exam 3 ICU

Which of the following infection control strategies should the nurse implement to decrease the risk of infection in the burn-injured patient? (Select all that apply.)

Apply topical antibacterial wound ointments/dressings Daily assess the need for central IV catheters Maintain strict aseptic technique during burn wound management

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?

Assess for signs of peptic ulcer.

Which of the following factors increase the burn patients risk for venous thromboembolism? (Select all that apply.)

Bedrest Delayed fluid resuscitation Burns to lower extremities

The nurse is assisting the patient to select foods from the menu that will promote wound healing. Which statement indicates the nurses knowledge of nutritional goals?

Choose foods that are high in protein, such as meat, eggs, and beans. These help the burns to heal

Which of the following would be seen in a patient with myxedema coma?

Decreased reflexes

A patient has been on daily, high-dose glucocorticoid therapy for the treatment of rheumatoid arthritis. His prescription runs out before his next appointment with his physician. Because he is asymptomatic, he thinks it is all right to withhold the medication for 3 days. What is likely to happen to this patient?

He will go into adrenal crisis.

Cellular immunity is mediated by

T lymphocytes

The process by which the body actively produces cells and mediators that result in the destruction of the antigen is called

active immunity

The nurse is caring for a patient with acute pancreatitis. To provide adequate pain control, the nurse

administers pain medication on a routine schedule

A 20-year-old female with a history of type 1 diabetes and an eating disorder is found unconscious. In the emergency department, the following lab values are obtained: Glucose 648 mg/dL pH 6.88 PaCO 220 mm Hg PaO295 mm Hg HCO3 undetectable Anion gap>31 Na+127 mEq/L K+ 3.5 mEq/L Creatinine 1.8 mg/dL

administration of a 1-L normal saline fluid bolus.

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.)

aminoglycosides. antiplatelet agents. cephalosporins. sulfonamides.

The patient has yellow skin and low hemoglobin and hematocrit levels. The nurse should look for

an elevated bilirubin level

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:

an immunoglobulin infusion

Causes of anemia include: (Select all that apply.)

blood loss. impaired production of red blood cells. increased destruction of red blood cells.

The nurse is caring for a patient who has undergone skin grafting of the face and arms for burn wound treatment. A primary nursing diagnosis is

body image disturbance

The patient is admitted with multiple myeloma. The nurse assesses the patient and is aware that the symptom most unique to this disease is

bone pain

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:

complete blood count (CBC) with differential

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

complete blood count, including platelet count

Of the four major blood components, plasma:

comprises about 55% of blood volume.

The liver detoxifies the blood by

converting fat-soluble compounds to water-soluble compounds

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

cut all three lumina and remove the tube

The nurse is caring for a patient who has had a portacaval shunt placed surgically. The nurse is aware that this procedure

decreases rebleeding

Acute adrenal crisis is caused by

deficiency of corticosteroids

Infection by Helicobacter pylori bacteria is a major cause of

duodenal ulcers

Trends in nutritional management of the patient with pancreatitis are changing. As a result, the nurse understands that

immediate oral feeding in patients with mild pancreatitis may help recovery

In patients with extensive burns, edema occurs in both burned and unburned areas because of

increased capillary permeability

The nurse notes that the patients neutrophil count is less than 500 cells/microliter. The nurse realizes that this patient is

is at severe risk for infection

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:

is at severe risk for infection

Inflammation is initiated by cellular injury and: (Select all that apply.)

is necessary for tissue repair is harmful when uncontrolled

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

ischemia associated with sepsis

When assessing bowel sounds, the nurse

listens for 5 minutes before noting absent bowel sounds

When assessing the patients bowel sounds, the nurse

listens to bowel sounds before palpation

When caring for a patient with HIV, the nurse should

monitor the patients medication regimen

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

observe for diarrhea

The patient is diagnosed with hepatitis. In caring for this patient, the nurse should

provide rest, nutrition, and antiemetics if needed

The patient is being admitted with GI bleeding. Blood work includes serial hemoglobin and hematocrit levels. The nurse understands that

the hematocrit value does not change substantially during the first few hours

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

1500 cells/microliter or higher

The nurse is providing postoperative care to a patient who underwent a transsphenoidal hypophysectomy for a benign pituitary tumor. The nurse administers replacement hydrocortisone, thyroid hormone, and vasopressin. The nurse evaluates that the vasopressin replacement is effective when

2 liters of urine are produced in a 24-hour period

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

2800 cells/microliter

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

AIDS is considered a chronic disease

Secondary immunodeficiency involves the loss of a previously functional immune defense system that can be caused by: (Select all that apply.)

