Ch 17: GI Alterations other, 15, CH 17 Hematologic & Immune Disorders, Ch. 12 Practice Questions Cardiovascular Alterations, Chapter 8: Hemodynamic Monitoring, Chapter 7: Dysrhythmia Interpretation and Management, Critical Care Chapter 9, Chapter 15:...

While monitoring a patient for signs of shock, the nurse understands which system assessment to be of priority? A. Central nervous system B. Gastrointestinal system C. Renal system D. Respiratory system

A

The nurse calculates the PaO2/FiO2 ratio for the following values: PaO2 is 78 mm Hg; FiO2 is 0.6 (60%). a. 46.8; meets criteria for ARDS b. 130; meets criteria for ARDS c. 468; normal lung function d. Not enough data to compute the ratio

b. 130; meets criteria for ARDS

A patient is having difficulty weaning from mechanical ventilation. The nurse assesses the patient for a potential cause of this difficult weaning, which includes:

hemoglobin of 8 g/dL.

Mannitol

osmotic diuretic that pulls water from brain into plasma. used to treat increased ICP dose: 0.5-1g/kg over 5-10 minutes. S/E: hypotension, dehydration, electrolyte imbalance, tachycardia

Goal serum osmolality:

< 320 mOsm/L

11. The process in which antibody and complement proteins attach to the target cell and enhance the phagocytes ability to engulf the target cell is known as: a. opsonization. b. phagocytosis. c. the lymphoreticular system. d. the portal circulation.

A

After receiving a handoff report from the night shift, the nurse completes the morning assessment of a patient with severe sepsis. Vital signs are: 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 past hour. The nurse initiates which provider prescription first? A. Administer infusion of 500 mL 0.9% normal saline every 4 hours as needed if the CVP is less than 5 mm Hg. B. Increase supplemental oxygen therapy to maintain SpO2 greater than 94%. C. Administer 40 mg furosemide (Lasix) intravenous 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 greater than 101° F.

A

The emergency department nurse admits a patient following a motor vehicle collision. Vital signs include blood pressure 70/50 mm Hg, heart rate 140 beats/min, respiratory rate 36 breaths/min, temperature 101° F and oxygen saturation (SpO2) 95% on 3 L of oxygen per nasal cannula. Laboratory results include hemoglobin 6.0 g/dL, hematocrit 20%, and potassium 4.0 mEq/L. Based on this assessment, what is most important for the nurse to include in the patient's plan of care? A. Insertion of an 18-gauge peripheral intravenous line B. Application of cushioned heel protectors C. Implementation of fall precautions D. Implementation of universal precautions

A

The nurse is caring for a mechanically ventilated patient following insertion of a left subclavian central venous catheter (CVC). Which action by the nurse best protects against the development of a central line-associated bloodstream infection (CLABSI)? A. Documentation of insertion date B. Elevation of the head of the bed C. Assessment for weaning readiness D. Appropriate sedation management

A

The nurse is caring for a patient admitted with cardiogenic shock. Hemodynamic readings obtained with a pulmonary artery catheter include a pulmonary artery occlusion pressure (PAOP) of 18 mm Hg and a cardiac index (CI) of 1.0 L/min/m2. What is the priority pharmacological intervention? A. Dobutamine B. Furosemide C. Phenylephrine D. Sodium nitroprusside

A

The nurse is caring for a patient admitted with hypovolemic shock. The nurse palpates thready brachial pulses but is unable to auscultate a blood pressure. What is the best nursing action? A. Assess the blood pressure by Doppler. B. Estimate the systolic pressure as 60 mm Hg. C. Obtain an electronic blood pressure monitor. D. Record the blood pressure as "not assessable."

A

The nurse is caring for a patient following insertion of an intraaortic balloon pump (IABP) for cardiogenic shock unresponsive to pharmacotherapy. Which hemodynamic parameter best indicates an appropriate response to therapy? A. Cardiac index (CI) of 2.5 L/min/m2 B. Pulmonary artery diastolic pressure of 26 mm Hg C. Pulmonary artery occlusion pressure (PAOP) of 22 mm Hg D. Systemic vascular resistance (SVR) of 1600 dynes/sec/cm−5

A

The nurse is caring for a patient in cardiogenic shock being treated with an intraaortic balloon pump (IABP). The family inquires about the primary reason for the device. What is the best statement by the nurse to explain the IABP? A. "The action of the machine will improve blood supply to the damaged heart." B. "The machine will beat for the damaged heart with every beat until it heals." C. "The machine will help cleanse the blood of impurities that might damage the heart." D. "The machine will remain in place until the patient is ready for a heart transplant."

A

The nurse is caring for a patient in septic shock. The nurse assesses the patient to have a blood pressure of 105/60 mm Hg, heart rate 110 beats/min, respiratory rate 32 breaths/min, oxygen saturation (SpO2) 95% on 45% supplemental oxygen via Venturi mask, and a temperature of 102° F. The physician orders stat administration of an antibiotic. Which additional physician order should the nurse complete first? A. Blood cultures B. Chest x-ray C. Foley insertion D. Serum electrolytes

A

The nurse is caring for an athlete with a possible cervical spine (C5) injury following a diving accident. The nurse assesses a blood pressure of 70/50 mm Hg, heart rate 45 beats/min, and respirations 26 breaths/min. The patient's skin is warm and flushed. What is the best interpretation of these findings by the nurse? A. The patient is developing neurogenic shock. B. The patient is experiencing an allergic reaction. C. The patient most likely has an elevated temperature. D. The vital signs are normal for this patient.

A

The patient is admitted with upper GI bleeding following an episode of forceful retching following excessive alcohol intake. The nurse suspects a Mallory-Weiss tear and is aware that: a. a Mallory-Weiss tear is a longitudinal tear in the gastroesophageal mucosa. b. this type of bleeding is treated by giving chewable aspirin. c. the bleeding, although impressive, is selflimiting with little actual blood loss. d. is not usually associated with alcohol intake or retching.

A A Mallory-Weiss tear is an arterial hemorrhage from an acute longitudinal tear in the gastroesophageal mucosa and accounts for 10% to 15% of upper GI bleeding episodes. It is associated with long-term nonsteroidal antiinflammatory drug or aspirin ingestion and with excessive alcohol intake. The upper GI bleeding usually occurs after episodes of forceful retching. Bleeding usually resolves spontaneously; however, lacerations of the esophagogastric junction may cause massive GI bleeding, requiring surgical repair

The nurse is caring for a patient who is passing bright red blood rectally. The nurse should expect to insert a nasogastric tube to: a. rule out massive upper GI bleeding. b. detect the presence of melena in the stomach. c. visually determine the presence of occult bleeding. d. obtain samples for guaiac to confirm current bleeding.

A Bright red or maroon blood (hematochezia) is usually a sign of a lower GI source of bleeding but can be seen when upper GI bleeding is massive (more than 1000 mL). Melena is shiny, black, foul-smelling stool; it is not present in the stomach. Occult bleeding means that blood is not visible and is detected only by testing the stool with a chemical reagent (guaiac).

The liver detoxifies the blood by: a. converting fat-soluble compounds to water-soluble compounds. b. converting water-soluble compounds to fat-soluble compounds. c. excreting fat-soluble compounds in feces. d. metabolizing inactive toxic substances to active forms.

A Drugs, hormones, and other toxic substances are metabolized by the liver into inactive forms for excretion. This process is usually accomplished by conversion of the fatsoluble compounds to water-soluble compounds. They can then be excreted via the bile or the urine.

The patient is admitted with generalized fatigue and a low hemoglobin and hematocrit (anemia). The patient denies vomiting and states that his last bowel movement earlier that day was normal in color and consistency. However, because GI blood loss can be a cause of anemia, the nurse should expect to: a. obtain a stool sample for guaiac testing. b. chart that the patient reports the presence of melena in his stool. c. inspect the patient's next stool for the presence of coffee-ground contents. d. obtain guaiac positive stools only if bleeding is current.

A GI blood loss is often occult or detected only by testing the stool with a chemical reagent (guaiac). Stool and nasogastric drainage can test guaiac positive for up to 10 days after a bleeding episode. Melena is shiny, black, foul-smelling stool and results from the degradation of blood by stomach acids or intestinal bacteria. Vomiting or drainage from a nasogastric tube that yields blood or coffee-ground-like material is associated with upper GI bleeding. However, blood or coffee-ground-like contents may not be present if bleeding has ceased or if it arises beyond a closed pylorus.

The patient is admitted with pancreatitis and has severe ascites. In caring for this patient, the nurse should: a. monitor the patient's blood pressure and evaluate for signs of dehydration. b. restrict intravenous and oral fluid intake because of fluid shifts. c. avoid the use of colloid IV solutions in managing the patient's fluid status. d. only use crystalloid fluids to prevent IV lines from clotting.

A In patients with severe acute pancreatitis, some fluid collects in the retroperitoneal space and peritoneal cavity. Patients sequester up to one third of their plasma volume. Initially, most patients develop some degree of dehydration and, in severe cases, hypovolemic shock. Fluid replacement is a high priority in the treatment of acute pancreatitis. The IV solutions ordered for fluid resuscitation are usually colloids or lactated Ringer's solution; however, fresh frozen plasma and albumin may also be used. IV fluid administration with crystalloids at 500 mL/hr is at times required to maintain hemodynamic status. Often, vigorous IV fluid replacement at 250 to 300mL/hr continues for the first 48 hours or a volume adequate to maintain a urine output of greater than or equal to 0.5 mL/kg body weight per hour. Fluid replacement helps to maintain perfusion to the pancreas and kidneys, reducing the potential for complications.

Infection by Helicobacter pylori bacteria is a major cause of: a. duodenal ulcers. b. Cushing's ulcers. c. Curling's ulcers. d. stress ulcers.

A Infection with Helicobacter pylori bacteria is a major cause of duodenal ulcers. A stress ulcer is an acute form of peptic ulcer that often accompanies severe illness, systemic trauma, or neurological injury. Stress ulcers that develop as a result of burn injury are often called Curling's ulcers. Stress ulcers associated with severe head trauma or brain surgery are called Cushing's ulcers.

The patient is getting neomycin for treatment of hepatic encephalopathy. While the patient is receiving this medication, it is especially important that the nurse: a. evaluate renal function studies daily. b. give the medication every 12 hours. c. evaluate liver studies for signs of neomycin-induced damage. d. obtain stool guaiac tests to ensure that pathogens are being destroyed.

A Neomycin is a broad-spectrum antibiotic that destroys normal bacteria found in the bowel, thereby decreasing protein breakdown and ammonia production. Neomycin is given orally every 4 to 6 hours. This drug is toxic to the kidneys (not liver) and therefore cannot be given to patients with renal failure. Daily renal function studies are monitored when neomycin is administered. Guaiac tests are used to detect occult bleeding

The nurse is caring for a patient with severe pancreatitis and who is orally intubated and on mechanical ventilation. The patient's calcium level this morning was 5.5 mg/dL. The nurse notifies the provider and: a. places the patient on seizure precautions. b. expects that the provider will come and remove the endotracheal tube. c. withhold any further calcium treatments. d. place an oral airway at the bedside.

A Patients with severe hypocalcemia (serum calcium level less than 6 mg/dL) should be placed on seizure precaution status, and respiratory support equipment should be available (e.g., oral airway, suction). In this case, the patient is already intubated so an oral airway is not needed. This value is critically low and replacement of calcium is expected.

The nurse is caring for a patient who is being treated for peptic ulcer disease. Suddenly, the patient yells that her abdomen is "killing" her. The nurse notes that the patient's abdomen is rigid. The nurse should: a. call the provider immediately. b. give the patient pain medication. c. remove the NG tube. d. give the patient an antacid

A Perforation of the gastric mucosa is the major GI complication of peptic ulcer disease. The most common signs of this complication are an abrupt onset of abdominal pain, followed rapidly by signs of peritonitis. Emergent surgery is indicated for treatment. Pain medication is not the treatment of choice in this situation. These patients almost always have nasogastric tubes placed for gastric decompression. Antacids and histamine blockers may or may not be indicated, depending on the cause of the upper GI bleeding. Mortality rates for patients with perforations range from 10% to 40%, depending on the age and condition of the patient at the time of surgery; therefore, it is essential that the provider be called immediately

The nurse is caring for a critically ill patient with end stage liver disease. The nurse knows that the patient is at risk for hyperdynamic circulation and varices. Which of the following assessments would indicate a hyperdynamic status? a. cardiac output of 8 L/min. b. normal sinus rhythm on the cardiac monitor. c. blood pressure of 180/90 mm Hg. d. Stools that are guaiac positive.

A 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 distention, pulmonary crackles, and decreased perfusion to all organs. Blood pressure decreases and dysrhythmias are common. Guaiac-positive stools may be an indication of gastrointestinal bleeding.

The nurse is caring for a patient who is receiving several cardiac medications designed to stimulate the sympathetic nervous system, vitamin B12, and an H2 blocker. The nurse should do which of the following? a. Assess for signs of peptic ulcer. b. Be watchful for increased saliva production. c. Evaluate for a decrease in potassium level. d. Give the patient medications to prevent anemia

A Secretion of mucus by Brunner's glands is inhibited by sympathetic stimulation, which leaves the duodenum unprotected from gastric juice. This inhibition is thought to be one of the reasons why this area of the GI tract is the site for more than 50% of peptic ulcers. Sympathetic stimulation produces a scant output of thick saliva. Vitamin B12 is critical for the formation of red blood cells (RBCs), and a deficiency in this vitamin causes anemia. However, the patient is receiving vitamin B12. The stomach also secretes fluid that is rich in sodium, potassium, and other electrolytes. Loss of these fluids via vomiting or gastric suction places the patient at risk for fluid and electrolyte imbalances and acidbase disturbances. However, nothing indicates that the patient is vomiting or has GI suction

The nurse is caring for a patient who has a peptic ulcer. To treat the ulcer and prevent more ulcers from forming, the nurse should be prepared to administer: a. H2-histamine receptor blockers. b. gastrin. c. vagal stimulation. d. vitamin B12.

A Stimulants of hydrochloric acid secretion include vagal stimulation, gastrin, and the chemical properties of chyme. Histamine, which stimulates the release of gastrin, also stimulates the secretion of hydrochloric acid. Current drug therapies for ulcer disease use H2-histamine receptor blockers that block the effects of histamine and therefore hydrochloric acid stimulation. Vitamin B12 is critical for the formation of red blood cells (RBCs), and a deficiency in this vitamin causes anemia but has no effect on ulcer formation. Gastrin is a hormone that stimulates acid. The vagus nerve helps digestion; however, vagal stimulation is not a treatment for peptic ulcer disease

The patient is being treated for an H. pylori infection with proton pump inhibitor, metronidazole, and tetracycline but is not responding. The nurse expects that: a. bismuth will be added to the current triple therapy. b. a 6-day course of levofloxacin may be used. c. a second-line therapy is not usually effective. d. the proton pump inhibitor will be changed to a higher dose.

A Triple-agent therapy with a proton pump inhibitor and two antibiotics for 14 days is the recommended treatment for eradication of H. pylori. In case first-line therapy fails, a bismuth-based quadruple therapy has been proven to be effective in 76% of patients. This second-line therapy consists of a PPI, bismuth, metronidazole, and a tetracycline. A 10- day course of levofloxacin may also be administered as a second-line therapy for H. pylori infections

After gastric bypass surgery, the patient is getting vitamin B12 via injection. The patient asks why he can't get the vitamin by mouth. The nurse explains that: a. the patient may not have enough intrinsic factor for normal absorption. b. the patient would have to drink water, and the small intestine can't handle water. c. the vitamin is absorbed in the upper part of the small bowel and would travel too fast. d. all vitamins are absorbed in the terminal ileum and it would take too long for B12.

A Vitamin B12 is absorbed in the terminal ileum in the presence of intrinsic factor produced in the stomach. Gastric bypass may lead to reduced levels of intrinsic factor. The small intestine also handles water, electrolyte, and vitamin absorption. Vitamins, with the exception of B12, and iron are absorbed in the upper part of the small bowel.

When caring for the patient with upper GI bleeding, the nurse assesses for which of the following? (Select all that apply.) a. Severity of blood loss b. Hemodynamic stability c. Vital signs every 30 minutes d. Signs of hypervolemic shock e. Necessity for fluid resuscitation

A B E Initial evaluation of the patient with upper GI bleeding involves a rapid assessment of the severity of blood loss, hemodynamic stability and the necessity for fluid resuscitation, and frequent monitoring of vital signs and assessments of body systems for signs of hypovolemic shock. Vital signs should be monitored at least every 15 minutes.

Nursing priorities for the management of acute pancreatitis include: (Select all that apply.) a. managing respiratory dysfunction. b. assessing and maintaining electrolyte balance. c. withholding analgesics that could mask abdominal discomfort. d. stimulating gastric content motility into the duodenum. e. utilizing supportive therapies aimed at decreasing gastrin release.

A B E Nursing and medical priorities for the management of acute pancreatitis include several interventions. Managing respiratory dysfunction is a high priority. Fluids and electrolytes are replaced to maintain or replenish vascular volume and electrolyte balance. Analgesics are given for pain control, and supportive therapies are aimed at decreasing gastrin release from the stomach and preventing the gastric contents from entering the duodenum.

The nurse is caring for a patient admitted with a spinal cord injury. Upon assessment, the nurse notes a complete loss of motor and sensory function below the patient's nipple line. What is the best understanding of this assessment finding by the nurse?

A complete cord lesion results in loss of motor and sensory function below the level of spinal cord injury.

8. The nurse is caring for an elderly patient who is being admitted for anemia of unknown cause. The patient has been on multiple medications at home for various ailments. In assessing the patients medication list, the nurse notes medications that may alter hemostasis, including: (Select all that apply.) a. aminoglycosides. b. antiplatelet agents. c. cephalosporins. d. vasoconstrictors. e. sulfonamides.

A, B, C, E

3. Inflammation is initiated by cellular injury and: (Select all that apply.) a. is necessary for tissue repair. b. inhibits the process called chemotaxis. c. is harmful when uncontrolled. d. is less efficient when complement proteins are present. e. occurs when mediators cause vasoconstriction.

A, C

9. In caring for the patient who has a coagulopathy, the nurse should: (Select all that apply.) a. assess fluids for occult blood. b. observe for oozing and bleeding and remove clots that form. c. limit invasive procedures. d. take temperatures rectally to increase accuracy. e. weigh dressings to assess blood loss.

A, C, E

The nurse is caring for a patient admitted with shock. The nurse understands which assessment findings best assess tissue perfusion in a patient in shock? (Select all that apply.) A. Blood pressure B. Heart rate C. Level of consciousness D. Pupil response E. Respirations F. Urine output

A, C, F

An emergency room nurse assesses a client who was rescued from a home fire. The client suddenly develops a loud, brassy cough. Which action should the nurse take first? a.Apply oxygen and continuous pulse oximetry. b.Provide small quantities of ice chips and sips of water. c.Request a prescription for an antitussive medication. d.Ask the respiratory therapist to provide humidified air.

ANS: A Brassy cough and wheezing are some of the signs seen with inhalation injury. The first action by the nurse is to give the client oxygen. Clients with possible inhalation injury also need continuous pulse oximetry. Ice chips and humidified room air will not help the problem, and antitussives are not warranted.

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

ANS: A A GCS score of 3 is indicative of a deep coma. Given the assessed respiratory rate of 10 breaths/min combined with the GSC score of 3, the nurse must focus on maintaining the patient's airway. There is no evidence to support the need for increased supplemental oxygen. A respiratory rate of 10 breaths/min may result in increased CO2 retention, which may further increase ICP through dilatation of cerebral vessels. Elevating the head of the bed and supporting bony prominences are appropriate nursing interventions for a patient in a deep coma; however, airway patency is the immediate priority. DIF: Cognitive Level: Application REF: pp. 355-356 OBJ: Describe the nursing and medical management of patients with increased intracranial pressure. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

The nurse is preparing to administer 100 mg of phenytoin (Dilantin) to a patient in status epilepticus. To prevent patient complications, what is the best action by the nurse? a. Ensure patency of intravenous (IV) line. b. Mix drug with 0.9% normal saline. c. Evaluate serum K+ level. d. Obtain an IV infusion pump.

ANS: A Ensuring a patent IV site prevents complications associated with infiltration of the medication (soft tissue necrosis). Mixing the drug with normal saline prevents crystallization of the medication and would be noticed prior to administration. Evaluating the serum K+ is not required prior to administration. The dose of phenytoin (Dilantin) ordered can be safely administered IV push over 2 minutes and does not require an infusion pump. DIF: Cognitive Level: Comprehension REF: Table 13-9 OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease. TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

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

ANS: A Nurses complete neurological assessments based on ordered frequency and the severity of the patient's condition. The newly admitted patient has an altered neurological status so frequent neurological assessments are most important to include in the patient's plan of care. Side to side position changes, range of motion exercises, and frequent oral suctioning are nursing actions that may need to be a part of the patient's plan of care but in the setting of increased intracranial pressure should not be regularly performed unless indicated. DIF: Cognitive Level: Application REF: p. 365 | Nursing Care Plan OBJ: Describe the nursing and medical management of patients with increased intracranial pressure. TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

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

ANS: A The patient's GCS score is 4 along with an ICP of 18 mm Hg. Although a portable chest x-ray and seizure precautions are appropriate to include in the plan of care, Mannitol 1 g intravenous is the priority intervention to reduce intracranial pressure. Ancef 1 g intravenous is appropriate given the indwelling ICP line; however, antibiotic therapy is not the priority in this scenario. DIF: Cognitive Level: Analysis REF: Table 13-9 OBJ: Describe the nursing and medical management of patients with increased intracranial pressure. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

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

ANS: A To reduce the risk of further injury, a patient experiencing seizure activity while sitting in a chair should be assisted to the floor with head adequately supported. Routine insertion of a nasogastric tube during seizure activity is not indicated unless there is risk for aspiration. Forceful insertion of a padded tongue blade should not be carried out during tonic-clonic activity; most likely the patient's jaws will be clenched shut. Forceful insertion may lead to further injury. Restraining a patient during seizure activity can be traumatizing and is not standard of care. DIF: Cognitive Level: Application REF: p. 387 OBJ: Describe the pathophysiology and management for status epilepticus. TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity

10. Acute kidney injury from post renal etiology is caused by: a. obstruction of the flow of urine. b. conditions that interfere with renal perfusion. c. hypovolemia or decreased cardiac output. d. conditions that act directly on functioning kidney tissue.

ANS: A Acute kidney injury resulting from obstruction of the flow of urine is classified as postrenal or obstructive renal injury. Conditions that result in AKI by interfering with renal perfusion are classified as prerenal and include hypovolemia and decreased cardiac output. Conditions that produce AKI by directly acting on functioning kidney tissue are classified as intrarenal.

37. Continuous venovenous hemofiltration is used to: a. remove fluids and solutes through the process of convection. b. remove plasma water in cases of volume overload. c. remove plasma water and solutes by adding dialysate. d. combine ultrafiltration, convection and dialysis.

ANS: A Continuous venovenous hemofiltration (CVVH) is used to remove fluids and solutes through the process of convection. Slow continuous ultrafiltration (SCUF) is used to remove plasma water in cases of volume overload. Continuous venovenous hemodialysis (CVVHD) is similar to CVVH in that ultrafiltration removes plasma water. It differs in that dialysate solution is added around the hemofilter membranes to facilitate solute removal by the process of diffusion. Continuous venovenous hemodiafiltration (CVVHDF) combines ultrafiltration, convection, and dialysis to maximize fluid and solute removal.

9. The nurse is caring for a patient who has undergone major abdominal surgery. The nurse notices that the patient's urine output has been less than 20 mL/hour for the past 2 hours. It is 0200 in the morning. The patient's blood pressure is 100/60 mm Hg, and the pulse is 110 beats per minute. Previously, the pulse was 90 beats per minute with a blood pressure of 120/80 mm Hg. The nurse should: a. contact the provider and expect an order for a normal saline bolus. b. wait until 0900 when the provider makes rounds to report the assessment findings. c. continue to evaluate urine output for 2 more hours. d. ignore the urine output, as this is most likely postrenal in origin.

ANS: A Most prerenal causes of AKI are related to intravascular volume depletion, decreased cardiac output, renal vasoconstriction, or pharmacological agents that impair autoregulation and GFR (Box 15-2).8 These conditions reduce the glomerular perfusion and the GFR, and the kidneys are hypoperfused. For example, major abdominal surgery can cause hypoperfusion of the kidney as a result of blood loss during surgery or as a result of excess vomiting or nasogastric suction during the postoperative period. The body attempts to normalize renal perfusion by reabsorbing sodium and water. If adequate blood flow is restored to the kidney, normal renal function resumes. Most forms of prerenal AKI can be reversed by treating the cause

24. The patient gets hemodialysis 3 days a week. He is 74 inches tall and weighs 100 kg. In planning the care for this patient, the nurse recommends: a. 2500 to 3500 kcal diet per day. b. protein intake less than 50 grams per day. c. potassium intake of 10 mEq per day. d. fluid intake of less than 500 mL per day.

ANS: A Nutritional recommendations include the following: caloric intake of 25 to 35 kcal/kg of ideal body weight per day (2500-3500 kcal) and protein intake of no less than 0.8 g/kg body weight. Patients who are extremely catabolic should receive 1.5 to 2 g/kg of ideal body weight per day, 75% to 80% of which contains all the required essential amino acids; sodium intake of 0.5 to 1.0 g/day; potassium intake of 20 to 50 mEq/day; calcium intake of 800 to 1200 mg/day; fluid intake equal to the volume of the patient's urine output plus an additional 600 to 1000 mL/day

25. The patient's potassium level is 7.0 mEq/L. Besides dialysis, which of the following actually reduces plasma potassium levels and total body potassium content safely in a patient with renal dysfunction? a. Kayexalate b. Kayexalate with sorbitol c. Regular insulin d. Calcium gluconate

ANS: A Only dialysis and administration of cation exchange resins (sodium polystyrene sulfonate [Kayexalate]) actually reduce plasma potassium levels and total body potassium content in a patient with renal dysfunction. In the past, sorbitol has been combined with sodium polystyrene sulfonate powder (Kayexalate) for administration. The concomitant use of sorbitol with Kayexalate has been implicated in cases of colonic intestinal necrosis; therefore, this combination is not recommended. Other treatments, such as administration of regular insulin and calcium gluconate only "protect" the patient for a short time until dialysis or cation exchange resins can be instituted.

42. The nurse is caring for a patient receiving peritoneal dialysis. The patient suddenly complains of abdominal pain and chills. The patient's temperature is elevated. The nurse should: a. assess peritoneal dialysate return. b. check the patient's blood sugar. c. evaluate the patient's neurological status. d. inform the provider of probable visceral perforation.

ANS: A Peritonitis is the most common complication of peritoneal dialysis therapy and is usually caused by contamination in the system. Peritonitis is manifested by abdominal pain, cloudy peritoneal fluid, fever and chills, nausea and vomiting, and difficulty in draining fluid from the peritoneal cavity.

36. Slow continuous ultrafiltration is also known as isolated ultrafiltration and is used to: a. remove plasma water in cases of volume overload. b. remove fluids and solutes through the process of convection. c. remove plasma water and solutes by adding dialysate. d. combine ultrafiltration, convection and dialysis.

ANS: A Slow continuous ultrafiltration (SCUF) is also known as isolated ultrafiltration and is used to remove plasma water in cases of volume overload. Continuous venovenous hemofiltration (CVVH) is used to remove fluids and solutes through the process of convection. Continuous venovenous hemodialysis (CVVHD) is similar to CVVH in that ultrafiltration removes plasma water. It differs in that dialysate solution is added around the hemofilter membranes to facilitate solute removal by the process of diffusion. Continuous venovenous hemodiafiltration (CVVHDF) combines ultrafiltration, convection, and dialysis to maximize fluid and solute removal.

5. Renin plays a role in blood pressure regulation by: a. activating the renin-angiotensin-aldosterone cascade. b. suppressing angiotensin production. c. decreasing sodium reabsorption. d. inhibiting aldosterone release.

ANS: A Specialized cells in the afferent and efferent arterioles and the distal tubule are collectively known as the juxtaglomerular apparatus. These cells are responsible for the production of a hormone called renin, which plays a role in blood pressure regulation. Renin is released whenever blood flow through the afferent and efferent arterioles decreases. A decrease in the sodium ion concentration of the blood flowing past the specialized cells (e.g., in hypovolemia) also stimulates the release of renin. Renin activates the renin-angiotensin-aldosterone cascade, which ultimately results in angiotensin II production. Angiotensin II causes vasoconstriction and release of aldosterone from the adrenal glands, thereby raising blood pressure and flow and increasing sodium and water reabsorption in the distal tubule and collecting ducts.

