Unit 1 Review Questions

C. Somnolence, lethargy, and coma are seen with CO2 retention. Nasal flaring, paradoxical respirations, and muscle retracts are seen with respiratory muscle fatigue (clinical alert).

A patient in acute respiratory failure is experiencing carbon dioxide narcosis secondary to increased CO2 retention. What assessment finding should the nurse expect? A. Nasal flaring B. Paradoxical respirations C. Somnolence D. Suprasternal muscle retractions

D. A patient with COPD will be most comfortable in an upright position that facilitates lung expansion. Proning will not be tolerated, and a 15-degree elevation is not high enough. A recliner is sometimes helpful, but not leaning back as far as it will go.

A patient presents to the emergency department in acute respiratory distress. She has a long-standing history of COPD. Which of the following positions should the nurse place this patient in for optimal tissue perfusion? A. Prone on a stretcher B. In a recliner leaning back as far as it will go C. Side-lying with HOB at 15 degrees D. Stretcher with HOB as high as it will go

A, D

After receiving handoff report from the night shift, the nurse completes the morning assessment of a patient with severe sepsis. Vital sign assessment notes blood pressure 95/60 mm Hg, heart rate 110 beats/min, respirations 32 breaths/min, oxygen saturation (SpO2)96% on 45% oxygen via Venturi mask, temperature 101.5° F, central venous pressure (CVP/RAP) 2 mm Hg, and urine output of 10 mL for the last hour. Given this report, the nurse obtains orders for treatment that include which of the following? (Select all) A. Administer infusion of 500 mL 0.9% normal saline every 4 hours as needed if the CVP is <5 mm Hg. B. Increase supplemental oxygen therapy to 60% Venturi mask. C. Administer 40 mg furosemide (Lasix) intravenously as needed if the urine output is less than 30 mL/hr. D. Administer acetaminophen (Tylenol) 650 mg suppository per rectum as needed to treat temperature >101° F.

D. Of all upper GI hemorrhages, 80% to 90% are self-limiting and stop with lavage therapy alone or on their own. A large-bore nasogastric tube, not a small-bore tube, is inserted and is connected to suction. Iced lavage is used in some centers, although the evidence for this use is not well documented. After lavage, the nasogastric tube may be left in or removed. Nasogastric tubes left in place may increase hydrochloric acid secretion in the stomach and cause increased bleeding.

In implementing large-volume gastric lavage for a patient with gastrointestinal (GI) bleeding, the nurse is aware that: A. Iced saline is required to stop GI bleeding B. Gastric tubes are left in place to reduce acid production C. Small-bore gastric tubes are always used D. Most upper GI hemorrhages are self-limiting

A. Noncardiogenic pulmonary edema is seen in ARDS secondary to damage to the alveolar-capillary membrane. Decreased cardiac output, tension pneumothorax, volutrauma, and hypoxemia are not causes.

The etiology of pulmonary edema in acute respiratory distress syndrome is related to: A. Damage to the alveolar-capillary membrane B. Decreased CO C. Tension pneumothorax D. Volutrauma and hypoxemia

C. Positive inotropic agents such as dobutamine (Dobutrex) are given to increase the contractile force of the heart in cardiogenic shock. Dopamine (Intropin) is used primarily in low cardiac output states to restore vascular tone and increase blood pressure, but not in cardiogenic shock. Neo-Synephrine would be contraindicated in cardiogenic shock, as the vasoconstriction it produces would exacerbate cardiac ischemia. Nitroprusside (Nipride), used for preload and after load reduction, can improve cardiac performance in shock states by its reduction of systemic vascular resistance.

The nurse admits a patient to the coronary care unit in cardiogenic shock. The nurse anticipates administering which medication in an effort to improve cardiac output by increasing the contractile force of the heart? A. Dopamine (Inotropin) B. Phenylephrine (Neo-Synephrine) C. Dobutamine (Dobutrex) D. Nitroprusside (Nipride)

A. LR solutions contain lactate, which the liver converts to bicarbonate. If liver function is normal, this will counteract lactic acidosis. However, LR should not be infused if lactic acidosis is severe. To replace every 1 mL of blood loss, 3 mL of crystalloid is administered. There is no evidence to support colloid administration being more beneficial than crystalloid administration in shock states. Hypotonic solutions such as 0.45% normal saline are not administered in shock states as these solutions rapidly leave the intravascular space, causing interstitial and intracellular edema.

