P test 3 (Practice test 2 & #3 E)
Smallpox is considered a significant bioterrorist threat because: SATA a. a large percentage of the U.S. population has no immunity to smallpox. b. it is highly transmittable from person to person. c. Vaccines for smallpox are no longer required d. it does not have an incubation period e. death usually occurs within 24 hours
*a. a large percentage of the U.S. population has no immunity to smallpox. *b. it is highly transmittable from person to person. *c. Vaccines for smallpox are no longer required
Following severe blunt chest trauma to the pt's right thorax, chest tubes are placed for a pneumothorax. Two days later, nursing assessment reveals severe dyspnea, tracheal deviation to the left, & subcutaneous emphysema to the right upper chest wall. The nurse's first action should be to: a. examine the chest tube drainage system for kinks or obstructions. b. place an immediate call to the physician's office for urgent intervention. c. apply oxygen and titrate to maintain O2 sats above 90%. d. increase suction on wall regulator to 160mm Hg.
*a. examine the chest tube drainage system for kinks or obstructions. Classic s/s of tension pneumothorax which can be caused by a kinked or obstructed chest tube. The data requires the nurse's immediate attention
Nurse may expect a pt w/suspected early ARDS to exhibit which? a. PaO2 90, PCO2 45, X-Ray showing enlarged heart, bradycardia b. Thick green sputum production, PaO2 75, pH 7.45 *c. Restlessness, suprasternal retractions, PaO2 65 d. Wheezes, slow deep respirations, PCO2 55, pH 7.25
*c. Restlessness, suprasternal retractions, PaO2 65
The nurse is evaluating care for the patient in shock. The following actual outcomes suggest that interventions have been successful (select all that apply): a. peripheral pulses +1 b. urine output 23 ml/hr *c. capillary refill less than 3 seconds *d. SaO2 96% *e. Serum glucose 82
*c. capillary refill less than 3 seconds *d. SaO2 96% *e. Serum glucose 82 Successful outcomes for a patient in shock include capillary refill less than 3 seconds, SaO2 greater than 92% and a normal serum glucose. A normal peripheral pulse is +2 and U/O should be over 30 ml/hr.
The RN has obtained a full set of vital signs & is in the process of obtaining the history of the pt's injury. These steps are consistent with a. pre-hospital assessment b. primary survey c. secondary survey d. tertiary survey
*c. secondary survey Secondary survey is a brief systematic process that aims to identify all injuries by including a full set of vital signs, history of the event, and head to toe assessment.
Sepsis is the most common cause of DIC. What statemnts concerning this life threatening complication is true? SATA a. The rapid onset is determined by intensity of trigger & is related to the condition of pt's liver, bone marrow & endothelium. b. In early phase, the pt may manifes thrombosis & microemboli. c. Coagulopathy is present, but excessive blood loss rarely results in hemorrhagic shock. d. Most critical intervention for DIC is early ID & tx of underlying cause.
a, b, d
Nurse assessing a pt w/suspected sepsis. Which predisposing factors are expectd to be found in pt w/septic shock? a. 45 y/o pt w/hx of renal insufficiency. b. 65 y/o w/cancer recovering from abdominal peritoneal resection. c. 27 y/o w/pyelonephritis responding to treatment w/an antibiotic. d. 50 y/o w/community acquired TB
a. 45 y/o pt w/hx of renal insufficiency. b. 65 y/o w/cancer recovering from abdominal peritoneal resection. c. 27 y/o w/pyelonephritis responding to treatment w/an antibiotic. d. 50 y/o w/community acquired TB
Which should be readily avail at the bedside of a pt w/a chest tube? a. A bottle of sterile water b. Another sterile chest tube c. A nebulizer set-up d. A 20 ml syringe with blunt tip
a. A bottle of sterile water
Which of the following should be readily available at the bedside of a patient with a chest tube a. A bottle of sterile water b. Another sterile chest tube c. A nebulizer set-up d. A 20 ml syringe with blunt tip
a. A bottle of sterile water A bottle of sterile water should be available so that if the tube becomes disconnected from the pleurovac, the exposed tube end could be put immediately under water in order to maintain a negative air pressure seal. There is no need for the other supplies.
An appropriate intervention for a patient with DIC inclue: a. Administer platelets as ordered b. Give IM injections in the deltoid only c. Administer Aspirin to prevent ischemia d. Administer NSAIDS for pain
a. Administer platelets as ordered A patient with DIC may need platelets to replace those depleted. IM injections are contraindicated, ASA and NSAIDS may contribute to bleeding.
A client with multiple rib fractures has a diagnosis of flail chest. What assessment findings should the nurse expect to find? SATA a. Cyanosis b. Apnea c. Pain in the thoracic area with chest movement. d. Uninjured chest wall retracts e. Paradoxical chest movement
a. Cyanosis c. Pain in the thoracic area with chest movement. e. Paradoxical chest movement
A client with multiple rib fractures has a diagnosis of flail chest. What assessment findings should the nurse expect to find? SATA a. Cyanosis b. Apnea c. Pain in the thoracic area with chest movement. d. Uninjured chest wall retracts e. Paradoxical chest movement
a. Cyanosis c. Pain in the thoracic area with chest movement. e. Paradoxical chest movement A flail chest is caused by several rib fractures that create a see-saw movement of the chest with expansion and relaxation.