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

ANS: A Temporary percutaneous catheters are commonly used in patients with acute kidney injury because they can be used immediately. Occasionally a percutaneous tunneled catheter is placed if the patient needs ongoing hemodialysis; however, these catheters are usually inserted in the operating room. An arteriovenous fistula is an internal, surgically created communication between an artery and a vein. This method produces a vessel that is easy to cannulate but requires 4 to 6 weeks before it is mature enough to use. Arteriovenous grafts are created by using different types of prosthetic material, most commonly polytetrafluoroethylene and Teflon. Grafts are placed under the skin and are surgically anastomosed between an artery and a vein. The graft site usually heals within 2 to 4 weeks.

39. The critical care nurse is responsible for monitoring the patient receiving continuous renal replacement therapy (CRRT). In doing so, the nurse should: a. assess that the blood tubing is warm to the touch. b. assess the hemofilter every 6 hours for clotting. c. cover the dialysis lines to protect them from light. d. use clean technique during vascular access dressing changes.

ANS: A The critical care nurse is responsible for monitoring the patient receiving CRRT. The hemofilter is assessed every 2 to 4 hours for clotting (as evidenced by dark fibers or a rapid decrease in the amount of ultrafiltration without a change in the patient's hemodynamic status). The CRRT system is frequently assessed to ensure filter and lines are visible at all times, kinks are avoided, and the blood tubing is warm to the touch. The ultrafiltrate is assessed for blood (pink-tinged to frank blood), which is indicative of membrane rupture. Sterile technique is performed during vascular access dressing changes.

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

ANS: A, B Hypotension is common and is usually the result of preexisting hypovolemia, excessive amounts of fluid removal, or excessively rapid removal of fluid. Dysrhythmias may occur during dialysis. Causes of dysrhythmias include a rapid shift in the serum potassium level, clearance of antidysrhythmic medications, preexisting coronary artery disease, hypoxemia, or hypercalcemia from rapid influx of calcium from the dialysate solution. Muscle cramps occur more commonly in chronic renal failure. Hemolysis, air embolism, and hyperthermia are rare complications of hemodialysis.

A nurse cares for a client with burn injuries during the resuscitation phase. Which actions are priorities during this phase? (Select all that apply.) a.Administer analgesics. b.Prevent wound infections. c.Provide fluid replacement. d.Decrease core temperature. e.Initiate physical therapy.

ANS: A, B, C Nursing priorities during the resuscitation phase include securing the airway, supporting circulation and organ perfusion by fluid replacement, keeping the client comfortable with analgesics, preventing infection through careful wound care, maintaining body temperature, and providing emotional support. Physical therapy is inappropriate during the resuscitation phase but may be initiated after the client has been stabilized.

3. Noninvasive diagnostic procedures used to determine kidney function include which of the following? (Select all that apply.) a. Kidney, ureter, bladder (KUB) x-ray b. Renal ultrasound c. Magnetic resonance imaging (MRI) d. Intravenous pyelography (IVP) e. Renal angiography

ANS: A, B, C Noninvasive diagnostic procedures are usually performed before any invasive diagnostic procedures are conducted. Noninvasive diagnostic procedures that assess the renal system are radiography of the kidneys, ureters, and bladder (KUB); renal ultrasonography; and magnetic resonance imaging. Invasive diagnostic procedures for assessing the renal system include intravenous pyelography, computed tomography, renal angiography, renal scanning, and renal biopsy.

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

ANS: A, B, C, E, F In unconscious patients with stable cervical spine, assess oculocephalic reflex (doll's eye): turn the patient's head quickly from side to side while holding the eyes open. Note movement of eyes. The doll's eye reflex is present if the eyes move bilaterally in the opposite direction of the head movement. DIF: Cognitive Level: Comprehension REF: pp. 393-396 OBJ: Complete an assessment on a critically ill patient with nervous system injury. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

A nurse cares for a client with burn injuries who is experiencing anxiety and pain. Which nonpharmacologic comfort measures should the nurse implement? (Select all that apply.) a.Music as a distraction b.Tactile stimulation c.Massage to injury sites d.Cold compresses e Increasing client control

ANS: A, B, E Nonpharmacologic comfort measures for clients with burn injuries include music therapy, tactile stimulation, massaging unburned areas, warm compresses, and increasing client control.

A nurse plans care for a client with burn injuries. Which interventions should the nurse implement to prevent infection in the client? (Select all that apply.) a.Ask all family members and visitors to perform hand hygiene before touching the client. b.Carefully monitor burn wounds when providing each dressing change. c.Clean equipment with alcohol between uses with each client on the unit. d.Allow family members to only bring the client plants from the hospital's gift shop. e.Use aseptic technique and wear gloves when performing wound care.

ANS: A, B, E To prevent infection in a client with burn injuries the nurse should ensure everyone performs hand hygiene, monitor wounds for signs of infection, and use aseptic technique, including wearing gloves when performing wound care. The client should have disposable equipment that is not shared with another client, and plants should not be allowed in the client's room.

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

ANS: A, C The goal for ischemic stroke is to keep the systolic blood pressure less than 220 mm Hg and the diastolic blood pressure 120 mm Hg. In hemorrhagic stroke, the goal is a mean arterial pressure less than 130 mm Hg. Neurological assessments are compared with the baseline assessments performed in the ED. The elapsed time of 8 hours since onset of symptoms prohibits thrombolytic therapy. The CO2 should be maintained within normal limits; this value is elevated. The elapsed time of 8 hours since onset of symptoms prohibits thrombolytic therapy. Restraints should be avoided. DIF: Cognitive Level: Analysis REF: pp. 382-383 OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease. TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity

A nurse cares for an older client with burn injuries. Which age-related changes are paired appropriately with their complications from the burn injuries? (Select all that apply.) a.Slower healing time - Increased risk for loss of function from contracture formation b.Reduced inflammatory response - Deep partial-thickness wound with minimal exposure c.Reduced thoracic compliance - Increased risk for atelectasis d.High incidence of cardiac impairments - Increased risk for acute kidney injury e.Thinner skin - May not exhibit a fever when infection is present

ANS: A, C, D Slower healing time will place the older adult client at risk for loss of function from contracture formation due to the length of time needed for the client to heal. A pre-existing cardiac impairment increases risk for acute kidney injury from decreased renal blood flow, and reduced thoracic compliance places the client at risk for atelectasis. Reduced inflammatory response places the client at risk for infection without a normal response, including fever. Clients with thinned skin are at greater risk for deeper wounds from minimal exposure.

2. The patient is admitted with acute kidney injury from a postrenal cause. Acceptable treatments for that diagnosis include: (Select all that apply.) a. bladder catheterization. b. increasing fluid volume intake. c. ureteral stenting. d. placement of nephrostomy tubes. e. increasing cardiac output.

ANS: A, C, D The location of the obstruction in the urinary tract determines the method by which the obstruction is treated and may include bladder catheterization, ureteral stenting, or the placement of nephrostomy tubes. Fluid volume intake may be recommended to treat prerenal causes of AKI. Increasing cardiac output would be indicated in certain prerenal causes of AKI.

6. The patient is in the critical care unit and will receive dialysis this morning. The nurse will: (Select all that apply.) a. evaluate morning laboratory results and report abnormal results. b. administer the patient's antihypertensive medications. c. assess the dialysis access site and report abnormalities. d. weigh the patient to monitor fluid status. e. give all medications except for antihypertensive medications.

ANS: A, C, D The patient receiving hemodialysis requires specialized monitoring and interventions by the critical care nurse. Laboratory values are monitored and abnormal results reported to the nephrologist and dialysis staff. The patient is weighed daily to monitor fluid status. On the day of dialysis, dialyzable (water-soluble) medications are not given until after treatment. The dialysis nurse or pharmacist can be consulted to determine which medications to withhold or administer. Supplemental doses are administered as ordered after dialysis. Administration of antihypertensive agents is avoided for 4 to 6 hours before treatment, if possible. Doses of other medications that lower blood pressure (narcotics, sedatives) are reduced, if possible. The percutaneous catheter, fistula, or graft is assessed frequently; unusual findings such as loss of bruit, redness, or drainage at the site must be reported. After dialysis, the patient is assessed for signs of bleeding, hypovolemia, and dialysis disequilibrium syndrome.

A nurse plans care for a client with burn injuries. Which interventions should the nurse include in this client's plan of care to ensure adequate nutrition? (Select all that apply.) a.Provide at least 5000 kcal/day. b.Start an oral diet on the first day. c.Administer a diet high in protein. d.Collaborate with a registered dietitian. e.Offer frequent high-calorie snacks.

ANS: A, C, D, E A client with a burn injury needs a high-calorie diet, including at least 5000 kcal/day and frequent high-calorie snacks. The nurse should collaborate with a registered dietitian to ensure the client receives a high-calorie and high-protein diet required for wound healing. Oral diet therapy should be delayed until GI motility resumes.

4. The most common reasons for initiating dialysis in acute kidney injury include which of the following? (Select all that apply.) a. Acidosis b. Hypokalemia c. Volume overload d. Hyperkalemia

ANS: A, C, D, E The most common reasons for initiating dialysis in acute kidney injury include acidosis, hyperkalemia, volume overload, and uremia. Dialysis is usually started early in the course of the renal dysfunction before uremic complications occur. In addition, dialysis may be started for fluid management when total parenteral nutrition is administered.

1. Identify which substances would indicate a problem with renal function. (Select all that apply). a. protein. b. sodium. c. creatinine. d. red blood cells. e. uric acid.

ANS: A, D, E The glomerular capillary membrane is approximately 100 times more permeable than other capillaries. It acts as a high-efficiency sieve and normally allows only substances with a certain molecular weight to cross. Normal glomerular filtrate is basically protein free and contains electrolytes, including sodium, chloride, and phosphate, and nitrogenous waste products, such as creatinine, urea, and uric acid, in amounts similar to those in plasma. Red blood cells, albumin, and globulin are too large to pass through the healthy glomerular membrane.

A nurse assesses a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which assessment finding should alert the nurse to a potential complication? a.Partial pressure of arterial oxygen (PaO2) of 80 mm Hg b.Urine output of 20 mL/hr c.Productive cough with white pulmonary secretions d.Core temperature of 100.6° F (38° C)

ANS: B A significant loss of fluid occurs with burn injuries, and fluids must be replaced to maintain hemodynamics. If fluid replacement is not adequate, the client may become hypotensive and have decreased perfusion of organs, including the brain and kidneys. A low urine output is an indication of poor kidney perfusion. The other manifestations are not complications of burn injuries.

The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by autocontamination? a.Use a disposable blood pressure cuff to avoid sharing with other clients. b.Change gloves between wound care on different parts of the client's body. c.Use the closed method of burn wound management for all wound care. d.Advocate for proper and consistent handwashing by all members of the staff.

ANS: B Autocontamination is the transfer of microorganisms from one area to another area of the same client's body, causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for infection, only changing gloves between performing wound care on different parts of the client's body can prevent autocontamination.

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

ANS: B Alignment of the head and neck may help prevent spinal cord damage in the event of a cervical spine injury. Hyperextension of the neck is contraindicated with a cervical spine injury. Immediate endotracheal intubation is not indicated with a suspected cervical spine injury unless the patient's airway is compromised. The use of assist devices to maintain immobilization of the cervical spine is indicated until injury has been ruled out. DIF: Cognitive Level: Comprehension REF: p. 392 OBJ: Describe nursing and medical management of patients with a spinal cord injury. TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity

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

ANS: B Autonomic dysreflexia, characterized by an exaggerated response of the sympathetic nervous system can be triggered by a variety of stimuli, including a kinked indwelling catheter, which would result in bladder distention. Other causes that should be ruled out prior to pharmacological intervention include fecal impaction. Treating the patient for a headache will not resolve symptoms of autonomic dysreflexia. Treatment must focus on identifying the underlying cause. Slow deep breathes will not correct the underlying problem. Assessing for underlying causes of autonomic dysreflexia should precede contacting the physician. DIF: Cognitive Level: Application REF: Box 13-5 OBJ: Describe nursing and medical management of patients with a spinal cord injury. TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity

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

ANS: B In the presence of hypotension and bradycardia, administering the medication over 2 minutes is too fast. Mixing medication with 0.9% normal saline prevents precipitation of the medication but will not prevent complications related to this scenario. Administering the medications via central line will not prevent complications related to this scenario. DIF: Cognitive Level: Application REF: Table 13-9 OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease. TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

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

ANS: B Maintaining perfusion to the spinal cord is critical in the management of spinal cord injury. Monitoring blood pressure is a priority. DIF: Cognitive Level: Comprehension REF: pp. 393-394 OBJ: Describe nursing and medical management of patients with a spinal cord injury. TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity

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

ANS: B Medications to control blood pressure are administered to prevent rebleeding before an aneurysm is secured. Following infusion, the patient's blood pressure remains dangerously high, so increasing the dose by 2.5 mg/hr is the best action by the nurse. Stopping the infusion or weaning the infusion is contraindicated before reaching the desired blood pressure. Notifying the physician of the blood pressure is not indicated until the upper limits of the infusion are reached without achieving the desired blood pressure. DIF: Cognitive Level: Analysis REF: Table 13-9 OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

The physician orders fosphenytoin (Cerebyx), 1.5 g intravenous (IV) loading dose for a 75-kg patient in status epilepticus. What is the most important action by the nurse? a. Contact the admitting physician. b. Administer drug over 10 minutes. c. Mix medication with 0.9% normal saline. d. Administer via central line.

ANS: B The nurse can administer the medication over 10 minutes as ordered (100-150 mg phenytoin equivalent [PE] over 1 full minute). The drug dose ordered is appropriate for the patient's weight. Fosphenytoin (Cerebyx) does not have to be administered with normal saline or via a central line. DIF: Cognitive Level: Application REF: Table 13-9 OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease. TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

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

ANS: B The nurse should administer lorazepam (Ativan) as ordered; lorazepam (Ativan) is the first-line medication for the treatment of status epilepticus. Phenytoin (Dilantin) is administered only when lorazepam fails to stop seizure activity or if intermittent seizures persist for longer than 20 minutes. Serum electrolytes and chest x-rays are appropriate orders but not the priority in this scenario. DIF: Cognitive Level: Application REF: Table 13-9 OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease. TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

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

ANS: B To ensure adequate cerebral perfusion, for a CVP of 2 mm Hg, blood pressure of 90/60 mm Hg, and heart rate of 115 beats/min, an infusion of 500 mL of albumin is most appropriate. Lasix is contraindicated in low volume states. Although Decadron and Dilantin are appropriate medications, in this scenario, they are not the priority medications. DIF: Cognitive Level: Application REF: p. 384 OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

20. The patient is complaining of severe flank pain when he tries to urinate. His urinalysis shows sediment and crystals along with a few bacteria. Using this information along with the clinical picture, the nurse realizes that the patient's condition is: a. prerenal. b. postrenal. c. intrarenal. d. not renal related.

ANS: B Analysis of urinary sediment and electrolyte levels is helpful in distinguishing among the various causes of acute kidney injury. Postrenal conditions may present with stones, crystals, sediment, bacteria, and clots from the obstruction. Coarse, muddy brown granular casts are classic findings in ATN (intrarenal), along with microscopic hematuria and a small amount of protein. In prerenal conditions, the urine typically has no cells but may contain hyaline casts. The flank pain and urinalysis definitely indicate a renal condition.

The term used to describe an increase in blood urea nitrogen (BUN) and serum creatinine is: a. oliguria. b. azotemia. c. acute kidney injury. d. prerenal disease.

ANS: B Azotemia refers to increases in blood urea nitrogen and serum creatinine. Oliguria is defined as urine output less than 0.5 mL/kg/hr. Elevation of BUN and creatinine can be the result of acute kidney injury or chronic kidney diseases. Conditions that result in AKI by interfering with renal perfusion are classified as prerenal.

12. The patient undergoes a cardiac catheterization that requires the use of contrast dyes during the procedure. To detect signs of contrast-induced kidney injury, the nurse should: a. not be concerned unless urine output decreases. b. evaluate the patient's serum creatinine for up to 72 hours after the procedure. c. obtain an order for a renal ultrasound. d. evaluate the patient's post void residual volume to detect intrarenal injury.

ANS: B Contrast- induced kidney injury is diagnosed by an increase in serum creatinine of 25%, or 0.5 mg/dL, within 48 to 72 hours following the administration of contrast. Urine output usually remains normal. The renal ultrasound and postvoid residual assessment are not warranted

23. The patient is admitted to the unit with the diagnosis of rhabdomyolysis. The patient is started on intravenous (IV) fluids and IV mannitol. Because mannitol is an osmotic diuretic, the nurse should: a. assess the patient's hearing. b. assess the patient's lungs. c. decrease IV fluids once the diuretic has been administered. d. give extra doses prior to giving radiological contrast agents.

ANS: B Mannitol, an osmotic diuretic often used in acute kidney injury caused by rhabdomyolysis, increases plasma volume. Patients may be at risk for the development of pulmonary edema due to the rapid expansion of intravascular volume triggered by mannitol. Hearing is assessed with administration of loop diuretics, such as furosemide, which have been associated with deafness. Aggressive fluid administration is required in rhabdomyolysis. Diuretics may increase the risk of acute kidney injury from volume depletion when they are given before procedures requiring radiological contrast agents or if the patient is hypovolemic. Adequate hydration prior to administration of diuretics is essential.

With sudden cessation of renal function, all body systems are affected by the inability to maintain fluid and electrolyte balance and eliminate metabolic waste. In critically ill patients, renal dysfunction: a. is a very rare problem. b. affects nearly two thirds of patients. c. has a low mortality once renal replacement therapy has been initiated. d. has little effect on morbidity, mortality, or quality of life.

ANS: B The kidney is the primary regulator of the body's internal environment. With sudden cessation of renal function, all body systems are affected by the inability to maintain fluid and electrolyte balance and eliminate metabolic waste. Renal dysfunction is a common problem in critically ill patients with nearly two thirds of patients experiencing some degree of renal dysfunction. The most severe cases requiring renal replacement therapy have a reported mortality of 50% to 60%. Acute kidney injury that progresses to chronic renal failure is associated with increased morbidity, mortality and reduced quality of life.

6. The nurse is caring for an elderly patient who was admitted with renal insufficiency. The nurse realizes that with advance age often comes declining renal function. An expected laboratory finding for this patient may be: a. an increased glomerular filtration rate (GFR). b. a normal serum creatinine level. c. increased ability to excrete drugs. d. hypokalemia.

ANS: B The most important renal physiological change that occurs with aging is a decrease in the GFR. After age 40, renal blood flow gradually diminishes at a rate of 10% per decade. With advancing age, there is also a decrease in renal mass, the number of glomeruli and peritubular density. Serum creatinine levels may remain the same in the elderly patient, even with a declining GFR, because of decreased muscle mass and hence decreased creatinine production. Tubular changes include a diminished ability to excrete drugs, including radiocontrast dyes used in diagnostic testing, which necessitates a decrease in drug dosing to avoid nephrotoxicity. Many medications, including antibiotics, require dose adjustments as kidney function declines. Age-related changes in renin and aldosterone levels also occur, which can lead to fluid and electrolyte abnormalities. Renin levels are decreased by 30% to 50% in the elderly, resulting in less angiotensin II production and lower aldosterone levels. Together these can cause an increased risk of hyperkalemia. The aging kidney is also slower to correct an increase in acids, causing a prolonged metabolic acidosis and the subsequent shifting of potassium out of cells and worsening hyperkalemia.

44. The patient has been admitted to the hospital with nausea and vomiting that started 5 days earlier. His blood pressure is 80/44 mm Hg and heart rate is 122 beats/min; he has not voided in 8 hours and his bladder is not distended. The nurse anticipates an order for "stat" administration of: a. a blood transfusion. b. fluid replacement with 0.45% saline. c. infusion of an inotropic agent. d. an antiemetic.

ANS: B This scenario indicates hypovolemia from the nausea and vomiting, requiring volume replacement. Hypovolemia resulting from large urine or gastrointestinal losses often requires the administration of a hypotonic solution, such as 0.45% saline. Blood products would be indicated only in the presence of bleeding following assessment of hemoglobin and hematocrit levels. The inotrope is contraindicated in the presence of volume depletion. An antiemetic may be needed; however, the priority to prevent shock and acute kidney injury is fluid administration.

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

ANS: C Bacterial meningitis is an infection of the pia and arachnoid layers of the meninges and the cerebrospinal fluid (CSF) in the subarachnoid space. As such, the patient can experience symptoms associated with cerebral irritation such photophobia and seizures. In addition, the patient is at increased risk for seizures because of a high temperature. The priority nursing action is to implement seizure precautions in an attempt to prevent injury. Elevating the head of the bead, keeping the lights dim, and maintaining bedrest are all appropriate nursing interventions but are not the priorities in this scenario. DIF: Cognitive Level: Application REF: p. 388 OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease. TOP: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control

A nurse assesses a client who has a burn injury. Which statement indicates the client has a positive perspective of his or her appearance? a."I will allow my spouse to change my dressings." b."I want to have surgical reconstruction." c."I will bathe and dress before breakfast." d."I have secured the pressure dressings as ordered."

ANS: C Indicators that the client with a burn injury has a positive perception of his or her appearance include a willingness to touch the affected body part. Self-care activities such as morning care foster feelings of self-worth, which are closely linked to body image. Allowing others to change the dressing and discussing future reconstruction would not indicate a positive perception of appearance. Wearing the dressing will assist in decreasing complications but will not enhance self-perception.

A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first? a.Assess the level of consciousness and pupillary reactions. b.Ascertain the time food or liquid was last consumed. c.Auscultate breath sounds over the trachea and bronchi. d.Measure abdominal girth and auscultate bowel sounds

ANS: C Inhalation injuries are present in 7% of clients admitted to burn centers. Drooling and difficulty swallowing can mean that the client is about to lose his or her airway because of this injury. Absence of breath sounds over the trachea and bronchi indicates impending airway obstruction and demands immediate intubation. Knowing the level of consciousness is important in assessing oxygenation to the brain. Ascertaining the time of last food intake is important in case intubation is necessary (the nurse will be more alert for signs of aspiration). However, assessing for air exchange is the most important intervention at this time. Measuring abdominal girth is not relevant in this situation.

A nurse cares for a client who has facial burns. The client asks, "Will I ever look the same?" How should the nurse respond? a."With reconstructive surgery, you can look the same." b."We can remove the scars with the use of a pressure dressing." c."You will not look exactly the same but cosmetic surgery will help." d."You shouldn't start worrying about your appearance right now."

ANS: C Many clients have unrealistic expectations of reconstructive surgery and envision an appearance identical or equal in quality to the preburn state. The nurse should provide accurate information that includes something to hope for. Pressure dressings prevent further scarring; they cannot remove scars. The client and the family should be taught the expected cosmetic outcomes.

A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which laboratory result should the nurse report to the health care provider immediately? a.Arterial pH: 7.32 b.Hematocrit: 52% c.Serum potassium: 6.5 mEq/L d.Serum sodium: 131 mEq/L

ANS: C The serum potassium level is changed to the degree that serious life-threatening responses could result. With such a rapid rise in potassium level, the client is at high risk for experiencing severe cardiac dysrhythmias and death. All the other findings are abnormal but do not show the same degree of severity; they would be expected in the emergent phase after a burn injury.

A nurse prepares to administer intravenous cimetidine (Tagamet) to a client who has a new burn injury. The client asks, "Why am I taking this medication?" How should the nurse respond? a."Tagamet stimulates intestinal movement so you can eat more." b."It improves fluid retention, which helps prevent hypovolemic shock." c."It helps prevent stomach ulcers, which are common after burns." d."Tagamet protects the kidney from damage caused by dehydration."

ANS: C Ulcerative gastrointestinal disease (Curling's ulcer) may develop within 24 hours after a severe burn as a result of increased hydrochloric acid production and a decreased mucosal barrier. This process occurs because of the sympathetic nervous system stress response. Cimetidine is a histamine2 blocker and inhibits the production and release of hydrochloric acid. Cimetidine does not affect intestinal movement and does not prevent hypovolemic shock or kidney damage.

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

ANS: C Cerebral vasospasm is a life-threatening complication following subarachnoid hemorrhage. Once an aneurysm has been repaired surgically, blood pressure is allowed to rise to prevent vasospasm. Volume expansion with 500 mL albumin is the priority intervention for a blood pressure of 95/50 mm Hg to prevent vasospasm and ensure cerebral perfusion. Blood cultures, acetaminophen administration, and Decadron are appropriate to include in the plan of care but are not priorities in this scenario. DIF: Cognitive Level: Analysis REF: p. 384 OBJ: Describe the nursing and medical management of patients with increased intracranial pressure. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

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

ANS: C Cerebral vessels dilate when PaCO2 levels increase, increasing cerebral blood volume. Cerebral vessels dilate when CO2 levels increase, increasing cerebral blood volume. To compensate for increased cerebral blood volume, cerebral spinal fluid may be displaced, but the scenario is asking for the effect of hypercarbia (elevated PaCO2) on cerebral blood flow. PaCO2 of 60 mm Hg is elevated, which would cause cerebral vasodilation and increased cerebral blood volume. DIF: Cognitive Level: Knowledge REF: p. 366 OBJ: Describe the pathophysiology of increased intracranial pressure. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

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

ANS: C In the presence of suspected cerebrospinal fluid leak, drainage should be unobstructed and free flowing. Small bandages may be applied to allow for fluid collection and assessment. Patients should be instructed not to blow their nose because that action may further aggravate the dural tear. Suction catheters should be inserted through the mouth rather than the nose to avoid penetrating the brain due to the dural tear. DIF: Cognitive Level: Application REF: p. 374 OBJ: Describe the nursing and medical management of patients with skull fractures. TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity

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

ANS: C Optimal gas exchange in a patient with increased intracranial pressure includes adequate oxygenation and ventilation of carbon dioxide. A pH of 7.38, PaCO2 of 35 mm Hg, and a PaO2 of 85 mm Hg indicates both. PaCO2 values greater than normal (35-45) can lead to cerebral vasodilatation and further increase cerebral blood volume and ICP. Carbon dioxide levels less than 35 mm Hg can lead to cerebral vessel vasoconstriction and ischemia. Adequate oxygenation of cerebral tissues is achieved by maintaining a PaO2 above 80 mm Hg. DIF: Cognitive Level: Comprehension REF: Nursing Care Plan: Spinal Cord Injury OBJ: Describe the nursing and medical management of patients with increased intracranial pressure. TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

The nurse is preparing to administer a routine dose of phenytoin (Dilantin). The physician orders phenytoin (Dilantin) 500 mg intravenous every 6 hours. What is the best action by the nurse? a. Administer over 2 minutes. b. Administer with 0.9% normal saline intravenous. c. Contact the physician. d. Assess cardiac rhythm.

ANS: C The ordered dose is an inappropriate maintenance dose. The nurse should contact the physician. Administering the dose over 2 minutes, administering with normal saline, and assessing the cardiac rhythm for bradycardia are normal administration guidelines for normal dose parameters. DIF: Cognitive Level: Application REF: Table 13-9 OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

The nurse is caring for a patient who has a diminished level of consciousness and who is mechanically ventilated. While performing endotracheal suctioning, the patient reaches up in an attempt to grab the suction catheter. What is the best interpretation by the nurse? a. The patient is exhibiting extension posturing. b. The patient is exhibiting flexion posturing. c. The patient is exhibiting purposeful movement. d. The patient is withdrawing to stimulation.

ANS: C This is a good example of purposeful movement that is sometimes seen in patients with reduced consciousness. Flexion posturing is characterized by rigid flexion and extension of the arms, wrist flexion, and clenched fists. Extension posturing is characterized by rigid extension of arms and legs with plantar extension of the feet. Withdrawing occurs when a patient moves an extremity away from a painful source of stimulation. DIF: Cognitive Level: Comprehension REF: p. 366 OBJ: Complete an assessment on a critically ill patient with nervous system injury. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

14. Which of the following patients is at the greatest risk of developing acute kidney injury? A patient who: a. has been on aminoglycosides for the past 6 days. b. has a history of controlled hypertension with a blood pressure of 138/88 mm Hg. c. was discharged 2 weeks earlier after aminoglycoside therapy of 2 weeks. d. has a history of fluid overload as a result of heart failure.

ANS: C Acute kidney injury can be caused by aminoglycoside nephrotoxicity, especially prolonged use of the drug (more than 10 days). Symptoms of acute kidney injury are usually seen about 1 to 2 weeks after exposure. Because of this delay, the patient must be questioned about any recent medical therapy for which an aminoglycoside may have been prescribed. The blood pressure of 138/88 mm Hg controlled by medication would not cause acute kidney injury, nor would fluid overload from exacerbation of heart failure.

