Critical Care test 2

The patient in progressive care unit following arteriovenous fistula implantation in the left upper arm, is due to have blood drawn with the next set of vital signs and assessment. When the nurse assesses the patient, the nurse should take what action?

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

The client being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious. The nurse suspects air embolism. What are the priority nursing actions? (select all that apply)

1. Administer oxygen to the client3. Notify the HCP and RRT4. Stop dialysis, and turn the client on the left side with head lower than feet

The nurse has been assigned the following patients. Which patients require assessment of blood glucose control as a nursing priority? (Select all that apply.)

29-year-old who is undergoing evaluation for pheochromocytoma 43-year-old with acute pancreatitis who is receiving total parenteral nutrition (TPN) 62-year-old morbidly obese female who underwent a hysterectomy for ovarian cancer 72-year-old who is receiving intravenous (IV) steroids for an exacerbation of chronic obstructive pulmonary disease (COPD)

The patient is a new postoperative patient. She weighs 75 kg. The nurse expects the minimal acceptable urine output to be what?

37 ML/hr

Thyroid storm

A fib

A patient presents to the emergency department with suspected thyroid storm. The nurse should be alert to monitoring for what cardiac rhythm while providing care to this patient?

Atrial fibrillation

The patient diagnosed with acute kidney injury and has been getting dialysis 3 days per week reports general malaise and is tachypneic. An arterial blood gas is ordered and shows that the patient's pH is 7.19, with a PCO2 of 30 mm Hg and a bicarbonate level of 13 mEq/L. The nurse prepares to take what action?

Administer IV sodium bicarbonate

A patient has been on daily, high-dose glucocorticoid therapy for the treatment of rheumatoid arthritis. The prescription will run out three days before the patient's next appointment with the primary care provider (PCP). The patient is asymptomatic and thinks it is all right to miss the medication for the 3 days. What is the likely outcome of missing the doses?

Adrenal crisis

The nurse caring for a patient who has undergone major abdominal surgery notices that the patient's urine output has been less than 20 mL/hour for the past 2 hours. At 0200 in the morning the patient's blood pressure is 100/60 mm Hg, and the pulse is 110 beats per minute. Previously, the pulse was 90 beats per minute with a blood pressure of 120/80 mm Hg. The nurse should take what action?

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

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?

HR 125 bpm hypovolemic shock

insluin pump you have pt. type 1 diabetic with a pump

DKA

What is a common cause of acute adrenal crisis?

Deficiency of corticosteroids

A patient diagnosed with pancreatic cancer has been admitted to the critical care unit with clinical signs consistent with syndrome of inappropriate secretion of antidiuretic hormone. The nurse anticipates that clinical management of this condition will include what intervention?

Fluid restriction

AKI nursing diagnosis

Fluid volume excess (oliguric phase) High risk for fluid volume deficit (diuretic phase) Risk for infection Altered nutrition: < body requirements Sensory-perceptual alterations Altered thought processes Fatigue Anxiety

A 32-year-old patient is admitted to the critical care unit with a diagnosis of diabetic ketoacidosis. Following aggressive fluid resuscitation and intravenous (IV) insulin administration, the blood glucose begins to normalize. In addition to glucose monitoring, which of the following electrolytes requires close monitoring?

K

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?

Kayexalate

Which of the following interventions is the highest priority for a patient with acute kidney injury (AKI)?

Monitor fluid and electrolytes

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

Notify the primary health care provider immediately.

Which laboratory values would be more common in patients with diabetic ketoacidosis?

PH 7.24

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)?

Reduce ambient room temperature and administer antipyretics.

Slow continuous ultrafiltration is also known as isolated ultrafiltration and is used for what purpose?

Remove plasma water in cases of volume overload.

NIHHS

The National Institutes of Health Stroke Scale,

A patient is receiving enteral feedings and has just vomited 250 mL of milky green liquid. The nurse holds the tube feeding, which had been infusing at 100 mL/hr. The nurse knows that the next action should be:

The patient is not tolerating the tube feeding. It should be held until he has absorbed the remaining tube feeding. Feedings may resume when residuals are less than 250 mL.

The most common reasons for initiating dialysis in acute kidney injury include which of the following?

acidosis volume overload hyperkalemia uremia

Renin

converts angiotensinogen to angiotensin, which stimulates the release of aldosterone from the adrenal cortex and lowers BP

abdominal surgery increase of weight in 24 hours

fluid retention

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.)

frequent neuro assessment Maintain MAP less than 130 mm Hg.

Complications common to patients receiving hemodialysis for acute kidney injury include which of the following? (Select all that apply.)

hypotension Dysrhythmias

peritoneal dialysis and complain of pain chills and nausea

infection

Creatine clearance checks

kidney function

The nurse is providing insulin education for an older adult patient with longstanding diabetes. An order has been written for the patient to take 20 units of insulin glargine at 10 PM nightly. The nurse should provide the patient with what information regarding the peak time for insulin action to occur?

no peak

The patient has a temporary percutaneous catheter in place for treatment of acute kidney injury. The catheter has been in place for 5 days. What action should the nurse take?

s/s of infection

Which of the following laboratory values would be found in a patient with syndrome of inappropriate secretion of antidiuretic hormone?

sodium 115