CC Exam 1

· Which of the following could indicate the presence of a tension pneumothorax? Given Answer:

· Correct Answer: Systolic blood pressure of 50 mm Hg in a patient who is becoming lethargic.

· The nurse is caring for a 22-year-old patient who came to the emergency department with acute respiratory distress. Which information about the patient requires the most rapid action by the nurse? Given Answer:

· Correct Answer: The patient's SaO2 is 85 mm Hg.

· Definition of Seizures?

· A disorder in which nerve cell activity in one part of the brain is disturbed

· A patient with severe hepatic cirrhosis has developed severe ascites. What is the most important nursing assessment?

· Correct Answer: Respiratory status

· Synchronized intermittent mandatory ventilation (SIMV) and pressure support is a common combination mode used in critical care. Which patient would benefit most from this mode?

A patient post abdominal surgery who is intubated and on the ventilator.

· A patient is admitted to ICU. Blood gases are: · pH 7.63 · PCO2 47mmHg · HCO3 30 mEq/L The medication most likely to be ordered to correct this acid-base imbalance is

Acetazolamide (diamox).

A nurse is caring for a patient who has been admitted for the treatment of advanced cirrhosis. What assessment should the nurse prioritize in this patient's plan of care?

Assessment for variceal bleeding

If a patient with pneumonia is too weak to perform the work of breathing, which mode of ventilation would be appropriate?

Assist/Control

When caring for an intubated, mechanically ventilated patient who is chemically paralyzed with vecuronium, which nursing intervention would you employ to determine the patient's need for suctioning?

Auscultation of the lung fields.

Available: Dopamine 500 mg in 250 mL D5W Order: Dopamine 5 mcg/kg/min The patient weighs 187 pounds. The patient will receive _____ mL/hr. (Round to nearest tenth and enter JUST the numeric answer.)

Case Sensitivity Exact Match Correct 12.8

What is kinking, obstruction from mucus, inc resistance, dec compliance

Cause of a high-pressure alarm on a ventilator

What is paresthesia in lower extremities moving to paralysis of all muscles resulting in respiratory arrest?

Complications of pt w/ Guillain-Barre syndrome --> (Weakness)

· What are barotrauma, hemodynamics dec CO inc HR dec BP, inc afterload and dec UO?

Complications of using positive pressure.

The patient has had a stroke or brain attack, believed to be ischemic in nature. The causes of an ischemic stroke are least likely to include which of the following?

Correct Answer: Hypertension

Your patient has a left pneumothorax. You note that the fluid in the water seal chamber rises with inspiration and falls on expiration. What should you do?

Correct Answer: Nothing, the system is working properly.

When counseling a patient who is inquiring about being an appropriate candidate for bariatric surgery, the nurse teaches the patient that which of the following is not a co-morbid condition in a patient with obesity.

Correct Answer: rheumatoid arthritis .

· For COPD pt, which one you need to report to doctor?

Drop of respiration from 24 per min to 8 per min

Which priority intervention should the nurse anticipate incorporating into the patients plan of care when hepatic encephalopathy initially develops?

Implementing a high carbohydrate diet.

A patient is admitted after an acute lung injury from smoke inhalation. If the patient develops acute respiratory distress syndrome (ARDS), what is the first symptom the nurse will find?

Increasing tachypnea and air hunger

The nurse notes that a patient's endotracheal tube (ET), which was at the 21-cm mark, is now at the 24-cm mark and the patient appears anxious and restless. Which action should the nurse take first?

Listen to the patient's lungs.

· An elderly patient is apprehensive about being in the ICU. The patient's stress can best be alleviated by

Listening to what the patient has to say.

What are early changes in LOC, crackles, tachypnea (Resp alk w/ hypoxemia), inc resistance, dec compliance, & tachycardia?

Manifestations of ARDS

What are elevating HOB 45 degrees, maintaining ETT cuff 15-25 mmHg, dorsal suctioning port on ET tube, good handwashing, & frequent oral care?

Measures to prevent VAP.

Which of the following are potential complications of mechanical ventilation

Pneumonia, pneumothorax, respiratory acidosis

What are VAP, barotrauma, alveoli hyper/hypoventilation, hypotension?

