Final Quiz Critical Care
. The nurse is caring for an 18-year-old 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 patients 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
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
The nurse is providing preoperative care to a patient who will receive a transplant. The patient has high panel reactive antibodies (PRA). As part of induction therapy for this patient, the nurse understands which medication to be of priority for administration in the operating room? a. Alemtuzumab (Campath) b. Tacrolimus (Prograf) c. Sirolimus (Rapamune) d. Cyclosporine (Neoral)
a
The nurse is working for a hospital that holds an agreement with a local organ procurement organization (OPO). The patient has a Glasgow Coma Scale (GCS) score of 3 and discussions have been held with the family about withdrawing life support. Which statement by the nurse best describes requirements that must be met to sustain Centers for Medicare and Medicaid Services (CMS) Conditions of Participation? a. I need to notify TransLife (OPO) of my patients impending death. b. I will contact the physician to obtain informed consent for organ donation. c. The charge nurse will notify TransLife (OPO) once the patient has been pronounced brain dead. d. I need the physician to evaluate my patients suitability for organ donation.
a
The transplant clinic nurse is conducting a pretransplant education session for patients being evaluated for liver transplantation. Which statement by the nurse provides the best explanation of the numeric system used to classify the severity of a patients liver disease? a. A score is calculated based upon kidney function, clotting time, and bilirubin levels. b. A score is calculated that ranges between 6 and 40, with the lower score being more serious. c. There are currently no exceptions to the MELD score calculation for severity of disease. d. The calculated score represents the patients risk of death within 1 year of diagnosis.
a
The transplant clinic nurse is educating a patient about the renal criteria that must be met in order to be placed on the transplant waiting list. Which statement by the patient best indicates an understanding of the criteria? a. I qualify if my glomerular filtration rate is less than 20 mL per minute. b. I will not qualify until I have to go on regular hemodialysis treatments. c. My blood type does not have to be a match with the donor blood type. d. The national waiting list is based on the ability to pay for medications.
a
. The transplant clinic coordinator is evaluating relatives of a patient with end-stage renal disease, whose blood type is A positive, for suitability as a living donor for kidney transplantation. Which family member best qualifies for evaluation? a. A 65-year-old brother with a history of hypertension; blood type A positive b. A 35-year-old female with a history of food allergies; blood type O negative c. A 14-year-old son, otherwise healthy with no history; blood type B negative d. A 70-year-old mother, with a history of sinus infections; blood type A positive
b
A renal transplant recipient presents to the outpatient transplant clinic with blood glucose values for the past 3 days exceeding 250 mg/dL. The patient takes prednisone 5 mg daily and tacrolimus (Prograf) 2 mg twice daily. Hemoglobin A1C level drawn the day of the clinic appointment was 8.5%. What is the best interpretation of this finding by the nurse? a. The patient is at increased risk for infection. b. The patient has developed posttransplant diabetes. c. Temporary elevations in blood sugars are normal. d. Discontinuation of steroids will normalize values.
b
The postanesthesia care unit receives handoff communication from the CRNA indicating that the renal transplant recipient received induction therapy in the operating room with antithymocyte globulin (ATG). What is the best understanding of the administration of this drug by the nurse? a. The drug is administered for recipients of CMV-positive donor organs. b. Administration of the drug decreases initial postoperative rejection rates. c. Antiproliferative agents are recommended for routine induction therapy. d. Antithymocyte globulin (ATG) is given as a single dose in the OR.
b
The transplant clinic nurse is conducting patient education on the importance of follow-up health screening activities important in detecting complications associated with long-term immunosuppressant therapy. Which statement is most important for the nurse to include in the discussion? a. Application of sunscreen may cause a reaction. b. Avoid sun exposure during peak hours of the day. c. Melanoma is the most common type of cancer. d. Skin examinations should occur every 5 years.
b
The transplant clinic nurse is educating a group of transplant recipients on health promotion and maintenance. What is the priority statement by the nurse? a. Adhere to all future scheduled appointments with the clinic. b. Obtain annual vaccinations for pneumonia from your physician. c. Report all routine lab results to your primary care physician. d. Notify the transplant clinic of all future hospital admissions.
b
Fifteen minutes after beginning a transfusion of O negative blood to a patient in shock, the nurse assesses a drop in the patients 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 patients Foley catheter. What are the priority nursing actions? (Select all that apply.) a. Administer acetaminophen (Tylenol). b. Document the patients response. c. Increase the rate of transfusion. d. Notify the blood bank. e. Notify the physician. f. Stop the transfusion.
