Final2

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

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

The nurse is listening to a lecture on the physiological consequences of acute respiratory distress syndrome (ARDS). Which statement indicates that teaching has been effective? "ARDS is associated with decreased compliance." "ARDS is associated with decreased physiological dead space." "ARDS is associated with increased resistance." "ARDS is associated with Pulmonary fibrosis."

"ARDS is associated with decreased compliance." ARDS is associated with decreased lung compliance.

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

A Acute kidney injury resulting from obstruction of the flow of urine is classified as postrenal or obstructive renal injury.

The nurse is caring for a nonverbal critically ill adult patient who cannot communicate. Which pain scale should the nurse select to use with this patient? A. Behavioral pain scale (BPS) B. Pain intensity (0-10) scale C. PQRST method D. Visual Analog Scale (VAS)

A. Behavioral pain scale (BPS)

Which strategies should the nurse manager implement to improve collaboration in the critical care setting? (SATA) A. Initiate interdisciplinary rounds B. Create joint programs for continuing education C. Institute morning briefings D. Exclude family members from rounds

A. Initiate interdisciplinary rounds, B. Create joint programs for continuing education, C. Institute morning briefings

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

B

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

B

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

B

What is a minimally acceptable urine output for a patient weighing 75 kg? a) Less than 30mL/hr b) 37 mL.hr c) 80 mL/hr d) 150 mL/hr

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

The nurse is administering intravenous norepinephrine at 5 mcg/kg/min via a 20-gauge peripheral intravenous (IV) catheter. Which assessment finding requires immediate action by the nurse? a) BP 100/60 mmHg b) Swelling at the IV site c) HR 110 bpm d) CVP 8 mmHg

B Swelling at the IV site is indicative of infiltration. Infusion of norepinephrine through an infiltrated IV site can lead to tissue necrosis and requires immediate intervention by the nurse.

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

B The patient is exhibiting signs of anaphylaxis. For anaphylaxis with hypotension, epinephrine 0.3 to 0.5 mg (3 to 5 mL of 1:10,000 solution) is administered intravenously. Diphenhydramine will help block histamine release, but epinephrine is the drug of choice for anaphylaxis with hypotension.

A(An) ____________________ often produces a superficial cutaneous injury but may cause cardiopulmonary arrest and transient but severe central nervous system deficits. a) chemical burn b) electrical burn c) heat burn d) infection

B Tissue damage results from the conversion of electrical energy into heat. Monitor the patient for cardiac dysrhythmias.

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

B, C, D

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

B, C, D, E

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

C

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

C

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

C

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

a. Insertion of a nasotracheal tube

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

a. Level I

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

b. Change in sputum characteristics

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

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

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

b. Inhaled bronchodilators and intravenous corticosteroids

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

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

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

b. diffusion of oxygen and carbon dioxide is impaired.

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

c. 100 mL/hr.

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

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

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

c. hypovolemia.

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

d. Thrombolytics

The nurse is calculating the rate for a regular rhythm. There are 20 small boxes before each R wave. The nurse interprets the rate to be: 50 beats/min. 75 beats/min. 85 beats/min. 100 beats/min.

75 beats/min. Small box method: The small box method is used to calculate the exact rate of a regular rhythm. In this method, two consecutive P and QRS waves are located. The number of small boxes between the highest points of these consecutive P waves is counted, and that number is divided into 1500 to determine the atrial rate in beats per minute. The number of small boxes between the highest points of two consecutive QRS waves is counted, and that number is divided into 1500 to determine the ventricular rate. This method is accurate only if the rhythm is regular.

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

A

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

A

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

A

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

A Interventions that have been associated with a reduction in CLABSI include timely removal of unnecessary central lines. Documentation of the line insertion date will assist in monitoring this measure.

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? a) CNS deficits b) Contractures c) Infection d) Stress ulcers

A Lightning injury frequently causes cardiopulmonary arrest. However, of those patients who survive, 70% will have transient central nervous system deficits.

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

A, B Hypotension is common and is usually the result of preexisting hypovolemia, excessive amounts of fluid removal, or excessively rapid removal of fluid. Dysrhythmias may occur during dialysis. Causes of dysrhythmias include a rapid shift in the serum potassium level, clearance of antidysrhythmic medications, preexisting coronary artery disease, hypoxemia, or hypercalcemia from rapid influx of calcium from the dialysate solution.

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

A, B, C

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

A, B, C, D

Anxiety differs from pain in that: (Select all that apply.) a. it is confined to neurological processes in the brain. b. it is linked to reward and punishment centers in the limbic system. c. it is subjective. d. there is no actual tissue injury.

A, B, D Unlike pain, anxiety is linked to the reward and punishment centers in the limbic system of the brain. It is totally neurological and does not involve tissue injury. Like pain, it is a subjective phenomenon. Both anxiety and pain are subjective in nature.

The nurse is caring for a patient admitted with shock. The nurse understands which assessment findings best assess tissue perfusion in a patient in shock? (Select all that apply). a) BP b) HR c) LOC d) Pupil response e) Respirations f) Urine output

A, C, F The level of consciousness assesses cerebral perfusion, urine output assesses renal perfusion, and blood pressure is a general indicator of systemic perfusion.

A client is taking long-term corticosteroids for myasthenia gravis. What teaching is most important? a. Avoid large crowds and people who are ill. b. Check blood sugars four times a day. c. Use two forms of contraception. d. Wear properly fitting socks and shoes.

ANS: A Corticosteroids reduce immune function, so clients taking these medications must avoid being exposed to illness. Long-term use can lead to secondary diabetes, but the client would not need to start checking blood glucose unless diabetes had been detected. Corticosteroids do not affect the effectiveness of contraception. Wearing well-fitting shoes would be important to avoid injury, but not just because the client takes corticosteroids.

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

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

The intensive care nurse is caring for a client who has Guillain-Barré syndrome. The nurse notes that the client's vital capacity has declined to 12 mL/kg, and the client is having difficulty clearing secretions. Which is the nurse's priority action? a. Place the client in a high Fowler's position. b. Prepare the client for elective intubation. c. Administer oxygen via a nasal cannula. d. Auscultate for breath sounds.

ANS: B Deterioration in vital capacity to less than 15 mL/kg and an inability to clear secretions are indications for elective intubation. The other interventions may assist with breathing and oxygenation but would not reverse the deterioration in vital capacity or help clear secretions.

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

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

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

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

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

ANS: C The ICP is above the normal level of 15 mm Hg. The CPP is within the normal range. All other listed responses are incorrect.

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

ANS: C The dosing regimen is initiated with a bolus of 30 mg/kg over 15 minutes, followed in 45 minutes by a continuous intravenous infusion of 5.4 mg/kg/hr for 23 hours. (30 mg ´ 70 kg) + (5.4 mg ´ 70 kg) ´ 23 hours = 10,794 mg.

3. Which of the following laboratory values would be more common in patients with diabetic ketoacidosis? a. Blood glucose >1000 mg/dL b. Negative ketones in the urine c. Normal anion gap d. pH 7.24

ANS: D A pH of 7.24 is indicative of an acidotic state that may accompany diabetic ketoacidosis. Glucose values of more than 1000 mg/dL are more commonly associated with hyperosmolar hyperglycemic syndrome. Diabetic ketoacidosis is associated with positive urine ketones and an increased anion gap.

17. 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

ANS: D Tenderness over the graft site may be indicative of acute rejection in a renal transplant recipient 2 weeks posttransplant. Blood pressure, serum creatinine, and hemoglobin values are all within acceptable ranges and do not require immediate action.

The nurse is caring for a client with trigeminal neuralgia. Which patient problem is the priority for the nurse? a. Facial twitching b. Problems with communication c. Ptosis and diplopia d. Severe facial pain

ANS: D The client with trigeminal neuralgia (TN) has severe burning or sharp pain that is worsened by facial movement or eating. While the client may also experience facial twitching, managing pain is the priority problem. The client with TN usually does not have problems with communication or facial paralysis.

13. Which of the following statements is true about the medical management of diabetic ketoacidosis? a. Serum lactate levels are used to guide insulin administration. b. Sodium bicarbonate is a first-line medication for treatment. c. The degree of acidosis is assessed through continuous pulse oximetry. d. Volume replacement and insulin infusion often correct the acidosis.

ANS: D Volume replacement promotes hemodilution in the face of a hyperosmolar state. Insulin administration promotes entry of glucose into cells and relieves ketosis. As volume is replaced and glucose normalizes, the acidosis often resolves. Insulin administration, not lactate levels, is guided by blood glucose values. Sodium bicarbonate is only administered to correct severe acidosis (pH < 7.1). Degree of acidosis is assessed through arterial blood gas readings and serum ketone levels.

The nurse is assessing a patient for a possible pulmonary embolus. Assessment findings may include which of the following? Select all that apply. Acute onset of chest pain Hemoptysis Low oxygen saturation level Pleural friction rub

Acute onset of chest pain Hemoptysis Low oxygen saturation level Chest pain, hemoptysis, and a low oxygen saturation level are signs and symptoms of pulmonary embolus. A pleural friction rub is seen with disorders such as pleural effusion.

Immediate interventions in the treatment of a patient with burns from tar include which of the following? Apply cool water. Remove clothing that has been in contact with the tar. Try to remove tar that isn't well adhered to the skin. Apply ice over the tar/burn wounds.

Apply cool water. Remove clothing that has been in contact with the tar. Scald, tar, and asphalt burns are treated by immediate removal of the saturated clothing and cooling with water. No attempts should be made to remove adherent tar at the scene. Ice is never applied to wounds as it will further damage tissue by causing vasocontriction.

The nurse is caring for a patient with a diagnosis of acute myocardial infarction (AMI). Which medication should the nurse anticipate administering to the patient to reduce platelet aggregation? Aspirin Lidocaine Nitroglycerin Oxygen

Aspirin Aspirin blocks synthesis of thromboxane A2, thus inhibiting aggregation of platelets.

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

B

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

B

Critical illness often results in family conflicts. Which scenario is most likely to result in the greatest conflict? A. A 21-year-old college student of divorced parents hospitalized with multiple trauma. She resides with her mother. The parents are amicable with each other and have similar values. The father blames the daughter's boyfriend for causing the accident. B. A 36-year-old male admitted for a ruptured cerebral aneurysm. He has been living with his 34-year-old girlfriend for 8 years, and they have a 4-year-old daughter. He does not have a written advance directive. His parents arrive from out-of-state and are asked to make decisions about his health care. He has not seen them in over a year. C. A 58-year-old male admitted for coronary artery bypass surgery. He has been living with his same-sex partner for 20 years in a committed relationship. He has designated his sister, a registered nurse, as his health care proxy in a written advance directive. D. A 78-year-old female admitted with gastrointestinal bleeding. Her hemoglobin is decreasing to a critical level. She is a Jehovah's Witness and refuses the treatment of a blood transfusion. She is capable of making her own decisions and has a clearly written advance directive declining any transfusions. Her son is upset with her and tells her she is "committing suicide."

B

The VALUE mnemonic is a helpful strategy to enhance communication with family members of critically ill patients. Which of the following statements describes a VALUE strategy? A. View the family as guests on the unit. B. Acknowledge family emotions. C. Learn as much as you can about family structure and function. D. Use a trained interpreter if the family does not speak English.

B

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

B

Which of the following situations may result in a low cardiac output and low cardiac index? (Select all that apply.) A. Exercise B. Hypovolemia C. Myocardial infarction D. Shock E. Fever

B, C, D

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

C

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

C

The nurse is caring for a patient with hyperactive delirium. The nurse focuses interventions toward keeping the patient: a. comfortable b. nourished c. safe d. sedated

C The greatest priority in managing delirium is keeping the patient safe. Sedation may contribute to development of delirium. Comfort and nutrition are important, but they are not priorities.

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

D

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

D

The intensive care nurse is working on a committee to reduce noise in the unit. Which recommendation should the nurse propose first? A. Change telephones to blinking lights instead of audible ringtones. B. Invest in call lights that page the nursing staff instead of beeping. C. Recommend that nurses turn off cardiac monitors on stable patients. D. Soundproof the pneumatic tube system.

D

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

D

The spouse of a patient who is hospitalized in the critical care unit following resuscitation for a sudden cardiac arrest at work demands to meet with the nursing manager. The spouse demands, "I want you to reassign us to another nurse. His current nurse is not in the room enough to make sure everything is okay." The nurse recognizes that this response most likely is due to the spouse's A. Desire to pursue a lawsuit if the assignment is not changed. B. Inability to participate in the husband's care. C. Lack of prior experience in a critical care setting. D. Sense of loss of control of the situation.

D

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

D

The nurse is caring for a patient in acute liver failure caused by an overdose of acetaminophen. The patient is not expected to survive the night. Which statement best reflects appropriate application of the MELD score in this situation? A. The patient's present situation reflects a MELD score of 22 B. Patient status indicates the patient is ineligible for transplant C. The MELD score indicates survival beyond 24 hours is unlikely D. Use of the MELD score is not applicable in this situation

D. Use of the MELD score is not applicable in this situation

The nurse is reviewing the medication history of a client diagnosed with myasthenia gravis (MG) who has been prescribed a cholinesterase (ChE) inhibitor. The nurse contacts the primary health care provider (PHCP) if the client is taking which medication?

Diazepam (Valium) The nurse contacts the PHCP if the client with MG who has been prescribed a ChE is also taking diazepam. Diazepam (Valium) would be avoided because it may increase the client's weakness.Acetaminophen (Tylenol) is an analgesic and antipyretic. It does not interact with ChE inhibitors. Furosemide (Lasix) is a diuretic and does not interact with ChE inhibitors. Ibuprofen (Motrin) is a nonsteroidal analgesic and does not interact with ChE inhibitors.

The nurse is caring for a patient with status asthmaticus in the emergency department. The nurse anticipates what therapies to be ordered? Select all that apply. Inhaled anticholinergic agent Inhaled rapid-acting beta-2 agonists Oxygen administration Systemic corticosteroids

Inhaled anticholinergic agent Inhaled rapid-acting beta-2 agonists Oxygen administration Systemic corticosteroids All are treatment of severe asthma exacerbation (Table 15-2).

Lung-protective strategies for mechanical ventilation to treat acute respiratory distress syndrome while also preventing complications include which of the following? High levels of sedation Low tidal volume of 6 mL/kg ideal body weight Oxygen levels (FiO2) 0.80-1.00 Positive end-expiratory pressure (PEEP) 25 cm H2O or higher

Low tidal volume of 6 mL/kg ideal body weight The target tidal volume is 6 mL/kg. High levels of sedation may be needed but are not a protective strategy. The target lung-protective oxygen level is 0.6. Lower levels of PEEP are desirable as the risk for barotrauma increases with higher levels of PEEP.

