CC quizzes

The intensive care nurse is responsible for the care of a patient with shock. What cardiac signs or symptoms would suggest to the nurse that the patient may be experiencing acute organ dysfunction? Select all that apply.

- Drop in systolic blood pressure of ³40 mm Hg from baselines - MAP of ˂60 mm Hg - Serum lactate elevated >4 mmol/L Signs of acute organ dysfunction in the cardiovascular system include systolic blood pressure <90 mm Hg or mean arterial pressure (MAP) <65 mm Hg, drop in systolic blood pressure >40 mm Hg from baselines or serum lactate >4 mmol/L. An exaggerated response to vasoactive medications and an adequate response to fluid resuscitation would not be noted.

Your patient's ABGs values are: pH 7.28; PaO2 80; PaCO2 30; HCO3 11; You know that the kidneys are trying to compensate by which of the following? Select all that apply. (2) combination of H+ with ammonia (NH3) to form ammonium (NH4+), and (3) excretion of weak acids. To compensate for acidosis, the kidneys can generate additional bicarbonate and eliminate excess H+,

- generate additional bicarb - combine H+ with ammonia (NH3) to form ammonium (NH4+) - secretion of small amounts of free hydrogen into the renal tubule - excretion of weak acids Under normal conditions, the body depends on the kidneys to reabsorb and conserve all of the bicarbonate they filter and excrete a portion of the acid produced by cellular metabolism. The three mechanisms of acid elimination are (1) secretion of small amounts of free hydrogen into the renal tubule, (2) combination of H+ with ammonia (NH3) to form ammonium (NH4+), and (3) excretion of weak acids. To compensate for acidosis, the kidneys can generate additional bicarbonate and eliminate excess H+, lowering the pH of the urine.

The diagnosis of acute pancreatitis is based an which of the following Signs and Symptoms? Select all that apply.

- history of abdominal pain - the presence of alcoholism - elevated serum amylase - elevated lipase level -the presence of gall stones The diagnosis of acute pancreatitis is based on a history of abdominal pain, the presence of known risk factors, physical examination findings, and diagnostic findings. Serum amylase and lipase levels are used in making the diagnosis of acute pancreatitis, although their elevation can be attributed to many other causes. In most cases, serum amylase and lipase levels are elevated within 24 hours of the onset of the symptoms. Serum amylase usually returns to normal within 48 to 72 hours, but serum lipase levels may remain elevated for a longer period, often days longer than amylase. Urinary amylase levels also become elevated and remain elevated longer than serum amylase levels. The white blood cell count is usually elevated; hypocalcemia is present in many patients.

Your patient's ABGs values are: pH 7.48; PaO2 60; PaCO2 30; HCO3 22; The patient is receiving mechanical ventilation with the SIMV mode. The nurse might expect which of the following orders after reporting the ABG results to the physician? Select all.

- increase FiO2 - add positive end expiratory pressure The pH is up (alkalosis) and the CO2 is decreased but this is due to the patient's PaOa being low. You see respiratory alkalosis in early ARDS or hypoxemic respiratory failure. This is a ventilation issue to you must adjust either the FiO2 or add PEEP. To increase PaO2 you may need to increase either or both.

The intervention with highest priority when a patient is admitted to the emergency department with a stroke is

- maintenance of respiratory function with a patent airway and oxygen administration. Aways remember ABCs in this course as your priorities. So the first priority in acute management of the patient with a stroke is preservation of life. Because the patient with a stroke may be unconscious or have a reduced gag reflex, it is most important to maintain a patent airway for the patient and to provide oxygen if respiratory effort is impaired. IB fluid replacement, treatment with osmotic diuretics, and perhaps hypothermia may be used for further treatment.

A patient has been admitted for severe dehydration due to prolonged diarrhea and vomiting. The physician places a central venous line to assess hemodynamic status. Which central venous pressure (CVP) reading would best correlate to the patient's clinical status?

1 mm Hg Recall from your hemodynamic monitoring readings that a normal CVP is 2-8 mm Hg, and that CVP is an excellent indicator of fluid volume status because it is an indirect measurement of the volume of venous return to the right side of the heart. A CVP measurement of 1 mm Hg is low and would correlate with this patient's history of dehydration. A CVP reading of 5 is normal. The other options are high CVP readings and would correlate with fluid volume excess, not dehydration.

DESCRIPTIONS OF VENT MODES 1. Controlled Mandatory Ventilation 2. Assist-Control Ventilation 3. Synchronized Intermittent Mandatory Ventilation (SIMV) 4. Pressure Support Ventilation 5. Positive End Expiratory Pressure (PEEP)

1. The ventilator provides all of the patient's minute ventilation and work of breathing; used when the patient has no respiratory drive. 2. The ventilator delivers a preset tidal volume and rate, and senses when the patient initiates a breath. When the patient initiates a spontaneous breath, the preset tidal volume is always delivered. Can lead to asynchrony between the patient and ventilator. 3. The ventilator provides a certain number of required breaths, but the patient can spontaneously breathe at their own rate and tidal volume between these breaths. Creates better harmony between the patient and the ventilator. 4. The ventilator is programmed to deliver a pre-set pressure level. When the patient initiates a breath, gas is delivered to the preselected pressure level and this pressure is maintained throughout inspiration. 5. This ventilatory maneuver creates positive pressure at the end of exhalation, keeping the alveoli open longer and restoring fuctional residual capacity (FRC).

You are the nurse supervising a 75 year old patient who is in a cardiac rehabilitation program after an uncomplicated myocardial infarction. You inform the patient that the ideal training age-related heart rate for a 75 year old (according to traditional standards) is

116 no rationale

A morbidly obese patient would be eliminated as a candidate for weight loss surgery if he/she has a body mass index (BMI) of

45 with comorbid schizophrenia A psychiatric condition that would make compliance with a strict post-op care regimen difficult if not impossible to achieve would probably rule out this patient. Bariatric surgery is appropriate for the other patients meet the acceptance criteria for this surgery.

Which patient is at greatest risk for developing multiple organ dysfunction syndrome (MODS)?

82-year-old patient with type 2 diabetes mellitus and chronic kidney disease who is admitted for peritonitis related to a peritoneal dialysis catheter infection. A patient with peritonitis is at high risk for developing sepsis. In addition, a patient with diabetes is at high risk for infections and impaired healing. Sepsis and septic shock are the most common causes of MODS. Individuals at greatest risk for developing MODS are older adults and persons with significant tissue injury or preexisting disease. MODS can be initiated by any severe injury or disease process that activates a massive systemic inflammatory response.

A patient has been diagnosed with chronic renal failure. What closely associated pathophysiologies should the nurse assess for? Select all

Arteriosclerotic dz Type 1 DM Type 2 DM Hypertension and diabetes mellitus account for more than 24% and 36%, respectively, of end-stage renal disease cases. Arteriosclerotic disease is a cause of hypertension and a sequela of uncontrolled diabetes mellitus. Traumatic injuries and septic shock lead to acute kidney injury.

