334 Final: PrepU Questions (all)

A patient admitted to the hospital is suspected to have rheumatic endocarditis. What diagnostic test does the nurse anticipate will be ordered?

* Throat culture* Rationale: Rheumatic fever is a preventable disease. Diagnosing and effectively treating streptococcal pharyngitis can prevent rheumatic fever and, therefore, rheumatic heart disease. If S/S of streptococcal pharyngitis are present, a throat culture is necessary to make an accurate diagnosis.

Optimal range of ICP

*0-10 mmHg* 15 = upper level of normal

*Cerebral Contusion:* During what time period after the injury will the effects of injury peak?

*18-36h* Rationale: Contusions are characterized by loss of consciousness associated with stupor and confusion. Other characteristics can include tissue alteration and neurologic deficit without hematoma formation, alteration in consciousness without localizing signs, and hemorrhage into the tissue that varies in size and is surrounded by edema. The effects of injury (hemorrhage and edema) peak after about 18 to 36 hours.

The client is scheduled for a breast lump excision and sentinel node biopsy. What should the nurse know in planning care for the client with a negative biopsy report?

*A wide excision of lump will be performed.* Rationale: The sentinel node is the first node in which a tumor will drain; if no malignant cells are found there, additional excision or radical removal will not be necessary. Excision of the lump along with a wide margin of cancer-free tissue is standard treatment for malignant tumors.

A 34-year-old patient is diagnosed with relapsing-remitting MS. The nurse explains to the patient's family that they should expect:

*Acute attacks with full recovery or residual deficit upon recovery* Rationale: With relapsing-remitting MS, recovery is usually complete with each relapse. Residual deficits may occur and accumulate over time, contributing to a functional decline.

A patient was brought into the ED after sustaining injuries due to an explosion while welding. The patient is breathing but has an oxygen saturation of 90%, a RR of 32, and is coughing. What is the priority action by the nurse?

*Administer oxygen with a nonrebreather mask.* Rationale: Blast lung results from the blast wave as it passes through air-filled lungs. The result is hemorrhage and tearing of the lung, ventilation-perfusion mismatch, and possible air emboli. Typical S/S include dyspnea, hypoxia, tachypnea or apnea (depending on severity), cough, chest pain, and hemodynamic instability. Management involves providing respiratory support that includes administration of supplemental oxygen with a nonrebreathing mask but may also require endotracheal intubation and mechanical ventilation.

After administration of epinephrine for an acute anaphylactic reaction, the nurse expects to administer which of the following drugs to treat severe bronchospasm?

*Aminophylline* (see word doc)

People in close contact with patients with meningococcal meningitis should be treated with:

*Antimicrobial chemoprophylaxis:* • rifampin (Rifadin) • ciprofloxacin hydrochloride (Cipro) • ceftriaxone sodium (Rocephin)

A patient who suffered a T6 lesion during a spinal cord injury (SCI) 10 days ago is progressing with treatment and rehabilitation following the immediate treatment of his injury. When preparing to help the physical therapist mobilize the patient for the first time since the injury, the nurse should prioritize which of the following assessments?

*Assessing the patient's BP.* Rationale: For the first 2 weeks following SCI, BP tends to be unstable and quite low. It gradually returns to pre-injury levels, but periodic episodes of severe orthostatic hypotension frequently interfere with efforts to mobilize the patient. Close monitoring of V/S before & during position changes is essential. The other listed assessments should be addressed but they are less closely r/t the specific risks associated with this procedure at this point in the patient's recovery.

A 26-year-old woman is thankful to be alive after rear-ending a truck with her car. However, she experienced a sternal fracture from the force of her car's airbag and has been breathing shallowly to avoid exacerbating her pain. The nurse should consequently prioritize assessments related to:

*Atelectasis* Rationale: To minimize the pain associated with a sternal fracture, the patient splints the chest by breathing in a shallow manner and avoids sighs, deep breaths, coughing, and movement. This breathing pattern has the potential to cause diminished ventilation, atelectasis (collapse of unaerated alveoli), pneumonitis, and hypoxemia.

When caring for a client who's being treated for hyperthyroidism, the nurse should:

*Balance the client's periods of activity and rest* Rationale: A client with hyperthyroidism needs to be encouraged to balance periods of activity and rest. Many clients with hyperthyroidism are hyperactive and complain of feeling very warm. Consequently, it's important to keep the environment cool and to teach the client how to manage his physical reactions to heat. Clients with hypothyroidism — not hyperthyroidism — complain of being cold and need warm clothing and blankets to maintain a comfortable temperature. They also receive thyroid replacement therapy, commonly feel lethargic and sluggish, and are prone to constipation. The nurse should encourage clients with hypothyroidism to be more active to prevent constipation.

Which condition may contribute to hyperparathyroidism?

*Chronic RF* Rationale: Because failing kidneys can't convert vitamin D, the serum calcium level declines. Parathyroid hormone release increases, causing hyperparathyroidism. Thyroidectomy may lead to hypoparathyroidism if the parathyroid is also removed during surgery. Serum calcium level may rise as a result of hyperparathyroidism, so it isn't a contributing factor. Steroid use causes calcium to leave bone, suppressing parathyroid hormone.

