Critical Care EAQs

The victims of a large scale near-drowning incident are brought to the emergency department. What is the minimum length of time all such victims should be kept under observation in the hospital?

23 hours

A burn victim has waxy white areas interspersed with pink and red areas on the anterior trunk and all of both arms. The nurse calculates the percentage of total body surface area (TBSA). Which percentage will the nurse report?

36

The client is in atrial fibrillation. Which information should the nurse consider about atrial fibrillation when planning care for this client?

A loss of atrial kick

A client has undergone nasal hypophysectomy surgery. During post-operative care, which finding indicates cerebrospinal leakage?

A yellow edge around nasal discharge

Which nursing action is most important to promote the nutritional status of a client during the acute phase of treatment after extensive burns?

Administer the prescribed intravenous fluid with the added vitamin C

The nurse notifies the primary healthcare provider that a client has been admitted to the high-risk unit in her thirty-sixth week of gestation. She is bleeding, has severe abdominal pain and a rigid fundus, and is demonstrating signs of impending shock. Which intervention should the nurse prepare for?

An immediate Cesarean birth

Which activity is performed first when a client is bitten by a brown recluse spider?

Applying cold compresses over the site

Which action should be the nurse's first priority for a client with major burns?

Assessing airway patency

A nurse is caring for a client who sustained a transection of the spinal cord with no other injuries. The nurse continually monitors this client for which medical emergency?

Autonomic dysreflexia

Which noninvasive assessment and management skills certification would the nurse be required to use for airway maintenance and cardiopulmonary resuscitation (CPR)?

Basic Life Support (BLS)

The nurse observes a window washer fall 25 feet (7.6 m) to the ground, rushes to the scene, and determines that the person is in cardiopulmonary arrest. What should the nurse do first?

Begin chest compressions

A client who was hospitalized with partial- and full-thickness burns over 30% of the total body surface area is to be discharged. The client asks the nurse, "How will my spouse be able to care for me at home?" How should the nurse interpret this statement?

Beginning realization of implications for the future

A client is on a cardiac monitor. The monitor begins to alarm showing ventricular tachycardia. What should the nurse do first?

Check a pulse

1. The nurse is planning to triage four clients based on their conditions. Which client should be triaged first according to the three-tiered triage system? Client A - Chest pain Client B - Displaced or multiple fractures Client C - Renal colic Client D - Strains and sprains

Client A

The nurse is planning to triage clients according to emergency severity index (ESI). Which client should be triaged under ESI-1 based on threat to life and stability of vital functions? Client A- Chest pain resulting from ischemia Client B- Cardiac arrest Client C- simple laceration Client D - hip fracture

Client B

The nurse is caring for four clients admitted at the same time under mass casualty conditions. Based on this data, which client should be given the highest priority for treatment? Client A - massive head truama Client B - open fracture with a distal pulse Client C - shock Client D - strains and contusions

Client C

The nurse is assessing four clients in the emergency department. Which client requires least priority according to the Glasgow Coma Scale? Client A - Eyes 1, Motor 2, Verbal 3 Client B- Eyes 2, Motor 3, Verbal 3 Client C - Eyes 3, Motor 5, Verbal 3 Client D - Eyes 4, Motor 5, Verbal 5

Client D

A client presents to the emergency department with weakness and dizziness. The blood pressure is 90/60 mm Hg, pulse is 92 and weak, and body weight reflects a 3-pound (1.4 kilogram) loss in two days. The weather has been hot. Which condition should the nurse conclude is the priority for this client?

Deficient fluid volume

A nurse is caring for a client who experienced serious burns in a fire. Which relationship between a client's burned body surface area and fluid loss should the nurse consider when evaluating fluid loss in a client with burns?

Direction proportional

The nurse is reassessing level of consciousness and mental status in a client who survived a fire. Which type of emergency assessment of the trauma client is the nurse performing?