When administering IV nitroglycerin to a patient with a myocardial infarction (MI), which action will the nurse take to evaluate the effectiveness of the medication?

Ask about chest discomfort The goal of IV nitroglycerin administration in MI is relief of chest pain by improving the balance between myocardial oxygen supply and demand. The nurse also will monitor heart rate and BP and observe for dysrhythmias, but these parameters will not indicate whether the medication is effective.

Which of the following would cause the nurse concern that her patient post Roux-en Y surgical procedure may have an anastomotic leak. Selelct all that apply.

ABD pain hiccups fever leukocytosis tachycardia Disruption at the site of anastomosis (i.e., surgically resected site) may cause leakage of gastric contents into the perito-neal cavity, causing infection and possible sepsis. Patients with anastomotic leaks typically exhibit fever, abdominal pain, tachycardia, hiccups, and leukocytosis which may progress to sepsis and possibly septic shock if not recognized and treated early.

The nurse notifies the physician that a patient who is scheduled for a computed tomography (CT) scan with contrast media has an allergy to shellfish. Which response by the physician should the nurse question?

Administer lorazepam before the procedure. An individual with an allergy to shellfish is at an increased risk to develop anaphylactic shock if contrast media is injected for a CT scan. To prevent anaphylactic shock, the nurse should always confirm the patient's allergies before diagnostic procedures (e.g., CT scan with contrast media). Appropriate interventions may include cancelling the procedure, completing the procedure without contrast media, or premedication with diphenhydramine or hydrocortisone. Intravenous fluids may be given to promote renal clearance of the contrast media and prevent renal toxicity and acute kidney injury. The use of an antianxiety agent such as lorazepam would not be effective in preventing an allergic reaction to the contrast media.

Following the initiation of intra-aortic balloon pump (IABP) therapy, which of the following nursing actions is most important?

Avoid bending or flexing the cannulated extremity. no rationale

A patient is admitted for repair of an abdominal aortic aneurysm and begins to complain of severe abdominal pain and a sense of impending doom. What assessment should the nurse perform first?

BP no rationale

A patient is diagnosed with an acute pulmonary embolism. When explaining to the patient what happened to cause respiratory failure, which information should the nurse include?

Blood flow through some areas of your lungs is decreased even though you are taking adequate breaths. In this question, the nurse needs to understand whether a ventilation or perfusion problem has caused the respiratory failure so that patient teaching may be implemented correctly. A pulmonary embolism occludes perfusion (circulation) to a part of the lungs, causing a V/Q (ventilation/perfusion) mismatch. With a PE, ventilation or air delivery is usually unaffected. The other options are all ventilation problems and do not correctly describe the pathophysiology of a PE

Which of the following therapies for acute hyperkalemia resulting in bradycardia and a prolonged QRS complex? Select all

Calcium gluconate Glucose and insulin infusion When the patient is having EKG changes, this becomes an emergent situation which requires interventions that act immediately. Calcium gluconate will assist the myocardium in contraction. Insulin and glucose will assist in pushing potassium into the cells. A fluid bolus would have no effect on the potassium level. Calcium carbonate is a phosphate binder and does not affect potassium. Kayexalate will take much too long to work on this patient.

The nurse is caring for a patient who has just had coronary artery bypass grafting and is experiencing significant hypotension. What nursing assessment would best confirm that the hypotension is related to blood loss?

Chest tube drainage in excess of 200 mL/hour no rationale

Your patient had a large ischemic stroke and is hospitalized in the neurologic intensive care unit. What interventions will be provided for this patient to decrease intracranial pressure? Select all that apply.

Elevate the HOB 45 degrees Administering mannitol Maintaining the PCO2 within the lower normal range. To decrease intracranial pressure, the patient's HOB is elevated above 30 degrees, head is kept midline, osmotic diuretics and hypertonic saline infusions are given to decrease cellular fluid along with keeping the PCO2 low normal to prevent vasodilation.You would not want the SaO2 to be below 90% so waiting until below 80 is much too late.

The patient has just returned to the floor after balloon valvuloplasty of the aortic valve and the nurse is planning appropriate assessments. The nurse should know that complications following this procedure include what? select all

Emboli Mitral valve damage Ventricular dysrhythmia no rationale

The critical care nurse is caring for a patient who is in cardiogenic shock. What assessments must the nurse perform on this patient? select all

Fluid status Action of meds Cardiac rhythm no rationale

During the acute phase of a stroke, the nurse assesses the patient's vital signs and neurologic status every 4 hours. A cardiovascular sign that the nurse would expect to see as the body attempts to increase cerebral blood flow is

HTN The body responds to the vasospasm and decreased circulation to the bran that occurs with a stroke by increasing the BP, frequently resulting in hypertension. The other options are important cardiovascular factors to assess, but they do not result from impaired cerebral blood flow

A critically ill patient has arterial blood gas results of PaO2 60 mm Hg, SaO2 80%, pH 7.35, PaCO2 35 mm Hg, and HCO3 24 mEq/L. How does the nurse interpret these results?

Hypoxemia and normal acid base balance These results show low PaO2 and SaO2 with normal pH, PaCO2, and HCO3. This combination of values defines hypoxemia with normal acid base balance.

A patient has been admitted with acute left systolic heart failure secondary to acute myocardial infarction. The patient has dyspnea and orthopnea and a cardiac rhythm of sinus tachycardia. The physiologic dysfunction for this type of heart failure is what?

Impaired contractility of the left ventricle no rationale

The patient with cirrhosis receives 100 ml of 25% serum albumin IV. Which finding would best indicate that the albumin is having its desired effect?

Increased urine output Patients with hepatic failure have hypoalbuminemia which leads to ascities due to the low oncotic pressure. Giving the patient albumin will increase the oncotic pressure which will pull water into the vascular system. More blood returns to the kidney so more urine is made. Yes, giving albumin will increase the level in the blood stream and this may lead to the patient breathing easier, but the purpose is to cause diuresis - increase urine output.

The nurse attempts to alleviate the anxiety of a patient with acute heart failure because restlessness

Increases the cardiac workload no rationale

Angina occurs with myocardial ischemia as a result of

Lactic acid accumulation during anaerobic metabolism The myocardium becomes hypoxic and switches to anaerobic metabolism within 10 seconds. Lactic acid begins to build irritating the cardiac nerve fibers which sent a pain message to the cardiac nerve and thoracic nerve roots.

Which nursing intervention would assist in the management of the liver failure patient with a nursing diagnosis of alteration of sensory perception and thought processing?

Limit protein intake Alteration of sensory perception and thought processing are indications of hepatic encephalopathy due to an increase in ammonia. Ammonia is the byproduct of protein metabolism. The best intervention would be to limit protein intake to decrease the ammonia level. The patient may be on a fluid restriction but this would be to decrease ascites. Cholestyramine is used to treat itching in patient with liver failure, also decreases cholesterol levels. We would not use Phenobarbitol or Dilantin for agitation in a patient with hepatic failure.

