You are the charge nurse in the ICU and the hospital needs a bed. Which of the following patients can go to the floor?

A pneumectomy patient that had surgery 2 days ago with vital signs RR 20, B/P 150/82, HR 90, and Temp 99.

A patient recently diagnosed with Guillain-Barré who had numbness in the upper chest with vital signs RR 12, B/P 100/80, HR 90, and Temp 100.

An appendectomy patient that is resting quietly with vital signs RR 26, B/P 85/60, HR 112, Temp 101.4.

A patient with restrictive cardiac myopathy with vital signs RR 24, B/P 100/70, HR 110, and Temp 98.6

Answer and Explanation

The Correct Answer is A

Rationale:
A. A pneumectomy patient that had surgery 2 days ago with vital signs RR 20, B/P 150/82, HR 90, and Temp 99 is correct. This patient is hemodynamically stable, with normal respiratory rate and heart rate, and a low-grade temperature that is not concerning. They are recovering appropriately postoperatively and do not require the intensive monitoring provided in the ICU, making them appropriate for transfer to the floor.

B. A patient recently diagnosed with Guillain-Barré who had numbness in the upper chest with vital signs RR 12, B/P 100/80, HR 90, and Temp 100 is incorrect. Guillain-Barré patients are at risk for rapid respiratory compromise due to neuromuscular weakness. Numbness in the upper chest may indicate early respiratory involvement, so this patient requires continued ICU-level monitoring.

C. An appendectomy patient that is resting quietly with vital signs RR 26, B/P 85/60, HR 112, Temp 101.4 is incorrect. Despite resting, the patient has signs of instability: hypotension, tachycardia, tachypnea, and fever, which may indicate sepsis or hemorrhage. They require ICU care for close monitoring and intervention.

D. A patient with restrictive cardiac myopathy with vital signs RR 24, B/P 100/70, HR 110, and Temp 98.6 is incorrect. Although not febrile, the patient shows mild tachypnea and tachycardia with borderline hypotension, which could signal heart failure exacerbation. ICU monitoring is appropriate to manage potential rapid deterioration.

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Correct Answer is D

Explanation

Rationale:
A. Tape the tube securely in place is incorrect as the first action. While securing the endotracheal tube is important to prevent displacement, it should follow verification of correct placement, not precede it. Taping an incorrectly positioned tube could worsen hypoxia or cause trauma.

B. Perform endotracheal suctioning is incorrect as an initial action. Suctioning is only necessary if there is evidence of airway obstruction or secretions. Suctioning before confirming tube placement could cause trauma or worsen oxygenation.

C. Request a CXR is incorrect as the first action. A chest X-ray is used to confirm tube placement but is not immediately available in most emergency situations. Immediate bedside verification is critical before imaging.

D. Auscultate breath sounds is correct. The first priority after endotracheal tube placement is to verify correct tube placement by assessing for bilateral breath sounds, symmetrical chest rise, and, if available, end-tidal CO2. Proper placement ensures that the patient is being ventilated effectively. Immediate verification prevents hypoxia, gastric insufflation, and other complications.

A. Obtain a cardiology consult. B. Suction the client less frequently. C. Administer an antidysrhythmic medication. D. Perform pre-oxygenation prior to suctioning.

Correct Answer is D

Explanation

Rationale:

A. While the client is experiencing tachycardia and dysrhythmia, this response is likely transient and related to suctioning rather than an underlying cardiac condition. Immediate cardiology consultation is not the first action; the nurse should first implement preventive measures.

B. Although excessive suctioning can cause adverse effects, the problem in this scenario is the acute cardiovascular response during suctioning, not the frequency of suctioning. Frequency adjustments alone will not prevent dysrhythmias if pre-oxygenation is not used.

C. Dysrhythmias caused by suctioning are typically transient and self-limiting. Medications are not indicated unless the dysrhythmia persists or is hemodynamically significant. The first intervention should focus on prevention.

D. Suctioning an endotracheal tube can reduce oxygen saturation and trigger vagal or sympathetic responses, leading to tachycardia, arrhythmias, or bradycardia. Pre-oxygenating the client with 100% oxygen for 30–60 seconds before suctioning reduces hypoxemia and the risk of cardiac arrhythmias. This is the standard preventive intervention recommended during suctioning of ventilated patients.

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You are the charge nurse in the ICU and the hospital needs a bed. Which of the following patients can go to the floor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The initial action by the nurse after placement of an endotracheal tube in any patient should be:

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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