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

ANS: C An arteriovenous fistula is an internal, surgically created communication between an artery and a vein. This method produces a vessel that is easy to cannulate but requires 4 to 6 weeks before it is mature enough to use

19. The patient is admitted with complaints of general malaise and fatigue, along with a decreased urinary output. The patient's urinalysis shows coarse, muddy brown granular casts and hematuria. The nurse determines that the patient has: a. acute kidney injury from a prerenal condition. b. acute kidney injury from postrenal obstruction. c. intrarenal disease, probably acute tubular necrosis. d. a urinary tract infection.

ANS: C Analysis of urinary sediment and electrolyte levels is helpful in distinguishing among the various causes of acute kidney injury. Coarse, muddy brown granular casts are classic findings in ATN. Microscopic hematuria and a small amount of protein also may be seen. In prerenal conditions, the urine typically has no cells but may contain hyaline casts. Postrenal conditions may present with stones, crystals, sediment, bacteria, and clots from the obstruction. Bacteria would be present in a urinary tract infection.

38. Continuous venovenous hemodialysis is used to: a. remove fluids and solutes through the process of convection. b. remove plasma water in cases of volume overload. c. remove plasma water and solutes by adding dialysate. d. combine ultrafiltration, convection and dialysis

ANS: C Continuous venovenous hemodialysis (CVVHD) is similar to CVVH in that ultrafiltration removes plasma water. It differs in that dialysate solution is added around the hemofilter membranes to facilitate solute removal by the process of diffusion. Continuous venovenous hemofiltration (CVVH) is used to remove fluids and solutes through the process of convection. Slow continuous ultrafiltration (SCUF) is also known as isolated ultrafiltration and is used to remove plasma water in cases of volume overload. Continuous venovenous hemodiafiltration (CVVHDF) combines ultrafiltration, convection and dialysis to maximize fluid and solute removal.

34. The patient is getting hemodialysis for the second time when he complains of a headache and nausea and, a little later, of becoming confused. The nurse realizes these are symptoms of: a. dialyzer membrane incompatibility. b. a shift in potassium levels. c. dialysis disequilibrium syndrome. d. hypothermia.

ANS: C Dialysis disequilibrium syndrome often occurs after the first or second dialysis treatment or in patients who have had sudden, large decreases in BUN and creatinine levels as a result of the hemodialysis. Because of the blood-brain barrier, dialysis does not deplete the concentrations of BUN, creatinine, and other uremic toxins in the brain as rapidly as it does those substances in the extracellular fluid. An osmotic concentration gradient established in the brain allows fluid to enter until the concentration levels equal those of the extracellular fluid. The extra fluid in the brain tissue creates a state of cerebral edema for the patient, which results in severe headaches, nausea and vomiting, twitching, mental confusion, and occasionally seizures. Dialyzer membrane incompatibility may cause hypotension. Hyperthermia, not hypothermia, may result if the temperature control devices on the dialysis machine malfunction. Potassium shifts may occur but would be manifested in cardiac dysrhythmias.

18. In calculating the glomerular filtration rate (GFR) results for women, the creatinine clearance is usually: a. the same as for men. b. greater than that for men. c. multiplied by 0.85. d. multiplied by 1.15.

ANS: C For women, the calculated result is multiplied by 0.85 to account for the smaller muscle mass as compared to men.

32. The nurse is assessing a patient with a new arteriovenous fistula, but does not hear a bruit or feel a thrill. Pulses distal to the fistula are not palpable. The nurse should: a. reassess the patient in an hour. b. raise the arm above the level of the patient's heart. c. notify the provider immediately. d. apply warm packs to the fistula site and reassess.

ANS: C Inadequate collateral circulation past the fistula or graft may result in loss of this pulse. The physician is notified immediately if no bruit is auscultated, no thrill is palpated, or the distal pulse is absent. Loss of bruit and thrill indicate a loss of blood flow most likely due to clotting. The patient will need to return to surgery as soon as possible for declotting. Raising the arm above the level of the heart will not help. Warm packs may or may not help

26. The patient is diagnosed with acute kidney injury and has been getting dialysis 3 days per week. The patient complains of general malaise and is tachypneic. An arterial blood gas is ordered and shows that the patient's pH is 7.19, with a PCO2 of 30 mm Hg and a bicarbonate level of 13 mEq/L. The nurse prepares to: a. administer morphine to slow the respiratory rate. b. prepare for intubation and mechanical ventilation. c. administer intravenous sodium bicarbonate. d. cancel tomorrow's dialysis session.

ANS: C Metabolic acidosis is the primary acid-base imbalance seen in acute kidney injury. Treatment of metabolic acidosis depends on its severity. Patients with a serum bicarbonate level of less than 15 mEq/L and a pH of less than 7.20 are usually treated with intravenous sodium bicarbonate. The goal of treatment is to raise the pH to a value greater than 7.20. Rapid correction of the acidosis should be avoided, because tetany may occur as a result of hypocalcemia. Renal replacement therapies also may correct metabolic acidosis because it removes excess hydrogen ions and bicarbonate is added to the dialysate and replacement solutions; therefore, dialysis would not be cancelled. The tachypnea is a compensatory mechanism for the metabolic acidosis, and treatments to decrease the respiratory rate are not indicated. Treatment is aimed at correcting the metabolic acidosis, and this scenario does not provide data to support the need for intubation.

33. The nurse is caring for a patient who has a temporary percutaneous dialysis catheter in place. In caring for this patient, the nurse should: a. apply a sterile gauze dressing to maintain sterility. b. replace the transparent dressing every 10 days to prevent manipulation. c. assess the catheter site for redness and/or swelling. d. use the catheter for drawing blood samples to reduce patient discomfort.

ANS: C Tenderness at the insertion site, swelling, erythema or drainage should be reported to the physician. Transparent, semipermeable polyurethane dressings are recommended as they allow continuous visualization for assessment of signs of infection. Replace transparent dressings on temporary percutaneous catheters at least every 7 days and no more than once a week for tunneled percutaneous catheters unless the dressing is soiled or loose. The catheter is not used for the administration of fluids or medications or for the sampling of blood unless a specific order is obtained to do so.

Conditions that produce acute kidney injury by directly acting on functioning kidney tissue are classified as intrarenal. The most common intrarenal condition is: a. prolonged ischemia. b. exposure to nephrotoxic substances. c. acute tubular necrosis (ATN). d. hypotension for several hours.

ANS: C The most common intrarenal condition is ATN. This condition may occur after prolonged ischemia (prerenal), exposure to nephrotoxic substances, or a combination of these. Some patients have ATN after only several minutes of hypotension or hypovolemia, whereas others can tolerate hours of renal ischemia without having any apparent tubular damage.

43. The patient is on intake and output (I&O) as well as daily weights. The nurse notes that output is considerably less than intake over the last shift, and daily weight is 1 kg more than yesterday. The nurse should: a. draw a trough level after the next dose of antibiotic. b. obtain an order to place the patient on fluid restriction. c. assess the patient's lungs. d. insert an indwelling catheter.

ANS: C The scenario indicates retention of fluid; therefore, the nurse must assess for symptoms of fluid overload, for example, by auscultating the lung fields. Adequate hydration is essential and fluid restriction would be determined by the physician upon physical examination and analysis of laboratory results. An indwelling urinary catheter should not routinely be inserted because it increases the risk of infection. A trough level is drawn just before the next dose of a drug is given and is an indicator of how the body has cleared the drug; it would not be done secondary to imbalanced intake and output.

A nurse assesses bilateral wheezes in a client with burn injuries inside the mouth. Four hours later the wheezing is no longer heard. Which action should the nurse take? a.Document the findings and reassess in 1 hour. b.Loosen any constrictive dressings on the chest. c.Raise the head of the bed to a semi-Fowler's position. d.Gather appropriate equipment and prepare for an emergency airway.

ANS: D Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose effective movement of air. When this occurs, wheezing is no longer heard, and neither are breath sounds. These clients can lose their airways very quickly, so prompt action is needed. The client requires establishment of an emergency airway. Swelling usually precludes intubation. The other options do not address this emergency situation.

The registered nurse assigns a client who has an open burn wound to a licensed practical nurse (LPN). Which instruction should the nurse provide to the LPN when assigning this client? a."Administer the prescribed tetanus toxoid vaccine." b."Assess the client's wounds for signs of infection." c."Encourage the client to breathe deeply every hour." d."Wash your hands on entering the client's room."

ANS: D Infection can occur when microorganisms from another person or from the environment are transferred to the client. Although all of the interventions listed can help reduce the risk for infection, handwashing is the most effective technique for preventing infection transmission

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

ANS: D In this scenario, the patient's temperature is elevated, which increases metabolic demands. Increases in metabolic demands increase cerebral blood flow and contribute to increased intracranial pressure (ICP). Cooling measures should be implemented. Insertion of an oral airway in an alert patient is contraindicated. While maintaining neutral head position and ensuring adequate periods of rest between nursing interventions are appropriate actions for patients with elevated ICP, treatment of the fever is of higher priority. DIF: Cognitive Level: Application REF: p. 369 OBJ: Describe the nursing and medical management of patients with increased intracranial pressure. TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity

The nurse is caring for a patient with an ICP of 18 mm Hg and a GCS score of 3. Following the administration of mannitol (Osmitrol), which assessment finding by the nurse requires further action? a. ICP of 10 mm Hg b. CPP of 70 mm Hg c. GCS score of 5 d. CVP of 2 mm Hg

ANS: D Osmotic diuretics draw water from normal brain cells, decreasing ICP and increasing CPP and urine output. An ICP of 10 mm Hg and CPP of 70 mm Hg are within normal limits. A GCS score of 5, while not optimum indicates a slight improvement. A CVP of 2 mm Hg indicates hypovolemia. To ensure adequate cerebral perfusion, further action on the part of the nurse is necessary. DIF: Cognitive Level: Application REF: p. 370 OBJ: Describe the nursing and medical management of patients with increased intracranial pressure. TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

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

ANS: D Patient assessment findings are indicative of a skull fracture. The presence of straw-colored nasal draining may be indicative of a CSF leak. Drainage should be monitored and allowed to flow freely. Application of a nasal drip pad is the most appropriate action. Monitoring airway patency and maintaining the head in a neutral position are not priorities in a patient who is awake and alert. Insertion of bilateral ear plugs is not standard of care. DIF: Cognitive Level: Application REF: p. 374 OBJ: Describe the nursing and medical management of patients with skull fractures. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

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

ANS: D Sustained increases in ICP lasting longer than 5 minutes should be avoided. This is accomplished by spacing nursing care activities to allow for rest between activities. All other nursing actions are a part of the patient's plan of care; however, spacing out interventions is the priority. DIF: Cognitive Level: Application REF: p. 365 OBJ: Describe the nursing and medical management of patients with increased intracranial pressure. TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity

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

ANS: D The charge nurse should assess the patient with an ICP of 20 mm Hg and a temperature of 104° F as this is an abnormal finding and should be investigated further. A patient with a GCS of 6 being mechanically ventilated has a secure airway and there is no indication of distress. Photophobia is an expected finding with meningitis and droplet precautions are appropriate for a patient with bacterial meningitis. DIF: Cognitive Level: Analysis REF: Nursing Care Plan: Traumatic Brain Injury OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

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

ANS: D These are classic symptoms of epidural and acute subdural hematomas: injury, lucid period, and progressive deterioration. The physician must be notified of this neurological emergency so appropriate interventions can be implemented. Although elevating the head of the bed, continuously monitoring the patient and applying stimulation as necessary to assess neurological response are appropriate interventions, notification of the physician is a priority given the severity in change of neurological status. DIF: Cognitive Level: Analysis REF: p. 376 OBJ: Describe the nursing and medical management of patients with increased intracranial pressure. TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity

41. An advantage of peritoneal dialysis is that: a. peritoneal dialysis is time intensive. b. a decreased risk of peritonitis exists. c. biochemical disturbances are corrected rapidly. d. the danger of hemorrhage is minimal.

ANS: D Advantages of peritoneal dialysis include that the equipment is assembled easily and rapidly, the cost is relatively inexpensive, the danger of acute electrolyte imbalances or hemorrhage is minimal, and dialysate solutions can be individualized. In addition, automated peritoneal dialysis systems are available. Disadvantages of peritoneal dialysis include that it is time intensive, requiring at least 36 hours for a therapeutic effect to be achieved; biochemical disturbances are corrected slowly; access to the peritoneal cavity is sometimes difficult; and the risk of peritonitis is high.

4. A normal urine output is considered to be: a. 80 to 125 mL/min. b. 180 L/day. c. 80 mL/min. d. 1 to 2 L/day.

ANS: D At a normal glomerular filtration rate (GFR) of 80 to 125 mL/min, the kidneys produce 180 L/day of filtrate. As the filtrate passes through the various components of the nephron's tubules, 99% is reabsorbed into the peritubular capillaries or vasa recta. Eventually, the remaining filtrate (1% of the original 180 L/day) is excreted as urine, for an average urine output of 1 to 2 L/day.

35. Continuous renal replacement therapy (CRRT) differs from conventional intermittent hemodialysis in that: a. a hemofilter is used to facilitate ultrafiltration. b. it provides faster removal of solute and water. c. it does not allow diffusion to occur. d. the process removes solutes and water slowly.

ANS: D CRRT is a continuous extracorporeal blood purification system managed by the bedside critical care nurse. It is similar to conventional intermittent hemodialysis in that a hemofilter is used to facilitate the processes of ultrafiltration and diffusion. It differs in that CRRT provides a slow removal of solutes and water as compared to the rapid removal of water and solutes that occurs with intermittent hemodialysis.

2. The nurse is caring for a patient who has sustained blunt trauma to the left flank area, and is evaluating the patient's urinalysis results. The nurse should become concerned when a. creatinine levels in the urine are similar to blood levels of creatinine. b. sodium and chloride are found in the urine. c. urine uric acid levels have the same values as serum levels. d. red blood cells and albumin are found in the urine.

ANS: D Normal glomerular filtrate is basically protein free and contains electrolytes, including sodium, chloride, and phosphate, and nitrogenous waste products, such as creatinine, urea, and uric acid, in amounts similar to those in plasma. Red blood cells, albumin, and globulin are too large to pass through the healthy glomerular membrane. Their presence in urine may indicate glomerular damage.

13. The nurse is caring for a patient with acute kidney injury who is being treated with hemodialysis. The patient asks if he will need dialysis for the rest of his life. Which of the following would be the best response? a. "Unfortunately, kidney injury is not reversible; it is permanent." b. "Kidney function usually returns within 2 weeks." c. "You will know for sure if you start urinating a lot all at once." d. "recovery is possible, but it may take several months."

ANS: D Renal dysfunction is potentially reversible during the initiation phase. This phase spans several hours to 2 days, during which time the normal renal processes begin to deteriorate, but actual intrinsic renal damage has not yet occurred. During the maintenance phase, intrinsic renal damage is established, and the GFR stabilizes at approximately 5 to 10 mL/min. This phase usually lasts 8 to 14 days, but it may last up to 11 months. The longer a patient remains in this stage, the slower the recovery and the greater the chance of permanent renal damage will be. The recovery phase is the period during which the renal tissue recovers and repairs itself. A gradual increase in urine output and an improvement in laboratory values occur. Recovery may take as long as 4 to 6 months.

27. The removal of plasma water and some low-molecular weight particles by using a pressure or osmotic gradient is known as: a. dialysis. b. diffusion. c. clearance. d. ultrafiltration.

ANS: D Ultrafiltration is the removal of plasma water and some low-molecular weight particles by using a pressure or osmotic gradient. Ultrafiltration is primarily aimed at controlling fluid volume, whereas dialysis is aimed at decreasing waste products and treating fluid and electrolyte imbalances. Diffusion (or clearance) is the movement of solutes such as urea from the patient's blood to the dialysate cleansing fluid, across a semipermeable membrane (the hemofilter).

13. Cellular immunity is mediated by: a. B lymphocytes. b. T lymphocytes. c. immunoglobulins. d. suppressor B cells.

B

43. The patient is admitted with anemia caused by blood loss and thrombocytopenia. His platelet count is 22,000/microliter. The patient is scheduled for a transfusion of RBCs and a transfusion of platelets. The nurse should: a. give the RBCs before the platelets. b. give the platelets before the RBCs. c. use local therapies to stop the bleeding. d. give the platelets and RBCs at the same time.

B

46. The patient is admitted with anemia and active bleeding. The nurse suspects intravascular disseminated coagulation (DIC). Definitive diagnosis of DIC is made by evidence of: a. a decrease in fibrin degradation products. b. an increased D-dimer level. c. thrombocytopenia. d. low fibrinogen levels.

B

8. Although monocytes may circulate for only 36 hours, they can survive for months or even years as tissue macrophages. Monocytes found in the liver are called: a.alveolar macrophages. b. Kupffers cells. c. histiocytes. d. monokines.

B

9. The nurse is evaluating the patients laboratory values and notes an IgG level of 240 mg/dL. The nurse realizes that this patient is a candidate for: a. no change in therapy because the level is normal. b. an immunoglobulin infusion. c. gene replacement therapy. d. increased doses of immunosuppressive medications.

B

The nurse has just completed an infusion of a 1000 mL bolus of 0.9% normal saline in a patient with severe sepsis. One hour later, which laboratory result requires immediate nursing action? A. Creatinine 1.0 mg/dL B. Lactate 6 mmol/L C. Potassium 3.8 mEq/L D. Sodium 140 mEq/L

B

The nurse is administering intravenous norepinephrine at 5 mcg/kg/min via a 20-gauge peripheral intravenous (IV) catheter. Which assessment finding requires immediate action by the nurse? A. Blood pressure 100/60 mm Hg B. Swelling at the IV site C. Heart rate of 110 beats/min D. Central venous pressure (CVP) of 8 mm Hg

B

The nurse is caring for a 70-kg patient in hypovolemic shock. Upon initial assessment, the nurse notes a blood pressure of 90/50 mm Hg, heart rate 125 beats/min, respirations 32 breaths/min, central venous pressure (CVP/RAP) of 3 mm Hg, and urine output of 5 mL during the past hour. Following physician rounds, the nurse reviews the orders and questions which order? A. Administer acetaminophen 650-mg suppository prn every 6 hours for pain. B. Titrate dopamine intravenously for blood pressure less than 90 mm Hg systolic. C. Complete neurological assessment every 4 hours for the next 24 hours. D. Administer furosemide 20 mg IV every 4 hours for a CVP greater than or equal to 20 mm Hg.

B

The nurse is caring for a patient in cardiogenic shock experiencing chest pain. Hemodynamic values assessed by the nurse include a cardiac index (CI) of 2.5 L/min/m2, heart rate of 70 beats/min, and a systemic vascular resistance (SVR) of 2200 dynes/sec/cm−5. Upon review of physician orders, which order is most appropriate for the nurse to initiate? A. Furosemide 20 mg intravenous (IV) every 4 hours as needed for CVP greater than or equal to ≥20 mm Hg B. Nitroglycerin infusion titrated at a rate of 5 to 10 mcg/min as needed for chest pain C. Dobutamine infusion at a rate of 2 to 20 mcg/kg/min as needed for CI less than 2 L/min/m2 D. Dopamine infusion at a rate of 5 to 10 mcg/kg/min to maintain a systolic BP of at least 90 mm Hg

B

The nurse is caring for a patient with severe sepsis who was resuscitated with 3000 mL of lactated Ringer's solution over the past 4 hours. Morning laboratory results show a hemoglobin of 8 g/dL and hematocrit of 28%. What is the best interpretation of these findings by the nurse? A. Blood transfusion with packed red blood cells is required. B. Hemoglobin and hematocrit results indicate hemodilution. C. Fluid resuscitation has resulted in fluid volume overload. D. Fluid resuscitation has resulted in third-spacing of fluid.

B

The nurse is to assist the provider in performing bedside endoscopy on a patient. The prevent respiratory complications, the nurse places the patient: a. supine in Trendelenburg position. b. in a left lateral reverse Trendelenburg position. c. flat with the feet elevated. d. in a semi-fowler's position.

B Because endoscopy is performed at the patient's bedside, the nurse assists with procedures and monitors for untoward effects. Maintenance of airway and breathing during endoscopic procedures is of major concern. Placement of the patient in a left lateral reverse Trendelenburg position helps to prevent respiratory complications.

The nurse is caring for a patient with liver disease. When assessing the patient's laboratory values, the nurse should: a. disregard the level of conjugated bilirubin. b. assess the indirect serum bilirubin. c. call the provider immediately if the direct bilirubin is elevated. d. be aware that unconjugated bilirubin is harmless.

B Bilirubin enters the circulation bound to albumin and is unconjugated. This portion of the bilirubin is reflected in the indirect serum bilirubin level. Accumulation of unconjugated bilirubin is toxic to cells. In the liver, bilirubin is conjugated with glucuronic acid. Conjugated bilirubin is soluble and excreted in bile. Some conjugated bilirubin returns to the blood and is reflected in the direct serum bilirubin level

The nurse is caring for a patient with a heart rate of 140 beats/min. The provider orders parasympathetic medications to slow down the heart rate. With this type of medication, the nurse should a. evaluate the patient for symptoms of constipation. b. observe for diarrhea. c. assess mucus membranes for signs of dryness. d. expect decreased bowel sounds.

B Functions of the GI system are influenced by neural and hormonal factors. Parasympathetic cholinergic fibers, or drugs that mimic parasympathetic effects, stimulate GI secretion and motility

The patient is admitted with the diagnosis of GI bleeding. The patient's heart rate is 140 beats per minute, and his blood pressure is 84/44 mm Hg. These values may indicate: a. a need for hourly vital signs. b. approximately 25% loss of total blood volume. c. resolution of hypovolemic shock. d. increased blood flow to the skin, lungs, and liver.

B Hypotension is an advanced sign of shock. As a rule, a systolic pressure of less than 100 mm Hg, a postural decrease in blood pressure of greater than 10 mm Hg, or a heart rate of greater than 120 beats/min reflects a blood loss of at least 1000 mL—25% of the total blood volume. Vital signs should be monitored at least every 15 minutes. As blood loss exceeds 1000 mL, the shock syndrome progresses, causing decreased blood flow to the skin, lungs, liver, and kidneys

Lactulose is considered the first-line treatment for hepatic encephalopathy and works by: a. causing ammonia to enter the bloodstream via the colon. b. trapping ammonia in the bowel for excretion. c. causing constipation and inhibiting the excretion of ammonia. d. creating an alkaline environment in the bowel.

B Lactulose is considered the first-line treatment for hepatic encephalopathy. Lactulose creates an acidic environment in the bowel that causes the ammonia to leave the bloodstream and enter the colon. Ammonia is trapped in the bowel. Lactulose also has a laxative effect that allows for elimination of the ammonia. Lactulose is given orally or via a rectal enema.

The patient is diagnosed with hepatitis. In caring for this patient, the nurse should: a. administer antiinflammatory medications. b. provide rest, nutrition, and antiemetics if needed. c. provide antianxiety medications freely to decrease agitation. d. instruct the patient to take over-thecounter antiinflammatory medications at home.

B No definitive treatment for acute inflammation of the liver exists. Goals for medical and nursing care include providing rest and assisting the patient in obtaining optimal nutrition. Medications to help the patient rest or to decrease agitation must be closely monitored because most of these drugs require clearance by the liver, which is impaired during the acute phase. Nursing measures such as administration of antiemetics may be helpful. Small, frequent, palatable meals and supplements should be offered. Patients must be instructed not to take any over-the-counter drugs that can cause liver damage. Alcohol should be avoided.

The nurse is assessing the patient and notices that his oral cavity is only slightly moist and contains a scant amount of thick saliva even though the patient's fluid intake has been sufficient. The nurses realizes that the condition of the patient's mouth is probably caused by: a. thoughts of food. b. sympathetic nerve stimulation. c. overstimulation of the sublingual glands. d. parasympathetic nerve stimulation.

B Saliva is the major secretion of the oropharynx and is produced by three pairs of salivary glands: submaxillary, sublingual, and parotid. Stimuli such as sight, smell, thoughts, and taste of food stimulate salivary gland secretion. Parasympathetic stimulation promotes a copious secretion of watery saliva. Conversely, sympathetic stimulation produces a scant output of thick saliva. The normal daily secretion of saliva is 1200 mL.

The patient is admitted for GI bleeding, but the source is not known. Before ordering endoscopy, the provider orders Sandostatin (octreotide) to be given intravenously. The purpose of this medication is to: a. increase portal pressure and improve liver function. b. decrease splanchnic blood flow and portal pressure. c. vasodilate the splanchnic arteriolar bed. d. increase blood flow in the liver's collateral circulation.

B Somatostatin or octreotide is commonly ordered to slow or stop bleeding. Early administration provides for stabilization before endoscopy. These drugs decrease splanchnic blood flow and reduce portal pressure, and have minimal adverse effects. Vasopressin is used to lower (not increase) portal pressure by vasoconstriction of the splanchnic arteriolar bed. Ultimately, it decreases pressure and flow in liver collateral circulation channels to decrease bleeding. However, vasopressin is not a first-line therapy because of its adverse effects.

The patient is admitted with constipation. In anticipation of treatment, the nurse prepares to: a. give medications that will suppress the autonomic nervous system. b. provide therapies that will innervate the autonomic nervous system. c. teach the patient that the submucosa is the innermost part of the gut wall. d. give medications intravenously since the submucosa has no blood vessels.

B The second layer of the gut wall, the submucosa, is composed of connective tissue, blood vessels, and nerve fibers. Beneath the mucosa, submucosa, and muscular layer are various nerve plexuses that are innervated by the autonomic nervous system. Disturbances in these neurons in a given segment of the GI tract cause a lack of motility. Therapies innervating the autonomic nervous system are thus appropriate. The muscular layer is the major layer of the wall. The serosa is the outermost layer

The nurse is caring for a critically ill patient with respiratory failure who is being treated with mechanical ventilation. As part of the patient's care to prevent stress ulcers, the nurse would provide: (Select all that apply.) a. vagal stimulation. b. proton pump inhibitors. c. anticholinergic drugs d. antacids. e. cholinergic drugs.

B C D

Vascular sounds such as bruits, heard in the abdomen during physical assessment, may indicate which of the following? (Select all that apply.) a. Obstructed portal circulation b. Dilated vessels c. Tortuous vessels d. Constricted vessels e. Presence of an abscess

B C D

The patient is admitted with end-stage liver disease. The nurse evaluates the patient for which of the following? (Select all that apply.) a. Hypoglycemia b. Malnutrition c. Ascites d. Hypercoagulation e. Disseminated intravascular coagulation

B C E Altered carbohydrate metabolism may result in unstable blood glucose levels. The serum glucose level is usually increased to more than 200 mg/dL. This condition is termed cirrhotic diabetes. Altered carbohydrate metabolism may also result in malnutrition and a decreased stress response. Protein metabolism, albumin synthesis, and serum albumin levels are decreased. 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. Clinical signs and symptoms range from bruising and nasal and gingival bleeding to frank hemorrhage. Disseminated intravascular coagulation may also develop.

18. Common to both the intrinsic and the extrinsic pathway is: a. factor XII b. factor VII. c. factor X. d. subendothelial collagen.

C

2. Erythrocytes (RBCs) are flexible biconcave disks without nuclei whose primary component is an oxygen-carrying molecule called: a. erythropoietin. b. a reticulocyte. c. hemoglobin. d. 2,3-DPG

C

20. A patient with a history of pulmonary embolism is being worked up for a potential coagulopathy that increases the risk for clotting. The nurse understands that the provider may order a test for a. factor VII deficiency. b. factor X deficiency. c. protein C deficiency. d. factor IX deficiency.

C

22. The patient is being seen for complaints of general malaise, fatigue, and shortness of breath. The patient states that he has felt this way since he had a cold 6 weeks earlier. The nurse should expect the provider to order: a. lymph node biopsy. b. differential blood count only. c. complete blood count (CBC) with differential. d. Bone marrow biopsy.

C

28. Critical to caring for the immunocompromised patient is the understanding that: a. the immunocompromised patient has normal white blood cell (WBC) physiology. b. the immunosuppression involves a single element or process. c. infection is the leading cause of death in these patients. d. immune incompetence is symptomatic even without pathogen exposure.

C

33. The patients white blood cell (WBC) level is 4000 cells/microliter. The differential shows a neutrophil count of 65% and a band level of 5%. The absolute neutrophil count is a. 4000 cells/microliter. b. 3000 cells/microliter. c. 2800 cells/microliter. d. 2600 cells/microliter.

C

36. The patient is diagnosed with lymphoma, but has a normal white blood cell (WBC) count. The nurse understands that this patient a. has normal WBC function since the WBC is normal. b. will have increased bruising and bleeding. c. is at risk for infection. d. is at risk for an allergic reaction.

