A.
Immediately apply restraints
✓
B.
Assess the cause of agitation (e.g., pain, hypoxemia, delirium), and consider sedation or analgesia as ordered
✓
C.
Leave the patient unattended
✓
D.
Increase the ventilator settings
✓
A.
Administer activated charcoal
✓
B.
Administer naloxone (Narcan) IV push
✓
C.
Administer a diuretic
✓
D.
Administer an antidepressant
✓
B.
Pulmonary embolism or pneumothorax
✓
C.
Myocardial infarction
✓
D.
Deep vein thrombosis
✓
A.
Improved tissue oxygenation
✓
B.
Increased oxygen demand or decreased oxygen delivery (e.g., hypoxemia, low cardiac output, anemia)
✓
C.
Decreased metabolic rate
✓
A.
Continue fluid resuscitation
✓
B.
Assess for fluid overload/pulmonary edema, notify physician, and consider decreasing fluid rate or administering diuretic
✓
C.
Administer more vasopressors
✓
D.
Increase oxygen flow rate
✓
A.
Apply a warm compress
✓
B.
Apply sterile pressure dressing, reinforce, and notify physician
✓
C.
Administer an anti-coagulant
✓
B.
Pancreatic necrosis and potential for multi-organ failure
✓
D.
Urinary tract infection
✓
A.
Leave it on the floor
✓
B.
Re-level the transducer to the phlebostatic axis and re-zero the system
✓
D.
Calibrate the monitor
✓
A.
Administer more benzodiazepines
✓
B.
Administration of a loading dose of fosphenytoin or levetiracetam
✓
C.
Administer a diuretic
✓
D.
Administer an opioid
✓
A.
Continue the infusion
✓
B.
Stop the antibiotic infusion immediately, assess airway/breathing, and prepare to administer epinephrine/antihistamines
✓
C.
Slow down the infusion rate
✓
D.
Administer a diuretic
✓
A.
Patient is recovering
✓
B.
High risk of barotrauma and lung injury
✓
C.
Low risk of lung injury
✓
D.
Patient is hyperventilating
✓
B.
Aortic dissection or papillary muscle rupture with mitral regurgitation
✓
D.
Deep vein thrombosis
✓
A.
Administer IV fluids
✓
B.
Prepare for pericardiocentesis or surgical drainage
✓
C.
Administer a diuretic
✓
A.
Increase the nicardipine infusion rate
✓
B.
Decrease or hold the nicardipine infusion, administer a fluid bolus if ordered, and notify the physician
✓
C.
Administer a vasopressor
✓
D.
Administer a diuretic
✓
A.
Assess for patient pain
✓
B.
Assess for a leak in the ventilator circuit, cuff leak, or patient disconnection
✓
C.
Check the patient's temperature
✓
A.
Discontinuation of all medications
✓
B.
Administration of hydrocortisone (stress-dose steroids)
✓
C.
Administration of a diuretic
✓
D.
Administration of an anticoagulant
✓
A.
Increase the patient's stimulation
✓
B.
Maintain head of bed at 30 degrees, ensure neck alignment, and administer mannitol/hypertonic saline as ordered
✓
C.
Administer a sedative
✓
D.
Administer a fluid bolus
✓
A.
Increase the respiratory rate
✓
B.
Assess for pain, anxiety, secretion buildup, or inadequate sedation, and troubleshoot ventilator settings
✓
C.
Decrease the tidal volume
✓
D.
Disconnect the patient from the ventilator
✓
