Cares 3 Practice Q's

What is ventricular tachycardia treated with?

Amiodarone For ventricular tachycardia with a pulse, it is a first-line drug Pulseless, defibrillate

Which of the following characteristics do NOT indicate normal perfusion? Heart rate of 140 Cardiac Output of 5 L/min Normal Heart Sounds Sinus Rhythm Capillary Refill of 2 seconds

Heart rate of 140

Which medication classification is the highest priority for administration when caring for a patient with Ineffective Perfusion as a result of Septic Shock? Corticosteroids Vasopressors Beta-adrenergic blocking agent Vasodilators

Vasopressors

a nurse is caring for a client who has valvular heart disease and is at risk for developing right-sided heart failure. which of the following manifestations should alert the nurse the client is developing this condition?

anorexia, nausea, weight gain, edema, ascites, distended abdomen

a nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a high CVP pressure should the nurse make?

fluid overload Rationale: The CVP is the pressure in the vena cava, or right atrium, and is reflective of preload. A client who has fluid overload would have a high CVP value.

conditions that can lead to respiratory alkalosis pH >7.45, PaCO2 <35, HCO3 22-26

hyperventilation

a nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP pressure should the nurse make?

hypovolemia Rationale: A low CVP indicates reduced right ventricular preload, which can be seen in clients who are experiencing hypovolemia, excessive blood loss, or overdiuresis.

conditions that can lead to metabolic acidosis pH <7.35, PaCO2 35-45, HCO3 <22

ketoacidosis

What is CVP a good indicator for? (select all that apply) Afterload Preload Stroke volume Cardiac Index

mainly preload

a nurse is assessing a client who has a pneumothorax with a chest tube in place. which of the following findings should the nurse notify the provider?

movement of the trachea toward the unaffected side rationale: A chest tube inserted for a spontaneous pneumothorax may result in the development of a tension pneumothorax, a medical emergency. An assessment of tracheal deviation is indicative of tension pneumothorax

a nurse is caring for a client who has a chest tube in place to a closed chest drainage system. which of the following findings should indicate to the nurse that the client's lung has re-expanded?

no fluctuations in the water seal chamber rationale: Fluctuation stops when the lung has re-expanded, but the nurse should check for other indications of re-expansion, such as equal breath sounds bilaterally, because fluctuation can also stop when the tubing is obstructed, a dependent loop hangs below the rest of the tubing, or the suction source is not functioning.

conditions that can lead to metabolic alkalosis pH >7.45, PaCO2 35-45, HCO3 >26

persistent vomiting

How does Ventricular Tachycardia present?

rapid rhythm with a widened QRS and no corresponding P waves.

a nurse is monitoring a client who has a chest tube in place connected to a wall suction due to a R-sided pneumothorax. the client complains of chest burning. which of the following actions should the nurse take?

reposition the client

a nurse is reviewing the arterial blood gas values for a client. the pH is 7.32, PaCO2 48, HCO3 is 23. the nurse should recognize as which acid-base balance?

respiratory acidosis pH <7.35, PaCO2 >45, HCO3 22-26 (normal)

Which Stage of Shock is the patient in when we see Multiple Organ Dysfunction Syndrome (MODS)? Initial Compensatory Progressive Refractory

Progressive

After receiving change-of-shift report on a medical unit, which patient should the nurse assess first?

A patient with septicemia who has intercostal and suprasternal retractions

A patient with severe chronic lung disease is hospitalized with respiratory distress. Which finding would suggest to the nurse that the patient has developed rapid decompensation?

Agitation or confusion Rationale: It is especially important to monitor specific and nonspecific signs of respiratory failure in patients with chronic lung disease because a small change can cause significant decompensation. Immediately report any change in mental status, such as agitation, combative behavior, confusion, or decreased level of consciousness.

The nurse is concerned about a postoperative patient's risk of injury during an episode of delirium. The most appropriate action by the nurse is to: Secure the patient in bed using a soft chest restraint. Ask the health care provider to order an antipsychotic drug. Instruct family members to remain at the patient's bedside and prevent injury. Assign unlicensed assistive personnel (UAP) to stay with and reorient the patient.

Assign unlicensed assistive personnel (UAP) to stay with and reorient the patient.

a nurse in an urgent care assesses a client who reports sudden onset of irregular palpitations, fatigue, and dizziness. the nurse finds a rapid and irregular HR with a sig. pulse deficit. which of the following dysrhythmias should the nurse expect to find on the EKG?

