-control (A/C)

Respiratory rate: 14/min

Tidal volume: 500 mL

PEEP: 5 cm H₂O

FiO₂: 100%

Cardiovascular

Heart sounds are audible. The cardiac monitor shows sinus tachycardia with occasional premature ventricular contractions (PVCs). The client's skin is cool, mottled, and clammy. Peripheral pulses are +1 in all four extremities.

Intra-Aortic Balloon Pump

The right groin balloon pump insertion site is dry and intact, with some bruising noted at the insertion site. The balloon pump is set at a 1:1 ratio.

The pulmonary artery catheter is secured in place with the following readings:

Pulmonary artery pressure: 45/20 mm Hg

Central venous pressure (CVP): 10 mm Hg

Pulmonary artery occlusion pressure (PAOP): 22 mm Hg

Cardiac output: 3 L/min

Cardiac index: 1.6 L/min/m²

Gastrointestinal

Nasogastric tube (NGT) placement is verified, and the tube is clamped.

Bowel sounds are normoactive in all four quadrants.

Genitourinary

Foley catheter is in place. Urine is clear and yellow. Urine output is minimal at 20 mL/hr.

Heparin 12 units/kg/hr

Amiodarone 1 mg/min

Dobutamine 2.5 mcg/kg/min

Propofol 5 mcg/kg/min

Complete Blood Count (CBC)

White blood cell count (WBC): 16,000/mm³

Hemoglobin: 11 g/dL

Hematocrit: 34%

Platelets: 180,000/mm³

Coagulation Studies

Prothrombin time (PT): 11 seconds

Partial thromboplastin time (PTT): 25 seconds (baseline)

International normalized ratio (INR): 0.9

Chemistry

Blood urea nitrogen (BUN): 8 mg/dL

Creatinine: 1.2 mg/dL

Potassium: 5.0 mEq/L

Magnesium: 1.8 mEq/L

Troponin: 0.6 ng/mL

Lactate: 2.0 mmol/L

The physician has ordered a norepinephrine infusion (8 mg/250 mL D5W) to begin at 0.01 mcg/kg/min. After 1 minute, the client's blood pressure is 80/51 mm Hg (MAP 61 mm Hg). The nurse increases the infusion to 0.02 mcg/kg/min. The client weighs 80 kg. Complete the sentence by selecting the correct option for each blank. The new infusion rate isNorepinephrine works bytherebyblood pressure andcoronary artery perfusion.

Hint : 🔢First calculate the medication concentration in mcg/mL.

Correct Answers

  • Blank 1 Correct Option: 3 mL/hr
  • Blank 2 Correct Option: Vasoconstriction
  • Blank 3 Correct Option: Increasing
  • Blank 4 Correct Option: Increasing
Rationale :

🧮The prescribed dose is 0.02 mcg/kg/min × 80 kg = 1.6 mcg/min.

🧴The available concentration is 8,000 mcg ÷ 250 mL = 32 mcg/mL.

⏱️The calculated rate is 1.6 mcg/min × 60 ÷ 32 mcg/mL = 3 mL/hr.

🩻Norepinephrine causes vasoconstriction, which increases systemic blood pressure and improves coronary perfusion pressure.

📌Core Message

The norepinephrine infusion should run at 3 mL/hr, producing vasoconstriction that increases blood pressure and coronary perfusion.

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5 :

Mrs. Marsh, a 60-year-old female, arrived at the emergency department (ED) today via EMS with nausea, vomiting, and left jaw pain. She stated that she has been feeling fatigued for over a week.

Hypertension

Hyperlipidemia

Diabetes mellitus

Smokes 1 pack of cigarettes per day for 40 years

An ECG in the emergency department showed a STEMI. A STEMI alert was initiated, and the client was quickly taken to the cardiac catheterization laboratory. She received four 81-mg chewable aspirin tablets from EMS, as well as 2 doses of sublingual nitroglycerin, with pain relief. In the emergency department, she received ticagrelor (Brilinta) 180 mg, a 4,000-unit bolus of heparin, and a heparin infusion initiated at 12 units/kg/hr. The client weighs 80 kg.

Mrs. Marsh underwent emergent cardiac catheterization with stent placement in the left anterior descending (LAD) coronary artery. During the procedure, the client experienced a ventricular fibrillation (VF) cardiac arrest. The client was defibrillated twice at 200 J and 300 J. Epinephrine 1 mg and amiodarone 300 mg were administered, followed by an amiodarone infusion at 1 mg/min. Return of spontaneous circulation (ROSC) was achieved.