The nurse explains to the patient who is to undergo CABG surgery that the procedure most often involves

Loosening the internal mammary artery from the chest wall and attaching it to a coronary artery distal to a stenosis. no rationale

When caring for a patient who has an intraaortic balloon pump in place, which action will be included in the plan of care?

Measure the patient's urinary output every hour. no rationale

A patient has been brought to the emergency department by EMS after being found unresponsive. Rapid assessment reveals anaphylaxis as a potential cause of the patient's condition. The care team should attempt to assess for what potential causes of anaphylaxis? Select all

Meds Foods Insect stings Substances that most commonly cause anaphylaxis include foods, medications, insect stings, and latex. Pollutants do not commonly cause anaphylaxis and autoimmune processes are more closely associated with types II and III hypersensitivities.

A patient is being discharged from the hospital following a myocardial infarction. Which statement by the patient indicates that further instruction about cardiac rehabilitation is needed?

My heart will be healed and as good as new when I finish the cardiac rehabilitation program. no rationale

When the nurse is assessing a patient with myasthenia gravis, which action will be most important to take?

Observe respiratory effort. Because respiratory insufficiency may be life threatening, it will be most important to monitor respiratory function. The other data also will be assessed but are not as critical.

The nurse is caring for a patient in cardiogenic shock after an acute myocardial infarction. Which clinical manifestations would be of most concern to the nurse?

PaO2 of 38 mm Hg, elevated serum lactate level of 46.5 mcg/dL, and bleeding from puncture sites Severe hypoxemia, lactic acidosis, and bleeding are clinical manifestations of the irreversible state of shock; recovery from this stage is not likely because of multiple organ system failure. Agitation, tachypnea, and increased serum creatinine are clinical manifestations of the progressive stage of shock. Decreased mean arterial pressure, jaundice, and cold, clammy skin are also clinical manifestations of the progressive stage of shock. Restlessness, tachycardia, and hypoactive bowel sounds are clinical manifestations that occur during the compensatory stage of shock.

Most individuals who have mitral valve prolapse never have any symptoms, although this is not the case for every patient. What symptoms might a patient have with mitral valve prolapse? Select all that apply.

Palpitations Fatigue Anxiety no rationale

When caring for a patient with pulmonary hypertension, which parameter will the nurse monitor to evaluate whether treatment has been effective?

Pulmonary vascular resistance (PVR) PVR is a major contributor to pulmonary hypertension, and a decrease would indicate that pulmonary hypertension was improving. The other parameters also may be monitored, but do not directly assess for pulmonary hypertension.

Which of the following manifestations of a stroke are more likely to occur with right brain stroke? Select all that apply.

Quick, impulsive behavior Neglect of the left side of the body Left homonymous hemianopsia Spatial-perceptual deficits Left brain strokes demonstrate: Paralysis or weakness on right side of body; Right visual field deficit; Aphasia (expressive, receptive, or global); Altered intellectual ability; Slow, cautious behavior. Right brain strokes demonstrate: Paralysis or weakness on left side of body Left visual field deficit; Spatial-perceptual deficits; Increased distractibility; Impulsive behavior and poor judgment; Lack of awareness of deficits.

A patient is in metabolic acidosis. Which finding would the nurse expect to observe as the body compensates for the acidosis?

Rapid, deep respirations no rationale

A patient has a systemic BP of 104/58 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first?

Report the BP and ICP to the health care provider. The patient's cerebral perfusion pressure is 59 mm Hg, below the normal of 70 to 100 mm Hg. Immediate changes in the patient's therapy such as fluid infusion or vasopressor administration are needed to improve the cerebral perfusion pressure. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation also will be done, but they are not the first actions that the nurse should take.

Which intervention would be appropriate with a nursing diagnosis of fluid volume excess in the liver failure patient?

Restrict sodium to 2000 mg/d Restricting sodium intake is the first choice in trying to decrease formation of ascites. These patient have hyperaldosterone due to is not being metabolized in the liver which leads to an increase in sodium causing fluid accumulation. If we limit the sodium then the body should try to remove the water associated with the elevated sodium. The next best choice would them be to restrict fluid.

Which of the following manifestations of a stroke are more likely to occur with left brain stroke? Select all

Slow, cautious behavior Aphasia Inability to remember words Left brain strokes demonstrate: Paralysis or weakness on right side of body; Right visual field deficit; Aphasia (expressive, receptive, or global); Altered intellectual ability; Slow, cautious behavior. Right brain strokes demonstrate: Paralysis or weakness on left side of body Left visual field deficit; Spatial-perceptual deficits; Increased distractibility; Impulsive behavior and poor judgment; Lack of awareness of deficits.

In order to prevent the complication of pulmonary embolism post weight loss surgery, the patient must stop ___________ three weeks prior to surgery.

Smoking Smoking causes vasocontriction and irritates the lining of the vessels increasing the risk of clot formation. Propranolol is a vasodilator and does not increase the risk of clots. Aspirin will actually decrease clotting therefore decrease the patient's risk for a PE. Actigall (ursodeoxycholic acid) is used to dissolve gall stones and would have no effect on blood to create a clot.

Human leukocyte antigen (HLA) matching is especially important in which of the following solid organ transplants?

Stem cell Stem cell transplants along with kidney transplants require close HLA matching. The other organs do not need to match as closely.

The serum ammonia level of a patient with cirrhosis is elevated. As a priority the nurse should

observe for increasing confusion Ammonia crosses the blood brain barrier resulting in confusion, agitation, disorientation and can lead to coma. It is important for the nurse to monitor for these changes to prevent patient injury.

Your patient is being admitted to the ICU for bleed esophageal varices. You know that treatment for this condition may include which of the following? Select all that apply.

TIPS procdure Sclerotherapy Octreotide (Sandostatin ) Ligation Balloon tamponade Treatment for bleed esophageal varices include sclerotherapy, ligation, TIPS, balloon tamponade, Octreotide or vasopressin. Propranolol is used to prevent bleeding and not used for active bleeding. Spironolactone is used to treat ascites - not varices.

The atelectasis associated with ARDS may be managed or reversed by the use of

positive end expiratory pressure (PEEP) As fluid compresses the alveoli and the cells decrease production of surfactant, the alveoli start to collapse. PEEP will assist in opening these back up to participate in gas exchange

The most common cause of transfusion-related death is due to

Transfusion-related acute lung injury Transfusion-related acute lung injury (TRALI) is a potentially fatal, idiosyncratic reaction that is defined as the development of acute lung injury occurring within 6 hours after a blood transfusion. All blood components have been implicated in TRALI, including IVIG, cryoprecipitate, and stem cells. TRALI is the most common cause of transfusion-related death

A patient has been admitted to the ICU in hypovolemic shock. Which parameter indicates adequate fluid replacement has been achieved?

Urine output is 1 ml/kg/hour Adequate fluid resuscitation is best measured by urine output, which should be at LEAST 0.5 mL/kg/hour. This patient's UOP is 1 mL/kg/hour, indicating that the patient's kidneys are being adequately perfused. A normal BP is not as sensitive an indicator of fluid resuscitation because BP may be falsely elevated in the compensatory stage of shock. HR of 110 indicates that the patient is in the compensated shock because the SNS has been activated.