Possible complications of mechanical ventilation

What are help w/ oxygenation (PEEP) and making inspiration easier (PS)?

Rationales for using PEEP and pressure support.

· A patient has a systemic BP of 108/51 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first?

Report the BP and ICP to the health care provider.

A patient with ARDS is intubated and pharmacologically paralyzed with vecuronium. Which nursing action is important while the patient is receiving Norcuron?

Routinely medicate the patient with pain medication and sedation to maintain comfort.

What are inc in RR, rhonchi on auscultation, dec SaO2, & high pressure alarm?

Signs the ventilated pt needs to be suctioned.

While suctioning a patient with an endotracheal tube, the nurse notes the occurrence of premature ventricular contractions on the patient's cardiac monitor. Which action is most appropriate upon this finding

Stop the procedure and re-oxygenate the patient.

Which assessment finding by the nurse when caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP) indicates that the PEEP may need to be decreased?

The patient has subcutaneous emphysema.

· When admitting a patient in possible respiratory failure with a high PaCO2, which assessment information will be of most concern to the nurse? The patient is lethargic. ·

The patient is lethargic.

· A patient with cirrhosis has an episode of bleeding esophageal varices that is controlled with administration of vasopressin and endoscopic sclerotherapy. To detect possible complications of the bleeding episode, it is most important for the nurse to monitor serum Given Answer:

ammonia levels.

· Your post-operative bariatric surgery patient is restless, tachycardic, hiccuping and complaining of left shoulder pain. You call the surgeon and report that you suspect the patient has developed

an anastomotic leak.

When taking care of a patient with severe acute pancreatitis, the nurse has an order for acetazolamide (Diamox). The rationale for giving this medication to the patient is

decrease the bicarbonate concentration of pancreatic secretion

The low pressure alarm is being triggered on your mechanically ventilated patient. Which of the following is a possible cause?

increased lung compliance

· Which of the following are NOT appropriate nursing interventions to prevent ventilator associated pneumonia (VAP) in the mechanically ventilated patient? Select all answers that apply.

· Administer antibiotics to all patients receiving mechanical ventilation to prevent VAP from occurring. Correct · Change the patient's ventilator circuit (tubing) at least three times a week. Correct · Deflate the cuff on the ET tube once a shift to prevent pooling of secretions. Correct · Elevate the head of the bed to 40-60 degrees unless contraindicated.

A patient is admitted to the hospital with dysphasia and right-sided weakness that completely resolves in a few hours. The nurse will anticipate teaching the patient about.

· Aspirin.

· A patient with acute respiratory distress syndrome (ARDS) is being cared for in a CCU. The nurse implements the ventilator bundle of care. Which of the following statements about this action is true?

· Bundles of care strategies combine several strategies that have been shown to improve patient outcomes.

Which essential nursing intervention should be done for each patient on a mechanical ventilator?

· Check for presence of bilateral breath sounds at least every two-four hours.

· After receiving change-of-shift report, which patient will the nurse assess first? Given Answer:

· Correct Answer: A patient with acute pancreatits who has respiratory alkalosis and crackles in both lung bases.

· A patient is receiving care in the intensive care unit for acute pancreatitis. The nurse is aware that pancreatic necrosis is a major cause of morbidity and mortality in patients with acute pancreatitis. Consequently, the nurse should assess for what signs or symptoms of this complication? Given Answer:

· Correct Answer: Acute abdominal pain, increased heart rate and decreased blood pressure.

· A patient with acute pancreatitis is being cared for in the intensive care. After several days of therapy, the patient has worsening hypoxemia along with fever, abdominal distention, and severe pain despite narcotic therapy. What complication of pancreatitis does the nurse most suspect? Given Answer:

· Correct Answer: Acute respiratory distress syndrome

· A patient has been admitted with alcoholic cirrhosis of the liver. His family states that he has been increasingly confused, delirious, and agitated. Which treatment is aimed at preventing further neurological changes? Given Answer:

· Correct Answer: Administration of Xifaxan (rifaximin).