C

37. The patient is admitted with multiple myeloma. The nurse assesses the patient and is aware that the symptom most unique to this disease is: a. fever. b. night sweats. c. bone pain. d. lymph node enlargement.

C

39. The patient comes to the hospital complaining of headache, fever, and sore throat for the past 2 weeks and is concerned that he might have acquired immune deficiency syndrome (AIDS). The patients blood work shows the presence of HIV antibodies. The nurse should explain that: a. HIV symptoms will continue throughout the patients life. b. HIV is an acute disease with a short prognosis. c. AIDS is considered a chronic disease. d. very few people with HIV develop AIDS.

C

4. The nurse is caring for a patient who has undergone a splenectomy, and notices that the patients platelet count has increased. The nurse realizes that the increase is due to: a. platelet response to infection. b. stimulation secondary to erythropoietin. c. the patients inability to store platelets. d. the platelets 120-day life cycle.

C

44. The patient has a platelet count of 9,000/microliter. The nurse realizes that: a. this is a normal platelet level. b. spontaneous bleeding may occur. c. the patient is at great risk for fatal hemorrhage. d. this level is considered slightly low.

C

6. The nurse is caring for a patient receiving chemotherapeutic agents, and notices that the patients neutrophils count is low. The nurse realizes that: a. the patient has a bacterial infection. b. a shift to the left is occurring. c. chemotherapeutic agents alter the ability to fight infection. d. neutrophils have a long life span and multiply slowly.

C

A patient is admitted after collapsing at the end of a summer marathon. The patient is lethargic, with a heart rate of 110 beats/min, respiratory rate of 30 breaths/min, and a blood pressure of 78/46 mm Hg. The nurse anticipates administering which therapeutic intervention? A. Human albumin infusion B. Hypotonic saline solution C. Lactated Ringer's bolus D. Packed red blood cells

C

The nurse is caring for a patient with active GI bleeding. Estimated blood loss is 1,000 mL. Which of the following assessments would the nurse expect to find with this amount of blood loss? a. all vital signs would expect to be normal with this amount of blood loss. b. oral temperature of 103°. c. heart rate 125 beats per minute. d. systolic blood pressure of 120 mm Hg

C As blood loss exceeds 1000 mL, the shock syndrome progresses, causing decreased blood flow to the skin, lungs, liver, and kidneys. Hypotension is an advanced sign of shock. As a rule, a systolic pressure of less than 100 mm Hg, a postural decrease in blood pressure of greater than 10 mm Hg, or a heart rate of greater than 120 beats/min reflects a blood loss of at least 1000 mL—25% of the total blood volume.

The nurse is assessing the patient admitted with pancreatitis. In doing so, the nurse: a. palpates the pancreas for size and shape. b. emphasizes to the patient that pancreatic inflammation does not spread. c. assesses symptoms that could indicate involvement of the stomach. d. explains to the patient that back pain is not a sign of pancreatitis.

C Because the pancreas lies retroperitoneally, it cannot be palpated; this characteristic explains why diseases of the pancreas can cause pain that radiates to the back. In addition, a well-developed pancreatic capsule does not exist, and this may explain why inflammatory processes of the pancreas can spread freely and affect the surrounding organs (stomach and duodenum).

When assessing the patient's bowel sounds, the nurse: a. listens to the abdomen after palpation is done. b. places the patient in a relaxed prone position. c. listens to bowel sounds before palpation. d. places a pillow over the patient's knees.

C Bowel sounds are high-pitched, gurgling sounds caused by air and fluid as they move through the GI tract. Bowel sounds are auscultated before palpation. However, auscultation after palpation can be done if no bowel sounds were heard to stimulate peristalsis. Optimal positioning of the patient to relax the abdomen is performed before auscultation is begun. A supine position with the patient's arms at the sides or folded at the chest is usually recommended. Placing a pillow under the patient's knees also helps to relax the abdominal wall

Metronidazole is being given to treat hepatic encephalopathy. When administering this medication, the nurse: a. watches the patient for diarrhea. b. evaluates renal function daily. c. assesses the patient for epigastric discomfort. d. instructs the patient that this medication must be taken for 2 weeks.

C Neomycin and metronidazole are considered second-line treatments for hepatic encephalopathy. Metronidazole is given 500 mg to 1.5 g/day for 1 week. Metronidazole does not cause diarrhea, and it is not nephrotoxic. Metronidazole may cause epigastric discomfort, which may in turn result in poor compliance with long-term treatment.

The nurse is caring for a patient with a Minnesota tube in place when the patient suddenly shows signs of severe pain and respiratory distress. The nurse should: a. cut the gastric balloon lumen and watch for improved symptoms. b. cut the esophageal lumen and watch for improvement. c. cut all three lumina and remove the tube. d. call the provider with an update of the patient's condition.

C Spontaneous rupture of the gastric balloon, upward migration of the tube, and occlusion of the airway are other possible complications that need to be assessed. Esophageal rupture may occur and is characterized by the abrupt onset of severe pain. In the event of either of these two life-threatening emergencies, all three lumina are cut and the entire tube is removed. For this reason, scissors are kept at the patient's bedside at all times. Endotracheal intubation is strongly recommended to protect the airway.

The patient is admitted with acute pancreatitis and is later diagnosed as having a pseudocyst. The nurse realizes that: a. surgery for pseudocysts must be done immediately. b. a cholecystectomy is usually done when pseudocysts are found. c. pseudocysts may resolve spontaneously, so surgery may be delayed. d. pseudocysts require pancreatic resection, removing the entire pancreas.

C Surgery may also be indicated for pseudocysts; however, surgery is usually delayed because some pseudocysts resolve spontaneously. Surgery may also be performed when gallstones are thought to be the cause of the acute pancreatitis. A cholecystectomy is usually performed. Pancreatic resection for acute necrotizing pancreatitis may be performed to prevent systemic complications of the disease process. In this procedure, dead or infected pancreatic tissue is surgically removed while most of the gland is preserved. The indication for surgical intervention is clinical deterioration of the patient despite the use of conventional treatments, or the presence of peritonitis.

The patient is being admitted with GI bleeding. Blood work includes serial hemoglobin and hematocrit levels. The nurse understands that: a. the hematocrit is a direct reflection of quick blood loss. b. as extravascular fluid enters the vascular space the hematocrit increases. c. the hematocrit value does not change substantially during the first few hours. d. the administration of intravenous fluids has no effect on hematocrit levels.

C The hematocrit (Hct) value does not change substantially during the first few hours after an acute bleeding episode. During this time, the severity of the bleeding must not be underestimated. Only when extravascular fluid enters the vascular space to restore volume does the Hct value decrease. This effect is further complicated by fluids and blood products that are administered during the resuscitation period.

The patient is admitted with severe abdominal pain due to pancreatitis. The patient asks the nurse, "What causes this? Why does it hurt so much?" The nurse should answer: a. "Pancreatitis is extremely rare and no one knows why it causes pain." b. "Pancreatitis is caused by diabetes; you should be checked." c. "Injury to certain cells in the pancreas causes it to digest (eat) itself, causing pain." d. "The pain is localized to the pancreas. Fortunately, it will not affect anything else."

C The most common theory regarding the development of pancreatitis is that an injury or disruption of pancreatic acinar cells allows leakage of the pancreatic enzymes into pancreatic tissue. The leaked enzymes (trypsin, chymotrypsin, and elastase) become activated in the tissue and start the process of autodigestion. Pancreatitis is one of the most common pancreatic diseases; it is not caused by diabetes. The activated enzymes break down tissue and cell membranes, causing edema, vascular damage, hemorrhage, necrosis, and fibrosis. These now toxic enzymes and inflammatory mediators are released into the bloodstream and cause injury to vessel and organ systems, such as the hepatic and renal systems.

The nurse is assessing a patient who is admitted with abdominal pain. To detect abdominal masses, the nurse: a. observes for skin pigmentation and discolorations. b. looks for pulsations originating from the vena cava. c. has the patient take a deep breath. d. watches for signs of pain and distention

C The nurse looks for any obvious abdominal masses, which are best seen on deep inspiration. Pulsations, if they are seen, usually originate from the aorta. The nurse observes for pigmentation of skin (jaundice), lesions, discolorations, old or new scars, and vascular and hair patterns that may indicate general nutrition and hydration status, not masses. Abdominal distention, particularly in the presence of pain, should always be investigated because it usually indicates trapped air or fluid within the abdominal cavity

Cerebral Perfusion Pressure (CPP) equation

CPP = MAP - ICP

The nurse is monitoring a patient's intracranial pressure (ICP). While the nurse is providing hygiene measures, she observes that the ICP reading is sustained at 18 mm Hg. What is the priority nursing action?

Cease stimulating the patient.

Herniation syndromes can be life-threatening situations. Which syndrome causes the supratentorial contents to shift downward and compress vital centers of the brainstem?

Central herniation

Select all of the factors that may predispose the patient to respiratory acidosis.

Central nervous system depression Overdose of sedatives

The nurse is caring for a patient with a ruptured cerebral aneurysm. During initial assessment, the nurse notes that the cerebrospinal fluid draining into a ventriculostomy system is blood tinged. What is the best interpretation of this finding by the nurse?

Cerebral aneurysms commonly rupture in the subarachnoid space.

The nurse is managing the blood pressure of a patient with a traumatic brain injury. When planning the care of this patient, which statement best represents appropriate blood pressure management?

Cerebral perfusion pressure (CPP) should be sustained at least 70 mm Hg.

Treatment for Hemorrhagic Stroke

Control BP, secure aneurysm, emergency ventriculostomy

The nurse is caring for a mechanically ventilated patient and responds to a high inspiratory pressure alarm. Recognizing possible causes for the alarm, the nurse assesses for which of the following? (Select all that apply.)

Coughing or attempting to talk Kinks in the ventilator tubing Need for suctioning

Parasympathetic nerves start in

Cranial Sacral

12. Two types of specific immune responses exist: humoral immunity and cell-mediated immunity. These responses: a. are mutually exclusive. b. Are non-specific immune responses. c. are producers of antigens. d. work together to provide immunity.

D

15. The mechanism responsible for the rejection of transplanted tissue and the destruction of single malignant cells is known as immunosurveillance. The nurse understands that this is a function of: a. helper T lymphocytes. b. suppressor T lymphocytes. c. T4 lymphocytes. d. killer T lymphocytes.

D

19. The nurse is caring for a patient with cirrhosis of the liver. The nurse notes fresh blood starting to ooze from the patients rectum and intravenous site. The nurse contacts the provider expecting an order for: a. an infusion of protein S factor. b. blood work to evaluate protein C level. c. a laboratory test to determine factor X level. d. vitamin K injections.

D

21. 21. The nurse understands that when clots breakdown in a patient with a hematological disorder, that which value will increase? a. hemoglobin. b. white blood cell count. c. vitamin K. d. fibrin split products.

D

26. The patient is complaining of severe joint pain as well as fatigue and shortness of breath. The nurse notices that the patients joints are swollen and his legs are edematous. The nurse realizes that these are symptoms of: a. anemia reflective of low volume. b. aplastic anemia. c. hemolytic anemia. d. sickle cell anemia.

D

3. Erythrocytes (RBCs) are generated from precursor stem cells under the influence of a growth factor called: a. reticulocytes. b. hemoglobin. c. 2,3-DPG. d. erythropoietin.

D

31. The nurse notes that the patients neutrophil count is less than 500 cells/microliter. The nurse realizes that this patient is: a. is at low risk for infection. b. is at mild risk for infection. c. is at moderated risk for infection. d. is at severe risk for infection.

D

34. The patient has a total white blood cell (WBC) count of 600 cells/microliter. The differential shows a normal neutrophil level of 70% with 5% bands. This patient: a. is at low risk for infection. b. is at mild risk for infection. c. is at moderated risk for infection. d. is at severe risk for infection.

D

35. Nursing care of patients with neutropenia is the same as for all immunocompromised patients. Desired patient outcomes related to medical and nursing interventions include absence of infection, negative cultures, and an absolute neutrophil count of : a. less than 500 cells/microliter. b. 500 to 1000 cells/microliter. c. 1000 to 1500 cells/microliter. d. 1500 cells/microliter or higher.

D

38. Cases of primary immunodeficiency are usually related to: a. aging. b. nutritional deficiencies. c. malignancies. d. a single gene defect.

D

40. When caring for a patient with HIV, the nurse should: a. not focus on the mouth, as infections of the mouth are rare. b. assure the patient that infections are not a major problem at this point. c. inform the patient that the disease does not affect the respiratory system. d. monitor the patients medication regimen.

D

A patient is admitted to the critical care unit following coronary artery bypass surgery. Two hours postoperatively, the nurse assesses the following information: pulse is 120 beats/min; blood pressure is 70/50 mm Hg; pulmonary artery diastolic pressure is 2 mm Hg; cardiac output is 4 L/min; urine output is 250 mL/hr; chest drainage is 200 mL/hr. What is the best interpretation by the nurse? A. The assessed values are within normal limits. B. The patient is at risk for developing cardiogenic shock. C. The patient is at risk for developing fluid volume overload. D. The patient is at risk for developing hypovolemic shock.

D

During the initial stages of shock, what are the physiological effects of decreased cardiac output? A. Arterial vasodilation B. High urine output C. Increased parasympathetic stimulation D. Increased sympathetic stimulation

D

The nurse has been administering 0.9% normal saline intravenous fluids in a patient with severe sepsis. To evaluate the effectiveness of fluid therapy, which physiological parameters would be most important for the nurse to assess? A. Breath sounds and capillary refill B. Blood pressure and oral temperature C. Oral temperature and capillary refill D. Right atrial pressure and urine output

D

The nurse is administering both crystalloid and colloid intravenous fluids as part of fluid resuscitation in a patient admitted in severe sepsis. What findings assessed by the nurse indicate an appropriate response to therapy? A. Normal body temperature B. Balanced intake and output C. Adequate pain management D. Urine output of 0.5 mL/kg/hr

D

The nurse is caring for a patient admitted with severe sepsis. Vital signs assessed by the nurse include blood pressure 80/50 mm Hg, heart rate 120 beats/min, respirations 28 breaths/min, oral temperature of 102° F, and a right atrial pressure (RAP) of 1 mm Hg. Which intervention should the nurse carry out first? A. Acetaminophen suppository B. Blood cultures from two sites C. IV antibiotic administration D. Isotonic fluid challenge

D

The nurse is caring for a patient admitted with the early stages of septic shock. The nurse assesses the patient to be tachypneic, with a respiratory rate of 32 breaths/min. Arterial blood gas values assessed on admission are pH 7.50, CO2 28 mm Hg, HCO3 26. Which diagnostic study result reviewed by the nurse indicates progression of the shock state? A. pH 7.40, CO2 40, HCO3 24 B. pH 7.45, CO2 45, HCO3 26 C. pH 7.35, CO2 40, HCO3 22 D. pH 7.30, CO2 45, HCO3 18

D

The nurse is caring for a patient in the early stages of septic shock. The patient is slightly confused and flushed, with bounding peripheral pulses. Which hemodynamic values is the nurse most likely to assess? A. High pulmonary artery occlusive pressure and high cardiac output B. High systemic vascular resistance and low cardiac output C. Low pulmonary artery occlusive pressure and low cardiac output D. Low systemic vascular resistance and high cardiac output

D

When assessing bowel sounds, the nurse: a. uses the "bell" part of the stethoscope. b. listens at least 15 minutes. c. expects bowel sounds to be regular in rhythm. d. listens for 5 minutes before noting "absent bowel sounds."

D Bowel sounds are best heard with the diaphragm of the stethoscope and are systematically assessed in all four quadrants of the abdomen. The frequency and character of the sounds are noted. The frequency of bowel sounds has been estimated at 5 to 35 per minute, and the sounds are usually irregular. The amount of time for bowel sounds to be auscultated ranges from 30 seconds to up to 7 minutes. It is recommended that bowel sounds be assessed a minimum of 5 minutes before an assessment of absence of bowel sounds can be made

The nurse is caring for a patient who has a Sengstaken-Blakemore tube in place. In caring for this patient, the nurse must: a. maintain as little traction as possible. b. apply external traction using side rail of the bed. c. deflate the gastric balloon before the esophageal balloon. d. deflate the esophageal balloon before the gastric balloon.

D It is crucial that the esophageal balloon be deflated before the gastric balloon is deflated, or else the entire tube will be displaced upward and occlude the airway. Correct positioning and traction are maintained by using an external traction source or a nasal cuff around the tube at the mouth or nose. External traction can be attached to a helmet or to the foot of the bed (not the side rail). Proper amounts of traction are essential because too little traction lets the balloon fall away from the gastric wall, resulting in insufficient pressure being placed on the bleeding vessels. Too much traction causes discomfort, gastric ulceration, or vomiting.

The patient is ordered to have large volume gastric lavage. The nurse will most likely need to: a. insert a small-bore nasogastric tube. b. use 2 to 4 liters of room temperature normal saline. c. remove the nasogastric tube before lavage is started. d. insert a large-bore nasogastric tube.

D Large-volume gastric lavage before endoscopy for acute upper gastrointestinal bleeding is safe and provides better visualization of the gastric fundus. A large-bore nasogastric tube is inserted and is connected to suction. If lavage is ordered, 1 to 2 liters of room temperature normal saline is instilled via nasogastric tube and is then gently removed by intermittent suction or gravity until the secretions are clear. After lavage, the nasogastric tube may be left in or removed.

Trends in nutritional management of the patient with pancreatitis are changing. As a result, the nurse understands that: a. patients with pancreatitis must eat nothing in order to prevent release of secretin. b. nasogastric suction is essential in treating patients with pancreatitis. c. a nasogastric tube is no longer required to treat patients with ileus. d. immediate oral feeding in patients with mild pancreatitis may help recovery

D Nasogastric suction and "nothing by mouth" status were classic treatments for patients with acute pancreatitis to suppress pancreatic exocrine secretion by preventing the release of secretin from the duodenum. Normally, secretin, which stimulates pancreatic secretion production, is stimulated when acid is in the duodenum; therefore, nasogastric suction has been a primary treatment. Nausea, vomiting, and abdominal pain may also be decreased with nasogastric suctioning. A nasogastric tube is also necessary in patients with ileus, severe gastric distention, and a decreased level of consciousness to prevent complication resulting from pulmonary aspiration. Trends in nutritional management are changing. Early nutritional support may be ordered to prevent atrophy of gut lymphoid tissue, prevent bacterial overgrowth in the intestine, and increase intestinal permeability. Immediate oral feeding in patients with mild acute pancreatitis is safe and may accelerate recovery. Early enteral nutrition appears effective and safe.

The patient is being admitted to the hospital. At home, the patient take an over-the-counter supplement of Vitamin D and is concerned because the doctor did not order that vitamin D to be given in the hospital. The nurse explains that a. the body does not store vitamins so the doctor will have to be called. b. the kidneys will produce enough vitamin D and that supplements are not needed. c. over-the-counter supplements are never given in the hospital. d. vitamins D is stored in the liver with a 10- month supply to prevent deficiency.

D The liver plays a central role in the storage, synthesis, and transport of various vitamins and minerals. It functions as a storage depot principally for vitamins A, D, and B12, where up to 3-, 10-, and 12-month supplies, respectively, of these nutrients are stored to prevent deficiency states. The kidneys do not produce vitamin D. Over-the-counter supplements are ordered depending on the patient's status.

. Positive end-expiratory pressure (PEEP) is a mode of ventilatory assistance that produces the following condition:

There is pressure remaining in the lungs at the end of expiration that is measured in cm H2O.

A patient has coronary artery bypass graft surgery and is transported to the surgical intensive care unit at noon. He is placed on mechanical ventilation. Interpret his initial arterial blood gas levels: pH 7.31 PaCO2 48 mm Hg Bicarbonate 22 mEq/L PaO2 115 mm Hg O2 saturation 99%

Uncompensated respiratory acidosis; hyperoxygenated

MULTIPLE RESPONSE 6. The patient's husband tells the nurse, "We didn't think she was having a heart attack because the pain was in her neck and back." The nurse explains: (Select all that apply.) a. "Pain can occur anywhere in the chest, neck, arms, or back. Don't hesitate to call the emergency medical services if you think it's a heart attack." b. "For many people chest pain from a heart attack occurs in the center of the chest, behind the breastbone." c. "The sooner the patient can get medical help, the less damage is likely to occur in case of a heart attack." d. "You need to make sure it's a heart attack before you call the emergency response personnel."

a. "Pain can occur anywhere in the chest, neck, arms, or back. Don't hesitate to call the emergency medical services if you think it's a heart attack." b. "For many people chest pain from a heart attack occurs in the center of the chest, behind the breastbone." c. "The sooner the patient can get medical help, the less damage is likely to occur in case of a heart attack." RATIONALE: Angina may occur anywhere in the chest, neck, arms, or back, but the most commonly described is pain or pressure behind the sternum. The pain often radiates to the left arm but can also radiate down both arms and to the back, the shoulder, the jaw, and/or the neck.

The normal width of the QRS complex is which of the following? (Select all that apply.) a. 0.06 to 0.10 seconds. b. 0.12 to 0.20 seconds. c. 1.5 to 2.5 small boxes. d. 3.0 to 5.0 small boxes. e. 0.04 seconds or greater.

a. 0.06 to 0.10 seconds. c. 1.5 to 2.5 small boxes.

The charge nurse is supervising the care of four critical care patients being monitored using invasive hemodynamic modalities. Which patient should the charge nurse evaluate first? a. A patient in cardiogenic shock with a cardiac output (CO) of 2.0 L/min b. A patient with a pulmonary artery systolic pressure (PAP) of 20 mm Hg c. A hypovolemic patient with a central venous pressure (CVP) of 6 mm Hg d. A patient with a pulmonary artery occlusion pressure (PAOP) of 10 mm Hg

a. A patient in cardiogenic shock with a cardiac output (CO) of 2.0 L/min

16. A patient is admitted to the emergency department with clinical indications of an acute myocardial infarction. Symptoms began 3 hours ago. The facility does not have the capability for percutaneous coronary intervention. Given this scenario, what is the priority intervention in the treatment and nursing management of this patient? a. Administer thrombolytic therapy unless contraindicated b. Diurese aggressively and monitor daily weight c. Keep oxygen saturation levels at least 88% d. Maintain heart rate above 100 beats/min

a. Administer thrombolytic therapy unless contraindicated Rationale: Medical treatment of AMI is aimed at relieving pain, providing adequate oxygenation to the myocardium, preventing platelet aggregation, and restoring blood flow to the myocardium through thrombolytic therapy or acute interventional therapy such as angioplasty. Since interventional cardiology is not available, thrombolytic therapy is indicated. Oxygen saturation should be maintained at higher levels to ensure adequate oxygenation to the heart muscle. An elevated heart rate increases oxygen demands and should be avoided. Diuresis is not indicated with this scenario.

MULTIPLE RESPONSE 2. Identify the priority interventions for managing symptoms of an acute myocardial infarction (AMI) in the ED. (Select all that apply). a. Administration of morphine b. Administration of nitroglycerin (NTG) c. Dopamine infusion d. Oxygen therapy

a. Administration of morphine b. Administration of nitroglycerin (NTG) d. Oxygen therapy RATIONALE: The initial pain of AMI is treated with morphine sulfate administered intravenously. NTG may be given to reduce the ischemic pain of AMI. NTG increases coronary perfusion because of its vasodilatory effects. Oxygen administration is important for assisting the myocardial tissue to continue its pumping activity and for repairing the damaged tissue around the site of the infarct.

The nurse is caring for a patient with cystic fibrosis (CF) and understands that treatment consists of which of the following? (Select all that apply.) a. Airway clearance therapies b. Antibiotic therapy c. Nutritional support d. Tracheostomy

a. Airway clearance therapies b. Antibiotic therapy c. Nutritional support

The nurse is preparing for insertion of a pulmonary artery catheter (PAC). During insertion of the catheter, what are the priority nursing actions? (Select all that apply.) a. Allay the patient's anxiety by providing information about the procedure. b. Ensure that a sterile field is maintained during the insertion procedure. c. Inflate the balloon during the procedure when indicated by the physician. d. Monitor the patient's cardiac rhythm throughout the entire procedure. e. Obtain informed consent by informing the patient of procedural risks.

a. Allay the patient's anxiety by providing information about the procedure. b. Ensure that a sterile field is maintained during the insertion procedure. c. Inflate the balloon during the procedure when indicated by the physician. d. Monitor the patient's cardiac rhythm throughout the entire procedure.

The nurse is caring for a 70-kg patient in septic shock with a pulmonary artery catheter. Which hemodynamic value indicates an appropriate response to therapy aimed at enhancing oxygen delivery to the organs and tissues? a. Arterial lactate level of 1.0 mEq/L b. Cardiac output of 2.5 L/min c. Mixed venous (SvO2 ) of 40% d. Cardiac index of 1.5 L/min/m2

a. Arterial lactate level of 1.0 mEq/L

The patient is in chronic junctional escape rhythm with no atrial activity noted. Studies have demonstrated normal AV node function. This patient may be a candidate for which type of pacing? a. Atrial pacing b. Ventricular pacing c. Dual-chamber pacing d. Transcutaneous pacing

a. Atrial pacing

Identify diagnostic criteria for ARDS. (Select all that apply.) a. Bilateral infiltrates on chest x-ray study b. Decreased cardiac output c. PaO2/ FiO2 ratio of less than 200 d. Pulmonary artery occlusion pressure (PAOP) of more than 18 mm Hg

a. Bilateral infiltrates on chest x-ray study c. PaO2/ FiO2 ratio of less than 200

A patient is admitted to the hospital with multiple trauma and extensive blood loss. The nurse assesses vital signs to be BP 80/50 mm Hg, heart rate 135 beats/min, respirations 36 breaths/min, cardiac output (CO) of 2 L/min, systemic vascular resistance of 3000 dynes/sec/cm-5, and a hematocrit of 20%. The nurse anticipates administration of which the following therapies or medications? a. Blood transfusion b. Furosemide (Lasix) c. Dobutamine (Dobutrex) infusion d. Dopamine hydrochloride (Dopamine) infusion

a. Blood transfusion

Sinus bradycardia is a symptom of which of the following? (Select all that apply.) a. Calcium channel blocker medication b. Beta-blocker medication c. Athletic conditioning d. Hypothermia e. Hyperthyroidism

a. Calcium channel blocker medication b. Beta-blocker medication c. Athletic conditioning d. Hypothermia

MULTIPLE RESPONSE 5. A patient is admitted with an acute myocardial infarction (AMI). The nurse monitors for which potential complications? (Select all that apply.) a. Cardiac dysrhythmias b. Heart failure c. Pericarditis d. Ventricular rupture

a. Cardiac dysrhythmias b. Heart failure c. Pericarditis d. Ventricular rupture RATIONALE: All are potential complications of AMI.

The nurse is caring for a 100-kg patient being monitored with a pulmonary artery catheter. The nurse assesses a blood pressure of 90/60 mm Hg, heart rate 110 beats/min, respirations 36/min, oxygen saturation of 89% on 3 L of oxygen via nasal cannula. Bilateral crackles are audible upon auscultation. Which hemodynamic value requires immediate action by the nurse? a. Cardiac index (CI) of 1.2 L/min/m3 b. Cardiac output (CO) of 4 L/min c. Pulmonary vascular resistance (PVR) of 80 dynes/sec/cm-5 d. Systemic vascular resistance (SVR) of 1800 dynes/sec/cm-5

a. Cardiac index (CI) of 1.2 L/min/m3

Upon entering the room of a patient with a right radial arterial line, the nurse assesses the waveform to be slightly dampened and notices blood to be backed up into the pressure tubing. What is the best action by the nurse? a. Check the inflation volume of the flush system pressure bag. b. Disconnect the flush system from the arterial line catheter. c. Zero reference the transducer system at the phlebostatic axis. d. Reduce the number of stopcocks in the flush system tubing.

a. Check the inflation volume of the flush system pressure bag.