An asymptomatic patient questions the nurse about mitral regurgitation and inquires about continuing exercises. Which of the following is the most appropriate nursing response?

*Continue exercise until mild symptoms develop.* Rationale: Exercise is not limited until mild symptoms develop. It is not important for an asymptomatic patient to avoid exercise and to take ample rest after exercise.

A client with Cushing's syndrome is admitted to the medical-surgical unit. During the admission assessment, the nurse notes that the client is agitated and irritable, has poor memory, reports loss of appetite, and appears disheveled. These findings are consistent with:

*Depression* Rationale: Agitation, irritability, poor memory, loss of appetite, and neglect of one's appearance may signal depression, which is common in clients with Cushing's syndrome. Neuropathy affects clients with diabetes mellitus — not Cushing's syndrome. Although hypoglycemia can cause irritability, it also produces increased appetite, rather than loss of appetite. Hyperthyroidism typically causes such signs as goiter, nervousness, heat intolerance, and weight loss despite increased appetite.

Initial and most common manifestation of MG

*Diplopia & ptosis* (SX involving ocular muscles) Others: weakness of the muscles of the face and throat, generalized weakness, and weakness of the facial muscles

A client with unresolved hemothorax is febrile, with chills and sweating. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. A possible explanation for these findings is:

*Empyema* Rationale: Any condition that produces fluid accumulation or sequestration of fluid with infective properties can lead to empyema, an accumulation of pus in a body cavity, especially the pleural space, as a result of bacterial infection. An infected chest tube site, lobar pneumonia, and P. carinii pneumonia can lead to fever, chills, and sweating associated with infection. However, in this case, turbid drainage indicates that empyema has developed. Pneumonia typically causes a productive cough. An infected chest tube wound would cause redness and pain at the site, not turbid drainage.

A patient brought to the hospital after a skiing accident was unconscious for a brief period of time at the scene, then woke up disoriented and refused to go to the hospital for treatment. The patient became very agitated and restless, then quickly lost consciousness again. What type of TBI is suspected in this situation?

*Epidural hematoma* Rationale: Epidural hematomas are often characterized by a brief loss of consciousness followed by a lucid interval in which the patient is awake and conversant. The patient then becomes increasingly restless, agitated, and confused as the condition progresses to coma.

In a client infected with HIV, CD4+ levels are measured to determine the:

*Extent of immune system damage* Rationale: CD4+ levels in the blood of an individual with HIV infection determine the extent of damage to the individual's immune system. The test indicates the individual's risk of an opportunistic infection but doesn't identify specific infections. Viral loads and resistance to specific antigens are determined using other diagnostic tests.

A patient has a severe neurologic impairment from a head trauma. What does the nurse recognize is the type of posturing that occurs with the most severe neurologic impairment?

*Flaccid* Rationale: LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response. The patient's responses are rated on a scale from 3 to 15. A score of 3 indicates severe impairment of neurologic function, brain death, or pharmacologic inhibition of the neurologic response. A score of 15 indicates that the patient is fully responsive. An inappropriate or nonpurposeful response is random and aimless. Posturing may be decorticate or decerebrate. The most severe neurologic impairment results in flaccidity. The motor response cannot be elicited or assessed when the patient has been administered pharmacologic paralyzing agents (i.e., neuromuscular blocking agents).

What are the *complications* of pneumonia?

*From Book:* • shock • sepsis • multi-system failure→ esp. RESP • atelectasis • pleural effusion (3 stages: uncomplicated, complicated, empyema) • superinfection • confusion *From PrepU:* • shock • septicemia • CHF • empyema • pleurisy • atelectasis • hypotension • etc.

The human body is an amazing mechanism with multiple compensatory mechanisms and built-in protection against invasion. One of these systems is the immune system which is a major factor in the prevention or development of cancer. *Which of the following is a weapon is the immune system "arsenal"?*

*Immune suppression* Rationale: If the immune system fails to recognize malignant cells or is not stimulated in any way to fight cancer cells, tumor growth is not inhibited. Malignant cells survive and proliferate.

How dies *viral* pneumonia differ from *bacterial* pneumonia?

*In viral pneumonia:* • blood cultures are sterile • sputum may be more copious • chills are less common • slow HR & RR

A patient has safely given birth to her first child, a healthy baby boy. The OB nurse who provided labor support is aware that the infant possesses natural (innate) immunity that can protect him from many pathogens. Which of the following statements most accurately describes an aspect of natural immunity?

*Innate immunity is dependent on the ability of cells to differentiate between "self" and "non-self" cells.* Rationale: Because of its nonspecificity, natural immunity maintains a broad spectrum of defense against and resistance to infection. The basis of this defense mechanism is the ability to distinguish between "self" and "non-self." Innate immunity does not involve the creation of antibodies and does not result from exposure to antigens. Acquired immunity is divided into the categories of active and passive immunity.