· Your patient is intubated by the pulmonologist. Which of the following is the responsibility of the nurse with regard to checking for the ET tube placement immediately after tube insertion? Given Answer:

· Correct Answer: Auscultate the lungs for the presence of bilateral breath sounds.

To verify the correct placement of an endotracheal tube after insertion, which action does the nurse take first?

· Correct Answer: Auscultates for the presence of bilateral breath sounds.

Available: Epinephrine hydrochloride 2 mg. in 500 mL D5W Order: Infuse epinephrine HCL at 2.5 mcg/min IV The patient will receive ______ mL/hour (Round answer to the nearest tenth. Please enter JUST the numeric answer.)

· Correct Answer: Case Sensitivity Exact Match Correct 37.5

· A patient is being cared for in the CCU after a ruptured cerebral aneurysm. The nurse finds new onset of hemiparesis, slight lethargy, and complaints of diplopia. What complication does the nurse suspect:

· Correct Answer: Cerebral artery vasospasm

· A patient with ARDS who is receiving mechanical ventilation using synchronized intermittent mandatory ventilation (SIMV) has settings of fraction of inspired oxygen (FiO2) 100%, tidal volume 500, rate 18, and positive end-expiratory pressure (PEEP) 8 cm. Which assessment finding is most important for the nurse to report to the health care provider?

· Correct Answer: Diminished breath sounds on right

· A patient has a chest tube inserted for a pneumothorax. The nurse notes intermittent bubbling in the water seal chamber. Which of the following is the appropriate action? Given Answer:

· Correct Answer: Document the findings.

· The patient with cirrhosis receives 100 ml of 25% serum albumin IV. Which finding would best indicate that the albumin is having its desired effect? Given Answer:

· Correct Answer: Increased urine output.

· Three weeks after a viral illness, a patient has an onset of weakness in the lower extremities that is progressing to the arms. The patient is admitted to the CCU with a diagnosis of rapidly progressing Guillain-Barré syndrome. What is the nursing care priority? Given Answer:

· Correct Answer: Monitor respiratory system closely.

· A patient being supported with endotracheal intubation and mechanical ventilation is increasingly agitated. Which of the following prn orders is the most appropriate nursing intervention? Given Answer:

· Correct Answer: Obtain arterial blood gas measurement.

A patient being mechanically ventilated with positive end-expiratory pressure and pressure support totaling 30 mm Hg has developed unequal chest expansion, absent breath sounds on the right, and tracheal deviation to the right. The patient is increasingly tachycardic, anxious, and agitated, and his pulmonary compliance is rapidly decreasing. What is the most appropriate nursing action?

· Correct Answer: Prepare for chest tube insertion.

· Which drug is administered to assist in maintaining hemostasis in esophageal varices? · Incorrect Neomycin sulfate.

· Correct Answer: Propranolol (Inderal).

· The nurse administers stool softeners to a patient esophageal varices from cirrhosis of the liver. The patient asks why he is receiving this. The nurse explain that it is given to Given Answer:

· Correct Answer: Reduction in ammonia production.

· A patient has a systemic BP of 100/60 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first? Given Answer:

· Correct Answer: Report the BP and ICP to the health care provider.

· The nurse observes for early manifestations of ARDS (acute respiratory distress syndrome) in high-risk patients. Which signs or symptoms indicate the possible onset of ARDS in susceptible patients? Given Answer:

· Correct Answer: Respiratory alkalosis, restlessness, and mild hypoxemia.

· A patient who has had a subarachnoid hemorrhage is being cared for in the intensive care unit. Which information about the patient is most important to communicate to the health care provider?

· Correct Answer: The patient's blood pressure is 89/60 mm Hg.

· A patient with multiple trauma and several other comorbidities is being supported with endotracheal intubation and mechanical ventilation and is scheduled for a tracheostomy. The family questions the appropriateness of this procedure. In explaining the rationale for the procedure to the family, what is the most important nursing point? Given Answer:

· Correct Answer: The tracheostomy inserted early result in fewer ventilated days.

Which of the following is used to decrease the risk for volutrauma and barotrauma in patients with ARDS?

· Correct Answer: Using pressure-limited mechanical ventilation.