The nurse educator is presenting a lecture on crystalloid fluid replacement therapy in shock states. Which statement by a nurse indicates that the teaching has been effective? A. LR should not be used if lactic acidosis is severe B. 3 mL of crystalloid is administered to replace 10 mL of blood loss C. Administration of colloids is preferred over crystalloids D. Solutions of 0.45% NS are used routinely in shock

A. Early goal-directed therapy includes administration of IV fluids to keep the central venous pressure at 8 mm Hg or greater. Additional therapeutic end points include a heart rate at less than 110 beats/min and a mean arterial blood pressure at 65 mm Hg or greater. Serum lactate levels are elevated in sepsis; target levels should be <2.2 mEq/L.

The nurse is caring for a patient admitted with severe sepsis. The physician orders include the administration of large volumes of isotonic saline solution as part of early goal-directed therapy. Which of the following best represents a therapeutic end point for goal-directed fluid therapy? A. Central venous pressure 8 mm Hg or greater B. Heart rate >60 beats/min C. Mean arterial pressure 50 mm Hg or greater D. Serum lactate >6 mEq/L

A. Neurological changes, such as anxiety and restlessness, are early signs of hypoxemia in respiratory failure. Other early signs are tachycardia and increased blood pressure. Cyanosis, dyspnea, and nasal flaring are later signs.

The nurse is caring for a patient at risk for respiratory failure. Which assessment findings would alert the nurse to potential respiratory failure? A. Anxiety and restlessness B. Cyanosis and hyperventilation C. Dyspnea and nasal flaring D. HTN and bradycardia

B.

The nurse is caring for a patient being treated with an intraaortic balloon pump. Which intervention is most important to include in the patient's plan of care? A. Turning side to side every 2 hours B. Assessing peripheral pulses C. Padding bony prominences D. Applying splint to affected limb

A. Abdominal distention, particularly in the presence of pain, should always be investigated because it usually indicates trapped air or fluid within the abdominal cavity. Pigmentation of skin (jaundice), lesions, discolorations, old or new scars, and vascular and hair patterns may indicate general nutrition and hydration status but not acute issues. The nurse looks for any obvious abdominal masses, which are seen best on deep inspiration. Pulsations, if they are seen, usually originate from the aorta. Motility of the stomach may be reflected in movement of the abdomen in lean patients, and is a normal sign. However, strong contractions are abnormal and indicate the presence of disease.

The nurse is caring for a patient complaining of abdominal pain. The nurse notes that the patient's abdomen is more distended that it was earlier that morning. The nurse interprets this as: A. The presence of trapped air or fluid in the abdominal cavity B. The pigmentation of the skin may indicate nutritional status C. An abdominal mass that may be present and growing D. The presence of strong abdominal contractions indicate the lack of disease

D. In neurogenic shock, there is an interruption of impulse transmission or blockage of sympathetic outflow, resulting in vasodilation, inhibition of baroreceptor response, and impaired thermoregulation. Interruption of sympathetic nerve innervation would result in bradycardia. Interruption of sympathetic nerve innervation would result in hypotension. Hypoventilation is not a physiological mechanism.

The nurse is caring for a patient in neurogenic shock. Which should the nurse assess for? A. Tachycardia B. HTN C. Hypoventilation D. Vasodilation

B. Care of a patient in shock is directed toward correcting or reversing the altered circulatory component and reversing tissue hypoxia. Restoring circulating intravascular volume is the priority in improving tissue perfusion and oxygen delivery.

The nurse is caring for a patient in shock. Which is a priority action by the nurse? A. Ensure adequate cellular hydration B. Maintain adequate tissue perfusion C. Prevent third-spacing of fluids D. Support mechanical ventilation

D. Maldistribution of blood flow refers to the uneven distribution of flow to various organs and pooling of blood in the capillary beds. This impaired blood flow leads to impaired tissue perfusion and a decreased oxygen supply to the cells, all of which contribute to multiple organ failure. Damage to the type II pneumocytes leads to ARDS. Consumption of clotting factors may cause DIC. Low arterial blood pressure leads to decreased cerebral perfusion pressure.

