Sole Chapters: 14, 16, 20, 21

What is a normal glomerular filtration rate? 1. 80-125 mL/min 2. 125-180 mL/min 3. Less than 80 mL/min 4. More than 189 mL/min

1. 80-125 mL/min

Which patient being cared for in the emergency department should the charge nurse evaluate first? 1. A patient with a complete spinal injury at the C5 dermatome level 2. An alert patient with a subdural bleed who is complaining of a headache 3. A patient with a Glasgow Coma Scale score of 15 on 3-L nasal cannula 4. An ischemic stroke patient with a blood pressure of 190/100 mm Hg

1. A patient with a complete spinal injury at the C5 dermatome level

An elderly individual from an assisted living facility presents with severe scald burns to the buttocks and back of the thighs. The caregiver from the ALF accompanies the patient to the emergency department and states that the bath water was "too hot" and that the "patient sat in the water too long." What should the nurse do? 1. Ask the caregiver to step out while examining the patient's burn injury 2. Ask the caregiver to describe exactly how the injury occurred 3. Immediately contact the police to report the suspected elder abuse 4. Ask the caregiver at what temperature the water heater is set in the home

1. Ask the caregiver to step out while examining the patient's burn injury

The nurse is caring for a patient who has a temporary percutaneous dialysis catheter in place. In caring, for this, the nurse should take what action? 1. Assess the catheter site for redness and/or swelling 2. Use the catheter for drawing blood samples to reduce patient discomfort 3. Replace the transparent dressing every 10 days to prevent manipulation 4. Apply a sterile gauze to maintain sterility

1. Assess the catheter site for redness and/or swelling

The patient is in the critical care unit and will receive dialysis this morning. The nurse will take which action SATA 1. Assess the dialysis access site and report abnormalities 2. Evaluate morning laboratory results and report abnormal results 3. Weight the patient to monitor fluid status 4. Give all medications except for antihypertensive medications 5. Administer the patient's antihypertensive medications

1. Assess the dialysis access site and report abnormalities 2. Evaluate morning laboratory results and report abnormal results 3. Weight the patient to monitor fluid status

The nurse is caring for patient who has been struck by lightning. Because of the nature of the injury, the nurse assesses the patient for which possible complication? 1. Central nervous system deficits 2. Stress ulcers 3. Infection 4. Contractures

1. Central nervous system deficits

3. During the assessment of a patient after a high-speed motor vehicle crash, which of the following findings would increase the nurse's suspicion of a pulmonary contusion? (Select all that apply.) 1. Chest wall ecchymosis 2. Diminished or absent breath sounds 3. Signs of hypoxia on room air 4. Fractured ribs 5. Pink-tinged or blood secretions

1. Chest wall ecchymosis 3. Signs of hypoxia on room air 4. Fractured ribs 5. Pink-tinged or blood secretions

The nurse is assisting the patient who is recovering from moderate burns to select foods from the menu that will promote wound healing. Which statement indicates the nurse's knowledge of nutritional goals? 1. Choose foods that are high in protein, such as meat, eggs, and beans. These help the burns to heal." 2. "It is important to choose foods like bread and pasta that are high in carbohydrates. These foods will give you energy and help you to heal faster." 3. "Select foods that have lots of fiber, such as whole grains and fruits. These will promote removal of toxins from the body that interfere with healing." 4. "Avoid foods that have saturated fats. Fats interfere with the ability of the burn wound to heal"

1. Choose foods that are high in protein, such as meat, eggs, and beans. These help the burns to heal."

4. It is important to prevent hypothermia in the trauma patient because hypothermia is associated with which of the following? (Select all that apply.) 1. Coagulopathies 2. Reduced tissue perfusion 3. Dysrhythmias 4. ARDS 5. Myocardial dysfunction

1. Coagulopathies 2. Reduced tissue perfusion 3. Dysrhythmias 5. Myocardial dysfunction

Which complication may manifest after an electrical injury? SATA 1. Compartment syndrome of extremities 2. Cardiac dysrhthmias 3. Seizures 4. Dark brown urine 5. Long bone fractures 6. Peptic ulcer disease 7. Hypertension 8. Acute cataract formation

1. Compartment syndrome of extremities 2. Cardiac dysrhthmias 3. Seizures 4. Dark brown urine 5. Long bone fractures 8. Acute cataract formation

Which of the following infection control strategies should the nurse implement to decrease the risk of infection in the burn-injured patient? (Select all that apply.) 1. Daily assess the need for central IV catheters 2. Change indwelling urinary catheter every 7 days 3. Maintain strict aseptic technique during burn wound management 4. Restrict family visitation 5. Apply topical antibacterial wound ointments/dressings

1. Daily assess the need for central IV catheters 3. Maintain strict aseptic technique during burn wound management 5. Apply topical antibacterial wound ointments/dressings

What type of burn is capable of producing either a superficial cutaneous injury or a cardiopulmonary arrest and transient by severe central nervous system deficits 1. Electrical burn 2. Infection 3. Heat burn 4. Chemical burn

1. Electrical burn

Which interventions can the nurse implement to assist the patient's family in coping with the traumatic injury. SATA 1. Establish a family spokesperson 2. Coordinate a family conference 3. Ask the family about their normal coping mechanisms 4. Limit visitation to set times throughout the day 5. Provide an effective communication system between staff and family

1. Establish a family spokesperson 2. Coordinate a family conference 3. Ask the family about their normal coping mechanisms 5. Provide an effective communication system between staff and family

In an unconscious patient, eye movements are tested by the oculocephalic response. Which statements regarding the testing of this reflex are true? (Select all that apply.) 1. Eye movement in the opposite direction as the head when turned indicates an intact reflex. 2. Increased intracranial pressure (ICP) is a contraindication to the assessment of this reflex. 3. Doll's eyes absent indicate a disruption in normal brainstem processing. 4. Doll's eyes present indicate brainstem activity. 5. Presence of cervical injuries is a contraindication to the assessment of this reflex. 6. Eye movement in the same direction as the head when turned indicates an intact reflex.

1. Eye movement in the opposite direction as the head when turned indicates an intact reflex. 2. Increased intracranial pressure (ICP) is a contraindication to the assessment of this reflex. 3. Doll's eyes absent indicate a disruption in normal brainstem processing. 4. Doll's eyes present indicate brainstem activity. 5. Presence of cervical injuries is a contraindication to the assessment of this reflex.