A patient is admitted to the ED for the treatment of a large wound to his right leg. After determining that his injuries did not pose an immediate threat to life, the nurse's next priority in treating the wound would be to:

*Inspect the wound to assess the extent of damage to underlying structures.* Rationale: Wound inspection and assessment is necessary to determine the severity of injury. The next step is cleansing the wound, which may include irrigation and debridement.

The nurse is aware that a delayed-type hypersensitivity reaction is an example of an immune response. The T lymphocytes involved in this type of reaction are:

*Killer T cells* Rationale: The cytotoxic (killer) T cells protect the body from antigens through the production and release of lymphokines.

The nurse working in the medical ICU has a patient admitted with mitral stenosis. The nurse knows that the pathophysiology of mitral stenosis is consistent with some of the following. Choose all that apply.

*Left atrial hypertrophy* Rationale: Poor left ventricular filling can cause decreased C.O. The increased blood volume in the left atrium causes it to dilate and hypertrophy.

A client with diabetes insipidus is extremely dehydrated and is unable to take oral fluids. Fluid therapy is prescribed. Which intervention would be most important for the client?

*Measuring UO every 30 minutes* Rationale: The nurse must measure the urine output every 30 minutes when administering prescribed fluid and drug therapy when the client is acutely ill or extremely dehydrated, fails to take oral fluids, or is beginning to receive medical treatment. Doing so ensures adequate kidney function. Although monitoring the rate of IV infusions, measuring fluid intake, and weighing the client daily are important, measuring the urine output every 30 minutes is the priority.

A patient newly admitted to the telemetry unit is experiencing progressive fatigue, hemoptysis, and dyspnea as a result of pulmonary venous hypertension. What valvular disorder would cause pulmonary venous hypertension?

*Mitral stenosis.* Rationale: The first symptom of mitral stenosis is often dyspnea on exertion as a result of pulmonary venous hypertension. Symptoms usually develop after the valve opening is reduced by 1/3 to 1/2 its usual size. Patients are likely to show progressive fatigue as a result of low C.O. The enlarged left atrium may create pressure on the left bronchial tree, resulting in a dry cough or wheezing. Patients may expectorate blood (ie, hemoptysis) or experience palpitations, orthopnea, paroxysmal nocturnal dyspnea (PND), and repeated respiratory infections. Pulmonary venous hypertension is *not* caused by aortic regurgitation, MVP, or aortic stenosis.

The nurse is caring for a client with a SCI. What test reveals the *level* of SCI?

*Neuro exam* Rationale: A neuro exam reveals the level of SCI. Radiography, myelography, and a CT scan show the evidence of fracture or compression of one or more vertebrae, edema, or a hematoma.

Hyperthyroidism-- test result for DX

*No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test* Rationale: In the TSH test, failure of the TSH level to rise after 30 minutes confirms hyperthyroidism. A decreased TSH level indicates a pituitary deficiency of this hormone. Below-normal levels of T3 and T4, as detected by radioimmunoassay, signal hypothyroidism. A below-normal T4 level also occurs in malnutrition and liver disease and may result from administration of phenytoin and certain other drugs.

A nurse is exposed to hepatitis C and receives a shot of gamma globulin. What type of immunity does this nurse have?

*Passive immunity* Rationale: Passive immunity develops when ready-made antibodies are given to a susceptible person. The antibodies provide immediate but short-lived protection from the invading antigen. No memory cells are produced, and the level of the injected antibodies diminishes over a period of several weeks to a few months. This type of immunity is not natural, artificially acquired active immunity, or naturally acquired active immunity.

A patient has been brought to the ED with multiple trauma after a MVA. After immediate threats to life have been corrected, the nurse and trauma team should:

*Perform a rapid physical assessment* to ID injuries & priorities of TX Rationale: This is a priority over detailed assessment, establishment of medical HX, and TX of FX's.

To establish an airway using the head-tilt-chin-lift maneuver in a patient without a suspected cervical spine injury, the first step would be to:

*Place the palm of one hand on the forehead and gently push the head backward.* Rationale: In the head-tilt-chin-lift maneuver, one hand is placed on the victim's forehead and firm backward pressure is applied with the palm to tilt the head back, which will move the tongue forward (away from the back of the throat). The fingers of the other hand are placed under the bony part of the lower jaw (mandible), near the chin, and gently lifted up.

Nursing care for a client in addisonian crisis should include which intervention?

*Placing the client in a private room* Rationale: The client in addisonian crisis has a reduced ability to cope with stress as a result of an inability to produce corticosteroids. A private room is easy to keep quiet, dimly lit, and temperature controlled. Also, visitors can be limited to reduce noise, promote rest, and decrease the risk of infection. The client should be kept on bed rest, receiving total assistance with ADLs to avoid stress as much as possible. Because extremes of temperature should be avoided, measures to raise the body temperature, such as extra blankets and turning up the heat, should be avoided.