The nurse is caring for a patient who has blood pooling in the capillary bed and arterial blood pressure too low to support perfusion of vital organs. Which symptoms should the nurse assess for? A. ARDS B. DIC C. Increased cerebral perfusion pressure D. Multisystem organ failure and/or dysfunction

A.

The nurse is caring for a patient who is being monitored with a central venous catheter. In preparing to record a right atrial pressure reading, what is most important for the nurse to keep in mind when recording an accurate value? A. Record the pressure at the end of expiration. B. Low pressures indicate ventricular dysfunction. C. High pressures are likely to indicate hypovolemia. D. Zero referencing is not needed before every recording.

A, B, D Management of hepatic encephalopathy involves addressing precipitating factors such as infection, gastrointestinal bleeding, and electrolyte and acid-base imbalances. Lactulose, neomycin, and metronidazole are medications that can be administered to reduce bacterial breakdown of protein in the bowel. Metronidazole is given 500 mg to 1.5 g/day for 1 week. Metronidazole may cause epigastric discomfort, which may in turn result in poor compliance with long-term treatment. Restriction of medications that are toxic to the liver is another important treatment. All medications that are metabolized by the liver should be reviewed for their therapeutic effect. Protein intake is limited to 20 to 40 g/day.

The nurse is caring for a patient with hepatic encephalopathy. Management of hepatic encephalopathy involves addressing precipitation factors. The nurse should provide: (Select all) A. Lactulose enemas B. Oral neomycin C. Metronidazole for 14 days D. Evaluation of ordered medications for liver toxicity E. Increasing dietary protein levels to aid in healing

B, C Solutions of 5% dextrose in water and 0.45% normal saline are hypotonic and are not used for fluid resuscitation. Hypotonic solutions rapidly leave the intravascular space, causing interstitial and intracellular edema. A systematic review of 30 randomized controlled trials found no benefit in giving colloids (e.g., albumin) over crystalloids and recommended against the administration of colloids in most patient populations.

The nurse is caring for a patient with hypovolemia. Which large volume crystalloid solution should the nurse anticipate the health care provider to order? (Select all) A. 5% dextrose B. LR C. NS D. Albumin

D. Distributive shock presents with widespread vasodilation and decreased systemic vascular resistance that result in a relative hypovolemia. Blood loss is associated with hypovolemic shock. Decreased cardiac output is a primary cause of cardiogenic shock. Primary internal sequestration of fluids that causes internal fluid loss is associated with hypovolemic shock.

The nurse is caring for a patient with possible distributive shock. Which should the nurse look for on assessment? A. Blood loss and hypovolemia B. Decreased CO C. Third-spacing of fluids into peritoneal space D. Vasodilation and relative hypovolemia

D.

The nurse is caring for a patient with severe sepsis. Vital signs assessed by the nurse include BP 88/60 mm Hg, HR 145 beats/min, RR 28 breaths/min, temperature 101° F, CVP 1 mm Hg, and SpO2 94% on 3 L/cannula. Which physician order should the nurse initiate first? A. Bedside glucose every 4 hours B. Tylenol 650 mg PR for temp > 101° F C. Urine culture and sensitivity D. 500 mL bolus of 0.9% normal saline

B.

The nurse is drawing labs on a patient with COPD in the critical care unit. Which baseline arterial blood gases (ABGs) should the nurse expect for this patient? A. PaO2 50 mm Hg; PaCO2 35 mm Hg B. PaO2 55 mm Hg; PaCO2 55 mm Hg C. PaO2 80 mm Hg; PaCO2 50 mm Hg D. PaO2 75 mm Hg; PaCO2 40 mm Hg

D. Special precautions must be taken to prevent spread of the virus when caring for the patient with hepatitis. These include the use of universal precautions while handling all items that are contaminated with the patient's body secretions, including patient care items such as thermometers, dishes, and eating utensils. Liver transplantation is the standard care of treatment for patients with progressive, irreversible acute or chronic liver disease for which there are no other medical or surgical options. Hepatitis can be either acute or chronic. The leading indication for liver transplantation is hepatitis C.