A client had a nerve laceration repair to the forearm and is being discharged in a cast. What statement by the client indicates a poor understanding of discharge instructions relating to cast care? a. "I can scratch with a coat hanger." b. "I should feel my fingers for warmth." c. "I will keep the cast clean and dry." d. "I will return to have the cast removed."

Nothing should be placed under the cast to use for scratching. The other statements show good indication that the client has understood the discharge instructions.

The nurse is caring for a patient in the ICU. Lab results show a PaCO2 greater than 45 mm Hg. How should the nurse interpret this? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Respiratory acidosis An elevated PaCO2 is seen in respiratory acidosis.

Which of the following statements are true regarding chemical injuries? Chemical burns are not as severe as thermal burns. Systemic effects such as CNS depression, pulmonary edema, and hypotension may occur. These injuries affect only the localized area of chemical contact. Tissue damage continues until the chemical is completely removed or neutralized. Depth of tissue injury is greatest from alkalies.

Systemic effects such as CNS depression, pulmonary edema, and hypotension may occur. Tissue damage continues until the chemical is completely removed or neutralized. Depth of tissue injury is greatest from alkalies. Systemic effects occur after burn injury as a result of release of chemical mediators. Chemicals can continue to cause tissue damage until removed or neutralized. Alkali agents cause the greatest tissue damage because of the protein denaturation and liquefaction that occur. Chemical burns can be more severe than thermal burns. Chemicals can be absorbed, causing wider injury than the area of contact.

The nurse is obtaining a health history for a 45-year-old woman with Guillain-Barré syndrome (GBS). Which statement by the client does the nurse correlate with the client's diagnosis? a. "My neighbor also had Guillain-Barré syndrome." b. "I had a viral infection about 2 weeks ago." c. "I am an artist and work with oil paints." d. "I have a history of a cardiac dysrhythmia."

The client with GBS often relates a history of acute illness, trauma, surgery, or immunization 1 to 3 weeks before the onset of neurologic symptoms. The other statements do not correlate with GBS.

The patient is admitted with an anterior wall myocardial infarction. With this diagnosis, the nurse would expect to see Q waves in which leads? Select all that apply. II III V3 V4 aVF

V3 V4 Pathological Q waves are found on ECGs of individuals who have had myocardial infarctions, and they represent myocardial muscle death. Anatomical regions are described as septal, anterior, lateral, inferior, and posterior. Septal leads are V1 and V2; anterior leads are V3 and V4; lateral leads are V5, V6, I, and aVL; and inferior leads are II, III, and aVF.

To maintain the patient's airway, which interventions are appropriate to implement with a trauma patient who sustained a spinal cord injury? (SATA) a. Avoid hyperextension of the neck. b. Observe respiratory pattern. c. Insert an oral airway if patient is alert. d. Elevate the head of bed 30 degrees. e. Observe depth of ventilation. f. Maintain complete spinal immobilization.

a, b, e, f

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

a. alveolar-capillary membrane.

Your patient was a passenger in a motor vehicle crash yesterday and suffered an open fracture of the femur. His condition was stable until an hour ago, when he began to complain of shortness of breath. His heart rate is 104 beats/min, respiratory rate is 30 breaths/min, BP is 90/60 mm Hg, and temperature is now 38.4°C. You suspect that he: a. has a fat embolism. b. has developed metabolic acidosis. c. is developing systemic inflammatory response syndrome (SIRS). d. is experiencing early multiple organ dysfunction syndrome (MODS).

a. has a fat embolism.

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

b. Hypoventilation and respiratory acidosis

A client with trigeminal neuralgia is admitted for a percutaneous stereotactic rhizotomy in the morning. The client currently reports pain. What does the nurse do next?

dministers pain medication as requested The next action the nurse needs to do is to give pain medication to the preoperative client with trigeminal neuralgia who is complaining of pain. Addressing the client's pain is the priority nursing intervention because pain is the main symptom of trigeminal neuralgia.After the client's pain has been addressed, the preoperative assessment can be completed, questions and concerns can be addressed, and any further testing can be completed. This client is not required to be NPO until after midnight.

All burn patients are at increased risk for acute respiratory distress syndrome (ARDS) due to: carboxyhemoglobinemia a decrease in cardiac output increased capillary permeability myoglobinemia

increased capillary permeability. Overwhelming systemic inflammatory response syndrome (SIRS) and increased capillary permeability throughout the body, including the lungs, increase the risk of ARDS. Carboxyhemoglobinemia causes restlessness, confusion, and loss of consciousness. Decreased cardiac output decreases pulmonary blood flow but is not a direct cause of ARDS. Myoglobinemia causes acute kidney injury.

Treatments for thrombocytopenia, other than transfusion, include: Select all that apply. thrombopoietin. aspirin. plasmapheresis. corticosteroids. splenectomy.

thrombopoietin plasmapheresis corticosteroids splenectomy Thrombopoietin, a platelet-stimulating cytokine, is being investigated as an alternative to platelet transfusion. Some thrombocytopenias are autoimmune induced and may respond to filtration of antibodies via plasmapheresis or immune suppression with corticosteroids. When the spleen is enlarged and tender and these other supportive therapies are unsuccessful, splenectomy can alleviate the autoimmune reaction. Aspirin is used to prevent platelet aggregation.

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

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

Patients often have recollections of the critical care experience. Which is likely to be the most common recollection of patients who required endotracheal intubation and mechanical ventilation? A. Difficulty in communicating B. Inability to get comfortable C. Pain D. Sleep disruption

A

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

A

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

A

Which of the following statements about family assessment is false? A. Assessment of structure (who comprises the family) is the last step in assessment. B. Interaction among family members is assessed. C. It is important to assess communication among family members to understand roles. D. Ongoing assessment is important, because family functioning may change during the course of illness.

A

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

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

A 100-kg patient gets hemodialysis 3 days a week. In planning the care for this patient, the nurse recommends a) a diet of 2500 to 3500 kcal/day b) protein intake of less than 50g per day c) potassium intake of 10 mEq per day d) fluid intake of less than 500 mL

A Nutritional recommendations include the following: caloric intake of 25 to 35 kcal/kg of ideal body weight per day (2500 to 3500 kcal) and protein intake of no less than 0.8 g/kg body weight.

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

A Only dialysis and administration of cation exchange resins (sodium polystyrene sulfonate) actually reduce plasma potassium levels and total body potassium content in a patient with renal dysfunction.

While monitoring a patient for signs of shock, the nurse understands which system assessment to be of priority? a) CNS b) GI system c) Renal system d) Respiratory system

A The central nervous system experiences decreased perfusion first. The patient will have central nervous system changes early during the course of shock, such as changes in the level of consciousness.

The nurse is caring for a patient who has positive end-expiratory pressure (PEEP) as an adjunct to the ventilation. When PEEP is increased, the nurse is prepared for which assessment finding? A decrease in cardiac output A decrease in inspiratory pressure An increase in tidal volume An increased work of breathing

A decrease in cardiac output Because PEEP increases intrathoracic pressure, cardiac output may decrease.

In the critically ill patient, an incomplete assessment and/or management of pain or anxiety may be hampered by which of the following? (Select all that apply.) a. Administration of neuromuscular blocking agents b. Delirium c. Effective nurse communication and assessment skills d. Nonverbal patients

A, B, D Delirium appears in approximately 80% of patients in the intensive care unit. Delirium is characterized by changing mental status, inattention, disorganized thinking, and altered levels of consciousness. Patients in the intensive care unit may not be able to verbalize because of the presence of an artificial airway, sedative medication, neuromuscular blocking agents, or brain injury. Effective nurse-to-patient communication and assessment skills would facilitate assessment of pain and anxiety.

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.) a) Applying splints that maintain the extremity in an extended position b) Implementing passive or active ROM exercises c) Keeping the limbs as immobile as possible d) Wrapping fingers and toes individually with bandages e) Administering muscle relaxants around the clock

A, B, D It is important to avoid immobility in patients with burns of the hands, feet, or major joints. Measures must be taken to maintain the function of the hands, feet, and major joints. Nursing interventions to maintain range of motion, applying splints to keep the extremities in a position of function, and individually wrapping fingers and toes are necessary to maintain function of the hands, feet, and joints. Effective pain management is necessary to encourage mobility.

The nurse is caring for a postoperative patient in the critical care unit. The physician has ordered patient-controlled analgesia (PCA) for the patient. The nurse understands that the PCA: (Select all that apply.) a. is a safe and effective method for administering analgesia. b. has potentially fewer side effects than other routes of analgesic administration. c. is an ideal method to provide critically ill patients some control over their treatment. d. provides good quality analgesia.

A, B, D PCA is safe and effective, provides good-quality analgesia, and has potentially fewer side effects than other routes. PCA management is rarely appropriate for critically ill patients because most patients are unable to depress the button, or they are too ill to manage their pain effectively.

Which complications may manifest after an electrical injury? (Select all that apply.) a) Long bone fractures b) Cardiac dysrhthmias c) Hypertension d) Compartment syndrome of extremities e) Dark brown urine f) Peptic ulcer disease g) Acute cataract formation h) Seizures

A, B, D, E, G, H Electrical injuries vary in severity of injury by the intensity of energy exposed to the body. Manifestations and complications may include cardiac dysrhythmias or cardiopulmonary arrest, hypoxia, deep tissue necrosis, rhabdomyolysis and acute kidney injury, compartment syndrome, long bone fractures, acute cataract formation, and neurological deficits (including seizures). Hypertension and peptic ulcer disease are not direct consequences of electrical burn injuries.

The critical care environment is stressful to the patient. Which interventions assist in reducing this stress? (Select all that apply.) A. Adjust lighting to promote normal sleep-wake cycles. B. Provide clocks, calendars, and personal photos in the patient's room. C. Talk to the patient about other patients you are caring for on the unit. D. Tell the patient the day and time when you are providing routine nursing interventions. E. Allow unlimited visitation tailored to the patient's individual needs.

A, B, E

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

A, C

It is important for critically ill patients to feel safe. Which nursing strategies help the patient to feel safe in the critical care setting? (Select all that apply.) A. Allow family members to remain at the bedside. B. Consult with the charge nurse before making any patient care decisions. C. Provide informal conversation by discussing your plans for after work. D. Respond promptly to call bells or other communication for assistance. E. Inform the patient that you have cared for many similar patients.

A, D

18. 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 mother's side of the family has a history of cancer."

ANS: A Current recreational drug use is a contraindication to transplantation. Family support is critical during posttransplant care. Adherence to dialysis indicates likely success in adhering to future treatment plans. A patient history of active or recent malignancy is a contraindication to transplantation.

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

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

21. Which of the following would be seen in a patient with myxedema coma? a. Decreased reflexes b. Hyperthermia c. Hyperventilation d. Tachycardia

ANS: A Myxedema coma is characterized by a hypometabolic state, and all body functions are slowed including cardiovascular function, decreased gastrointestinal mobility, cold intolerance, and diminished reflexes. Hyperthermia is characteristic of thyroid storm. Hyperventilation is characteristic of thyroid storm and diabetic ketoacidosis. Tachycardia is characteristic of thyroid storm.

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

ANS: A Nurses complete neurological assessments based on ordered frequency and the severity of the patient's condition. The newly admitted patient has an altered neurological status so frequent neurological assessments are most important to include in the patient's plan of care. Side to side position changes, range of motion exercises, and frequent oral suctioning are nursing actions that may need to be a part of the patient's plan of care but in the setting of increased intracranial pressure should not be regularly performed unless indicated.

he nurse is assessing a client with trigeminal neuralgia. Which clinical manifestation does the nurse expect to observe? a. Excruciating pain b. Decreased mobility c. Controllable facial twitching d. Increased talkativeness

ANS: A Signs of trigeminal neuralgia are excruciating pain and uncontrollable facial twitching which causes the client to avoid talking, smiling, eating, or attending to hygienic needs. Sensory and mobility deficits are not associated with trigeminal neuralgia.

22. The nurse is providing postoperative education to a transplant patient's 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."

ANS: A The traditional method of rejection surveillance in a heart transplant recipient is through endometrial biopsies performed weekly during the first six weeks posttransplant. Shortness of breath can be a symptom of rejection, but only in combination with other symptoms. Rejection is confirmed through biopsy. Over time, with frequent biopsies, cardiac tissue becomes scarred, making detection of rejection impossible.

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

ANS: A To reduce the risk of further injury, a patient experiencing seizure activity while sitting in a chair should be assisted to the floor with head adequately supported. Routine insertion of a nasogastric tube during seizure activity is not indicated unless there is risk for aspiration. Forceful insertion of a padded tongue blade should not be carried out during tonic-clonic activity; most likely the patient's jaws will be clenched shut. Forceful insertion may lead to further injury. Restraining a patient during seizure activity can be traumatizing and is not standard of care.

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

A

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

ANS: A, C The goal for ischemic stroke is to keep the systolic blood pressure less than 220 mm Hg and the diastolic blood pressure 120 mm Hg. In hemorrhagic stroke, the goal is a mean arterial pressure less than 130 mm Hg. Neurological assessments are compared with the baseline assessments performed in the ED. The elapsed time of 8 hours since onset of symptoms prohibits thrombolytic therapy. The CO2 should be maintained within normal limits; this value is elevated. The elapsed time of 8 hours since onset of symptoms prohibits thrombolytic therapy. Restraints should be avoided.

The nurse is caring for a client diagnosed with Guillain Barre syndrome. Which assessment findings require nursing action? (Select all that apply.) a. Blood pressure of 80/42 b. A respiratory rate of 24 c. Shallow breathing pattern d. A peripheral oxygen saturation (SpO2) of 85% e. Diminished breath sounds in all lung fields

ANS: A, C, D, E All choices except B are abnormal assessment findings that can occur in clients with this disease. A respiratory rate of 24 is slightly elevated but does not require nursing action.

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

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

22. 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? a. Congestive heart failure b. Hypovolemic shock c. Infection d. Volume overload

ANS: B Pituitary surgery or manipulation of the pituitary stalk during surgery may precipitate diabetes insipidus. Profound diuresis that accompanies diabetes insipidus may result in hypovolemic shock. Fluid volume deficit, not overload, accompanies diabetes insipidus. Increased risk of infection may accompany hyperglycemia and elevated cortisol levels. Fluid volume overload is more characteristic of SIADH.

An older adult client is hospitalized with Guillain-Barré syndrome. The client is given amitriptyline (Elavil). After receiving the hand-off report, what actions by the nurse are most important? (Select all that apply.) a. Administering the medication as ordered b. Advising the client to have help getting up c. Consulting the provider about the drug d. Cutting the dose of the drug in half e. Placing the client on safety precautions

ANS: B, C, E Amitriptyline is a tricyclic antidepressant and is considered inappropriate for use in older clients due to concerns of anticholinergic effects, confusion, and safety risks. The nurse should tell the client to have help getting up, place the client on safety precautions, and consult the provider. Since this drug is not appropriate for older clients, cutting the dose in half is not warranted.