Atrial fibrillation Rationale: causes disorganized twitching of the atrial muscles. the rate is irregular with no visible P waves. the ventricular response is irregular which results in an irregular pulse and pulse deficit.

a nurse is caring for a client who is in the compensatory (non-progressive) stage of shock. which of the following findings should the nurse expect? mottled skin (progressive stage) BP 115/68 HR 160/min Hypokalemia

BP 115/68 others: hyperkalemia, skin is cool, pale, diaphoretic

conditions that can lead to respiratory acidosis

COPD and pneumonia

Which of the following is true about disseminated intravascular coagulation? Characterized by both thrombosis and bleeding Most commonly caused by hereditary clotting disorders Initiated by atherosclerosis Accompanied by a low mortality rate

Characterized by both thrombosis and bleeding

A patient who has been in the ICU for 4 days has disturbed sensory perception from sleep deprivation. Which action should the nurse include in the plan of care? Administer prescribed sedatives or opioids at bedtime to promote sleep. Cluster nursing activities so that the patient has uninterrupted rest periods. Silence the alarms on the cardiac monitors to allow 30-40 minute naps. Eliminate assessments between 2200 and 0600 to allow uninterrupted sleep.

Cluster nursing activities so that the patient has uninterrupted rest periods.

What information can you obtain from an arterial line? Continuous blood pressure monitoring Venous blood gases ECG monitoring Continuous oximetry

Continuous blood pressure monitoring

Which of the following characteristics do NOT indicate normal gas exchange? Respiratory rate of 16 Chest x-ray with no abnormalities Hemoglobin of 13.2 gm/dL Oxygen saturation of 93% Crackles on lung auscultation

Crackles on lung auscultation

The nurse is caring for a patient with severe sepsis. Vital signs assessed by the nurse include BP 88/60 mm Hg, HR 145 beats/min, RR 28 breaths/min, temperature 101° F, CVP 1 mm Hg, and SpO2 94% on 3 L/cannula. Which physician order should the nurse initiate first? A. Bedside glucose every 4 hours B. Tylenol 650 mg PR for temp > 101° C. Urine culture and sensitivity D. 500 mL bolus of 0.9% normal saline

D. 500 mL bolus of 0.9% normal saline

a nurse is reviewing lab values for a client who is at risk for DIC. which of the following values should the nurse report to the provider?

Fibrinogen 85 (low)

A 40-year-old male presents to triage with vague, midsternal chest discomfort, occurring intermittently for one month. This morning, he reports a similar episode, which has now resolved. Currently complains of mild nausea, but feels pretty good. Medical history: Smoker. He is alert, with skin warm and dry, does not appear to be in any distress. What ESI level is this?

ESI level 2. This patient is high-risk, due to history of angina for 1 month. The patient complained of symptoms of acute coronary syndrome earlier in the morning. Smoking is a significant risk factor; however, the patient presentation is concerning enough to be considered high risk. These are symptoms significant for a potential cardiac ischemic event. Acute myocardial infarction is frequently accompanied or preceded by waxing and waning symptoms. An immediate electrocardiogram is necessary.

What is happening to the left atrium in MVS?

Excess blood volume is staying in the left atrium causing increased pressure in the left atrium. That blood volume backs from the left atrium to the pulmonary vasculature.

First degree AV block

First-degree AV block is a regular rhythm with a prolonged P-R interval. A pulse deficit does not occur.

Which of the following statements is correct regarding Heparin administration for DIC? Heparin should never be ordered for a patient in DIC. Heparin would be ordered to prevent the abnormal clotting in capillaries and arterioles. Heparin would be ordered to prevent excessive bleeding in a patient with DIC. Heparin would only be ordered for a patient with chronic DIC from a malignancy.

Heparin would be ordered to prevent the abnormal clotting in capillaries and arterioles.

A patient's ABG results include pH 7.31, Paco2 50 mm Hg, Pao2 51 mm Hg, and HCO3 24 mEq/L. Oxygen is administered at 2 L/min, and the patient is placed in high-Fowler's position. An hour later, the ABGs are repeated with results of pH 7.36, Paco2 40 mm Hg, Pao2 60 mm Hg, and HCO3 24 mEq/L. What is most important for the nurse to do?