Which nursing actions are most important for a patient with a right radial arterial line? (Select all that apply.) a. Checking the circulation to the right hand every 2 hours b. Maintaining a pressurized flush solution to the arterial line setup c. Monitoring the waveform on the monitor for dampening d. Restraining all four extremities with soft limb restraints

a. Checking the circulation to the right hand every 2 hours b. Maintaining a pressurized flush solution to the arterial line setup c. Monitoring the waveform on the monitor for dampening

During the assessment of a patient after a high-speed motor vehicle crash, which of the following findings would increase the nurse's suspicion of a pulmonary contusion? (Select all that apply.) a. Chest wall ecchymosis b. Diminished or absent breath sounds c. Pink-tinged or blood secretions d. Signs of hypoxia on room air e. Paradoxical chest wall movement

a. Chest wall ecchymosis c. Pink-tinged or blood secretions d. Signs of hypoxia on room air

The nurse is preparing to obtain a right atrial pressure (RAP/CVP) reading. What are the most appropriate nursing actions? (Select all that apply.) a. Compare measured pressures with other physiological parameters. b. Flush the central venous catheter with 20 mL of sterile saline. c. Inflate the balloon with 3 mL of air and record the pressure tracing. d. Obtain the right atrial pressure measurement during end exhalation. e. Zero reference the transducer system at the level of the phlebostatic axis.

a. Compare measured pressures with other physiological parameters. d. Obtain the right atrial pressure measurement during end exhalation. e. Zero reference the transducer system at the level of the phlebostatic axis.

13. The patient presents to the ED with severe chest discomfort. He is taken for cardiac catheterization and angiography that shows 80% occlusion of the left main coronary artery. Which procedure will be most likely followed? a. Coronary artery bypass graft surgery b. Intracoronary stent placement c. Percutaneous transluminal coronary angioplasty (PTCA) d. Transmyocardial revascularization

a. Coronary artery bypass graft surgery Rationale: Coronary artery bypass graft surgery is indicated for significant left main coronary occlusion (>50%)

Which of the following patients would require greater amounts of fluid resuscitation to prevent acute kidney injury associated with rhabdomyolysis? (Select all that apply.) a. Crush injury to right arm b. Gunshot wound to the abdomen c. Lightning strike of the left arm and chest d. Pulmonary contusion and rib fracture e. Penetrating wound to both legs

a. Crush injury to right arm c. Lightning strike of the left arm and chest

The patient with acute respiratory distress syndrome (ARDS) would exhibit which of the following symptoms? a. Decreasing PaO2 levels despite increased FiO2 administration b. Elevated alveolar surfactant levels c. Increased lung compliance with increased FiO2 administration d. Respiratory acidosis associated with hyperventilation

a. Decreasing PaO2 levels despite increased FiO2 administration

MULTIPLE RESPONSE 1. The patient has been in chronic heart failure for the past 10 years. He has been treated with beta-blockers and angiotensin-converting enzyme inhibitors as well as diuretics. His symptoms have recently worsened, and he presents to the ED with severe shortness of breath and crackles throughout his lung fields. His respirations are labored and arterial blood gases show that he is at risk for respiratory failure. Which of the following therapies may be used for acute, short-term management of the patient? (Select all that apply). a. Dobutamine b. Intraaortic balloon pump c. Nesiritide (Natrecor) d. Ventricular assist device

a. Dobutamine b. Intraaortic balloon pump c. Nesiritide (Natrecor) RATIONALE: This patient is showing signs and symptoms of an acute exacerbation of heart failure. Dobutamine and nesiritide are medications administered for acute short-term management; mechanical assist with an intraaortic balloon pump also may be warranted.

The nurse is caring for a mechanically ventilated patient. The nurse understands that strategies to prevent ventilator-associated pneumonia include which of the following? (Select all that apply.) a. Drain condensate from the ventilator tubing away from the patient. b. Elevate the head of the bed 30 to 45 degrees. c. Instill normal saline as part of the suctioning procedure. d. Perform regular oral care with chlorhexidine.

a. Drain condensate from the ventilator tubing away from the patient. b. Elevate the head of the bed 30 to 45 degrees. d. Perform regular oral care with chlorhexidine.

MULTIPLE RESPONSE 3. Which statements are true regarding the symptoms of an AMI? (Select all that apply.) a. Dysrhythmias are common occurrences. b. Men have more atypical symptoms than women. c. Midsternal chest pain is a common presenting symptom. d. Some patients are asymptomatic.

a. Dysrhythmias are common occurrences. c. Midsternal chest pain is a common presenting symptom. d. Some patients are asymptomatic. RATIONALE: Chest pain is a common presenting symptom in AMI. Dysrhythmias are commonly seen in AMI. Some individuals may have ischemic episodes without knowing it, thereby having a "silent" infarction. Women are more likely to have atypical signs and symptoms, such as shortness of breath, nausea and vomiting, and back or jaw pain.

4. A patient presents to the emergency department (ED) with chest pain that he has had for the past 2 hours. He is nauseous and diaphoretic, and his skin is dusky in color. The electrocardiogram shows ST elevation in leads II, III, and aVF. Which therapeutic intervention would the nurse question? a. Emergent pacemaker insertion b. Emergent percutaneous coronary intervention c. Emergent thrombolytic therapy d. Immediate coronary artery bypass graft surgery

a. Emergent pacemaker insertion Rationale: The goals of management of AMI are to dissolve the lesion that is occluding the coronary artery and to increase blood flow to the myocardium. Options include emergent percutaneous intervention, such as angioplasty, emergent coronary artery bypass graft surgery, or thrombolytic therapy if the patient has been symptomatic for less than 6 hours. No data in this scenario warrant insertion of a pacemaker.

17. A patient has been prescribed nitroglycerin in the ED for chest pain. In taking the health history, the nurse will be sure to verify whether the patient has taken medications prior to admission for: a. Erectile dysfunction b. Prostate enlargement c. Asthma d. Peripheral vascular disease

a. Erectile dysfunction Rationale: A history of the patient's use of sildenafil citrate (Viagra) or similar medications taken for erectile dysfunction is necessary to know when considering NTG administration. These medications potentiate the hypotensive effects of nitrates; thus, concurrent use is contraindicated. It is also important to determine whether the patient has any food or drug allergies.

Which interventions can the nurse implement to assist the patient's family in coping with the traumatic event? (Select all that apply.) a. Establish a family spokesperson and communication system. b. Ask the family about their normal coping mechanisms. c. Limit visitation to set times throughout the day. d. Coordinate a family conference. e. Determine how the family perceives the event

a. Establish a family spokesperson and communication system. b. Ask the family about their normal coping mechanisms. d. Coordinate a family conference. e. Determine how the family perceives the event

The trauma nurse understands which information related to the older trauma patient? (Select all that apply.) a. Falls are the leading cause of death in the older population. b. Physiologic capacity is an important predictor of outcome. c. Hypotension in the elderly can appear as normotension. d. Chronic diseases do not have much effect on the older trauma patient. e. Fractures to bones other than hips are uncommon from trauma.

a. Falls are the leading cause of death in the older population. b. Physiologic capacity is an important predictor of outcome. c. Hypotension in the elderly can appear as normotension.

Select the strategies for preventing deep vein thrombosis (DVT) and pulmonary embolus (PE). (Select all that apply.) a. Graduated compression stockings b. Heparin or low-molecular weight heparin for patients at risk c. Sequential compression devices d. Strict bed rest

a. Graduated compression stockings b. Heparin or low-molecular weight heparin for patients at risk c. Sequential compression devices

Which of the following are common causes of sinus tachycardia? (Select all that apply.) a. Hyperthyroidism b. Hypovolemia c. Hypothyroidism d. Heart Failure e. Sleep

a. Hyperthyroidism b. Hypovolemia d. Heart Failure

Which of the following are physiological effects of positive end-expiratory pressure (PEEP) used in the treatment of ARDS? (Select all that apply.) a. Increase functional residual capacity b. Prevent collapse of unstable alveoli c. Improve arterial oxygenation d. Open collapsed alveoli

a. Increase functional residual capacity b. Prevent collapse of unstable alveoli c. Improve arterial oxygenation d. Open collapsed alveoli

Which of the following statements apply to trauma patients and their potential complications? (Select all that apply.) a. Indwelling urinary catheters are a source of infection. b. Patients often develop infection and sepsis secondary to central line catheters. c. Pneumonia is often an adverse outcome of mechanical ventilation. d. Wounds require sterile dressings to prevent infection.

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

When performing an initial pulmonary artery occlusion pressure (PAOP), what are the best nursing actions? (Select all that apply.) a. Inflate the balloon for no more than 8 to 10 seconds while noting the waveform change. b. Inflate the balloon with air, recording the volume necessary to obtain a reading. c. Maintain the balloon in the inflated position for 8 hours following insertion. d. Zero reference and level the air-fluid interface of the transducer at the level of the phlebostatic axis.

a. Inflate the balloon for no more than 8 to 10 seconds while noting the waveform change. b. Inflate the balloon with air, recording the volume necessary to obtain a reading. d. Zero reference and level the air-fluid interface of the transducer at the level of the phlebostatic axis.

Which of the following interventions would not be appropriate for a patient who is admitted with a suspected basilar skull fracture? a. Insertion of a nasotracheal tube b. Insertion of an indwelling urinary catheter c. Endotracheal intubation d. Placement of an oral airway

a. Insertion of a nasotracheal tube

Which of the following are components of the Institute for Healthcare Improvement's (IHI's) ventilator bundle? (Select all that apply.) a. Interrupt sedation each day to assess readiness to extubate. b. Maintain head of bed at least 30 degrees elevation. c. Provide deep vein thrombosis prophylaxis. d. Provide prophylaxis for peptic ulcer disease. e. Swab the mouth with foam swabs every 2 hours.

a. Interrupt sedation each day to assess readiness to extubate. b. Maintain head of bed at least 30 degrees elevation. c. Provide deep vein thrombosis prophylaxis. d. Provide prophylaxis for peptic ulcer disease.

MULTIPLE RESPONSE 7. Which clinical manifestations are indicative of right ventricular failure? (Select all that apply.) a. Jugular venous distention b. Peripheral edema c. Crackles audible in the lungs d. Weak peripheral pulses

a. Jugular venous distention b. Peripheral edema RATIONALE: Rationale: Jugular venous distention, liver tenderness, hepatomegaly, and peripheral edema are signs of right ventricular failure.

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

a. Level I

The nurse is caring for a patient who is being turned prone as part of treatment for acute respiratory distress syndrome. The nurse understands that the priority nursing concern for this patient is which of the following? a. Management and protection of the airway b. Prevention of gastric aspiration c. Prevention of skin breakdown and nerve damage d. Psychological support to patient and family

a. Management and protection of the airway

Which of the following findings require immediate nursing interventions in a patient with a traumatic brain injury? (Select all that apply.) a. Mean arterial pressure 48 mm Hg b. Elevated serum blood alcohol level c. Nonreactive pupils d. Respiratory rate of 10 breaths/min e. Open skull fracture

a. Mean arterial pressure 48 mm Hg c. Nonreactive pupils d. Respiratory rate of 10 breaths/min e. Open skull fracture

Because of the location of the AV node, the possible P waveforms that are associated with junctional rhythms include which of the following? (Select all that apply.) a. No P wave b. Inverted P wave c. Shortened PR interval d. P wave after the QRS complex e. Normal P wave and PR interval

a. No P wave b. Inverted P wave c. Shortened PR interval d. P wave after the QRS complex

Which of the following statements is true regarding venous thromboembolism (VTE) and pulmonary embolus (PE)? a. PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk factors for VTE. b. Bradycardia and hyperventilation are classic symptoms of PE. c. Dyspnea, chest pain, and hemoptysis occur in nearly all patients with PE. d. Most critically ill patients are at low risk for VTE and PE and do not require prophylaxis.

a. PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk factors for VTE.

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

a. Placement of an intraosseous catheter

Nursing priorities to prevent ineffective coagulation include which of the following? (Select all that apply.) a. Prevention of hypothermia b. Administration of fresh frozen plasma as ordered c. Administration of potassium as ordered d. Administration of calcium as ordered e. Monitoring CBC and coagulation studies

a. Prevention of hypothermia b. Administration of fresh frozen plasma as ordered d. Administration of calcium as ordered

The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which action by the nurse best reduces the risk of catheter- related bloodstream infection (CRBSI)? a. Review daily the necessity of the central venous catheter. b. Cleanse the insertion site daily with isopropyl alcohol. c. Change the pressurized tubing system and flush bag daily. d. Maintain a pressure of 300 mm Hg on the flush bag.

a. Review daily the necessity of the central venous catheter.

1. The patient is admitted with a suspected acute myocardial infarction (MI). In assessing the 12-lead electrocardiogram (ECG) changes, which findings would indicate to the nurse that the patient is in the process of an evolving Q wave myocardial infarction(MI)? a. ST-segment elevation on ECG and elevated CPK-MB or troponin levels b. Depressed ST-segment on ECG and elevated total CPK c. Depressed ST-segment on ECG and normal cardiac enzymes d. Q wave on ECG with normal enzymes and troponin levels

a. ST-segment elevation on ECG and elevated CPK-MB or troponin levels Rationale: ST segment elevation and elevated cardiac enzymes are seen in Q wave MI.

The nurse is caring for a patient who has atrial fibrillation. Sequelae that place the patient at greater risk for mortality/morbidity include which of the following? (Select all that apply.) a. Stroke b. Ashman beats c. Pulmonary emboli d. Prolonged PR interval e. Decreased cardiac output

a. Stroke c. Pulmonary emboli e. Decreased cardiac output

Which of the following is true about a patient diagnosed with sinus arrhythmia? a. The heart rate varies, dependent on vagal tone and respiratory pattern. b. Immediate treatment is essential to prevent death. c. Sinus arrhythmia is not well tolerated by most patients. d. PR and QRS interval measurements are prolonged.

a. The heart rate varies, dependent on vagal tone and respiratory pattern.

12. A patient presents to the ED complaining of severe substernal chest pressure radiating to his left shoulder and back that started about 12 hours ago. The patient delayed coming to the ED since he was hoping the pain would go away. The patient's 12-lead ECG shows ST-segment depression in the inferior leads. Troponin and CK-MB are both elevated. The hospital does not have the capability for percutaneous coronary intervention. Thrombolysis is one possible treatment. Based on these data, the nurse understands that? a. The patient is not a candidate for thrombolysis. b. The patient's history makes him a good candidate for thrombolysis. c. Thrombolysis is appropriate for a candidate having a non-Q wave MI. d. Thrombolysis should be started immediately.

a. The patient is not a candidate for thrombolysis. Rationale: To be eligible for thrombolysis, the patient must be symptomatic for less than 6 hours.

The etiology of noncardiogenic pulmonary edema in acute respiratory distress syndrome (ARDS) is related to damage to the: a. alveolar-capillary membrane. b. left ventricle. c. mainstem bronchus. d. trachea.

a. alveolar-capillary membrane.

During rounds, the physician alerts the team that proning is being considered for a patient with acute respiratory distress syndrome. The nurse understands that proning is: a. an optional treatment if the PaO2/FiO2 ratio is less 100. b. less of a risk for skin breakdown because the patient is face down. c. possible with minimal help from co-workers. d. used to provide continuous lateral rotational turning.

a. an optional treatment if the PaO2/FiO2 ratio is less 100.

A community-based external disaster is initiated after a tornado moved through the city. A nurse from the medical records review department arrives at the emergency department asking how to assist. The best response by a nurse working for the trauma center would be to a. assign the nurse administrative duties, such as obtaining patient demographic information. b. assign the nurse to a triage room with another nurse from the emergency department. c. thank the nurse but inform her to return to her department as her skill set is not a good match for patients' needs. d. have the nurse assist with transport of patients to procedural areas.

a. assign the nurse administrative duties, such as obtaining patient demographic information.

The nurse is reading the cardiac monitor and notes that the patient's heart rhythm is extremely irregular and there are no discernible P waves. The ventricular rate is 90 beats per minute, and the patient is hemodynamically stable. The nurse realizes that the patient's rhythm is: a. atrial fibrillation. b. atrial flutter. c. atrial flutter with rapid ventricular response. d. junctional escape rhythm.

a. atrial fibrillation.

The nurse is caring for a patient in acute respiratory failure and understands that the patient should be positioned: (Select all that apply.) a. high Fowler's. b. side lying with head of bed elevated. c. sitting in a chair. d. supine with the bed flat.

a. high Fowler's. b. side lying with head of bed elevated. c. sitting in a chair.

The patient has an irregular heart rhythm. To determine an accurate heart rate, the nurse first: a. identifies the markers on the ECG paper that indicate a 6-second strip. b. counts the number of large boxes between two consecutive P waves. c. counts the number of small boxes between two consecutive QRS complexes. d. divides the number of complexes in a 6-second strip by 10.

a. identifies the markers on the ECG paper that indicate a 6-second strip.

The patient's heart rhythm shows an inverted P wave with a PR interval of 0.06 seconds. The heart rate is 54 beats per minute. The nurse recognizes the rhythm as a junctional escape rhythm, and understands that the rhythm is due to the: a. loss of sinus node activity. b. increased rate of the AV node. c. increased rate of the SA node. d. decreased rate of the AV node.

a. loss of sinus node activity.

The nurse is caring for a patient who is on a cardiac monitor. The nurse realizes that the sinus node is the pacemaker of the heart because it is: a. the fastest pacemaker cell in the heart. b. the only pacemaker cell in the heart. c. the only cell that does not affect the cardiac cycle. d. located in the left side of the heart.

a. the fastest pacemaker cell in the heart.

The patient has a permanent pacemaker inserted. The provider has set the pacemaker to the demand mode at a rate of 60 beats per minute. The nurse realizes that: a. the pacemaker will pace only if the patient's intrinsic heart rate is less than 60 beats per minute. b. the demand mode often competes with the patient's own rhythm. c. the demand mode places the patient at risk for the R-on-T phenomenon. d. the fixed rate mode is safer and is the mode of choice.

a. the pacemaker will pace only if the patient's intrinsic heart rate is less than 60 beats per minute.

The patient is having premature ventricular contractions (PVCs). The nurse's greatest concern should be: a. the proximity of the R wave of the PVC to the T wave of a normal beat. b. the fact that PVCs are occurring, because they are so rare. c. if the number of PVCs are decreasing. d. if the PVCs are wider than 0.12 seconds.

a. the proximity of the R wave of the PVC to the T wave of a normal beat.

The patient is in third-degree heart block (complete heart block) and is symptomatic. The treatment for this patient is which of the following? (Select all that apply.) a. transcutaneous pacemaker. b. atropine IV. c. temporary transvenous pacemaker. d. permanent pacemaker. e. amiodarone IV.

a. transcutaneous pacemaker. c. temporary transvenous pacemaker. d. permanent pacemaker.

The nurse is educating a patient's family member about a pulmonary artery catheter (PAC). Which statement by the family member best indicates understanding of the purpose of the PAC? a. "The catheter will provide multiple sites to give intravenous fluid." b. "The catheter will allow the physician to better manage fluid therapy." c. "The catheter tip comes to rest inside my brother's pulmonary artery." d. "The catheter will be in position until the heart has a chance to heal."

b. "The catheter will allow the physician to better manage fluid therapy."

22. The patient's wife is feeling overwhelmed and tells the nurse that she doesn't know if she can manage to cook different dinners for her husband and the rest of the family to satisfy his cholesterol-reducing diet. The nurse tells her: a. "It will be worth it to have him healthy, won't it?" b. "The low-cholesterol diet is one from which everyone can benefit." c. "As long as you change at least a few things in the diet, it will be okay." d. "You can go on the diet with him, and then just let the children eat whatever they want."

b. "The low-cholesterol diet is one from which everyone can benefit." Rationale: Some cardiologists advocate a reduction of the low-density lipoprotein goal to the 50 to 70 mg/dL range for everyone, not only those with a known cardiovascular disease.

24. Which comment by the patient indicates a good understanding of her diagnosis of coronary heart disease? a. "I had a heart attack because I work too hard and it puts too much strain on my heart." b. "The pain in my chest gets worse each time it happens. I think that there is more damage to my heart vessels as time goes on." c. "If I change my diet and exercise more, I should get over this and be healthy." d. "What kind of pills can you give me to get me over this and back to my lifestyle?"

b. "The pain in my chest gets worse each time it happens. I think that there is more damage to my heart vessels as time goes on." RATIONALE: Coronary heart disease is a progressive atherosclerotic disorder of the coronary arteries that results in narrowing or complete occlusion.

28. The patient's wife is confused about the scheduling of a stent insertion. She says that she thought the angioplasty was surgery to fix her husband's heart problem. The nurse explains to her: a. "The angioplasty was a failure, and so this procedure has to be done to fix the heart vessel." b. "The stent is inserted to enhance the results of the angioplasty, by helping to keep the vessel open and prevent it from closing again." c. "This procedure is being done instead of using clot-dissolving medication to help keep the heart vessel open." d. "The stent will remove any clots that are in the vessel and protect the heart muscle from damage."

b. "The stent is inserted to enhance the results of the angioplasty, by helping to keep the vessel open and prevent it from closing again." RATIONALE: Stents are inserted to optimize the results of other treatments for acute vessel closure (percutaneous transluminal coronary angioplasty, atherectomy, fibrinolytics) and to prevent restenosis.

A patient at high risk for pulmonary embolism is receiving Lovenox. The nurse explains to the patient: a. "I'm going to contact the pharmacist to see if you can take this medication by mouth." b. "This injection is being given to prevent blood clots from forming." c. "This medication will dissolve any blood clots you might get." d. "You should not be receiving this medication. I will contact the physician to get it stopped."

b. "This injection is being given to prevent blood clots from forming."

Electrocardiogram (ECG) paper contains a standardized grid where the horizontal axis measures time and the vertical axis measures voltage or amplitude. The nurse must understand that each horizontal box indicates: a. 200 milliseconds or 0.20 seconds duration. b. 40 milliseconds or 0.04 seconds duration. c. 3 seconds duration. d. millivolts of amplitude.

b. 40 milliseconds or 0.04 seconds duration.

The normal rate for the SA node when the patient is at rest is: a. 40 to 60 beats per minute. b. 60 to 100 beats per minute. c. 20 to 40 beats per minute. d. more than100 beats per minute.

b. 60 to 100 beats per minute.

Which of the following injuries would result in a greater likelihood of internal organ damage and risk for infection? a. A fall from a 6-foot ladder onto the grass b. A shotgun wound to the abdomen c. A knife wound to the right chest d. A motor vehicle crash in which the driver hits the steering wheel

b. A shotgun wound to the abdomen

The physician writes an order to discontinue a patient's left radial arterial line. When discontinuing the patient's invasive line, what is the priority nursing action? a. Apply an air occlusion dressing to insertion site. b. Apply pressure to the insertion site for 5 minutes. c. Elevate the affected limb on pillows for 24 hours. d. Keep the patient's wrist in a neutral position.

b. Apply pressure to the insertion site for 5 minutes.

MULTIPLE RESPONSE 8. Which nursing interventions would be appropriate after angioplasty? (Select all that apply.) a. Elevate the head of the bed by 45 degrees for 6 hours b. Assess pedal pulses on the involved limb every 15 minutes for 2 hours c. Monitor the vascular hemostatic device for signs of bleeding d. Instruct the patient bend his/her knee every 15 minutes while the sheath is in place

b. Assess pedal pulses on the involved limb every 15 minutes for 2 hours c. Monitor the vascular hemostatic device for signs of bleeding d. Instruct the patient bend his/her knee every 15 minutes while the sheath is in place RATIONALE: The head of the bed must not be elevated more than 30 degrees, and the patient should be instructed to keep the affected leg straight. Bed rest is 6 to 8 hours in duration, unless a vascular hemostatic device is used. The nurse observes the patient for bleeding or swelling at the puncture site and frequently assesses adequacy of circulation to the involved extremity.

25. The patient has undergone open chest surgery for coronary artery bypass grafting. One of the nurse's responsibilities is to monitor the patient for which common postoperative dysrhythmia? a. Second degree heart block b. Atrial fibrillation or flutter c. Ventricular ectopy d. Premature junctional contractions

b. Atrial fibrillation or flutter RATIONALE: Atrial fibrillation and flutter are dysrhythmias common after cardiac surgery.

The nurse is preparing to measure the thermodilution cardiac output (TdCO) in a patient being monitored with a pulmonary artery catheter. Which action by the nurse best ensures the safety of the patient? a. Ensure the transducer system is zero referenced at the level of the phlebostatic axis. b. Avoid infusing vasoactive agents in the port used to obtain the TdCO measurement. c. Maintain a pressure of 300 mm Hg on the flush solution using a pressure bag. d. Limit the length of the noncompliant pressure tubing to a maximum 48 inches.

b. Avoid infusing vasoactive agents in the port used to obtain the TdCO measurement.

Following insertion of a pulmonary artery catheter (PAC), the physician orders the nurse to obtain a blood sample for mixed venous oxygen saturation (SvO2). Which action by the nurse best ensures the obtained value is accurate? a. Zero referencing the transducer at the level of the phlebostatic axis following insertion b. Calibrating the system with a central venous blood sample and arterial blood gas value c. Ensuring patency of the catheter using a 0.9% normal saline solution pressurized at 300 mm Hg d. Using noncompliant pressure tubing that is no longer than 36 to 48 inches and has minimal stopcocks

b. Calibrating the system with a central venous blood sample and arterial blood gas value

It is important to prevent hypothermia in the trauma patient because hypothermia is associated with which of the following? (Select all that apply.) a. ARDS b. Coagulopathies c. Dysrhythmias d. Myocardial dysfunction e. Fat embolism

b. Coagulopathies c. Dysrhythmias d. Myocardial dysfunction

A 36-year-old driver was pulled from a car after it collided with a tree and the gas tank exploded. What assessment data suggest the patient suffered tissue damage consistent with a blast injury? a. Blood pressure 82/60 mm Hg, heart rate 122 beats/min, respiratory rate 28 breaths/min b. Crackles (rales) on auscultation of bilateral lung fields c. Responsive only to painful stimuli d. Irregular heart rate and rhythm

b. Crackles (rales) on auscultation of bilateral lung fields

Which of the following statements about mass casualty triage during a disaster is true? a. Priority treatments and interventions focus primarily on young victims. b. Disaster victims with the greatest chances for survival receive priority for treatment. c. Once interventions have been initiated, health care providers cannot stop the treatment of disaster victims. d. Color-coded systems in which green indicates the patient of greatest need are used during disasters.

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

The nursing is caring for a patient who has had an arterial line inserted. To reduce the risk of complications, what is the priority nursing intervention? a. Apply a pressure dressing to the insertion site. b. Ensure all tubing connections are tightened. c. Obtain a portable x-ray to confirm placement. d. Restrain the affected extremity for 24 hours.

b. Ensure all tubing connections are tightened.

The nurse assesses a patient who is admitted for an overdose of sedatives. The nurse expects to find which acid-base alteration? a. Hyperventilation and respiratory acidosis b. Hypoventilation and respiratory acidosis c. Hypoventilation and respiratory alkalosis d. Respiratory acidosis and normal oxygen levels

b. Hypoventilation and respiratory acidosis

Which of the following situations may result in a low cardiac output and low cardiac index? (Select all that apply.) a. Exercise b. Hypovolemia c. Myocardial infarction d. Shock

b. Hypovolemia c. Myocardial infarction d. Shock

Which of the following statements are true regarding fluid resuscitation during the care of a trauma patient? (Select all that apply.) a. 5% Dextrose is recommended for rapid crystalloid infusion. b. IV fluids may need to be warmed to prevent hypothermia. c. Massive transfusions should be avoided to improve patient outcomes. d. Only fully crossmatched blood products are administered. e. Hypertonic saline solutions are often used during initial resuscitation.

b. IV fluids may need to be warmed to prevent hypothermia. c. Massive transfusions should be avoided to improve patient outcomes

Which of the following statements is true regarding oral care for the prevention of ventilator-associated pneumonia (VAP)? (Select all that apply.) a. Tooth brushing is performed every 2 hours for the greatest effect. b. Implementing a comprehensive oral care program is an intervention for preventing VAP. c. Oral care protocols should include oral suctioning and brushing teeth. d. Protocols that include chlorhexidine gluconate have been effective in preventing VAP.

b. Implementing a comprehensive oral care program is an intervention for preventing VAP. c. Oral care protocols should include oral suctioning and brushing teeth. d. Protocols that include chlorhexidine gluconate have been effective in preventing VAP.

The nurse is assessing a patient. Which assessment would cue the nurse to the potential of acute respiratory distress syndrome (ARDS)? a. Increased oxygen saturation via pulse oximetry b. Increased peak inspiratory pressure on the ventilator c. Normal chest radiograph with enlarged cardiac structures d. PaO2/FiO2 ratio > 300

b. Increased peak inspiratory pressure on the ventilator

An acute exacerbation of asthma is treated with which of the following? a. Corticosteroids and theophylline by mouth b. Inhaled bronchodilators and intravenous corticosteroids c. Prone positioning or continuous lateral rotation d. Sedation and inhaled bronchodilators

b. Inhaled bronchodilators and intravenous corticosteroids

While caring for a patient with a small bowel obstruction, the nurse assesses a pulmonary artery occlusion pressure (PAOP) of 1 mm Hg and hourly urine output of 5 mL. The nurse anticipates which therapeutic intervention? a. Diuretics b. Intravenous fluids c. Negative inotropic agents d. Vasopressors

b. Intravenous fluids

19. A patient was admitted in terminal heart failure and is not eligible for transplant. The family wants everything possible done to maintain life. Which procedure might be offered to the patient for this condition to increase the patient's quality of life? a. Intraaortic balloon pump (IABP) b. Left ventricular assist device (LVAD) c. Nothing, because the patient is in terminal heart failure d. Nothing additional; medical management is the only option

b. Left ventricular assist device (LVAD) Rationale: LVADs are capable of partial to complete circulatory support for short- to long-term use. At present, the LVAD is therapy for patients with terminal heart failure. It would provide better management than medical therapy alone. The IABP is for short-term management of acute heart failure.