A patient with ST-segment elevation in several ECG leads is diagnosed as having an acute myocardial infarction. Which question should the nurse ask to determine whether the patient is a candidate for fibrinolytic (thrombolytic) therapy?

What time did your CP begin? Fibrinolytics must be given within 6 hours of onset of the chest pain for the drug to be effective in lysing the clot in the coronary artery and restoring blood flow. The time of onset of the pain is the critical information for the nurse to obtain. One adult aspirin is NOT a contraindication for fibrinolytic therapy because the platelet inhibition effects would be minimal with such a dose.

2 major causes of intrarenal acute renal injury are Select all

aminoglycoside ABx radiocontrast dye administration The use of aminoglycoside antibiotics and radiocontrast dye administration can cause damage to the kidney itself (intrarenal failure). Calculi, obstructed foley, and BPH all result in postrenal failure. Dehydration and hypovolemic shock could eventually lead to intrarenal failure but are more attributed to prerenal failure.

The laboratory test that would indicate that the liver of a patient with cirrhosis is compromised and Neomycin administration might be helpful would be

ammonia level Neomycin is given to patients with elevated ammonia levels to decrease the ammonia forming bacteria in the GI tract when lactulose alone is not effective.

The partial pressure of oxygen in arterial blood (PaO2) is normally decreased

at higher altitudes At higher altitudes, the atmospheric pressure decreases resulting in a lower PaO2. This is why airplane cabins are pressurized--to help maintain adequate oxygenation at high altitudes. PaO2 is decreased in older adults, not in children.

The major causes of post renal acute renal injury are Select all

benign prostatic hypertrophy renal calculi an obstructed Foley catheter Calculi, obstructed foley, and BPH all result in postrenal failure. Dehydration and hypovolemic shock could eventually lead to intrarenal failure but are more attributed to prerenal failure. The use of aminoglycoside antibiotics and radiocontrast dye administration can cause damage to the kidney itself (intrarenal failure).

The nurse will monitor most closely for clinical manifestations of hypercapnia when a patient in the Emergency Department has

chest trauma and multiple rib fractures Hypercapnic failure is a ventilation issue. The only problem listed that would impede ventilation is chest trama and rib fractures. The other choices would lead to hypoxemic failure - an oxygenation issue.

The blood gas abnormality which will most probably occur in the initial phase of ARDS is

respiratory alkalosis ARDS is an oxygenation issue initially. As the brain senses there is a decrease in the amount of availalbe O2, it sends out messages for the lungs to breathe deeper and faster. If it is an oxygenation issue - the lungs can still remove CO2, they just cannot exchange O2 so the CO2 will start to drop causing the Acid Base Imbalance of Respiratory Alkalosis.

ABGs values: pH 7.30; PaO2 90; PaCO2 68; HCO3 28 The pt w/ COPD is receiving mechanical ventilation with the SIMV mode. The nurse might expect which of the following orders after reporting the ABG results to the physician? (select all)

↓ FiO2 ↑ rate ↑ volume A COPD pt should have an ABG indicating compensated respiratory acidosis w/ mild hypoxemia. (pH 7.35 to 7.39, ↑ CO2, PaO2 70s, HCO3 >26). The pH is down, below 7.35 so the pt is no longer compensating; the CO2 is elevated which we expect, but probably too high due to the pH. The PaO2 should be in the 70's and this one is too high. What do you remember about giving pts with COPD oxygen? It can decrease the respiratory drive which has occurred here. This is probably an over oxygenation issue so you probably need to decrease the FiO2 so the drive to breathe returns and in the mean time, increase the number of breaths the ventilator is giving the pt.

The nurse is assessing the patient with a circumferential burn to the left upper extremity. The nurse anticipates the performance of an escharotomy with which of the following assessment findings? Select all that apply.

- Absent distal radial pulses Progressive diminution of ultrasound signal Decrease in capillary refill Skin color, sensation, capillary refill, and peripheral pulses should be assessed and documented. Loss or a progressive diminution of the ultrasound signal is an indication for escharotomy. Limited range of motion can occur with any type of injury to an extremity and would not be an indicator for an escharotomy. Pink nail beds would be a normal finding.

A patient had a cardiac catheterization and is now in the recovery area. What nursing interventions should be included in the plan of care? Select all that apply.

- Evaluating termperature and color in the affected extremity - Checking the insertion site for hematoma formation - Assessing the peripheral pulses in the affected extremity Observing the catheter access site for bleeding or hematoma formation and assessing peripheral pulses in the affected extremity for temperature and and color along with the dorsalis pedis and posterior tibial pulses in the lower extremity, radial pulse in the upper extremity every 15 minutes for 1 hour, every 30 minutes for 1 hour, and hourly for 4 hours or until discharge. BP and heart rate are also assessed during these same time intervals. The patient will remain on bedrest for the first 6-8 hours post procedure.

A patient admitted to the hospital for evaluation of chest pain has no abnormal serum markers 4 hours after the onset of pain. A noninvasive diagnostic test that can differentiate angina from other types of chest pain is a(n)

- Exercise stress test The Exercise stress test woudl be the best option. An EKG at rest would not indicate anything. The TEE does not show if the patient is having any chest pain and angiogram is an invasive procedure.

The student nurse is preparing a teaching plan for a patient being discharged status post MI. What should the student include in the teaching plan? Select all

- Need for dietary modifications - Need for careful monitoring for cardiac sx - Need for carefully regulated exercise Dietary modifications, exercise, weight loss, and careful monitoring are important strategies for managing three major cardiovascular risk factors: hyperlipidemia, hypertension, and diabetes. There is no need to increase fluid intake and activity should be slowly and deliberately increased.

A patient develops a hemolytic reaction to a blood transfusion. The infusion is stopped, the physician and lab notified, and the patient is stabilized. What further actions should the nurse take after this occurs? Select all that apply.

- Obtain appropriate blood specimens. - Document the reaction according to policy. - Collect a urine sample to detect hemoglobin. If a hemolytic transfusion reaction or bacterial infection is suspected, the nurse does the following: obtains appropriate blood specimens from the patient; collects a urine sample as soon as possible to detect hemoglobin in the urine; and documents the reaction according to the institution's policy. Diphenhydramine is for anaphyllactic reactions. Iron chelation therapy is for iron toxicity due to multiple blood transfusion, not due to hemolytic reaction.

After regaining consciousness following a head injury, a patient is extremely confused. The nurse provides new information slowly and in small amounts because

teaching is based on information progressing from the simple to the complex. Patients with TBIs tend to have issues with short term memory so starting with simplex and eventually trying to advance to more complex is the best approach. Their attention span is also short so make sure you are in a quiet area to limit distractions.

Your patient is mechanically ventilated due to severe hypoxemia with ARDS and receiving Fentanyl and Proprofol along with a neuromuscular blocker (NMB). You assessing the level of the NMB for the pt using a peripheral nerve stimulator. Which of the following are acceptable results for this patient? Select all that apply.