Disability

Which clinical manifestation can a client experience during a fat embolism syndrome (FES)?

Dyspnea

A client is to be transferred from the coronary care unit to a progressive care unit. The client asks the nurse, "Are you sure I'm ready for this move?" What should the nurse determine that the client most likely is experiencing based on this statement?

Fear

A nurse is caring for a client who recently had a kidney transplant. Which priority assessment finding requires follow up by the nurse?

Fever

A nurse is assessing a client's ECG reading. The client's atrial and ventricular heart rates are equal at 88 beats per min. The PR interval is 0.14 seconds, and the QRS width is 0.10 seconds. Rhythm is regular with normal P waves and QRS complexes. How will the nurse interpret this rhythm?

Normal sinus rhythm

What is an appropriate nursing intervention for a neonate with respiratory distress syndrome (RDS)?

Position the infant to promote respiratory efforts

A client was admitted with full-thickness burns 2 weeks ago. Since admission, the client has lost an average of 1 lb (0.5 kg) of weight each day. Which action will the nurse most likely take based upon the adjusted dietary plan?

Provide high-protein drinks

The nursing student is learning about submersion injuries. Which component of sea water does the nurse know to be responsible for making it hypertonic compared to body fluids?

Salt

What are the potential life-threatening conditions that should be considered during the primary survey for a client admitted after a fire accident? Select all that apply.

Shock Inhalation injury Direct cardiac injury

A nurse is notified that the latest potassium level for a client in acute kidney injury is 6.2 mEq (6.2 mmol/L). Which action should the nurse take first?

Take vital signs and notify the primary HCP

A client has received ABO-incompatible blood from a donor by mistake. Which type of hypersensitivity reaction will occur in the client?

Type 2

A client with a head injury is admitted to the hospital. Which assessment finding alerts the nurse to increasing intracranial pressure?

Widening pulse pressure

After an acute coronary syndrome a client begins a supervised, progressive jogging regimen and asks the nurse how to tell whether it is helping. What is the best response by the nurse?

o "You will be able to run progressively longer distance before tiring"

Which nursing interventions are important when caring for clients receiving IV digoxin? Select all that apply

o Monitor the HR closely o Check the blood levels of digoxin o Monitor the serum potassium level

An infant of a diabetic mother is admitted to the neonatal intensive care unit. What is the priority nursing intervention for this infant?

o Obtaining heel blood to test the glucose level

A pregnant client with severe abdominal pain and heavy bleeding is being prepared for a cesarean birth. What is the priority medical intervention?

o Obtaining informed consent and assessing the client for drug allergies

A pregnant client is admitted with abdominal pain and heavy vaginal bleeding. What is the priority nursing action?

Administering oxygen

A client with severe preeclampsia is hospitalized. Which action should the nurse initiate first to ensure her physical safety?

Institute seizure precautions

A client's burn wounds are scheduled to be debrided mechanically. Which equipment will the nurse prepare?

Scissors and forceps

A woman comes to the office of her healthcare provider reporting shortness of breath and epigastric distress that is not relieved by antacids. To which question would a woman experiencing a myocardial infarction respond differently than a man?

"Do you have chest pain?"

The nurse is assessing four clients in the postanesthesia care unit (PCU) who are on opioid treatment. Which client does the nurse expect will benefit from an immediate treatment with naloxone? Client A - frequently drowsy, arousable, drifts off to sleep during conversation, 15 breaths per minute Client B - slightly drowsy, easily aroused, 24 breaths per minute Client C- awake and alert, 32 breaths per minute Client D - minimal response to verbal and physical stimuatlion, 10 breaths per minute

Client D

What is a common metabolic cause of hypothermia?

Hypoglycemia

The nurse is caring for a client who is admitted to the birthing unit with a diagnosis of abruptio placentae. Which complication associated with a placental abruption should the nurse carefully monitor this client for?