Hattie Willoughby, a 62-year-old female, is 2 weeks post-CABG and is returning to her cardiologist due to new symptoms. She reports heaviness in her chest, and pain between her breasts. She reports that leaning forward decreases the pain. After his thorough examination, the cardiologist admits her to the hospital to rule out pericarditis. Which of the following is not a contributing cause to pericarditis?

*Pneumonia* Rationale: Pericarditis usually is secondary to endocarditis, myocarditis, chest trauma, or MI, or develops after cardiac surgery.

A nurse encourages a client with an immunologic disorder to eat a nutritionally balanced diet to promote optimal immunologic function. Which snacks have the greatest probability of stimulating autoimmunity?

*Potato chips and chocolate milk shakes* Rationale: A diet containing excessive fat, such as that found in potato chips and milk shakes, seems to contribute to autoimmunity — overreaction of the body against constituents of its own tissues. Raisins, carrot sticks, fruit, mineral water, applesauce, and saltine crackers are snacks containing adequate amounts of vitamin A, zinc, and carotene, which are beneficial for the body.

A patient has been diagnosed with mitral valve prolapse (MVP) following an echocardiogram and will begin treatment imminently. When planning this patient's care, the nurse will prioritize:

*Preserving the patient's existing level of function.* Rationale: Patients with MVP are often asymptomatic, and treatment and nursing management are aimed at managing symptoms and preserving function. MVP does not predispose the patient to infection, pericardial effusion, or ischemic heart disease.

A patient is suspected to have an air embolus after being in close proximity to an explosion at a sports arena. What position should the nurse place the patient in to prevent migration of the embolus?

*Prone left lateral position* Rationale: This position prevents embolus migration & will require emergent treatment in a hyperbaric chamber.

A critical care nurse is aware of the high incidence and prevalence of ventilator-associated pneumonia (VAP) in high-acuity settings. In order to reduce patients' risks of developing VAP, what intervention should the nurse prioritize?

*Provide frequent, thorough mouth care.* Rationale: • Mouth care to be given at a minimum *q4h* in order to maintain mucosal integrity and prevent pooling of secretions. • Keep HOB elevated to at least 30 degrees. • Lung auscultation is an important assessment, but this action alone does not actively prevent VAP. • Prophylactic antibiotics are not normally used to prevent VAP.

A 72-year-old patient is status post right knee replacement, and the nurse recognizes the patient's risk of hospital-acquired pneumonia (HAP). What is a priority nursing measure for the prevention of HAP?

*Providing anticipatory interventions & preventative care.* Vaccines prevent pneumonia in 50% of healthy populations.

A client presents to a physician's office complaining of dyspnea with exertion, weakness, and coughing up blood. Further examination reveals peripheral edema, crackles, and JVD. The nurse anticipates the physician will make which diagnosis?

*Pulmonary HTN* Rationale: • Dyspnea, weakness, hemoptysis, and right-sided heart failure are all signs of pulmonary HTN. • Clients with COPD present with chronic cough, dyspnea on exertion, and sputum production. • Those with empyema are acutely ill and have signs of acute respiratory infection or pneumonia. • Clients with pulmonary tuberculosis usually present with low-grade fever, night sweats, fatigue, cough, and weight loss.

A patient has sustained a crush injury to the abdomen due to a construction site accident. The nurse knows that, in conjunction with maintaining the airway, breathing, and circulation, the patient must be observed for indicators of acute:

*Renal failure* Rationale: Prolonged hypotension causes kidney damage and acute renal insufficiency; myoglobinuria, secondary to muscle damage, can cause acute tubular necrosis and acute RF.

The transferring nurse is providing info to the receiving nurse. Place in correct order the steps for providing the report through the use of SBAR.

*S:* The client vomited 400 mL of bright red blood with clots present. *B:* The client's BP is now 80/54, down from 114/76. Pulse rate is 114 bpm, up from 82 bpm. *A:* The client is exhibiting hypovolemia from GI blood loss. *R:* I have notified the HCP who ordered 2 units of packed RBC's that need to be administered. Rationale: SBAR is a communication tool that refers to Situation-Background-Assessement-Recommendation. The situation is the client vomiting blood. The background is the V/Ss. The assessment is the client exhibiting hypovolemia. The recommendation is the blood to be administered.

You are an oncology nurse and have just begun infusion of a patient's first dose of doxorubicin (Adriamycin) for the treatment of the patient's soft-tissue sarcoma. Shortly after beginning the infusion, the patient complains of pain at the infusion site, which is now swollen and reddened, and the IV pump has alarmed with a report of occlusion. As a result, you suspect extravasation. What action should you prioritize?

*Stop the infusion and aspirate from the patient's IV line.* Rationale: If extravasation is suspected, the medication administration should be stopped immediately. The nurse should attempt to aspirate any residual drug from the IV line prior to removal of the IV cannula. A flush would exacerbate potential tissue damage.