· Complications associated with Acute Respiratory Distress Syndrome (ARDS) include all of the following except Given Answer:

· Correct Answer: cardiogenic shock.

As the nurse caring for a ventilator-dependent patient who is receiving Norcuron (vecuronium bromide), you assess the level of neuromuscular blockade using "Train-of Four" (TOF) peripheral nerve stimulation. You observe that the patient has two twitches. You will need to

· Correct Answer: document this in the chart as an expected reaction.

· When assessing a patient for signs of hepatic encephalopathy, the nurse asks the patient to Given Answer:

· Correct Answer: extend the arm and hand.

· In the late-stage of Acute Respiratory Distress Syndrome (ARDS), difficulty maintaining oxygenation and ventilation is a result of

· Correct Answer: fibroproliferative changes to the lung.

· Which of the following is not a complication of heaptic failure? Given Answer:

· Correct Answer: hypoaldosteronism.

· A patient has a stroke affecting the left hemisphere of the brain. Based on knowledge of the effects of leftt brain damage, the nurse establishes a nursing diagnosis of Given Answer:

· Correct Answer: impaired verbal communication related to speech-language deficits.

· Four hours after mechanical ventilation is initiated for a patient with chronic obstructive pulmonary disease (COPD), the patient's arterial blood gas (ABG) results include a · pH of 7.30 · PaO2 of 80 mm Hg · PaCO2 of 69 mm Hg · HCO3 of 23 mEq/L (23 mmol/L) · The nurse will anticipate the need to

· Correct Answer: increase the tidal volume (VT).

A patient is admitted from surgery post-colon rupture repair. He is on the ventilator and has required fluid resuscitation and vasopressors. A diagnosis of Acute Respiratory Distress Syndrome (ARDS) is made characterized by all of the following except.

· Correct Answer: increased lung compliance.

· The most important nursing intervention in caring for a patient with Acute Respiratory Distress Syndrome (ARDS) is Given Answer:

· Correct Answer: maintain patient's synchrony with the ventilator and level of sedation.

· The oxygen delivery system chosen for the patient in acute respiratory failure should:

· Correct Answer: maintain the PaO2 60 mm Hg or greater at the lowest possible O2 concentration.

· A patient sustains a puncture wound of the chest wall as the result of an industrial accident. The nurse knows that a chest tube will be inserted to reestablish Given Answer:

· Correct Answer: negative pressure in the pleural space.

· Which arterial blood gas (ABG) report would the nurse expect to find on her patient with chronic kidney disease? Given Answer:

· Correct Answer: pH 7.33; PaCO2 33 mm Hg; PaO2 88 mm Hg; HCO3 18 mEq/L

· Which arterial blood gas (ABG) report would the nurse expect in a patient with advanced chronic obstructive pulmonary disease (COPD)? Given Answer:

· Correct Answer: pH 7.34; PaCO2 66 mm Hg; PaO2 68 mm Hg; HCO3 30 mEq/L

· Which arterial blood gas (ABG) report would the nurse expect in a patient with early acute respiratory distress syndrome (ARDS)? Given Answer:

· Correct Answer: pH 7.48; PaCO2 30 mm Hg; PaO2 60 mm Hg; HCO3 24 mEq/L

· A patient has just returned from having a CT scan. The nurse assesses patient on mechanical ventilation who is receiving positive end-expiratory pressure (PEEP) and notes the ET tube is at 26 cm and was at 24cm before. On assessment she notes disappearance of breath sounds on the left side. The nurse would first suspect Given Answer:

· Correct Answer: the ET tube had slipped into the right bronchus.

· A patient with chronic COPD is on mechanical assist-control ventilation. ABGs are: · pH 7.37 · PaO2 70 · PaCO2 48 · HCO3 26. The nurse determines that

· Correct Answer: the patient is responding optimally to the ventilator settings.

· What is the MAJOR PURPOSE of the water in the chest drainage water seal collection bottle? Given Answer:

· Correct Answer: to prevent entrance of air into the intrapleural space

· A patient with a Sengstaken-Blakemore tube. As the nurse caring for the patient, you know that the greatest danger from rupture or sudden deflation of the gastric balloon is

· Correct Answer: upward progression of the tube.

