final exam
A patient who has received a transplant is being taught about cyclosporine. Which statement made by the patient would indicate the teaching was effective?
"I will need to monitor my blood pressure."
Which statement would indicate that a patient who has received an organ transplant understands the teaching about immunosuppressive medications?
"My drug dosages will be lower because the medications enhance each other."
The nurse is caring for a patient with heparin-induced thrombocytopenia (HIT). The nurse knows the patient is at high risk for bleeding and injury. Which interventions would be included in the plan of care? (Select all that apply.)
- Avoid intramuscular injections. - Use a soft-bristled toothbrush when providing mouth care. - Use a draw sheet when repositioning the patient in bed. - Shave the patient with an electric shaver only.
The nurse is caring for a patient who is being mechanically ventilated due to respirator failure. For what complications should the nurse closely monitor? Select all that apply.
- Barotrauma - Volutrauma - Ventilator-associated pneumonia (VAP)
The nurse is caring for a patient who is experiencing acute respiratory distress due to accumulation of nasal secretions in the airways. What is appropriate to include in the patient's plan of care? Select all that apply.
- Encourage the patient to cough - Administer nebulized acetylcysteine
What nursing actions are essential for the prevention of VAP? Select all that apply.
- Frequent hand washing - Frequent mouth care and oral hygiene - Sterile technique during endotracheal suctioning
What is the arterial oxygen/fraction of inspired oxygen (PaO2/FIO2, or P/F) ratio in acute respiratory distress syndrome (ARDS)?
- Less than 200
A patient is brought to the emergency department after a house fire. The patient sustained an inhalation injury. The nurse is aware that this injury predisposes the patient to the development of what complication
ARDS
Which nursing intervention will help prevent spikes in intracranial pressure in the post-neurosurgical patient?
Administer an antiemetic to prevent vomiting.
An unresponsive trauma patient has been admitted to the emergency department. Which statement regarding opening the airway is accurate?
Airway assessment must incorporate cervical spine immobilization.
The nurse is admitting a patient with asthma is in acute respiratory distress. The nurse auscultates the patient's lungs and notes cessation of the inspiratory wheezing. The patient has not yet received any medication. What should this finding most likely suggest to the nurse?
Airway constriction requiring intensive interventions
A patient is brought to the emergency department after a house fire. He fell asleep with a lit cigarette, and the couch ignited. What is the nurse's first priority?
Assess the airway and provide 100% oxygen.
A patient is admitted with a C5-C6 subluxation fracture. He is able to move his legs better than he can move his arms. The nurse suspects the patient may have which type of injury?
Central cord syndrome
What is one of the earliest signs of increased intracranial pressure (ICP)?
Change in level of consciousness
What results in surfactant dysfunction during the injury phase of acute respiratory distress syndrome (ARDS)?
Damage to alveolar type I and II cells
A patient is admitted with a C5-C6 subluxation fracture. He is able to move his legs better than he can move his arms. Nursing care for the patient includes which intervention?
Maintain mean arterial pressure (MAP) at 85 to 95 mm Hg.
Which diuretic is the most effective in the reduction of increased intracranial pressure (ICP)?
Mannitol
A nurse is caring for a patient diagnosed with acute respiratory distress syndrome. The nurse is aware that these patients often will require which intervention?
Mechanical ventilation
A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. What medication would the nurse expect the practitioner to order for this patient?
vasopressin octreotide
The organ procurement organization coordinator writes orders to initiate standard donor care. Which interventions are parts of standard donor care? (Select all that apply.)
- Maintain head of bed at 30 to 40 degrees elevation. - Continue routine pulmonary suctioning and side-to-side body positioning. - Warming blanket to maintain body temperature above 36.5° C.
What nursing actions are part of the Acute Respiratory Distress Syndrome Clinical Network (ARDSNet) protocol? Select all that apply.
- Minimization of oxygen requirements - Ventilation of the patient with smaller tidal volumes - Ventilation of the patient using positive end-expiratory pressure
A nurse is monitoring a patient with stiff lungs due to acute respiratory distress syndrome (ARDS). What compensatory clinical events may the nurse expect in this patient? Select all that apply.