Increase the oxygen flow rate to 4 L/min Rationale: The initial arterial blood gas (ABG) report indicates partially compensated respiratory acidosis with moderate hypoxemia. The next ABG results indicate improvement, but the hypoxemia continues (Pao2 remains low). The patient should receive a higher concentration of oxygen to treat hypoxemia.

is crepitus in the area above and surrounding the insertion site of a chest tube with pneumothorax an expected finding?

It can be an expected finding in the client who has a pneumothorax and will persist for several hours following evacuation of the pneumothorax

A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a right pneumothorax. Which collaborative action will the nurse anticipate next?

Lower the positive end-expiratory pressure (PEEP) Rationale: Because barotrauma is associated with high airway pressures, the level of PEEP should be decreased. The other actions will not decrease the risk for another pneumothorax.

A nurse is caring for a patient with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation using synchronized intermittent mandatory ventilation (SIMV). The settings include fraction of inspired oxygen (FiO2) of 80%, tidal volume of 450, rate of 16/minute, and positive end-expiratory pressure (PEEP) of 5 cm. Which assessment finding is most important for the nurse to report to the health care provider?

O2 saturation of 100% Rationale: The FiO2 of 80% increases the risk of O2 toxicity. Because the patient's O2 sat is 100%, a decrease in FiO2 is indicated to avoid toxicity.

A patient is admitted with a chest wound and experiencing extreme dyspnea, tachycardia, and hypoxia. The chest wound is located on the left mid-axillary area of the chest. On assessment, you note there is unequal rise and fall of the chest with absent breath sounds on the left side. You also note a "sucking" sound when the patient inhales and exhales. The patient's chest x-ray shows a pneumothorax. What type of pneumothorax is this known as

Open Pneumothorax Rationale: This description is of an open pneumothorax. An open pneumothorax happens when there is an opening in the chest wall ( from a gun shot, stabbing etc.) that creates a passage between the outside air and intrapleural space. This allow air to pass back and forth during inspiration and expiration. The body will shunt air through the opening in the chest well instead of the trachea (if the opening on the chest is large enough) which will create a "sucking" sound.

A patient is admitted with a chest wound and experiencing extreme dyspnea, tachycardia, and hypoxia. The chest wound is located on the left mid-axillary area of the chest. On assessment, you note there is unequal rise and fall of the chest with absent breath sounds on the left side. You also note a "sucking" sound when the patient inhales and exhales. The patient's chest x-ray shows a pneumothorax. Which of the following options below is a nursing intervention you would provide to this patient?

Place a sterile occlusive dressing over the chest wound and tape it on three sides Rationale: The nursing intervention would be to place a sterile occlusive dressing over the wound and tape it on 3 sides (leaving one side NOT taped). This will allow exhaled air to leave the opening but seal over the opening when inhaling (hence not letting pressure build in the intrapleural space and prevent a tension pneumothorax).

a nurse is planning care for a client who has ARDS. which of the following interventions should the nurse include in the plan?

Place in a prone position

Which of the following conditions is not a common complication seen with disseminated intravascular coagulation (DIC)? Hemorrhage Multi-organ dysfunction (MODS) Clotting Retinitis

Retinitis

Sinus bradycardia

Sinus bradycardia is a slow heart rate with a regular rhythm. Therefore, a pulse deficit does not occur.

Sinus tachycardia

Sinus tachycardia is a rapid heart rate with a regular rhythm. Therefore, a pulse deficit does not occur.

Which action is the highest priority action for the nurse when caring for a patient with ineffective Gas Exchange? Supplemental O2 Obtain a chest x-ray Obtain an ABG Administer a corticosteroid

Supplemental O2

What is happening to the valve during Aortic Valve Regurgitation (AVR)?

The aortic valve does not close completely and allows backward flow of blood into the left ventricle.

a nurse is caring for a group of older adult clients. which of the following manifestations indicates one of the clients is experiencing delirium?

a client attempts to climb out of bed and repeatedly states she must get home.

a nurse is teaching a client who has a family hx of hemophilia A about manifestations of the disorder. the nurse should include which of the following manifestations in the teaching?

disabling joint pain

Emergency Severity Index (ESI) Triage Levels

▪Level 1- requires immediate life-saving interventions ▪Level 2 - high risk situation, confused/disoriented, severe pain or distress ▪Level 3 - many resources are needed ▪Level 4 - one or more resource needed ▪Level 5 - no resources are needed Escalate to higher level (uptriage) if in danger zone category

The nurse admits a 35-year-old patient to the emergency department following a 3-day history of nausea and vomiting. Vital signs assessed by the nurse include a BP of 70/50 mm Hg, HR 145 beats/min, RR 36 breaths/min, and SpO2 of 92% on room air. The nurse recognizes which classification of shock? A.Cardiogenic B.Anaphylactic C.Obstructive D. Hypovolemic

D. Hypovolemic

A 22-year-old female with 10/10 abdominal pain for two days. Denies nausea, vomiting, diarrhea, or urinary frequency. Her heart rate is 84 and she is eating ice cream. What ESI level is this?