A critical component of the nursing role caring for a pt with SIRS is: a. Detecting early signs of organ dysfunction b. administering glucocorticoids to reduce inflammation c. maintaining hemoglobin at 9 or lower d. Assess lung sounds every 12 hours
a. Detecting early signs of organ dysfunction A critical component is vigilant assessment & ongoing monitoring to detect early signs of deterioration or organ dysfunction.
A pts ABG values on admission are: PO2 85, PCO2 38, pH 7.31, HCO3 18 indicates: a. Metabolic Acidosis b. Hyperventilation c. Respiratory Acidosis d. Cardiac Dysfunction
a. Metabolic Acidosis
The nurse would suspect DIC if the pts lab results indicated the following: a. PTT 120; Platelets 45; Fibrinogen 50 b. Platelets 425; Hematocrit 28; PTT 95 c. PTT 15; Hematocrit 54; Fibrinogen 480 d. Platelets 500; Hematocrit 52; PTT 8
a. PTT 120; Platelets 45; Fibrinogen 50
The nurse would suspect DIC if the pts lab results indicate? a. PTT 120; Platelets 45; Fibrinogen 50 b. Platelets 425; Hematocrit 28; PTT 95 c. PTT 15; Hematocrit 54; Fibrinogen 480 d. Platelets 500; Hematocrit 52; PTT 8
a. PTT 120; Platelets 45; Fibrinogen 50 Occurs as a complication of infection, malignancy, or a hemorrhagic episode. It's inappropriate accelerated systemic activation of the coagulation cascade, resulting in simultaneous hemorrhage and thrombosis Increased PT/Decreased Platelets & Fibrinogen levels.
A patient suffering from whole body radiation with 400 rads is assigned to your team. As the RN you would expect to find the following on assessment: (Select all that apply) a. Purpura b. Alopecia c. Severe leukopenia d. Paralysis e. Bradycardia
a. Purpura b. Alopecia c. Severe leukopenia Radiation exposure of 200- 600 rads can cause purpura, alopecia, and severe leukopenia. Paralysis and bradycardia are not symptoms of radiation exposure.
Early effect that shock has on body is a. SNS activation in attempt to preserve blood flow to vital organs. b. vasoconstriction in heart & brain that causes stimulation of renin-angiotensin system. c. decreased tissue perfusion results in aerobic metabolism leading to the development of lactic alkalosis. d. increased capillary permeability that leads to altered vascular fluid volume lvl.
a. SNS activation in attempt to preserve blood flow to vital organs.
37. A patient presents complaining of difficulty breathing and generalized weakness after having suffered chest pain for approximately 1 hour the previous night. Assessment data: Skin Pale, diaphoretic Breath Sounds equal, crackles throughout Perfusion Capilary beds dusky, jugular venous distention present, B/P 98/50 Pulse 118, thready Respirations 26, labored Temperture 98.6F Which condition is the patient suspected of suffering
a. Septic shock b. Neurogenic shock c. Hypovolemic shock *d. Cardiogenic shock General Feedback: "The early clinical presentation of a patient with cardiogenic shock is similar to that of a patient with acute decompensated heart failure, s/s may include tachycardia, hypotension, narrow pulse pressure, crackles in lungs. p.1719
Which of the following bioterrorism agents may be prevented with a vaccine? SATA a. Smallpox b. Tularemia c. Plague d. Anthrax
a. Smallpox d. Anthrax
A patient in shock presents with vital signs of HR 130, BP 60/40. After receiving both fluids and vasopressors, which evaluation parameter would best indicate an improvement in the patient's shock condition (Select all that apply): a. Urine output 40 ml/hr b. Blood pressure 100/60 c. Heart rate 124 d. SaO2 88% e. Central Venous Pressure (CVP) 2mm/Hg
a. Urine output 40 ml/hr b. Blood pressure 100/60 Outcomes for successful resuscitation of the patient in shock include urine output more than 30 ml/hr and improved BP. Heart rate should be less than 100, O2 Saturation over 92% and a CVP of 4-8 mm/Hg.
While assessing a pt in shock, nurse notes drop in the systolic BP 92 to 76 when hob is elevated 75 degrees. This finding indicates a need for a. additional fluid replacement. b. antibiotic administration. c. infusion of a sympathomimetic drug. d. administration of vasodilator.
a. additional fluid replacement.
A patient is brought to the emergency department with an iron bar protruding from the abdomen following an industrial accident. Which of the following actions would the nurse accomplish first a. assess the BP and pulse. b. carefully remove the iron bar. c. determine the presence bowel sounds. d. determine when the patient last ate.
a. assess the BP and pulse. Initial assessment=determining whether the pt has hypovolemic shock as a result of bleeding. Don't remove iron bar. A patient with an iron bar in place will be taken to surgery and assessed for bladder trauma there.
A pt w/massive trauma & possible SCI is admitted to ED. To determine if pt is has neurogenic shock in addition to hypovolemic shock nurse assesses for: a. bradycardia. b. hypotension. c. cool, clammy skin. d. increase systemic vascular resis (SVR).
a. bradycardia.
A patient with massive trauma and possible spinal cord injury is admitted to the ED. To determine if the pt is experiencing neurogenic shock in addition to hypovolemic shock the nurse assesses for: a. bradycardia. b. hypotension. c. cool, clammy skin. d. dilated pupils.
a. bradycardia. Bradycardia is the only answer that is unique to neurogenic shock. Hypotension=seen with all shock states. Cool clammy skin is not common in distributive type of shocks because of the massive vasodilation. Subnormal temp not a clear indicator of neurogenic shock because pts w/neurogenic shock can take on the temperature of environment & is not a reliable indicator.