- Respiratory alkalosis - Increase in cardiac output - Increase in respiratory rate and a decrease in tidal volume
The nurse is caring for a patient on mechanical ventilation. What are the nursing interventions that prevent the development of volutrauma in a patient on a ventilator? Select all that apply.
- Smaller tidal volumes - Pressure-control ventilation
The nurse is caring for a patient in hypovolemic shock secondary to cirrhosis of the liver. The nurse understands that this type of shock results from shifting of fluid into the abdominal cavity. What is the resulting hypovolemia called?
Absolute hypovolemia
A patient involved in a house fire is brought by ambulance to the emergency department. The patient is breathing spontaneously but appears agitated and does not respond appropriately to questions. The nurse knows the patient has inhaled carbon monoxide and probably has carbon monoxide (CO) poisoning. What action should the nurse take next?
Administer 100% high-flow oxygen via a nonrebreathing mask.
The nurse is caring for a patient in septic shock due secondary to pneumonia. The nurse knows that evidence-based guidelines for the treatment of septic shock include which interventions? (Select all that apply.)
Administer norepinephrine to maintain mean arterial pressure of 65 mm Hg. Start enteral nutrition within the first 48 hours after diagnosis of septic shock. Administer 30 mL/kg crystalloid for hypotension or lactate greater than or equal to 4 mmol/L.
The nurse and a new graduate nurse are caring for a patient with extensive burns. They are discussing skin grafts. Which statement indicates the new graduate understood the information?
Autografts provide permanent coverage and are the least expensive.
What complication can a high peak airway pressure used in the mechanical ventilation of a patient with acute respiratory distress syndrome (ARDS) cause?
Barotrauma
A nurse is caring for a patient who is receiving sirolimus. The nurse knows to monitor the patient for what side effect?
Bleeding
Major trauma patients are at high risk of developing deep venous thrombosis and pulmonary embolism. The nurse understands that trauma patients are at risk due to which factors?
Blood stasis Injury to the intimal surface of the vessel Hypercoagulopathy Immobility
Potential recipients are matched with donors based on what factors?
Blood type Human leukocyte antigen Severity of illness Location of recipient Waiting time on the list
A patient is admitted with a massive head trauma. The patient is unresponsive and on mechanical ventilation. The electroencephalogram (EEG) is negative for brain waves. The family has agreed to organ donation. How would this organ donor be classified?
Brain-dead donor
A patient was admitted with gram-negative sepsis a few days ago. Today the nurse notes continual oozing from intravenous sites and ecchymosis beneath the blood pressure cuff. The patient's platelet count is normal, and international normalized ratio (INR) is elevated. What other laboratory value would be valuable in definitively diagnosing the patient's condition?
D-Dimer level
Contracture development leading to impaired physical mobility can occur after a major burn injury. Splints are applied to prevent or correct contractures. Priority nursing interventions concerning this therapy include which action?
Daily assessment for proper fit and effectiveness
A patient has been admitted with muscle trauma and crush injuries. The nurse understands that this patient is at high risk for the development of acute kidney injury secondary to rhabdomyolysis. Which findings would suggest the patient is developing this complication? (Select all that apply.)
Dark tea-colored urine Decreased urine output Increased serum creatine kinase level
The nurse is caring for a patient with blunt abdominal trauma. The nurse understands that patient is at risk for abdominal compartment syndrome. Which findings would the nurse expect to note as evidence of this complication? (Select all that apply.)
Decreased cardiac output Increased peak pulmonary pressures Decreased urine output Hypoxemia
A patient has been admitted with hypovolemic shock due to blood loss. Which finding would the nurse expect to note to support this diagnosis?
Decreased level of consciousness
Which independent nursing measures can assist in reducing increased intracranial pressure (ICP)?
Decreasing noxious stimuli
Which nursing problem would be appropriate for a patient who has received a kidney transplant?