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

ANS: C As blood loss exceeds 1000 mL, the shock syndrome progresses, causing decreased blood flow to the skin, lungs, liver, and kidneys. Hypotension is an advanced sign of shock. As a rule, a systolic pressure of less than 100 mm Hg, a postural decrease in blood pressure of greater than 10 mm Hg, or a heart rate of greater than 120 beats/min reflects a blood loss of at least 1000 mL25% of the total blood volume.

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

ANS: C Cerebral vessels dilate when PaCO2 levels increase, increasing cerebral blood volume. Cerebral vessels dilate when CO2 levels increase, increasing cerebral blood volume. To compensate for increased cerebral blood volume, cerebral spinal fluid may be displaced, but the scenario is asking for the effect of hypercarbia (elevated PaCO2) on cerebral blood flow. PaCO2 of 60 mm Hg is elevated, which would cause cerebral vasodilation and increased cerebral blood volume.

24. Which of the following laboratory values would be found in a patient with syndrome of inappropriate secretion of antidiuretic hormone? a. Fasting blood glucose 156 mg/dL b. Serum potassium 5.8 mEq/L c. Serum sodium 115 mEq/L d. Serum sodium 152 mEq/L

ANS: C SIADH causes a dilutional hyponatremia, and central nervous system symptoms can occur. A low serum sodium (below 135 mEq/L) may accompany the syndrome. Glucose elevation is not a classic sign of SIADH. Hyperkalemia does not accompany the dilutional hyponatremia of SIADH. Serum sodium levels are typically lower in the dilutional hyponatremia that accompanies SIADH.

The nurse is preparing a client for a Tensilon (edrophonium chloride) test. What action by the nurse is most important? a. Administering anxiolytics b. Having a ventilator nearby c. Obtaining atropine sulfate d. Sedating the client

ANS: C Atropine is the antidote to edrophonium chloride and should be readily available when a client is having a Tensilon test. The nurse would not want to give medications that might cause increased weakness or sedation. A ventilator is not necessary to have nearby, although emergency equipment should be available.

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

ANS: D Early intervention for ischemic stroke is recommended. Thrombolytics must be given within 3 hours of the onset of symptoms. Although assessment of allergies, as well accompanying symptoms such as a headache and general orientation, are a part of a complete neurological assessment and should be performed, time of onset of symptoms is critical to the type of treatment.

The nurse learns that the pathophysiology of Guillain-Barré syndrome includes segmental demyelination. The nurse should understand that this causes what? a. Delayed afferent nerve impulses b. Paralysis of affected muscles c. Paresthesia in upper extremities d. Slowed nerve impulse transmission

ANS: D Demyelination leads to slowed nerve impulse transmission. The other options are not correct.

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

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

The nurse is caring for a patient at risk for respiratory failure. Which assessment findings would alert the nurse to potential respiratory failure? Anxiety and restlessness Cyanosis and hyperventilation Dyspnea and nasal flaring Hypertension and bradycardia

Anxiety and restlessness Neurological changes, such as anxiety and restlessness, are early signs of hypoxemia in respiratory failure. Other early signs are tachycardia and increased blood pressure. Cyanosis, dyspnea, and nasal flaring are later signs.

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

B

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

B

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

B

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

B

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

B

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

B

A normal GFR is a) less than 80 mL/min b) 80-125 mL/min c) 125-180 mL/min d) more than 189 mL/min

B At a normal glomerular filtration rate (GFR) of 80 to 125 mL/min, the kidneys produce 180 L/day of filtrate.

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 Lactate level has been used as an indicator of decreased oxygen delivery to the cells, adequacy of resuscitation in shock, and as an outcome predictor.

The assessment of pain and anxiety is a continuous process. The first priority for treating pain and/or anxiety in the critical care setting is to: A. Ask the patient frequently if he or she needs pain/anxiety medication B. Identify and treat the underlying causes of pain and anxiety C. Medicate routinely with pain/antianxiety medications to keep the patient comfortable D. Wait for the patient to ask for medication and give it promptly

B. Identify and treat the underlying causes of pain and anxiety

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

C

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

C Acute kidney injury can be caused by aminoglycoside nephrotoxicity, especially prolonged use of the drug (more than 10 days). Symptoms of acute kidney injury are usually seen about 1 to 2 weeks after exposure. Because of this delay, the patient must be questioned about any recent medical therapy for which an aminoglycoside may have been prescribed.

The nurse is assessing pain levels in a critically ill patient using the Behavioral Pain Scale. The nurse recognizes ________ as indicating the greatest level of pain. a. brow lowering b. eyelid closing c. grimacing d. relaxed facial expression

C The Behavioral Pain Scale issues the most points, indicating the greatest amount of pain, to assessment of facial grimacing.

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

D

Changing visitation policies can be challenging. The nurse manager recognizes which of the following as an effective strategy for promoting changes in practice? A. Ask the clinical nurse specialist to lead a journal club on open visitation after each nurse is tasked to read one research article about visitation. B. Discuss the pros and cons of open visitation at the next staff meeting. C. Invite the nurses with the most experience to develop a revised policy. D. Task the unit-based nurse practice council to invite volunteers to serve on the council to revise the current policy toward more liberal visitation.

D

The nurse manager is reviewing the World Health Organization's guidelines on noise in the critical care environment. How does the nurse manager interpret these guidelines? A. Noise can be eliminated with acoustic ceiling tiles B. Noise can be minimized by shutting off alarms C. Noise is something the nurse just has to deal with D. Noise levels often exceed recommended levels

D. Noise levels often exceed recommended levels

The nurse admits a patient to the coronary care unit in cardiogenic shock. The nurse anticipates administering which medication in an effort to improve cardiac output by increasing the contractile force of the heart? Dopamine (Intropin) Phenylephrine (Neo-Synephrine) Dobutamine (Dobutrex) Nitroprusside (Nipride)

Dobutamine (Dobutrex) Positive inotropic agents such as dobutamine (Dobutrex) are given to increase the contractile force of the heart in cardiogenic shock. Dopamine (Intropin) is used primarily in low cardiac output states to restore vascular tone and increase blood pressure, but not in cardiogenic shock. Neo-Synephrine would be contraindicated in cardiogenic shock, as the vasoconstriction it produces would exacerbate cardiac ischemia. Nitroprusside (Nipride), used for preload and after load reduction, can improve cardiac performance in shock states by its reduction of systemic vascular resistance.

The nurse is caring for a patient admitted with possible disseminated intravascular coagulation (DIC). Which laboratory test should the nurse anticipate that the health care provider will order? Complete blood count (CBC) with differential Fibrin degradation product (FDP) Vitamin K level White blood count (WBC)

Fibrin degradation product (FDP) When plasmin digests fibrinogen, fragments known as fibrin split products, or fibrin degradation products, are produced and function as potent anticoagulants. Fibrin split products are not normally present in the circulation but are seen in some hematological disorders, including DIC. The CBC reports the total RBC count and RBC indices, hematocrit, hemoglobin, WBC count and differential, platelet count, and cell morphologies; it does not detect clotting. WBCs play a key role in the defense against infectious organisms and foreign antigens, not clotting. Vitamin K deficiency is commonly associated with impaired hemostasis and bleeding, not clotting.

The nurse is caring for a client with Guillain-Barré syndrome (GBS) who is receiving intravenous immunoglobulin (IVIG). Which assessment finding warrants immediate evaluation?

Headache with stiff neck Immediate evaluation is needed when a client with GBS receiving IVIG complains of a headache with stiff neck. This may be a sign of aseptic meningitis, a possible serious complication of IVIG therapy.Chills, generalized malaise, and a low-grade fever are minor adverse effects of IVIG therapy and do not indicate that the therapy must be stopped.

If the sinus node were diseased or ischemic and no longer firing as the heart's primary pacemaker, the nurse would anticipate which normal compensatory mechanism? Premature junctional beats Junctional escape rhythm, rate of 45 Junctional tachycardia, rate of 100 Accelerated junctional rhythm, rate of 75

Junctional escape rhythm, rate of 45 Junctional escape rhythm occurs when the dominant pacemaker, the SA node, fails to fire. The escape rhythm may consist of many successive beats, or it may occur as a single escape beat that follows a pause, such as a sinus pause. The normal intrinsic rate for the AV node and junctional tissue is 40 to 60 beats/min. An accelerated junctional rhythm has a rate between 60 and 100 beats/min, and the rate for junctional tachycardia is greater than 100 beats/min. Irritable areas in the AV node and junctional tissue can generate premature beats that are earlier than the next expected beat.

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

Normal saline (0.9%) is recommended for fluid volume resuscitation. Hypotonic solutions are avoided to prevent an increase in cerebral edema. Normal saline solution is recommended for fluid volume resuscitation because isotonic fluids do not increase cerebral edema. The goal is to keep serum osmolality less than 320 mOsm/L. Hypotonic solutions, such as 0.45% saline solution, are avoided because they increase cellular swelling and cerebral edema.

The nurse is caring for a patient in neurogenic shock. Which should the nurse assess for? Tachycardia Hypertension Hypoventilation Vasodilation

Vasodilation In neurogenic shock, there is an interruption of impulse transmission or blockage of sympathetic outflow, resulting in vasodilation, inhibition of baroreceptor response, and impaired thermoregulation. Interruption of sympathetic nerve innervation would result in bradycardia. Interruption of sympathetic nerve innervation would result in hypotension. Hypoventilation is not a physiological mechanism.

A 55-year-old trauma patient hit the steering wheel and has a cardiac contusion. Which are potential complications of the injury? (SATA) a. Flail chest b. Dysrhythmias c. Hypotension d. Myocardial ischemia

b, c, d

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

b. 130; meets criteria for ARDS

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

b. Increased peak inspiratory pressure on the ventilator

The nurse is working in the emergency department when a patient arrives who has experienced chest trauma. Which condition should the nurse be the most concerned with for this patient? a. Cardiac tamponade b. Flail chest c. Hemothorax d. Pulmonary contusion

d. Pulmonary contusion

The nurse notices ventricular tachycardia on the heart monitor. The nurse's first action should be to: determine patient responsiveness and presence of a pulse. immediately defibrillate the patient and provide CPR. administer intravenous amiodarone or lidocaine. cardiovert electrically into a more sustainable rhythm.

determine patient responsiveness and presence of a pulse. Determine whether the patient has a pulse. If no pulse is present, provide emergent basic and advanced life-support interventions, including defibrillation. If a pulse is present and the blood pressure is stable, the patient can be treated with intravenous amiodarone or lidocaine. Cardioversion is used as an emergency measure in patients who become hemodynamically unstable but continue to have a pulse. It may also be used in nonemergency situations, such as when a patient has asymptomatic VT.

A 67-year-old female is admitted to the emergency department complaining of midback pain and shortness of breath for the preceding 2 hours. She also complains of nausea and states that she vomited twice before coming to the hospital. She denies any chest discomfort or arm pain. The nurse prepares to the treat the patient for a diagnosis of: flu symptoms. anxiety attack. myocardial infarction (MI). osteoporosis.

myocardial infarction (MI). Women are more likely to have atypical signs and symptoms of acute myocardial infarction (AMI), such as shortness of breath, nausea and vomiting, and back or jaw pain.

The nurse is listening to a lecture on the role of basophils. Which statement by the nurse indicates that teaching has been effective? "Basophils are the defense against parasites." "Basophils respond to inflammation and allergic reactions." "Basophils will mature into neutrophils." "Basophils involve the detoxification of proteins."

"Basophils respond to inflammation and allergic reactions." Basophils play an important role in acute systemic allergic reactions and inflammatory responses. "Bands" are immature neutrophils. Eosinophils are important in the defense against allergens and parasites and are thought to be involved in the detoxification of foreign proteins

A 45-year-old male is visiting the wellness clinic and has been newly diagnosed as a stage I hypertensive patient. His blood pressure assessment over the past 6 months has consistently been 145/92 mm Hg. The patient asks, "What is blood pressure?" What is the best response by the nurse? "A complex measurement that should be discussed only with your physician." "A measurement that should be 120/80 mm Hg unless complications are present." "A measurement that takes into consideration the amount of blood your heart is pumping and the size of the vessel diameter the heart must pump against." "The amount of pressure exerted on the veins by the blood."

"A measurement that takes into consideration the amount of blood your heart is pumping and the size of the vessel diameter the heart must pump against." The contractile force of the heart is the driving pump behind blood flow through the cardiovascular system. The ease of blood flow is a measurement of diameter of the vessel (resistance) and the volume and viscosity of blood through the cardiovascular circuit. It is within the scope of practice of a nurse to educate the patient about blood pressure. Blood pressure values may have a wide range dependent upon the pumping action of the heart, vessel diameter, and blood volume. Variations can be tolerated, but trends that remain high should be evaluated further. Blood pressure measurement is a reflection of pumping action of the heart, vessel diameter, and blood volume.

The nurse explains to the new RN that angiotensin-converting enzyme inhibitors (ACE inhibitors) should be started within 24 hours of acute myocardial infarction (AMI). Which statement by the new RN indicates that teaching has been effective? "ACE inhibitors are started within 24 hours to prevent hibernating myocardium." "ACE inhibitors are started within 24 hours to prevent myocardial remodeling." "ACE inhibitors are started within 24 hours to prevent myocardial stunning." "ACE inhibitors are started within 24 hours to prevent tachycardia."

"ACE inhibitors are started within 24 hours to prevent myocardial remodeling." Myocardial remodeling is a process mediated by angiotensin II, aldosterone, catecholamine, adenosine, and inflammatory cytokines; it causes myocyte hypertrophy and loss of contractile function in the areas of the heart distant from the site of infarctions. ACE inhibitors should be ordered.

The nurse is educating a new RN on the therapeutic effect of head-of-the-bed elevation and neutral head and neck alignment on a patient with increased intracranial pressure (ICP). Which statement by the new RN indicates that teaching has been effective? "Head-of-the-bed elevation lowers ICP by allowing for elevations in CO2 to dilate cerebral arteries." "Head-of-the-bed elevation lowers ICP by facilitating venous drainage and decreasing venous obstruction." "Head-of-the-bed elevation lowers ICP by maintaining an open airway." "Head-of-the-bed elevation lowers ICP by reducing the risk of snoring."

"Head-of-the-bed elevation lowers ICP by facilitating venous drainage and decreasing venous obstruction." Head-of-the-bed elevation and a neutral head position that avoids hyperextension or hyperflexion facilitate jugular venous drainage, helping to minimize increases in ICP. Elevated CO2 contributes to cerebral vessel vasodilation, which can increase cerebral blood volume and further elevate ICP. Maintaining an open airway alone does not minimize increases in ICP. Reducing the risk of snoring by maintaining an open airway alone does not minimize increases in ICP.