The nurse suspects the EARLY onset of ARDS in a susceptible pt who develops: a. dyspnea, restlessness, and mild hypoxemia. b. tachypnea and hypertension with elevated PaO2. c. diffuse crackles and rhonchi on chest auscultation. d. paradoxical respiration with increased secretions.
a. dyspnea, restlessness, and mild hypoxemia. Early presentations of ARDS, the pt may have no resp symptoms, or may exhibit symptoms of dyspnea, tachypnea, cough & restlessness." p. 1758. Diffuse crackles and rhonchi are not specific to ARDS.
The development of MODS is confirmed in a patient who manifests: a. elevated serum amylase & lipase, serum creatinine of 3.8, & platelet count of 15,000. b. a RR 45, PaCO2 of 60, & chest x-ray w/bilateral diffuse patchy infiltrates. c. urine output 30ml/hr, BUN 65, & WBC 1,120. d. with an upper GI bleed, hemoglobin 7 & hematocrit of 25%.
a. elevated serum amylase & lipase, serum creatinine of 3.8, & platelet count of 15,000.
A pt w/ARDS has progressed to the fibrotic stage. The pt's family members are anxious about the pt's condition. In addressing the family's concerns it is important for the nurse to: a. support & help them understand the realistic expectations that chances of survival are poor. b. inform family that H/H nurses will help them maintain mechanical vent at home after the pt is discharged. c. refer family to social services & case mngmnt to transfer pt to LTC d. provide encouragement & support because pt's disease process started to resolve
a. support & help them understand the realistic expectations that chances of survival are poor.
4. A pt with (ARDS) progressed to the fibrotic stage. The pt's family are anxious about pt's condition. In addressing the family's concerns it is important for the nurse to: a. support family & help them to understand the realistic expectation that the pt's chance of survival is poor. b. inform family that home health will be able to help them maintain mechanical ventilation at home after pt is dischrged. c. refer family to social services & case management to transfer the pt to a LTC. d. provide encouragement & support to the family because the pt's disease process has started to resolve.
a. support the family and help them to understand the realistic expectation that the patient's chance of survival is poor. The fibrotic stage is the final stage of ARDS and has a grave prognosis. The patient will, most probably not be discharged to home or a long-term care facility.
As the triage nurse in a busy Emergency Department, the following four patients walk in. Which one should be seen first a. A 54 year old school teacher with her left arm in a sling b. A 23 year old college student who burned off his beard while camping c. An 82 year old nursing home resident with complaints of frequent loose brown colored stools d. A 43 year old plumber with intermittent 6/10 pain behind the right scapula
b. A 23 year old college student who burned off his beard while camping General Feedback: Exposure to fire and smoke put the student at risk for airway compromise due to progressing edema and smoke inhalation, making this the first priority.
A nurse is assessing the following patients. Which of the following patients is most likely to develop sepsis a. A 45 year old with a history of renal insufficiency. b. A 65 year old with colon cancer who is 2 days post-op from a bowel resection. c. A 27 year old with severe depression who attempted suicide with a Prozac overdose. d. A 50 year old with community acquired tuberculosis.
b. A 65 year old with colon cancer who is 2 days post-op from a bowel resection. Recent surgery is a large risk factor for infection and sepsis.
Which of the following is a complication of sepsis a. Pulmonary fibrosis b. Acute respiratory distress syndrome c. Mitral valve prolapse d. Tension pneumothorax
b. Acute respiratory distress syndrome (ARDS)=complication assoc w/sepsis. Infection in blood or other tissues accounts for more than 30% of cases.
Which of the following types of medications would a nurse expect to administer to a patient in anaphylactic shock? SATA a. Dobutamine (Dobutrex) b. Adrenalin (Epinephrine) c. Diphenhydramine (Benadryl) d. Furosemide (Lasix) e. Atropine Sulfate (Atropine)
b. Adrenalin (Epinephrine) c. Diphenhydramine (Benadryl) Methylprednisolone-given for anaphylactic shock. Dobutamine is a short-term inotropic medication . . . but is contra-indicated in shock w/o adequate fluid replacement. Morphine is a vasodilator. This patient needs fluid replacement.
A 42 year old victim of a terrorist attack arrives in the Emergency Department. Police inform the staff that this patient has been exposed to Anthrax (Bacilllus anthracis). As the RN responsible for his care you would know that: (Select all that apply) a. this patient requires droplet isolation b. Cipro (ciprofloxacin)is the drug of choice for treatment c. Respiratory status must be closely monitored d. Hematological status must be closely monitored e. Gentamicin (garamycin) is the drug of choice for treatment
b. Cipro (ciprofloxacin)is the drug of choice for treatment c. Respiratory status must be closely monitored Resp status must be monitored because it may cause hemorrhage & destruction of lung tissue w/inhalation of spores. There are no hematological effects and anthrax is only spread through direct contact through spores.