ESI level 3. Since she is able to eat ice cream, you would not give your last open bed for this patient. She will probably require at least two resources.

What are complications associated with invasive lines (central line, arterial line, pulmonary artery catheter)? (Select all that apply) Tachycardia Infection Hemorrhage Thrombus formation

Infection Hemorrhage Thrombus formation

a nurse is monitoring a client who is on telemetry. which of the following findings on the EKG strip should the nurse recognize as a normal sinus rhythm?

The P wave falls before the QRS complex Rationale: The nurse should recognize that in normal sinus rhythm the P wave, representing atrial depolarization, falls before the QRS wave. others: T wave is upright position, P-R interval is 0.12-.20 s, QRS duration is <.12s

What is happening to the valve during Aortic Valve Stenosis (AVS)?

The aortic valve opening is narrowed or stiffened and restricts forward blood flow from the left ventricle to the aorta.

What is afterload? The amount of arterial pressure necessary to maintain adequate perfusion of vital organs The volume within the ventricle at the end of diastole The forces opposing ventricular ejection Is the resistance of the systemic vascular bed

The forces opposing ventricular ejection

What is happening to the valve during Mitral Valve Regurgitation (MVR)?

The mitral valve does not close completely and allows backward flow of blood into the left atrium.

Pathophysiology of Mitral Valve Prolapse?

The mitral valve leaflets and the papillary muscles that allows the leaflets to prolapse, or buckle, back into the left atrium during systole.

What is happening to the valve during Mitral Valve Stenosis (MVS)?

The mitral valve opening is narrowed or stiffened and restricts forward blood flow into the next chamber.

A patient who is hospitalized with pneumonia is disoriented and confused 3 days after admission. Which information indicates that the patient is experiencing delirium rather than dementia? The patient was oriented and alert when admitted. The patient's speech is fragmented and incoherent. The patient is oriented to person but disoriented to place and time. The patient as a history of increasing confusion over several years.

The patient was oriented and alert when admitted.

What is preload? The volume within the ventricle at the end of diastole A necessary component to calculate cardiac output The volume ejected with each heartbeat The forces opposing ventricular ejection

The volume within the ventricle at the end of diastole

Why is it important to zero an arterial line? To ensure the arterial line is still indicated To reduce infection To ensure accuracy To optimize the results on the monitor

To ensure accuracy

Which of the following is a LATE sign of the development of a tension pneumothorax?

Tracheal deviation Rationale: With a tension pneumothorax, you will quickly see hypotension, tachycardia, and dyspnea as the mediastinum shifts from the extra pressure in the intrapleural space on the affected side. A late sign of a tension pneumothorax is that the trachea will eventually shift to the unaffected side.

a patient is admitted to ICU from sx following abdominal aortic aneurysm repair. which assessment finding would the nurse report immediately.

UO of 20ml/hr for the last 2 hrs Rationale: monitor renal perfusion post abdominal aortic aneurysm repair. The renal arteries are clamped during surgery so we could see signs of AKI post surgery.

a nurse in an ED is caring for a client who has a sucking chest wound resulting from a gunshot. the client has a BP of 100/60, weak pulse of 118/min, RR 40/min. what action should the nurse take first?

administer O2 via nasal cannula. Rationale: The sucking chest wound indicates the client has a pneumothorax and/or a hemothorax. Administering oxygen will increase the oxygen exchange in the lungs and the oxygen available to the tissues

a nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. which of the following manifestations should alert the nurse the client is developing this condition?

breathlessness

a nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. the nurse notes slow, steady bubbling in the suction control chamber. which of the following actions should the nurse take?

continue to monitor the client's respiratory status Rationale: Slow, steady bubbling in the suction control chamber is an expected finding. Therefore, the nurse should continue to monitor the client's respiratory status.

a nurse is caring for a client who develops a ventricular fibrillation rhythm. the client is unresponsive, pulseless, and apneic. which of the following actions is the nurse's priority?

defibrillation rationale: The greatest risk to the client is death from a lack of cardiac output. Ventricular fibrillation is a lethal rhythm in which the ventricles are in a quivering pattern and there is no atrial activity. Defibrillation is essential to resolve ventricular fibrillation promptly and convert the rhythm to restore cardiac output. The nurse should follow defibrillation with cardiopulmonary resuscitation and repeated defibrillation, if necessary, to convert the ventricular fibrillation into a sustainable rhythm.