The nurse is orienting a new RN in the care of a patient with respiratory distress due to emphysema. The patient is being treated with O2 via a Venturi mask with 35% oxygen. Which statement by the new RN indicates that teaching has been effective, when the nurse questions the new RN about the use of the Venturi mask? "A nasal cannula will dry the mucous membranes and cause an increased risk of infection." "Her alveoli cannot absorb higher levels of O2 because of the emphysema." "Her alveoli have been damaged and may rupture with higher doses of O2." "Her respiratory center requires low O2 concentration to stimulate breathing."

"Her respiratory center requires low O2 concentration to stimulate breathing." In patients with COPD, the respiratory drive is stimulated by hypoxemia, not increased levels of carbon dioxide. Administration of oxygen in high levels will impair the respiratory drive.

When checking a patient's pulmonary artery occlusion pressure, the nurse inflates the balloon as ordered, not inflating the balloon for more than 8 to 10 seconds. The patient asks the rationale behind the nurse's actions. Which statement should the nurse make? "Prolonged inflation can obstruct blood flow, resulting in ischemia." "Prolonged inflation increases the risk of catheter balloon rupture." "Prolonged inflation increases the likelihood of thermistor damage." "Prolonged inflation will reduce tension on the pulmonary artery wall."

"Prolonged inflation can obstruct blood flow, resulting in ischemia." Prolonged inflation of the pulmonary artery catheter balloon will compromise blood flow forward of the balloon, risking pulmonary infarction. Overinflation with a high volume of air in the balloon, rather than prolonged inflation, can lead to balloon rupture. Balloon inflation does not influence thermistor damage. Prolonged inflation will increase tension on the pulmonary artery wall.

The nurse is orienting a new RN to the ICU. The nurse begins to review orders recently entered by the cardiologist and to explain their rationale to the new RN. Medication orders include dobutamine (Dobutrex) 400 mg in 250 mL 5% dextrose in water titrated to keep cardiac index >2 L/min/m2. Which statement by the new RN indicates that teaching has been effective? "The cardiac index is the amount of blood pumped out by a ventricle per minute." "The cardiac index is the amount of blood ejected with each ventricular contraction." "The cardiac index is the pressure created by the volume of blood in the left heart." "The cardiac index is the measurement specific to the patient's size or body area."

"The cardiac index is the measurement specific to the patient's size or body area." Cardiac index is cardiac output individualized to a patient's body surface area or size. Cardiac output is the amount of blood pumped out by a ventricle per minute. The amount of blood ejected with each ventricular contraction is stroke volume. The pressure created by the volume of blood in the left heart is pulmonary artery occlusive pressure.

The nurse is listening to a lecture about the most crucial phase of treatment in burn care. Which statement by the nurse indicates that teaching has been effective? "The most crucial phase of burn treatment is the acute phase." "The most crucial phase of burn treatment is the emergent phase." "The most crucial phase of burn treatment is the rehabilitative phase." "The most crucial phase of burn treatment is the resuscitative phase."

"The most crucial phase of burn treatment is the resuscitative phase." The acute and rehabilitation phases will not progress if the resuscitative phase is not successful; the greatest physiological insults tend to occur during this time. The acute phase follows the resuscitative phase; during this time the fluid shifts have stabilized and the patient tends to be more hemodynamically stable. There is no "emergent" phase of burn care. The rehabilitative phase begins after the acute phase ends; the patient is most stable during this time.

The nurse is educating a new RN on preparing a patient for assessment of cardiac output using an esophageal monitor. Which statement by the new RN indicates that teaching was effective? "The procedure involves a thin probe inserted into the esophagus." "Patients require deep sedation provided by an anesthesia provider." "The procedure immediately assesses right ventricular performance." "There are no absolute contraindications for the procedure."

"The procedure involves a thin probe inserted into the esophagus." The procedure involves insertion of a thin silicone probe into the distal esophagus. The probe is easily placed similarly to an orogastric or nasograstric tube, so patients require little to no sedation. The procedure provides an immediate assessment of left ventricular performance. There are several contraindications to the procedure, including esophageal stricture and esophagegeal varices (see Box 8-9).

The nurse is interpreting the rhythm strip of a patient and measures the QRS complex as being three small boxes in width. The nurse interprets this width as: 0.04 seconds. 0.10 seconds. 0.12 seconds. 0.16 seconds.

0.12 seconds. ECG paper contains a standardized grid in which the horizontal axis measures time and the vertical axis measures voltage or amplitude. Larger boxes are circumscribed by darker lines and the smaller boxes by lighter lines. The larger boxes contain 5 smaller boxes on the horizontal line and 5 on the vertical line for a total of 25 per large box. Horizontally, the smaller boxes denote 0.04 seconds each or 40 milliseconds; the larger box contains five smaller boxes and thus equals 0.20 seconds or 200 milliseconds. Along the uppermost aspect of the ECG paper are vertical hash marks that occur every 15 large boxes. The area between these marks equals 3 seconds.

Your patient weighs 60 kg and has a 40% total body surface area (TBSA) burn injury. Fluid resuscitation orders are for 4 mL/kg/% burn of a lactated Ringer's solution. What volume should the nurse anticipate infusing during the first 8 hours? 2400 mL 3600 mL 4800 mL 9600 mL

4800 mL Fluid calculation is: 4 mL × 60 kg × 40 = 9600 mL, with half the amount, or 4800 mL, being given in the first 8 hours. 2400 mL and 3600 mL are too little volume; 9600 mL represents the 24-hour fluid resuscitation volume to be administered.

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

A

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

A

Elderly patients who require critical care treatment are at risk for increased mortality, functional decline, or decreased quality of life after hospitalization. Assuming each of these patients was discharged from the hospital, which of the following patients is at greatest risk for decreased functional status and quality of life? A. A 70-year-old man who had coronary artery bypass surgery. He developed complications after surgery and had difficulty being weaned from mechanical ventilation. He required a tracheostomy and gastrostomy. He is being discharged to a long-term acute care hospital. He is a widower. B. A 79-year-old woman admitted for exacerbation of heart failure. She manages her care independently but needed diuretic medications adjusted. She states that she is compliant with her medications but sometimes forgets to take them. She lives with her 82-year-old spouse. Both consider themselves to be independent and support each other. C. A 90-year-old man admitted for a carotid endarterectomy. He lives in an assisted living facility (ALF) but is cognitively intact. He is the "social butterfly" at all of the events at the ALF. He is hospitalized for 4 days and discharged to the ALF. D. An 84-year-old woman who had stents placed to treat coronary artery occlusion. She has diabetes that has been managed, lives alone, and was driving prior to hospitalization. She was discharged home within 3 days of the procedure.

A

The nurse is a member of a committee to design a critical care unit in a new building. Which design trend would best facilitate family-centered care? A.Ensure that the patient's room is large enough and has adequate space for a sleeper sofa and storage for family members' personal belongings. B. Include a diagnostic suite in close proximity to the unit so that the patient does not have to travel far for testing. C. Incorporate a large waiting room on the top floor of the hospital with a scenic view and amenities such as coffee and tea. D. Provide access to a scenic garden for meditation.

A

The nurse is caring for a 100-kg patient being monitored with a pulmonary artery catheter. The nurse assesses a blood pressure of 90/60 mm Hg, heart rate 110 beats/min, respirations 36/min, oxygen saturation of 89% on 3 L of oxygen via nasal cannula. Bilateral crackles are audible upon auscultation. Which hemodynamic value requires immediate action by the nurse? A. Cardiac index (CI) of 1.2 L/min/m3 B. Cardiac output (CO) of 4 L/min C. Pulmonary vascular resistance (PVR) of 80 dynes/sec/cm-5 D. Systemic vascular resistance (SVR) of 1400 dynes/sec/cm-5

A

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

A

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

A

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

A A high PAOP and a low cardiac index are findings consistent with cardiogenic shock. Positive inotropic agents (e.g., dobutamine) are given to increase the contractile force of the heart.

The nurse is caring for a patient admitted w/ 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 mmHg c) Obtain an electronic blood pressure monitor d) Record the blood pressure as "not assessable"

A Auscultated blood pressures in shock may be significantly inaccurate due to vasoconstriction. If blood pressure is not audible, the approximate value can be assessed by palpation or ultrasound.

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 Desired outcomes for a patient in cardiogenic shock with an IABP include decreased SVR, diminished symptoms of myocardial ischemia (chest pain, ST-segment elevation), increased stroke volume, and increased cardiac output and cardiac index. A cardiac index of 2.5 L/min is within normal limits.

After receiving a handoff report from the night shift, the nurse completes the morning assessment of a patient with severe sepsis. Vital signs are: blood pressure 95/60 mm Hg, heart rate 110 beats/min, respirations 32 breaths/min, oxygen saturation (SpO2) 96% on 45% oxygen via Venturi mask, temperature 101.5° F, central venous pressure (CVP/RAP) 2 mm Hg, and urine output of 10 mL for the past hour. The nurse initiates which provider prescription first? a) Administer infusion of 500 mL 0.9% normal saline every 4 hours as needed if the CVP is less than 5 mm Hg. b) Increase supplemental oxygen therapy to maintain SpO2 greater than 94%. c) Administer 40 mg furosemide (Lasix) intravenous as needed if the urine output is less than 30 mL/hr. d) Administer acetaminophen (Tylenol) 650- mg suppository per rectum as needed to treat temperature greater than 101° F.

A Fluid volume resuscitation is the priority in patients with severe sepsis to maintain circulating blood volume and end-organ perfusion and oxygenation. A 500-mL IV bolus of 0.9% normal saline is appropriate given the patient's CVP of 2 mm Hg and hourly urine output of 10 mL/hr.

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

A Given the patient's diagnosis, laboratory results, and supporting vital signs, restoring circulating blood volume is a priority and can be accomplished following insertion of an appropriate gauge IV (18) to facilitate blood and fluid administration.

The nurse is caring for a patient receiving intravenous ibuprofen for pain management. The nurse recognizes which laboratory assessment to be a possible side effect of the ibuprofen? a. Elevated creatinine b. Elevated platelet count c. Elevated white blood count d. Low liver enzymes

A Ibuprofen can result in renal insufficiency, which may be noted in an elevated serum creatinine level. Thrombocytopenia (low platelet count) is another possible side effect. An elevated white blood count indicates infection. Although ibuprofen is cleared primarily by the kidneys, it is also important to assess liver function, which would show elevated liver enzymes, not low values.

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 In cardiogenic shock, cardiac output and cardiac index decrease. Right atrial pressure, pulmonary artery pressures, and pulmonary artery occlusion pressure increase and volume backs up into the pulmonary circulation and the right side of the heart.

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

A Most prerenal causes of AKI are related to intravascular volume depletion, decreased cardiac output, renal vasoconstriction, or pharmacological agents that impair autoregulation and GFR (Box 16-2). These conditions reduce the glomerular perfusion and the GFR, and the kidneys are hypoperfused. For example, major abdominal surgery can cause hypoperfusion of the kidney as a result of blood loss during surgery or as a result of excess vomiting or nasogastric suction during the postoperative period. The body attempts to normalize renal perfusion by reabsorbing sodium and water. If adequate blood flow is restored to the kidney, normal renal function resumes. Most forms of prerenal AKI can be reversed by treating the cause.

The most important nursing intervention for patients who receive neuromuscular blocking agents is to: a. administer sedatives in conjunction with the neuromuscular blocking agents. b. assess neurological status every 30 minutes. c. avoid interaction with the patient, because he or she won't be able to hear. d. restrain the patient to avoid self-extubation.

A Neuromuscular blocking agents cause paralysis only; they do not cause sedation. Therefore, concomitant administration of sedatives is essential. Neurological status is monitored according to unit protocol. Nurses should communicate with all critically ill patients, regardless of their status. If the patient is paralyzed, restraining devices may not be needed.

Nociceptors differ from other nerve receptors in the body in that they: a. adapt very little to continual pain response. b. inhibit the infiltration of neutrophils and eosinophils. c. play no role in the inflammatory response. d. transmit only the thermal stimuli.

A Nociceptors are stimulated by mechanical, chemical, or thermal stimuli. Nociceptors differ from other nerve receptors in the body in that they adapt very little to the pain response. The body continues to experience pain until the stimulus is discontinued or therapy is initiated. This is a protective mechanism so the body tissues being damaged will be removed from harm. Nociceptors usually initiate inflammatory responses near injured capillaries. As such, the response promotes infiltration of injured tissues with neutrophils and eosinophils.

The nurse is caring for a critically ill trauma patient who is expected to be hospitalized for an extended period of time. Which of the following nursing interventions would improve the patient's well-being and reduce anxiety the most? a. Arrange for the patient's dog to be brought into the unit (per protocol). b. Contact the pet therapy department to bring a therapy dog in to visit. c. Secure the harpist to come and play soothing music for an hour every afternoon. d. Wheel the patient out near the unit aquarium to observe the tropical fish.

A Nonpharmacological approaches are helpful in reducing stress and anxiety, and each of these activities has the potential for improving the patient's well-being. The patient is likely to benefit most from the presence of his or her own dog rather than the therapy dog.

A 63-year-old patient is admitted with new-onset fever; flulike symptoms; blisters over the arms, chest, and neck; and red, painful oral mucous membranes. The patient should be further evaluated for which possible non-burn-injured skin disorder? a) Toxic epidermal necrolysis b) Staphylococcal scalded skin syndrome c) Necrotizing soft tissue infection d) Graft vs. host disease

A Patients with toxic epidermal necrolysis, Stevens-Johnson Syndrome (SJS), and erythema multiforme present with acute-onset fever and flulike symptoms, with erythema and blisters developing within 24 to 96 hours; skin and mucous membranes slough, resulting in a significant and painful partial-thickness injury.

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

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

A 45-year-old male postsurgical patient is on a ventilator in the critical care unit. He has been tolerating the ventilator well and has not required any sedation. He becomes tachycardic and hypertensive. His respiratory rate has increased to 28 breaths/min. The ventilator is set on synchronized intermittent mandatory ventilation (SIMV) at a rate of 10 breaths/min. The patient has been suctioned recently via his endotracheal tube, and his airway is clear. He responds appropriately to the nurse's commands. The nurse should: a. assess the patient's level of pain. b. decrease the SIMV rate on the ventilator. c. provide sedation as ordered. d. suction the patient again.

A Pulse, respirations, and blood pressure frequently result from activation of the sympathetic nervous system by the pain stimulus. Because the patient is postoperative, the patient should be assessed for the presence of pain and need for pain medication. Decreasing the SIMV does nothing because the patient is already overriding the ventilator. Providing sedation may calm the patient but will not solve the problem if the physiological changes are from pain. The patient has just been suctioned and his lungs are clear. There is no need to suction again.

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

A Slow continuous ultrafiltration (SCUF) is also known as isolated ultrafiltration and is used to remove plasma water in cases of volume overload.

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

A Temporary percutaneous catheters are commonly used in patients with acute kidney injury because they can be used immediately.

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

A The IABP improves coronary artery perfusion, reduces afterload, and improves perfusion to vital organs. An IABP acts through counterpulsation, augmenting the pumping action of the heart, displacing blood to improve both forward and backward blood flow.