The nurse is listening to a lecture on hepatitis. Which statement by the nurse indicates that teaching has been effective? A. "Liver transplantation is a first-line treatment to prevent complications" B. "Hepatitis is self-limiting and is followed by full recovery" C. "No special precautions are needed when caring for someone with this disease" D. "Universal precautions should be followed to prevent spread of the virus"

A.

The nurse is listening to a lecture on the physiological consequences of acute respiratory distress syndrome (ARDS). Which statement indicates that teaching has been effective? A. "ARDS is associated with decreased lung compliance" B. "ARDS is associated with decreased physiological dead space" C. "ARDS is associated with increased resistance" D. "ARDS is associated with pulmonary fibrosis"

B. Various pharmacological therapies have been researched in the treatment of acute pancreatitis. Drugs given to rest the pancreas have been studied, specifically anticholinergics, glucagon, somatostatin, cimetidine, and calcitonin, but these have not been shown to be effective. Prevention of stress ulcers is achieved through the use of histamine blockers and antacids. Antibiotics have also been studied in the treatment of inflammation of the pancreas with the idea of preventing pancreatic pseudocysts or abscesses. It is not known whether antibiotics improve survival or merely prevent septic complications. The role of prophylactic systemic antibiotics in acute pancreatitis is unsettled, as studies evaluating the benefits and harms have produced disparate results.

The nurse is listening to a lecture on the various pharmacological therapies in the treatment of acute pancreatitis. Which statement by the nurse indicates that teaching has been effective? A. "Anticholinergic medications help by decreasing secretin secretion" B. "Somatostatin is ineffective in the treatment of pancreatitis" C. "Prophylactic systemic antibiotics improve survival" D. "Calcitonin is essential in preventing complications of hypocalcemia"

D.

The nurse is orienting a new RN in the care of a patient with respiratory distress due to emphysema. The patient is being treated with O2 via a Venturi mask with 35% oxygen. Which statement by the new RN indicates that teaching has been effective, when the nurse questions the new RN about the use of the Venturi mask? A. "A nasal cannula will dry the mucous membranes and cause an increased risk of infection" B. "Her alveoli cannot absorb higher levels of O2 because of the emphysema" C. "Her alveoli have been damaged and may rupture with higher doses of O2" D. "Her respiratory center requires low O2 concentration to stimulate breathing"

D.

The nurse is orienting a new RN to the ICU. The nurse begins to review orders recently entered by the cardiologist and to explain their rationale to the new RN. Medication orders include dobutamine (Dobutrex) 400 mg in 250 mL 5% dextrose in water titrated to keep cardiac index >2 L/min/m2. Which statement by the new RN indicates that teaching has been effective? A. "The cardiac index is the amount of blood pumped out by a ventricle per minute." B. "The cardiac index is the amount of blood ejected with each ventricular contraction." C. "The cardiac index is the pressure created by the volume of blood in the left heart." D. "The cardiac index is the measurement specific to the patient's size or body area."

A, B The PAC balloon should be injected with 1.5 mL NS or sterile water.

The nurse needs to obtain a cardiac output measurement from a patient who has just had a pulmonary artery catheter inserted. What are important interventions for ensuring accurate pressure and cardiac output measurements? (Select all) A. Ensure rapid injection of fluid through the injectate port B. Zero reference the transducer system at the phlebostatic axis C. Inflate the PAC balloon with 5 mL of air D. Use LR solution for the injectate

A. Asterixis, a flapping tremor of the hand, is an early sign of hepatic encephalopathy that can be assessed by the nurse. The provider needs to be notified as early as possible. Measures for decreasing ammonia production are necessary. Protein intake is limited to 20 to 40 g/day. Tremors are not normal in patients with liver failure. They are a sign of progression of the disease.

The patient has been on the progressive care unit for the past 7 days with the diagnosis of liver failure. The nurse notes that the patient has developed a flapping tremor of the hand. The nurse should: A. Notify the provider because this is a sign that the disease is progressing B. Continue to monitor the patient until more overt symptoms appear C. Request that the provider increase the patient's protein intake to 60 g/day D. Recognize that the tremors are normal for someone with liver disease

A. In chronic liver failure, liver cell structure and function are impaired, resulting in portal hypertension. As a result, part of the venous blood in the splanchnic system is diverted from the liver to the systemic circulation by the development of connections to neighboring low-pressure veins. This phenomenon is termed collateral circulation. Bleeding esophageal or gastric varices are usually a medical emergency because they cause massive upper GI bleeding.