9. The patient is admitted with an acute myocardial infarction (AMI). Three days later the nurse is concerned that the patient may have a papillary muscle rupture. Which assessment data may indicate a papillary muscle rupture? a. Gallop rhythm b. Murmur c. S1 heart sound d. S3 heart sound

b. Murmur Rationale: The presence of a new murmur warrants special attention, particularly in a patient with an AMI. A papillary muscle may have ruptured, causing the valve to close incorrectly, which can be indicative of severe damage and impending complications.

The nurse is caring for a patient with a left subclavian central venous catheter (CVC) and a left radial arterial line. Which assessment finding by the nurse requires immediate action? a. A dampened arterial line waveform b. Numbness and tingling in the left hand c. Slight bloody drainage at subclavian insertion site d. Slight redness at subclavian insertion site

b. Numbness and tingling in the left hand

The nurse is assessing a patient with acute respiratory distress syndrome. An expected assessment is: a. cardiac output of 10 L/min and low systemic vascular resistance. b. PAOP of 10 mm Hg and PaO2 of 55. c. PAOP of 20 mm Hg and cardiac output of 3 L/min. d. PAOP of 5 mm Hg and high systemic vascular resistance.

b. PAOP of 10 mm Hg and PaO2 of 55.

When providing information on trauma prevention, it is important to realize that individuals age 35 to 54 years are most likely to experience which type of trauma incident? a. High-speed motor vehicle crashes b. Poisonings from prescription or illegal drugs c. Violent or domestic traumatic altercations d. Work-related falls

b. Poisonings from prescription or illegal drugs

The nurse is caring for a mechanically ventilated patient being monitored with a left radial arterial line. During the inspiratory phase of ventilation, the nurse assesses a 20 mm Hg decrease in arterial blood pressure. What is the best interpretation of this finding by the nurse? a. The mechanical ventilator is malfunctioning. b. The patient may require fluid resuscitation. c. The arterial line may need to be replaced. d. The left limb may have reduced perfusion.

b. The patient may require fluid resuscitation.

18. Which of the following cardiac diagnostic tests would include monitoring the gag reflex before giving the patient anything to eat or drink? a. Barium swallow b. Transesophageal echocardiogram c. MUGA scan d. Stress test

b. Transesophageal echocardiogram Rationale: In transesophageal echocardiography, an ultrasound probe is fitted on the end of a flexible gastroscope, which is inserted into the posterior pharynx and advanced into the esophagus. After the procedure, the patient is unable to eat until the gag reflex returns.

The nurse returns from the cardiac catheterization laboratory with a patient following insertion of a pulmonary artery catheter and assists in transferring the patient from the stretcher to the bed. Prior to obtaining a cardiac output, which action is most important for the nurse to complete? a. Document a pulmonary artery catheter occlusion pressure. b. Zero reference the transducer system at the phlebostatic axis. c. Inflate the pulmonary artery catheter balloon with 1 mL air. d. Inject 10 mL of 0.9% normal saline into the proximal port.

b. Zero reference the transducer system at the phlebostatic axis.

The patient's heart rate is 70 beats per minute, but the P waves come after the QRS complex. The nurse correctly determines that the patient's heart rhythm is: a. a normal junctional rhythm. b. an accelerated junctional rhythm. c. a junctional tachycardia. d. atrial fibrillation.

b. an accelerated junctional rhythm.

When fluid is present in the alveoli: a. alveoli collapse and atelectasis occurs. b. diffusion of oxygen and carbon dioxide is impaired. c. hypoventilation occurs. d. the patient is in heart failure.

b. diffusion of oxygen and carbon dioxide is impaired.

The rhythm on the cardiac monitor is showing numerous pacemaker spikes, but no P waves or QRS complexes following the spikes. The nurse realizes this as: a. normal pacemaker function. b. failure to capture. c. failure to pace. d. failure to sense.

b. failure to capture.

The nurse is examining the patient's cardiac rhythm strip in lead II and notices that all of the P waves are upright and look the same except one that has a different shape and is inverted. The nurse realizes that the P wave with the abnormal shape is probably: a. from the SA node since all P waves come from the SA node. b. from some area in the atria other than the SA node. c. indicative of ventricular depolarization. d. normal even though it is inverted in lead II.

b. from some area in the atria other than the SA node.

During the treatment and management of the trauma patient, maintaining tissue perfusion, oxygenation, and nutritional support are strategies to prevent a. disseminated intravascular coagulation. b. multisystem organ dysfunction. c. septic shock. d. wound infection.

b. multisystem organ dysfunction.

One of the functions of the atrioventricular (AV) node is to: a. pace the heart if the ventricles fail. b. slow the impulse arriving from the SA node. c. send the impulse to the SA node. d. allow for ventricular filling during systole.

b. slow the impulse arriving from the SA node.

27. The patient's wife asks the nurse if the angioplasty will remove all the buildup in the vessel walls so that the patient will be healthy again. The nurse explains: a. "The operation will remove all of the plaque, and if your husband exercises and diets he will be free of cardiac problems." b. "The surgery will remove all the buildup, but it will reaccumulate and he will probably need this surgery again this time next year." c. "The best outcome will be if 20% to 50% of the diameter of the vessel can be restored. Your husband will need to diet and exercise carefully to avoid further cardiac risk." d. "The surgeon will only be able to get 5% to 10% of the plaque, but this will bring about marked relief of your husband's symptoms."

c. "The best outcome will be if 20% to 50% of the diameter of the vessel can be restored. Your husband will need to diet and exercise carefully to avoid further cardiac risk." RATIONALE: A successful angioplasty procedure is one in which the stenosis is reduced to less than 50% of the vessel lumen diameter, although most clinicians aim for less than 20% final diameter stenosis.

21. The cardiologist has told the patient and family that the diagnosis is hypertrophic cardiomyopathy. Later they ask the nurse what the patient did wrong to cause this condition. The nurse explains: a. "This is a result of a high-cholesterol diet and poor exercise habits." b. "The heart has not been getting enough aerobic exercise and has developed this condition. In cardiac rehabilitation they will work with the patient to strengthen his heart through special exercises." c. "This is an inherited condition. You should give serious consideration to having family members screened for it." d. "This is a result of clot formation in the blood vessels in the heart. We will need to use medications to reduce the risk of further clotting."

c. "This is an inherited condition. You should give serious consideration to having family members screened for it." RATIONALE: Hypertrophic cardiomyopathy is a genetically inherited disease that affects the myocardial sarcomere.

Which of the following patients have the greatest risk of developing acute respiratory distress syndrome (ARDS) after traumatic injury? a. A patient who has a closed head injury with a decreased level of consciousness b. A patient who has a fractured femur and is currently in traction c. A patient who has received large volumes of fluid and/or blood replacement d. A patient who has underlying chronic obstructive pulmonary disease

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

The charge nurse is supervising care for a group of patients monitored with a variety of invasive hemodynamic devices. Which patient should the charge nurse evaluate first? a. A patient with a central venous pressure (RAP/CVP) of 6 mm Hg and 40 mL of urine output in the past hour b. A patient with a left radial arterial line with a BP of 110/60 mm Hg and slightly dampened arterial waveform c. A patient with a pulmonary artery occlusion pressure of 25 mm Hg and an oxygen saturation of 89% on 3 L of oxygen via nasal cannula d. A patient with a pulmonary artery pressure of 25/10 mm Hg and an oxygen saturation of 94% on 2 L of oxygen via nasal cannula

c. A patient with a pulmonary artery occlusion pressure of 25 mm Hg and an oxygen saturation of 89% on 3 L of oxygen via nasal cannula

20. The physician orders a pharmacological stress test for a patient with activity intolerance. The nurse would anticipate that the drug of choice would be a. Dopamine b. Dobutamine c. Adenosine d. Atropine

c. Adenosine Rationale: If a patient is unable physically to perform the exercise, a pharmacological stress test can be done. Adenosine is preferred over dobutamine because of its short duration of action and because reversal agents are not needed.

Which of the following best defines the term traumatic injury? a. All trauma patients can be successfully rehabilitated. b. Traumatic injuries cause more deaths than heart disease and cancer. c. Alcohol consumption, drug abuse, or other substance abuse contribute to traumatic events. d. Trauma mainly affects the older adult population.

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

The nurse is caring for a patient with an arterial monitoring system. The nurse assesses the patient's noninvasive cuff blood pressure to be 70/40 mm Hg. The arterial blood pressure measurement via an intraarterial catheter in the same arm is assessed by the nurse to be 108/70 mm Hg. What is the best action by the nurse? a. Activate the rapid response system. b. Place the patient in Trendelenburg position. c. Assess the cuff for proper arm size. d. Administer 0.9% normal saline bolus.

c. Assess the cuff for proper arm size.

After pulmonary artery catheter insertion, the nurse assesses a pulmonary artery pressure of 45/25 mm Hg, a pulmonary artery occlusion pressure (PAOP) of 20 mm Hg, a cardiac output of 2.6 L/min and a cardiac index of 1.9 L/min/m2. Which physician order is of the highest priority? a. Apply 50% oxygen via venture mask. b. Insert an indwelling urinary catheter. c. Begin a dobutamine (Dobutrex) infusion. d. Obtain stat cardiac enzymes and troponin.

c. Begin a dobutamine (Dobutrex) infusion.

10. While instructing a patient on what occurs with a myocardial infarction, the nurse plans to explain which process? a. Coronary artery spasm. b. Decreased blood flow (ischemia). c. Death of cardiac muscle from lack of oxygen (tissue necrosis). d. Sporadic decrease in oxygen to the heart (transient oxygen imbalance).

c. Death of cardiac muscle from lack of oxygen (tissue necrosis). Rationale: Acute myocardial infarction is death (tissue necrosis) of the myocardium that is caused by lack of blood supply from the occlusion of a coronary artery and its branches.

While inflating the balloon of a pulmonary artery catheter (PAC) with 1.0 mL of air to obtain a pulmonary artery occlusion pressure (PAOP), the nurse encounters resistance. What is the best nursing action? a. Add an additional 0.5 mL of air to the balloon and repeat the procedure. b. Advance the catheter with the balloon deflated and repeat the procedure. c. Deflate the balloon and obtain a chest x-ray study to determine line placement. d. Lock the balloon in the inflated position and flush the distal port of the PAC with normal saline.

c. Deflate the balloon and obtain a chest x-ray study to determine line placement.

2. The nurse is assessing a patient with left-sided heart failure. Which symptom would the nurse expect to find? a. Dependent edema b. Distended neck veins c. Dyspnea and crackles d. Nausea and vomiting

c. Dyspnea and crackles Rationale: In left-sided heart failure, signs and symptoms are related to pulmonary congestion. Dependent edema and distended neck veins are related to right-sided heart failure.

7. A patient with coronary artery disease is having a cardiac evaluation to assess for possible valvular disease. Which study best identifies valvular function and measures the size of the cardiac chambers? a. 12-lead electrocardiogram b. Cardiac catheterization c. Echocardiogram d. Electrophysiology study

c. Echocardiogram Rationale: Echocardiography is a noninvasive, acoustic imaging procedure and involves the use of ultrasound to visualize the cardiac structures and the motion and function of cardiac valves and chambers.

The nurse is caring for a mechanically ventilated patient with a pulmonary artery catheter who is receiving continuous enteral tube feedings. When obtaining continuous hemodynamic monitoring measurements, what is the best nursing action? a. Do not document hemodynamic values until the patient can be placed in the supine position. b. Level and zero reference the air-fluid interface of the transducer with the patient in the supine position and record hemodynamic values. c. Level and zero reference the air-fluid interface of the transducer with the patient's head of bed elevated to 30 degrees and record hemodynamic values. d. Level and zero reference the air-fluid interface of the transducer with the patient supine in the side-lying position and record hemodynamic values.

c. Level and zero reference the air-fluid interface of the transducer with the patient's head of bed elevated to 30 degrees and record hemodynamic values.

3. A patient is admitted with an acute myocardial infarction (AMI). The nurse knows that an angiotensin-converting enzymes (ACE) inhibitor should be started within 24 hours to reduce the incidence of which process? a. Myocardial stunning b. Hibernating myocardium c. Myocardial remodeling d. Tachycardia

c. Myocardial remodeling Rationale: Myocardial remodeling is a process mediated by angiotensin II, aldosterone, catecholamine, adenosine, and inflammatory cytokines, which causes myocyte hypertrophy and loss of contractile function in the areas of the heart distant from the site of infarctions. ACE inhibitors reduce the incidence of remodeling.

6. A patient is admitted with an angina attack. The nurse anticipates which drug regimen to be initiated? a. ACE inhibitors and diuretics b. Morphine sulfate and oxygen c. Nitroglycerin, oxygen, and beta-blockers d. Statins, bile acid, and nicotinic acid

c. Nitroglycerin, oxygen, and beta-blockers Rationale: Conservative intervention for the patient experiencing angina includes nitrates, beta-blockers, and oxygen.

MULTIPLE RESPONSE 4. Acute myocardial infarction (AMI) can be classified as which of the following? (Select all that apply.) a. Angina b. Nonischemic c. Non-Q wave d. Q wave

c. Non-Q wave d. Q wave RATIONALE: AMI can be classified as Q wave or non-Q wave.

A patient presents to the emergency department in acute respiratory failure secondary to community-acquired pneumonia. The patient has a history of chronic obstructive pulmonary disease. The nurse anticipates which treatment to facilitate ventilation? a. Emergency tracheostomy and mechanical ventilation b. Mechanical ventilation via an endotracheal tube c. Noninvasive positive-pressure ventilation (NPPV) d. Oxygen at 100% via bag-valve-mask device

c. Noninvasive positive-pressure ventilation (NPPV)

5. A patient is admitted with the diagnosis of unstable angina. The nurse knows that the physiological mechanism present is most likely which of the following? a. Complete occlusion of a coronary artery b. Fatty streak within the intima of a coronary artery c. Partial occlusion of a coronary artery with a thrombus d. Vasospasm of a coronary artery

c. Partial occlusion of a coronary artery with a thrombus Rationale: In unstable angina, some blood continues to flow through the affected coronary artery; however, flow is diminished related to partial occlusion. The pain in unstable angina is more severe, may occur at rest, and requires more frequent nitrate therapy.

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

c. Prepare to suction the oropharynx while maintaining cervical spine immobilization.

14. The patient is admitted with recurrent supraventricular tachycardia that the cardiologist believes to be related to an accessory conduction pathway or a reentry pathway. The nurse anticipates which procedure to be planned for this patient? a. Implantable cardioverter-defibrillator placement b. Permanent pacemaker insertion c. Radiofrequency catheter ablation d. Temporary transvenous pacemaker placement

c. Radiofrequency catheter ablation Rationale: Radiofrequency catheter ablation is a method of interrupting a supraventricular tachycardia, a dysrhythmia caused by a reentry circuit, and an abnormal conduction pathway.

The nurse working in a trauma center administers blood products to a severely hemorrhaging trauma patient in a 1:1:1 ratio. Which blood products does the nurse include in this transfusion protocol? (Select all that apply.) a. Whole blood b. Universal donor blood only c. Red blood cells d. Platelets e. Plasma

c. Red blood cells d. Platelets e. Plasma

Which of the following acid-base disturbances commonly occurs with the hyperventilation and impaired gas exchange seen in severe exacerbation of asthma? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

c. Respiratory acidosis

11. A 72-year-old woman is brought to the ED by her family. The family states that she's "just not herself." Her respirations are slightly labored, and her heart monitor shows sinus tachycardia (rate 110 beats/min) with frequent premature ventricular contractions (PVCs). She denies any chest pain, jaw pain, back discomfort, or nausea. Her troponin levels are elevated, and her 12-lead electrocardiogram (ECG) shows elevated ST segments in leads II, III, and AVF. The nurse knows that these symptoms are most likely associated with which diagnosis? a. Hypokalemia b. Non-Q wave MI c. Silent myocardial infarction d. Unstable angina

c. Silent myocardial infarction Rationale: Some individuals may have ischemic episodes without knowing it, thereby having a "silent" infarction. These can occur with no presenting signs or symptoms. Asymptomatic or nontraditional symptoms are more common in elderly persons, in women, and in diabetic patients.

Following insertion of a central venous catheter, the nurse obtains a stat chest x-ray film to verify proper catheter placement. The radiologist reports to the nurse: "The tip of the catheter is located in the superior vena cava." What is the best interpretation of these results by the nurse? a. The catheter is not positioned correctly and should be removed. b. The catheter position increases the risk of ventricular dysrhythmias. c. The distal tip of the catheter is in the appropriate position. d. The physician should be called to advance the catheter into the pulmonary artery.

c. The distal tip of the catheter is in the appropriate position.

The patient is asymptomatic but is diagnosed with second-degree heart block Mobitz I. The patient is on digitalis medication at home. The nurse should expect that: a. the patient has had an anterior wall myocardial infarction. b. the physician will order the digitalis to be continued in the hospital. c. a digitalis level would be ordered upon admission. d. the patient will require a transcutaneous pacemaker.

c. a digitalis level would be ordered upon admission.

The patient is admitted with sinus pauses causing periods of loss of consciousness. The patient is asymptomatic, awake and alert, but fatigued. He answers questions appropriately. When admitting this patient, the nurse should first: a. prepare the patient for temporary pacemaker insertion. b. prepare the patient for permanent pacemaker insertion. c. assess the patient's medication profile. d. apply transcutaneous pacemaker paddles.

c. assess the patient's medication profile.

Intrapulmonary shunting refers to: a. alveoli that are not perfused. b. blood that is shunted from the left side of the heart to the right and causes heart failure. c. blood that is shunted from the right side of the heart to the left without oxygenation. d. shunting of blood supply to only one lung.

c. blood that is shunted from the right side of the heart to the left without oxygenation.

15. The patient presents to the ED with sudden severe sharp chest discomfort radiating to his back and down both arms, as well as numbness in his left arm. While taking the patient's vital signs, the nurse notices a 30-point discrepancy in systolic blood pressure between the right and left arm. Based on these findings, the nurse should: a. contact the physician and report the cardiac enzyme results. b. contact the physician and prepare the patient for thrombolytic therapy. c. contact the physician immediately and begin prepping the patient for surgery. d. give the patient aspirin and heparin.

c. contact the physician immediately and begin prepping the patient for surgery. Rationale: These symptoms indicate the possibility of acute aortic dissection. Symptoms often mimic those of AMI or pulmonary embolism. Aortic dissection is a surgical emergency. Signs and symptoms include chest pain and arm paresthesia.

The basic underlying pathophysiology of acute respiratory distress syndrome results from: a. a decrease in the number of white blood cells available. b. damage to the right mainstem bronchus. c. damage to the type II pneumocytes, which produce surfactant. d. decreased capillary permeability.

c. damage to the type II pneumocytes, which produce surfactant.

A near-infrared spectroscopy (NIRS) probe is placed in a trauma patient during the resuscitation phase to: a. assess severity of metabolic acidosis. b. determine intraperitoneal bleeding. c. determine tissue oxygenation. d. prevent complications of over-resuscitation.

c. determine tissue oxygenation.

The patient has a permanent pacemaker in place with a demand rate set at 60 beats/min. The cardiac monitor is showing a heart rate of 44 beats/min with no pacemaker spikes. The nurse realizes this as: a. normal pacemaker function. b. failure to capture. c. failure to pace. d. failure to sense.

c. failure to pace.

In the trauma patient, symptoms of decreased cardiac output are most commonly caused by a. cardiac contusion. b. cardiogenic shock. c. hypovolemia. d. pericardial tamponade.

c. hypovolemia.

The QT interval is the total time taken for ventricular depolarization and repolarization. Prolongation of the QT interval: a. decreases the risk of lethal dysrhythmias. b. usually occurs when heart rate increases. c. increases the risk of lethal dysrhythmias. d. can only be measured with irregular rhythms.

c. increases the risk of lethal dysrhythmias.

A strategy for preventing thromboembolism in patients at risk who cannot take anticoagulants is: a. administration of two aspirin tablets every 4 hours. b. infusion of thrombolytics. c. insertion of a vena cava filter. d. subcutaneous heparin administration every 12 hours.

c. insertion of a vena cava filter.

A 24-year-old unrestrained driver who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. The primary survey of this patient upon arrival to the ED a. includes a cervical spine x-ray study to determine the presence of a fracture. b. involves turning the patient from side to side to get a look at his back. c. is done quickly in the first few minutes to get a baseline assessment and establish priorities. d. is a methodical head-to-toe assessment identifying injuries and treatment priorities.

c. is done quickly in the first few minutes to get a baseline assessment and establish priorities.

The nurse notices that the patient has a first-degree AV block. Everything else about the rhythm is normal. The nurse should: a. prepare to place the patient on a transcutaneous pacemaker. b. give the patient atropine to shorten the PR interval. c. monitor the rhythm and patient's condition. d. give the patient an antiarrhythmic medication.

c. monitor the rhythm and patient's condition.

The nurse is caring for a patient with acute respiratory distress syndrome who is hypoxemic despite mechanical ventilation. The physician orders a nontraditional ventilator mode as part of treatment. Despite sedation and analgesia, the patient remains restless and appears to be in discomfort. The nurse informs the physician of this assessment and anticipates an order for: a. continuous lateral rotation therapy. b. guided imagery. c. neuromuscular blockade. d. prone positioning.

c. neuromuscular blockade.

The nurse understands that in a third-degree AV block: a. every P wave is conducted to the ventricles. b. some P waves are conducted to the ventricles. c. none of the P waves are conducted to the ventricles. d. the PR interval is prolonged.

c. none of the P waves are conducted to the ventricles.

A definitive diagnosis of pulmonary embolism can be made by: a. arterial blood gas (ABG) analysis. b. chest x-ray examination. c. pulmonary angiogram. d. ventilation-perfusion scanning.

c. pulmonary angiogram.

The charge nurse has a Vigileo pulse contour cardiac output monitoring system available for use in the surgical intensive care unit. For which patient is use of this device most appropriate? a. A patient with a history of aortic insufficiency admitted with a postoperative myocardial infarction b. A mechanically ventilated patient with cardiogenic shock being treated with an intraaortic balloon pump c. A patient with a history of atrial fibrillation having frequent episodes of paroxysmal supraventricular tachycardia d. A mechanically ventilated patient admitted following repair of an acute bowel obstruction

d. A mechanically ventilated patient admitted following repair of an acute bowel obstruction

The nurse is caring for a patient with a pulmonary artery catheter. Assessment findings include a blood pressure of 85/40 mm Hg, heart rate of 125 beats/min, respiratory rate 35 breaths/min, and arterial oxygen saturation (SpO2) of 90% on a 50% venturi mask. Hemodynamic values include a cardiac output (CO) of 1.0 L/min, central venous pressure (CVP) of 1 mm Hg, and a pulmonary artery occlusion pressure (PAOP) of 3 mm Hg. The nurse questions which of the following physician's order? a. Titrate supplemental oxygen to achieve a SpO2 > 94%. b. Infuse 500 mL 0.9% normal saline over 1 hour. c. Obtain arterial blood gas and serum electrolytes. d. Administer furosemide (Lasix) 20 mg intravenously.

d. Administer furosemide (Lasix) 20 mg intravenously.

The nurse is caring for a patient with an admitting diagnosis of congestive failure. While attempting to obtain a pulmonary artery occlusion pressure in the supine position, the patient becomes anxious and tachypneic. What is the best action by the nurse? a. Limit the patient's supine position to no more than 10 seconds. b. Administer anxiety medications while recording the pressure. c. Encourage the patient to take slow deep breaths while supine. d. Elevate the head of the bed 45 degrees while recording pressures.

d. Elevate the head of the bed 45 degrees while recording pressures.

The nurse is caring for a patient with a left radial arterial line, and a pulmonary artery catheter inserted into the right subclavian vein. Which action by the nurse best ensures the safety of the patient being monitored with invasive hemodynamic monitoring lines? a. Document all waveform values. b. Limit the pressure tubing length. c. Zero reference the system daily. d. Ensure alarm limits are turned on.

d. Ensure alarm limits are turned on.

During insertion of a pulmonary artery catheter, the physician asks the nurse to assist by inflating the balloon with 1.5 mL of air. As the physician advances the catheter, the nurse notices premature ventricular contractions on the monitor. What is the best action by the nurse? a. Deflate the balloon while slowly withdrawing the catheter. b. Instruct the patient to cough and deep-breathe forcefully. c. Inflate the catheter balloon with an additional 1 mL of air. d. Ensure lidocaine hydrochloride (IV) is immediately available.

d. Ensure lidocaine hydrochloride (IV) is immediately available.

23. Percutaneous coronary intervention is contraindicated for patients with lesions in which coronary artery? a. Right coronary artery b. Left coronary artery c. Circumflex d. Left main coronary artery

d. Left main coronary artery RATIONALE: Stenosis of the left mainstem artery is considered unacceptable for percutaneous intervention.

The nurse is concerned that a patient is at increased risk of developing a pulmonary embolus and develops a plan of care for prevention to include which of the following? a. Antiseptic oral care b. Bed rest with head of bed elevated c. Coughing and deep breathing d. Mobility

d. Mobility

The nurse is preparing to obtain a pulmonary artery occlusion pressure (PAOP) reading for a patient who is mechanically ventilated. Ensuring that the air-fluid interface is at the level of the phlebostatic axis, what is the best nursing action? a. Place the patient in the supine position and record the PAOP immediately after exhalation. b. Place the patient in the supine position and document the average PAOP obtained after three measurements. c. Place the patient with the head of bed elevated 30 degrees and document the average PAOP pressure obtained. d. Place the patient with the head of bed elevated 30 degrees and record the PAOP just before the increase in pressures during inhalation.

d. Place the patient with the head of bed elevated 30 degrees and record the PAOP just before the increase in pressures during inhalation.

The nurse is caring for a patient with acute respiratory failure and identifies "Risk for Ineffective Airway Clearance" as a nursing diagnosis. A nursing intervention relevant to this diagnosis is: a. Elevate head of bed to 30 degrees. b. Obtain order for venous thromboembolism prophylaxis. c. Provide adequate sedation. d. Reposition patient every 2 hours.

d. Reposition patient every 2 hours.

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

d. Serum lactate levels

Patients with musculoskeletal injury are at increased risk for compartment syndrome. What is an initial symptom of a suspected compartment syndrome? a. Absence of pulse in affected extremity b. Pallor in the affected area c. Paresthesia in the affected area d. Severe, throbbing pain in the affected area

d. Severe, throbbing pain in the affected area

Which of the following interventions is a strategy to prevent fat embolism syndrome? a. Administer lipid-lowering statin medications. b. Intubate the patient early after the injury to provide mechanical ventilation. c. Provide prophylaxis with low-molecular weight heparin. d. Stabilize extremity fractures early.

d. Stabilize extremity fractures early.

A patient has been admitted to the emergency department with a massive hemothorax. What action by the nurse takes priority? a. Place the patient on a cardiac monitor b. Prepare for rapid intubation c. Seal the wound with occlusive dressings d. Start 2 large bore IVs

d. Start 2 large bore IVs

8. A patient has elevated blood lipids. The nurse anticipates which classification of drugs to be prescribed for the patient? a. Bile acid resins b. Nicotinic acid c. Nitroglycerin d. Statins

d. Statins Rationale: The statins have been found to lower low-density lipoproteins (LDLs) more than other types of lipid-lowering drugs

Which of the following treatments may be used to dissolve a thrombus that is lodged in the pulmonary artery? a. Aspirin b. Embolectomy c. Heparin d. Thrombolytics

d. Thrombolytics

While caring for a patient with a pulmonary artery catheter, the nurse notes the pulmonary artery occlusion pressure (PAOP) to be significantly higher than previously recorded values. The nurse assesses respirations to be unlabored at 16 breaths/min, oxygen saturation of 98% on 3 L of oxygen via nasal cannula, and lungs clear to auscultation bilaterally. What is the priority nursing action? a. Increase supplemental oxygen and notify respiratory therapy. b. Notify the physician immediately of the assessment findings. c. Obtain a stat chest x-ray film to verify proper catheter placement. d. Zero reference and level the catheter at the phlebostatic axis.

d. Zero reference and level the catheter at the phlebostatic axis.