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

A The critical care nurse is responsible for monitoring the patient receiving CRRT. The hemofilter is assessed every 2 to 4 hours for clotting (as evidenced by dark fibers or a rapid decrease in the amount of ultrafiltration without a change in the patient's hemodynamic status). The CRRT system is frequently assessed to ensure filter and lines are visible at all times, kinks are avoided, and the blood tubing is warm to the touch.

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

A The most profound feature of neurogenic shock is bradycardia with hypotension from the decreased sympathetic activity.

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 Timely identification of the causative organism through blood cultures and the initiation of appropriate antibiotics following obtaining blood cultures improve the survival of patients with sepsis or septic shock.

The patient has a temporary transvenous, demand-type ventricular pacemaker. The rate on the pacemaker is set at 60 beats/min. Which of the following situations would be of concern? A paced rhythm of 60 beats/min is seen on the monitor; no other waveforms are seen. A pacemaker spike is seen on the T wave of the preceding beat. The patient's inherent (own) rate falls to 58 and the pacemaker fires. The patient's inherent rate is 70 beats/min; no pacemaker spikes are seen.

A pacemaker spike is seen on the T wave of the preceding beat. Failure to sense manifests as pacer spikes that fall earlier than the programmed rate. This can cause an artificial R-on-T phenomenon similar to when a PVC occurs during the T wave, and ventricular tachycardia may occur.

Noninvasive diagnostic procedures used to determine kidney function include which of the following? (Select all that apply.) a) KUB x-ray b) Renal ultrasound c) MRI d) IVP e) Renal angiography

A, B, C Noninvasive diagnostic procedures that assess the renal system are radiography of the kidneys, ureters, and bladder (KUB); renal ultrasonography; and magnetic resonance imaging.

Which of the following statements about the pain management of a burn victim are true? (Select all that apply.) a) Additional pain medication may be needed because of rapid body metabolism. b) Pain medication should be given before procedures such as debridement, dressing changes, and physical therapy. c) Patients with a history of drug and alcohol abuse will require higher doses of pain medication. d) The IM route is preferred for pain medication administration. e) Patients w/ a history of drug and alcohol abuse should not need as much pain medication as other patients.

A, B, C The rapid metabolism associated with burn injury may require additional pain medication. Many of the procedures associated with burn wounds are painful, such as dressing changes. Adequate pain medication should be given before the procedures. Edema in burned patients alters the absorption of medications that are injected intramuscularly; therefore, drugs must be administered by the IV route. A history of drug and/or alcohol abuse does not change the pain experience for this patient; they will need as much pain medication as other burn patients and in fact may need more due to increased tolerance to the effects of the medication.

The critical care environment is often stressful to a critically ill patient. Identify stressors that are common. (Select all that apply.) A. Alarms that sound from various devices B. Bright fluorescent lighting C. Lack of day-night cues D. Sounds from the mechanical ventilator E. Visiting hours tailored to meet individual needs

A, B, C, D

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

A, B, C, D

Which of the following factors predispose the critically ill patient to pain and anxiety? (Select all that apply.) a. Inability to communicate b. Invasive procedures c. Monitoring devices d. Nursing care

A, B, C, D All of these factors predispose the patient to pain or anxiety.

actors in the critical care unit that may predispose the client to increased pain and anxiety include: (Select all that apply.) a. an endotracheal tube. b. frequent vital signs. c. monitor alarms. d. room temperature.

A, B, C, D Anxiety is likely to result from loss of control, the inability to communicate, continuous noise and lighting, excessive stimulation (including repeated vital sign measurements), lack of mobility, and uncomfortable room temperatures. Increased anxiety levels often lead to increased pain perception.

Which of the following are accepted nonpharmacological approaches to managing pain and/or anxiety in critically ill patients? (Select all that apply.) a. Environmental manipulation b. Explanations of monitoring equipment c. Guided imagery d. Music therapy

A, B, C, D Manipulating the environment so it appears less hostile helps decrease anxiety, as does continually reorienting the patient.. Focus techniques such as guided imagery and music therapy can create a state of relaxation.

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

A, B, C, E

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

A, B, C, E

Which nursing actions are most important for a patient with a right radial arterial line? (Select all that apply.) A. Checking the circulation to the right hand every 2 hours B. Maintaining a pressurized flush solution to the arterial line setup C. Monitoring the waveform on the monitor for dampening D. Restraining all four extremities with soft limb restraints E. Ensuring all junctions remain tightly connected

A, B, C, E

Noise in the critical care unit can have negative effects on the patient. Which of the following interventions assists in reducing noise levels in the critical care setting? (Select all that apply.) A. Ask the family to bring in the patient's iPod or other device with favorite music. B. Invite a volunteer harpist to play on the unit on a regular basis. C. Remodel the unit to have two-patient rooms to facilitate nursing care. D. Remodel the unit to install acoustical ceiling tiles. E. Turn the volume of equipment alarms as low as they can be adjusted, and "off" if possible.

A, B, D

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

A, B, D

An autograft is used to optimally treat a partial- or full-thickness wound that (Select all that apply.) a) involves a joint b) involved the face, hands, or feet c) is infected d) requires more than 2 weeks for healing e) involved very large surface areas

A, B, D Autograft skin will allow for faster healing with less scar formation and a shorter hospitalization. Grafting is not done while a burn is infected. There may not be enough healthy skin to graft large areas.

Choose the items that are common to both pain and anxiety. (Select all that apply.) a. Cyclical exacerbation of one another b. Require good nursing assessment for proper treatment c. Response only to real phenomena d. Subjective in nature

A, B, D Both pain and anxiety are subjective in nature. One can exacerbate the other in a vicious cycle that often requires good nursing assessment in order to manage the precipitating problem and break the cycle. Anxiety is a response to a real or perceived fear. Pain is a response to real or "phantom" phenomenon but always involves transmission of nerve impulses. Both relate to the patient's perceptions of pain and fear. Anxiety is a response to real or perceived fear, and pain is a response to a real or "phantom" phenomenon.

In the healthy individual, pain and anxiety: (Select all that apply.) a. activate the sympathetic nervous system. b. decrease stress levels. c. help remove one from harm. d. increase performance levels.

A, C, D In the healthy person, pain and anxiety are adaptive mechanisms used to increase performance levels or to remove one from potential harm. The "fight or flight" response occurs in response to pain and/or anxiety and involves the activation of the sympathetic nervous system. Pain and anxiety, however, can induce significant stress.

Which of the following statements regarding pain and anxiety are true? (Select all that apply.) a. Anxiety is a state marked by apprehension, agitation, autonomic arousal, and/or fearful withdrawal. b. Critically ill patients often experience anxiety, but they rarely experience pain. c. Pain and anxiety are often interrelated and may be difficult to differentiate because their physiological and behavioral manifestations are similar. d. Pain is defined by each patient; it is whatever the person experiencing the pain says it is.

A, C, D Pain is defined by each patient, anxiety is associated with marked apprehension, and pain and anxiety are often interrelated. Critically ill patients commonly have both pain and anxiety.

A patient requires neuromuscular blockade (NMB) as part of treatment of refractive increased intracranial pressure. The nursing care for this patient includes: (Select all that apply.) a. administration of sedatives concurrently with neuromuscular blockade. b. dangling the patient's feet over the edge of the bed and assisting the patient to sit up in a chair at least twice each day. c. ensuring that deep vein thrombosis prophylaxis is initiated. d. providing interventions for eye care, oral care, and skin care.

A, C, D Patients receiving NMB must be provided total care, including eye, skin, and oral care interventions. Patients are at high risk for deep vein thrombosis secondary to drug-induced paralysis and bed rest. Sedatives must be administered concurrently with NMB, because NMBs have no sedative effects. Although many critically ill patients are assisted to the chair, chair activity is not appropriate for patients receiving NMB; passive exercise is most appropriate.

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

A, C, D The location of the obstruction in the urinary tract determines the method by which the obstruction is treated and may include bladder catheterization, ureteral stenting, or the placement of nephrostomy tubes.

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

A, C, D The patient receiving hemodialysis requires specialized monitoring and interventions by the critical care nurse. Laboratory values are monitored and abnormal results reported to the nephrologist and dialysis staff. The patient is weighed daily to monitor fluid status. On the day of dialysis, dialyzable (water-soluble) medications are not given until after treatment.

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.) a) Apply topical antibacterial wound ointments/dressings b) Change indwelling urinary catheter every 7 days c) Daily assess the need for central IV catheters d) Restrict family visitation e) Maintain strict aseptic technique during burn wound management

A, C, E Nurses can help reduce the risk of infection by using topical antibacterial wound ointments and dressings as prescribed, daily questioning the need for invasive devices such as central IV access and indwelling urinary catheters, and maintaining aseptic technique during all care provided to the patient. Changing the indwelling urinary catheter will not reduce the risk of infection; wound care is achieved by aseptic technique; and restricting family is not an intervention related to infection prevention.

The nurse is caring for a 48-year-old patient who is intubated and on a ventilator following extensive abdominal surgery. Although the patient is responsive, the nurse is not able to read the patient's lips as the patient attempts to mouth the words. Which of the following assessment tools would be the most appropriate for the nurse to use when assessing the patient's pain level? (Select all that apply.) a. The FACES scale b. Pain IntensityScale c. The PQRST method d. The Visual Analogue Scale

A, D The PQRST method and the Pain Intensity Scale require verbalization and/or writing to communicate pain level. The FACES scale and the Visual Analogue Scale can be used by simply having the patient point to the appropriate place. Because of this, they are the easiest to use with children, people with language barriers, and intubated patients.

To reduce relocation stress in patients transferring out of the intensive care unit, the nurse can (Select all that apply.) A. Ask the nurses on the intermediate care unit to give the family a tour of the new unit. B. Contact the intensivist to see if the patient can stay one additional day in the critical care unit so that he and his family can adjust better to the idea of a transfer. C. Ensure that the patient will be located near the nurses' station in the new unit. D. Invite the nurse who will be assuming the patient's care to meet with the patient and family in the critical care unit prior to transfer. E. Help the patient and family focus on the positive meaning of a transfer.

A, D, E

To qualify as a living organ donor, several characteristics are required. Which statement(s) best reflect characteristics of living organ donors? (SATA) A. Between the ages of 18 and 60 B. Similar ethnicity as recipient C. No history of heart disease D. Blood type of recipient E. No history of diabetes

A. Between the ages of 18 and 60, C. No history of heart disease, D. Blood type of recipient, E. No history of diabetes

Which of the following nonpharmacological approaches by the nurse may be useful in the management of pain and anxiety in the critically ill patient? (SATA) A. Encouraging family members to bring familiar items from home B. Guided imagery C. Involving family members in the patient's care D. Music therapy E. Patient-controlled analgesia

A. Encouraging family members to bring familiar items from home, B. Guided imagery, C. Involving family members in the patient's care, D. Music therapy

The nurse is caring for a patient experiencing pain, anxiety, and agitation. Which factors assist the nurse in creating a personalized care plan for this patient? (SATA) A. Extreme anxiety and pain may lead to agitation B. Many critically ill patients experience panic and fear C. Pain and anxiety stimulate the parasympathetic nervous system D. Patients may develop PTSD as a result of an ICU stay

A. Extreme anxiety and pain may lead to agitation, B. Many critically ill patients experience panic and fear, D. Patients may develop PTSD as a result of an ICU stay

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

ANS: A A GCS score of 3 is indicative of a deep coma. Given the assessed respiratory rate of 10 breaths/min combined with the GSC score of 3, the nurse must focus on maintaining the patient's airway. There is no evidence to support the need for increased supplemental oxygen. A respiratory rate of 10 breaths/min may result in increased CO2 retention, which may further increase ICP through dilatation of cerebral vessels. Elevating the head of the bed and supporting bony prominences are appropriate nursing interventions for a patient in a deep coma; however, airway patency is the immediate priority.

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

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

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

ANS: A A patient with a C5 complete spinal injury is at risk for ineffective breathing patterns and should be assessed immediately for any airway compromise. A GCS score of 15 indicates a neurologically intact patient. The patient with a subdural bleed is alert and not in danger of any immediate compromise. The goal for ischemic stroke is to keep the systolic BP less than 220 mm Hg and the diastolic blood pressure less than 120 mm Hg.

3. 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

ANS: A A patient with a GCS score of 3 and no activity on EEG is facing impending death. The OPO should be notified. There are no indications of impending death in any of the other patient scenarios.

5. 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

ANS: A Absence of a corneal reflex indicates altered brainstem activity and is a component used in the clinical evaluation of brain death. Reactive pupils, withdrawal reaction to painful stimuli, and the ability to maintain core temperature indicate brainstem activity.

15. A 20-year-old female with a history of type 1diabetes and an eating disorder is found unconscious. In the emergency department, the following lab values are obtained: Glucose648 mg/dL pH6.88 PaCO220 mm Hg PaO295 mm Hg HCO3- undetectable Anion gap>31 Na+127 mEq/L K+ 3.5 mEq/L Creatinine1.8 mg/dL After the patient's airway and ventilation have been established, the next priority for this patient is: a. administration of a 1-L normal saline fluid bolus. b. administration of 0.1 unit of regular insulin IV push followed by an insulin infusion. c. administration of 20 mEq KCl in 100 mL. d. IV push administration of 1 amp of sodium bicarbonate.

ANS: A After airway is established, the next priority in management of DKA is fluid resuscitation with 1 liter of normal saline over 1 hour. The fluid resuscitation should begin prior to administration of insulin. Potassium may be added to fluid replacement bags after the first liter of normal saline has infused, provided that the serum potassium is greater than 3.3 mEq/L. Although bicarbonate replacement is indicated in this clinical situation, the bicarbonate is administered by infusion, not by IV push, until the pH exceeds 7.0.

6. 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)

ANS: A Alemtuzumab (Campath) is a monoclonal antibody used as an induction agent in patients that are at high immunological risk. Tacrolimus (Prograf), sirolimus (Rapamune), and cyclosporine (Neoral) are all immunosuppressive agents used as part of ongoing maintenance therapy.

A client who has myasthenia gravis is receiving atropine for a cholinergic crisis. Which intervention does the nurse implement for this client? a. Suction the client to remove secretions. b. Turn and reposition the client every 2 hours. c. Measure urinary output every 30 minutes. d. Administer prescribed anticholinergic drugs as needed.

ANS: A Atropine can cause thickening of secretions and formation of mucous plugs. The client is maintained on a ventilator during the crisis. Measures to remove secretions to prevent the buildup of secretions and the possibility of pneumonia are most important. The other interventions do not relate to the administration of atropine.

The nurse teaches a client who has autonomic dysfunction about injury prevention. Which statement indicates that the client correctly understands the teaching? a. "I will change positions slowly." b. "I will avoid wearing cotton socks." c. "I will use an electric razor." d. "I will use a heating pad on my feet."