During assessment, the nurse would expect to find which of the following on a patient who has been a victim of a sub-lethal dose of whole body ionizing radiation exposure eight days ago a. Widening pulse pressure b. Decreased white blood cell count c. Constipation d. Elevated BUN
b. Decreased white blood cell count
The spouse of a patient who has just been admitted to the intensive care unit (ICU) with multiple traumatic injuries has just arrived in the ICU waiting room. Which action should the nurse take first a. Take the family member to the patient's room. b. Describe the patient's injuries and the care that is being provided. c. Discuss ICU visitation policies and encourage family visits. d. Invite the spouse to participate in a multidisciplinary care conference
b. Describe the patient's injuries and the care that is being provided. Lack of information=major source of anxiety & should be addressed first. Fam should be prepared for the pt's appearance & ICU environment b4 visiting the pt for 1st time. ICU visiting=individualized to each pt & family not dictated by visitation policies. Inviting family to participate in multidisciplinary conference is appropriate but not the initial action.
The spouse of a pt just admitted to (ICU) w/multiple traumatic injuries just arrived in ICU waiting room. Which action should nurse take first a. Take the family member to the pt's room. b. Describe pt's injuries & care being provided. c. Discuss ICU visitation policies & encourage family visits. d. Invite spouse to participate in a multidisciplinary care conference
b. Describe the pt's injuries & care being provided.
Which of the following interventions are appropriate to prevent Ventilator Associated Pneumonia (VAP)? SATA a. Suction endotracheal tube every hour *b. Elevate the HOB to 30 degrees c. Avoid performing sub glottal suctioning *d. Frequent oral care *e. Maintain a closed ventilator circuit
b. Elevate the head of the bed to 30 degrees d. Frequent oral care e. Maintain a closed ventilator circuit
Which of the following interventions are appropriate to prevent Ventilator Associated Pneumonia (VAP)? SATA a. Suction the endotracheal tube every hour b. Elevate the head of the bed to 30 degrees c. Avoid performing sub glottal suctioning d. Frequent oral care e. Maintain a closed ventilator circuit
b. Elevate the head of the bed to 30 degrees d. Frequent oral care e. Maintain a closed ventilator circuit Sub-glottal suctioning should be performed. Frequent suctioning should be avoided.
Most appropriate for a male client w/an ABG: pH 7.5, PaCO2 26, O2 sat 96%, HCO3 24, & PaO2 94 a. Admin prescribed decongestant. b. Instruct pt to breathe in a paper bag. c. Offer pt fluids frequently. d. Admin prescribed supplemental O2.
b. Instruct pt to breathe in a paper bag.
Which is a true characteristic of (MODs)? a. The cardiac system will be the first organ to show symptoms. *b. It's caused by the immune system's uncontrolled response to illness or injury. c. Decreasing the IV fluid delays progression of symptoms. d. There is progressive impairment of one or more organ system
b. It is caused by the immune system's uncontrolled response to illness or injury.
Results of ABG's are: pH: 7.5, PaCO2: 50, PaO2: 88, HCO3: 28; Base excess: +5. Evaluate the acid-base imbalance. a. Partially compensated respiratory alkalosis b. Partially compensated metabolic alkalosis c. Uncompensated metabolic alkalosis d. Compensated respiratory alkalosis
b. Partially compensated metabolic alkalosis
Which assessment finding would you expect to find in a patient with DIC? a. Rapid clotting times. b. Petechiae, oozing from injection sites, and hematuria. c. Increased platelet levels. d. Pain and swelling in the leg.
b. Petechiae, oozing from injection sites, and hematuria. General Feedback: The correct answer depicts petechiae.
A pt is admitted w/multiple rib fractures. The nurse notes an area over client's right clavicle is puffy & "crackling noise w/palpation. Based on assessment, what complication would the nurse anticipate a. Paradoxical respir and flail chest. b. Presence of a pneumothorax. c. Infiltrated subclavian IV w/fluid infusing. d. Hypercapnia & increasing lvls of hypoxia.
b. Presence of a pneumothorax.
The causative agent of plague is a. Bacillus anthracis. b. Yersinia pestis. c. Francisella tularemia. d. Ebola virus.
b. Yersinia pestis.
The nurse recognizes that sepsis is present in a patient who manifests: a. a Pa Co2 of 48 and WBC of 13,000. b. a RR of 24 and a WBC of 18,000. c. a heart rate of 82 and a PaCO2 of 30. d. a temp of 99.8 F and confusion.
b. a RR of 24 & a WBC of 18,000. Meets the clinical and lab criteria for determining the presence of sepsis. Other criteria include: PaCO2 90, and Temp > 101.4 or
Monitoring during fluid replacement is most important for: a. accident victim w/hypovolemic shock. b. a patient wcardiogenic shock due to recent MI. c. post surgical pt experiencing septic shock. d. pt suffering from anaphylactic shock following a bee sting.
b. a patient wcardiogenic shock due to recent MI.
A 32 y/o painter admitted to hospital after falling off ladder & breaking left arm. In the ER, the nurse begins to medicate him w/non-steroidal anti-inflammatory, for pain. Prior to administering this drug, the nurse must know: a. if the pt is taking any antihypertensive meds. b. if the patient has a history of gastric ulcers or GI problems. c. if there is a hx of cataracts in his family. d. if the pt has had any surgeries on the opposite arm.
b. if the patient has a history of gastric ulcers or GI problems.
A 32-year-old house painter admitted to the hospital after falling off a ladder and breaking his left arm. In the emergency room, the nurse begins to medicate him with a non-steroidal anti-inflammatory, for pain. Prior to administering this drug, the nurse must know: a. if the patient is taking any antihypertensive medications. b. if the patient has a history of gastric ulcers or GI problems. c. if there is a history of cataracts in his family. d. if the patient has had any surgeries on the opposite arm.
b. if the patient has a history of gastric ulcers or GI problems. A major side effect of NSAIDs is GI bleed. There is no contraindication for administering this medication to a patient with hypertention.