- One twitch out of four - Two twitches out of four Assessment of the patient should include train-of-four (TOF) peripheral nerve stimulation, physiologic signs of pain or anxiety (changes in heart rate and BP), and ventilator synchrony. The TOF assessment involves the use of a peripheral nerve stimulator to deliver four successive stimulating currents to elicit muscle twitches. A base line is established by increasing the impulse level up until the unsedated/unparalyzed patient has 4 out of 4 muscle twitches. Then the NMB drip is started and increased to the goal. The number of twitches will vary with the percentage of neuromuscular blockade. The usual goal is one or two twitches out of four (about 80-90% blockade). The Goal of NMB is to give enough drug to produce enough paralysis so that mechanical ventilation goals are met; not to overparalyze and predisposed to long-term complications. 0 twitches means the patient has too much drug!

Which of the following are possible complications of mechanical ventilation?

- PTX - Aldosterone release Aspiration, barotrauma (pneumothorax), decreased cardiac output, and retention of sodium and water due to decreased renal perfusion are the only correct answers. Mechanical ventilation can increase thoracic pressure leading to barotrauma of the alveoli and it can decrease venous return which decreases cardiac output which leads to decrease perfusion to kidneys resulting in the retention of sodium and water. Having an endotracheal tube or tracheostomy tube will increase risk of aspiration.

In helping to diagnose an acute MI, which electrocardiographic (ECG) change will be of most concern to the nurse when admitting a patient with chest pain?

- ST-segment elevation ST elevation indicates myocardial cells are dying. Absent Q waves, PACs and sinus tachycardia are not indications of a MI.

The ECG changes that occur with an MI are seen in the leads that view the involved surface of the heart. The expected ECG changes are Select all that apply.

- T-wave inversion - ST-segment elevation - development of an abnormal Q wave The ECG changes that occur with an MI are seen in the leads that view the involved surface of the heart. The expected ECG changes are T-wave inversion, ST-segment elevation, and development of an abnormal Q wave.

The nurse is concerned that a patient is experiencing a transient ischemic attack. What did the nurse most likely assess in this patient?

- Visual disturbance - Numbness and tingling on side of the face. Neurologic manifestations of a TIA vary according to location and size the cerebral vessel involved and had a sudden onset. Commonly occurring deficits include contralateral numbness or weakness of the leg, hand, forearm, and corner of the mouth which may be associated with facial drooping.The patient may have aphasia and visual disturbances such as blurring or fleeting blindness of one eye

When caring for the patient with acute pancreatitis, the nurse must consider pain relief measures. Which of the following nursing interventions could the nurse provide? Select all that apply.

- Withholding oral feedings to limit the release of secretin - Encourage bed rest to decrease the metabolic rate - Administering parernteral opioid analgesics as ordered All oral intake is withheld to inhibit stimulation of the pancreas and its secretion of enzymes. Pain relief may require parenteral opioids such as morphine, fentanyl (Sublimaze), or hydromorphone. Antiemetic agents may be prescribed to prevent vomiting. Parenteral fluids and electrolytes are prescribed to restore and maintain fluid balance. Nasogastric suction may be used to relieve nausea and vomiting or to treat abdominal distention and paralytic ileus. The nurse provides frequent oral hygiene and care to decrease discomfort from the nasogastric tube and relieve dryness of the mouth. The acutely ill patient is maintained on bed rest to decrease the metabolic rate and reduce the secretion of pancreatic and gastric enzymes.

Your patient in ICU has developed disseminated intravascular coagulation (DIC). You know which of the following are possible interventions for this patient to treat this process.

- administer heparin - blood products - Treat underlying condition Treatment for disseminated intravascular coagulation includes treating the underlying condition triggering DIC; administer heparin, aminocaproic acid (EACA), blood products

The degree of impairment affected by a stroke depends on Select all that apply.

- the rapidity of the onset of sx - presence or absence of collateral circulation. - the amount of tissue area involved. Clinical manifestations of altered neurologic function differ, depending primarily on the specific cerebral artery involved and the areal of the brain that is perfused by the artery. The degree of impairment depends on rapidity of onset, the size of the lesion, and the presence of collateral circulation

A patient is admitted to the hospital after sustaining burns to the anterior trunk (chest and abdomen), both arms, and face. Using the "Rule of Nines," the nurse estimates that the percent of body surface area burned is

40.5% The anterior trunk (chest and abdomen) is about 18% of TBSA each arm is about 9% TBSA, and the face is about 4.5% TBSA. 18 + 9 + 9 + 4.5 = 40.5% TBSA burned (estimated) with the Rule of Nines.

A 165 lb. patient has a 45% total body surface area (TBSA) burn. Using the Parkland formula for fluid resuscitation, the nurse should set the pump to administer how many mLs per hour for the first 8 hours?.

843.8 Using the Parkland formula of kgs X % TSA burned X 4mL, you get 75 X 45 X 4 which comes to 13500 with half (6750mL) to be given over the first 8 hours; 6750 divided by 8 hours comes to 843.75 which rounded to one tenth is 843.8 mL per hour which is the infusion rate for the IV pump

On initial admission of a trauma victim to the emergency department, the nurse completes a primary survey. The patient is awake and tachypneic, is using accessory muscles of respiration, has unequal chest expansion, and is very anxious. There are absent breath sounds on the right and cyanosis on 100% oxygen, and the trachea is deviated to the left. What action takes the highest priority during the primary survey?

Chest tube insertion These symptoms are congruent with tension pneumothorax, a life-threatening emergency that requires immediate needle thoracotomy or chest tube insertion to preserve life. Since the patient is breathing and talking, the upper airway is adequately clear, so suctioning of the upper airway and assisting ventilation with a bag-mask device are not necessary at this time. The patient will need IV started, but Airway and Breathing come before C circulation.

The major causes of prerenal acute renal injury are Select all

HF dehydration hypovolemiic shock Dehydration, heart failure, and hypovolemic shock could eventually lead to intrarenal failure but are more attributed to prerenal failure. The use of aminoglycoside antibiotics and radiocontrast dye administration can cause damage to the kidney itself (intrarenal failure). Calculi, obstructed foley, and BPH all result in postrenal failure.

The nurse is caring for a patient with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the patient may be experiencing increased brain compression causing brain stem damage?

Hyperthermia Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic BP, and widening pulse pressure. As brain compression increases, respirations become rapid, BP may decrease, and the pulse slows further. A rapid rise in body temperature is regarded as unfavorable. Hyperthermia increases the metabolic demands of the brain and may indicate brain stem damage.

The priority nursing intervention for a patient with facial trauma is

Immobilization of the C spine Always start trauma with maintaining Cervical Spine immobilization then you start your ABC: Airway (is it open, clear and patent), Breathing (is the patient breathing adequately), Circulation (does the patient have a pulse, is the patient bleeding profusely).

Tachycardia that is a response of the sympathetic nervous system to the pain of ischemia in detrimental because not only does it increase oxygen demand, but it

Impairs perfusion of the coronary arteries The myocardium receives its blood during diastole. In tachycardic rhythms, there is less time for the myocardium to receive blood resulting in decrease in perfusion.