Deficient fluid volume
The nurse is caring for a patient with type 2 heparin-induced thrombocytopenia (HIT). The nurse knows that pulmonary embolism is a serious complication of HIT. Which findings would alert the nurse to the presence of this complication?
Dyspnea, pleuritic pain, and rales
The nurse is caring for a patient after a liver transplant. Which finding would be of most concern to the nurse?
Elevated prothrombin time
A patient who has sustained an indirect lung injury due to a severe head wound is diagnosed with acute respiratory distress syndrome (ARDS). Which pathophysiologic change does the nurse anticipate on the second day after the lung injury?
Engorgement of the peribronchial interstitial space
A patient diagnosed with acute respiratory distress syndrome who is endotracheally intubated on mechanical ventilation has a decreasing oxygen saturation level with an increasing heart rate. Which nursing action is the priority?
Ensure the airway is clear and patent
A patient with a known penicillin allergy develops anaphylactic shock after a dose of ampicillin was given in error. Which medication would the nurse administer first?
Epinephrine
A patient is admitted to the burn unit after a house fire. The patient sustained extensive burns to the chest, back, left arm, right arm, right upper leg, and areas on the face. The nurse is unable to obtain a palpable pulse or a Doppler pulse in the right arm. What procedure should the nurse anticipate next?
Escharotomy
A patient has been admitted with septic shock related to tissue necrosis. The nurse knows the initial goal for medical management for this patient is which intervention?
Finding and eradicating the cause of infection
A patient has had a kidney transplant. The nurse knows that monitoring of which parameter would have the highest priority?
Fluid volume
The nurse is caring for a patient with acute liver failure. The practitioner asks the nurse to assess the patient for asterixis. How should the nurse assess for this symptom?
Have the patient extend the arms and dorsiflex the wrists.
A trauma patient's condition has deteriorated. The nurse notes changes in patient's condition, including trachea shift, absence of breath sounds on the left side, and hypotension. The nurse suspects that the patient has developed what complication?
Hemothorax
Rejection that occurs within hours after the transplantation and results in immediate graft failure is referred to as what type of rejection?
Hyperacute
A patient has developed septic shock. The nurse knows that the patient is at risk for gastrointestinal dysfunction. What happens to the gastrointestinal tract in the patient with septic shock?
Hypoperfusion results in loss of gut barrier function
A patient is admitted to the burn unit with extensive burns after a house fire. The patient's vital signs and physical exam include a heart rate of 140 beats/min, a urine output of 25 mL/h, and clear lung sounds. What adjustment, if any, needs to be made to the fluid resuscitation plan?
IV rate should be increased and fluid status closely watched.
The nurse is caring for a patient in cardiogenic shock. The nurse recognizes that the patient's signs and symptoms are the result of what problem?
Inability of the heart to pump blood forward
A patient has been admitted with a flail chest and pulmonary contusion. Which finding will cause a nurse to suspect that the patient's condition is deteriorating?
Increased work of breathing
A patient has been admitted with hypovolemic shock due to traumatic blood loss. Which nursing measure can best facilitate the administration of large volumes of fluid?
Inserting a large-diameter peripheral intravenous catheter
A patient is brought to the emergency department with extensive burns after a house fire. What is an important nursing intervention for this patient during the resuscitation phase?
Intravenous opiates and assessment of pulses in both arms
The nurse is caring for a patient with acute liver failure. The patient has elevated ammonia levels. Which medication would the nurse expect the practitioner to order for this patient?
Lactulose
Older trauma patients have a higher mortality than younger trauma patients. The nurse understands that this fact is probably related to what physiologic change?
Limited physiologic reserve
A patient is admitted with a brain and spinal cord injury secondary to a motor vehicle crash. The nurse is monitoring the patient for signs of neurogenic shock. Clinical findings in neurogenic shock are related to which pathophysiologic process?
Loss of sympathetic nervous system innervation
A patient is admitted after she develops disseminated intravascular coagulation (DIC) after a vaginal delivery. Which laboratory value would the nurse expect to note to support this diagnosis?