ANS: A Autonomic dysfunction causes orthostatic hypotension. The client should change positions slowly to prevent orthostatic hypotension. Autonomic dysfunction can cause peripheral polyneuropathy, so the client should be taught to wear socks and shoes at all times and not to use a heating pad. The disorder does not cause bleeding; therefore the client can use any type of razor.

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

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

19. 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."

ANS: A Candidates are placed on the UNOS national waiting list once they become dialysis dependent or have a glomerular filtration rate of less than 20 mL/minute if not on dialysis. ABO compatibility is necessary for successful renal transplantation. A point system is used to rank candidates to determine who will receive a kidney when a donor becomes available.

27. The nurse is caring for a patient who suffered a head trauma following a fall. The patient's 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; and creatinine 1.8 mg/dL. The findings are consistent with which disorder? a. Cerebral salt wasting b. Diabetes insipidus c. Syndrome of inappropriate secretion of antidiuretic hormone d. Thyroid storm

ANS: A Cerebral salt wasting may occur after head trauma and is characterized by low sodium in the face of classic physical and laboratory signs of fluid volume deficit or dehydration, including tachycardia, hypotension, dry mucous membranes, weight loss, and poor skin turgor. The patient also may experience the classic signs of hyponatremia, including a serum sodium less than 135 mg/dL, confusion, lethargy, seizures, and coma. Diabetes insipidus is characterized by clinical signs of dehydration with elevated serum sodium. SIADH is characterized by hyponatremia and fluid volume overload. Thyroid storm would not directly affect sodium levels.

7. The nurse is caring for a 27-year-old patient with a diagnosis of head trauma. The nurse notes that the patient's urine output has increased tremendously over the past 18 hours. The nurse suspects that the patient may be developing: a. diabetes insipidus. b. diabetic ketoacidosis. c. hyperosmolar hyperglycemic syndrome. d. syndrome of inappropriate secretion of antidiuretic hormone.

ANS: A Diabetes insipidus results in large volumes of urine; dehydration and hypovolemia can result. Head trauma and resulting increased intracranial pressure are potential causes of diabetes insipidus. High urine output following head trauma is associated with diabetes insipidus. Even though hyperosmolar hyperglycemic syndrome results in osmotic diuresis, the cause is a deficiency in insulin in type 2 diabetes, not head trauma. SIADH may occur with head trauma but results in reduced urine output and, potentially, hypervolemia.

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

ANS: A Droplet precautions are maintained for a patient with bacterial meningitis until 24 hours after the initiation of antibiotic therapy to reduce the potential for spread of the infection. Washing hands and scrubbing the hub of injection ports are practices that help reduce the risk of infection, but added precautions are necessary for preventing the spread of bacterial meningitis. Disposing all bloody dressings in biohazard bags is a standard universal precaution and is not specific to bacterial meningitis.

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

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

11. 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.

ANS: A Fluid replacement therapy is a priority in a postoperative renal transplant patient with a CVP of 2 mm Hg and elevated heart rate. An oxygen saturation of 95% on 3 L/min via cannula is an acceptable value. The patient is normothermic; application of active warming measures is not indicated. Although pain assessment is an important part of postoperative nursing care, it is not the priority in this scenario.

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

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

1. 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 patient's 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 patient's suitability for organ donation."

ANS: A Hospitals that receive Medicare or Medicaid reimbursement must notify the local OPO in cases of impending death. It is the responsibility of the organ procurement organization, not the physician, to obtain family consent for organ donation and to evaluate the patient for potential suitability as a donor. Notification of the organ procurement organization must occur prior to death, not after the patient has been pronounced dead.

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

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

18. 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? a. Atrial fibrillation b. Idioventricular rhythm c. Junctional rhythm d. Sinus bradycardia

ANS: A Increased heart rate and tachydysrhythmia, including atrial fibrillation, may accompany thyroid storm. Bradycardiac rhythms may be suggestive of hypothyroidism.

Infection by Helicobacter pylori bacteria is a major cause of: a. duodenal ulcers. b. Cushings ulcers. c. Curlings ulcers. d. stress ulcers.

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

15. 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.

ANS: A It is mandatory to report any donor-derived infections to the organ procurement organization (OPO). The priority action is to notify the transplant coordinator. Verifying results with the lab technician, if indicated, would be the responsibility of the transplant coordinator. Repeating viral studies and continuing to monitor for signs of rejection are appropriate actions but not the immediate priority.

25. 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.

ANS: A Laboratory values should be trended, but the nurse should notify the physician of the elevated liver enzyme results, as significantly elevated results could indicate hepatic artery thrombosis. Glucose of 85 mg/dL is considered within normal limits by most laboratories and would not require treatment with glucose or insulin to normalize. Repeating the enzyme results in 4 hours would be appropriate, but it is not the immediate priority.

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

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

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

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

6. 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? a. He will go into adrenal crisis. b. He will go into thyroid storm. c. His autoimmune disease will go into remission. d. Nothing; it is appropriate to stop the medication for 3 days.

ANS: A Patients on long-term corticosteroid therapy are at high risk for adrenal crisis, because therapy suppresses the endogenous production of steroids. Adrenal crisis may be precipitated by sudden withdrawal of glucocorticoid therapy. Thyroid storm may occur when antithyroid medications are suddenly withdrawn. Rheumatoid arthritis is likely to exacerbate with the withdrawal of glucocorticoids. Adrenal crisis may occur shortly after withdrawal of glucocorticoids.

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: a. places the patient on seizure precautions. b. expects that the provider will come and remove the endotracheal tube. c. withhold any further calcium treatments. d. place an oral airway at the bedside.

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

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

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

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

ANS: A Portal hypertension causes two main clinical problems for the patient: hyperdynamic circulation and development of esophageal or gastric varices. Liver cell destruction causes shunting of blood and increased cardiac output. Vasodilation is also present (so vasodilators are not needed), which causes decreased perfusion to all body organs, even though the cardiac output is very high. This phenomenon is known as high-output failure or hyperdynamic circulation. Clinical signs and symptoms are those of heart failure and include jugular vein distention, pulmonary crackles, and decreased perfusion to all organs. Blood pressure decreases and dysrhythmias are common. Guaiac-positive stools may be an indication of gastrointestinal bleeding.

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

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

The nurse instructs a client who has myasthenia gravis to take prescribed medications on time and to eat meals 45 to 60 minutes after taking anticholinesterase drugs. The client asks why the timing of meals is so important. Which is the nurse's best response? a. "This timing allows the drug to have maximum effect, so it is easier for you to chew, swallow, and not choke." b. "This timing prevents your blood sugar level from dropping too low and causing you to be at risk for falling." c. "These drugs are very irritating to your stomach and could cause ulcers if taken too long before meals." d. "These drugs cause nausea and vomiting. By waiting a while after you take the medication, you are less likely to vomit."

ANS: A Skeletal muscle weakness extends to the ability to chew and swallow. Clients who have myasthenia gravis are at risk for aspiration during meals. Timing the medication so that most of the meal is eaten when the drugs have produced their peak effect enables the client to chew and swallow more easily. The medication has no effect on blood glucose levels, ulcers, or nausea.

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

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

32. 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.

ANS: A The LAS is based on lab values, diagnostic tests, and medical diagnosis; candidates with higher LASs have higher priority than those with lower scores. Lungs from children and adults are offered to pediatric and adolescent candidates first. The LAS is used for all patients who are listed on the organ donor registry. The LAS was developed to estimate the change of first-year survival after transplantation.

23. 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 patient's 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 patient's risk of death within 1 year of diagnosis."

ANS: A The Model for End-Stage Liver Disease (MELD) score uses the patient's serum creatinine, international normalized ratio (INR) for prothrombin time, and serum bilirubin to predict survival. Calculated MELD scores range between 6 and 40, with higher scores directly associated with the patient's risk of death in 3 months. Patients with an acute onset of liver disease and a life expectancy of hours to a few days are the only exception to the use of a calculated MELD score. The MELD score measures the severity of liver disease.

A client who has myasthenia gravis is recovering after a thymectomy. Which complication does the nurse monitor for in this client? a. Sudden onset of shortness of breath b. Swelling of the lower extremities c. Lower abdominal tenderness d. Decreased urinary output

ANS: A The complication to be alert for is pneumothorax or hemothorax. The nurse monitors the client for chest pain, sudden onset of shortness of breath, diminished chest wall expansion, decreased breath sounds, restlessness, and changes in vital signs. The other symptoms are not likely to occur or are not related to removal of the thymus.

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

ANS: A The patient's GCS score is 4 along with an ICP of 18 mm Hg. Although a portable chest x-ray and seizure precautions are appropriate to include in the plan of care, Mannitol 1 g intravenous is the priority intervention to reduce intracranial pressure. Ancef 1 g intravenous is appropriate given the indwelling ICP line; however, antibiotic therapy is not the priority in this scenario.

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

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

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

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

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

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

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

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

An older client is hospitalized with Guillain-Barré syndrome. A family member tells the nurse the client is restless and seems confused. What action by the nurse is best? a. Assess the client's oxygen saturation. b. Check the medication list for interactions. c. Place the client on a bed alarm. d. Put the client on safety precautions.

ANS: A In the older adult, an early sign of hypoxia is often confusion and restlessness. The nurse should first assess the client's oxygen saturation. The other actions are appropriate, but only after this assessment occurs.

A client with myasthenia gravis (MG) asks the nurse to explain the disease. What response by the nurse is best? a. "MG is an autoimmune problem in which nerves do not cause muscles to contract." b. "MG is an inherited destruction of peripheral nerve endings and junctions." c. "MG consists of trauma-induced paralysis of specific cranial nerves." d. "MG is a viral infection of the dorsal root of sensory nerve fibers."

ANS: A MG is an autoimmune disorder in which nerve fibers are damaged and their impulses do not lead to muscle contraction. MG is not an inherited or viral disorder and does not paralyze specific cranial nerves.

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

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

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

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

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

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

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

ANS: A, B, C, E, F In unconscious patients with stable cervical spine, assess oculocephalic reflex (doll's eye): turn the patient's head quickly from side to side while holding the eyes open. Note movement of eyes. The doll's eye reflex is present if the eyes move bilaterally in the opposite direction of the head movement.

A client with myasthenia gravis is prescribed pyridostigmine (Mestinon). What teaching should the nurse plan regarding this medication? (Select all that apply.) a. "Do not eat a full meal for 45 minutes after taking the drug." b. "Seek immediate care if you develop trouble swallowing." c. "Take this drug on an empty stomach for best absorption." d. "The dose may change frequently depending on symptoms." e. "Your urine may turn a reddish-orange color while on this drug."

ANS: A, B, D Pyridostigmine should be given with a small amount of food to prevent GI upset, but the client should wait to eat a full meal due to the potential for aspiration. If difficulty with swallowing occurs, the client should seek immediate attention. The dose can change on a day-to-day basis depending on the client's manifestations. Taking the drug on an empty stomach is not related although the client needs to eat within 45 to 60 minutes afterwards. The client's urine will not turn reddish-orange while on this drug.

4. What psychosocial factors may potentially contribute to the development of diabetic ketoacidosis? (Select all that apply.) a. Altered sleep/rest patterns b. Eating disorder c. Exposure to influenza d. High levels of stress e. Lack of financial resources

ANS: A, B, D, E Psychosocial factors may lead to changes in diabetes self-management practices that precipitate diabetic ketoacidosis. Eating disorders may complicate 20% of recurrent cases of DKA in young women. Changes in sleep patterns and psychosocial stressors may lead to increased insulin demands in the face of declining self-care practices. Financial and time limitations impacted the ability to monitor for changes in control. Exposure to influenza is a physiological factor; it would not be a psychosocial factor associated with DKA.

5. Factors associated with the development of nephrogenic diabetes insipidus include which of the following? (Select all that apply.) a. Heredity b. Medications, including phenytoin (Dilantin) and lithium carbonate c. Meningitis d. Pituitary tumors e. Sickle cell disease

ANS: A, B, E Nephrogenic diabetes insipidus occurs when adequate amounts of antidiuretic hormone are produced with limited renal response. Causative factors for nephrogenic diabetes insipidus are heredity, preexisting renal disease, multisystem diseases such as multiple myeloma and sickle cell disease, chronic electrolyte disturbances, and medications. Meningitis may result in neurogenic diabetes insipidus. Pituitary tumors may result in neurogenic diabetes insipidus.

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

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

The nurse caring for a client with Guillain-Barré syndrome has identified the priority client problem of decreased mobility for the client. What actions by the nurse are best? (Select all that apply.) a. Ask occupational therapy to help the client with activities of daily living. b. Consult with the provider about a physical therapy consult. c. Provide the client with information on support groups. d. Refer the client to a medical social worker or chaplain. e. Work with speech therapy to design a high-protein diet.

ANS: A, B, E Improving mobility and strength involves the collaborative assistance of occupational therapy, physical therapy, and speech therapy. While support groups, social work, or chaplain referrals may be needed, they do not help with mobility.

1. The family of a critically ill patient has asked to discuss organ donation with the patient's nurse. When preparing to answer the family's questions, the nurse understands which concern(s) most often influence a family's 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

ANS: A, B, E, F Common fears and concerns that can influence a family's decision to donate include fear of disfigurement of the donor, fear of inferior medical care being provided to the donor in order to hasten the process, fear that the donor may not really be deceased, and concern that the family of the donor will assume the financial burden associated with the donation. The number of individuals awaiting transplant along with the current UNOS registry system ensures all procured organs will be transplanted. The age and location of recipients are not disclosed by the OPO.

2. Mechanisms for development of diabetes insipidus include which of the following? (Select all that apply.) a. ADH deficiency b. ADH excess c. ADH insensitivity d. ADH replacement therapy e. Water deprivation

ANS: A, C Diabetes insipidus is caused by either a deficiency in ADH production (neurogenic) or impaired renal response to ADH (nephrogenic). ADH excess is characteristic of syndrome of inappropriate secretion of antidiuretic hormone. ADH replacement therapy is a treatment for neurogenic diabetes insipidus. Water deprivation would result in increased ADH secretion and further augment dehydration associated with diabetes insipidus.

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

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

A client has just undergone surgery for peripheral nerve trauma. Which interventions does the nurse include in the client's plan of care? (Select all that apply.) a. Immobilization of the affected area with a splint b. Rotation of cold and heat therapy c. Occupational therapy d. Skin care, including hygiene and ointments e. High-fat, low-protein diet

ANS: A, C, D Care for the client with peripheral nerve trauma includes immobilization before and after surgery, and skin care to prevent skin breakdown and promote healing. The client may likely require physical or occupations therapy during the recovery process. The client will have decreased sensation, so cold and heat therapy should not be used. The client will require a diet high in protein to promote healing.