A patient with an acute brain injury is receiving IV mannitol, an osmotic diuretic. If this medication is effective, what does the nurse expect?

Increased cerebral perfusion pressure By encouraging reduction of cerebral edema, mannitol reduces intracranial pressure and increases cerebral perfusion pressure and cerebral perfusion. An increase in serum osmolarity above 320 mOsm is indicative of the development of acute tubular necrosis, a complication of mannitol therapy. Reduction of the Glasgow Coma Scale values and development of fixed and dilated pupils indicate a probable increase in intracranial pressure, which is not a positive development and is not related to the mannitol therapy.

A patient sustained an injury to the right arm after falling off a motorcycle. The patient is complaining of severe pain and is unable to feel the fingers of the right hand. Radial pulse is absent. What is the priority intervention by the nurse?

Notify the physician. The physician should be notified immediately since this patient is exhibiting signs of decreased circulation and nerve involvement, which could be an indication of compartment syndrome. Patients with compartment syndrome exhibit pain out of proportion to the injury. Decreased sensation, pallor, and pulselessness are late signs of compartment syndrome and the viability of the affected extremity is at risk. The orthopedic or general surgeon should be notified immediately so that the compartment syndrome pressures can be measured and a fasciotomy performed, if necessary, to save the extremity. The extremity should never be elevated or wrapped when compartment syndrome is suspected because this will decrease arterial inflow and exacerbate ischemia. Applying ice packs will not increase blood flow to the affected extremity.

During a motor vehicle accident, a patient sustained blunt trauma to the head and face, resulting in hairline skull fracture and a LeFort III maxillofacial fracture. The patient has a Glasgow Coma Scale of 7 and bruising across the chest and upper abdomen and multiple small superficial bleeding abrasions and lacerations. On admission to the emergency department, what is the nursing care priority?

Perform endotracheal intubation Facial fractures have a high likelihood of compromising the airway from direct trauma and resultant edema. A GCS of less than 8 we intubate. Protection of the airway is always the highest priority. The other answers should also be accomplished but have a lower priority.

Which of these nursing actions should be accomplished first for a patient who has suffered a burn injury while working on an electrical power line and was thrown to the ground?

Place a cervical collar on the patient. When an electrical current travels through the body it causes muscles to contract violently which can lead to multiple fractures including the spinal cord. Patients with electrical burns are treats as a trauma patient which includes application of a cervical collar or immobilization device. Then cardiac monitor and VS. The patient does not need to be assessed for contact points.

A patient is admitted to the emergency department with gastrointestinal bleeding. The patient?s vital signs are blood pressure 78/58 mm Hg, pulse 124 beats/minute, respirations 28 breaths/minute, and temperature 97.2 degrees F (36.2 degrees C). Which physician order should the nurse complete first?

Rapidly administer 1000 mL normal saline solution intravenously. Isotonic crystalloids, such as normal saline solution, should be used in the initial resuscitation of hypovolemic shock. Vasopressor drugs (e.g., norepinephrine) may be considered if the patient does not respond to fluid resuscitation and blood products. Other orders (e.g., insertion of nasogastric tube and indwelling bladder catheter and obtaining the diagnostic studies) can be initiated after fluid resuscitation is initiated.

The physiologic responses producing clinical findings specific to a tension pneumothorax are

Rising intrathoracic pressure and decreased cardiac output In a tension pneumothorax air rapidly escapes from the lung into the pleural space, collapsing the lung and increasing thoracic pressure. Increasing thoracic pressure decreases venous return resulting in a decrease in cardiac output.

A firefighter is admitted with partial-thickness burns of the face and neck, sustained while putting out a fire that involved toxic industrial substances. What would be most significant in determining whether airway obstruction may occur in the patient?

Singed nasal hair. Indicators of possible inhalation injury include (1) injury occurring in an enclosed space; (2) burns of the face or neck; (3) singed nasal hair; (4) hoarseness, high-pitched voice change, stridor; (5) soot in sputum; (6) dyspnea or tachypnea and other signs of reduced oxygen levels (hypoxemia); and (7) erythema and blistering of the oral or pharyngeal mucosa

The patient has a large burn wound that is mostly a full-thickness injury. Wound care included surgical excision and grafting with a variety of materials. The patient and family ask the nurse to explain why repeated surgical procedures are necessary. What is the best explanation the nurse can give the family?

Successful autografting requires preparation of the wound bed Autografting and cultured epithelial autografting are the only permanent wound care solutions for large burns. Use of these substances is most successful when the wound bed is encouraged to develop neocapillaries through preliminary surgical débridement and use of temporary graft materials such as heterografts and synthetic wound closure dressings. Success of autografting is best when these procedures are accomplished in several steps.

Clinical manifestations of neurogenic shock include which of the following?

Venous pooling Bradycardia Warm Skin Loss of sympathetic innervation causes a decrease in cardiac output, venous pooling in the extremities, and peripheral vasodilation resulting in mild hypotension, bradycardia, and warm skin. In addition, the patient doe not perspire on the paralyzed portions of the body because sympathetic activity is blocked

A trauma patient becomes restless and agitated with cyanosis around the mouth. He has diminished breath sounds bilaterally. The priority intervention for this patient is to

apply high-flow oxygen using a non-rebreather mask These are signs of hypoxemia. Patient needs Oxygen while you are attempting to identify what the patient is decompensating.

Battles sign is often indicative of

basilar fracture. The thinnest part of the skull is at the base. We are always concerned with severe facial injuries resulting in the raccoon eyes or in the bruising over the mastoid which could indicate a fracture of the brain. We assess for signs of leaking CSF from the ear or nose.

Your patient with myasthenia gravis is given Pyridostigmine bromide (Mestinon), an anticholinesterase medication. How do you assess that it is effective?

controlled fatigue and improved muscle strength Pyridostigmine bromide (Mestinon)should increase muscle strength and control fatigue which should help increase strength for respiration. Steroids may be used to decrease antibodies. Diarrhea is not an indication of effectiveness of the drug.

The major purpose of using dialysis is to

correct imbalances of fluid and electrolytes. The purpose of dialysis is to correct fluid and electrolyte imabalances that the kidney would normally do. It does not correct the renal dysfunction - that continues to exist.

While auscultating a trauma victim's chest for breath sounds you believe you hear muffle heart sounds. You assess that this

could be cardiac tamponade and needs a pericardial centesis Muffled heart sounds is part of Beck's triad indicating a possible cardiac tamponade which needs immediate intervention. You would hear bowel sounds in the chest if there were a tear in the diaphragm.

The incidence of ischemic stroke in patients with Transient Ischemic Attacks (TIAs) and other risk factors is reduced with the administration of

daily low-dose aspirin. The administration of antiplatelet agents, such as aspirin, dypyridamole and ticlopidine, reduces the incidence of stroke in those at risk. Antiocoagulants are also used for prevention of embolic strokes, but increase the risk for hemorrhage. diuretcis are not indicated for stroke prevention other than for their role in controlling blood pressure and antilipemic agents have not been found to have a significant effect on stroke prevention. The calcium-channel block nimodipine is used in patients with subarachnoid hemorrhage to decrease the effects of vasospasm and minimize tissue damage.