AIDS. aging. nutritional deficiencies. immunosuppressive therapies

The nurse is caring for a patient who has circumferential full-thickness burns of his forearm? A priority in the plan of care is

Active and passive range of motion every hour

Which of the following statements about the pain management of a burn victim are true? (Select all that apply.)

Additional pain medication may be needed because of rapid body metabolism Pain medication should be given before procedures such as debridement, dressing changes, and physical therapy Patients with a history of drug and alcohol abuse will require higher doses of pain medication

Which of the following are appropriate nursing interventions for the patient in myxedema coma? (Select all that apply.)

Administer levothyroxine (Synthroid) as ordered Initiate passive rewarming interventions Monitor airway and respiratory effort

The nurse is caring for a patient with burns to the hands, feet, and major joints. The nurse plans care to include which of the following? (Select all that apply.)

Applying splints that maintain the extremity in an extended position Implementing passive or active range-of-motion exercises Wrapping fingers and toes individually with bandages

An elderly individual from an assisted living facility presents with severe scald burns to the buttocks and back of the thighs. The caregiver from the ALF accompanies the patient to the emergency department and states that the bath water was too hot and that the patient sat in the water too long. What should the nurse do?

Ask the caregiver to step out while examining the patients burn injury

A patient presents to the emergency department with suspected thyroid storm. The nurse should be alert to which of the following cardiac rhythms while providing care to this patient?

Atrial fibrillation

Vascular sounds such as bruits, heard in the abdomen during physical assessment, may indicate which of the following?

Dilated vessels Tortuous vessels Constricted vessels

The nurse is conducting an admission assessment of an 82-year-old patient who sustained a 12% burn from spilling hot coffee on the hand and arm. Which statement is of priority to assist in planning treatment?

Do you have a heart condition or heart failure?

Patients with burns may have mesh grafts or sheet grafts. Which of the following sites is most likely to have a sheet graft applied?

Face

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

Kupffers cells

Which complications may manifest after an electrical injury? (Select all that apply.)

Long bone fractures Cardiac dysrhythmias Compartment syndrome of extremities Dark brown urine Acute cataract formation Seizures

The nurse understands that negative-pressure wound therapy may be used in the treatment of partial- thickness burn wounds to do which of the following?

Remove excessive wound fluid and promote moist wound healing

The nurse is planning care to meet the patients pain management needs related to burn treatment. The patient is alert, oriented, and follows commands. The pain is worse during the day when various treatments are scheduled. Which statement to the physician best indicates the nurses knowledge of pain management for this patient?

The patients pain varies depending on the treatment given. Can we try patient-controlled analgesia to see if that helps the patient better?

A 63-year-old patient is admitted with new onset fever; flulike symptoms; blisters over her arms, chest, and neck; and red, painful, oral mucous membranes. The patient should be further evaluated for which possible nonburn injured skin disorder?

Toxic epidermal necrolysis

Which of the following statements is true about the medical management of diabetic ketoacidosis?

Volume replacement and insulin infusion often correct the acidosis.

The patient asks the nurse if the placement of the autograft over his full-thickness burn will be the only surgical intervention needed to close his wound. The nurses best response would be

Yes, an autograft will transfer your own skin from one area of your body to cover the burn wound

Cases of primary immunodeficiency are usually related to

a single gene defect

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

an increased D-dimer level

A reduction in the number of circulating RBCs or hemoglobin, which leads to inadequate oxygenation of tissues, is known as

anemia

The patient is admitted with the diagnosis of GI bleeding. The patients heart rate is 140 beats per minute, and his blood pressure is 84/44 mm Hg. These values may indicate

approximately 25% loss of total blood volume

In caring for the patient who has a coagulopathy, the nurse should: (Select all that apply.)

assess fluids for occult blood. limit invasive procedures. weigh dressings to assess blood loss.

