Explanation: The patient’s data indicate that the patient is in shock, which is a lifethreatening condition characterized by inadequate tissue perfusion and organ dysfunction.
The patient has a low blood pressure, a high heart rate, a fever, and a metabolic acidosis, which suggest that the patient may have septic shock, which is caused by a severe infection that triggers a systemic inflammatory response. The nurse should anticipate an order to administer phenylephrine (Neo-Synephrine), which is a vasopressor agent that constricts the blood vessels and increases the blood pressure and tissue perfusion.
Phenylephrine is recommended as a first-line agent for septic shock by the Surviving Sepsis Campaign guidelines1. 8.4% sodium bicarbonate is not indicated for the treatment of septic shock, as it may worsen the acid-base balance and increase the risk of complications2. 0.9% sodium chloride is a normal saline solution that may be used for fluid resuscitation, but it may not be sufficient to restore the blood pressure and may cause fluid overload, hyperchloremia, and kidney injury3. Amiodarone (Cordarone) is an antiarrhythmic drug that is used to treat ventricular tachycardia or fibrillation, but it is not effective for septic shock and may cause hypotension, bradycardia, and other adverse effects4.

Explanation: The initial step in facilitating a change in practice regarding visiting hours should involve a literature search on family visitation practices. This allows the nurse to gather evidence-based information that can support any proposed changes. After gathering sufficient evidence, the nurse can then schedule an interdisciplinary team meeting to discuss the findings, consult with medical staff, and draft a new policy if necessary. References: CCRN Exam Handbook, AACN, page 35, section on Professional Caring and Ethical Practice.

Explanation: The intended effects of medications for a patient in acute CHF are to reduce CVP and reduce SVR, as this would decrease the preload and afterload on the failing heart and improve the cardiac output and tissue perfusion. CVP (central venous pressure) is a measure of the pressure in the right atrium and reflects the volume status of the patient. SVR (systemic vascular resistance) is a measure of the resistance in the systemic circulation and reflects the tone of the blood vessels. Medications that can reduce CVP and SVR in acute CHF include diuretics, nitrates, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and vasodilators12. Increasing CVP and reducing SVR would increase the preload and decrease the afterload, which may be beneficial for some patients with low cardiac output and low filling pressures, but not for patients with acute CHF and volume overload3. Reducing CVP and increasing SVR would decrease the preload and increase the afterload, which would worsen the cardiac function and oxygen demand in acute CHF3. Increasing CVP and increasing SVR would increase both the preload and the afterload, which would also worsen the cardiac function and oxygen demand in acute CHF3.

Explanation: Glucagon is a hormone that stimulates the liver to release glucose from glycogen stores or from gluconeogenesis. However, when the hepatocytes are damaged by alcoholism or other causes of hepatic failure, glucagon is ineffective because the liver cannot respond to its signal. Glucagon administration is contraindicated for hypoglycemic patients with hepatic failure because it will not raise their blood glucose levels and may worsen their acidosis and electrolyte imbalance123

Explanation: The appropriate outcomes for a patient with status asthmaticus are normal PaCO2 and increased FEV1. Status asthmaticus is a severe and life-threatening asthma exacerbation that does not respond to conventional treatment. It causes severe bronchoconstriction, air trapping, and mucus plugging, leading to hypoxemia, hypercapnia, and respiratory failure. The goals of treatment are to reverse the airway obstruction, improve gas exchange, and prevent complications. PaCO2 is the partial pressure of carbon dioxide in the blood, which reflects the adequacy of ventilation. FEV1 is the forced expiratory volume in one second, which measures the amount of air that can be forcefully exhaled in the first second of a breath. It reflects the degree of bronchoconstriction and airflow limitation. A patient with status asthmaticus typically has elevated PaCO2 and reduced FEV1 due to poor ventilation and severe obstruction. Therefore, normalizing PaCO2 and increasing FEV1 indicate improvement in the patient’s condition and response to treatment.

Explanation: A copious amount of serous drainage from a liver resection incision may indicate a bile leak, which can cause pain, infection, and delayed healing. The nurse should anticipate applying several abdominal dressings to absorb the fluid and protect the wound. The nurse should also monitor the patient for signs of infection, such as fever, increased white blood cell count, and foul-smelling drainage. The nurse should notify the surgeon of the excessive drainage and follow the orders for further interventions, such as imaging studies, drainage catheter placement, or surgical repair. Antibiotics may be prescribed, but they are not the first-line treatment for a bile leak. Incision and debridement of the wound may be necessary if there is necrotic tissue or infection, but it is not the initial action. Applying a drainage pouch to the site may not be sufficient to contain the large amount of fluid and may increase the risk of skin breakdown.