The client is now intubated, and an intra-aortic balloon pump (IABP) was inserted via the right femoral artery. The ejection fraction (EF) is estimated at 15% to 20%. Additional invasive monitoring includes a pulmonary artery catheter inserted via the right internal jugular vein and a right radial arterial line.

Blood pressure: 80/50 mm Hg (MAP 60 mm Hg)

Heart rate: 110/min

Respiratory rate: 16/min

SpO₂: 94%

Temperature: 38.2°C

General Appearance and Neurological Status

The client is resting and pale. She opens her eyes to commands and can squeeze both hands and wiggle her toes on command.

RASS score: -1

Respiratory

Breath sounds are clear bilaterally in the upper lobes, with occasional wheezing noted. Bilateral rales are present in the lower lobes.

Endotracheal tube: Size 8, secured at 23 cm at the lip.

Cardiovascular

Heart sounds are audible. The cardiac monitor shows sinus tachycardia with occasional premature ventricular contractions (PVCs). The client's skin is cool, mottled, and clammy. Peripheral pulses are +1 in all four extremities.

Intra-Aortic Balloon Pump

The right groin balloon pump insertion site is dry and intact, with some bruising noted at the insertion site. The balloon pump is set at a 1:1 ratio.

The pulmonary artery catheter is secured in place with the following readings:

Pulmonary artery pressure: 45/20 mm Hg

Central venous pressure (CVP): 10 mm Hg

Pulmonary artery occlusion pressure (PAOP): 22 mm Hg

Cardiac output: 3 L/min

Cardiac index: 1.6 L/min/m²

Gastrointestinal

Nasogastric tube (NGT) placement is verified, and the tube is clamped.

Bowel sounds are normoactive in all four quadrants.

Genitourinary

Foley catheter is in place. Urine is clear and yellow. Urine output is minimal at 20 mL/hr.

Heparin 12 units/kg/hr

Amiodarone 1 mg/min

Dobutamine 2.5 mcg/kg/min

Propofol 5 mcg/kg/min

Complete Blood Count (CBC)

White blood cell count (WBC): 16,000/mm³

Hemoglobin: 11 g/dL

Hematocrit: 34%

Platelets: 180,000/mm³

Coagulation Studies

Prothrombin time (PT): 11 seconds

Partial thromboplastin time (PTT): 25 seconds (baseline)

International normalized ratio (INR): 0.9

Chemistry

Blood urea nitrogen (BUN): 8 mg/dL

Creatinine: 1.2 mg/dL

Potassium: 5.0 mEq/L

Magnesium: 1.8 mEq/L

Cardiac

Troponin: 0.6 ng/mL

Lactate: 2.0 mmol/L

The nurse is evaluating the client's response to the interventions performed. For each of the new assessment findings, indicate whether the client's condition has improved, has not changed, or is worsening.

New Assessment Findings Improved No Change Worsening
Blood pressure 90/60 mm Hg (MAP 70 mm Hg)
Cardiac index 1.6 L/min/m²
PAOP 18 mm Hg
Urine output 10 mL/hr
Decreased responsiveness and weaker hand grasps
Lactate 4.0 mmol/L

Hint : 📋Compare each new finding with the client's previous measurement.

Correct Answers

  • Blood pressure 90/60 mm Hg (MAP 70 mm Hg) [ Improved ]
  • Cardiac index 1.6 L/min/m² [ No Change ]
  • PAOP 18 mm Hg [ Improved ]
  • Urine output 10 mL/hr [ Worsening ]
  • Decreased responsiveness and weaker hand grasps [ Worsening ]
  • Lactate 4.0 mmol/L [ Worsening ]
Rationale :

📈The increase in MAP from 60 to 70 mmHg indicates improved systemic perfusion pressure.

🔄The cardiac index remains 1.6, showing that cardiac pumping ability has not improved.

💦The decrease in PAOP from 22 to 18 mmHg indicates improvement in elevated left-sided filling pressure.

🚨Decreased urine output, neurological deterioration, and rising lactate indicate worsening end-organ tissue perfusion.

📌Core Message

Treatment response is judged by improvement in hemodynamics and end-organ perfusion, not blood pressure alone.