The nurse is caring for a patient whose vital signs are as follows: T - 102.8 F, BP 98/52, pulse 130/minute and respiratory rate 32/minute. ABG results show: pH = 7.55, PaCO2 = 28, PaO2 = 86, HCO3 =23. The most appropriate nursing diagnosis would be: a. altered tissue perfusion r/t metabolic alkalosis. b. ineffective breathing pattern r/t respiratory alkalosis. c. sensory/perceptual alteration r/t respiratory alkalosis d. impaired gas exchange r/t metabolic alkalosis.
b. ineffective breathing pattern related to respiratory alkalosis. Data shows RR 32 very high. Priorities A-B-C's & gases show the pt is blowing off CO2 causing respiratory alkalosis not metabolic alkalosis as in
To monitor a patient with severe acute pancreatitis for the early organ damage associated with MODS, the most important assessment for the nurse to make are a. stool for occult blood and bowel sounds b. lung sounds and oxygenation status c. serum creatinine and urinary output d. serum bilirubin levels and skin color
b. lung sounds and oxygenation status The respiratory system is often the first system to show signs of dysfunction in SIRS and MODS. Inflammatory mediators have a direct effect of the pulmonary vasculature. Alveolar edema occurs
The ED nurse is performing a PRIMARY survey on trauma Pt by first assessing: a. the acuity of pt's pain lvl to determine priority of care. b. the status of airway & presence of any deformities. c. whether the pt is responsive enough to provide needed history. d. VS including pulse oximetry.
b. the status of airway and presence of any deformities.
A pt is concerned about possible risk of anthrax exposure says to a nurse "I'm planning to ask my primary care provider for a Rx of Cipro to keep just in case I'm exposed." Which response should the nurse make to the client a. "That is a good idea. Do you have any questions on how to take the medication?" b. "Are you allergic to any medications, specifically any antibiotics?" c. "Antibiotics must be used only for confirmed cases of anthrax or direct exposure." d. "You should avoid infected people to prevent the disease."
c. "Antibiotics must be used only for confirmed cases of anthrax or direct exposure."
Which nursing action in the care of a mechanically vented pt w/ARDS is most appropriate for RN to delegate LPN working in a LTC setting? a. Teaching family about prognosis of the disease process b. Assessment of the pt's breath sounds *c. Admin of enteral tube feedings d. Obtaining pulmonary artery pressures
c. Admin of enteral tube feedings
Which of the following diagnostic tests would help the nurse to evaluate both oxygenation and ventilation in a patient with acute respiratory failure a. Chest x-rays b. Pulse oximetry c. Arterial blood gas analysis d. Pulmonary artery wedge pressures
c. Arterial blood gas analysis Most common dx study for respi failure is ABGs. ABG analysis determines the level of PaCO2, PaO2 and blood pH.
When anaphylatic shock is suspected, a nurse first action in the ED is to: a. Administer oxygen at 1 liter/minute. b. Determine the causative agent. c. Assess lungs for abnormal sounds. d. Start two 18 gauge peripheral IVs.
c. Assess lungs for abnormal sounds.
A client sustains a significant blood loss secondary to a trauma. The nurse anticipates using which of the following fluids to best replace the losses a. Crystalloids b. Colloids c. Blood d. Lipids
c. Blood
25. Which of the following is a risk factor for a patient developing MODS a. Minor burns b. Appendectomy c. Multiple blood transfusions d. Spinal injury
c. Multiple blood transfusions
Although highly contagious, this disease has been declared to be globally eradicated: a. Yellow fever b. Bubonic plague c. Smallpox d. Tularemia
c. Smallpox Smallpox is the only disease which has been globally eradicated in 1980. There is a vaccine available for those exposed. No other disease has been declared eradicated.
Pts wife visiting she observes the pt's chest drainage system & begins to question nurse about amt of bloody drainage in system. Best response from the nurse? a. Your husband's been really sick. This must be a difficult time. Let's sit down and talk about it." b. I have checked out all of the equipment & it is working fine, you do not need to worry about it" c. System is draining collected fluid from around lungs. Drainage is expected & doesn't mean he's bleeding." d. The chest tube is draining secretions from his chest, it's important for him to deep breathe frequently."
c. System is draining collected fluid from around lungs. The drainage is expected & doesn't mean he's bleeding.
The charge nurse is preparing to make assignments on a resp floor. Which of the following pts is most appropriate for the nurse to assign to a (LPN) a. The patient with pneumonia who has an SpO2 of 89% b. The patient being admitted from the emergency department after chest trauma with a pneumothorax c. The patient with a cough on respiratory isolation to rule out TB d. The patient with an asthma exacerbation with a history of intubation
c. The patient with a cough on respiratory isolation to rule out TB Most stable pt. A patient with hypoxia, an asthmatic patient with a history of intubation, and a patient with a new pneumothorax are all potentially unstable. Being on respiratory isolation does not indicate that the patient is unstable.