1. Which of the following are appropriate nursing interventions for the patient in myxedema coma? (Select all that apply.) a. Administer levothyroxine (Synthroid) as ordered. b. Encourage the intake of foods high in sodium. c. Initiate passive rewarming interventions. d. Monitor airway and respiratory effort. e. Monitor urine osmolality.

ANS: A, C, D Myxedema coma is a severe manifestation of hypothyroidism. Treatment entails replacement of thyroid hormone, airway management related to respiratory depression and potential airway obstruction related to tongue edema, thermoregulation, management of edema and congestive heart failure symptoms, and patient education. Edema may accompany myxedema and necessitate use of sodium restriction. Urine osmolality is monitored in conditions that affect antidiuretic hormone levels.

The nurse is preparing to send a cerebrospinal fluid sample to the laboratory. Which actions does the nurse implement during this procedure? (Select all that apply.) a. Use Standard Precautions. b. Wear sterile gloves when handling the specimen. c. Place the specimen on ice. d. Send the specimen in a sealed bag displaying a biohazard symbol. e. Confirm the specimen label with the client's identification band.

ANS: A, D, E The Standard Precautions approach is based on the premise that a medical history and a physical examination cannot reliably identify all those infected by pathogens. Consequently, health care workers should consider all human blood and body fluids as potentially infectious and must use appropriate protective measures to prevent possible exposure. Specimens should be labeled appropriately and transported in a sealed bag displaying the biohazard symbol. The nurse should use Standard Precautions when handling the specimen. The nurse should also confirm the identification of the client and the specimen. The nurse does not need sterile gloves, and the specimen should not be iced.

27. 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.

ANS: B A patient taking steroids and calcineurin inhibitors is at risk for the development of posttransplant diabetes as a complication of long-term medication therapy. Although the lab values in isolation do not indicate infection, blood sugars must be normalized to promote healing. Hemoglobin A1C levels indicate the level of blood sugar control over the past 2 to 3 months. Findings should not be considered temporary. Although steroids can elevate blood sugar values, discontinuation of steroid therapy may not be feasible in all transplant recipients.

28. 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.

ANS: B Administration of antiproliferative agents such as antithymocyte globulin (ATG) has been shown to decrease rejection rates in the initial postoperative period. Antiviral agents are administered if CMV donor status is positive. Antiproliferative agents are recommended as first choice for induction therapy in recipients at high immunological risk. ATG is given in the operating room as well as for several days postoperative.

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

ANS: B Alignment of the head and neck may help prevent spinal cord damage in the event of a cervical spine injury. Hyperextension of the neck is contraindicated with a cervical spine injury. Immediate endotracheal intubation is not indicated with a suspected cervical spine injury unless the patient's airway is compromised. The use of assist devices to maintain immobilization of the cervical spine is indicated until injury has been ruled out.

16. Acute adrenal crisis is caused by: a. acute renal failure. b. deficiency of corticosteroids. c. high doses of corticosteroids. d. overdose of testosterone.

ANS: B An adrenal crisis occurs because of a lack of corticosteroids. This may be due to lack of endogenous cortisol production, lack of ACTH production, or inhibition of natural cortisol production by exogenous cortisol administration. Acute renal failure would not be associated with adrenal crisis. High doses of corticosteroids are associated with Cushing's syndrome. Testosterone overdose would not be associated with adrenal crisis. Steroid hormones may possess some corticoid properties.

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: a. measure abdominal girth to determine the amount of fluid accumulation. b. position the patient in a semi-Fowlers position. c. prepare the patient for emergent paracentesis. d. administer diuretics.

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

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

ANS: B Autonomic dysreflexia, characterized by an exaggerated response of the sympathetic nervous system can be triggered by a variety of stimuli, including a kinked indwelling catheter, which would result in bladder distention. Other causes that should be ruled out prior to pharmacological intervention include fecal impaction. Treating the patient for a headache will not resolve symptoms of autonomic dysreflexia. Treatment must focus on identifying the underlying cause. Slow deep breathes will not correct the underlying problem. Assessing for underlying causes of autonomic dysreflexia should precede contacting the physician.

4. Which of the following is a high-priority nursing diagnosis for both diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome? a. Activity intolerance b. Fluid volume deficient c. Hyperthermia d. Impaired nutrition, more than body requirements

ANS: B Both diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome result in dehydration and hypovolemia; therefore, fluid volume deficit is a priority nursing diagnosis. Even though activity intolerance is a potential nursing diagnosis related to the fatigue associated with metabolic changes in hyperglycemic conditions, it is not a first priority. Hyperthermia is associated with thyroid crisis. Although overweight and obesity are risk factors for type 2 diabetes, during metabolic crisis, the patient has inadequate energy available to tissues because of limited availability and poor utilization of insulin.

7. 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

ANS: B Denervation of the lung that occurs during lung transplantation causes changes in mucus production and ciliary movement. As a result, to promote the drainage of secretions and prevent mucus plugging, endotracheal and oral suctioning should be a priority of nursing care in the postoperative lung transplant patient. Head of bed elevation, side to side repositioning, and application of sequential compression stockings are appropriate nursing interventions, but they are not the priority intervention.

2. The nurse is managing a donor patient six hours prior to the scheduled harvesting of the patient's 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

ANS: B Donor management, focuses on maintaining hemodynamic stability and normal laboratory parameters. Care of the patient is under the direction of the OPO coordinator working collaboratively with the physician and critical care nurses. Standardized order sets are usually used, and they focus on preserving organ function and viability.Immediate action is required for an arterial blood gas value of pH 7.30; PaCO2 38 mmHg; HCO3 16 mEq/L which indicates metabolic acidosis. All other values are within normal limits.

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: a. a need for hourly vital signs. b. approximately 25% loss of total blood volume. c. resolution of hypovolemic shock. d. increased blood flow to the skin, lungs, and liver.

ANS: B Hypotension is an advanced sign of shock. As a rule, a systolic pressure of less than 100 mm Hg, a postural decrease in blood pressure of greater than 10 mm Hg, or a heart rate of greater than 120 beats/min reflects a blood loss of at least 1000 mL25% of the total blood volume. Vital signs should be monitored at least every 15 minutes. As blood loss exceeds 1000 mL, the shock syndrome progresses, causing decreased blood flow to the skin, lungs, liver, and kidneys.

1. 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: a. adrenal insufficiency. b. diabetic ketoacidosis. c. hyperosmolar, hyperglycemic state. d. hypoglycemia.

ANS: B If the insulin pump fails, the patient with type 1 diabetes will have a complete interruption of insulin delivery; diabetic ketoacidosis will occur. Adrenal insufficiency would not result from insulin pump failure. Hyperosmolar, hyperglycemic state is a hyperglycemic complication associated with type 2 diabetes; this patient has type 1 diabetes. Interruption of insulin delivery in type 1 diabetes would result in hyperglycemia, not hypoglycemia.

he nurse recognizes which pathophysiologic feature as a hallmark of Guillain-Barré syndrome? a. Nerve impulses are not transmitted to skeletal muscle. b. The immune system destroys the myelin sheath. c. The distal nerves degenerate and retract. d. Antibodies to acetylcholine receptor sites develop.

ANS: B In Guillain-Barré syndrome, the immune system destroys the myelin sheath, causing segmental demyelination. Nerve impulses are transmitted more slowly but remain in place. Antibodies are not developed. The nerves do not degenerate and retract.

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

ANS: B In the presence of hypotension and bradycardia, administering the medication over 2 minutes is too fast. Mixing medication with 0.9% normal saline prevents precipitation of the medication but will not prevent complications related to this scenario. Administering the medications via central line will not prevent complications related to this scenario.

The nurse is assessing a client who had a dissection of all branches of the right trigeminal nerve. When asked to wrinkle his forehead, the client wrinkles only the left side. Which is the nurse's best action? a. Place the client in high Fowler's position. b. Document the finding. c. Assess the corneal reflex. d. Notify the health care provider.

ANS: B Loss of motor and sensory function after complete trigeminal nerve dissection is normal. No intervention is necessary.

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

ANS: B Maintaining perfusion to the spinal cord is critical in the management of spinal cord injury. Monitoring blood pressure is a priority.

13. 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."

ANS: B Medication trough levels are used to guide dosing. The patient should not take his morning dose of medications until labs have been drawn so that an accurate trough level is obtained. Transplant medication is administered at regular dosing intervals (e.g. every 12 hours) to maintain therapeutic drug levels and intervals should not be independently adjusted. Medication should not be skipped when lab is drawn. The patient should be instructed to take the medication immediately after lab work has been drawn. Medication is not to be held for an entire day as doing so places the patient at risk for rejection.

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

ANS: B Medications to control blood pressure are administered to prevent rebleeding before an aneurysm is secured. Following infusion, the patient's blood pressure remains dangerously high, so increasing the dose by 2.5 mg/hr is the best action by the nurse. Stopping the infusion or weaning the infusion is contraindicated before reaching the desired blood pressure. Notifying the physician of the blood pressure is not indicated until the upper limits of the infusion are reached without achieving the desired blood pressure.

The nurse teaches a client with Guillain-Barré syndrome (GBS) about the recovery rate of this disorder. Which statement indicates that the client correctly understands the teaching? a. "I need to see a lawyer because I do not expect to recover from this disease." b. "I will have to take things slowly for several months after I leave the hospital." c. "I expect to be able to return to work in construction soon after I get discharged." d. "I wonder if my family will be able to manage my care now that I am paralyzed."

ANS: B Most clients make a full recovery from GBS. Recovery can take as long as 6 months to 2 years. Fatigue is a major lingering symptom for most of those diagnosed with this disorder. Clients are not permanently paralyzed. They are in an acute care environment during the acute phase of the disorder.

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

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

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

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

34. 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."

ANS: B Renal biopsy confirms the presence of rejection. Admission lab results will provide information related to the current functional level of the kidney but will not confirm rejection. Monitoring the patient will not confirm the presence of rejection. An ultrasound of the kidney will determine if there is blood flow to the kidney but will not provide information at the cellular level.

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: a. thoughts of food. b. sympathetic nerve stimulation. c. overstimulation of the sublingual glands. d. parasympathetic nerve stimulation.

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

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

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

21. 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.

ANS: B Status 1A is the most urgent status assigned to advanced heart failure awaiting transplantation. Status 1A patients are expected to die within a week without transplant. Status 1B patients are less urgent and can be managed at home with a left ventricular assist device. A patient with advanced heart failure being managed with medications is being managed appropriately. An advanced heart failure patient not successfully managed on medications has the option of listing for a heart transplant.

28. 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? a. Administer the insulin glargine and continue the IV insulin infusion for 24 hours. b. Administer the insulin glargine and discontinue the IV infusion in several hours. c. Discontinue the IV infusion and administer the insulin aspart with the next meal. d. Discontinue the IV infusion and administer the Lantus insulin at bedtime.

ANS: B Subcutaneous insulin should be administered 1 to 4 hours before discontinuing the intravenous infusion to allow the patient to reach adequate plasma insulin levels to prevent redevelopment of DKA. Continuation of the insulin infusion in conjunction with the long-acting insulin glargine would result in hypoglycemia. Discontinuation of intravenous insulin prior to administration of subcutaneous insulin would result in reoccurrence of DKA in a patient with type 1 diabetes.

A client suspected to have myasthenia gravis is scheduled for the Tensilon (edrophonium chloride) test. Which prescribed medication does the nurse prepare to administer if complications of this test occur? a. Epinephrine b. Atropine sulfate c. Diphenhydramine d. Neostigmine bromide

ANS: B Tensilon increases cholinergic responses and can slow the heart rate down so that ectopic beats dominate, causing cardiac fibrillation or arrest. Atropine sulfate is an anticholinergic drug. The other medications are not appropriate for complications of this test.

The nurse is caring for a client who has myasthenia gravis. Which nursing intervention does the nurse implement to reduce muscle weakness in this client? a. Administer a therapeutic massage. b. Collaborate with the physical therapist. c. Perform passive range-of-motion exercises. d. Reposition the client every 2 hours.

ANS: B The hallmark of myasthenia gravis is muscle weakness that increases with fatigue. The nurse provides assistance with ADLs to prevent fatigue. The nurse collaborates with the physical therapist in teaching the client energy conservation techniques. Therapeutic massage, passive range of motion, and repositioning will not reduce muscle weakness.

The nurse is caring for a client who has undergone peripheral nerve repair. Which priority assessment does the nurse perform postoperatively? a. Evaluate extremity mobility. b. Assess the skin surrounding the cast. c. Test distal extremities for sensation. d. Auscultate bowel sounds.

ANS: B The nurse assesses the skin surrounding the cast hourly for tightness, warmth, and color. If the cast is too tight, the nurse notifies the provider immediately. The other assessments should be completed after a circulatory assessment.

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

ANS: B The nurse can administer the medication over 10 minutes as ordered (100-150 mg phenytoin equivalent [PE] over 1 full minute). The drug dose ordered is appropriate for the patient's weight. Fosphenytoin (Cerebyx) does not have to be administered with normal saline or via a central line.

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

ANS: B The nurse should administer lorazepam (Ativan) as ordered; lorazepam (Ativan) is the first-line medication for the treatment of status epilepticus. Phenytoin (Dilantin) is administered only when lorazepam fails to stop seizure activity or if intermittent seizures persist for longer than 20 minutes. Serum electrolytes and chest x-rays are appropriate orders but not the priority in this scenario.

16. 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."

ANS: B The nurse should instruct the patient to avoid sun exposure during peak hours of the day. Application of sunscreen is a priority to reduce the risk of sunburn and subsequent skin cancer. The most common type of skin cancer is squamous cell cancer. Skin examinations should be conducted annually.

14. 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 individual's priority action? a. Drink additional water to prevent dehydration. b. Eat something with 15 g of simple carbohydrates. c. Go to the first aid station to have glucose checked. d. Take another dose of the oral agent.

ANS: B The patient is displaying classic symptoms of hypoglycemia. The patient is on sulfonylurea therapy, which carries the risk of hypoglycemia. The walking may be more exercise than she is used to and may thereby cause hypoglycemia. Fifteen grams of carbohydrate is appropriate for initial management of hypoglycemia. Hypoglycemia does not place the patient at risk for dehydration. The patient requires immediate treatment and could pass out while going to the first aid station. It cannot be assumed that the gym has access to diabetes treatment supplies. Additional doses of oral diabetes medications should not be taken without consulting the healthcare team. An additional dose of glipizide could promote further hypoglycemia.

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

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

12. 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."

ANS: B There are many factors that can delay normal functioning of a transplanted renal graft (e.g., prolonged cold times, altered perfusion states during surgery). It can take a few days for the transplant to function optimally. Low urine output alone is not the sole indicator of kidney failure or an acute rejection episode. Hemodialysis treatments are not routine in the presence of low urine output following a renal transplant.

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

ANS: B To ensure adequate cerebral perfusion, for a CVP of 2 mm Hg, blood pressure of 90/60 mm Hg, and heart rate of 115 beats/min, an infusion of 500 mL of albumin is most appropriate. Lasix is contraindicated in low volume states. Although Decadron and Dilantin are appropriate medications, in this scenario, they are not the priority medications.

