A postoperative client is admitted to the intensive care unit (ICU) with an inflated pressure infuser containing a solution of heparin 2 units/ml attached to an intra-arterial (IA) cannula. Which finding indicates that the heparin infusion has achieved its therapeutic use?

Heparin is infused in less than four hours.

Systolic blood pressure greater than 120 mm Hg.

No knee pain upon forced dorsiflexion.

Intra-arterial cannula remains patent.

Answer and Explanation

The Correct Answer is D

A. Heparin is infused in less than four hours. The heparinized solution used in an intra-arterial (IA) pressure infuser is not intended for systemic anticoagulation but rather to maintain catheter patency. The infusion rate is typically slow and continuous, and completing the infusion in less than four hours is not an indicator of effectiveness.
B. Systolic blood pressure greater than 120 mm Hg. Heparin in an IA pressure infuser does not directly affect blood pressure. Its purpose is to prevent clot formation within the catheter, ensuring uninterrupted arterial pressure monitoring. BP readings are monitored separately and are not an indicator of heparin’s therapeutic effect.
C. No knee pain upon forced dorsiflexion. This assessment is used to evaluate deep vein thrombosis (DVT) (Homan's sign), which is not related to arterial catheter function. The low-dose heparin in the pressure infuser does not provide systemic anticoagulation, making this finding irrelevant.
D. Intra-arterial cannula remains patent. The primary purpose of heparinized flush solutions in IA lines is to prevent clot formation within the catheter and maintain patency for continuous blood pressure monitoring or arterial blood sampling. A patent arterial line confirms that the heparin infusion is achieving its intended effect.

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Correct Answer is C

Explanation

A. Administer a PRN dose of benzodiazepine.
Benzodiazepines can cause respiratory depression and prolong delirium, especially in clients recovering from mechanical ventilation and sedation. The client’s confusion is likely transient post-extubation delirium, which often resolves with reorientation and safety measures rather than sedation.
B. Increase the oxygen concentration to 60%.
The client is maintaining an oxygen saturation of 98% on 40% FiO₂, indicating adequate oxygenation. Increasing the oxygen concentration to 60% is unnecessary and may increase the risk of oxygen toxicity.
C. Apply bilateral wrist restraints.
The client is confused and attempting to get out of bed, increasing the risk of falls and accidental self-injury. Restraints should be used as a last resort after ensuring non-pharmacological interventions (e.g., reorientation, sitter, bed alarms) are ineffective or unavailable. If applied, restraints must be monitored closely and removed as soon as possible.
D. Notify the rapid response team.
The client’s vital signs are stable, and oxygenation is adequate. Although confusion is concerning, it does not indicate an immediate life-threatening emergency requiring a rapid response team. Instead, the nurse should implement safety interventions and continue close monitoring.

A. Elevate the head of the bed and provide a pillow under the client's head. B. Suction the endotracheal tube every 15 minutes to reduce choking. C. Intersperse treatments and nursing care with frequent rest periods. D. Change positions frequently while providing basic nursing care.

Correct Answer is C

Explanation

A. Elevate the head of the bed and provide a pillow under the client's head. While elevating the head of the bed to 30 degrees can help reduce ICP by promoting venous drainage, placing a pillow under the head may cause neck flexion, which can obstruct venous outflow and worsen intracranial pressure. Instead, the head should be maintained in a neutral midline position without excessive flexion or extension.
B. Suction the endotracheal tube every 15 minutes to reduce choking. Frequent suctioning can increase ICP due to coughing and vagal stimulation. Suctioning should be performed only as needed and using minimized suction duration to prevent sudden rises in intracranial pressure.
C. Intersperse treatments and nursing care with frequent rest periods. Clustering too many nursing interventions together can overstimulate the client and cause spikes in ICP. Providing adequate rest periods between activities such as repositioning, suctioning, and assessments allows intracranial pressure to return to baseline levels, helping to prevent sustained increases.
D. Change positions frequently while providing basic nursing care. Frequent repositioning can cause sudden fluctuations in ICP, especially if movements are abrupt or cause venous obstruction. Turning the client slowly and maintaining the head in a neutral position is recommended to avoid exacerbating intracranial hypertension.

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A postoperative client is admitted to the intensive care unit (ICU) with an inflated pressure infuser containing a solution of heparin 2 units/ml attached to an intra-arterial (IA) cannula. Which finding indicates that the heparin infusion has achieved its therapeutic use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse is monitoring for signs of increased intracranial pressure (ICP) in a client who attempted suicide by jumping from a tenth floor balcony. The client is intubated and mechanically ventilated. Which intervention should the nurse implement to minimize rises in ICP?

Correct Answer is C

Explanation

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