Nurse is preparing assignments on a resp floor. Which patient is most appropriate for nurse to assign to (LPN) a. The pt w/pneumonia & SpO2 of 89% b. The pt admitted from ED after chest trauma w/a pneumothorax c. The pt w/cough on resp isolation to rule out TB d. The pt w/asthma exacerbation w/hx of intubation
c. The pt w/cough on resp isolation to rule out TB
Which of the following statements best describes the management of MODS? a. The use of proton pump inhibitors & H2 agents to increase pH of stomach inhibit development of stress ulcers, an ileus, & malabsrption b. Maintaining vent settings that ensure tidal volume of at least 6 mL/kg of body wt will keep lungs from being injured by endothelial damage. c. There is no specific therapies for MODS other than supportive care and the early recognition of dysfunctional organ(s). d. Much of the organ damage that occurs w/MODS in the setting of severe sepsis is associated w/pre-existing conditions.
c. There is no specific therapies for MODS other than supportive care and the early recognition of dysfunctional organ(s).
MODS develops in severe sepsis as a result of SIRS, DIC & damage to endothelium. What best describes management of MODS? a. Use of PPI & H2 agents to increase pH of stomach, inhibit development of stress ulcers,ileus& malabsorption issues. b. Maintaining vent settings that ensure tidal vol of at least 6 mL/kg of body wt keeps lungs from injury by endothelial damage. c. There's no specific therapies for MODS other than supportive care & early recognition of dysfunctional organ(s). d. Much organ damage occurs w/MODS in the setting of severe sepsis is associated w/pre-existing conditions.
c. There's no specific therapies for MODS other than supportive care & early recognition of dysfunctional organ(s).
A pt is being evaluated in the (ED) after chest trauma & suspecte pneumothorax & obstructive shock. Which finding is indicative of pneumothorax becoming a tension pneumothorax: SATA a. Pt complains of pleuritic chest pain b. Subcutaneous Emphysema c. Tracheal Deviation d. The pt's systolic BP drops 110 to 80 e. Patient complains of dyspnea
c. Tracheal Deviation d. The pt's systolic BP drops 110 to 80
1. A 36-year-old female is admitted with vomiting and dehydration due to having the flu for 3 days. ABGs are pH 7.48, PaCO2 40, HCO3 33, SaO2 95%. What do these values indicate to the nurse a. Compensated metabolic acidosis b. Uncompensated respiratory alkalosis c. Uncompensated metabolic alkalosis d. Compensated metabolic alkalosis
c. Uncompensated metabolic alkalosis The pH is high indicating alkalosis. The bicarbonate is high indicates a metabolic alkalosis. The PaCo2 is normal indicating that there is no compensation taking place.
To evaluate both oxygenation & ventilation in a pt w/acute respiratory failure, the nurse uses? a. chest x-ray. b. pulse oximetry. c. arterial blood gas analysis. d. hemodynamic monitoring.
c. arterial blood gas analysis.
A triage nurse in a busy ED assesses a pt who complains of 6/10 abdominal pain & states "I had a temp of 104.6 F at home." The nurse's first action should be to a. ask the healthcare provider to order a non-steroidal antiinflammatory (NSAID) medication for the patient. b. obtain a clean catch urine specimen for urinalysis. c. assess the patient's current vital signs. d. tell the patient that it may be several hours before being seen by a doctor.
c. assess the patient's current vital signs.
10. A triage nurse in a busy emergency department assesses a patient who complains of 6/10 abdominal pain and states "I had a temperature of 104.6 F (40.3 C) at home." The nurse's first action should be to a. ask the healthcare provider to order a non-steroidal anti-inflammatory (NSAID) medication for the patient. b. obtain a clean catch urine specimen for urinalysis. c. assess the patient's current vital signs. d. tell the patient that it may be several hours before being seen by a doctor.
c. assess the patient's current vital signs. The first action by a nurse is always assessment. You need to assess the patient's current vital signs prior to medicating, getting a urine specimen, or informing the patient about the wait time.
A pt has a chest tube attached to a drainage system connected to suction. An order to ambulate the patient is received. The nurse should a. clamp chest tube and carefully ambulate the pt a short distance. b. question order as pts with chest tubes should be on bedrest. c. carefully ambulate the pt keeping drainage system lower than the patient's chest. d. disconnect drainage system from the chest tube, ambulate the pt, then reconnect the chest tube upon returning the client to bed.
c. carefully ambulate the patient keeping the drainage system lower than the patient's chest. Nurses should not routinely clamp a chest tube except when changing the drainage system or detecting air leaks. Patients are able to be ambulatory with chest tubes. A nurse would never want to disconnect the chest tube from the drainage system!
A pt is brought to the ED following a MV crash. Pt suffered blunt trauma to the abdomen. The pt is splinting the abdomen & complaining of pain. Bowel sounds hypoactive. A peritoneal lavage reveals negative results. Based on the above, the nurse plans for a. preparation for a paracentesis. b. orders for a blood transfusion. c. continued monitoring of pt's condition d. immediate prep of patient for surgery.
c. continued monitoring of the patient's condition.
The nurse suctions the patient's endotracheal tube when the patient: a. has diminished lung sound in all lobes. b. has not been suctioned for two hours. c. has coarse rhonchi over central airways d. needs stimulation to cough and deep breath
c. has coarse rhonchi over central airways Rhonchi can be cleared via suctioning. A. Represents atelectasis which does not indicate suctioning.
Maintenance of fluid balance in the patient with ARDS involves: a. hydration using hypotonic solutions b. administration of surfactant c. mild fluid restriction and diuretics as necessary d. keeping the Hemoglobin levels above 12 gms/dl
c. mild fluid restriction and diuretics as necessary Patient with ARDS is usually placed on mild fluid restriction and diuretics as necessary. Hypotonic solutions are not used=increase pulm edema Surfactant in the adult ARDS=doesn't improve outcome hemoglobin level usually kept around 9-10g/dl.