References:
Problems after cancer surgery to remove part of your liver: This article states that “The bile ducts connect the liver and gallbladder to the small bowel. There is a risk of bile leaking from the ducts on the cut surface of the liver. This may cause pain, sickness and a high temperature. Rarely, you might need another operation to repair the leak.”
Understanding Liver Abscess Treatment - Saint Luke’s Health System: This article states that “The provider uses CT scan or ultrasound to help place the wire in the right spot. A thin, flexible tube (catheter) is then placed over the wire and into the abscess. The tube is left in place for 5 to 7 days to drain the fluid. In some cases, surgery may be done to cut into the liver abscess and drain it.”
How Much Time Does it Take to Recover from Liver Surgery?: This article states that “If you have any drainage from your incision or if the area around your incision is puffy or red, visit your surgeon. Take a shower every day with warm water. When you are ready to take solid foods, make sure to eat 4 to 6 small meals every day. Do not lift heavy weights for 8 weeks after your surgery.”

Explanation: An increase in intracranial pressure (ICP) above 25 mm Hg often results in changes in the waveform morphology observed in the monitoring of intracranial pressure. Specifically, the amplitude of P2 becomes greater than P1, which is indicative of decreased intracranial compliance. This pattern is known as the "pathological waveform," suggesting increased intracranial pressure and decreased ability of the brain to accommodate the pressure changes. References: CCRN Exam Handbook, AACN, page 23, section on Neurological.

Explanation: In a patient with a chest tube, an air leak in the pleural space is indicated by an increase in bubbling in the water-seal chamber. Bubbling in this chamber occurs when air escapes from the pleural space into the chest drainage system. An increase in bubbling signifies an ongoing air leak, indicating that air is still entering the pleural space, often due to a bronchopleural fistula or lung injury.References: = CCRN Exam Handbook, page 36

Explanation: Phentolamine (Regitine) is the antidote for norepinephrine extravasation, which is the leakage of the vasopressor from the vein into the surrounding tissue. Phentolamine reverses the vasoconstriction and ischemia caused by norepinephrine by blocking the alpha-adrenergic receptors. Phentolamine should be administered intradermally around the site of extravasation as soon as possible, and the infusion should be stopped but the IV catheter should not be removed until some of the norepinephrine is aspirated. A warm compress may worsen the tissue damage by increasing the absorption of norepinephrine, and lowering the extremity may increase the edema and pain. Removing the IV immediately may prevent the aspiration of norepinephrine and the administration of phentolamine.

References:
Episode 240: What to do with norepinephrine extravasation: This article explains the steps to take when norepinephrine extravasates, including the use of phentolamine, and the reasons to avoid cold compress, lowering the extremity, and removing the IV.
What are current recommendations for treatment of drug extravasation?: This article summarizes the latest recommendations for treatment of extravasation, and lists phentolamine as the immediate topical therapy for norepinephrine extravasation.

Explanation: Pulmonary hypertension leads to increased pressure in the pulmonary circulation, which can cause right ventricular hypertrophy and failure. This results in systemic venous congestion, presenting as distended neck veins. Crackles, rhonchi, and pink frothy sputum are more indicative of pulmonary edema or other respiratory conditions rather than pulmonary hypertension. References: AACN Adult CCRN Certification Review Course, AACN CCRN Exam Handbook.

Explanation: Abdominal compartment syndrome (ACS) involves increased intraabdominal pressure, which can significantly impact various body systems. One of the major concerns is its effect on respiratory function, leading to increased peak inspiratory pressure. This happens because the elevated pressure in the abdomen can push up against the diaphragm, making it harder for the lungs to expand during inhalation. Increased urine output is unlikely as ACS usually leads to decreased renal perfusion and output. Increased preload and decreased intracranial pressure are not typically associated with ACS. References: = CCRN Exam Handbook, AACN Adult CCRN Certification Review Course

Explanation:



Hypotension, or low blood pressure, is a late finding in hypovolemic shock, which means that it occurs when the condition has progressed to a severe stage. Hypotension indicates that the body’s compensatory mechanisms, such as vasoconstriction, tachycardia, and increased cardiac output, have failed to maintain adequate perfusion and oxygen delivery to the vital organs. Hypotension is a sign of impending circulatory collapse and organ failure, and requires immediate intervention to restore blood volume and blood pressure. Hypotension is usually defined as a systolic blood pressure below 90 mmHg or a mean arterial pressure below 65 mmHg1.