Amlodipine is ordered for a patient with newly diagnosed Prinzmetal's (variant) angina. When teaching the patient, the nurse will include the information that amlodipine will

decrease spasm of the coronary arteries. Prinzmetal's angina is caused by coronary artery spasm. Calcium channel blockers (e.g., amlodipine, nifedipine [Procardia]) are a first-line therapy for this type of angina. Platelet inhibitors, such as aspirin, help prevent coronary artery thrombosis, and b-blockers decrease sympathetic stimulation of the heart. Medications or activities that increase myocardial contractility will increase the incidence of angina by increasing oxygen demand.

A clinical manifestation of respiratory acidosis is

decreased level of consciousness. Respiratory acidosis is caused by CO2 retention. High CO2 levels in the blood can cause change in LOC: ssomnolence (drowsiness), disorientation, and other mental status changes, hence the term "CO2 narcosis". Tingling of the extremities and nausea and vomiting are due to alkalosis. Hypotension, not hypertension can be seen with acidosis ;because acidosis can depress myocardial contractility.

Burn shock results from Select all

direct cutaneous injury systemic inflammatory mediators ,intravascular volume loss Burn shock results from the combination of direct cutaneous injury, intravascular volume loss, and systemic inflammatory mediators affecting multiple physiologic systems

Manifestation of nephrotic syndrome include Select all

edema hypoalbuminemia Nephrotic syndrome is a type of renal failure characterized by increased glomerular permeability and is manifested by massive proteinuria. Clinical findings include a marked increase in protein (particularly albumin) in the urine (proteinuria), a decrease in albumin in the blood (hypoalbuminemia), diffuse edema, high serum cholesterol, and low-density lipoproteins (hyperlipidemia).

A patient who was brought to the Emergency Department with a T-6 injury begins to experience dyspnea and shortness of breath. Considering the level of the patient's injury, you'd assess the breathing difficulty is caused by

edema of the spinal cord above the level of injury. We are always concerned with high T injuries that the patient may start to develop respiratory distress either due to wearing out from having to use abdominal muscles or from the edema occurring within the spinal cord to move upward which would impact even more muscles including the diaphragm.

The nurse knows that the major rationale for the early initiation of enteral feedings in the patient with a major burn is to

ensure adequate calorie and protein intake Burns produce a hypermetabolic state proportional to the size of the wound. These patients require adequate calorie and protein intake and enteral feedings are initiated as soon as GI function is ensured (bowel sounds are present, etc.). Adequate fluids and vitamins and minerals are also needed after a burn. Early enteral feeding will not minimize or prevent fluid shifts during the acute phase of injury and may be dangerous if the patient is in shock or has a paralytic ileus.

A patient in anaphylactic shock just arrived in your Emergency Department. You should be prepared to administer which primary drug?

epinephrine Anaphylactic shock results in bronchospasm and maldistribution of blood flow due to a severe allergic response. Epinephrine's actions on the SNS result in bronchodilation (stimulation of beta-2 receptors) and vasoconstriction (stimulation of alpha-1 receptors) which will stabilize the patient. Steroids and Benadryl are second line drugs to stop the allergic response and reduce inflammation. Nipride will be lethal to this patient because it causes vasodilation and will further drop the patient's blood pressure.

Hypotension during a hemodialysis treatment is usually a sign of

excessive fluid removal no rationale

When assessing a patient for signs of hepatic encephalopathy, the nurse asks the patient to

extend the arm and hand Asterixis is an involuntary flapping of the arms seen in Stage 2 encephalopathy. To test for this the patient is asked to extend the arm and hand and the nurse would look for the flapping motion.

In an advanced shock state, the pulse oximetry probe should be placed on the patient's

forehead A patient in shock will hve decreased perfusion the further away from the heart. The ear, nose, or forehead may be used with the right probe,

You are admitting a patient with hepatic failure. You anticipate the patient may have which of the following complications with hepatic failure? Select all that apply.

hyperaldosteronism esophageal varices ascites hepatic encephalopathy Complications of heaptic failure include increased risk of bleeding, esophageal varicies, ascites, hepatic encephalopathy, increased amounts of aldosterone, fluid overload, fever, infection. There is an increase in the PTT due to loss of clotting factors.

Which of the following electrolyte imbalances would the nurse need to monitor in the patient immediately after the burn? Select all

hyperkalemia hyponatremia Immediately after burn injury, hyperkalemia (excessive potassium) may result from massive cell destruction. Hyponatremia (serum sodium depletion) may be present as a result of plasma loss

Kidneys compensate for significant reductions in Glomerular Filtration Rate (GFR) by

hypertrophy of the remaining nephrons Nephrons will hypertrophy to attempt to take on the extra load as other nephrons die.

Patients who undergo solid organ transplants usually need to take which type of medications for life?

immunosuppressive To decrease rejection of a transplanted organ, the patient must remain on immunosupressant drugs for life.

Large weight gains are common in shock patients because of

increased capillary permeability It is the increase in capillary permeability due to the release of mediators that results in third spacing of fluid.

The nurse must be vigilant in treating a shock patient's elevated temperature and shivering because both cause

increased metabolic need for oxygen. Septic shock in particular can cause fever and shivering due to endotoxin release. Anything that increases the patient's metabolic rate, such as fever and shivering, will increase the patient's metabolic need for oxygen at a time when the cells are already underperfused. Fever and shivering will increase CO2 production, not decrease it. The other options are incorrect.

The major cause of death associated with acute kidney injury is

infection In acute kidney injury the major caus of death is infection, in chronic kidney disease it is cardiovascular disease.

The most common complication following organ transplant is

infection When a patient receives a transplant organ their immune system has to be compromised to prevent rejection, however this makes them at high risk of infection.

After prolonged cardiopulmonary bypass, a patient develops increasing shortness of breath and hypoxemia. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by left ventricular failure, the nurse will anticipate assisting with

inserting a pulmonary artery catheter Sometimes it is hard to tell if a patient is developing acute decompensated heart failure or Acute Respiratory Distress Syndrom. A chest x-ray will show fluid in the lungs for both. An ABG will show hypoxemia for both. A VQ scan is used to assess ventilation/perfusion and would be equal for both. The only way to know if it is heart failure or lung failure is to insert a PA catheter. If it is heart failure, the PAWP will be elevated due to increased blood volume in the pulmonary capillary bed. If it is ARDS, the PAWP will be below 20 indicating the fluid is extravascular indicating ARDS.

To obtain an accurate central venous pressure (CVP) reading, the nurse must

level the transducer with the phlebostatic axis The transducer must be in the correct position for the reading to be accurate. The nurse must level the transducer with the phlepbostatic axis at the beginning of each shift, when the bed position has been changed, or if concerned that the reading may not be accurate.