Atonic seizures are characterized by:

*Sudden loss of muscle tone that results in a fall* Rationale: Atonic seizures are characterized by sudden loss of muscle tone, resulting in falls or a "drop" to the ground, with rapid recovery. Clonic seizures are characterized by jerking movements, which involve muscles on both sides of the body. Absence (petit mal) seizures refer to short episodes of staring and loss of awareness. Myoclonic seizures (bilaterally massive epileptic) are characterized by jerking movements of a muscle or muscle group, without loss of consciousness

What is the *diagnostic feature of ARDS*?

*Sudden unresponsive arterial hypoxemia* Rationale: Clinically, the acute phase of ARDS is marked by a rapid onset of severe dyspnea that usually occurs 12 to 48 hours after the initiating event. A characteristic feature is arterial hypoxemia that does *not* respond to supplemental oxygen.

It is important for a nurse to refer an HIV-positive client to support groups and resources because:

*Support groups and resources provide information about new HIV drug development and clinical drug trials to clients* Rationale: A very important nursing intervention is to refer HIV-positive clients to support groups and resources for information about new HIV drug development, clinical drug trials, AIDS drug assistance programs, and progress on vaccine development. It is not true that support groups only provide better emotional and psychological support to HIV-positive patients or that the nurses become incapable of managing such patients after a point of time. In addition, it is not mandatory by the state to refer HIV-positive patients to support groups.

A water seal system for chest drainage has been inserted into a patient who suffered chest trauma during a motor vehicle accident. At the beginning of the night shift, the nurse has entered the patient's room to assess the system and the patient's condition. Which of the following assessment findings suggests that the system is operating correctly and the patient is maintaining oxygenation?

*The water level in the water seal chamber increases when the patient inhales.* Rationale: • The water seal chamber has a one-way valve or water seal that prevents air from moving back into the chest when the patient inhales. There is an increase in the water level with inspiration and a return to the baseline level during exhalation; this is referred to as TIDALING. • Intermittent bubbling in the water seal chamber is normal, but continuous bubbling can indicate an air leak. • Water levels should at no time reach the top of the water seal chamber.

A bowel resection is scheduled for a client with the diagnosis of colon cancer with metastasis to the liver and bone. Which statement by the nurse best explains the purpose of the surgery?

*Tumor removal will promote comfort.* Rationale: Palliative surgeries, such as bowel resection, may be performed to promote comfort by relieving pain and pressure on organs within the abdominal cavity. Primary treatment refers to surgery that is likely to provide a cure, which is not likely in metastatic disease. With metastasis, primary tumor removal does not prevent further tumor growth in distant sites. The diagnosis of colon cancer with metastasis suggests cell pathology has already been determined.

An oropharyngeal airway should be inserted:

*Upside down and then rotated 180 degrees.* Rationale: Insert the oropharyngeal airway with the tip facing up toward the roof of the mouth until it passes the uvula. Rotate the tip 180 degrees so that the tip is pointed down toward the pharynx.

Assessment of patient w/ MS -- expected symptoms

*Vision changes* Rationale: Vision changes, such as diplopia, nystagmus, and blurred vision, are symptoms of MS. Deep tendon reflexes may be increased or hyperactive — not absent. Babinski's reflex may be positive. Tremors at rest aren't characteristic of MS; however, intentional tremors (those occurring with purposeful voluntary movement) are common in clients with MS. Affected muscles are spastic, rather than flaccid.

Importance of *vitamin D* supplementation

*Vitamin D deficiency has been associated with increased risk of:* • common cancers • autoimmune diseases • inflammatory disorders

Four clients injured in an automobile accident enter the ED at the same time. The triage nurse evaluates them immediately. The nurse should assign the highest priority to the client with the:

*maxillofacial injury and gurgling respirations* Rationale: ED triage involves giving priority to clients at highest risk for loss of life, limb, or vision. Clients with poor prognoses are given a lesser priority. The client with the maxillofacial injury and gurgling respirations needs immediate attention because of an impaired airway. The spinal cord injury client doesn't exhibit immediate airway needs. The client with the severe head injury and no blood pressure has a grave prognosis. Although the client in early labor is an urgent priority, early labor doesn't surpass airway compromise in importance.

A patient is brought to the ED by ambulance with a gunshot wound to the abdomen. The nurse knows that the most common hollow organ injured in this type of injury is what?

*small bowel*

The client reports SOB. RR= 32. SpO2= 85%. The nurse performs the following actions in this order.

1) Consult with the rapid response team. 2) Obtain order for O2 3) Put face mask on pt. 4) Obtain ABG w/ FiO2 at 35%. 5) Change to nasal cannula for meals.

Hemodynamic monitoring in critical care includes assessing the effects of preload. What are the *causes of increased preload*?

1) Increased fluid volume 2) Vasoconstriction

5 disorders of common, primary immunodeficiencies

1. humoral immunity 2. T-cell defects 3. Phagocytic disorders 4. Complement production 5. Combined B- and T-cell defects

How does pneumonia present differently among the *elderly* than among younger patients?

The classic SX (cough, chest pain, sputum production, and *fever*) may be absent or masked in elderly patients. Also, the presence of some signs may be misleading.