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

between 85,000/microliter and 135,000/microliter.

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

bismuth will be added to the current triple therapy

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 patients abdomen is rigid. The nurse should

call the provider 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?

cardiac output of 8 L/min

The nurse is caring for a patient receiving chemotherapeutic agents, and notices that the patients neutrophils count is low. The nurse realizes that

chemotherapeutic agents alter the ability to fight infection

When dealing with hematological malignancies, therapies that have significant management roles include: (Select all that apply.)

chemotherapy. biotherapy. bone marrow transplantation. radiation

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

decrease splanchnic blood flow and portal pressure

The nurse is caring for a patient who has a Sengstaken-Blakemore tube in place. In caring for this patient, the nurse must

deflate the esophageal balloon before the gastric balloon

Exudate formation at the inflammatory site functions to: (Select all that apply.)

dilute toxins. deliver proteins. carry away toxins.

A(An) ____________________ often produces a superficial cutaneous injury but may cause cardiopulmonary arrest and transient but severe central nervous system deficits.

electrical burn

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

enhance humoral immune response

Erythrocytes (RBCs) are generated from precursor stem cells under the influence of a growth factor called

erythropoietin

The patient is admitted with acute pancreatitis. The nurse should

evaluate C-reactive protein as a gauge of severity

In vivo, the primary activator of the coagulation cascade occurs via the

extrinsic pathway

Common to both the intrinsic and the extrinsic pathway is

factor X

The nurse understands that when clots breakdown in a patient with a hematological disorder, that which value will increase?

fibrin split products

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

give the platelets before the RBCs

Erythrocytes (RBCs) are flexible biconcave disks without nuclei whose primary component is an oxygen- carrying molecule called:

hemoglobin.

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

hemolytic anemia

When examining the patients laboratory values, the nurse notices an elevation in the eosinophil count. The nurse realizes that eosinophils become elevated

in response to allergens and parasites

Critical to caring for the immunocompromised patient is the understanding that

infection is the leading cause of death in these patients

Numbers of white blood cells (WBCs) are increased in circumstances of: (Select all that apply.)

inflammation allergy invasion by pathogenic organisms

Autoimmunity can result from: (Select all that apply.)

injury to tissues. infection. malignancy. unknown causes

An autograft is used to optimally treat a partial- or full-thickness wound that:(Select all that apply.)

involves a joint. involves the face, hands, or feet. requires more than 2 weeks for healing.

The patient is diagnosed with lymphoma, but has a normal white blood cell (WBC) count. The nurse understands that this patient

is at risk for infection

Silver is used as an ingredient in many burn dressings because

it is effective against a wide spectrum of wound pathogens

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

killer T lymphocytes

The nurse is assessing a patient being admitted for anemia. The nurse sees no overt signs of bleeding. The nurse understands that

many patients have bleeding that is not obvious

Lymphocytes are made up of B cells and T cells. B cells

mediate humoral immunity

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

opsonization

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

pH 7.24

The patient is admitted for chemotherapy, but the nurse notices laboratory values indicating that the patient is immunosuppressed. The nurse should

place the patient in a single room with a HEPA filtration system

Accepted treatments for disseminated intravascular coagulation (DIC) may require: (Select all that apply.)

platelet infusions. administration of fresh frozen plasma. cryoprecipitate. packed RBCs.