The patient has end-stage chronic liver failure and has been vomiting "coffee-ground" material. The provider has ordered the insertion of a nasogastric tube. In inserting the tube, the nurse must be aware that: A. Esophageal varices may be present and rupture could lead to bleeding B. The splanchnic system does not develop collateral circulation in low-pressure veins C. Portal hypertension is a result of varices formation D. The most common site for varices formation is the rectum

A, B, D, E Kupffer's cells in the liver play an important role in fighting infections throughout the body. Loss of this function predisposes the patient to severe infections, particularly gram-negative sepsis. The liver also removes activated clotting factors from the general circulation to prevent widespread clotting in the system. Loss of this function predisposes the patient to clot formation and to complications such as pulmonary embolus. Decreased metabolism and storage of vitamins A, B12, and D, and of iron, glucose, and fat predispose the patient to many nutritional deficiencies. The liver loses a well-known function of detoxifying drugs, ammonia, and hormones. Loss of ammonia conversion to urea in the liver is responsible for many of the altered thought processes seen in liver failure, because ammonia is allowed to enter the central nervous system directly. These alterations range from minor sensory perceptual changes, such as tremors, slurred speech, and impaired decision making, to dramatic confusion or profound coma.

The patient has end-stage liver disease. The nurse realizes that, because of this, the patient is at risk for: (Select all) A. Gram-negative sepsis B. Pulmonary embolus C. Low blood ammonia levels D. Nutritional deficiencies E. Confusion/coma

D. With liver disease, altered carbohydrate metabolism may result in unstable blood glucose levels, a condition called cirrhotic diabetes. Low albumin is present but does not affect blood glucose. Altered fat metabolism may result in a fatty liver and cause fatigue and decreased activity tolerance. Cirrhosis is not associated with pancreatic dysfunction.

The patient is admitted with cirrhosis and has a blood sugar of 250 mg/dL. The nurse interprets this result as: A. A dysfunctional pancreas B. Altered fat metabolism due to fatty liver C. Low albumin levels D. Cirrhotic diabetes

C. Liver cells have the capacity to regenerate. Over time, liver cells that become damaged are removed by the body's immune system and are replaced with healthy liver cells. Therefore, most patients with hepatitis recover and regain normal liver function.

The patient is admitted with hepatitis and asks the nurse what his prognosis is. Which statement by the nurse would be the most accurate? A. "Unfortunately, damaged liver cells do not regenerate, so recovery will depend on how much we can save." B. "The damaged liver cells will be replaced by scar tissue but will no longer be functional." C. "Liver cells can regenerate, so most patients with hepatitis recover and regain normal liver function." D. "Most people with hepatitis require liver transplantation. If we can find a donor, you should be all right."

B. Altered carbohydrate metabolism may result in unstable blood glucose levels, which does not lead to ascites. Low albumin levels are also thought to be associated with the development of ascites, a complication of hepatic failure. Fibrinogen is an essential protein that is necessary for normal clotting. A low plasma fibrinogen level, coupled with decreased synthesis of many blood clotting factors, predisposes the patient to bleeding.

The patient is admitted with severe ascites related to chronic liver disease. In trying to determine the cause of the ascites, the nurse should evaluate which laboratory values? A. Blood glucose levels B. Albumin levels C. Fibrinogen levels D. Clotting factors

A, B Portal hypertension causes two main clinical problems for the patient: hyperdynamic circulation and development of esophageal or gastric varices. Liver cell destruction causes shunting of blood and increased cardiac output. Vasodilation is also present (so vasodilators are not needed), which causes decreased perfusion to all body organs, even though the cardiac output is very high. This phenomenon is known as high-output failure or hyperdynamic circulation. Clinical signs and symptoms are those of heart failure and include jugular vein distension, pulmonary crackles, and decreased perfusion to all organs. Initially, the patient may have hypertension, flushed skin, and bounding pulses. Blood pressure decreases and dysrhythmias are common.

The patient is diagnosed with portal hypertension. The nurse would expect to see signs of: (Select all) A. Hyperdynamic circulation (high-output failure) B. Development of esophageal or gastric varices C. Decreased CO D. A stable cardiac rhythm and rate E. Clear lung sounds and increased organ perfusion

A.