A nurse is caring for a patient who is experiencing multiple organ dysfunction syndrome (MODS). The primary goal for this patient is to: a. decrease systemic vascular resistance. b. mitigate refractory hypoxemia. c. promote perfusion of organs. d. promote healing of fibrotic tissue of lung.
c. promote perfusion of organs. Measures to reverse MODS are aimed at controlling the initiating event, promoting adequate organ perfusion, & maintaining nutritional support. The first affected organ of MODs is lung, the fibrotic tissue (scar tissue) indicates loss of function that cannot be reversed.
Select appropriate interventions for the patient with ARDS: (Select all that apply): a. Nasal cannula at 6 Liters/min b. Maintain the patient in a supine postion c. provide chest physical therapy d. inspect arterial line for redness e. initiate nutritional consult
c. provide chest physical therapy d. inspect arterial line for redness e. initiate nutritional consult Interventions include chest positioning, postural drainage, and vibration to mobilize secretions. All of this encompassess chest physical therapy.
You are the nurse in the ED during emergency triage care. Which pt would receive priority care. A pt with: a. multiple lacerations of face & head. b. bilateral fractured femurs. c. skull fracture and neck trauma. d. eye injuries & compound fractures to the arms.
c. skull fracture and neck trauma.
The patient's ventilator alarm sounds. The nurse examines the equipment and the patient but is unable to immediately determine the cause. As the patient's conditions worsens, the nurse's next action should be to: a. call the respiratory therapist. b. increase ventilator's oxygen flow rate. c. ventilate the pt using an Ambu bag. d. call code & begin CPR immediately.
c. ventilate the patient using an Ambu bag. It's imperative that the nurse manually ventilate the pt with Ambu bag while awaiting respiratory therapy to check the machine. No indication that the pt doesn't have pulse or is in resp arrest so not appropriate to call a code.
A nurse is triaging several pts who have arrived in the ED. Which order should the nurse place the following pts to see the physician: a 2 y/o w/fever of 102 rectally; a 64 y/o w/chest pain & weakness; a 40 y/o w/difficulty breathing; a 23 y/o with N/V for last 8 hours. a. 23 y/o, 2 y/o, 64 y/o, 40 y/o b. 64 y/o, 23 y/o, 40 y/o, 2 y/o c. 40 y/o, 2 y/o, 64 y/o, 23 y/o d. 40 y/o, 64 y/o, 2 y/o, 23 y/o
d. 40 y/o, 64 y/o, 2 y/o, 23 y/o
23. A nurse is triaging several patients who have arrived in the emergency department. Choose which order the nurse should place the following patients to be seen by the physician: a 2-year-old with a fever of 102 rectally; a 64-year-old with chest pain and weakness; a 40-year-old who has difficulty breathing; a 23-year-old with nausea and vomiting for last 8 hours. a. 23-year-old, 2-year-old, 64-year-old, 40-year-old b. 64-year-old, 23-year-old, 40-year-old, 2-year-old c. 40-year-old, 2-year-old, 64-year-old, 23-year-old d. 40-year-old, 64-year-old, 2-year-old, 23-year-old
d. 40-year-old, 64-year-old, 2-year-old, 23-year-old The 40-year-old is first priority in order to stabilize the airway, the 64-year-old is second due to chest pain and weakness and potential MI, the child has a fever and should be assessed for fluid volume status, and the 23-year-old is classified as non-urgent and should be seen last.
Which of the following types of shock features laryngeal edema and circulatory failure a. Cardiogenic shock b. Septic shock c. Neurogenic shock d. Anaphylactic shock
d. Anaphylactic shock Anaphylactic shock features the immune response release vasoactive mediators and causes increasing vascular permeability, and thus laryngeal edema.
Nursing action to be included in the plan of care for a pt w/a chest tube connected to a closed water seal drainage system a. Gently strip the chest tube frequently b. Position the drainage system at the chest level c. Clamp the chest tube during transport to x-ray d. Assist with coughing, turning and deep breathing
d. Assist with coughing, turning and deep breathing
Pt complaining of sob & weakness after chest pain for 1 hr the previous night. Assess data: Skin Pale, diaphoretic, Breath Sounds equal, crackles throughout, Perfusion Capilary beds dusky, JVD present, BP 98/50, P 118, thready, RR 26 labored, T 98.6F Which cond is the pt suspected of suffering? a. Septic shock b. Neurogenic shock c. Hypovolemic shock d. Cardiogenic shock
d. Cardiogenic shock
The nurse is assessing the chest tube for proper functioning in a pt who had CABG surgery. The nurse should be concerned if ? a. A column of water 20 cm high in the suction control chamber b. 75 mL of bright red blood in the drainage collection chamber c. An intact occlusive dressing at the insertion site d. Constant bubbling in the water seal chamber
d. Constant bubbling in the water seal chamber
Nurse assesses pt's chest tube & notes continuous bubbling in the water seal chamber. Based on this finding,what action should the nurse take 1st? a. Adjust the gauge on the wall suction. b. Add sterile water 2water seal chamber c. Notify the physician d. Inspect the chest tube set-up for an air leak
d. Inspect the chest tube set-up for an air leak
The nurse is assessing a patient's chest tube and notes continuous bubbling in the water seal chamber. Based on this finding, which of the following is the most appropriate first action for the nurse to take a. Adjust the gauge on the wall suction. b. Add sterile water to the water seal chamber c. Notify the physician d. Inspect the chest tube set-up for an air leak
d. Inspect the chest tube set-up for an air leak Continuous bubbling in the water seal chamber indicates a possible leak. The nurse should initially assess for the source of the air leak.