b, d, e, f
. 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
A family member approaches the nurse caring for their gravely ill son and states, We want to donate our sons organs. What is the best action by the nurse? a. Arrange a multidisciplinary meeting with physicians. b. Consult the hospitals ethics committee for a ruling. c. Notify the organ procurement organization (OPO). d. Obtain family consent to withdraw life support.
c
A patient is admitted after collapsing at the end of a summer marathon. She 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 Ringers bolus d. Packed red blood cells
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 in cardiogenic shock who is being treated with an infusion of dobutamine (Dobutrex). The physicians order calls for the nurse to titrate the infusion to achieve a cardiac index of >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 (Dobutrex). d. Assess the patients 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 96.8 F. Which intervention is most important for the nurse to include in the patients plan of care? a. Administration of atropine sulfate (Atropine) b. Application of 100% oxygen via facemask c. Application of slow rewarming measures d. Infusion of IV phenylephrine (Neo-Synephrine)
c
The nurse is caring for a patient in the critical care unit who, after being declared brain dead, is being managed by the OPO transplant coordinator. Thirty minutes into the shift, assessment by the nurse includes a blood pressure 75/50 mm Hg, heart rate 85 beats/min, and respiratory rate 12 breaths/min via assist/control ventilation. The oxygen saturation (SpO2) is 99% and core temperature 93.8 F. Which physician order should the nurse implement first? a. Apply forced air warming device to keep temperature > 96.8 b. Obtain basic metabolic panel every 4 hours until surgery c. Begin phenylephrine (Neo-Synephrine) for systolic BP < 90 mm Hg d. Draw arterial blood gas every 4 hours until surgery
c
The nurse is caring for a renal transplant recipient in the postanesthesia care unit. Handoff communication from the OR included a reported output of 500 mL following anastomosis of the renal vessels and reperfusion. One hour after the transplant recipient was admitted to the PACU, the RN notes no urine output. Which physician order should the nurse implement first? a. Administer 20 mg furosemide intravenous (IV) every 4 hours as needed for urine output < 30 mL/hr. b. Administer a 500-mL bolus of 0.9% normal saline intravenously over 2 hours. c. Irrigate the indwelling urinary catheter gently with 30 mL 0.9% normal saline. d. Provide maintenance IV fluids of D5 NS to infuse at 100 mL/hr.
c
Which statement best represents appropriate donor-to-recipient criteria for liver transplantation? a. Blood type and HLA tissue type b. HLA tissue type and body type c. Body type and body size d. Blood type and donor history
c
. 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
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
A patient presents to the outpatient transplant clinic stating, I would like to donate one of my kidneys. What is the best response by the nurse? a. To be a living donor, you must be related to the recipient. b. You must be over the age of 30 to be a living donor. c. Living donor donation is coordinated by UNOS. d. Let us orient you to the process required to become a donor.
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 charge nurse of a transplant unit is reviewing the clinical course of several transplant patients being cared for in the unit. Which patient assessed by the charge nurse requires immediate action? a. Renal transplant recipient, 1 day post op with a 3/10 pain level b. Lung transplant recipient, 1 day post op with a productive cough c. Heart transplant recipient, 1 day post op with a cardiac output of 4 L/min d. Liver transplant recipient, 12 hours post op with a serum glucose of 58 mg/dL
d
After receiving a handoff report from the night shift, the nurse completes the morning assessment of a patient with severe sepsis. Vital sign assessment notes 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 active physician order first? a. Administer infusion of 500 mL 0.9% normal saline every 4 hours as needed if the CVP is < 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 > 101 F.
a
The charge nurse is reviewing the status of patients in the critical care unit. Which patient should the nurse notify the organ procurement organization to evaluate for possible organ donation? a. A 36-year-old patient with a Glasgow Coma Scale score of 3 with no activity on electroencephalogram b. A 68-year-old male admitted with unstable atrial fibrillation who has suffered a stroke c. A 40-year-old brain-injured female with a history of ovarian cancer and a Glasgow Coma Scale score of 7 d. A 53-year-old diabetic male with a history of unstable angina status post resuscitation
a
The family of a critically ill patient has asked to discuss organ donation with the patients nurse. When preparing to answer the familys questions, the nurse understands which concern(s) most often influence a familys decision to donate? (Select all that apply.) a. Donor disfigurement influences on funeral care b. Fear of inferior medical care provided to donor c. Age and location of all possible organ recipients d. Concern that donated organs will not be used e. Fear that the potential donor may not be deceased f. Concern over financial costs associated with donation
a, b, e, f,
The nurse is caring for a young adult 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,
The nurse is caring for a patient with severe sepsis who was resuscitated with 3000 mL of lactated Ringer 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
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 (Benadryl) 50 mg intravenously b. Epinephrine 3 to 5 mL of a 1:10,000 solution intravenously c. Methylprednisolone (Solu-Medrol) 125 mg intravenously d. Ranitidine (Zantac) 50 mg intravenously
b
The nurse is caring for a renal transplant patient admitted with an acute rejection episode. The patient asks the nurse how the doctors will know if the kidney has been rejected. What is the best response by the nurse? a. Your admission lab results will determine if your kidney is being rejected. b. A procedure called a renal biopsy will be the best way to confirm rejection. c. Monitoring over the next few days will determine if your kidney is failing. d. An ultrasound of your kidney will determine if your kidney has failed.
