Advanced Med Surg. Exam 2 - practice questions

For stage I and II of most head and neck cancers, what treatment would the nurse generally anticipate?

•Stage I & II - radiation - external beam or brachytherapy (implanted iridium seeds) (Stage III & IV - surgery, radiation and chemotherapy)

Head and neck cancer risk factors

50 - 60 year old more common in men than women Tobacco, excessive alcohol, exposure to carcinogens, HPV

No AKI and CKD on this exam!

:)

A patient with a history of type 1 diabetes and an eating disorder is found unconscious. In the emergency department, the following lab values are obtained: Glucose: 648 mg/dL pH: 6.88 PaCO2: 20 mm Hg PaO2: 95 mm Hg HCO3¯: undetectable Anion gap: >31 Na+: 127 mEq/L K+: 3.5 mEq/L Creatinine: 1.8 mg/dL After the patient's airway and ventilation have been established, the next priority for this patient is: a. administration of a 1-L normal saline fluid bolus. b. administration of 0.1 unit of regular insulin IV push followed by an insulin infusion. c. administration of 20 mEq KCl in 100 mL. d. IV push administration of 1 amp of sodium bicarbonate.

A After airway is established, the next priority in management of DKA is fluid resuscitation with 1 liter of normal saline over 1 hour. The fluid resuscitation should begin before administration of insulin.

The patient with acute respiratory distress syndrome (ARDS) would exhibit which of the following symptoms? a. Decreasing PaO2 levels despite increased FiO2 administration b. Elevated alveolar surfactant levels c. Increased lung compliance with increased FiO2 administration d. Respiratory acidosis associated with hyperventilation

A Patients with ARDS often have hypoxemia refractory to treatment. Surfactant levels are often diminished in ARDS. Compliance decreases in ARDS. In early ARDS, hyperventilation may occur along with respiratory alkalosis.

Which of the following is a high-priority nursing diagnosis for both diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome? a. Activity intolerance b. Fluid volume deficient c. Hyperthermia d. Impaired nutrition, more than body requirements

B Both diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome result in dehydration and hypovolemia; so fluid volume deficit is a priority nursing diagnosis.

The nurse assesses a patient who is admitted for an overdose of sedatives. The nurse expects to find which acid-base alteration? a. Hyperventilation and respiratory acidosis b. Hypoventilation and respiratory acidosis c. Hypoventilation and respiratory alkalosis d. Respiratory acidosis and normal oxygen levels

B Hypoventilation is common after overdose and results in impaired elimination of carbon dioxide and respiratory acidosis.

An acute exacerbation of asthma is treated with which of the following? a. Corticosteroids and theophylline by mouth b. Inhaled bronchodilators and intravenous corticosteroids c. Prone positioning or continuous lateral rotation d. Sedation and inhaled bronchodilators

B Inhaled bronchodilators and intravenous corticosteroids are standard treatment for the exacerbation of asthma; they promote dilation of the bronchioles and decreased inflammation of the airways. Proning and continuous lateral rotation are therapies to treat hypoxemia secondary to acute respiratory distress syndrome. Sedation is not recommended.

The nurse has just completed an infusion of a 1000 mL bolus of 0.9% normal saline in a patient with severe sepsis. One hour later, which laboratory result requires immediate nursing action? a. Creatinine 1.0 mg/dL b. Lactate 6 mmol/L c. Potassium 3.8 mEq/L d. Sodium 140 mEq/L

B: Lactate level has been used as an indicator of decreased oxygen delivery to the cells, adequacy of resuscitation in shock, and as an outcome predictor Other values are normal

A patient with type 1 diabetes who is receiving a continuous subcutaneous insulin infusion via an insulin pump contacts the clinic to report mechanical failure of the infusion pump. The nurse instructs the patient to begin monitoring for signs of: a. adrenal insufficiency. b. diabetic ketoacidosis. c. hyperosmolar, hyperglycemic state. d. hypoglycemia.

B: Hyperosmolar, hyperglycemic state is a hyperglycemic complication associated with type 2 diabetes; this patient has type 1 diabetes

The basic underlying pathophysiology of acute respiratory distress syndrome results in a. a decrease in the number of white blood cells available. b. damage to the right mainstem bronchus. c. damage to the type II pneumocytes, which produce surfactant. d. decreased capillary permeability.

C Acute respiratory distress syndrome results in damage to the pneumocytes, increased capillary permeability, and noncardiogenic pulmonary edema.

Which of the following acid-base disturbances commonly occurs with the hyperventilation and impaired gas exchange seen in severe exacerbation of asthma? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

C Although the patient with a severe exacerbation of asthma hyperventilates, gas exchange is impaired, which causes respiratory acidosis.