Low platelet counts and elevated D-dimer concentrations and fibrinogen degradation products
A patient was admitted with gram-negative sepsis a few days ago. Today the nurse notes continual oozing from intravenous sites and ecchymosis beneath the blood pressure cuff. The patient's platelet count is normal, and international normalized ratio (INR) is elevated. The nurse places highest priority on which treatment goal?
Maintain adequate organ perfusion.
A patient is in the exudative phase of acute respiratory distress syndrome (ARDS). What does the nurse determine the function of surfactant will be in this phase?
Maintain alveolar stability
A patient is admitted with a severe diffuse axonal injury (DAI) secondary to a motor vehicle crash. The patient's plan of care would involve which nursing action?
Monitor blood pressure and temperature every hour.
The nurse is caring for a critically ill patient who is receiving heparin and understands that the patient is at risk for developing heparin-induced thrombocytopenia (HIT). Which intervention would be included into the patient's plan of care to monitor for this potential complication?
Monitor platelet count every 2 or 3 days from day 4 to day 14.
Which medication is prescribed to decrease cerebral vasospasm?
Nimodipine
The nurse is performing chest auscultation of a patient who is suspected of having acute respiratory distress syndrome (ARDS). What findings will the nurse document that indicate that the patient is in the early stages of this disorder?
Normal or fine scattered crackles
A patient is admitted with massive head trauma. The patient is unresponsive and on mechanical ventilation. The electroencephalogram (EEG) is negative for brain waves. The family has agreed to organ donation. When the nurse turns the patient's head quickly from side to side, the patient's eyes do not move. The nurse knows this is the result of the loss of what reflex?
Oculocephalic
The nurse is caring for a patient receiving mechanical ventilation with high levels of positive end-expiratory pressure (PEEP). What complication should the nurse monitor for in this patient?
PEEP is used to open collapsed alveoli but it decreases cardiac output and causes barotrauma
A patient has been admitted with a flail chest. What findings would the nurse expect to note supporting this diagnosis?
Paradoxical respiratory movement
A patient is admitted after being burned while lighting the barbecue. The injuries appear moist and red with some blister formation and the patient states they are very painful. What kind of burn would the nurse document in the patient's record?
Partial-thickness, second-degree burn
The nurse is caring for a patient with multiple-organ dysfunction syndrome (MODS). The nurse understands that earlier nutritional support is critical for the patient to prevent profound weight loss. Why does this occur in patient MODS?
Patient experiences hypermetabolism.
The nurse understands that certain trauma patients are at risk for developing fat embolism syndrome. Which group of patients is a high risk for this complication?
Patients with orthopedic trauma
A patient has been admitted with anaphylactic shock due to an unknown allergen. The nurse understands that the decrease in the patient's cardiac output is the result of which mechanism?
Peripheral vasodilation
What physiologic process can result in excessive burn edema and shock in a patient with injuries totaling more than 50% total body surface area (TBSA) burn?
Plasma colloid osmotic pressure is decreased because of protein leakage into the extravascular space.
A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. The nurse knows that varices are caused by which pathophysiologic mechanism?
Portal hypertension resulting in diversion of blood from a high-pressure area to a low-pressure area
A patient has developed acute respiratory distress syndrome (ARDS) in the intensive care unit. What nursing action will assist in the treatment of this disorder?
Positioning strategy
The nurse assesses a patient admitted two days ago with a diagnosis of chest trauma after a motor vehicle accident. Oxygen is being delivered at 60% by way of Venturi mask. Which assessment finding indicates the development of adult respiratory distress syndrome?
Progressive hypoxemia
The nurse is caring for a patient with decreased oxygenation that does not respond to elevation of the head of the bed. Which is the most appropriate position to improve oxygenation in a patient to recruit more alveoli?
Prone position
A patient has been admitted with acute liver failure. Which interventions would the nurse expect as part of the interprofessional collaborative management plan? (Select all that apply.)