A burn patient in the rehabilitation phase of injury is increasingly anxious and unable to sleep. The nurse should consult with the provider to further assess the patient for:

posttraumatic stress disorder

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

protein C deficiency

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

provide RBC transfusion because this level is below the normal threshold

The nurse is caring for a patient with an electrical injury. The nurse understands that patients with electrical injury are at a high risk for acute kidney injury secondary to

release of myoglobin from injured tissues

The nurse is caring for a patient with a chemical burn injury. The priority nursing intervention is to

remove the patients clothes and flush the area with water

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:

sickle cell anemia

The patient is admitted with neutropenia. The nurse should continually assess the patient for

signs of systemic infection

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

the increase in neutrophil count

The patient has a platelet count of 9,000/microliter. The nurse realizes that

the patient is at great risk for fatal hemorrhage

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

the patients inability to store platelets

With minor vessel injury, primary hemostasis is achieved

usually within seconds

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

vitamin K injection

Two types of specific immune responses exist: humoral immunity and cell-mediated immunity. These responses

work together to provide immunity

Mechanisms for development of diabetes insipidus include which of the following? (Select all that apply.)

ADH deficiency ADH insensitivity

The nurse is caring for a burn-injured patient who weighs 154 pounds, and the burn injury covers 50% of his body surface area. The nurse calculates the fluid needs for the first 24 hours after a burn injury using a standard fluid resuscitation formula of 4 mL/kg/% burn of intravenous (IV) fluid for the first 24 hours. The nurse plans to administer what amount of fluid in the first 24 hours?

14L 154 pounds/2.2 = 70 kg 4 x 70 kg x 50 = 14,000 mL, or 14 liters.

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 female who is undergoing evaluation for pheochromocytoma 43-year-old male 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 female who is receiving intravenous (IV) steroids for an exacerbation of chronic obstructive pulmonary disease (COPD)

A patient with long-standing type 1 diabetes presents to the emergency department with a loss of consciousness and seizure activity. The patient has a history of renal insufficiency, gastroparesis, and peripheral diabetic neuropathy. Emergency personnel reported a blood glucose of 32 mg/dL on scene. When providing discharge teaching for this patient and family, the nurse instructs on the need to do which of the following? (Select all that apply.)

Administer 15 grams of carbohydrate orally for severe episodes of hypoglycemia Increase home blood glucose monitoring and report patterns of hypoglycemia to the provider Perform blood glucose monitoring before exercising and driving

A patient with newly diagnosed type 1 diabetes is being transitioned from an infusion of intravenous (IV) regular insulin to an intensive insulin therapy regimen of insulin glargine (Lantus) and insulin aspart (NovoLog). How should the nurse manage this transition in insulin delivery?

Administer the insulin glargine and discontinue the IV infusion in several hours

What psychosocial factors may potentially contribute to the development of diabetic ketoacidosis?

Altered sleep/rest patterns Eating disorder High levels of stress Lack of financial resources

Which of the following patients is at the highest risk for hyperosmolar hyperglycemic syndrome

An 83-year-old, long-term care resident with type 2 diabetes and advanced Alzheimers disease who recently developed influenza

A college student was admitted to the emergency department after being found unconscious by a roommate. The roommate informs emergency medical personnel that the student has diabetes and has been experiencing flulike symptoms, including vomiting, since yesterday. The patient had been up all night studying for exams. The patient used the last diabetes testing supplies 3 days ago and has not had time to go to the pharmacy to refill prescription supplies. Based upon the history, which laboratory findings would be anticipated in this client? (Select all that apply.)

Blood glucose 524 mg/dL HCO3 10 mEq/L pH 7.23

The nurse is caring for patient who has been struck by lightning. Because of the nature of the injury, the nurse assesses the patient for which of the following?

Central nervous system deficits

The nurse is caring for a patient who suffered a head trauma following a fall. The patients heart rate is 112 beats/min and blood pressure is 88/50 mm Hg. The patient has poor skin turgor and dry mucous membranes. The patient is confused and restless. The following laboratory values are reported: serum sodium is 115 mEq/L blood urea nitrogen (BUN) 50 mg/dL creatinine 1.8 mg/dL. The findings are consistent with which disorder?

Cerebral salt wasting

An individual with type 2 diabetes who takes glipizide (Glucotrol) to control her blood glucose has begun a formal exercise program at a local gym. While exercising on the treadmill, she becomes pale, diaphoretic, and shaky. She has a headache and feels as though she is going to pass out. What is the individuals priority action?