The nurse is working on the night shift when she notices sinus bradycardia on the patient's cardiac monitor. The nurse should: a. give atropine to increase heart rate. b. begin transcutaneous pacing of the patient. c. start a dopamine infusion to stimulate heart function. d. assess for hemodynamic instability.

d. assess for hemodynamic instability.

The nurse is talking with the patient when the monitor alarms and shows a wavy baseline without a PQRST complex. The nurse should: a. defibrillate the patient immediately. b. initiate basic life support. c. initiate advanced life support. d. assess the patient and the electrical leads.

d. assess the patient and the electrical leads.

The patient's heart rate is 165 beats per minute. His cardiac monitor shows a rapid rate with narrow QRS complexes. The P waves cannot be seen, but the rhythm is regular. The patient's blood pressure has dropped from 124/62 to 78/30. His skin is cold and diaphoretic and he is complaining of nausea. The nurse prepares the patient for: a. administration of beta-blockers. b. administration of atropine. c. transcutaneous pacemaker insertion. d. emergent cardioversion.

d. emergent cardioversion.

The nurse is caring for a patient who sustained rib fractures after hitting the steering wheel of the car during a motor vehicle crash. The patient is spontaneously breathing and receiving oxygen via a face mask; the oxygen saturation is 95%. During the nurse's assessment, the oxygen saturation drops to 80%. The patient's blood pressure has dropped from 128/76 mm Hg to 84/60 mm Hg. The nurse assesses that breath sounds are absent throughout the left lung fields. The nurse notifies the provider and anticipates a. administration of lactated Ringer's solution (1 L) wide open. b. chest x-ray study to determine the etiology of the symptoms. c. endotracheal intubation and mechanical ventilation. d. needle thoracostomy and chest tube insertion.

d. needle thoracostomy and chest tube insertion.

A PaCO2 of 48 mm Hg is associated with:

hypoventilation.

A 65-year-old patient is admitted to the progressive care unit with a diagnosis of community-acquired pneumonia. The patient has a history of chronic obstructive pulmonary disease and diabetes. A set of arterial blood gases obtained on admission without supplemental oxygen shows pH 7.35; PaCO2 55 mm Hg; bicarbonate 30 mEq/L; PaO2 65 mm Hg. These blood gases reflect:

hypoxemia and compensated respiratory acidosis.

A patients status worsens and needs mechanical ventilation. The pulmonologist wants the patient to receive 10 breaths/min from the ventilator but wants to encourage the patient to breathe spontaneously in between the mechanical breaths at his own tidal volume. This mode of ventilation is called:

intermittent mandatory ventilation

The nurse is caring for a patient with an endotracheal tube. The nurse understands that endotracheal suctioning is needed to facilitate removal of secretions and that the procedure:

is done as indicated by patient assessment.

The nurse is caring for a patient whose ventilator settings include 15 cm H2O of positive end-expiratory pressure (PEEP). The nurse understands that although beneficial, PEEP may result in:

low cardiac output secondary to increased intrathoracic pressure

The nurse is caring for a mechanically ventilated patient and notes the high pressure alarm sounding. The nurse cannot quickly identify the cause of the alarm and notes the patients oxygen saturation is decreasing and heart rate and respiratory rate are increasing. The nurses priority action is to:

manually ventilate the patient while calling for a respiratory therapist.

Oxygen saturation (SaO2) represents:

oxygen that is chemically combined with hemoglobin.

Neuromuscular blocking agents are used in the management of some ventilated patients. Their primary mode of action is:

paralysis.

A mode of pressure-targeted ventilation that provides positive pressure to decrease the workload of spontaneous breathing through the endotracheal tube is:

pressure support ventilation.

A patient presents to the emergency department demonstrating agitation and complaining of numbness and tingling in his fingers. His arterial blood gas levels reveal the following: pH 7.51, PaCO2 25, HCO3 25. The nurse interprets these blood gas values as:

uncompensated respiratory alkalosis.

Jugular Oxygen Saturation

60 - 70 % Values < 50% indicate ischemia

Goal MAP:

70 - 90 mmHg

Normal ICP

0 - 15 mmHg

Furosemide

reduces cerebral edema by drawing water and sodium out of brain interstitium to treat cerebral edema. S/E: ototoxicity, polyuria, gastric irritation, muscle cramps, hypotension, dehydration, embolism, vascular thrombosis

1. Numbers of white blood cells (WBCs) are increased in circumstances of: (Select all that apply.) a. inflammation. b. allergy. c. invasion by pathogenic organisms. d. malnutrition. e. immune diseases.

A, B, C

10. Accepted treatments for disseminated intravascular coagulation (DIC) may require: (Select all that apply.) a. platelet infusions. b. administration of fresh frozen plasma. c. cryoprecipitate. d. packed RBCs. e. heparin.

A, B, C, D

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

ANS: A Droplet precautions are maintained for a patient with bacterial meningitis until 24 hours after the initiation of antibiotic therapy to reduce the potential for spread of the infection. Washing hands and scrubbing the hub of injection ports are practices that help reduce the risk of infection, but added precautions are necessary for preventing the spread of bacterial meningitis. Disposing all bloody dressings in biohazard bags is a standard universal precaution and is not specific to bacterial meningitis. DIF: Cognitive Level: Comprehension REF: p. 388 OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease. TOP: Nursing Process Step: Planning MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control

A nurse administers topical gentamicin sulfate (Garamycin) to a client's burn injury. Which laboratory value should the nurse monitor while the client is prescribed this therapy? a.Creatinine b.Red blood cells c.Sodium d.Magnesium

ANS: A Gentamicin is nephrotoxic, and sufficient amounts can be absorbed through burn wounds to affect kidney function. Any client receiving gentamicin by any route should have kidney function monitored. Topical gentamicin will not affect the red blood cell count or the sodium or magnesium levels.

A nurse cares for a client with burn injuries from a house fire. The client is not consistently oriented and reports a headache. Which action should the nurse take? a.Increase the client's oxygen and obtain blood gases. b.Draw blood for a carboxyhemoglobin level. c.Increase the client's intravenous fluid rate. d.Perform a thorough Mini-Mental State Examination.

ANS: B These manifestations are consistent with moderated carbon monoxide poisoning. This client is at risk for carbon monoxide poisoning because he or she was in a fire in an enclosed space. The other options will not provide information related to carbon monoxide poisoning.

A nurse uses the rule of nines to assess a client with burn injuries to the entire back region and left arm. How should the nurse document the percentage of the client's body that sustained burns? a.9% b.18% c.27% d.36%

ANS: C According to the rule of nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the client received burns to the back (18%) and one arm (9%), totaling 27% of the body.

The nurse teaches burn prevention to a community group. Which statement by a member of the group should cause the nurse the greatest concern? a."I get my chimney swept every other year." b."My hot water heater is set at 120 degrees." c."Sometimes I wake up at night and smoke." d."I use a space heater when it gets below zero."

ANS: C House fires are a common occurrence and often lead to serious injury or death. The nurse should be most concerned about a person who wakes up at night and smokes. The nurse needs to question this person about whether he or she gets out of bed to do so, or if this person stays in bed, which could lead to falling back asleep with a lighted cigarette. Although it is recommended to have chimneys swept every year, skipping a year does not pose as much danger as smoking in bed, particularly if the person does not burn wood frequently. Water heaters should be set below 140° F. Space heaters should be used with caution, and the nurse may want to ensure that the person does not allow it to get near clothing or bedding.

A nurse teaches a client being treated for a full-thickness burn. Which statement should the nurse include in this client's discharge teaching? a."You should change the batteries in your smoke detector once a year." b."Join a program that assists burn clients to reintegration into the community." c."I will demonstrate how to change your wound dressing for you and your family." d."Let me tell you about the many options available to you for reconstructive surgery."

ANS: C Teaching clients and family members to perform care tasks such as dressing changes is critical for the progressive goal toward independence for the client. All of the other options are important in the rehabilitation stage. However, dressing changes have priority.

A nurse reviews the following data in the chart of a client with burn injuries: 36-year-old female with bilateral leg burns NKDA Health history of asthma and seasonal allergies Bilateral leg burns present with a white and leather-like appearance. No blisters or bleeding present. Client rates pain 2/10 on a scale of 0-10. Based on the data provided, how should the nurse categorize this client's injuries? a.Partial-thickness deep b.Partial-thickness superficial c.Full thickness d.Superficial

ANS: C The characteristics of the client's wounds meet the criteria for a full-thickness injury: color that is black, brown, yellow, white, or red; no blisters; minimal pain; and firm and inelastic outer layer. Partial-thickness superficial burns appear pink to red and are painful. Partial-thickness deep burns are deep red to white and painful. Superficial burns are pink to red and are also painful.

A nurse cares for a client who has burn injuries. The client's wife asks, "When will his high risk for infection decrease?" How should the nurse respond? a."When the antibiotic therapy is complete." b."As soon as his albumin levels return to normal." c."Once we complete the fluid resuscitation process." d."When all of his burn wounds have closed."

ANS: D Intact skin is a major barrier to infection and other disruptions in homeostasis. No matter how much time has passed since the burn injury, the client remains at high risk for infection as long as any area of skin is open. Although the other options are important goals in the client's recovery process, they are not as important as skin closure to decrease the client's risk for infection.

A nurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. Which action should the nurse take next? a.Administer furosemide (Lasix). b.Perform chest physiotherapy. c.Document and reassess in an hour. d.Place the client in an upright position.

ANS: D Pulmonary edema can result from fluid resuscitation given for burn treatment. This can occur even in a young healthy person. Placing the client in an upright position can relieve lung congestion immediately before other measures can be carried out. Although Lasix may be used to treat pulmonary edema in clients who are fluid overloaded, a client with a burn injury will lose a significant amount of fluid through the broken skin; therefore, Lasix would not be appropriate. Chest physiotherapy will not get rid of fluid.

Fifteen minutes after beginning a transfusion of O negative blood to a patient in shock, the nurse assesses a drop in the patient's blood pressure to 60/40 mm Hg, heart rate 135 beats/min, respirations 40 breaths/min, and a temperature of 102° F. The nurse notes the new onset of hematuria in the patient's Foley catheter. What are the priority nursing actions? (Select all that apply.) A. Administer acetaminophen. B. Document the patient's response. C. Increase the rate of transfusion. D. Notify the blood bank. E. Notify the provider. F. Stop the transfusion.

D, E, F

Cerebral Glucose <20 mg/dL

Damage

A patients ventilator settings are adjusted to treat hypoxemia. The fraction of inspired oxygen is increased from .60 to .70, and the positive end-expiratory pressure is increased from 10 to 15 cm H2O. Shortly after these adjustments, the nurse notes that the patients blood pressure drops from 120/76 mm Hg to 90/60 mm Hg. What is the most likely cause of this decrease in blood pressure?

Decrease in cardiac output

Monro-Kellie doctrine

Increase in any one component requires a reduction in one or both of other components to sustain normal ICP

Partial Pressure of Brain Tissue Oxygen (PbtO2)

Goal is > 20 mmHg

Under normal circumstances the cerebral vasculature exhibits pressure and chemical autoregulation. What happens when autoregulation is lost?

Hypertension increases cerebral blood flow. (Autoregulation is the ability of the cerebral vessels to adjust their diameter in response to arterial pressure changes within the brain. If mean arterial blood pressure rises, cerebral vessels will constrict to prevent excessive distention of the cerebral arteries. When autoregulation is lost, cerebral vessels are no longer able to regulate diameter and as a result hypertension increases cerebral perfusion pressure.)

Cushing's Triad

Indication of ICP; includes HTN, bradycardia, and widening pulse pressure

Basal Ganglia

Motor control of fine body movements

A 53-year-old, 80-kg patient is admitted to the cardiac surgical intensive care unit after cardiac surgery with the following arterial blood gas (ABG) levels. What is the nurses interpretation of these values? pH 7.4 PaCO2 40 mm Hg Bicarbonate 24 mEq/L PaO2 95 mm Hg O2 saturation 97% Respirations 20 breaths per minute

Normal ABG values

The patient is admitted with a condition that requires cardiac rhythm monitoring. To apply the monitoring electrodes, the nurse must first: a. apply a moist gel to the chest. b. make certain that the electrode gel is dry. c. avoid soaps to avoid skin irritation. d. clip chest hair if needed.

d. clip chest hair if needed.

The nurse is caring for a mechanically ventilated patient. The physicians are considering performing a tracheostomy because the patient is having difficulty weaning from mechanical ventilation. Related to tracheostomy, the nurse understands which of the following?

The greatest risk after a percutaneous tracheostomy is accidental decannulation.

Intraparenchymal hemorrhage is usually caused by

Uncontrolled hypertension

Sympathetic nervous system originates in

Thoracic and lumbar regions

The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which assessment finding 2 hours after insertion by the nurse warrants immediate action? a. Diminished breath sounds over left lung field b. Localized pain at catheter insertion site c. Measured central venous pressure of 5 mm Hg d. Slight bloody drainage around insertion site

a. Diminished breath sounds over left lung field

29. The nurse is providing care to a patient on fibrinolytic therapy. Which statement from the patient warrants further assessment and intervention by the critical care nurse? a. "My back is killing me!" b. "There is blood on my toothbrush!" c. "Look at the bruises on my arms!" d. "My arm is bleeding where my IV is!"

a. "My back is killing me!" RATIONALE: The nurse must continually monitor for clinical manifestations of bleeding. Mild gingival bleeding and oozing around venipuncture sites are common and not a cause for concern. Severe lower back pain and ecchymoses are suggestive of retroperitoneal bleeding. If serious bleeding occurs, all fibrinolytic heparin therapies must be discontinued, and volume expanders or coagulation factors, or both, are administered.

The nurse is caring for a postoperative patient with chronic obstructive pulmonary disease (COPD). Which assessment would be a cue to the patient developing postoperative pneumonia? a. Bradycardia b. Change in sputum characteristics c. Hypoventilation and respiratory acidosis d. Pursed-lip breathing

b. Change in sputum characteristics

The patient is admitted with a fever and rapid heart rate. The patient's temperature is 103° F (39.4° C).The nurse places the patient on a cardiac monitor and finds the patient's atrial and ventricular rates are above 105 beats per minute. P waves are clearly seen and appear normal in configuration. QRS complexes are normal in appearance and 0.08 seconds wide. The rhythm is regular, and blood pressure is normal. The nurse should focus on providing: a. medications to lower heart rate. b. treatment to lower temperature. c. treatment to lower cardiac output. d. treatment to reduce heart rate.

b. treatment to lower temperature.

Range-of-motion exercises, early ambulation, and adequate hydration are interventions to prevent a. catheter-associated infection. b. venous thromboembolism. c. fat embolism. d. nosocomial pneumonia.

b. venous thromboembolism.

The patient is scheduled to have a permanent pacemaker implanted. The patient asks the nurse, "How long will the battery in this thing last?" The nurse should answer, a. "Life expectancy is about 1 year. Then it will need to be replaced." b. "Pacemaker batteries can last up to 25 years with constant use." c. "Battery life varies depending on usage, but it can last up to 10 years." d. "Pacemakers are used to treat temporary problems so the batteries don't last long."

c. "Battery life varies depending on usage, but it can last up to 10 years."

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

c. 100 mL/hr.

When assessing the 12-lead electrocardiogram (ECG) or a rhythm strip, it is helpful to understand that the electrical activity is viewed in relation to the positive electrode of that particular lead. When an electrical signal is aimed directly at the positive electrode, the inflection will be: a. negative. b. upside down. c. upright. d. equally positive and negative.

c. upright.

Nicardipine

calcium channel blocker, vasodilator, lowers bp. s/e: headache, confusion, hypotension, nausea, vomiting, tachycardia, ECG changes, ST segment depression.

The nurse is caring for a patient who is mechanically ventilated. As part of the nursing care, the nurse understands that:

communication with intubated patients is often difficult.

The nurse is assessing the exhaled tidal volume (EVT) in a mechanically ventilated patient. The rationale for this assessment is to:

compare the tidal volume delivered with the tidal volume prescribed.

When ICP remains at 20 mmHg for 5 minutes or longer, it can cause

herniation

Pulse oximetry measures:

oxygen saturation.

One of the early signs of the effect of hypoxemia on the nervous system is:

restlessness.

Current guidelines recommend the oral route for endotracheal intubation. The rationale for this recommendation is that nasotracheal intubation is associated with a greater risk for:

sinusitis and infection.

Dexamethasone

stroid that has a stabilizing effect on cell membrane, and decreases inflammation by suppressing white blood cells. dose: 10-20 mg IV loading dose over 1 minute for cerebral edema S/E: flushing, sweating, hypertension, tachycardia, thrombocytopenia, weakness, diarrhea, nausea, GI irritation, poor wound healing, hyperglycemia, muscle wasting, hypokalemia

An emergency room nurse cares for a client admitted with a 50% burn injury at 10:00 this morning. The client weighs 90 kg. Using the Parkland formula, calculate the rate at which the nurse should infuse intravenous fluid resuscitation when started at noon. (Record your answer using a whole number.) _____ mL/hr

1500 mL/hr The Parkland formula is 4 mL/kg/% total body surface area burn. This client needs 18,000 mL of fluid during the first 24 hours postburn. Half of the calculated fluid replacement needs to be administered during the first 8 hours after injury, and half during the next 16 hours. This client was burned at 10:00 AM, and fluid was not started until noon. Therefore, 9000 mL must be infused over the next 6 hours at a rate of 1500 mL/hr to meet the criteria of receiving half the calculated dose during the first 8 postburn hours.

Increased CO2 causes

Vasodilation and increased ICP

A patients endotracheal tube is not secured tightly. The respiratory care practitioner assists the nurse in taping the tube. After the tube is retaped, the nurse auscultates the patients lungs and notes that the breath sounds over the left lung fields are absent. The nurse suspects that:

the endotracheal tube is in the right mainstem bronchus.

The amount of effort needed to maintain a given level of ventilation is termed:

work of breathing.

14. The ratio of helper T4 cell to suppressor T cells is normally 2:1. A lower than normal ratio may indicate acquired immunodeficiency syndrome (AIDS). This is because T4 cells: a. enhance humoral immune response. b. suppress the humoral response. c. suppress the cell-mediated response. d. are a feature of an autoimmune disease.

A

An emergency room nurse implements fluid replacement for a client with severe burn injuries. The provider prescribes a liter of 0.9% normal saline to infuse over 1 hour and 30 minutes via gravity tubing with a drip factor of 30 drops/mL. At what rate should the nurse administer the infusion? (Record your answer using a whole number and rounding to the nearest drop.) ____ drops/min

333 drops/min 1000 mL divided by 90 minutes, then multiplied by 30 drops, equals 333 drops/min.

Normal CPP

60 - 100

24. The patient is admitted with complaints of chronic fatigue and shortness of breath. The nurse notices that the patient is tachycardic and has multiple bruises and petechiae on his body and arms. The patient also complains of frequent nosebleeds. The nurse should evaluate the patients ____________ a. complete blood count, including platelet count b. hemoglobin and hematocrit c. electrolyte values. d. blood culture results

A

Pain control is a nursing priority in patients with acute pancreatitis because pain: a. increases pancreatic secretions. b. is caused by decreased distention of the pancreatic capsule. c. decreases the patient's metabolism. d. is caused by dilation of the biliary system.

A Pain control is a nursing priority in patients with acute pancreatitis not only because the disorder produces extreme patient discomfort but also because pain increases the patient's metabolism and thus increases pancreatic secretions. The pain of pancreatitis is caused by edema and distention of the pancreatic capsule, obstruction of the biliary system, and peritoneal inflammation from pancreatic enzymes. Pain is often severe and unrelenting and is related to the degree of pancreatic inflammation.

6. When dealing with hematological malignancies, therapies that have significant management roles include: (Select all that apply.) a. chemotherapy. b. biotherapy. c. bone marrow transplantation. d. surgery. e. radiation.

A, B, C, E

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

ANS: C The ICP is above the normal level of 15 mm Hg. The CPP is within the normal range. All other listed responses are incorrect. DIF: Cognitive Level: Comprehension REF: p. 361 OBJ: Complete an assessment on a critically ill patient with nervous system injury. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

The nurse assesses a client who has a severe burn injury. Which statement indicates the client understands the psychosocial impact of a severe burn injury? a."It is normal to feel some depression." b."I will go back to work immediately." c."I will not feel anger about my situation." d."Once I get home, things will be normal."

ANS: A During the recovery period, and for some time after discharge from the hospital, clients with severe burn injuries are likely to have psychological problems that require intervention. Depression is one of these problems. Grief, loss, anxiety, anger, fear, and guilt are all normal feelings that can occur. Clients need to know that problems of physical care and psychological stresses may be overwhelming.

A nurse delegates hydrotherapy to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this activity? a."Keep the water temperature constant when showering the client." b."Assess the wound beds during the hydrotherapy treatment." c."Apply a topical enzyme agent after bathing the client." d."Use sterile saline to irrigate and clean the client's wounds."

ANS: A Hydrotherapy is performed by showering the client on a special shower table. The UAP should keep the water temperature constant. This process allows the nurse to assess the wound beds, but a UAP cannot complete this act. Topical enzyme agents are not part of hydrotherapy. The irrigation does not need to be done with sterile saline.

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

ANS: A A patient with a C5 complete spinal injury is at risk for ineffective breathing patterns and should be assessed immediately for any airway compromise. A GCS score of 15 indicates a neurologically intact patient. The patient with a subdural bleed is alert and not in danger of any immediate compromise. The goal for ischemic stroke is to keep the systolic BP less than 220 mm Hg and the diastolic blood pressure less than 120 mm Hg. DIF: Cognitive Level: Analysis REF: pp. 393-394 OBJ: Describe nursing and medical management of patients with a spinal cord injury. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

7. When examining the patients laboratory values, the nurse notices an elevation in the eosinophil count. The nurse realizes that eosinophils become elevated: a. with acute bacterial infections. b. in response to allergens and parasites. c. when the spleen is removed. d. in situations that do not require phagocytosis.

B

22. Daily weights are being recorded for the patient. His urine output has been less than his intravenous and oral intake. His weight yesterday was 97.5 kg. This morning it is 99 kg. The nurse understands that this corresponds to a(n): a. fluid retention of 1.5 liters. b. fluid loss of 1.5 liters. c. equal intake and output due to insensible losses. d. fluid loss of 0.5 liters.

ANS: A A 1-kg gain in body weight is equal to a 1000-mL fluid gain. This patient has gained 1.5 kg, or 1.5 liters of fluid.

The most common cause of acute kidney injury in critically ill patients is: a. sepsis. b. fluid overload. c. medications. d. hemodynamic instability.

ANS: A The etiology of AKI in critically ill patients is often multifactorial and develops from a combination of hypovolemia, sepsis, medications, and hemodynamic instability. Sepsis is the most common cause of AKI.

9. Lymphocytes are made up of B cells and T cells. B cells: a. mature in lymphoid tissue. b. mediate humoral immunity. c. migrate to the thymus gland. d. destroy virus-infected cells.

B

A nurse receives new prescriptions for a client with severe burn injuries who is receiving fluid resuscitation per the Parkland formula. The client's urine output continues to range from 0.2 to 0.25 mL/kg/hr. Which prescription should the nurse question? a.Increase intravenous fluids by 100 mL/hr. b.Administer furosemide (Lasix) 40 mg IV push. c.Continue to monitor urine output hourly. d.Draw blood for serum electrolytes STAT.

ANS: B The plan of care for a client with a burn includes fluid and electrolyte resuscitation. Furosemide would be inappropriate to administer. Postburn fluid needs are calculated initially by using a standardized formula such as the Parkland formula. However, needs vary among clients, and the final fluid volume needed is adjusted to maintain hourly urine output at 0.5 mL/kg/hr. Based on this client's inadequate urine output, fluids need to be increased, urine output needs to be monitored hourly, and electrolytes should be evaluated to ensure appropriate fluids are being infused.

15. The patient has elevated blood urea nitrogen (BUN) and serum creatinine levels with a normal BUN/creatinine ratio. These levels most likely indicate: a. increased nitrogen intake. b. acute kidney injury, such as acute tubular necrosis (ATN). c. hypovolemia. d. fluid resuscitation.

ANS: B A normal BUN/creatinine ratio is present in ATN. In ATN, there is actual injury to the renal tubules and a rapid decline in the GFR; hence, BUN and creatinine levels both rise proportionally as a result of increased reabsorption and decreased clearance. Hypovolemia would result in prerenal condition, which usually increases the BUN/creatinine ratio.

21. The patient is a new postoperative patient. She weighs 75 kg. The nurse expects the minimal acceptable urine output to be: a. less than 30 mL/hour. b. 37 mL/hour. c. 80 mL/hour. d. 150 mL/hour.

ANS: B Normal urine output is 0.5 to 1 mL/kg of body weight each hour.

40. Peritoneal dialysis is different from hemodialysis in that peritoneal dialysis: a. is more frequently used for acute kidney injury. b. uses the patient's own semipermeable membrane (peritoneal membrane). c. is not useful in cases of drug overdose or electrolyte imbalance. d. is not indicated in cases of water intoxication.

ANS: B Peritoneal dialysis is the removal of solutes and fluid by diffusion through a patient's own semipermeable membrane (the peritoneal membrane) with a dialysate solution that has been instilled into the peritoneal cavity. This renal replacement therapy is not commonly used for the treatment of acute kidney injury because of its comparatively slow ability to alter biochemical imbalances. Clinical indications for peritoneal dialysis include acute and chronic kidney injury, severe water intoxication, electrolyte disorders, and drug overdose.

29. The patient has a temporary percutaneous catheter in place for treatment of acute kidney injury. The catheter has been in place for 5 days. The nurse should: a. prepare to assist with a routine dialysis catheter change to replace the existing catheter. b. evaluate the patient for signs and symptoms of infection. c. teach the patient that the catheter is designed for long-term use. d. use one of the three lumens for fluid administration.

ANS: B Routine replacement of hemodialysis catheters to prevent infection is not recommended. The decision to remove or replace the catheter is based on clinical need and/or signs and symptoms of infection. The typical catheter has a single or double lumen and is designed only for short-term renal replacement therapy during acute situations. The catheter is not used for fluid and medication administration.

After assessing an older adult client with a burn wound, the nurse documents the findings as follows: Heart rate: 110 beats/min Blood pressure: 112/68 mm Hg Respiratory rate: 20 breaths/min Oxygen saturation: 94% Pain: 3/10 Red blood cell count: 5,000,000/mm3 White blood cell count: 10,000/mm3 Platelet count: 200,000/mm3 Left chest burn wound, 3 cm ´ 2.5 cm ´ 0.5 cm, wound bed pale, surrounding tissues with edema present Based on the documented data, which action should the nurse take next? a.Assess the client's skin for signs of adequate perfusion. b.Calculate intake and output ratio for the last 24 hours. c.Prepare to obtain blood and wound cultures. d.Place the client in an isolation room.

ANS: C Older clients have a decreased immune response, so they may not exhibit signs that their immune system is actively fighting an infection, such as fever or an increased white blood cell count. They also are at higher risk for sepsis arising from a localized wound infection. The burn wound shows signs of local infection, so the nurse should assess for this and for systemic infection before the client manifests sepsis. Placing the client in an isolation room, calculating intake and output, and assessing the client's skin should all be implemented but these actions do not take priority over determining whether the client has an infection.

A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg. Her blood pressure is 144/90 mm Hg, and her mean arterial pressure (MAP) is 108 mm Hg. What is the cerebral perfusion pressure (CPP)? a. 54 mm Hg b. 72 mm Hg c. 90 mm Hg d. 126 mm Hg

ANS: C CPP = MAP - ICP. In this case, CPP = 108 mm Hg - 18 mm Hg = 90 mm Hg. All other calculated responses are incorrect. DIF: Cognitive Level: Comprehension REF: pp. 360-361 OBJ: Complete an assessment on a critically ill patient with nervous system injury. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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

ANS: C The dosing regimen is initiated with a bolus of 30 mg/kg over 15 minutes, followed in 45 minutes by a continuous intravenous infusion of 5.4 mg/kg/hr for 23 hours. (30 mg 70 kg) + (5.4 mg 70 kg) 23 hours = 10,794 mg. DIF: Cognitive Level: Comprehension REF: Table 13-9 OBJ: Describe nursing and medical management of patients with a spinal cord injury. TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity

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

ANS: C, E Neither heparin nor pressure bags nor pressurized flush systems are used for ICP monitoring setups. ICP is recorded as a mean value with the transducer system zero referenced at the level of the foramen of Munro. Manually flushing the device may result in an increase in ICP. DIF: Cognitive Level: Knowledge REF: p. 362 OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

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

ANS: D Early intervention for ischemic stroke is recommended. Thrombolytics must be given within 3 hours of the onset of symptoms. Although assessment of allergies, as well accompanying symptoms such as a headache and general orientation, are a part of a complete neurological assessment and should be performed, time of onset of symptoms is critical to the type of treatment. DIF: Cognitive Level: Application REF: p. 379 OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

31. The patient is in progressive care unit following arteriovenous fistula implantation in his left upper arm, and is due to have blood drawn with his next set of vital signs and assessment. When the nurse assesses the patient, the nurse should: a. draw blood from the left arm. b. take blood pressures from the left arm. c. start a new intravenous line in the left lower arm. d. auscultate the left arm for a bruit and palpate for a thrill.

