Critical Care Nursing Flashcards

What does a hemodynamic reading of CVP 2 mmHg indicate?

Answer: Hypovolemia (low intravascular volume) requiring fluid resuscitation

Central Venous Pressure (CVP) normal range is 2-8 mmHg. CVP of 2 mmHg (at the low end/below normal) suggests hypovolemia — decreased intravascular volume. The nurse should anticipate fluid resuscitation orders and assess for signs of dehydration and poor perfusion.

What is the nurse's priority action when a patient's ventilator alarm sounds 'High Pressure'?

Answer: Assess the patient immediately for secretions, kinking, biting, pneumothorax, or bronchospasm

High pressure alarm means increased resistance to airflow. Causes: secretions (suction needed), kinked/compressed tubing, patient biting tube (insert bite block), bronchospasm (administer bronchodilator), tension pneumothorax (emergency), or decreased lung compliance. Assess patient before the ventilator.

What are the signs of cardiac tamponade?

Answer: Beck's triad: hypotension, distended neck veins, and muffled heart sounds

Cardiac tamponade presents with Beck's triad: hypotension (low cardiac output), distended jugular veins (impaired venous return), and muffled/distant heart sounds (fluid around heart). Additional signs: pulsus paradoxus (>10 mmHg BP drop during inspiration), tachycardia, and narrowed pulse pressure.

What is the correct compression-to-ventilation ratio for adult CPR?

Answer: 30:2

Current AHA/Saudi Heart Association guidelines: 30 chest compressions to 2 ventilations for adult CPR (single or two rescuers with advanced airway). Compressions should be at least 5 cm deep, at a rate of 100-120/min, with full chest recoil. Minimize interruptions (<10 seconds).

What is sepsis and what are the nursing priorities for early recognition?

Answer: Life-threatening organ dysfunction caused by dysregulated host response to infection — monitor for SIRS criteria, lactate levels, and organ dysfunction

Sepsis recognition (qSOFA): altered mental status, respiratory rate ≥22, systolic BP ≤100 mmHg. Nursing priorities: early recognition, obtain blood cultures BEFORE antibiotics, administer broad-spectrum antibiotics within 1 hour, aggressive fluid resuscitation (30 mL/kg crystalloid), monitor lactate, and assess organ function.

How should a nurse manage a patient with an arterial line?

Answer: Zero and level the transducer at the phlebostatic axis, monitor waveform, assess the site for bleeding/infection, and perform Allen's test before insertion

Arterial line nursing care: zero/level transducer at phlebostatic axis (4th ICS, mid-axillary), verify waveform quality, maintain continuous flush system, assess insertion site (bleeding, infection, circulation distal to site), perform Allen's test before radial insertion, and never flush rapidly (risk of retrograde cerebral embolism).