The optimal measurement of intravascular fluid status during the immediate fluid resuscitation phase of burn treatment? 1. Hourly I&O 2. BUN 3. Daily weight 4. Serum potassium

1. Hourly I&O

The nurse is caring for a mechanically ventilated patient with a brain injury. Arterial blood gas values indicate a PaCO2 of 60 mm Hg. The nurse understands this value to have which effect on cerebral blood flow? 1. Increased cerebral blood volume due to vessel dilation 2. No effect on cerebral blood flow (PaCO2 of 60 mm Hg is normal) 3. Altered cerebral spinal fluid production and reabsorption 4. Decreased cerebral blood volume due to vessel constriction

1. Increased cerebral blood volume due to vessel dilation

2. Trauma patients are at high risk for multiple complications not only due to the mechanism of injury but also due to the patients' long-term management. Which of the following statements apply to trauma patients? (Select all that apply.) 1. Indwelling urinary catheters are a source of infection. 2. Patients often develop infection and sepsis secondary to central line catheters. 3. Pneumonia is often an adverse outcome of mechanical ventilation. 4. Wounds require sterile dressings to prevent infection. 5. Early ambulation is critical to achieving desired outcomes

1. Indwelling urinary catheters are a source of infection. 2. Patients often develop infection and sepsis secondary to central line catheters. 3. Pneumonia is often an adverse outcome of mechanical ventilation.

An 18-year-old unrestrained passenger who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. This patient should be treated at which level trauma center? 1. Level I 2. Level III 3. Level IV 4. Level II

1. Level I

Which of the following findings require immediate nursing interventions related to the assessment of a patient with a traumatic brain injury? (Select all that apply.) 1. MAP of 48 2. History of PTSD 3. Respiratory rate of 10 breaths/min 4. Elevated serum alcohol level 5. Non-reactive pupils

1. MAP of 48 3. Respiratory rate of 10 breaths/min 5. Non-reactive pupils

Fluid resuscitation is an important component of managing the trauma patient. Which of the following statements are true regarding the care of a trauma patient? (Select all that apply.) 1. Massive transfusions should be avoided to improve patient outcomes 2. Type O blood can be administered in emergency situation 3. Only fully cross-matched blood products are administered 4. 5% dextrose is recommended for rapid crystalloid infusion 5. IV fluids may need to be warmed to prevent hypothermia

1. Massive transfusions should be avoided to improve patient outcomes 2. Type O blood can be administered in emergency situation 5. IV fluids may need to be warmed to prevent hypothermia

The nurse is caring for a patient 3 days following a complete cervical spine injury at the C3 level. The patient is in spinal shock. Following emergent intubation and mechanical ventilation, what is the priority nursing action? 1. Monitor blood pressure. 2. Maintain body temperature. 3. Use proper hand washing. 4. Pad all bony prominences

1. Monitor blood pressure.

What event triggers AKI from post renal etiology? 1. Obstruction of the flow of urine 2. Conditions that interfere with renal perfusion 3. Conditions that act directly on functioning kidney tissue 4. Hypovolemia or decreased cardiac output

1. Obstruction of the flow of urine

While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the patient's left naris. What is the best nursing action? 1. Place a nasal drip pad under the nose. 2. Insert bilateral cotton nasal packing. 3. Have the patient blow the nose until clear. 4. Suction the left nares until the drainage clears.

1. Place a nasal drip pad under the nose.

7. Nursing priorities to prevent ineffective coagulation include which of the following? (Select all that apply.) 1. Prevention of hypothermia 2. Prevention of infection 3. Administration of potassium as ordered 4. Administration of fresh frozen plasma as ordered 5. Administration of calcium as ordered

1. Prevention of hypothermia 4. Administration of fresh frozen plasma as ordered 5. Administration of calcium as ordered

Presence of which substances would indicate a problem with renal function. SATA 1. RBC 2. Protein 3. Sodium 4. Creatinine 5. Uric acid

1. RBC 2. Protein 5. Uric acid

While caring for a patient with a closed head injury, the nurse assesses the patient to be alert with a blood pressure 130/90 mm Hg, heart rate 60 beats/min, respirations 18 breaths/min, and a temperature of 102° F. To reduce the risk of increased intracranial pressure (ICP) in this patient, what are the priority nursing actions? 1. Reduce ambient room temperature and administer antipyretics. 2. Insert an oral airway and monitor respiratory rate and depth. 3. Ensure adequate periods of rest between nursing interventions. 4. Maintain neutral head alignment and avoid extreme hip flexion.

1. Reduce ambient room temperature and administer antipyretics.

The nurse is caring for a patient with an electrical injury. The nurse understands that patients with electrical injury are at a high risk for acute kidney injury secondary to what related process? 1. Release of myoglobin from injured tissues 2. Nephrotoxic antibiotics for prevention of infection 3. Increased incidence of ureteral stones 4. Hypervolemia from burn resuscitation

1. Release of myoglobin from injured tissues

The nurse understands that negative-pressure wound therapy may be used in the treatment of partial-thickness burn wounds to accomplish what outcome? 1. Remove excessive wound fluid and promote moist wound healing 2. Quantify wound drainage amount for more accurate output assessment 3. Maintain a closed wound system to decrease the risk of infection 4. Increase patient mobility with large burn wounds

1. Remove excessive wound fluid and promote moist wound healing

Continuous venovenous hemofiltration (CVVH) is used for what purpose> 1. Remove fluids and solutes through the process of convection 2. Combine ultrafiltration, convection, and dialysis 3. Remove plasma water and solutes by adding dialysate 4. Remove plasma water in cases of volume overload

1. Remove fluids and solutes through the process of convection

Slow continuous ultrafiltration is also known as isolated ultrafiltration and is used for what purpose? 1. Remove plasma water in cases of volume overload 2. Remove plasma water and solutes by adding dialysate 3. Combine ultrafiltration, convection and dialysis 4. Remove fluids and solutes through the process of convection

1. Remove plasma water in cases of volume overload

Noninvasive diagnostic procedures used to determine kidney function include which of the following? SATA 1. Renal ultrasound 2. Kidney, ureter, bladder (KUB) x-ray 3. Intravenous pyelography (IVP) 4. Renal angiography 5. Magnetic resonance imagining (MRI)

1. Renal ultrasound 2. Kidney, ureter, bladder (KUB) x-ray 5. Magnetic resonance imagining (MRI)

Which of the following patients would require greater amounts of fluid resuscitation to prevent acute kidney injury associated with rhabdomyolysis? (Select all that apply.) 1. Second degree burns to 40% of the body 2. Pulmonary contusion and rib fractures 3. Lightning strike to the left arm and chest 4. Gunshot wound to the abdomen 5. Crush injury to right arm