b
The nurse is managing a donor patient six hours prior to the scheduled harvesting of the patients organs. Which assessment finding requires immediate action by the nurse? a. Morning serum blood glucose of 128 mg/dL b. pH 7.30; PaCO2 38 mm Hg; HCO3 16 mEq/L c. Pulmonary artery temperature of 97.8 F d. Central venous pressure of 8 mm Hg
b
The nurse is preparing to admit a patient with heart failure who has been listed on the UNOS transplant list as status 1A. What is the best understanding of this classification by the nurse? a. The patient can be managed at home with a left ventricular assist device. b. Hospitalization is required with mechanical support and vasoactive infusions. c. The patient has advanced heart failure and is being managed with medication. d. An advanced heart failure patient not successfully managed on medications.
b
The nurse is providing discharge instructions to a renal transplant recipient. The patient has a follow-up appointment the next day for routine post-transplant laboratory bloodwork, including trough levels of anti-rejection medications.Which instruction describes what the patient should do regarding the anti-rejection medications the next day? a. Take your morning dose of medications at midnight with sips of water. b. Take your morning dose of medications after labs have been drawn. c. Skip your morning dose of medications and then resume your evening doses. d. Hold all doses of your medications the day you have labs drawn.
b
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 patients 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 educating a renal transplant patient about his immunosuppressant medication therapy. Which statement by the patient best indicates an appropriate understanding? a. I will be gradually weaned off my medications during my lifetime. b. After 6 months, I will be down to taking one medication for life. c. My doctors may try to stop my steroids soon after my transplant. d. I will only need to take my mediations every other day for life.
c
The nurse has been administering 0.9% normal saline intravenous fluids as part of early goal-directed therapy protocols 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 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. Assuming physician orders, 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 obtains initial vital signs on a patient 2 weeks posttransplant who presents for follow-up monitoring to the outpatient transplant clinic. Which assessment finding by the nurse requires immediate action? a. Blood pressure of 100/60 mm Hg b. Serum creatinine of 1.5 mg/dL c. Hemoglobin of 9.2 gm/dL d. Tenderness over graft site
d
Which clinical scenario best represents hyperacute rejection? a. A cardiac transplant patient with a 3-month history of shortness of breath b. A lung transplant patient with small pustules that follow a dermatome c. A liver transplant patient with several small lumps under the skin d. An implanted renal transplant that, upon reperfusion, becomes cyanotic
d
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 patients 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 assesses morning lab results for a postoperative day 1 liver transplant recipient. Lab results noted by the nurse include aspartate transaminase (AST) 365 U/L; alanine aminotransferase (ALT) 400 U/L; and serum glucose of 85 mg/dL. What is the best action by the nurse? a. Notify the physician of liver enzyme results. b. Treat hypoglycemia with 50 mL 5% dextrose. c. Repeat the liver enzyme results in 4 hours. d. Prepare to administer IV insulin infusion.
a
The nurse is caring for a mechanically ventilated patient following insertion of a left subclavian central venous catheter (CVC). What action by the nurse best protects against the development of a central lineassociated 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 (Dobutrex) b. Furosemide (Lasix) c. Phenylephrine (Neo-Synephrine) d. Sodium nitroprusside (Nipride)
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 who is 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 a patient who is being evaluated clinically for brain death by a physician. Which assessment findings by the nurse support brain death? a. Absence of a corneal reflex b. Unequal, reactive pupils c. Withdrawal from painful stimuli d. Core temperature of 100.8 F
a
The nurse is caring for a renal transplant recipient in the post-anesthesia care unit. Blood pressure is 125/70 mm Hg; heart rate is 115 beats/min; respiratory rate is 24 breaths/min; oxygen saturation (SpO2) is 95% on 3 L/min of oxygen via nasal cannula, temperature is 97.8 F, and the central venous pressure (CVP/RAP) is 2 mm Hg. What is the best action by the nurse? a. Administer fluid replacement therapy; monitor intake and output closely. b. Increase supplemental oxygen to 100% non-rebreather mask; notify physician. c. Apply thermal warming blanket; administer all fluids through warming device. d. Assess the patient for pain; administer pain medications as ordered.