A 22-year-old female on college break presents to the triage desk complaining of sudden onset of feeling very sick, severe sore throat, and feeling "feverish." She is dyspneic and drooling at triage, and her skin is hot to touch. What ESI level is this?

▪ESI level 2. This patient is at high risk for epiglottitis. This is a life-threatening condition characterized by edema of the vocal cords. Onset is rapid, with a high temp (usually >101.3°F/38.5°C), lethargy, anorexia, sore throat. Patients do not have a harsh cough associated with croup, often assume the tripod position, and also have mouth drooling, an ominous sign, and may demonstrate an exhausted facial expression. Epiglottitis is more common in children, but may occur in adults; usually age 20 to 40. These patients are at high risk for airway obstruction and need rapid access of an airway (preferably in the operating room).

What is happening to the LA during MVR?

Blood volume and pressure increase BEHIND the regurgitant valve which would be the left atrium. This is because the blood "backflows" into the previous chamber during systole.

What is happening to the left ventricle in AVR?

Blood volume and pressure increase BEHIND the regurgitant valve which would be the left ventricle.

What is the most appropriate initial treatment regimen in a patient with disseminated intravascular coagulation secondary to bacterial sepsis? Immediate platelet transfusion Broad-spectrum antibiotics Surgical exploration Immediate packed red blood cell transfusion

Broad-spectrum antibiotics

what does bubbling of the water in the water seal chamber with exhalation indicate?

Bubbling in this chamber indicates air is being removed from the client's pleural space, allowing re-expansion of the lung. *It should occur during exhalation, coughing, and sneezing.* Excessive bubbling in this chamber may indicate an air leak and should be further investigated by the nurse.

An 8-month-old presents with fever, cough, and vomiting. The baby has vomited twice this morning; no diarrhea. Mom states the baby is usually healthy but has "not been eating well lately." Doesn't own a thermometer, but knows the baby is "hot" and gave acetaminophen two hours prior to arrival. The baby is wrapped in a blanket, eyes open, appears listless, skin hot and moist, sunken fontanel. Respirations are regular and not labored. What ESI level is this?

ESI level 2. High risk for sepsis or severe dehydration. If the baby was alert and active with good eye contact, similar complaints, and a fever of 100.4°F or greater, the ESI category would be 3. The temperature is not needed to make the assessment that the baby is high risk. The presence of lethargy and a sunken fontanel are indications of severe dehydration.

A 60-year-old male presents with complaint of dark stools for one month with vague abdominal pain. Past medical history: None. Pulse is tachycardic at a rate of 140 and he has a blood pressure of 80 palpable. His skin is pale and diaphoretic. What ESI level is this?

ESI level 1 Patient is placed in ESI level 1 after consideration of heart rate, skin condition and blood pressure. Tachycardia and hypotension indicate blood loss. The patient needs immediate hemodynamic support.

EMS arrives with a 25-year-old female with the sudden onset of significant vaginal bleeding, with 9/10 abdominal pain. The patient is 7 months pregnant. BP 92/pal, HR 130. What ESI level is this?

ESI level 1 She is at high risk for abruptio placentae, and needs an immediate cesarean section to save the fetus. Abruption occurs when the placenta separates from its normal site of implantation. Primary causes include hypertension, trauma, illegal drug use, and short umbilical cord. Bleeding may be dark red or absent when hidden behind the placenta. Abruption is usually associated with pain of varying intensity.

A 40-year-old male presents to triage with a gradual increase in shortness of breath over the past two days associated with chest pain. Past medical history: colon cancer. He is in moderate respiratory distress, skin warm and dry. What ESI level is this?

ESI level 2 High risk for a variety of complications associated with cancer, i.e., pleural effusion, congestive heart failure, further malignancy, and pulmonary embolus. A history of cancer can help identify high-risk status.

A 60-year-old male complains of sudden loss of vision in the left eye that morning. Patient denies pain or discomfort. Past medical history: CAD, HTN. The patient is slightly anxious but no distress. What ESI level is this?