A nurse is visiting the home of a client with AIDS who is experiencing HIV encephalopathy. When developing the plan of care for the client and his caregiver, the nurse identifies the nursing diagnosis of disturbed thought processes related to confusion and disorientation secondary to HIV encephalopathy. Which expected outcome would be most appropriate for the nurse to document on the client's plan of care?

The client can state that he is at his home.

A medical patient developed a new onset SOB with pulse oximetry (POX) ranging between 70-75% and a RR of 30-35 bpm. The patient did not respond to O2 therapy with nasal prongs and was fitted with a partial rebreathing mask by the respiratory therapist. When maintaining this patient's oxygen delivery system, the nurse should:

ensure that the reservoir bag remains inflated at all times

*Mechanical Ventilation*- Which SETTINGS are specified by the PCP?

• (respiratory) *rate* • *tidal volume* • *PEEP* (positive end expiratory pressure) • FiO2 (fraction of inspired oxygen)

A nurse working in the medical ICU has a patient admitted with mitral stenosis. The nurse is precepting a new graduate and explains the pathophysiology of the condition. Which of the following statements made by the new graduate would reflect an *appropriate* understanding of the disease process? SAA.

• *"Increased blood flow in the left atrium causes left atrial hypertrophy."* • *"There is a narrowing between the left atrium and left ventricle."* Rationale: Poor left ventricular filling can cause decreased C.O. The increased blood volume in the left atrium causes it to dilate and hypertrophy. The left atrium and ventricle are affected with mitral stenosis. Mitral regurgitation causes the lungs to become congested.

Cerebrospinal fluid (CSF) studies would indicate which of the following in a patient suspected of having meningitis? SAA.

• *Decreased glucose* • *Increased protein* • *Increased WBC's*

A 38-year old female client has begun to suffer from RA. She is also being assessed for disorders of the immune system. She works as an aide at a facility which cares for children infected with AIDS. Which of the following factors will hold the greatest implications during the client's assessment? SAA.

• *Her work environment* • *Her history of immunizations and allergies* • *Her use of other drugs* (The client's age, home environment, and diet do not have any major implications during the assessment because they do not indicate the client's susceptibility to illness.)

A 58-year-old construction worker fell from a 25-foot scaffolding and incurred a closed head injury as a result. As his ICP continues to increase, the potential of herniation also increases. If the brain herniates, which of the following are potential consequences? SAA.

• *Neuro dysfunction* (permanent or temporary) • *Death* • *Impaired cellular activity*

A 46-year-old man has been diagnosed with *pericarditis* and has begun treatment. When assessing this patient, the nurse should prioritize assessments relevant to what *complications* of pericarditis? SAA.

• *Pericardial effusion* • *Cardiac tamponade* Rationale: Nurses caring for patients with pericarditis must be aware of the potential of serious complications. The two major complications of pericarditis are pericardial effusion, the accumulation of fluid in the pericardial sac, and cardiac tamponade, compression of the heart from excessive fluid build-up. MI, cardiac arrest, and TIAs are *not* frequent complications of pericarditis

The client has a HR of 38 bpm. An external pacemaker is prescribed. The nurse plans to:

• *Place pacer electrodes on the front and back of the client's chest* • *Administer pain & sedative meds* (b/c of shock intensity) • *Monitor function of the pacer* (r/t pt's cardiac cycle) Rationale: Immediate goal is to restore HR >60 bpm. The RN will assist the HCP to insert a transvenous pacemaker when prescribed. Placement of internal wires for a pacemaker will be checked with a portable chest x-ray (not by RN).

Immediate Complications of SCI

• *Respiratory arrest* • *Spinal shock* Rationale: Respiratory arrest and spinal shock are the immediate complications of spinal cord injury. Tetraplegia is paralysis of all extremities when there is a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Autonomic dysreflexia is a long-term complication of spinal cord injury.

Which of the following are the *first* symptoms of cardiac tamponade? SAA.

• *SOB* • *Chest tightness* • *Dizziness* • *Restlessness* Rationale: The patient may also have tachycardia. JVD and other signs of rising central venous pressure develop later.

Antidepressants used in TX of AIDS

• *Tofranil* • *Norpramin* • *Prozac* Rationale: Antidepressants such as Tofranil, Norpramin, and Prozac may be used, because these medications also alleviate the fatigue and lethargy that are associated with depression. Megace is an appetite stimulant. Mycelex is used for esophageal or oral candidiasis.

A patient with acute mitral regurgitation should be assessed for the most common initial symptoms. SAA.

• *Weakness* • *Dyspnea* • *Orthopnea* • *Fatigue* Rationale: Palpitations, peripheral edema, and ascites do not occur initially; they occur when the RIGHT ventricle fails.

The nurse is caring for a patient with hyperparathyroidism and observes a calcium level of 16.2 mg/dL. What interventions does the nurse prepare to provide to reduce the calcium level?