1. Second degree burns to 40% of the body 3. Lightning strike to the left arm and chest 5. Crush injury to right arm

The nurse is providing care to manage the pain of a patient with burns. The physician has ordered opiates to be given intramuscularly. The nurse contacts the physician to change the order to intravenous administration because: 1. Tissue edema may interfere with drug absorption of injectable routes 2. Hypermetabolism limits effectiveness of medications administered intramuscularly 3. Burn pain is so severe it requires relief by the fastest route available 4. Intramuscular injections cause additional skin disruption

1. Tissue edema may interfere with drug absorption of injectable routes

The nurse is caring for a mechanically ventilated patient admitted with a traumatic brain injury. Which arterial blood gas value assessed by the nurse indicates optimal gas exchange for a patient with this type of injury? 1. pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg 2. pH 7.38; PaCO2 28 mm Hg; HCO3 26 mEq/L; PaO2 65 mm Hg 3. pH 7.38; PaCO2 40 mm Hg; HCO3 24 mEq/L; PaO2 70 mm Hg 4. pH 7.38; PaCO2 55 mm Hg; HCO3 22 mEq/L; PaO2 85 mm Hg

1. pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg

The patient asks the nurse if the placement of the autograft over his full-thickness burn will be the only surgical intervention needed to close his wound. The nurse's best response would be: 1. "An autograft is a biological dressing that will eventually be replaced by your body generating new tissue." 2. " Yes, an autograft will transfer your own skin from one area of your body to cover the burn wound." 3 "Unfortunately, an autograft skin is temporary graft and a second surgery will be needed to close the wound." 4. "Unfortunately, autografts frequently do not adhere well to burn wounds an a xenograft will be necessary to close the wound."

2. " Yes, an autograft will transfer your own skin from one area of your body to cover the burn wound."

The nurse is planning care to meet the patient's pain management needs related to burn treatment. The patient is alert, oriented, and follows commands. The pain is worse during the day when various treatments are scheduled. Which statement to the physician best indicates the nurse's knowledge of pain management for this patient? 1. "Can we ask the music therapist to come by each morning to see if that will help the patient's pain?" 2. "The patient's pain varies depending on the treatment given. Can we try patient-controlled analgesia to see if that helps the patient better?" 3. "The patient's pain is often unrelieved. It would be best if we can schedule the opioids around the clock." 4. "The patient's pain is often unrelieved. I suggest that we also add benzodiazepines to the opioids around the clock."

2. "The patient's pain varies depending on the treatment given. Can we try patient-controlled analgesia to see if that helps the patient better?"

The primary care provider has opted to treat a patient with a complete spinal cord injury with glucocorticoids. The orders are for 30 mg/kg over 15 minutes followed in 45 minutes with an infusion of 5.4 mg/kg/min for 23 hours. What is the total 24-hour dose for the 70-kg patient? 1. 12,750 mg 2. 10,794 mg 3. 5000 mg 4. 2478 mg

2. 10,794 mg

The nurse is caring for a patient admitted with a subarachnoid hemorrhage following surgical repair of the aneurysm. Assessment by the nurse notes blood pressure 90/60 mm Hg, heart rate 115 beats/min, respiratory rate 28 breaths/min, oxygen saturation (SpO2) 99% on supplemental oxygen at 3 L/min by cannula, a Glasgow Coma Score of 4, and a central venous pressure (CVP) of 2 mm Hg. After reviewing the orders, which order is of the highest priority? 1. Furosemide 20 mg intravenous push as needed 2. 500 mL albumin intravenous infusion 3. Decadron 10 mg intravenous push 4. Dilantin 50 mg intravenous push

2. 500 mL albumin intravenous infusion

The nurse is caring for an elderly patient who was admitted with renal insufficiency realizes that with advance age often comes declining renal function. What is an expected laboratory finding for this patient? 1. Hypokalemia 2. A normal serum creatinine level 3. An increased GFR 4. Lower serum levels of prescribed medications

2. A normal serum creatinine level

Which patient has the greatest risk of developing ARDS after traumatic injury? 1. A patient who has a fractured femur and is currently in traction 2. A patient who has received large volumes of fluid and/or replacement 3. A patient who has underlying COPD 4. A patient who has a closed head injury with a decreased LOC

2. A patient who has received large volumes of fluid and/or replacement

After receiving the hand-off report from the day shift charge nurse, which patient should the evening charge nurse assess first? 1. A patient with bacterial meningitis on droplet precautions 2. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104° F 3. A patient with meningitis complaining of photophobia 4. A mechanically ventilated patient with a GCS of 6

2. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104° F

Renal plays a role in blood pressure regulation by what process 1. Decreasing of sodium reabsorption 2. Activation of the renin-angiotensin-aldosterone cascade 3. Suppression of angiotensin production 4. Inhibition of aldosterone release

2. Activation of the renin-angiotensin-aldosterone cascade

Which of the following statements about the pain management of a burn victim are true? (Select all that apply.) 1. The intramuscular route is preferred for pain medication administration 2. Additional pain medication may be needed because of rapid body metabolism 3. Patients with a history of drug and alcohol abuse will require higher doses of pain medication 4. Oral medication is the preferred administration 5. Pain medication should be given before procedures such as debridement, dressing changes, and physical therapy

2. Additional pain medication may be needed because of rapid body metabolism 3. Patients with a history of drug and alcohol abuse will require higher doses of pain medication 5. Pain medication should be given before procedures such as debridement, dressing changes, and physical therapy

The nurse is caring for a patient admitted to the emergency department in status epilepticus. Vital signs assessed by the nurse include blood pressure 160/100 mm Hg, heart rate 145 beats/min, respiratory rate 36 breaths/min, oxygen saturation (SpO2) 96% on 100% supplemental oxygen by non-rebreather mask. After establishing an intravenous (IV) line, which order should the nurse implement first? 1. Obtain stat serum electrolytes. 2. Administer lorazepam. 3. Administer phenytoin. 4. Obtain stat portable chest x-ray

2. Administer lorazepam.

The nurse responds to a high heart rate alarm for a patient in the neurological intensive care unit. The nurse arrives to find the patient sitting in a chair experiencing a tonic-clonic seizure. What is the best nursing action? 1. Open the patient's mouth and insert a padded tongue blade. 2. Assist the patient to the floor and provide soft head support. 3. Insert a nasogastric tube and connect to continuous wall suction. 4. Restrain the patient's extremities until the seizure subsides.