The nurse is assigned to care for a patient who presented to the emergency department with diabetic ketoacidosis. A continuous insulin intravenous infusion is started, and hourly bedside glucose monitoring is ordered. The targeted blood glucose value after the first hour of therapy is a. 70 to 120 mg/dL. b. a decrease of 25 to 50 mg/dL compared with admitting values. c. a decrease of 35 to 90 mg/dL compared with admitting values. d. less than 200 mg/dL.

C Initial insulin infusions should be administered with a target blood glucose reduction of 35 to 90 mg/dL per hour. Decreases of less than this rate may be associated with inadequate insulin replacement and allow for the persistence of the ketotic state. Rapid reductions of blood glucose may precipitate life-threatening cerebral edema; thus, controlled reduction of glucose is required.

A patient presents to the emergency department in acute respiratory failure secondary to community-acquired pneumonia. The patient has a history of chronic obstructive pulmonary disease. The nurse anticipates which treatment to facilitate ventilation? a. Emergency tracheostomy and mechanical ventilation b. Mechanical ventilation via an endotracheal tube c. Noninvasive positive-pressure ventilation (NPPV) d. Oxygen at 100% via bag-valve-mask device

C Noninvasive measures are often recommended in the initial treatment of the patient with chronic obstructive pulmonary disease to prevent intubation and ventilator dependence. The history of chronic obstructive pulmonary disease increases the risk for ventilator dependence, so noninvasive options are a priority. Bag-valve ventilation with 100% oxygen is not required at this time and could depress the respiratory drive that exists. Emergency tracheostomy is not indicated, as there is no indication of an obstructed airway.

A patient is admitted to the critical care unit with a diagnosis of diabetic ketoacidosis. Following aggressive fluid resuscitation and intravenous (IV) insulin administration, the blood glucose begins to normalize. In addition to glucose monitoring, which of the following electrolytes requires close monitoring? a. Calcium b. Chloride c. Potassium d. Sodium

C Potassium must be closely monitored. In the early stages of diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome, the potassium value is often high, but it may lower to critical levels once fluid balance has been restored and glucose has returned to more normal levels. Insulin administration used in the treatment of diabetic ketoacidosis further promotes the lowering of potassium as the electrolyte is relocated to the cellular bed.

Intrapulmonary shunting refers to: a. alveoli that are not perfused. b. blood that is shunted from the left side of the heart to the right and causes heart failure. c. blood that is shunted from the right side of the heart to the left without oxygenation. d. shunting of blood supply to only one lung.

C Shunting refers to blood that is not oxygenated in the lungs.

Which of the following laboratory values would be more common in patients with diabetic ketoacidosis? a. Blood glucose >1000 mg/dL b. Negative ketones in the urine c. Normal anion gap d. pH 7.24

D A pH of 7.24 is indicative of an acidotic state that may accompany diabetic ketoacidosis. Glucose values of more than 1000 mg/dL are more commonly associated with hyperosmolar hyperglycemic syndrome. Diabetic ketoacidosis is associated with positive urine ketones and an increased anion gap.

In the management of diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome, when is an intravenous (IV) solution that contains dextrose started? a. Never; normal saline is the only appropriate solution in diabetes management b. When the blood sugar reaches 70 mg/dL c. When the blood sugar reaches 150 mg/dL d. When the blood glucose reaches 250 mg/dL

D Normal saline is the best initial fluid choice for management of hyperglycemic states. However, when the glucose reaches about 250 mg/dL, solutions containing dextrose are added to prevent hypoglycemia.

1. The nurse is caring for a patient with acute respiratory failure and identifies "Risk for Ineffective Airway Clearance" as a nursing diagnosis. A nursing intervention relevant to this diagnosis is to a. elevate the head of the bed to 30 degrees. b. obtain an order for venous thromboembolism prophylaxis. c. provide adequate sedation. d. reposition the patient every 2 hours.

D Repositioning the patient will facilitate mobilization of secretions. Elevating the head of bed is an intervention to prevent infection. Venous thromboembolism prophylaxis is ordered to prevent complications of immobility. Sedation is an intervention to manage anxiety, and administration of sedatives increases the risk for retained secretions.

Tracheotomy vs. Tracheostomy

Tracheotomy: Surgical incision into the trachea to establish an airway Tracheostomy: Stoma that results from the tracheotomy

What should the nurse keep at the bedside when caring for a tracheostomy patient? (think risk of accidental dislodgment)

Tube of equal or smaller size is kept at bedside for emergency reinsertion!!!

Can a patient with a temporary trach speak? If so, how?

Yes, but it is difficult & takes practice. Speech requires air to pass over vocal cords. Tracheostomy tubes and valves have been designed to facilitate speech (called fenestrated trachs). Spontaneously breathing patients may be able to talk by deflating cuff, allowing exhaled air to flow over vocal cords. Speech therapy usually helps too.