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6 :
Laboratory TestResultReference Range
ABG pH7.27.35–7.45
ABG PaO₂75 mm Hg75–100 mm Hg
ABG PaCO₂51 mm Hg35–45 mm Hg
ABG HCO₃⁻28 mEq/L22–26 mEq/L
WBC35,000 cells/mm³4.5–10.5 × 10³ cells/mm³
Platelets250,000/mm³140,000–450,000/mm³
Potassium (serum)4.0 mEq/L3.5–5.0 mEq/L
Sodium (serum)140 mEq/L135–145 mEq/L
Magnesium1.5 mEq/L1.5–2.1 mEq/L
Lactate level4.5 mmol/L0.5–2.2 mmol/L
Blood cultureGram-negative cocciNegative
Urine culturePending—
Sputum culturePending—

0900

Client was admitted to the ICU in respiratory distress after minimal response to high-flow oxygen for a pulse oximeter reading of 83% on room air. Crackles heard bilaterally in the lower lobes with diminished breath sounds in the right middle lobe; S1 and S2 auscultated; bowel sounds positive in all 4 quadrants; skin warm, dry, and intact.

Temperature: 99.8°F (37.7°C)

Heart rate: 110/min

Respiratory rate: 30/min

Blood pressure: 158/90 mm Hg

Pulse oximeter: 87% on 100% non-rebreather mask

Pain: 0/10

The nurse is reviewing the client's assessment findings. Which 4 findings are the most urgent? Select 4 that apply.

Answer Options

Hint : 🚑Choose findings that demonstrate the most severe problems with oxygenation and tissue perfusion.

Correct Answers:

  • Lactate 4.5 mmol/L
  • pH 7.2
  • Respiratory rate 30/min
  • Pulse oximeter 87%

Rationale :

🧫A lactate of 4.5 indicates significant tissue hypoxia or inadequate tissue perfusion.

⚗️A pH of 7.2 represents severe acidemia and indicates significant physiologic deterioration.

😮‍💨A respiratory rate of 30/min demonstrates marked respiratory distress and increased work of breathing.

🫁An oxygen saturation of 87% despite 100% oxygen indicates severe failure of oxygenation.

📌Core Message

Severe hypoxemia, acidemia, tachypnea, and elevated lactate indicate critical respiratory and tissue-perfusion compromise.

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7 :
Laboratory TestResultReference Range
ABG pH7.27.35–7.45
ABG PaO₂75 mm Hg75–100 mm Hg
ABG PaCO₂51 mm Hg35–45 mm Hg
ABG HCO₃⁻28 mEq/L22–26 mEq/L
WBC35,000 cells/mm³4.5–10.5 × 10³ cells/mm³
Platelets250,000/mm³140,000–450,000/mm³
Potassium (serum)4.0 mEq/L3.5–5.0 mEq/L
Sodium (serum)140 mEq/L135–145 mEq/L
Magnesium1.5 mEq/L1.5–2.1 mEq/L
Lactate level4.5 mmol/L0.5–2.2 mmol/L
Blood cultureGram-negative cocciNegative
Urine culturePending—
Sputum culturePending—

0900

Client was admitted to the ICU in respiratory distress after minimal response to high-flow oxygen for a pulse oximeter reading of 83% on room air. Crackles heard bilaterally in the lower lobes with diminished breath sounds in the right middle lobe; S1 and S2 auscultated; bowel sounds positive in all 4 quadrants; skin warm, dry, and intact.

Temperature: 99.8°F (37.7°C)

Heart rate: 110/min

Respiratory rate: 30/min

Blood pressure: 158/90 mm Hg

Pulse oximeter: 87% on 100% oxygen via non-rebreather mask

Pain: 0/10

For each finding, click to indicate whether the finding is consistent with acute respiratory failure or pneumonia. Each finding may support more than one condition.

Finding Acute Respiratory Failure Pneumonia
Crackles in bilateral lower lobes
Pulse oximeter 87% on 100% oxygen via non-rebreather mask
PaCO₂ 51 mm Hg
pH 7.2

Hint : 🔬Separate evidence of infection from evidence of impaired oxygenation and ventilation.

Correct Answers

  • Crackles in bilateral lower lobes [ Acute Respiratory Failure ; Pneumonia ]
  • Pulse oximeter 87% on 100% oxygen via non-rebreather mask [ Acute Respiratory Failure ]
  • PaCO₂ 51 mm Hg [ Acute Respiratory Failure ]
  • pH 7.2 [ Acute Respiratory Failure ]
Rationale :

🫧Bilateral crackles can occur with pneumonia and can contribute to impaired pulmonary gas exchange.