What is the best understanding of mixed venous oxygen saturation by the nurse? A. An overall picture of oxygen delivery and consumption B. The amt of oxygen attached to each Hgb molecule C. The amt of oxygen perfusion taking place w/in the myocardium D. The amt of oxygen the lungs are able to mix with the blood

A.

When checking a patient's pulmonary artery occlusion pressure, the nurse inflates the balloon as ordered, not inflating the balloon for more than 8 to 10 seconds. The patient asks the rationale behind the nurse's actions. Which statement should the nurse make? A. "Prolonged inflation can obstruct blood flow, resulting in ischemia." B. "Prolonged inflation increases the risk of catheter balloon rupture." C. "Prolonged inflation increases the likelihood of thermistor damage." D. "Prolonged inflation will reduce tension on the pulmonary artery wall."

B. In septic shock, inflammatory mediators damage the endothelial cells that line blood vessels, producing profound vasodilation and increased capillary permeability. Initially this results in a high heart rate, hypotension, and low SVR, and subsequently in low right atrial pressure.

Which hemodynamic values should the nurse anticipate in a patient who is in the initial stages of septic shock state? A. Low HR; high BP B. High HR; low RAP C. High PAOP; low CO D. High SVR; normal BP

A, D Maintaining the head of bed at 30 to 45 degrees and providing oral care are two interventions to prevent VAP that the nurse can implement. The special endotracheal tube reduces the risk for VAP; however, this is not a nursing intervention. The patient should be sedated based on specific targets. Deep sedation should be avoided because it prolongs time on mechanical ventilation, increasing the patient's risk for VAP.

Which of the following are nursing interventions to prevent ventilator-associated pneumonia (VAP)? (Select all) A. Elevate the HOB at least 30 degrees B. Intubate patient with an endotracheal tube with continuous subglottis aspiration of secretions C. Maintain a deep level of sedation D. Provide regular oral care, including the use of chlorhexidine

D. The initial treatment of hypoxemia is delivery of oxygen at a low flow rate. The Venturimask allows a designated percentage of oxygen to be delivered. The initial treatment is low-flow oxygen. If the patient fails to respond to this treatment, noninvasive ventilation (CPAP or BiPAP) may be indicated. A non-rebreather mask at 80% delivers a high percentage of oxygen, which may impair the patient's respiratory drive. Bag-valve-mask ventilation is not indicated.

Which of the following treatments should the nurse anticipate administering to a hypoxic patient admitted with exacerbation of COPD? A. Bag-valve-mask ventilation w/oxygen at 15 L/min B. Continuous positive airway pressure via face mask C. Non-rebreather mask with 80% oxygen D. Oxygen via Venturi mask at 40% oxygen

C.

A patient asks the nurse, "What is blood pressure?" What is the best response by the nurse? A. "A complex measurement that should be discussed only with your physician" B. "A measurement that should be 120-80 mm Hg unless complications are present" C. "A measurement that takes into consideration the amount of blood your heart is pumping and the size of the vessel diameter the heart must pump against" D. "The amount of pressure exerted on the veins by the blood"

A, B, C

The nurse is assessing a patient for a possible pulmonary embolus. Assessment findings may include which of the following? (Select all) A. Acute onset of chest pain B. Hemoptysis C. Low oxygen saturation D. Pleural friction rub

D.

What is the best action by the nurse to level and zero a hemodynamic monitoring system transducer? A. Level the air-fluid interface of the zeroing transducer at the height of the patient's mattress. B. Position the air-fluid interface of the zeroing transducer at the fifth intercostal space, midclavicular line. C. Position the air-fluid interface of the zeroing transducer at the phlebostatic axis (fourth intercostal space, midaxillary line). D. Level the air-fluid interface of the zeroing transducer at the second intercostal space, anterior-axillary line.

D.

What is the best position for the nurse to place the patient in to obtain a right atrial pressure measurement? A. Left side-lying with the head of the bed elevated 30 degrees B. Prone, lying on the abdomen with slight head elevation C. Right side-lying with the head of the bed elevated 30 degrees D. Supine, either flat or with the head of the bed no more than 60 degrees