· Which of the following statements would be considered appropriate interventions for a patient with an endotracheal (ET) tube? Select all that apply.

· Cuff pressure should be between 20 and 25 cm H2O. · Cuff pressures should be checked every 6 to 8 hours. · Humidified oxygen should always be introduced through the tube.

· A patient in the ICU with acute respiratory distress syndrome (ARDS) complains of worsening dyspnea. Which of the following physiological changes associated with ARDS are most responsible for this patient's impaired ventilation? SATA

· Decreased lung compliance · Increased airway resistance

· The criteria that may result in early termination of weaning from mechanical ventilation include:

· EKG changes Correct · diaphoresis Correct · increased accessory muscle use Correct · respiratory rate greater than 30 breaths per minute Correct Answers: Correct

· Which of the following assessment findings would indicate an increasing intracranial pressure (ICP) in a client with head trauma? Select all that apply.

· Elevated systolic blood pressure (widened pulse pressure) · Bradycardia · Irregular respirations · Vomiting

· The nurse is caring for a patient in the ICU with a right pneumothorax which is being treated with a chest tube. Which actions are appropriate for the nurse to take when caring for this patient? SATA

· Encourage the patient to maintain an upright position · Maintain an occlusive dressing around the chest tube at the insertion site.

· The nurse is caring for a patient diagnosed with a right pneumothorax which is being treated with a chest tube to re-expand the lung. Which actions are appropriate for the nurse to take when caring for this patient?

· Encourage the patient to maintain high Fowler's position. Correct · Maintain an occlusive dressing around the chest tube at the insertion site.

· Which of the following would a nurse anticipate seeing in a patient with Parkinson Disease?

· Gait impairment · Drooling of face · Mask-like face · Postural instability · Resistance to passive limb movement · Slowing of active physical movement · Rhythmic, slow turning motion of the forearm

· Which of the following are diagnostic findings in a patient with ARDS?

· History of a gut ischemia. Correct · New interstitial infiltrates on a chest x-ray. Correct · History of near drowning. Correct

· · A patient with a pulmonary embolism is intubated and placed on mechanical ventilation. When suctioning the endotracheal tube, the nurse should

· Hyper-oxygenate with 100% oxygen before and after suctioning

The nurse is caring for a patient in the ICU admitted with ARDS after exposure to toxic fumes from a hazardous spill at work. The patient has become hypoxemic with crackles auscultated bilaterally. What is the cause of this complication of ARDS?

· Hypovolemia secondary to leakage of fluid into the interstitial spaces.

· A nurse is participating in the emergency care of a patient who has just developed variceal bleeding. Which intervention(s) should the nurse anticipate? SATA

· IV administration of vasopressin · IV administration of octreotide · Balloon tamponade · Endoscopic variceal ligation

· Symptoms associated with right-sided stroke?

· Impulsive behavior

· A 60 kg. patient is receiving mechanical ventilation in the assist/control mode with the following settings; tidal volume (Vt) 400 mL, rate 16/minute, FIO2 50% and PEEP 5 cm of H2O. The patient continues to produce ABGs consistent with respiratory acidosis. Which interventions would potentially correct these ABG results? SATA

· Increase the tidal volume to 500 mL. · Increase the rate to 18 breaths/minute

· After shift report, the nurse assesses a ventilated patient and finds the respiratory rate higher than expected. The nurse also notices other symptoms associated with ARDS. Which of the following would the nurse also report to the physician? Select all that apply. Given Answers:

· Increased peak airway pressures. · Tachycardia. · Hypotension.

· Complication of ETT?

· Laryngeal nerve damage · Posterior trach wall penetration · Infection · Aspiration

· Patient had seizures, what's the first priority?

· Lay patient on one side

· The doctor orders pressure support of 10 cm H2O to be added to the synchronous intermittent mandatory ventilation to assist weaning the patient from the ventilator. You know that pressure support is used to

· Make inspiration easier

In which order will the nurse take these actions when assisting with oral intubation of a patient who is having respiratory distress?