2. Assist the patient to the floor and provide soft head support.

The patient in progressive care unit following arteriovenous fistula implantation in the left upper arm, is due to have blood drawn with the next set of vital signs and assessment. When the nurse assesses the patient, the nurse should take what action? 1. Start a new intravenous line in the left lower arm 2. Auscultate the left arm for a bruit and palpate for a thrill 3. Take blood pressure from the left arm 4. Draw blood from the left arm

2. Auscultate the left arm for a bruit and palpate for a thrill

Which of the following factors increase the burn patient's risk for venous thromboembolism? (Select all that apply.) 1. Electrical burn injury 2. Bedrest 3. Burn injury less than 10% 4. Burns to lower extremities 5. Delayed fluid resuscitation

2. Bedrest 4. Burns to lower extremities 5. Delayed fluid resuscitation

The nurse is caring for a patient who has undergone skin grafting of the face and arms for burn wound treatment. A primary nursing diagnosis is: 1. Decreased CO 2. Body image disturbance 3. Fluid volume deficit 4. Altered nutrition, less than body requirements

2. Body image disturbance

The nurse admits a patient to the emergency department with new onset of slurred speech and right-sided weakness. What is the priority nursing action to assure effective care? 1. Assess the patient's general orientation. 2. Determine the time of symptom onset. 3. Determine the patient's drug allergies. 4. Assess for the presence of a headache

2. Determine the time of symptom onset.

The patient has a temporary percutaneous catheter in place for treatment of AKI. The catheter has been in place for 5 days. What action should the nurse take? 1. Prepare to assist with routine dialysis catheter change to replace the existing catheter 2. Evaluate the patient for signs and symptoms of infection 3. Teach the patient that the catheter is designed for long-term use 4. Use of the three lumens for fluid administration

2. Evaluate the patient for signs and symptoms of infection

The nurse admits a patient to the critical care unit following a motorcycle crash. Assessment findings by the nurse include blood pressure 100/50 mm Hg, heart rate 58 beats/min, respiratory rate 30 breaths/min, and temperature of 100.5° F. The patient is lethargic, responds to voice but falls asleep readily when not stimulated. Which nursing action is most important to include in this patient's plan of care? 1. Range of motion to extremities 2. Frequent neurological assessments 3. Side to side position changes 4. Frequent oropharyngeal suctioning

2. Frequent neurological assessments

6. An autograft is used to optimally treat a partial- or full-thickness wound that: (Select all that apply.) 1. Is infected 2. Involves the face, hands, or feet 3. Involves a joint 4. Involves very large surface areas 5. Requires more than 2 weeks for healing

2. Involves the face, hands, or feet 3. Involves a joint 5. Requires more than 2 weeks for healing

The nurse receives a patient from the emergency department following a closed head injury. After insertion of an ventriculostomy, the nurse assesses the following vital signs: blood pressure 100/60 mm Hg, heart rate 52 beats/min, respiratory rate 24 breaths/min, oxygen saturation (SpO2) 97% on supplemental oxygen at 45% via Venturi mask, Glasgow Coma Scale score of 4, and intracranial pressure (ICP) of 18 mm Hg. Which order should the nurse institute first? 1. Ancef 1 g intravenous 2. Mannitol 1 g intravenous 3. Seizure precautions 4. Portable chest x-ray

2. Mannitol 1 g intravenous

During the treatment and management of the trauma patient, maintaining tissue perfusion, oxygenation, and nutritional support are strategies to prevent what potential complication? 1. Wound infection 2. Multisystem organ dysfunction 3. Septic shock 4. Disseminated intravascular coagulation

2. Multisystem organ dysfunction

Which of the following patients is at the greatest risk of developing AKI? 1. One who had a diagnostic test using a radiocontrast media 6 days 2. One discharge 2 weeks earlier after aminoglycoside therapy of 2 weeks 3. One with a history of controlled hypertension with blood pressure of 138/88 mm Hg 4. One with a history of fluid overload as a result of heart failure

2. One discharge 2 weeks earlier after aminoglycoside therapy of 2 weeks

8. The nurse is having difficulty inserting a large caliber intravenous catheter to facilitate fluid resuscitation to a hypotensive trauma patient. The nurse recommends which of the following emergency procedures to facilitate rapid fluid administration? 1. Insertion of a femoral catheter by a trauma surgeon 2. Placement of an intraosseous catheter 3. Rapid transfer to the operating room 4. Placement of a central line placement

2. Placement of an intraosseous catheter

The nurse is preparing to monitor intracranial pressure (ICP) with a fluid-filled monitoring system. The nurse understands which principles and/or components to be essential when implementing ICP monitoring? (Select all that apply.) 1. Manually flushing the device "prn" 2. Recording ICP as a "mean" value 3. Use of a pressurized flush system 4. Use of a heparin flush solution 5. Zero referencing the transducer system

2. Recording ICP as a "mean" value 5. Zero referencing the transducer system

The need for fluid resuscitation can be assessed best in the trauma patient by monitoring and trending which of the following tests? 1. Hourly urine output 2. Serum lactate levels 3. Arterial oxygen saturation 4. Mean arterial pressure

2. Serum lactate levels

Which intervention is a strategy to prevent fat embolism syndrome? 1. Provide prophylaxis with low-molecular weight heparin 2. Stabilize extremity fractures early 3. Intubate the patient early after the injury to provide mechanical ventilation 4. Administer lipid-lowering statin medications

2. Stabilize extremity fractures early

The patient's serum creatinine level is 0.7 mg/dL. The expected BUN level should be 1. 7-14 mg/dL 2. 1-2 mg/dL 3. 10-20 mg/dL 4. 20-30 mg/dL

3. 10-20 mg/dL

The nurse is caring for a burn-injured patient who weighs 154 pounds, and the burn injury covers 50% of his body surface area. The nurse calculates the fluid needs for the first 24 hours after a burn injury using a standard fluid resuscitation formula of 4 mL/kg/% burn of intravenous (IV) fluid for the first 24 hours. The nurse plans to administer what amount of fluid in the first 24 hours? 1. 28 L 2. 2800 mL 3. 14 L 4. 7000 mL