Hypovolemic shock

A client had a craniotomy for excision of a brain tumor. After surgery, the nurse monitors the client for increased intracranial pressure. Which clinical finding supports an increase in intracranial pressure?

Lowered level of consciousness

The nurse is providing postprocedure care to a client who had a cardiac catheterization. The client begins to manifest signs and symptoms associated with embolization. Which action should the nurse take?

Notify the HCP immediately

A nurse is assessing a client with a cast to the extremity. Which assessment finding is the priority?

Numbness

Twelve hours after a subtotal gastrectomy, a nurse identifies large amounts of bloody drainage from the client's nasogastric (NG) tube. Which action should the nurse take?

Obtain vital signs

While mopping the kitchen floor, a client at 37 weeks' gestation experiences a sudden sharp pain in her abdomen with a period of fetal hyperactivity. When the client arrives at the prenatal clinic, the nurse examines her and detects fundal tenderness and a small amount of dark-red bleeding. What does the nurse conclude is the probable cause of these clinical manifestations?

Partial abruptio placentae

During a vertex vaginal birth the nurse notes meconium-stained amniotic fluid. What is the priority nursing intervention for the newborn?

Suctioning the airway

Why is the Glasgow Coma Scale used by the nurse while performing an assessment in a traumatized client?

To assess level of consciousness

A client who sustained a burn injury involving 36% of the body surface area is receiving hydrotherapy. Which is the best nursing intervention when providing wound care?

Use a consistent approach to care and encourage participation

A woman fractured her left tibia and fibula one week ago and has a cast in place. She is taking acetaminophen (Tylenol) with codeine for pain and an oral contraceptive. She began experiencing left calf pain 3 days ago and began having shortness of breath and chest pain 15 minutes ago. When the shortness of breath and chest pain increase, she calls the emergency department and communicates this information to the triage nurse. What is the triage nurse's best response?

o "Give me your name and address. I am sending an ambulance to your home. You need emergency care."

A client receives an autograft for a severe burn and is taught how to change the dressing. One week after receiving the graft, the client identifies that the edges of the graft are curling up and asks the nurse about it. Which is the best response by the nurse?

o "May I take a look at it?"

A client's extensive burns are being treated with silver nitrate 0.5% dressings. A week after treatment is begun, the nurse identifies that the client's sodium level is 135 mEq/L (135 mmol/L) and the potassium level is 3.0 mEq/L (3.0 mmol/L). The nurse notifies the primary healthcare provider. Which prescription should the nurse be prepared to administer?

o Add potassium chloride to the existing intravenous lactated Ringer solution

A client who had extensive pelvic surgery 24 hours ago becomes cyanotic, is gasping for breath, and reports right-sided chest pain. What should the nurse do first?

o Administer oxygen using a face mask

A client with a recent history of sinusitis develops meningitis and demonstrates a positive Brudzinski sign. What is the priority nursing care?

o Administering prescribed antibiotics

What is the priority nursing action for a scorpion bite?

o Assessing the client's vital signs

A client falls from a two-story building and is taken to the hospital unconscious. Which finding identified during the initial nursing assessment should be of MOST concern to the nurse?

o Bleeding from the ears

A hospitalized client puts the call light on and reports a sudden onset of chest pain that feels like a pressure or weight on the chest. The client also states, "I feel nauseated and very weak." Which action should the nurse take?

o Call the rapid response team

Which client would the nurse treat first according to a three-tiered triage system? o Client with respiratory distress o Client with multiple soft tissue injuries o Client with new onset of respiratory tract infection o Client with skin rash and simple lower limb fracture

o Client with respiratory distress

A nurse assesses a client who is suspected of being in myasthenic crisis. Which assessment finding is most definitive in support of this conclusion?

o Difficulty breathing

A nurse is caring for a client who has a burn in the emergent stage. Which assessment is the highest priority?