🔻An SpO₂ of 87% despite 100% oxygen demonstrates severe oxygenation failure.

🌬️A PaCO₂ of 51 mmHg demonstrates inadequate alveolar ventilation and carbon dioxide retention.

🧪A pH of 7.2 indicates significant acidemia associated with acute respiratory compromise.

📌Core Message

Pneumonia can contribute to acute respiratory failure, while severe hypoxemia, hypercapnia, and acidemia demonstrate failed gas exchange.

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8 :
Laboratory TestResultReference Range
ABG pH7.27.35–7.45
ABG PaO₂75 mm Hg75–100 mm Hg
ABG PaCO₂51 mm Hg35–45 mm Hg
ABG HCO₃⁻28 mEq/L22–26 mEq/L
WBC35,000 cells/mm³4.5–10.5 × 10³ cells/mm³
Platelets250,000/mm³140,000–450,000/mm³
Potassium (serum)4.0 mEq/L3.5–5.0 mEq/L
Sodium (serum)140 mEq/L135–145 mEq/L
Magnesium1.5 mEq/L1.5–2.1 mEq/L
Lactate level4.5 mmol/L0.5–2.2 mmol/L
Blood cultureGram-negative cocciNegative
Urine culturePending—
Sputum culturePending—

0900

Client was admitted to the ICU in respiratory distress after minimal response to high-flow oxygen for a pulse oximeter reading of 83% on room air. Crackles heard bilaterally in the lower lobes with diminished breath sounds in the right middle lobe; S1 and S2 auscultated; bowel sounds positive in all 4 quadrants; skin warm, dry, and intact.

Temperature: 99.8°F (37.7°C)

Heart rate: 110/min

Respiratory rate: 30/min

Blood pressure: 158/90 mm Hg

Pulse oximeter: 87% on 100% oxygen via non-rebreather mask

Pain: 0/10

Complete the sentence using the list of options provided. Based on the client's assessment, the priority of care at this time is tobecause this intervention will

Hint : 🔑Choose the intervention that provides immediate airway and breathing support.

Correct Answers

  • Blank 1 Correct Option: intubate
  • Blank 2 Correct Option: provide mechanical ventilation support
Rationale :

🆘The client remains severely hypoxemic despite 100% supplemental oxygen, indicating failure of current respiratory support.

🛟Intubation establishes a secure airway when the client cannot maintain adequate oxygenation independently.

⚙️Mechanical ventilation provides controlled respiratory support and improves oxygenation and ventilation.

🥇Using the ABC priority framework, airway and breathing must be stabilized before treatment of the underlying cause.

📌Core Message

When severe hypoxemia persists despite oxygen therapy, intubation and mechanical ventilation become the priority.

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9 :
Laboratory TestResultReference Range
ABG pH7.27.35–7.45
ABG PaO₂75 mm Hg75–100 mm Hg
ABG PaCO₂51 mm Hg35–45 mm Hg
ABG HCO₃⁻28 mEq/L22–26 mEq/L
WBC35,000 cells/mm³4.5–10.5 × 10³ cells/mm³
Platelets250,000/mm³140,000–450,000/mm³
Potassium (serum)4.0 mEq/L3.5–5.0 mEq/L
Sodium (serum)140 mEq/L135–145 mEq/L
Magnesium1.5 mEq/L1.5–2.1 mEq/L
Lactate level4.5 mmol/L0.5–2.2 mmol/L
Blood cultureGram-negative cocciNegative
Urine culturePending—
Sputum culturePending—

0900

Client was admitted to the ICU in respiratory distress after minimal response to high-flow oxygen for a pulse oximeter reading of 83% on room air. Crackles heard bilaterally in the lower lobes with diminished breath sounds in the right middle lobe; S1 and S2 auscultated; bowel sounds positive in all 4 quadrants; skin warm, dry, and intact.

Temperature: 99.8°F (37.7°C)

Heart rate: 110/min

Respiratory rate: 30/min

Blood pressure: 158/90 mm Hg

Pulse oximeter: 87% on 100% oxygen via non-rebreather mask

Pain: 0/10

The nurse plans care for the client after initiating mechanical ventilation. For each potential intervention, click to specify whether the intervention is indicated or not indicated to include in the plan of care.

Potential Intervention Indicated Not Indicated
Administer sedatives
Repeat chest X-ray
Schedule suctioning every 2 hours
Administer amiodarone
Administer IV antibiotics
Position supine with head midline
Obtain an electrocardiogram (ECG)

Hint : 🛠️Think about interventions required to safely manage a newly intubated client.