3. 14 L

Daily weights are being recorded for a patient with urine output that has been less than intravenous and oral intake. The patient's weight was 97.5 kg and this morning it is 99kg. The nurse understands that this corresponds to what? 1. A fluid loss of 1.5 L 2. A fluid loss of 0.5 L 3. A fluid retention of 1.5 L 4. An equal intake and output due to insensible losses

3. A fluid retention of 1.5 L

The nurse is caring for a patient who has circumferential full-thickness burns of his forearm? A priority intervention in the plan of care? 1. Keep the extremity in a dependent position 2. Splinting the forearm 3. Active and passive range of motion every hour 4. Preparing for an escharotomy as a prophylactic measure

3. Active and passive range of motion every hour

The nurse is to administer 100 mg phenytoin intravenous (IV). Vital signs assessed by the nurse include blood pressure 90/60 mm Hg, heart rate 52 beats/min, respiratory rate 18 breaths/min, and oxygen saturation (SpO2) 99% on supplemental oxygen at 3 L/min by cannula. To prevent complications, what is the best action by the nurse? 1. Administer via central line. 2. Administer over 2 minutes. 3. Administer over 5 minutes. 4. Mix medication with 0.9% normal saline

3. Administer over 5 minutes.

Which statement best defines the term traumatic injury? 1. All trauma patients can be successfully rehabilitated 2. Traumatic injuries cause more deaths that heart disease and cancer 3. Alcohol consumption, drug abuse, or other substance abuse contribute to traumatic events 4. Trauma mainly affects the older adult population

3. Alcohol consumption, drug abuse, or other substance abuse contribute to traumatic events

The nurse is caring for a patient with burns to the hands, feet, and major joints. The nurse plans care to include which of the following? (Select all that apply.) 1. Administering muscle relaxants around the clock 2. Keeping the limbs as immobile possible 3. Applying splints that maintain the extremity in an extended position 4. Wrapping fingers and toes individually with bandages 5. Implementing passive or active range-of-motion exercises

3. Applying splints that maintain the extremity in an extended position 4. Wrapping fingers and toes individually with bandages 5. Implementing passive or active range-of-motion exercises

The patient is on intake and output as well as dialy weights. The nurse notes that output is considerably less than intake over the last shift, and daily weight is 1 kg more than yesterday. The nurse should take what action? 1. Draw a trough level after the next dose of antibiotic 2. Insert an indwelling catheter 3. Assess the patient's lungs 4. Obtain an order to place the patient on fluid restriction

3. Assess the patient's lungs

The nurse is caring for a patient with an intracranial pressure ICP of 18 mm Hg and a GCS score of 3. Following the administration of mannitol, which assessment finding by the nurse requires further action? 1. CPP of 70 mm Hg 2. ICP of 10 mm Hg 3. CVP of 2 mm Hg 4. GCS score of 5

3. CVP of 2 mm Hg

Continuous venovenous hemodialysis is used for what purpose? 1. Remove plasma water in cases of volume overload 2. Remove plasma water and solutes by adding dialysate 3. Combine ultrafiltration, convention and dialysis 4. Remove fluids and solutes through the process of convection

3. Combine ultrafiltration, convention and dialysis

The nurse is preparing to administer a routine dose of phenytoin. The primary care provider orders phenytoin 500 mg intravenous every 6 hours. What is the best action by the nurse? 1. Administer over 2 minutes. 2. Assess cardiac rhythm. 3. Contact the primary care provider to discuss the order. 4. Administer with 0.9% normal saline intravenous.

3. Contact the primary care provider to discuss the order.

What statement about mass casualty triage during a disaster is true? 1. Priority treatments and interventions focus primarily on young victims 2. Once interventions have been initiated, healthcare providers cannot stop the treatment of disaster victime 3. Disaster victims with the greatest chances for survival receive priority for treatment 4. Color-coded systems in which green indicates the patient of greatest need are used during disasters

3. Disaster victims with the greatest chances for survival receive priority for treatment

How is peritoneal dialysis different from hemodialysis? 1. It is not indicated in cases of water intoxication 2. It is more frequently used for AKI 3. It uses the patient's own semipermeable membrane (peritoneal membrane) 4. It is not useful in cases of drug overdose or electrolyte imbalance

3. It uses the patient's own semipermeable membrane (peritoneal membrane)

The nurse admits a patient to the emergency department (ED) with a suspected cervical spine injury. What is the priority nursing action? 1. Remove cervical collar upon arrival to the ED. 2. Prepare for immediate endotracheal intubation. 3. Maintain proper head and neck alignment. 4. Keep the neck in the hyperextended position

3. Maintain proper head and neck alignment.

The nurse is caring for a patient admitted with new onset of slurred speech, facial droop, and left-sided weakness 8 hours ago. Diagnostic computed tomography scan rules out the presence of an intracranial bleed. Which actions are most important to include in the patient's plan of care? (Select all that apply.) 1. Maintain CO2 level at 50 mm Hg. 2. Restrain affected limb to prevent injury. 3. Make frequent neurological assessments. 4. Maintain MAP less than 130 mm Hg. 5. Prepare for thrombolytic administration

3. Make frequent neurological assessments. 4. Maintain MAP less than 130 mm Hg.

A patient admitted with severe burns to his face and hands is showing signs of extreme agitation. The nurse should explore the mechanism of burn injury possibly related to what data noted in the patient's medical history? 1. PTSD 2. Excessive alcohol use 3. Methamphetamine use 4. Subacute delirium

3. Methamphetamine use

The nurse is caring for a patient who sustained rib fractures after hitting the steering wheel of his car. The patient is spontaneously breathing and receiving oxygen via a face mask; the oxygen saturation is 95%. During the nurse's assessment, the oxygen saturation drops to 80%. The patient's blood pressure has dropped from 128/76 mm Hg to 84/60 mm Hg. The nurse assesses that breath sounds are absent throughout the left lung fields. The nurse notifies the physician and anticipates what prescribed intervention 1. Endotracheal intubation and mechanical ventilation 2. Chest x-ray study to determine the etiology of the symptoms 3. Needle thoracostomy and chest tube insertion 4. Administration of LR 1L wide open

3. Needle thoracostomy and chest tube insertion

The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at the scene briefly but is now conscious upon arrival at the emergency department (ED) with a GCS score of 15. One hour later, the nurse assesses a GCS score of 3. What is the priority nursing action? 1. Stimulate the patient hourly. 2. Elevate the head of the bed. 3. Notify the primary care provider immediately. 4. Continue to monitor the patient.