ANS: D An arteriovenous fistula should be auscultated for a bruit and palpated for the presence of a thrill or buzz every 8 hours. The extremity that has a fistula or graft must never be used for drawing blood specimens, obtaining blood pressure measurements, administering intravenous therapy, or giving intramuscular injections. Such activities produce pressure changes within the altered vessels that could result in clotting or rupture

17. In determining the glomerular filtration rate (GFR) or creatinine clearance, a 24-hour urine is obtained. If a reliable 24-hour urine collection is not possible, a. it is not possible to determine the GFR. b. the BUN may be used to determine renal function. c. an elevated BUN/creatinine ratio can be used. d. a standardized formula may be used to calculate GFR.

ANS: D Historically, timed 24-hour urine collections have been used to evaluate GFR or creatinine clearance. If a reliable 24-hour urine collection is not possible, the Cockcroft and Gault formula may be used to determine the creatinine clearance from a serum creatinine value. The BUN level is not a reliable indicator of kidney function because the rate of protein metabolism is not constant. An increased BUN/creatinine ratio is typically noted with prerenal conditions, but does not provide an estimate of GFR.

Transient Ischemic Attacks

Sudden onset of a temporary focal neurological deficit caused by stenosis of the carotid arteries. Symptoms last 24 hours or less.

25. The nurse is assessing a patient being admitted with complaints of fatigue and shortness of breath as well as abdominal tenderness. The nurse notes that the patient is jaundiced; the physical examination reports an enlarged liver The nurse suspects that the patient has a. aplastic anemia. b. hemolytic anemia. c. sickle cell anemia. d. anemia due to acute blood loss.

B

The patient has a hemoglobin of 8.5 g/dL and hematocrit of 27%. The nurse administers 2 units of packed red blood cells to the patient and repeats the labwork a few hours later. The new hemoglobin and hematocrit would be expected to be: a. hemoglobin 7.5 g/dL and hematocrit 25%. b. hemoglobin 9.5 g/dL and hematocrit 29%. c. hemoglobin 10.5 g/dL and hematocrit 32%. d. hemoglobin 12.5 g/dL and hematocrit 36%

C One unit of packed RBCs can be expected to increase the Hgb value by 1 g/dL and the Hct value by 2% to 3%, but this effect is influenced by the patient's intravascular volume status and whether the patient is actively bleeding

The liver plays a major role in homeostasis by: a. synthesizing factor I but not factor II. b. synthesizing clotting factors without the need for vitamin K. c. removing active clotting factors from the circulation. d. synthesizing factor II but not factor I.

C The liver synthesizes fibrinogen (factor I); prothrombin (factor II); and factors VII, IX, and X. Vitamin K is essential for the synthesis of other clotting factors. The liver also removes active clotting factors from the circulation and therefore prevents clotting in the macrovasculature and microvasculature.

GCS score of 3 - 8

Call HCP; indication for pressure monitoring

Cerebral Glucose <70 mg/dL

Confusion

In assessing the patient complaining of abdominal pain, it is important for the nurse to understand that: a. pain receptors in the abdomen are more likely to be localized. b. pain of a peptic ulcer is easily distinguished from that of heart attack. c. visceral pain often leads to tachycardia and hypertension. d. increasing intensity of pain is always significant.

D Pain assessment is challenging. Pain receptors in the abdomen are less likely to be localized and are mediated by common sensory structures projected to the skin. Therefore, distinguishing the pain of a peptic ulcer or cholecystitis from that of a myocardial infarction is often difficult. Abdominal pain often is caused by engorged mucosa, pressure in the mucosa, distention, or spasm. Visceral pain is likely to cause pallor, perspiration, bradycardia, nausea and vomiting, weakness, and hypotension. Increasing intensity of pain, especially after surgery or other intervention, is always significant and usually signifies complicating factors, such as inflammation, gastric distention, hemorrhage into tissue or the peritoneal space, or peritonitis

The nurse is caring for a patient who has had a portacaval shunt placed surgically. The nurse is aware that this procedure: a. improves survival in patients with varices. b. decreases the risk of encephalopathy. c. decreases the incidence of ascites. d. decreases rebleeding.

D Surgical shunts decrease rebleeding but do not improve survival. The procedure is associated with a higher risk of encephalopathy and makes liver transplantation, if needed, more difficult. A temporary increase in ascites occurs after all these procedures, and careful assessments and interventions are required in the care of this patient population.

The patient is admitted with acute pancreatitis. The nurse should: a. assess pain level because pancreatic pain is unique in character. b. examine laboratory values for low amylase levels. c. expect lipase levels to decrease within 24 hours. d. evaluate C-reactive protein as a gauge of severity.

D The diagnosis of acute pancreatitis is based on clinical findings, the presence of associated disorders, and laboratory testing. Pain associated with acute pancreatitis is similar to that associated with peptic ulcer disease, gallbladder disease, intestinal obstruction, and acute myocardial infarction. This similarity exists because pain receptors in the abdomen are poorly differentiated as they exit the skin surface. Serum lipase and amylase tests are the most specific indicators of acute pancreatitis because as the pancreatic cells and ducts are destroyed, these enzymes are released. An elevated serum amylase level is a characteristic diagnostic feature. Amylase levels usually rise within 12 hours after the onset of symptoms and return to normal within 3 to 5 days. Serum lipase levels increase within 4 to 8 hours of clinical symptom onset and then decrease within 8 to 14 days. C-reactive protein increases within 48 hours and is a marker of severity.

Occipital Lobe

Visual interpretation

The nurse is discharging a patient home following treatment for community-acquired pneumonia. As part of the discharge teaching, the nurse instructs: a. "If you get the pneumococcal vaccine, you'll never get pneumonia again." b. "It is important for you to get an annual influenza shot to reduce your risk of pneumonia." c. "Stay away from cold, drafty places because that increases your risk of pneumonia when you get home." d. "Since you have been treated for pneumonia, you now have immunity from getting it in the future."

b. "It is important for you to get an annual influenza shot to reduce your risk of pneumonia."

The nurse notices ventricular tachycardia on the heart monitor. When the patient is assessed, the patient is found to be unresponsive with no pulse. The nurse should: a. treat with intravenous amiodarone or lidocaine. b. begin cardiopulmonary resuscitation and advanced life support. c. provide electrical cardioversion. d. ignore the rhythm since it is benign.

b. begin cardiopulmonary resuscitation and advanced life support.

26. An essential aspect of teaching that may prevent recurrence of heart failure is: a. notifying the physician if a 2-lb weight gain occurs in 24 hours. b. compliance with diuretic therapy. c. taking nitroglycerin if chest pain occurs. d. assessment of an apical pulse.

b. compliance with diuretic therapy. RATIONALE: Reduction or cessation of diuretics usually results in sodium and water retention, which may precipitate heart failure.

The nurse is caring for a patient with a diagnosis of pulmonary embolism. The nurse understands that the most common cause of a pulmonary embolus is: a. amniotic fluid embolus. b. deep vein thrombosis from lower extremities. c. fat embolus from a long bone fracture. d. vegetation that dislodges from an infected central venous catheter.

b. deep vein thrombosis from lower extremities.

The nurse is discharging a patient with asthma. As part of the discharge instruction, the nurse instructs the patient to prevent exacerbation by: a. obtaining an appointment for follow-up pulmonary function studies 1 week after discharge. b. limiting activity until patient is able to climb two flights of stairs. c. taking all asthma medications as prescribed. d. taking medications on a "prn" basis according to symptoms.

c. taking all asthma medications as prescribed.

methylprednisolone (Solu Medrol)

improves blood flow to injury site, facilitating tissue repair. dose: 30 mg/kg IV over 15 minutes

In assessing a patient, the nurse understands that an early sign of hypoxemia is: a. clubbing of nail beds b. cyanosis c. hypotension d. restlessness

d. restlessness

Phenytoin

depresses seizure activity by altering ion transport into the motor cortex. S/E: bradycardia, hypotension, nystagmus, gingival hyperplasia, agranulocytosis, SJS, cardiac arrest, heart block

labetalol

nonselective beta blocker to decrease BP dose: 10-20 mg IVP over 2 minutes. S/E: bradycardia, hypotension, HF, bronchospams, ventricular dysrhythmias, weakness, fatigue

27. The patient has yellow skin and low hemoglobin and hematocrit levels. The nurse should look for: a. an elevated bilirubin level. b. a low reticulocyte count. c. sickled cells. d. low white blood cell and platelet counts.

A

30. The patient is admitted for chemotherapy, but the nurse notices laboratory values indicating that the patient is immunosuppressed. The nurse should: a. place the patient in a single room with a HEPA filtration system. b. tell staff that hand washing is not recommended when working with this patient. c. start as many intravenous lines as possible to provide potential antibiotics. d. avoid the use of antimicrobial soaps when bathing and providing perineal care.

A

32. The patient is admitted with neutropenia. The nurse should continually assess the patient for: a. signs of systemic infection. b. a drop in temperature from its normal set point. c. the absence of chills. d. bradycardia.

A

45. The patients platelet count is 35,000/microliter. The provider orders the administration of 10 units of single-donor platelets. After transfusion, the nurse can expect the patients platelet count to be: a. between 85,000/microliter and 135,000/microliter. b. Between 50,000/microliter and 75,000/microliter. c. greater than 150,000/microliter. d. between 150,000/microliter and 185,000/microliter.

A

5. The nurse examines the patients complete blood count with differential analysis and notices that the patients neutrophils are elevated, but the lymphocytes are lower than normal. The drop in lymphocyte count in the differential is most likely due to: a. the increase in neutrophil count b. a new viral infection. c. a decreased number of bands. d. the lack of immature neutrophils.

A

A patient is admitted to the cardiac care unit with an acute anterior myocardial infarction. The nurse assesses the patient to be diaphoretic and tachypneic, with bilateral crackles throughout both lung fields. Following insertion of a pulmonary artery catheter by the physician, which hemodynamic values is the nurse most likely to assess? A. High pulmonary artery diastolic pressure and low cardiac output B. Low pulmonary artery occlusive pressure and low cardiac output C. Low systemic vascular resistance and high cardiac output D. Normal cardiac output and low systemic vascular resistance

A

41. The nurse is assessing a patient being admitted for anemia. The nurse sees no overt signs of bleeding. The nurse understands that: a. all patients with bleeding disorders demonstrate active bleeding. b. many patients have bleeding that is not obvious. c. mucous membranes have a high threshold for bleeding. d. capillaries in mucous membranes lie deep in the membrane.

B

A nurse cares for a client with burn injuries. Which intervention should the nurse implement to appropriately reduce the client's pain? a.Administer the prescribed intravenous morphine sulfate. b.Apply ice to skin around the burn wound for 20 minutes. c.Administer prescribed intramuscular ketorolac (Toradol). d.Decrease tactile stimulation near the burn injuries.

ANS: A Drug therapy for pain management requires opioid and nonopioid analgesics. The IV route is used because of problems with absorption from the muscle and the stomach. For the client to avoid shivering, the room must be kept warm, and ice should not be used. Ice would decrease blood flow to the area. Tactile stimulation can be used for pain management.

3. A normal glomerular filtration rate is: a. less than 80 mL/min. b. 80 to 125 mL/min c. 125 to 180 mL/min d. more than 189 mL/min

ANS: B At a normal glomerular filtration rate (GFR) of 80 to 125 mL/min, the kidneys produce 180 L/day of filtrate. As the filtrate passes through the various components of the nephron's tubules, 99% is reabsorbed into the peritubular capillaries or vasa recta.

16. The patient's serum creatinine level is 0.7 mg/dL. The expected BUN level should be: a. 1-2 mg/dL. b. 7-14 mg/dL. c. 10-20 mg/dL. d. 20-30 mg/dL.

ANS: B The normal BUN/creatinine ratio is 10:1 to 20:1. Therefore, the expected range for this creatinine level would be 7 to 14 mg/dL.

17. In vivo, the primary activator of the coagulation cascade occurs via the: a. intrinsic pathway. b. extrinsic pathway. c. common pathway. d. either intrinsic or extrinsic pathway.

B

23. A reduction in the number of circulating RBCs or hemoglobin, which leads to inadequate oxygenation of tissues, is known as: a. polycythemia. b. anemia. c. iron deficiency. d. an increase in hemoglobin.

B

1. Of the four major blood components, plasma: a. is made up of circulating ions. b. comprises about 55% of blood volume. c.is transported to the cells by serum proteins. d.comprises about 45% of blood volume.

B

10. The process by which the body actively produces cells and mediators that result in the destruction of the antigen is called: a. passive immunity. b. active immunity. c. autoimmunity. d. recognition of self as nonself.

B

Ten minutes following administration of an antibiotic, the nurse assesses a patient to have edematous lips, hoarseness, and expiratory stridor. Vital signs assessed by the nurse include blood pressure 70/40 mm Hg, heart rate 130 beats/min, and respirations 36 breaths/min. What is the priority intervention? A. Diphenhydramine 50 mg intravenously B. Epinephrine 3 to 5 mL of a 1:10,000 solution intravenously C. Methylprednisolone 125 mg intravenously D. Ranitidine 50 mg intravenously

B

The nurse has just completed administration of a 500 mL bolus of 0.9% normal saline in a patient with hypovolemic shock. The nurse assesses the patient to be slightly confused, with a mean arterial blood pressure (MAP) of 50 mm Hg, a heart rate of 110 beats/min, urine output of 10 mL for the past hour, and a central venous pressure (CVP/RAP) of 3 mm Hg. What is the best interpretation of these results by the nurse? A. Patient response to therapy is appropriate. B. Additional interventions are indicated. C. More time is needed to assess response. D. Values are normal for the patient condition.

B

The nurse is caring for a patient with severe ascites due to chronic liver failure. The patient is lying supine in bed and complaining of difficulty breathing. The nurse's first action should be to: a. measure abdominal girth to determine the amount of fluid accumulation. b. position the patient in a semi-Fowler's position. c. prepare the patient for emergent paracentesis. d. administer diuretics

B Ascites is problematic because as more fluid is retained, it pushes up on the diaphragm, thereby impairing breathing. Positioning the patient in a semi-Fowler's position allows for free diaphragm movement. Frequent monitoring of abdominal girth alerts the nurse to fluid accumulation, but the most immediate and easiest action would be to place the patient in semi-Fowler's position. Paracentesis is sometimes done to relieve symptoms, but it is not usually done emergently. Diuretics must be administered cautiously because if the intravascular volume is depleted too quickly, acute renal failure may be induced.

The patient is admitted with acute pancreatitis and is demonstrating severe abdominal pain, vomiting, and ascites. Using the Ranson classification criteria, the nurse determines that this patient: a. has a 99% chance of survival. b. has a 15% chance of dying. c. has a 40% chance of dying. d. has no chance of survival.

B Patients with acute pancreatitis can develop mild or fulminant disease. As a consequence, research has addressed criteria for predicting the prognosis of patients with acute pancreatitis. The early classification criteria were developed by Ranson, who suggested that the number of signs present within the first 48 hours of admission directly relates to the patient's chance of significant morbidity and mortality. In Ranson's research, patients with fewer than three signs had a 1% mortality rate, those with three or four signs had a 15% mortality rate, those with five or six signs had a 40% mortality rate, and those with seven or more signs had a 100% mortality rate.

5. Causes of anemia include: (Select all that apply.) a. hypoxic states. b. blood loss. c. impaired production of red blood cells. d. increased destruction of red blood cells. e. chronic obstructive pulmonary disease.

B, C, D

2. Autoimmunity can result from: (Select all that apply.) a. recognition of tissue as self. b. injury to tissues. c. infection. d. malignancy. e. unknown causes.

B, C, D, E

7. Secondary immunodeficiency involves the loss of a previously functional immune defense system that can be caused by: (Select all that apply.) a. a single gene defect. b. AIDS. c. aging. d. nutritional deficiencies. e. immunosuppressive therapies

B, C, D, E

4. Exudate formation at the inflammatory site functions to: (Select all that apply.) a. opsonize bacteria. b. dilute toxins. c. deliver proteins. d. attach to the target cell. e. carry away toxins.

B, C, E

Three components of ICP

Brain tissue, blood, and CSF

Autonomic dysreflexia is characterized by an exaggerated response of the sympathetic nervous system to a variety of stimuli. Common causes of autonomic dysreflexia include: (Select all that apply.) 1- Bladder Distention 2- Fecal Impaction 3 - Sinus Bradycardia 4 - UTI

Bladder distention, and fecal impaction (Causes of autonomic dysreflexia include bladder distention, stimulation to the bladder by a kinked Foley catheter, stimulation to the bowel by fecal impaction, rectal examination, or suppository insertion. Sinus bradycardia is a symptom of autonomic dysreflexia. Urinary tract infection is not a cause of autonomic dysreflexia; urinary retention is a cause.)

16. With minor vessel injury, primary hemostasis is achieved: a. after several minutes. b. with fibrin to solidify the platelet plug. c. usually within seconds. d. as a permanent solution.

C

The nurse is caring for a patient admitted following a motor vehicle crash. Over the past 2 hours, the patient has received 6 units of packed red blood cells and 4 units of fresh frozen plasma by rapid infusion. To prevent complications, what is the priority nursing intervention? A. Administer pain medication. B. Turn patient every 2 hours. C. Assess core body temperature. D. Apply bilateral heel protectors.

C

The nurse is caring for a patient admitted to the critical care unit 48 hours ago with a diagnosis of severe sepsis. As part of this patient's care plan, what intervention is most important for the nurse to discuss with the multidisciplinary care team? A. Frequent turning B. Monitoring intake and output C. Enteral feedings D. Pain management

C

The nurse is caring for a patient in cardiogenic shock who is being treated with an infusion of dobutamine. The physician's order calls for the nurse to titrate the infusion to achieve a cardiac index of greater than or equal to 2.5 L/min/m2. The nurse measures a cardiac output, and the calculated cardiac index for the patient is 4.6 L/min/m2. What is the best action by the nurse? A. Obtain a stat serum potassium level. B. Order a stat 12-lead electrocardiogram. C. Reduce the rate of dobutamine. D. Assess the patient's hourly urine output.

C

The nurse is caring for a patient in spinal shock. Vital signs include blood pressure 100/70 mm Hg, heart rate 70 beats/min, respirations 24 breaths/min, oxygen saturation 95% on room air, and an oral temperature of 94.8° F. Which intervention is most important for the nurse to include in the patient's plan of care? A. Administration of atropine sulfate (Atropine) B. Application of 100% oxygen via face mask C. Application of slow rewarming measures D. Infusion of IV phenylephrine (Neo-Synephrine)

C

The nurse is starting to administer a unit of packed red blood cells (PRBCs) to a patient admitted in hypovolemic shock secondary to hemorrhage. Vital signs include blood pressure 60/40 mm Hg, heart rate 150 beats/min, respirations 42 breaths/min, and temperature 100.6° F. What is the best action by the nurse? A. Administer blood transfusion over at least 4 hours. B. Notify the physician of the elevated temperature. C. Titrate rate of blood administration to patient response. D. Notify the physician of the patient's heart rate.

C

Which patient being cared for in the emergency department is most at risk for developing hypovolemic shock? A. A patient admitted with abdominal pain and an elevated white blood cell count B. A patient with a temperature of 102° F and a general dermal rash C. A patient with a 2-day history of nausea, vomiting, and diarrhea D. A patient with slight rectal bleeding from inflamed hemorrhoids

C

42. The nurse is caring for a patient diagnosed with anemia. This mornings hematocrit level is 24%. Platelet level is 200,000/microliter. The nurse can expect to: a. continue monitoring the patient, as this hematocrit is normal. b. administer platelets to help control bleeding. c. give fresh frozen plasma to decrease prothrombin time. d. provide RBC transfusion because this level is below the normal threshold.

D

The nurse is caring for a patient with the diagnosis of sepsis. The patient is on a ventilator in the critical care unit, and is receiving a proton pump inhibitors (PPI) to reduce the risk for a stress ulcer. In this scenario, a stress ulcer is likely secondary to: a. infection with Helicobacter pylori bacteria. b. decreased acetylcholine production. c. a decreased number of parietal cells. d. ischemia associated with sepsis.

D A stress ulcer is an acute form of peptic ulcer that often accompanies severe illness, systemic trauma, or neurological injury. Ischemia is the prior etiology associated with stress ulcer formation. Ischemic ulcers develop within hours of an event such as hemorrhage, multisystem trauma, severe burns, heart failure, or sepsis. The shock, anoxia, and sympathetic responses decrease mucosal blood flow leading to ischemia. The secretion of acid is important in the pathogenesis of ulcer disease. Acetylcholine (a neurotransmitter), gastrin (a hormone), and secretin (a hormone) stimulate the chief cells, which stimulate acid secretion. Parietal cell mass in people with peptic ulcer disease is 1.5 to 2 times greater than in persons without disease. Infection with Helicobacter pylori bacteria is a major cause of duodenal ulcers.

The nurse is caring for a patient with acute pancreatitis. To provide adequate pain control, the nurse: a. should suggest that the patient receive epidural analgesia. b. provides oral pain medication on an "as needed" (PRN) basis. c. removes any nasogastric tubes. d. administers pain medication on a routine schedule.

D Analgesic administration is a nursing priority. Adequate pain control requires the use of IV opiates, often in the form of a patient-controlled analgesia (PCA) pump. In the case in which a PCA pump is not ordered, pain medications are administered on a routine schedule, rather than as needed, to prevent uncontrollable abdominal pain. Insertion of a nasogastric tube connected to low intermittent suction may help ease pain.

Medication used to decrease brain tissue volume?

Diuretics; decrease tissue volume by pulling fluid into vasculature. Ex: Mannitol After administration, CVP increases until fluid is excreted.

The nurse is assisting with endotracheal intubation and understands correct placement of the endotracheal tube in the trachea would be identified by which of the following? (Select all that apply.)

Equal bilateral breath sounds upon auscultation Position above the carina verified by chest x-ray Positive detection of carbon dioxide (CO2) through CO2 detector devices

Which of the following devices is best suited to deliver 65% oxygen to a patient who is spontaneously breathing?

Face mask with non-rebreathing reservoir

A 53-year-old, 80-kg patient is admitted to the cardiac surgical intensive care unit after cardiac surgery. Four hours after admission to the surgical intensive care unit at 4 PM, the patient has stable vital signs and normal arterial blood gases (ABGs), and is placed on a T-piece for ventilatory weaning. During the nurses 7 PM (1900) assessment, the patient is restless, heart rate has increased to 110 beats/min, respirations are 36 breaths/min, and blood pressure is 156/98 mm Hg. The cardiac monitor shows sinus tachycardia with 10 premature ventricular contractions (PVCs) per minute. Pulmonary artery pressures are elevated. The nurse suctions the patient and obtains pink, frothy secretions. Loud crackles are audible throughout lung fields. The nurse notifies the physician, who orders an ABG analysis, electrolyte levels, and a portable chest x-ray study. How does the nurse interpret the following blood gas levels? pH 7.28 PaCO2 46 mm Hg Bicarbonate 22 mEq/L PaO2 58 mm Hg O2 saturation 88%

Hypoxemia and uncompensated respiratory acidosis

In a patient with increased intracranial pressure (ICP), which of the following cranial nerves would be assessed for consensual light response, elevation of the eyelids, and eye movement?

III, IV, VI

A patient is being mechanically ventilated in the synchronized intermittent mandatory ventilation mode at a rate of 4 breaths/min. His spontaneous respirations are 12 breaths/min. He receives a dose of morphine sulfate, and his respirations decrease to 4 breaths/min. What adjustments may need to be made to the patients ventilator settings?

Increase the synchronized intermittent mandatory ventilation respiratory rate.

Most common cause of Hemorrhagic Stroke

Intraparenchymal hemmorhage and cerebral aneurysm or A/V malformations. Other causes include too much heparin or warfarin.

Tissue plasminogen activator (T-PA)

Is the only approved therapy for acute ischemic stroke, and must be given within 3 hours of symptom onset

What type of fluid is used?

Isotonic fluids because they remain in the vasculature. Colloids and blood products may also be administered to restore volume.

What is the therapeutic effect of head-of-the-bed elevation and neutral head and neck alignment on increased intracranial pressure (ICP)?

Lowering ICP by facilitating venous drainage and decreasing venous obstruction

Most common location for stroke

Middle cerebral artery

A 53-year-old, 80-kg patient is admitted to the cardiac surgical intensive care unit after cardiac surgery. Four hours after admission to the surgical intensive care unit at 4 PM, the patient has stable vital signs and normal arterial blood gases (ABGs) and is placed on a T-piece for ventilatory weaning. During the nurses 7 PM (1900) assessment, the patient is restless, heart rate has increased to 110 beats/min, respirations are 36 breaths/min, and blood pressure is 156/98 mm Hg. The cardiac monitor shows sinus tachycardia with 10 premature ventricular contractions (PVCs) per minute. Pulmonary artery pressures are elevated. The nurse suctions the patient and obtains pink, frothy secretions. Loud crackles are audible throughout lung fields. The nurse notifies the physician, who orders an ABG analysis, electrolyte levels, and a portable chest x-ray study. In communicating with the physician, which statement indicates the nurse understands what is likely occurring with the patient?

My assessment indicates potential fluid overload.

Which statements best represent optimal fluid administration for the management of increased intracranial pressure? (Select all that apply.) 1 - Normal saline (0.9%) is recommended for fluid volume resuscitation. 2 - The goal is to keep serum osmolality greater than 320 mOsm/L. 3 - 0.45% saline solution is acceptable for fluid volume resuscitation. 4 - Hypotonic solutions are avoided to prevent an increase in cerebral edema.

Normal saline (0.9%) is recommended for fluid volume resuscitation and Hypotonic solutions are avoided to prevent an increase in cerebral edema.

The nurse is preparing to admit a patient from the ED who has sustained a complete spinal cord lesion at the C5 level. When planning the patient's care, which nursing intervention is most important?

Perform hourly incentive spirometry.

Temporal Lobes

Processing, association, and interpretation of auditory; comprehending language in Wernicke's area

Parietal Lobes

Processing, association, and interpretation of sensory information from opposite side of the body

The nurse notes that the patients arterial blood gas levels indicate hypoxemia. The patient is not intubated and has a respiratory rate of 22 breaths/min. The nurses first intervention to relieve hypoxemia is to:

notify the provider of values and obtain order for oxygen.

A patient is being mechanically ventilated in the synchronized intermittent mandatory ventilation mode at a rate of 4 breaths/min. His spontaneous respirations are 12 breaths/min. He receives a dose of morphine sulfate, and his respirations decrease to 4 breaths/min. Which acid-base disturbance will likely occur?

Respiratory acidosis

The physician orders the following mechanical ventilation settings for a patient who weighs 75 kg. The patients spontaneous respiratory rate is 22 breaths/min. What arterial blood gas abnormality may occur if the patient continues to be tachypneic at these ventilator settings? Settings: Tidal volume: 600 mL (8 mL per kg) FiO2: 0.5 Respiratory rate: 14 breaths/min Mode assist/control Positive end-expiratory pressure: 10 cm H2O

Respiratory alkalosis

The nurse is caring for a patient with an assessed Glasgow Coma Scale score of 3. What is the best understanding of this finding?

There is impairment of the reticular activating system (RAS), resulting in coma. (The reticular activating system (RAS) controls arousal, the sleep-wake cycle, selective attention, and perceptual awareness. The patient with a Glasgow Coma Scale score of 3 has an impaired RAS system. )

Enalapril

ace inhibitor used to decrease BP. S/E: headache, hypotension, dysrhythmias, acute kidney injury, neutropenia, angioedema

The nurse is calculating the rate for a regular rhythm. There are 20 small boxes between each P wave and 20 small boxes between each R wave. What is the ventricular rate? a. 50 beats/min b. 75 beats/min c. 85 beats/min d. 100 beats/min

b. 75 beats/min

When assessing the patient for hypoxemia, the nurse recognizes that an early sign of the effect of hypoxemia on the cardiovascular system is:

tachycardia.