Correct Answers

  • Administer sedatives [ Indicated ]
  • Repeat chest X-ray [ Indicated ]
  • Schedule suctioning every 2 hours [ Not Indicated ]
  • Administer amiodarone [ Not Indicated ]
  • Administer IV antibiotics [ Indicated ]
  • Position supine with head midline [ Not Indicated ]
  • Obtain an electrocardiogram (ECG) [ Indicated ]
Rationale :

😌Sedatives improve comfort and can promote synchrony with mechanical ventilation.

🩻A chest X-ray helps confirm endotracheal tube placement and evaluate pulmonary abnormalities.

💉IV antibiotics address the infectious process contributing to the client's respiratory condition.

📈An ECG provides important information about the client's cardiac rhythm during critical illness.

📌Core Message

Post-intubation care includes sedation, airway-placement verification, infection treatment, and continued cardiopulmonary assessment.

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10 :
Laboratory TestResultReference Range
ABG pH7.27.35–7.45
ABG PaO₂75 mm Hg75–100 mm Hg
ABG PaCO₂51 mm Hg35–45 mm Hg
ABG HCO₃⁻28 mEq/L22–26 mEq/L
WBC35,000 cells/mm³4.5–10.5 × 10³ cells/mm³
Platelets250,000/mm³140,000–450,000/mm³
Potassium (serum)4.0 mEq/L3.5–5.0 mEq/L
Sodium (serum)140 mEq/L135–145 mEq/L
Magnesium1.5 mEq/L1.5–2.1 mEq/L
Lactate level4.5 mmol/L0.5–2.2 mmol/L
Blood cultureGram-negative cocciNegative
Urine culturePending—
Sputum culturePending—

0900

Client was admitted to the ICU in respiratory distress after minimal response to high-flow oxygen for a pulse oximeter reading of 83% on room air. Crackles heard bilaterally in the lower lobes with diminished breath sounds in the right middle lobe; S1 and S2 auscultated; bowel sounds positive in all 4 quadrants; skin warm, dry, and intact.

0930

Client was intubated with a #6 endotracheal tube and placed on assist-control mechanical ventilation.

Rate: 14/min

PEEP: 5 cm H₂O

FiO₂: 60%

1000

Chest X-ray obtained.

IV placed and midazolam administered.

EKG shows sinus tachycardia.

0900

Temperature: 99.8°F (37.7°C)

Heart rate: 110/min

Respiratory rate: 30/min

Blood pressure: 158/90 mm Hg

Pulse oximeter: 87% on 100% oxygen via non-rebreather mask

Pain: 0/10

0930

Temperature: 99.8°F (37.7°C)

Heart rate: 110/min

Respiratory rate: 14/min

Blood pressure: 180/90 mm Hg

Pulse oximeter: 96%

Client is restless.

Nursing Orders

Insert urinary catheter

Titrate oxygen to maintain pulse oximeter reading ≥ 95%

Start IV of 0.9% normal saline at 75 mL/hr

Amoxicillin 500 mg IVPB every 12 hours

Midazolam 2–4 mg IVP every 1 hour as needed for agitation

Acetaminophen 650 mg per rectum every 8 hours as needed for temperature > 100.8°F

Suction endotracheal tube as needed

Perform 12-lead EKG

Call for chest X-ray

Obtain arterial blood gas (ABG) in 30 minutes

The nurse reassesses the client at 1000 and compares the findings to 0930. For each finding, click to specify whether the finding indicates that the client's status has improved, declined, or is unchanged.

Assessment Finding Improved No Change Declined
Heart rate
Temperature
Respiratory rate
Blood pressure
Pulse oximetry
Agitation

Hint : 📝Compare each 1000 finding with the client's status at 0930.

Correct Answers

  • Heart rate [ Improved ]
  • Temperature [ No Change ]
  • Respiratory rate [ No Change ]
  • Blood pressure [ Improved ]
  • Pulse oximetry [ Declined ]
  • Agitation [ Improved ]
Rationale :

💖The source identifies the heart rate as improved when the client is reassessed.

🌡️The temperature is identified as unchanged from the previous assessment.

🫁The respiratory rate is also classified as unchanged after mechanical ventilation.

😌The client's agitation improves following administration of midazolam.

📌Core Message

Reassessment shows improvement in heart rate, blood pressure, and agitation, while the decline in oxygenation requires continued attention.

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Total Questions: 10

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