Patient in shock w/VS: HR 130, BP 60/40. After receiving fluids & vasopressors, what would best indicate improvement in the patient's shock condition a. Heart rate of 124 beats/minute b. Blood pressure of 100/70 c. Central venous pressure (CVP) 2 d. Urine output of 40 ml/hr
d. Urine output of 40 ml/hr
A patient admitted with a Urinary Tract Infection becomes increasingly confused and has the following vital signs: BP 90/76, HR 120, RR 20, T 101.6.& She is diagnosed with shock. Due to the nature of this shock, the nurse would anticipate this early treatment: a. positive inotropic agents. b. vasodilators. c. blood products. d. broad spectrum antibiotics.
d. broad spectrum antibiotics. The data suggests that the client has urosepsis which should be treated initially with broad spectrum antibiotics.
In formulating a nursing care plan for a patient with ARDS, the primary goal would be to: a. improve nutritional status to promote healing. b. decrease viscosity of secretions by aggressive hydration. c. administer prophylactic antibiotics to avoid sepsis. d. improve gas exchange to increase tissue perfusion.
d. improve gas exchange to increase tissue perfusion. The goals for ARDS are to improve oxygenation and to treat the underlying condition.
Patient suffered moderate blood loss doesn't respond adequately to fluid replacement. Order given for dopamine hydrochloride infusion. Desired effect of this drug in this situation is: a. decreased renal blood flow. b. vasodilation. c. increased heart rate. d. increased cardiac output.
d. increased cardiac output.
A patient who has suffered from moderate blood loss does not respond adequately to fluid replacement. An order is given for dopamine hydrochloride infusion. The desired therapeutic effect of this drug in this situation is: a. decreased renal blood flow. b. vasodilation. c. increased heart rate. d. increased cardiac output.
d. increased cardiac output. Improves contractility to increase C/O & improve tissue perfusion. HR can be increased w/Dopamine infusion however, this is not the desired therapeutic effect in this pt. This is the underlying effect of the drug. As it increases perfusion throughout the body there will be an increased renal blood flow but this is not the only reason dopamine is given. Dopamine is not given to affect preload.
A pt recovering from ARDS is on vent set on CPAP mode. This setting indicates to the nurse that the patient: a. needs to be on an Acetylcholine Blocker drug to promote maximal ventilation/perfusion. b. is receiving a pre-set number of ventilations each minute. c. most likely has a need for high concentrations of oxygen. d. is being weaned & is breathing spontaneously.
d. is being weaned and is breathing spontaneously.
A patient recovering from ARDS is on a vent set on Continuous Positive Airway Pressure (CPAP) mode. This setting indicates to the nurse that the patient: a. needs to be on an Acetylcholine Blocker drug to promote maximal ventilation/perfusion. b. is receiving a pre-set number of ventilations each minute. c. most likely has a need for high concentrations of oxygen. d. is being weaned and is breathing spontaneously.
d. is being weaned and is breathing spontaneously. a) incorrect. use of Acetylcholine blocker would paralyze pt & would require full ventilatory support. CPAP can't be used with this mode of ventilation. b) incorrect. CPAP requires pt to breathe spontaneously so vent doesn't provide TV or breaths in this mode. c) incorrect. If pt requires high concentrations of O2=not ready to be weaned & will require more vent support than CPAP.
Pt w/Guillain-Barré dvlops resp acidosis from reduced alveolar ventilation. Which combo of ABG values confirms resp acidosis? a. pH 7.50, PaCO2 30, HCO3 28 b. pH 7.40, PaCO2 35, HCO3 22 c. pH 7.35, PaCO2 40, HCO3 30 d. pH 7.25, PaCO2 50, HCO3 28
d. pH 7.25, PaCO2 50, HCO3 28
Best nursing intervention for a pt in septic shock who has nursing dx of fear r/t perceived threat of death is to a. assure pt everything will be all right. b. ask HCP to prescribe a sedative drug for the patient. c. leave pt alone w/family whenever possible d. place pt's call bell where it can easily be reached.
d. place pt's call bell where it can easily be reached.
A pt w/ARDS is placed on mechanical vent w/use of PEEP. PEEP works by: a. preventing fibrotic infiltration of the lung tissue. b. applying positive pressure during inhalation to fully inflate the lungs. c. providing for delivery of 100% O2 to lungs under pressure. d. preventing alveolar collapse by keeping lungs partially expanded during expiration.
d. preventing alveolar collapse by keeping lungs partially expanded during expiration.
A pt w/ARDS is placed on mechanical ventilation with the use of PEEP. PEEP works by: a. preventing the fibrotic infiltration of the lung tissue. b. applying positive pressure during inhalation to fully inflate the lungs. c. providing for the delivery of 100% oxygen to the lungs under pressure. d. preventing alveolar collapse by keeping them partially expanded during expiration.
d. preventing alveolar collapse by keeping them partially expanded during expiration. The rationale for placing a patient with ARDS on a ventilator and with PEEP is to prevent alveolar collapse to improve oxygenation status. The positive pressure is applied at the end of expiration not during expiration.