Your patient has the following ABGs pH 7.16 PaCO2 40 HCO3 13 PaO2 96SaO2 96% The body's natural compensation for this is

lungs would hyperventilate The question asks you to analyze the ABG and comprehend the correct compensatory mechanism for the acid-base disturbance. The pH is very low (acidosis). The PaCO2 is normal. The serum HCO3 is decreased to 13, indicating metabolic acidosis. To compensate and attempt to eliminate excess acid from the body, the lungs would hyperventilate to remove CO2. Over time, the pH should hopefully normalize. In addition, the underlying cause of the acidosis should be identified and treated. Hypoventilation would cause the body to retain CO2 and worsen the acidosis.

In counseling the patient about sexual activity following an MI, the nurse

may discuss sexual activity while teaching about other physical activity. no rationale

The drug of choice for pain control in the burn injured patient is

morphine sulfate Burn wounds produce significant pain and are managed by strong opioids such as morphine. Hydromorphone, methadone, and fentanyl may also be used. Codeine does not produce adequate analgesia for a major burn. Ibuprofen can cause gastric distress and will not produce adequate analgesia. Meperidine produces a metabolite, normeperidine, that will be difficult for the patient to excrete if any degree of impaired kidney function is present.

A client who is having an acute MI complains of chest pain after 3 nitro tablets. The nursing intervention that would be most effective in relieving the client's pain would be:

morphine sulfate 2 mg. IV If the patient continues to have pain after 3 nitroglycerin tablets, Morphine is the next step. The patient will probably already be on O2 and have received the ASA. Lidocaine is used for ventricular dysrhythmias - has not effect on chest pain

During postoperative teaching with a patient who had a mitral valve replacement with a mechanical valve, the nurse instructs the patient regarding the

need for frequent laboratory blood testing no rationale

Cardiac tamponade is suspected in a patient who has acute pericarditis. To assess for the presence of pulsus paradoxus, the nurse should

note when Korotkoff sounds are audible during both inspiration and expiration. no rationale

The most common complication of peritoneal dialysis is

peritonitis Though sterile technique is taught, each time a solution is infused there is always that risk of contamination resulting in infection. The drainage should always be observed for cloudiness as an indicator of infection.

Primary assessment of a motor vehicle crash (MVC) victim reveals: increasing respiratory distress, absent breath sounds over the upper third of the right lung, tachycardia, and probable fracture of the right humerus. The best action for the nurse to take next would be to

prepare for insertion of a chest tube. This patient is demonstrating signs and symptoms of a pneumothorax. During the primary assessment, potential threats to stability of the ABC's are addressed immediately, before the rest of the assessment is completed. Since a pneumothorax can result in respiratory arrest, a chest tube should be inserted to re-expand the lung. An ECG should be obtained next, followed by inquiries about medication allergies and then splinting the fracture. The nurse would want to know about potential medication allergies before any analgesics are given prior to splinting the fracture.

A patient has a pulmonary artery catheter inserted for monitoring cardiovascular status. With the pulmonary artery catheter the most accurate measurement of the patient's left ventricular pressure would be the

pulmonary capillary wedge pressure When the balloon to the PA catheter is inflated and wedged in the artery, it "looks" forward to the left ventricle giving and indirect pressure for that left ventricle. If elevated, it indicates too much volume on the left side of the heart meaning blood is not moving forward usually due to left ventricular failure.

The nurse is caring for a patient with acute pancreatitis. The patient has an order for an anticholinergic medication. The nurse explains that the patient will be receiving medication for what reason?

to reduce gastric and pancreatic secretions Anticholinergic drugs cause a decrease is saliva production and decrease activity of the Gi tract decreasing peristalsis which decrease the stimulation of the pancreas to release enzymes.

A patient sustained a crush injury to the chest and is diagnosed with a flail chest. On assessment, the nurse should expect to observe

respiratory distress and an area of the chest wall bulges outward on expiration. A flailed chest occurs when several ribs are broken in two places and no longer stable. This results in paradoxical movement of the chest wall as the patient inspires the chest wall sinks inward and on exhalation bulges outward) and can lead to respiratory distress rapidly. Muffled heart sounds and increased CVP are due to cardiac tamponade. Cardiac dysrhythmias are an indication of cardiac trauma.

Your patient with hypovolemic shock has an elevated serum lactate (lactic acid) level. You know this indicates

significant hypoperfusion This indicates the cells are inadqueately perfused and have switched from aerobic to anaerobic metabolism.

To promote communication during rehabilitation of the patient with aphasia, an appropriate nursing intervention is to

talk about activities of daily living that are familiar to the pt During rehabilitation, the patient with aphasia needs frequent, meaningful verbal stimulation that has relevance for him or her. Conversation by the nurse and family should address ADLs that are familiar to the patient. Gestures, picture, and simple statements are more appropriate in the acute phase, when patients may be overwhelmed by verbal stimuli. Flashcards are often perceived by the patient as childish and meaningless.

A patient comes to the emergency department immediately after experiencing numbness of the face and an inability to speak, but while the patient awaits examination, the symptoms disappear and the patient request discharge. The nurse stress that it is important for th patient to be evaluated primarily because

the patient has probably experienced a transient ischemic attack (TIA), which is a sign of progressive cerebral vascular disease. A TIA is a temporary focal loss of neurologic function caused by ischemia of an area of the brain, usually lasting only about 3 hours. TIAs may be due to microemboli from heart disease or carotid or cerebral thrombi and are a warning of progressive disease. Evaluation is necessary to determine the cause of the neurologic deficit and provide prophylactic treatment if possible.

Definitive diagnosis of acute rejection of a solid organ transplant is accomplished by a

tissue biopsy The only way to diagnose acute rejection of a solid organ transplant is by tissue biopsy. The Heartsbreath test can be used along with an endomyocardial biopsy to grade the severity of rejection post heart transplant, but it is of no value in diagnosing rejection of other solid organs.

The nurse is caring for a patient with increased intracranial pressure. Why should the nurse expect osmotic diuretics or hypertonic saline infusion to be prescribed for this patient?

to draw edematous fluid into the vascular system Osmotic diuretics are hyperosmotic agents that draw fluid out of brain cells by increasing the osmolality of the blood. These medications excrete water and leave behind solutes. Osmotic diuretics are used to treat hyperthermia, prevent seizures, or prevent GI bleeds.

Nursing interventions for a patient with ascites caused by liver failure include

weighing patient daily placing patient in semi-Fowler's position Ascites is best managed by weighing the patient daily and placing him/her in a sitting position to encourage lung expansion and prevent respiratory complications. The supine position will limit lung expansion and may lead to pneumonia or atelectasis. The patient with liver disease usually needs K+ in the diet due to hepatorenal syndrome and the use of diuretics to manage ascites and edema. In a patient with severe ascites, fluids may need to be restricted, not encouraged.

A nurse caring for a patient with an intracerebral bleed will be monitoring the patient for Cushing's triad. What will the nurse recognize as the symptoms associated with Cushing's triad?

widening pulse pressure bradycardia irregular respirations Cushing triad include bradycardia, widening pulse pressure (increasing systolic pressure while diastolic stays the same or decreases), and irregular respirations.