Pulse oximetry and serial arterial blood gas measurements Monitoring electrolyte blood levels Assessing for signs of cerebral edema
What is the earliest sign of deterioration in a patient with a flail chest?
Respiratory rate increase
The nurse has been caring for a patient with liver dysfunction. The practitioner has just performed a liver biopsy at the bedside. Following a liver biopsy, how would the nurse position the patient?
Right side for 2 hours
An elderly patient is admitted with pneumonia. This morning the patient is febrile, tachycardic, tachypneic, and confused. The nurse suspects the patient may be developing what problem?
Sepsis
What is the most common cause of disseminated intravascular coagulation (DIC)?
Sepsis caused by gram-negative organisms
A nurse is discussing the concept of shock with a new graduate nurse. Which statement indicates the new graduate nurse understood the information?
Shock is an acute, widespread process of inadequate tissue perfusion.
The nurse is caring for a patient who has had a recent heart transplant. Which signs and symptoms would alert the nurse that the patient is rejecting the transplant? (Select all that apply.)
Shortness of breath Disturbance in mood Pulmonary crackles Sudden onset of edema
Which topical antimicrobial agent is commonly used as a broad-spectrum and fights against gram-positive and -negative bacteria?
Silver sulfadiazine
A patient with extensive burns is undergoing skin grafting. The nurse understands pain control is best achieved with what strategies during the early phase of recovery?
Small doses of intravenous opioids titrated to effect
A patient has been admitted with a neurologic disorder. With which disorder should the nurse be the most vigilant for the development of neurogenic shock?
Spinal cord injury
A patient who was an unrestrained driver in a high-speed, head-on motor vehicle collision presents with dyspnea, tachycardia, hypotension, jugular venous distention, tracheal deviation to the left, and decreased breath sounds on the right side. The nurse suspects these findings are indicative of which disorder?
Tension pneumothorax
A patient is admitted after being burned in a house fire. The nurse feels that the patient should be transferred to a burn center. Which factor is most important when determining whether or not to refer a patient to a burn center?
The medical history of the patient and the size and depth of the burn injury
Which of the following statements regarding Guillain-Barré syndrome (GBS) supports the admission to a critical care unit?
The most common cause of death is respiratory arrest.
What happens to patients that meet criteria for imminent death?
They are referred to the organ procurement organizations in a timely manner.
The nurse is caring for a patient who is had trans-sphenoidal surgery for removal of a pituitary tumor. The nurse observes a large amount of clear drainage from the nose. The provider requests the drainage be tested for the presence of glucose. Why did the physician order this test?
To assess for a cerebrospinal fluid leak
The nurse is developing a plan of care for a patient with acute respiratory distress syndrome. What does the nurse determine to be the primary goal of oxygen therapy for the treatment of this patient?
To correct hypoxemia
The nurse is caring for a patient with sepsis due to necrotic tissue. The nurse knows that necrotic tissue can stimulate the inflammatory immune response. Which biochemical mediator is secreted in response to endotoxin or tissue injury?
Tumor necrosis factor
A nurse and a nursing student are discussing management of the trauma patient. The nurse asks the student what the AVPU method is used for during the primary survey. Which response would indicate the new graduate nurse understood the information?
Used to assess level of consciousness
A patient has sustained an epidural hematoma after a 10-foot fall from a roof. The nurse understands that an epidural hematoma is a condition that has which characteristic?
Usually arterial in nature
The nurse is caring for a patient after a lung transplant. Which intervention would be a priority for the nurse?
Wean the patient from the ventilator.
A patient with severe traumatic brain injury has been admitted to the critical care unit. What is one intervention to minimize secondary brain injury?
administer fluids to keep the systolic blood pressure greater than 90 mm Hg.
A patient in cardiogenic shock is being treated in the critical care unit. Which findings would the nurse expect to note in the patient to support this diagnosis? (Select all that apply.)
heart rate greater than 100 beats/min; cool, pale, moist skin; weak, thready pulse; and increased right atrial pressure and pulmonary artery occlusion pressure.
