Critical Care Quiz 2 : Midcourse Study Plan

Which are the priority emergency assessments the nurse will perform for a client with bomb blast injuries? Select all that apply. One, some, or all responses may be correct. A. Airway B. Breathing C. Circulation D. Giving comfort measures E. Facilitating family presence F. Exposure or environmental control

A. Airway B. Breathing C. Circulation F. Exposure or environmental control

Which action would the nurse take first after noting a flat line on a client's cardiac monitor? A. Assess the client's pulse. B. Start cardiopulmonary resuscitation. C. Check another lead to confirm asystole. D. Call the hospital emergency response team.

A. Assess the client's pulse.

The nurse is caring for a client during the emergent phase after the client sustained serious burns that involved a large surface of the skin. Which nursing intervention is the priority during this phase? A. Alleviating pain B. Preventing infection C. Replacing blood loss D. Restoring fluid volume

D. Restoring fluid volume

When a critically ill client has a pulmonary artery catheter inserted, which measurement provides the most useful information about the client's left ventricular pressure? A. Right atrial pressure B. Central venous pressure C. Pulmonary artery diastolic pressure D. Pulmonary artery wedge pressure

D. Pulmonary artery wedge pressure

Which would be included in the plan of care for a preterm newborn who is given oxygen by way of a hood? A. Ensuring that the oxygen is continuously warmed and humidified B. Monitoring to see that the infant's skin and mucous membranes are remaining bright pink C. Informing the parents that oxygen will be given at 4 L/min and that blindness is not a risk D. Checking the oxygen level in the hood every 4 hours and monitoring oxygen saturation continuously

A. Ensuring that the oxygen is continuously warmed and humidified

Which equipment will the nurse prepare for a client whose burn wounds are scheduled to be debrided mechanically? A. Enzymatic agents B. Scissors and forceps C. Autolytic semiocclusive dressing D. Continuous passive-motion device

B Scissors and forceps

While caring for a client who sustained a severe head injury in an accident, the nurse observes that the client is constantly passing urine and is dehydrated. Which would the nurse suspect is the cause of the client's condition? A. Decreased secretion of aldosterone B. Decreased secretion of antidiuretic hormone C. Decreased secretion of parathyroid hormone D. Decreased secretion of atrial natriuretic peptide

B. Decreased secretion of antidiuretic hormone

An unconscious child is admitted to the pediatric intensive care unit with a closed head injury. What is the nurse's primary goal for this child? A. Prevention of unnecessary trauma to the vital organs B. Limitation of stimuli that increase intracranial pressure C. Establishment of access routes for infusion of medications D. Enhancement of the health team's management of the illness

B. Limitation of stimuli that increase intracranial pressure

Which intervention would the nurse complete immediately for a client experiencing autonomic dysreflexia? A. Administering an alpha blocker B. Placing the client in a sitting position C. Giving nifedipine or nitrate as prescribed D. Monitoring blood pressure (BP) every 15 minutes

B. Placing the client in a sitting position

The nurse is caring for a client during the emergent phase of a severe burn injury. Which parenteral intervention prescribed by the health care provider would the nurse question? A. Colloids B. Potassium C. Hypertonic saline D. Lactated Ringer solution

B. Potassium

Which diagnostic test result will the nurse review after noticing large U waves on the electrocardiogram (ECG) for a client who was just admitted to the cardiac unit? A. Troponin T B. Serum potassium C. Oxygen saturation D. C-reactive protein

B. Serum potassium

Which is the first action the nurse would take when responding to an apnea monitor alarm that signifies a 10-second cessation of respirations? A. Assess for changes in skin color. B. Use tactile stimuli on the chest or extremities. C. Check the monitor for signs of a malfunction. D. Resuscitate with a face mask and an Ambu bag.

B. Use tactile stimuli on the chest or extremities.

A child who barely survived a near-drowning episode is in critical condition when she suddenly opens her eyes and smiles. The parent says, 'Look! I think she'll get better now.' Which is the best response by the nurse? A. 'You're right; that's a very good sign.' B. 'Try to have your child hold your hand.' C. 'We're doing everything we can to promote recovery.' D. 'God certainly must be watching over your child today.'