a
The nurse is providing postoperative education to a transplant patients family. When asked about detecting rejection, which answer by the nurse is most appropriate? a. Endomyocardial biopsies will be performed weekly for the first six weeks after surgery. b. Increased shortness of breath most likely indicates immediate, acute rejection of the heart. c. Biopsies of the heart are done every 6 months after the day of the transplant surgery. d. As time passes, the more biopsies that are performed, the more reliable the results become.
a
The transplant clinic social worker is completing a social history on a patient with end-stage renal disease who is being evaluated for transplant. Which statement by the patient warrants further action? a. I only smoke marijuana on an occasional basis. b. I have two sisters who live within two hours of me. c. I have attended all of my scheduled dialysis sessions. d. My mothers side of the family has a history of cancer.
a
Which statement best describes the lung allocation score (LAS) used to prioritize lung transplant recipients? a. The LAS is based on lab values, diagnostic tests, and medical diagnosis. b. Lungs from children and adolescents are offered to adults first. c. The LAS is limited to candidates under the age of 65 years. d. The score was developed to estimate 5-year survival rates.
a
While following up on a postoperative renal transplant recipient, the nurse discovers that the donor tested positive for cytomegalovirus (CMV). What is the priority action by the nurse? a. Notify the OPO transplant coordinator. b. Verify results with the lab technician. c. Repeat all pre-procedure viral studies. d. Continue to monitor for signs of rejection.
a
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 has just completed administration of a 1000-L bolus of 0.9% normal saline. 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 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 (Levophed) at 5 mcg/kg/min via a 20-gauge peripheral intravenous (IV) catheter. What 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 (Tylenol) 650-mg suppository prn every 6 hours for pain. b. Titrate dopamine (Intropin) intravenously for blood pressure < 90 mm Hg systolic. c. Complete neurological assessment every 4 hours for the next 24 hours. d. Administer furosemide (Lasix) 20 mg IV every 4 hours for a CVP > 20 mm Hg.
b
The nurse is caring for a mechanically ventilated patient following bilateral lung transplantation. When planning the care of this patient, what is the priority nursing intervention? a. Thirty-degree elevation of head of bed b. Endotracheal suctioning as needed c. Frequent side to side repositioning d. Sequential compression stockings
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 (Lasix) 20 mg intravenous (IV) every 4 hours as needed for CVP > 20 mm Hg b. Nitroglycerin infusion titrated at a rate of 5-10 mcg/min as needed for chest pain c. Dobutamine (Dobutrex) infusion at a rate of 2-20 mcg/kg/min as needed for CI < 2 L/min/m2 d. Dopamine (Intropin) infusion at a rate of 5-10 mcg/kg/min to maintain a systolic BP of at least 90 mm Hg
b
The nurse is caring for a postoperative renal transplant recipient in the critical care unit. After seeing minimal urine output in the catheter for most of the day, the patient expresses concern to the nurse. What is the best response by the nurse? a. Your kidney has unfortunately failed and will be removed. b. It can take a few days for your kidney to start working c. You are experiencing an acute rejection episode. d. You will have to undergo daily hemodialysis treatments.
b
The nurse is preparing to administer a renal transplant recipients first dose of mycophenolate mofetil (CellCept). Prior to administering the medication, the nurse appropriately reviews drug formulary information. What is the best understanding of this medication by the nurse? a. It is a calcineurin inhibitor used for induction therapy. b. It is an antimetabolite used for maintenance therapy. c. It is a polyclonal antibody used for maintenance therapy. d. It is an mTOR inhibitor used for maintenance therapy.
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
c
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 following a bilateral lung transplant. When planning postoperative care of the patient, priority is placed on pulmonary hygiene. Which statement provides the best explanation for this priority? a. Immunosuppressant medications reduce the bodys ability to fight infections. b. During the early postoperative period, atelectasis decreases oxygenation. c. Pulmonary hygiene reduces the risk of early primary graft dysfunction. d. Loss of cough reflex results in decreased ability to remove secretions effectively.
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