o Extent of burn

A postoperative client returned from the postanesthesia care unit (PACU) this morning with a patient-controlled analgesia (PCA) pump running with a basal rate of hydromorphone. The nurse assesses the client's vital signs as blood pressure 90/60 mm Hg, heart rate 96 beats per min, and respiratory rate of 10 breaths per min. Which action should the nurse take next?

o Give naloxone intravenous push med per protocol

The nurse is caring for a client 4 days after the client was admitted to the hospital with burns on the trunk and arms. The nurse collaborates with the dietician to develop a dietary plan for the following day. Which plan will the nurse follow?

o High caloric intake, liberal potassium intake, and 3g protein/kg/day

During the first 48 hours after a client has sustained a thermal injury, which conditions should the nurse assess for?

o Hyperkalemia and hyponatremia

A client is recovering from a myocardial infarction. Which action should the nurse take before developing the client's teaching plan?

o Identify the learning needs of the client

What is the priority nursing intervention for a client bitten by a snake?

o Immobilizing the affected extremity using a split

A client is admitted to the hospital with partial- and full-thickness burns of the chest and face sustained while trying to extinguish a brush fire. Which is the nurse's priority concern?

o Inadequate gas exchange caused by smoke inhalation

A nurse is performing external cardiac compression. Which action should the nurse take?

o Interlock the fingers with the heel of one hand on the sternum and the heel of the other on top of it

One hour postpartum a nurse assesses the amount of vaginal bleeding and determines that a client's uterus has become relaxed and boggy. Which intervention is a priority for the nurse to take in this situation?

o Massage the uterus until firm

A client has a diagnosis of partial-thickness burns. While planning care, the nurse recalls that the client's burn is different than full-thickness burns. Which information did the nurse recall?

o Partial thickness burns are often painful, reddened and have blisters

A burn client is receiving the open method for wound treatment. Which information will the nurse explain to the client?

o Personal protective equipment will be worn by staff

A client is postoperative from open heart surgery. What should the nurse do to decrease or control the sensory and cognitive disturbances?

o Plan for maximum periods of rest

A nurse is caring for a client with severe burns. The nurse determines that this client is at risk for hypovolemic shock. Which physiologic finding supports the nurse's conclusion?

o Plasma proteins moving out of the intravascular compartment

While auscultating the lungs of a client admitted with severe preeclampsia, the nurse identifies crackles. What inference does the nurse make when considering the presence of crackles in the lungs?

o Pulmonary edema has developed

A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. Which are the priority nursing assessments?

o Quality of respirations and presence of pulses

The victims of a terrorist attack involving sarin are brought to the emergency department. Which statement does the nurse know to be true regarding the characteristics of sarin?

o Sarin can cause death within minutes of exposure

The nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which is the priority concern of the nurse when caring for this client?

o Skin integrity

A client has been taking 3 mg of risperidone twice a day for the past 8 days. At the follow-up appointment, the client reports tremors, shortness of breath, a fever, and sweating. What will the nurse do?

o Take the client's vital signs and arrange for immediate transport to a hospital

A client presenting to the emergency department with chest pain and dizziness is found to be having a myocardial infarction and subsequently suffers cardiac arrest. The healthcare team is able to successfully resuscitate the client. Lab work shows that the client now is acidotic. How does the nurse interpret the cause of the acidosis?

o The decreased tissue perfusion caused lactic acid production

Which statement effectively describes the steps to be taken by healthcare personnel when responding to healthcare facility fires?

o The respiratory status of clients on life support should be maintained manually

What should the nurse consider when providing care to a client in the acute phase of treatment for a full-thickness burn?

o The risk of septicemia and its potential complications from treatment

1. A client is admitted with a marginal placenta previa. Which item should the nurse have readily available?

o Two units for typed and screen blood

The nurse is caring for a client whose contraction stress test result (CST) is positive. The nurse remains with the client and continues to assess the fetal and maternal monitor strips. Which complication does the nurse anticipate?

o Uteroplacental insufficiency