C. 'We're doing everything we can to promote recovery.'

As a surface rewarming measure for a client who is hypothermic, which is the highest temperature up to which the fluid can be heated for peritoneal lavage? A. 98.6°F (37°C) B. 111.2°F (44°C) C. 113°F (45°C) D. 120.2°F (49°C)

C. 113°F (45°C)

When a client in the coronary care unit develops ventricular tachycardia, which action will the nurse take first? A. Initiate immediate defibrillation. B. Perform synchronized cardioversion. C. Assess client pulse and blood pressure. D. Start cardiopulmonary resuscitation (CPR).

C. Assess client pulse and blood pressure.

When the emergency department nurse is caring for a client with acute coronary syndrome who reports severe crushing chest pressure, which prescribed medication is best for the nurse to administer? A. Ibuprofen 650 mg orally B. Acetaminophen 650 mg orally C. Nitroglycerin 0.4 mg sublingually D. Morphine sulfate 4 mg intravenously

D. Morphine sulfate 4 mg intravenously

The nurse is caring for a client during the first few hours after admission to the burn unit with full-thickness burns of the trunk and head. Which nursing goal is the priority during the emergent phase of this injury? A. Preventing pain B. Managing leukopenia C. Preventing infection D. Managing fluid loss

D. Managing fluid loss

After an anterior fossa craniotomy, a client is placed on controlled mechanical ventilation. Which action would the nurse take to promote adequate cerebral blood flow? A. Clear the ear of draining fluid. B. Discontinue anticonvulsant therapy. C. Position the client's head turned to the left. D. Monitor serum carbon dioxide levels.

D. Monitor serum carbon dioxide levels.

Which goal is the nurse trying to achieve when placing a client with severe burns on a circulating air bed? A. Increasing mobility B. Preventing contractures C. Limiting orthostatic hypotension D. Preventing pressure on peripheral blood vessels

D. Preventing pressure on peripheral blood vessels

A severely burned client has been hospitalized for 3 days and is now in the acute phase. Until now recovery has been uneventful, but the client begins to exhibit extreme restlessness. Which complication would the nurse conclude the client is most likely developing? A. Kidney failure B. Cerebral hypoxia C. Metabolic acidosis D. Hypovolemic shock

B. Cerebral hypoxia

When a client who has had a myocardial infarction suddenly develops a heart rate of 120 beats/minute, which action would the nurse take first? A. Offer reassurance. B. Check blood pressure. C. Call for an electrocardiogram (ECG). D. Activate the hospital rapid response team.

B. Check blood pressure.

Which type of emergency assessment is the nurse performing when the nurse reassesses level of consciousness and mental status in a client who survived a fire? A. Airway B. Disability C. Breathing D. Full set of vital signs

B. Disability

A child loses consciousness a few days after a traumatic head injury that resulted in a subdural hematoma. While assessing extraocular movements, the nurse notes that the child is displaying the oculocephalic reflex. Which would the nurse conclude about the presence of the oculocephalic reflex in an unconscious child? A. Unusual B. Expected C. Suppressed D. Hyperactive

B. Expected

A toddler in the pediatric intensive care unit is on a ventilator. The nurse asks what would be done when condensation collects in ventilator tubing. How would the nurse manager respond? A. 'Notify the physician assistant.' B. 'Decrease the amount of humidity.' C. 'Empty the fluid and reconnect the tubing to the ventilator.' D. 'Measure the fluid and mark it on the intake and output record.'

C. 'Empty the fluid and reconnect the tubing to the ventilator.'

A client who has paroxysmal supraventricular tachycardia reports a mild 'fluttering feeling' in the chest and has a blood pressure of 110/55 mm Hg. Which potential treatment by the health care provider would the nurse question? A. Intravenous adenosine B. Intravenous metoprolol C. Carotid sinus massage D. Synchronized cardioversion

D. Synchronized cardioversion Because the client is hemodynamically stable and experiencing only mild symptoms associated with the tachycardia, synchronized cardioversion is not indicated at this time.