3. Notify the primary care provider immediately.

2. When providing information on trauma prevention, it is important to realize that individuals age 25 to 44 years are most likely to experience which type of trauma incident? 1. Violent or domestic traumatic altercations 2. High-speed MVC 3. Poisonings from prescription or illegal drugs 4. Work-related falls

3. Poisonings from prescription or illegal drugs

What is an initial symptom of a suspected compartment snydrome? 1. Pallor in the affected area 2. Paresthesia in the affected area 3. Severe, throbbing pain in the affected area 4. Absence of a pulse in affected extremity

3. Severe, throbbing pain in the affected area

What is normal urine output? 1. 80-125 mL/min 2. 80 mL/min 3. 180 L/day 4. 1-2 L/day

4. 1-2 L/day

The nurse is caring for a patient 5 days following clipping of an anterior communicating artery aneurysm for a subarachnoid hemorrhage. The nurse assesses the patient to be more lethargic than the previous hour with a blood pressure 95/50 mm Hg, heart rate 110 beats/min, respiratory rate 20 breaths/min, oxygen saturation (SpO2) 95% on 3 L/min oxygen via nasal cannula, and a temperature of 101.5° F. Which order should the nurse institute first? 1. Decadron 20 mg intravenous push every 4 hours 2. Acetaminophen 650 mg per rectum 3. Blood cultures (2 specimens) for temperature > 101° F 4. 500 mL albumin infusion intravenously

4. 500 mL albumin infusion intravenously

A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg.; blood pressure is 144/90 mm Hg, and mean arterial pressure (MAP) is 108 mm Hg. What is the cerebral perfusion pressure (CPP)? 1. 72 mm Hg 2. 54 mm Hg 3. 126 mm Hg 4. 90 mm Hg

4. 90 mm Hg

The primary care provider orders fosphenytoin, 1.5 g intravenous (IV) loading dose for a 75-kg patient in status epilepticus. What is the most important action by the nurse? 1. Administer via central line. 2. Contact the primary care provider to discuss the order. 3. Mix medication with 0.9% normal saline. 4. Administer drug at a slow infusion rate

4. Administer drug at a slow infusion rate

The patient diagnosed with acute kidney injury and has been getting dialysis 3 days per week reports general malaise and is tachypneic. An arterial blood gas is ordered and shows that the patient's pH is 7.19, with a PCO2 of 30 mmHg and a bicarbonate level of 12 mEq/L. The nurse prepares to take what action? 1. Administer morphine to slow the respiratory rate 2. Prepare for intubation and mechanical ventilation 3. Cancel tomorrow's dialysis session 4. Administer intravenous sodium bicarbonate

4. Administer intravenous sodium bicarbonate

The nurse is caring for a patient admitted to the ED following a fall from a 10-foot ladder. Upon admission, the nurse assesses the patient to be awake, alert, and moving all four extremities. The nurse also notes bruising behind the left ear and straw-colored drainage from the left nare. What is the most appropriate nursing action? 1. Maintain neutral head position. 2. Monitor airway patency. 3. Insert bilateral ear plugs. 4. Apply a small nasal drip pad.

4. Apply a small nasal drip pad.

The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine injury who is reporting a severe headache. The nurse assesses a blood pressure of 180/90 mm Hg, heart rate 60 beats/min, respirations 24 breaths/min, and 50 mL of urine via indwelling urinary catheter for the past 4 hours. What is the best action by the nurse? 1. Notify the physician of the patient's blood pressure. 2. Encourage the patient to take slow, deep breaths. 3. Administer acetaminophen as ordered for the headache. 4. Assess for a kinked urinary catheter and assess for bowel impaction.

4. Assess for a kinked urinary catheter and assess for bowel impaction.

What is the most likely site to have a sheet graft applied? 1. Arm 2. Leg 3. Chest 4. Face

4. Face

The patient has been admitted to the hospital with nausea and vomiting that started 5 days earlier with a blood pressure of 80/44 mm Hg and heart rate of 122 beats/min. The patient reports having not voided in 8 hours but there is no distention of the bladder. The nurse anticipates what "stat" order? 1. Infusion of inotropic agent 2. A blood transfusion 3. An antiemetic 4. Fluid replacement with 0.45% saline

4. Fluid replacement with 0.45% saline

5. A 24-year-old unrestrained driver who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. The primary survey of this patient upon arrival to the ED: 1. A methodical head-to-toe assessment identifying injuries and treatment priorities 2. Turning the patient from side to side to get a look at his back 3. A cervical spine x-ray study to determine the presence of a fracture 4. Getting a baseline assessment and establish priorities

4. Getting a baseline assessment and establish priorities

In the trauma patient, what is the most common causes of symptoms of decreased CO 1. Cardiogenic shock 2. Cardiac contusion 3. Pericardial tamponade 4. Hypovolemia

4. Hypovolemia

While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mm Hg and a CPP of 85 mm Hg. What is the best interpretation by the nurse? 1. ICP is high; CPP is low. 2. Both pressures are high. 3. Both pressures are low. 4. ICP is high; CPP is normal

4. ICP is high; CPP is normal

The nurse has just received a patient from the emergency department with an admitting diagnosis of bacterial meningitis. To prevent the spread of nosocomial infections to other patients, what is the best action by the nurse? 1. Dispose of all bloody dressings in biohazard bags. 2. Scrub the hub of all central line ports prior to use. 3. Wash hands thoroughly before leaving the room. 4. Implement droplet precautions upon admission.

4. Implement droplet precautions upon admission.

The nurse is caring for a patient admitted with bacterial meningitis. Vital signs assessed by the nurse include blood pressure 110/70 mm Hg, heart rate 110 beats/min, respiratory rate 30 breaths/min, oxygen saturation (SpO2) 95% on supplemental oxygen at 3 L/min, and a temperature 103.5° F. What is the priority nursing action? 1. Keep lights dim at all times. 2. Maintain bed rest at all times. 3. Elevate the head of the bed 30 degrees. 4. Implement seizure precautions.

4. Implement seizure precautions.

The nurse, caring for a patient following a subarachnoid hemorrhage, begins a nicardipine infusion. Baseline blood pressure assessed by the nurse is 170/100 mm Hg. Five minutes after beginning the infusion at 5 mg/hr, the nurse assesses the patient's blood pressure to be 160/90 mm Hg. What is the best action by the nurse? 1. Begin weaning the infusion. 2. Notify the physician of the BP. 3. Stop the infusion for 5 minutes. 4. Increase the dose by 2.5 mg/hr.