· Oxygenate the patient with a bag-valve-mask system for several minutes. Correct 1. · Place the patient in the supine position. Correct 2. · Inflate the cuff of the endotracheal tube. Correct 3. · Attach an end-tidal CO2 detector to the endotracheal tube. Correct 4. · Obtain a portable chest-x-ray. Correct 5.

· Which of the following are indications for using Propofol (dirpivan) and Norcuron (vecuronium)? Select all that apply.

· Poor compliance with high peak airway pressures. · Pressure-controlled inverse-ratio ventilation. · Asynchronous respirations during mechanical ventilation.

· A nurse educator is reviewing the indications for chest drainage systems with a group of medical nurses. What indications should the nurses identify?

· Post pneumonectomy Correct · Tension pneumothorax Correct · Chylothorax Correct

· When a patient with ARDS (acute respiratory distress syndrome) is receiving high PEEP and high tidal volume ventilation. The nurse should observe the patient for which sign of barotrauma?

· Progressive hypoxemia

· A patient is receiving supplemental oxygen therapy. What is the most important first nursing assessment for this patient?

· Respiratory effort and rate

· When assessing a patient with these blood gases, you would expect to see which compensatory response? · pH 7.60 · PaCO2 45 mmHg · HCO3 38 mEq/L · PaO2 98 mmHg · SaO2 90%

· Shallow, slower respirations.

· A patient is admitted to ICU. Blood gases are: · pH 7.13 · PCO2 37mmHg · HCO3 10 mEq/L The medication most likely to be ordered to correct this acid-base imbalance is

· Sodium Bicarbonate.

· Volume support is used for

· Suctioning

What is 1 to 2 twitches?

· The number of twitches when using a PNS indicating the pt is receiving appropriate amount of paralytic. ·

When caring for a patient who has Guillain-Barré syndrome, which assessment data obtained by the nurse will require the most immediate action?

· The patient has continuous drooling of saliva.

·A patient who has had a subarachmoid hemorrhage is being cared for in the intensive care unit. Which information about the patient is most important to communicate to the health care provider?

· The patient's blood pressure is 89/60 mm Hg

· A nurse is assessing a client who is interested in undergoing bariatric surgery. Which of the following are criteria for candidacy? Select all that apply.

· Understanding of required lifestyle changes. Correct · History of slepp apnea. Correct · Body mass index (BMI) of 47. Correct

·A nurse caring for a patient with an intracerebral bleed will be monitoring the patient for Cushing's triad. What will the nurse recognize as the symptoms associated with Cushing's Triad?

· Widening pulse pressure · Bradycardia · Irregular respiration

· Which of the following would cause a patient to have a pH 7.49? Select all that apply.

· a respiratory dysfunction if present with decreased PaCO2. Correct · a metabolic dysfunction if present with increased HCO3. Correct

· Positive pressure ventilation can cause: Select all that apply.

· alveolar hypoventilation. Correct · decreased tissue perfusion. Correct · decreased central venous pressure.Correct

· You are caring for a patient who just returned from surgery with a new tracheostomy. You know that possible complications of tracheostomy are: Select all that apply.

· infection. · aspiration. · penetration of the posterior tracheal wall. · injury to the laryngeal nerve.

The doctor orders pressure support of 10 cm H2O to be added to the synchronous intermittent mandatory ventilation to assist weaning the patient from the ventilator. You know that pressure support is used to

· make inspiration easier.

· A patient is admitted to the CCU after aneurysm clipping. Treatment of increase cerebral perfusion include:

· nimodipine (Nimotop) · volume expansion using crystalloid or colloid solutions · hemodilution-induce hypertension

· Clamping of chest tubes is recommended in which of the situations? · Select all that apply. Given Answers:

· per physician order to assess resolution of pneumothorax. Correct · to replace the chest tube drainage unit. Correct · to locate the source of an air leak if bubbling occurs in the water seal chamber. Correct

· A patient in the ICU with acute respiratory distress syndrome (ARDS) complains of worsening dyspnea. Which of the following physiological changes associated with ARDS are most responsible for this patient's impaired ventilation? Select all that apply.

· surfactant dysfunction · increased airway resistance · atelectasis · fibrosis