The nurse is caring for a patient admitted with hypovolemic shock. The nurse palpates thready brachial pulses but is unable to auscultate a blood pressure. What is the best nursing action? a. Assess the blood pressure by Doppler. b. Estimate the systolic pressure as 60 mm Hg. c. Obtain an electronic blood pressure monitor. d. Record the blood pressure as "not assessable."

a. Assess the blood pressure by Doppler. Auscultated blood pressures in shock may be significantly inaccurate due to vasoconstriction. If blood pressure is not audible, the approximate value can be assessed by palpation or ultrasound. If brachial pulses are palpable, the approximate measure of systolic blood pressure is 80 mm Hg. This action has the potential to delay further assessment of a compromised patient in shock. Documenting a blood pressure as not assessable is inappropriate without further attempts using different modalities.

While monitoring a patient for signs of shock, the nurse understands which system assessment to be of priority? a. Central nervous system b. Gastrointestinal system c. Renal system d. Respiratory system

a. Central nervous system Question is asking which shows signs of shock first, so it is CNS rather than respiratory

The nurse is caring for a patient admitted with cardiogenic shock. Hemodynamic readings obtained with a pulmonary artery catheter include a pulmonary artery occlusion pressure (PAOP) of 18 mm Hg and a cardiac index (CI) of 1.0 L/min/m2. What is the priority pharmacological intervention? a. Dobutamine b. Furosemide c. Phenylephrine d. Sodium nitroprusside

a. Dobutamine A high PAOP and a low cardiac index are findings consistent with cardiogenic shock. Positive inotropic agents (e.g., dobutamine) are given to increase the contractile force of the heart. As contractility increases, cardiac output and index increase and improve tissue perfusion.

A patient is admitted to the cardiac care unit with an acute anterior myocardial infarction. The nurse assesses the patient to be diaphoretic and tachypneic, with bilateral crackles throughout both lung fields. Following insertion of a pulmonary artery catheter by the physician, which hemodynamic values is the nurse most likely to assess? a. High pulmonary artery diastolic pressure and low cardiac output b. Low pulmonary artery occlusive pressure and low cardiac output c. Low systemic vascular resistance and high cardiac output d. Normal cardiac output and low systemic vascular resistance

a. High pulmonary artery diastolic pressure and low cardiac output

Ten minutes following administration of an antibiotic, the nurse assesses a patient to have edematous lips, hoarseness, and expiratory stridor. Vital signs assessed by the nurse include blood pressure 70/40 mm Hg, heart rate 130 beats/min, and respirations 36 breaths/min. What is the priority intervention? a. Diphenhydramine 50 mg intravenously b. Epinephrine 3 to 5 mL of a 1:10,000 solution intravenously c. Methylprednisolone 125 mg intravenously d. Ranitidine 50 mg intravenously

b. Epinephrine 3 to 5 mL of a 1:10,000 solution intravenously Pt showing signs of anaphylactic shock WITH HYPOTENSION! (Corticosteroids, such as methylprednisolone, are used to reduce inflammation, but epinephrine is the drug of choice for anaphylaxis with hypotension. Ranitidine will help block histamine release, but epinephrine is the drug of choice for anaphylaxis with hypotension.)

When fluid is present in the alveoli, a. alveoli collapse, and atelectasis occurs. b. diffusion of oxygen and carbon dioxide is impaired. c. hypoventilation occurs. d. the patient is in heart failure.

b. diffusion of oxygen and carbon dioxide is impaired.

Which patient being cared for in the emergency department is most at risk for developing hypovolemic shock? a. A patient admitted with abdominal pain and an elevated white blood cell count b. A patient with a temperature of 102° F and a general dermal rash c. A patient with a 2-day history of nausea, vomiting, and diarrhea d. A patient with slight rectal bleeding from inflamed hemorrhoids

c. A patient with a 2-day history of nausea, vomiting, and diarrhea

A patient is admitted after collapsing at the end of a summer marathon. The patient is lethargic, with a heart rate of 110 beats/min, respiratory rate of 30 breaths/min, and a blood pressure of 78/46 mm Hg. The nurse anticipates administering which therapeutic intervention? a. Human albumin infusion b. Hypotonic saline solution c. Lactated Ringer's bolus d. Packed red blood cells

c. Lactated Ringer's bolus The patient is experiencing symptoms of hypovolemic shock. Isotonic crystalloids, such as normal saline and lactated Ringer's solutions, are the priority intervention.