Eat something with 15 g of simple carbohydrates.

An elderly female patient has presented to the emergency department with altered mental status, hypothermia, and clinical signs of heart failure. Myxedema is suspected. Which of the following laboratory findings support this diagnosis?

Elevated thyroid-stimulating hormone

Which of the following is a high-priority nursing diagnosis for both diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome?

Fluid volume deficient

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:

H2-histamine receptor blockers.

Factors associated with the development of nephrogenic diabetes insipidus include which of the following? (Select all that apply.)

Heredity Medications, including phenytoin (Dilantin) and lithium carbonate Sickle cell disease

In hyperosmolar hyperglycemic syndrome, the laboratory results are similar to those of diabetic ketoacidosis, with three major exceptions. What differences would you expect to see in patients with hyperosmolar hyperglycemic syndrome?

Higher serum glucose, higher osmolality, and no ketosis

The nurse is caring for a patient who underwent pituitary surgery 12 hours ago. The nurse will give priority to monitoring the patient carefully for which of the following?

Hypovolemic shock

When paramedics notice singed hairs in the nose of a burn patient, it is recommended that the patient be intubated. What is the reasoning for the immediate intubation?

Inhalation injury above the glottis may cause significant edema that obstructs the airway

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

Injury to certain cells in the pancreas causes it to digest (eat) itself, causing pain

The patient is admitted with end-stage liver disease. The nurse evaluates the patient for which of the following?

Malnutrition Ascites Disseminated intravascular coagulation

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?

Potassium

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

Serum sodium 115 mEq/L

When caring for the patient with upper GI bleeding, the nurse assesses for which of the following?

Severity of blood loss Hemodynamic stability Necessity for fluid resuscitation

A patient presents to the emergency department (ED) with the following clinical signs: Pulse: 132 beats/min Blood pressure: 88/50 mm Hg Respiratory rate: 32 breaths/min Temperature: 104.8 F Chest x-ray: Findings consistent with congestive heart failure Cardiac rhythm: Atrial fibrillation with rapid ventricular response These signs are consistent with which disorder?

Thyroid storm

The nurse is caring for a patient with head trauma who was admitted to the surgical intensive care unit following a motorcycle crash. What is an important assessment that will assist the nurse in early identification of an endocrine disorder commonly associated with this condition?

Urine osmolality

In the management of diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome, when is an intravenous (IV) solution that contains dextrose started?

When the blood glucose reaches 250 mg/dL

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 Mallory-Weiss tear is a longitudinal tear in the gastroesophageal mucosa

The nurse is assigned to care for a patient who presented to the emergency department with diabetic ketoacidosis. A continuous insulin intravenous infusion is started, and hourly bedside glucose monitoring is ordered. The targeted blood glucose value after the first hour of therapy is

a decrease of 50 to 75 mg/dL compared with admitting values

The nurse is caring for a patient with liver disease. When assessing the patients laboratory values, the nurse should

assess the indirect serum bilirubin.

The nurse is assessing the patient admitted with pancreatitis. In doing so, the nurse:

assesses symptoms that could indicate involvement of the stomach

Metronidazole is being given to treat hepatic encephalopathy. When administering this medication, the nurse

assesses the patient for epigastric discomfort

The nurse is caring for a 27-year-old patient with a diagnosis of head trauma. The nurse notes that the patients urine output has increased tremendously over the past 18 hours. The nurse suspects that the patient may be developing

diabetes insipidus

A patient with type 1 diabetes who is receiving a continuous subcutaneous insulin infusion via an insulin pump contacts the clinic to report mechanical failure of the infusion pump. The nurse instructs the patient to begin monitoring for signs of

diabetic ketoacidosis

The patient is getting neomycin for treatment of hepatic encephalopathy. While the patient is receiving this medication, it is especially important that the nurse

evaluate renal function studies daily

A patient 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

fluid restriction

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

has a 15% chance of dying

The nurse is assessing a patient who is admitted with abdominal pain. To detect abdominal masses, the nurse

has the patient take a deep breath

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?