4. Increase the dose by 2.5 mg/hr.

When paramedics notice singed hairs in the nose of a burn patient, it is recommended that the patient be intubated. What is the reasoning for the immediate intubation? 1. The singed hairs and soot in the nostrils will cause dysfunction of the cilia in the airways 2. The patient will have a copious amount of mucus that will need to be suctioned 3. Carbon monoxide poisoning always when soot is visible 4. Inhalation injury above the glottis may cause significant edema that obstructs the airway

4. Inhalation injury above the glottis may cause significant edema that obstructs the airway

Why is silver is used as an ingredient in many burn dressings? 1. Stimulates wound healing 2. Stimulates tissue granulation 3. Provides topical pain relief 4. Is effective against a wide spectrum of wound pathogens

4. Is effective against a wide spectrum of wound pathogens

With sudden cessation of renal function, all body systems are affected by the inability to maintain fluid and electrolyte balance and eliminate metabolic waste. In critically ill patients, what statement regarding renal dysfunction is true? 1. It has little effect on morbidity, mortality, or quality of life 2. It has a low mortality once renal replacement therapy has been initiated 3. It is a very rare problem 4. It affects nearly two thirds of patients

4. It affects nearly two thirds of patients

The nurse assesses a patient with a skull fracture and notes a Glasgow Coma Scale score of 3. Additional vital signs assessed by the nurse include blood pressure 100/70 mm Hg, heart rate 55 beats/min, respiratory rate 10 breaths/min, oxygen saturation (SpO2) 94% on oxygen at 3 L per nasal cannula. What is the priority nursing action? 1. Increase supplemental oxygen delivery. 2. Support bony prominences with padding. 3. Elevate the head of the patient's bed. 4. Monitor the patient's airway patency.

4. Monitor the patient's airway patency.

A burn patient in the rehabilitation phase of injury is increasingly anxious and unable to sleep. The nurse should consult with the provider to further assess the patient for what possible mental health condition 1. Suicidal intentions 2. Bipolar disorder 3. Acute delirium 4. PTSD

4. PTSD

The nurse has admitted a patient to the ED following a fall from a first-floor hotel balcony. The patient is 22 years old and smells of alcohol. The patient begins to vomit in the ED. Which of the following interventions is most appropriate? 1. Offer the patient an emesis basin so that you can measure the amount of emesis 2. Insert an oral airway to prevent aspiration and to protect the airway 3. Send a specimen of the emesis to the laboratory for analysis of blood alcohol content 4. Prepare to suction the oropharynx while maintaining C-spine immobilization

4. Prepare to suction the oropharynx while maintaining C-spine immobilization

The nurse is caring for a mechanically ventilated patient with a sustained ICP of 18 mm Hg. The nurse needs to perform an hourly neurological assessment, suction the endotracheal tube, perform oral hygiene care, and reposition the patient to the left side. What is the best action by the nurse? 1. Apply bilateral heel protectors after repositioning. 2. Elevate the patient's head of the bed 30 degrees. 3. Hyperoxygenate during endotracheal suctioning. 4. Provide rest periods between nursing interventions.

4. Provide rest periods between nursing interventions.

What is the priority nurse intervention for a patient who experienced a chemical burn injury? 1. Remove all jewelry 2. Apply saline compresses 3. Contact a poison center for directions on neutralizing agents 4. Remove the patient's clothes and flush the area with water

4. Remove the patient's clothes and flush the area with water

What is the advantage of peritoneal dialysis? 1. Peritoneal dialysis is time intensive 2. Any biochemical disturbances are corrected rapidly 3. It has a decrease risk of peritonitis 4. The danger of hemorrhage is minimal

4. The danger of hemorrhage is minimal

A 63-year-old patient is admitted with new onset fever; flulike symptoms; blisters over her arms, chest, and neck; and red, painful, oral mucous membranes. The patient should be further evaluated for which possible non-burn injured skin disorder? 1. Graft vs host disease 2. Staphylococcal scalded skin syndrome 3. Necrotizing soft tissue infection 4. Toxic epidermal necrolysis

4. Toxic epidermal necrolysis

The patient has elevated blood urea nitrogen (BUN) and serum creatinine levels with a normal BUN/creatinine ratio. What do these levels most likely indicate?

A. Acute kidney injury, such as acute tubular necrosis (ATN)

The critical care nurse is responsible for monitoring the patient receiving continuous renal replacement therapy (CRRT). In doing so, what should the nurse do? A. Assess that the blood tubing is warm to the touch B. Cover the dialysis lines to protect them from light C. Use clean technique during vascular access dressing changes D. Assess the hemofilter q6h for clotting

A. Assess that the blood tubing is warm to the touch

The patient is admitted with acute kidney injury from a postrenal cause. Acceptable treatments for that diagnosis include what intervention? ( Select all that apply.) A. Bladder catheterization B. Placement of nephrostomy tubes C. Increasing CO D. Ureteral stenting E. Increasing fluid volume intake

A. Bladder catheterization B. Placement of nephrostomy tubes D. Ureteral stenting

The nurse caring for a patient who has undergone major abdominal surgery notices that the patient's urine output has been less than 20 mL/hour for the past 2 hours. At 0200 in the morning the patient's blood pressure is 100/60 mm Hg, and the pulse is 110 beats per minute. Previously, the pulse was 90 beats per minute with a blood pressure of 120/80 mm Hg. The nurse should take what action? A. Contact the primary health care provider and expect an order for a normal saline bolus B. Wait until 0900 when the provider makes rounds to report assessment findings C. Ignore the urine output, as this is most likely postrenal origin D. Continue to monitor urine output for 2 more hours

A. Contact the primary health care provider and expect an order for a normal saline bolus

The patient is a new postoperative patient. She weighs 75 kg. The nurse expects the minimal acceptable urine output to be what 1. 37 mL/hr 2. Less than 30 mL/hr 3. 80 mL/hr 4. 150 mL/hr

1. 37 mL/hr

Range-of-motion exercises, early ambulation, and adequate hydration are interventions to prevent this common complication observed in trauma patients? 1. Venous thromboembolism 2. Fat embolism 3. Nosocomial pneumonia 4. Catheter-associated infection

1. Venous thromboembolism

The nurse is conducting an admission assessment of an 82-year-old patient who sustained a 12% burn from spilling hot coffee on the hand and arm. Which statement is of priority to assist in planning treatment? 1. "Do you have any drug or food allergies?" 2. "Do you have a heart condition or heart failure?" 3. "Do you live alone?" 4. "Have you had any surgeries?"