ESI level 2. High risk for central retinal artery occlusion caused by an embolus. This is one of the few true ocular emergencies and can occur in patients with risk factors of coronary artery disease, hypertension, or embolus. Without rapid intervention, irreversible loss of vision can occur in 60 to 90 minutes.

A 70-year-old female with her right arm in a cast is brought to triage by her daughter. The daughter states that her mother fell yesterday and fractured her arm. The patient is complaining of pain. Daughter states, "They put this cast on yesterday, but I think it's too tight." Daughter reports her mother has been very restless at home and thinks her mother is in pain. Patient has a history of Alzheimer's disease. The patient is confused and mumbling (at baseline per daughter); face flushed. She is unable to provide verbal description of her complaints. Her right upper extremity is in a short arm cast; digits appear tense, swollen and ecchymotic. Nail beds are pale; capillary refill delayed. Patient is not wearing a sling. What ESI level is this?

ESI level 2. High risk for compartment syndrome. Despite the patient being a poor historian, the triage nurse should be able to identify some of the signs of threatened compartment syndrome: Pain, pallor, pulselessness, paresthesia, and paralysis. The patient requires immediate life-saving intervention: Cutting of the cast and further evaluation for potential compartment syndrome.

A 68-year-old male brought in by his wife for sudden onset of left arm weakness, slurred speech, and difficulty walking. Symptoms began 2 hours prior to arrival. Past medical history: Atrial fibrillation. Meds: Lanoxin. The patient is awake, oriented, mildly short of breath. Speech is slurred; right-sided facial droop is present. Left upper-extremity weakness noted with 2/5 muscle strength. What ESI level is this?

ESI level 2. This patient is presenting with signs of an acute stroke and requires immediate evaluation. If he meets criteria for thrombolytic therapy, he may still be in the time window of less than three hours, but every minute counts with this patient. He is a very high-priority ESI level-2 patient.

A 34-year-old male presents to triage with right lower quadrant pain, 5/10, all day. Pain is associated with loss of appetite, nausea and vomiting. Past medical history: None. The patient appears in moderate discomfort, skin warm and dry, guarding abdomen. What ESI level is this?

ESI level 3. However, the patient could be upgraded to ESI level 2 if vital signs were abnormal, i.e., heart rate greater than 100. Signs of acute appendicitis include mild-tosevere right lower quadrant pain with loss of appetite, nausea, vomiting, low-grade fever, muscle rigidity, and left lower quadrant pressure that intensifies the right lower quadrant pain. The presence of all these symptoms and tachycardia would indicate a high risk for a surgical emergency.

What is happening to the left ventricle in AVS?

Excess blood volume is staying in the left ventricle causing increased pressure in the left ventricle. That blood volume backs from the left ventricle to the left atrium and into the pulmonary vasculature.

When assessing a patient with sepsis, which finding would alert the nurse to the onset of acute respiratory distress syndrome (ARDS)?

Fine, scattered crackles on auscultation of the chest Rationale: The initial presentation of acute respiratory distress syndrome is often subtle. At the time of the initial injury, and for several hours to 1 to 2 days afterward, the patient may not experience respiratory symptoms, or the patient may exhibit only dyspnea, tachypnea, cough, and restlessness. Chest auscultation may be normal or may reveal fine, scattered crackles.

Which lab result is NOT consistent with a diagnosis of DIC? Increased D-dimer Decreased platelets Increased partial thromboplastin time (PTT) Increased fibrinogen

Increased fibrinogen

A patient develops increasing dyspnea and hypoxemia 2 days after heart surgery. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by heart failure, the nurse will plan to assist with:

Insertion of a pulmonary artery catheter Rationale: Pulmonary artery wedge pressures are normal in the patient with ARDS because the fluid in the alveoli is caused by increased permeability of the alveolar-capillary membrane rather than by the backup of fluid from the lungs (as occurs in cardiogenic pulmonary edema). The other tests will not help in differentiating cardiogenic from noncardiogenic pulmonary edema.

What three important elements are important in the ICU nurse's role when considering ICU delirium (ICU Psychosis)? Assess, Treat, Evaluate Early Admission, Early Discharge, Prevention Prevention, Early Recognition, Treatment Mobilize, Recognize, Treat

Prevention, Early Recognition, Treatment

a nurse is caring for a patient with hypovolemic shock. what is an expected finding?

oliguria others: tachypnea, skin that is pale, cyanotic, or mottled, hypotension, tachycardia