The nurse is caring for a patient with acute respiratory distress syndrome who is hypoxemic despite mechanical ventilation. The provider prescribes a nontraditional ventilator mode as part of treatment. Despite sedation and analgesia, the patient remains restless and appears to be in discomfort. The nurse informs the provider of this assessment and anticipates an order for a. continuous lateral rotation therapy. b. guided imagery. c. neuromuscular blockade. d. prone positioning.

c. neuromuscular blockade. Guided imagery is an excellent nonpharmacological approach to manage anxiety; however, the nontraditional mode of ventilation usually requires that the patient receive neuromuscular blockade. Lateral rotation is not a mode of ventilation; it is used as part of a progressive mobility program for critically ill patients.

Which of the following patients is at the highest risk for hyperosmolar hyperglycemic syndrome? a. An 18-year-old college student with type 1 diabetes who exercises excessively b. A 45-year-old woman with type 1 diabetes who forgets to take her insulin in the morning c. A 75-year-old man with type 2 diabetes and coronary artery disease who has recently started on insulin injections d. An 83-year-old, long-term care resident with type 2 diabetes and advanced Alzheimer's disease who recently developed influenza

d. An 83-year-old, long-term care resident with type 2 diabetes and advanced Alzheimer's disease who recently developed influenza C is at risk for HYPOglycemia, A and B are type 1, not type 2 diabetes

In hyperosmolar hyperglycemic syndrome, the laboratory results are similar to those of diabetic ketoacidosis, with three major exceptions. What differences would you expect to see in patients with hyperosmolar hyperglycemic syndrome? a. Lower serum glucose, lower osmolality, and greater ketosis b. Lower serum glucose, lower osmolality, and milder ketosis c. Higher serum glucose, higher osmolality, and greater ketosis d. Higher serum glucose, higher osmolality, and no ketosis

d. Higher serum glucose, higher osmolality, and no ketosis

During the initial stages of shock, what are the physiological effects of decreased cardiac output? a. Arterial vasodilation b. High urine output c. Increased parasympathetic stimulation d. Increased sympathetic stimulation

d. Increased sympathetic stimulation

The nurse is caring for a patient in the early stages of septic shock. The patient is slightly confused and flushed, with bounding peripheral pulses. Which hemodynamic values is the nurse most likely to assess? a. High pulmonary artery occlusive pressure and high cardiac output b. High systemic vascular resistance and low cardiac output c. Low pulmonary artery occlusive pressure and low cardiac output d. Low systemic vascular resistance and high cardiac output

d. Low systemic vascular resistance and high cardiac output

The nurse has been administering 0.9% normal saline intravenous fluids in a patient with severe sepsis. To evaluate the effectiveness of fluid therapy, which physiological parameters would be most important for the nurse to assess? a. Breath sounds and capillary refill b. Blood pressure and oral temperature c. Oral temperature and capillary refill d. Right atrial pressure and urine output

d. Right atrial pressure and urine output

A patient is admitted to the critical care unit following coronary artery bypass surgery. Two hours postoperatively, the nurse assesses the following information: pulse is 120 beats/min; blood pressure is 70/50 mm Hg; pulmonary artery diastolic pressure is 2 mm Hg; cardiac output is 4 L/min; urine output is 250 mL/hr; chest drainage is 200 mL/hr. What is the best interpretation by the nurse? a. The assessed values are within normal limits. b. The patient is at risk for developing cardiogenic shock. c. The patient is at risk for developing fluid volume overload. d. The patient is at risk for developing hypovolemic shock.

d. The patient is at risk for developing hypovolemic shock. The patient is at risk for hypovolemia, not volume overload, as evidenced by excessive hourly chest drainage and urine output.

Which of the following statements is true about the medical management of diabetic ketoacidosis? a. Serum lactate levels are used to guide insulin administration. b. Sodium bicarbonate is a first-line medication for treatment. c. The degree of acidosis is assessed through continuous pulse oximetry. d. Volume replacement and insulin infusion often correct the acidosis.

d. Volume replacement and insulin infusion often correct the acidosis.

In assessing a patient, the nurse understands that an early sign of hypoxemia is a. clubbing of nail beds. b. cyanosis. c. hypotension. d. restlessness.

d. restlessness. Central nervous system signs, such as restlessness, are early indications of low oxygen levels.

The nurse is caring for a patient admitted with severe sepsis. Vital signs assessed by the nurse include blood pressure 80/50 mm Hg, heart rate 120 beats/min, respirations 28 breaths/min, oral temperature of 102° F, and a right atrial pressure (RAP) of 1 mm Hg. Which intervention should the nurse carry out first? a. Acetaminophen suppository b. Blood cultures from two sites c. IV antibiotic administration d. Isotonic fluid challenge

d. Isotonic fluid challenge

Mrs H. has been diagnosed with laryngeal cancer and decides to go ahead with the total laryngectomy. She wants to know how this will effect her speech.

laryngectomy = vocal cords removed, however she will be able to learn a new method of speech / communication with speech therapist (but will not be the same as her normal speech)