2. "Do you have a heart condition or heart failure?"

Which of the following injuries would result in a greater likelihood of internal organ damage and risk for infection? 1. A knife wound to the right chest 2. A shotgun wound to the abdomen 3. A fall from a 6-ft ladder onto the grass 4. A MVC in which the driver hits the steering wheel

2. A shotgun wound to the abdomen

In patients with extensive burns, what process is responsible for edema occurring in both burned and unburned areas? 1. Decreased glomerular filtration 2. Increased capillary permeability 3. Catecholamine- induced vasoconstriction 4. Loss of integument barrier

2. Increased capillary permeability

What is the most common cause of acute kidney injury (AKI) in critically ill patients? 1. Medications 2. Sepsis 3. Fluid overload 4. Hemodynamic instability

2. Sepsis

What term is used to describe an increase in BUN and serum creatinine? 1. Oliguria 2. AKI 3. Azotemia 4. Prerenal disease

3. Azotemia

The patient receiving hemodialysis 3 days a week is 74 inches tall and weighs 100kg. In planning the care for this patient, the nurse provides what nutritional recommendation 1. Limiting protein intake to less than 50 g/day 2. Encouraging potassium intake of 10 mEq/day 3. Intaking 2500- 3500 kcal diet per day 4. Limiting fluid intake of less than 500 mL/day

3. Intaking 2500- 3500 kcal diet per day

The patient reporting severe flank pain when urinating has a urinalysis that shows sediment and crystals along with a few bacteria. This information suggestions what about the nature of the condtion 1. It is intrarenal 2. It is prerenal 3. It is postrenal 4. It is not renal related

3. It is postrenal

Tissue damage from burn injury activates an inflammatory response that increases the patient's risk for: 1. ARDS 2. AKI 3. Stress ulcers 4. Infection

4. Infection

The removal of plasma water and some low-molecular weight particles by using a pressure or osmotic gradient is identified by what term? 1. Clearance 2. Diffusion 3. Dialysis 4. Ultrafiltration

4. Ultrafiltration

How does continuous renal replacement therapy (CRRT) differ from conventional intermittent hemodialysis?

A. The process removes solutes and water slowly.

The most common reasons for initiating dialysis in acute kidney injury include which of the following? (Select all that apply.) A. Uremia B. Hypokalemia C. Hyperkalemia D. Acidosis E. Volume overload

A. Uremia C. Hyperkalemia D. Acidosis E. Volume overload

The patient's potassium level is 7.0 mEq/L. Besides dialysis, which of the following actually reduces plasma potassium levels and total body potassium content safely in a patient with renal dysfunction?

B. Kayexalate

The correct order of actions in the management of the postoperative surgical trauma patient who has been admitted to the critical care unit after surgery is: a. connect the patient to bedside monitor and mechanical ventilator b. obtain VS, rhythm, oxygen saturation, and neurological status c. assess airway, breathing, and circulation d. reassess and evaluate patency of IV lines, and adjust rate of fluid administration as ordered

C, A, B, D

The nurse is caring for a patient receiving peritoneal dialysis. The patient suddenly reports experiencing abdominal pain and chills. The patient's temperature is elevated. The nurse should take what action? A. Inform the provider of probable visceral perforation B. Check the patients blood sugar C. Assess peritoneal dialysate return. D. Check the patients neurologic status

C. Assess peritoneal dialysate return.

The nurse is caring for a patient who has sustained blunt trauma to the left flank area, and is evaluating the patient's urinalysis results. What related assessment finding should concern the nurse? A. Sodium and chloride are found in the urine B. Red blood cells and albumin are found in the urine. C. Uric acid levels has the same value as serum levels D. Creatinine levels in the urine are similar to blood levels

B. Red blood cells and albumin are found in the urine.

The patient getting hemodialysis for the second time reports a headache and nausea and, a little later, of becoming confused. The nurse realizes these are symptoms of what possible complication? 1. A shift in potassium levels 2. Dialyzer membrane incompatibility 3. Dialysis disequilibrium syndrome 4. Hypothermia

C. Dialysis disequilibrium syndrome

What is the correct priority order of actions in prehospital primary survey for burn injuries a. Assess ABCs and cervical spine b. Provide oxygen therapy if smoke inhalation is suspected c. Make rapid head-to-toe assessment to rule out additional trauma d. Stop the burning process and prevent further injury

D, A, B, C

Prevention of hypothermia is crucial in caring for trauma patients. The correct order of actions for the preparation for the trauma patient is a. Remove wet clothing b. Warm fluids and blood products before administration c. Cover the patient with an external warming device d. Warm the ED or ICU room before the patient's arrival

D, A, C, B

The nurse assessing a patient with a new arteriovenous fistula, does not hear a bruit or feel a thrill. Pulses distal to the fistula are not palpable. The nurse should take what action?

D. Notify the primary health care provider immediately

A patient with a 60% burn in the acute phase of treatment develops a tense abdomen, decreasing urine output, hypercapnia, and hypoxemia. Based on this assessment, the nurse anticipates interventions to evaluate and treat the patient for what complication? 1. Intraabdominal hypertension 2. ARDS 3. DIC disorder 4. AKI

Intraabdominal

Complications common to patients receiving hemodialysis include which of the following? (Select all that apply.) a. Hypotension b. Dysrhythmias c. Muscle cramps d. Hemolysis e. Air embolism

a. Hypotension b. Dsyrhythmias

The patient is in need of immediate hemodialysis, but has no vascular access. The nurse prepares the patient for insertion of: a. a percutaneous catheter at the bedside. b. a percutaneous tunneled catheter at the bedside. c. an arteriovenous fistula. d. an arteriovenous graft.

a. a percutaneous catheter at the bedside.

Treatment and/or prevention of rhabdomyolysis in at-risk patients includes aggressive fluid resuscitation to achieve urine output of: a. 30 mL/hr. b. 50 mL/hr. c. 100 mL/hr. d. 300 mL/hr.

c. 100 mL/hr.

The patient has just returned from having an arteriovenous fistula placed. The patient asks, When will they be able to use this and take this other catheter out? The nurse should reply, a. It can be used immediately so the catheter can come out anytime. b. It will take 2 to 4 weeks to heal before it can be used. c. The fistula will be usable in about 4 to 6 weeks. d. The fistula was made using graft material so it depends on the manufacturer.

c. The fistula will be usable in about 4 to 6 weeks.