• Administration of calcitonin • Intravenous isotonic saline solution in large quantities • Monitoring the patient for fluid overload Rationale: Acute hypercalcemic crisis can occur in patients with hyperparathyroidism with extreme elevation of serum calcium levels. Serum calcium levels greater than 13 mg/dL (3.25 mmol/L) result in neurologic, cardiovascular, and kidney symptoms that can be life threatening (Fischbach & Dunning, 2009). Rapid rehydration with large volumes of IV isotonic saline fluids to maintain urine output of 100 to 150 mL per hour is combined with administration of calcitonin (Shane & Berenson, 2012). Calcitonin promotes renal excretion of excess calcium and reduces bone resorption. The saline infusion should be stopped and a loop diuretic may be needed if the patient develops edema. Dosage and rates of infusion depend on the patient profile. The patient should be monitored carefully for fluid overload.

The client had a triple-lumen central catheter inserted in the right subclavian vein and will now receive total parenteral nutrition (TPN). The nurse includes which of the following in the plan of care?

• Auscultate lung sounds. • Check catheter site q2h • Monitor blood glucose level q6h Rationale: The nurse auscultates lung sounds because a central catheter places the client at risk for pneumothorax. The insertion site needs to be checked usually every 2 hours for infection, leakage, and irritation. Because of the high glucose level in the TPN solution, the client's blood glucose level is checked every 6 hours. The TPN solution is placed on an intravenous pump, not gravity flow, because of the high osmolality of the solution. The IV tubing is changed with every TPN bag or every 24 hours.

Primary immunodeficiencies predispose people to what 3 conditions?

• Cancer • Frequent & severe infections • Autoimmunity

Immunodeficiency disorders are caused by defects or deficiencies in:

• Complement system • B and T lymphocytes • Phagocytic cells

A nurse works in an employee health department of a hospital. She was asked to treat a staff nurse who was exposed to blood from a patient with an HIV infection. The nurse practitioner instituted a PEP protocol that includes which actions?

• Continue HIV meds for 4 weeks postexposure • Initiate postexposure testing after 4 weeks • Finish postexposure testing at 6 months

A patient is having diagnostic testing for suspected hyperthyroidism. Which of the following diagnostics correlate with this endocrine disorder?

• Decrease in serum TSH • Increased T3 • Increased T4 • Increase in radioactive iodine uptake

*Neurogenic shock:* clinical manifestations

• Decreased C.O. • Venous pooling in the extremities • Peripheral vasodilation→ mild hypotension, bradycardia, and warm skin • No sweating (b/c sympathetic activity is blocked)

Actions of *osmotic diuretic mannitol*

• Dehydrates brain tissue • Reduces cerebral edema • Reduces blood viscosity (and hematocrit) • Enhances cerebral blood flow

Examples of *carcinogens*

• Dietary substances • Environmental factors • Viruses • Chemical agents • Defective genes • Medically prescribed interventions

The nurse is providing an educational presentation on dietary recommendations for reducing the risk of cancer. Which of the following food selections would demonstrate a good understanding of the info provided in the presentation?

• Egg white omelet with spinach and mushrooms • Steamed broccoli and carrots • Turkey breast on whole wheat bread Rationale: Foods high in fat and those that are smoked or preserved with salt or nitrates are associated with increased cancer risks. An omelet made of egg whites and vegetables is a healthy low fat selection as are steamed broccoli/carrots and turkey breast on whole grain bread. A salad can be a healthy selection but Caesar salads contain much fat from the dressing and addition of cheeses and fried chicken. Salmon that is not smoked would be a good selection. Quiche usually contains high-fat milk, crème, eggs, and cheese.

When malignant cells are killed (TLS), intracellular contents are released into the bloodstream, which leads to:

• Hyperkalemia • Hyperuricemia • Hyperphosphatemia

In a SCI, neurogenic shock develops due to loss of the ANS functioning below the level of the lesion. Which of the following indicators of neurogenic shock would the nurse expect to find?

• Hypotension • Venous pooling • Tachypnea • Hypothermia Rationale: The vital organs are affected in a spinal cord injury, causing the blood pressure and heart rate to decrease. This loss of sympathetic innervation causes a variety of other clinical manifestations, including a decrease in cardiac output, venous pooling in the extremities, and peripheral vasodilation resulting in mild hypotension, bradycardia, and warm skin. In addition, the patient does not perspire on the paralyzed portions of the body because sympathetic activity is blocked; therefore, close observation is required for early detection of an abrupt onset of fever.

A client in the ICU is experiencing decreased afterload resulting from the use of nitrates for chest pain. What effects on the heart will the client experience? (Select all that apply.)

• Increased stroke volume • Decreased ventricular work • Decreased myocardial oxygen requirements Rationale: The effect on the heart from the use of nitrates, which cause vasodilation and thus decrease afterload, are the 3 listed above.

RN palpates enlarged inguinal lymph nodes on the left. What should the RN document?

• Location • Size • Reports of tenderness • Consistency (Joints are assessed for tenderness, swelling, increased warmth, and limited ROM.)

The nurse is planning the care of a patient with a TBI in the neurosurgical ICU. In developing the plan of care, what interventions should be a priority?