heart rate 125 beats per minute

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

hemoglobin 10.5 g/dL and hematocrit 32%

The optimal measurement of intravascular fluid status during the immediate fluid resuscitation phase of burn treatment is

hourly intake and urine output

The most significant clinical finding of acute adrenal crisis associated with fluid and electrolyte balance is

hyperkalemia

The nurse is to assist the provider in performing bedside endoscopy on a patient. The prevent respiratory complications, the nurse places the patient

in a left lateral reverse Trendelenburg position

Pain control is a nursing priority in patients with acute pancreatitis because pain

increases pancreatic secretions

In assessing the patient complaining of abdominal pain, it is important for the nurse to understand that

increasing intensity of pain is always significant

Tissue damage from burn injury activates an inflammatory response that increases the patients risk for

infection

The patient is ordered to have large volume gastric lavage. The nurse will most likely need to

insert a large-bore nasogastric tube

A patient with a 60% burn in the acute phase of treatment develops a tense abdomen, decreasing urine output, hypercapnia, and hypoxemia. Based on this assessment, the nurse anticipates interventions to evaluate and treat the patient for:

intraabdominal hypertension

Nursing priorities for the management of acute pancreatitis include

managing respiratory dysfunction. assessing and maintaining electrolyte balance utilizing supportive therapies aimed at decreasing gastrin release

A patient admitted with severe burns to his face and hands is showing signs of extreme agitation. The nurse should explore the mechanism of burn injury possibly related to

methamphetamine use

The patient is admitted with pancreatitis and has severe ascites. In caring for this patient, the nurse should

monitor the patients blood pressure and evaluate for signs of dehydration

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

obtain a stool sample for guaiac testing

The nurse is providing insulin education for an elderly patient with longstanding diabetes. An order has been written for the patient to take 20 units of insulin glargine (Lantus) at 10 PM nightly. The nurse should instruct the patient that the peak of the insulin action for this agent is:

peakless

The nurse is caring for a patient with severe pancreatitis and who is orally intubated and on mechanical ventilation. The patients calcium level this morning was 5.5 mg/dL. The nurse notifies the provider and

places the patient on seizure precautions

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 nurses first action should be to

position the patient in a semi-Fowlers position

The nurse is caring for a critically ill patient with respiratory failure who is being treated with mechanical ventilation. As part of the patients care to prevent stress ulcers, the nurse would provide

proton pump inhibitors. anticholinergic drugs antacids

The patient is admitted with constipation. In anticipation of treatment, the nurse prepares to

provide therapies that will innervate the autonomic nervous system.

The patient is admitted with acute pancreatitis and is later diagnosed as having a pseudocyst. The nurse realizes that

pseudocysts may resolve spontaneously, so surgery may be delayed

The liver plays a major role in homeostasis by

removing active clotting factors from the circulation

The nurse is caring for a patient who is passing bright red blood rectally. The nurse should expect to insert a nasogastric tube to

rule out massive upper GI bleeding

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 patients fluid intake has been sufficient. The nurses realizes that the condition of the patients mouth is probably caused by

sympathetic nerve stimulation.

A patient is admitted to the oncology unit with a small cell lung carcinoma. During the admission, the patient is noted to have a significant decrease in urine output accompanied by shortness of breath, edema, and mental status changes. The nurse is aware that this clinical presentation is consistent with

syndrome of inappropriate secretion of antidiuretic hormone (SIADH)

After gastric bypass surgery, the patient is getting vitamin B12 via injection. The patient asks why he cant get the vitamin by mouth. The nurse explains that:

the patient may not have enough intrinsic factor for normal absorption.

The nurse is providing care to manage the pain of a patient with burns. The physician has ordered opiates to be given intramuscularly. The nurse contacts the physician to change the order to intravenous administration because:

tissue edema may interfere with drug absorption of injectable routes

Lactulose is considered the first-line treatment for hepatic encephalopathy and works by

trapping ammonia in the bowel for excretion

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

vitamins D is stored in the liver with a 10-month supply to prevent deficiency