• Making nursing assessments • Setting priorities for nursing interventions • Anticipating needs and complications • Initiating rehabilitation

Actions of chemical mediators

• Minimize blood loss • Walling off the pathogen • Activating phagocytes • Promoting formation of fibrous scar tissue • Regeneration of scar tissue

When a patient takes vincristine, an antineoplastic agent that inhibits DNA and protein synthesis, the patient needs to be informed that he should report which of the following symptoms that would be an expected side-effect of motor neuropathy?

• Muscle weakness • Cramps and spasms in the legs • Loss of balance and coordination (Burning and tingling sensations are signs of SENSORY nerve damage.)

Acute diabetes insipidus is associated with significantly increased mortality. What clinical manifestations should the nurse be alert to?

• Nocturia • Urine specific gravity of 1.003 • Large amounts of dilute urine • Dry mucous membranes Rationale: Without the action of antidiuretic hormone (ADH) on the distal nephron of the kidney, an enormous daily output of very dilute urine (3 to 20 L) with nocturia, frequency, and a specific gravity of 1.001 to 1.005 occur. Dry mucous membranes occur due to fluid volume deficit.

Meningitis -- expected clinical manifestations

• Photophobia • Positive Kernig's sign • Positive Brudzinski's sign • Nuchal rigidity *May have fever*

The nurse is caring for a client who is receiving mechanical ventilation. The physician is increasing the PEEP from 5 cm H2O to 7 cm H20. What complications from this level may arise?

• Pneumothorax • Alveolar rupture • Decreased C.O. Rationale: Levels of PEEP above 5cm H2O put the client at risk for alveolar rupture, pneumothorax, and decreased cardiac output via referred pressure counteracting forward blood flow from the heart. The *ventilator-induced damage*= *barotrauma.*

Late signs of RICP

• Projectile vomiting • Hemiplegia • Loss of brainstem reflexes • Decreased RR • Altered resp. patterns (Cheyne-Stokes breathing) Early signs-- purposeless movement, H/A, restlessness, pupil changes

Nursing Interventions to Prevent UTI

• Remove the urinary catheter within 48 hours. • Cleanse the catheter with soap and water after each BM. • Use leg strap to anchor catheter to leg Rationale: Empty bag MORE frequently than q12h. RN maintains a CLOSED system even when obtaining urine specimen.

An older adult patient who is postmenopausal informs the nurse that she believes she has developed another urinary tract infection (UTI). The nurse understands that postmenopausal females are at greater risk for UTIs. What risk factors do female patients in this age group have? SAA.

• Residual urine • Urinary incontinence • Estrogen deficiency

A patient with a recent diagnosis of HIV infection has expressed to the nurse that he is motivated to learn as much about his disease as possible. The patient has heard and read about the role of the different T cells, but is unclear of their roles in the immune response. Which of the following roles of T cells should the nurse identify? SAA.

• Stimulating the immune system • Secreting cytokines • Directly attacking antigens • Activating other T cells T cells do NOT produce antibodies.

Nursing action for extravasation of a chemo agent would include which of the following nursing actions? Select all that apply.

• Stop the medication infusion at the first sign of extravasation • Aspirate any residual drug from the IV line • Administer an antidote, if indicated (NOT- the application of warmth would be contraindicated b/c it would cause vasodilation, which would increase the absorption of irritant into the local tissues)

*HIV:* routes of transmission

• The risk of acquiring HIV through the transfusion of blood products is almost nonexistent. • The amount of HIV contained in body fluids on exposure is associated with the risk for infection. • HIV can be found in seminal fluid, vaginal secretions, and breast milk. • Sharing of infected equipment used to inject drugs increases the risk for infection. *Rationale:* HIV-1 is transmitted in body fluids that contain free virons and infected CD+4 T cells. These fluids include blood, seminal fluid, vaginal secretions, amniotic fluid, and breast milk. The amount of HIV and infected cells in the body fluid is associated with the probability that the exposure will result in infection. Blood and blood products can transmit HIV to recipients; however, the risk associated with transfusions have been virtually eliminated as the result of intensive donor screening. Mother-to-child transmission may occur in utero, at the time of delivery, or through breastfeeding. Most perinatal infections are thought to occur during delivery. Sharing infected equipment during drug injections increases a person's risk for acquiring HIV.

*SIADH:* lab values

• hyponatremia (serum sodium <134 mEq/L) • decreased serum osmolality (<280 mOsm/kg) • increased urine osmolality (>800 mOsm/kg) • urinary sodium of over 20 mEq/L

In the interest of public health, the CDC has developed HIV Transmission Prevention strategies. The strategies address the routes by which HIV can be transmitted and steps that can be taken to reduce or eliminate transmission. Which categories of risk are addressed by these strategies? Select all that apply.

• illegal drugs • sexual activity

In differentiating between benign and malignant cells, what characteristics would you cite?

• method and rate of growth • ability to metastasize or spread • general effects • destruction of tissue • ability to cause death