26. 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."

ANS: B To protect against viruses that would be detrimental to a transplant recipient, it is most important for transplant patients to consult with their clinic providers to obtain the appropriate vaccinations. Adherence to future scheduled appointments, reporting lab results, and notifying the clinic of all future hospitalizations are part of long-term care, but appropriate vaccinations are essential to the health of the patient.

4. 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

ANS: B To qualify as a living donor, an individual must be free from hypertension, diabetes, cancer, kidney disease, and heart disease and generally between 18 and 60 years of age. A 35-year-old female with a history of food allergies; blood type O negative (universal donor) best qualifies for evaluation. The brother and mother, although blood-type compatible, are outside of acceptable age ranges for living donation. The minor son does not qualify based on blood type.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

6. The nurse has been assigned the following patients. Which patients require assessment of blood glucose control as a nursing priority? (Select all that apply.) a. 18-year-old male who has undergone surgical correction of a fractured femur b. 29-year-old female who is undergoing evaluation for pheochromocytoma c. 43-year-old male with acute pancreatitis who is receiving total parenteral nutrition (TPN) d. 62-year-old morbidly obese female who underwent a hysterectomy for ovarian cancer e. 72-year-old female who is receiving intravenous (IV) steroids for an exacerbation of chronic obstructive pulmonary disease (COPD)

ANS: B, C, D, E Risk factors for development of stress-induced hyperglycemia are a prior history of diabetes or hyperglycemia; obesity; pancreatitis; cirrhosis; glucocorticoids; excess epinephrine; advanced age; nutrition support; and various medications. The young male with the fractured femur is at low risk for stress-induced hyperglycemia.

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

ANS: B, C, E Altered carbohydrate metabolism may result in unstable blood glucose levels. The serum glucose level is usually increased to more than 200 mg/dL. This condition is termed cirrhotic diabetes. Altered carbohydrate metabolism may also result in malnutrition and a decreased stress response. Protein metabolism, albumin synthesis, and serum albumin levels are decreased. Low albumin levels are also thought to be associated with the development of ascites, a complication of hepatic failure. Fibrinogen is an essential protein that is necessary for normal clotting. A low plasma fibrinogen level, coupled with decreased synthesis of many blood-clotting factors, predisposes the patient to bleeding. Clinical signs and symptoms range from bruising and nasal and gingival bleeding to frank hemorrhage. Disseminated intravascular coagulation may also develop. DIF: Cognitive Level: Analysis REF: p. 534

3. 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.) a. Blood glucose 43 mg/dL b. Blood glucose 524 mg/dL c. HCO3- 10 mEq/L d. PaCO2 37 mm Hg e. pH 7.23

ANS: B, C, E The patient is presenting with laboratory evidence of diabetic ketoacidosis. Diabetic ketoacidosis is characterized by hyperglycemia and low bicarbonate levels, low CO2, and low pH. A blood glucose of 43 mg/dL is indicative of hypoglycemia. The reported carbon dioxide level is normal and is not consistent with acute DKA, for which compensatory tachypnea would be expected along with a low PaCO2.

A client with myasthenia gravis is malnourished. What actions to improve nutrition may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assessing the client's gag reflex b. Cutting foods up into small bites c. Monitoring prealbumin levels d. Thickening liquids prior to drinking e. Weighing the client daily

ANS: B, D Cutting food up into smaller bites makes it easier for the client to chew and swallow. Thickened liquids help prevent aspiration. The UAP can weigh the client, but this does not help improve nutrition. The nurse assesses the gag reflex and monitors laboratory values.

7. 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.) a. Administer glucagon 1 mg intramuscularly any time the blood glucose is less than 70 mg/dL. b. Administer 15 grams of carbohydrate orally for severe episodes of hypoglycemia. c. Discontinue the insulin pump by removing the infusion set catheter. d. Increase home blood glucose monitoring and report patterns of hypoglycemia to the provider. e. Perform blood glucose monitoring before exercising and driving.

ANS: B, D, E This patient experienced a severe hypoglycemic episode. The patient is at risk for this because of a history of autonomic neuropathy as evidenced by gastroparesis, which causes erratic gastric emptying and glucose absorption, and renal insufficiency, which can result in erratic clearance of insulin. Patients with hypoglycemia unawareness should increase blood glucose monitoring; carry a glucagon emergency kit and instruct a family member of friend on administration; monitor before high-risk activities such as driving and exercising; and use caution with alcohol ingestion. Glucagon or 50% dextrose is administered for severe hypoglycemic episodes when a patient is unconscious or extremely uncooperative. Oral glucose replacement may be dangerous in a severe reaction because of the risk of aspiration. Mild and moderate hypoglycemic reactions should be managed with oral glucose replacement. Insulin pump therapy may be suspended temporarily during a hypoglycemic episode but should not be discontinued. The infusion set catheter should not be removed during a hypoglycemic episode.

17. The most significant clinical finding of acute adrenal crisis associated with fluid and electrolyte balance is: a. fluid volume excess. b. hyperglycemia. c. hyperkalemia d. hypernatremia

ANS: C Adrenal insufficiency may be characterized by inadequate amounts of cortisol and aldosterone. Aldosterone acts to retain sodium, resulting is water retention and potassium loss. Inadequate levels of aldosterone therefore result in hyponatremia, fluid loss, and hyperkalemia. Inadequate cortisol levels may cause weight loss, weakness, and hypoglycemia. Fluid volume deficit may accompany adrenal crisis as a result of sodium loss from decreases in cortisol and aldosterone. Hypoglycemia may accompany adrenal crisis as a consequence of inadequate amounts of cortisol, which limits gluconeogenesis. Hyponatremia may accompany adrenal crisis because of sodium losses secondary to aldosterone insufficiency that often accompanies the condition.

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

ANS: C Bacterial meningitis is an infection of the pia and arachnoid layers of the meninges and the cerebrospinal fluid (CSF) in the subarachnoid space. As such, the patient can experience symptoms associated with cerebral irritation such photophobia and seizures. In addition, the patient is at increased risk for seizures because of a high temperature. The priority nursing action is to implement seizure precautions in an attempt to prevent injury. Elevating the head of the bead, keeping the lights dim, and maintaining bedrest are all appropriate nursing interventions but are not the priorities in this scenario.

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

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

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

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

24. 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

ANS: C Blood type and body size are the two criteria necessary for matching a donor liver to a recipient. HLA tissue typing is not used because it has not been known to affect outcomes. Donors are carefully screen for infectious diseases and carcinomas during the process, but blood type and body type are the essential matching criteria.

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

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

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

ANS: C CPP = MAP - ICP. In this case, CPP = 108 mm Hg - 18 mm Hg = 90 mm Hg. All other calculated responses are incorrect.

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

ANS: C Cerebral vasospasm is a life-threatening complication following subarachnoid hemorrhage. Once an aneurysm has been repaired surgically, blood pressure is allowed to rise to prevent vasospasm. Volume expansion with 500 mL albumin is the priority intervention for a blood pressure of 95/50 mm Hg to prevent vasospasm and ensure cerebral perfusion. Blood cultures, acetaminophen administration, and Decadron are appropriate to include in the plan of care but are not priorities in this scenario.

9. 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

ANS: C Hemodynamic stability is a priority in donor management. Following brain death, loss of autoregulation results in intense vasodilation. To maintain perfusion to the vital organs, the priority action is to begin a phenylephrine (Neo-Synephrine) infusion to get systolic BP > 90 mm Hg. Maintaining normothermia is the next priority. Obtaining laboratory tests and arterial blood gasses is a part of donor management but not the priority in this scenario.

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

ANS: C In the presence of suspected cerebrospinal fluid leak, drainage should be unobstructed and free flowing. Small bandages may be applied to allow for fluid collection and assessment. Patients should be instructed not to blow their nose because that action may further aggravate the dural tear. Suction catheters should be inserted through the mouth rather than the nose to avoid penetrating the brain due to the dural tear.

5. 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. 70 to 120 mg/dL. b. a decrease of 25 to 50 mg/dL compared with admitting values. c. a decrease of 50 to 75 mg/dL compared with admitting values. d. less than 200 mg/dL.

ANS: C Initial insulin infusions should be administered with a target blood glucose reduction of 50 to 75 mg/dL per hour. Decreases of less than this rate may be associated with inadequate insulin replacement and allow for the persistence of the ketotic state. Rapid reductions of blood glucose may precipitate life-threatening cerebral edema; thus, controlled reduction of glucose is required.

8. A family member approaches the nurse caring for their gravely ill son and states, "We want to donate our son's organs." What is the best action by the nurse? a. Arrange a multidisciplinary meeting with physicians. b. Consult the hospital's ethics committee for a ruling. c. Notify the organ procurement organization (OPO). d. Obtain family consent to withdraw life support.

ANS: C It is the ultimate responsibility of the organ procurement organization to approach the family and obtain consent for organ donation. The best action by the nurse is to notify the OPO. Arranging a multidisciplinary meeting with physicians and consulting the hospital's ethics committee are not appropriate actions in this scenario. Informed consent to withdraw life support is provided by the physician.

29. The nurse is preparing to administer a renal transplant recipient's 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.

ANS: C Mycophenolate mofetil (CellCept) is an antimetabolite that inhibits T lymphocytes. CellCept is used for maintenance immunosuppression therapy.

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

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

A client who has Guillain-Barré syndrome is scheduled for plasmapheresis. Before the procedure, which clinical manifestation does the nurse use to determine patency of the client's arteriovenous shunt? a. Palpable distal pulses b. A pink, warm extremity c. The presence of a bruit d. Shunt pressure higher than 25 mm Hg

ANS: C Nursing care of the client undergoing plasmapheresis includes care of the shunt. The nurse checks for bruits every 2 to 4 hours for patency. Pulse and extremity assessments do not provide information related to shunt patency. Pressure within the shunt is not tested before treatment to determine patency.

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

ANS: C Optimal gas exchange in a patient with increased intracranial pressure includes adequate oxygenation and ventilation of carbon dioxide. A pH of 7.38, PaCO2 of 35 mm Hg, and a PaO2 of 85 mm Hg indicates both. PaCO2 values greater than normal (35-45) can lead to cerebral vasodilatation and further increase cerebral blood volume and ICP. Carbon dioxide levels less than 35 mm Hg can lead to cerebral vessel vasoconstriction and ischemia. Adequate oxygenation of cerebral tissues is achieved by maintaining a PaO2 above 80 mm Hg.

10. 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? a. Calcium b. Chloride c. Potassium d. Sodium.

ANS: C Potassium must be closely monitored. In the early stages of diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome, the potassium value is often high, but it may lower to critical levels once fluid balance has been restored and glucose has returned to more normal levels. Insulin administration used in the treatment of diabetic ketoacidosis further promotes lowering of potassium as the electrolyte is relocated to the cellular bed. Calcium levels do not drastically change in hyperosmolar states and are not a primary concern unless phosphate replacement is initiated. Chloride levels typically follow sodium levels and normalize with fluid replacement. Sodium levels may initially be elevated as a result of dehydration but will be corrected with fluid replacement.

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

ANS: C Spontaneous rupture of the gastric balloon, upward migration of the tube, and occlusion of the airway are other possible complications that need to be assessed. Esophageal rupture may occur and is characterized by the abrupt onset of severe pain. In the event of either of these two life-threatening emergencies, all three lumina are cut and the entire tube is removed. For this reason, scissors are kept at the patients bedside at all times. Endotracheal intubation is strongly recommended to protect the airway. DIF: Cognitive Level: Application REF: p. 522

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

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

33. 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.

ANS: C Surgical complications following renal transplantation include ureteral obstruction. The nurse should gently irrigate the Foley catheter to determine patency. Furosemide administration should not occur until catheter obstruction has been ruled out. Administration of a fluid bolus should not occur until catheter obstruction has been ruled out. Maintenance fluids administration should be a part of the plan of care but is not the priority in this scenario.

The nurse is planning discharge teaching for a client who has peripheral neuropathy of the lower extremities. Which instruction does the nurse include in the teaching plan? a. "Cut all calluses and corns from your feet as soon as you notice them." b. "Your balance will be steadier if you go barefoot while at home." c. "Use a thermometer to check the temperature of bath water." d. "Avoid using lotion on the feet and legs."

ANS: C The client with neuropathy has loss of sensation in the lower extremities, which can predispose the client to thermal injury. The client should be instructed to use a thermometer to check the temperature of the bath water to avoid a burn. Checking the water with the hands is not recommended because neuropathy may have a stocking and glove distribution that could also affect the hands. The client should be taught to wear shoes at all times, to assess feet and legs daily, to keep skin moist and clean, and not to cut calluses or corns from the feet.

25. 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: a. administration of 3% normal saline. b. administration of exogenous vasopressin. c. fluid restriction. d. low sodium diet.

ANS: C The first treatment of this condition is volume restriction; other treatments may not be needed if restrictions work. Extreme fluid restrictions (800 to 1000 mL/day) may be required in the treatment of SIADH. Hypertonic saline administration may be used to treat severe hyponatremia (serum sodium < 110 mEq/L) but is not used in most cases. The administration of hypertonic saline carries significant risk. Vasopressin replacement would provide additional ADH and further complicate SIADH. Sodium replacement may be required to treat the hemodilution associated with SIADH.

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

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

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

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

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

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

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

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

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

ANS: C The ordered dose is an inappropriate maintenance dose. The nurse should contact the physician. Administering the dose over 2 minutes, administering with normal saline, and assessing the cardiac rhythm for bradycardia are normal administration guidelines for normal dose parameters.

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

ANS: C This is a good example of purposeful movement that is sometimes seen in patients with reduced consciousness. Flexion posturing is characterized by rigid flexion and extension of the arms, wrist flexion, and clenched fists. Extension posturing is characterized by rigid extension of arms and legs with plantar extension of the feet. Withdrawing occurs when a patient moves an extremity away from a painful source of stimulation.

20. 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."

ANS: C Transplant programs vary in the immunosuppressant medications that are prescribed; some programs withdraw steroids after a predetermined amount of time. Transplant recipients will be on immunosuppressant medications for life taking, at minimum, two medications—a calcineurin inhibitor or mTOR inhibitor and an antimetabolite. Medications are taken at regular daily prescribed intervals to maintain therapeutic blood levels.

24. The nurse teaches a client who has Guillain-Barré syndrome (GBS) about pain management. Which statement indicates that the client correctly understands the teaching? a. "I can use the button on the pump as often as I want to get more pain medication." b. "Aspirin will provide the best relief from my pain associated with this disease." c. "A combination of morphine and distraction helps bring me relief right now." d. "I should not have any pain as a result of impaired motor and sensory neurons."

ANS: C Typical pain from GBS often is not relieved by medication other than opiates. Distraction, repositioning, massage, heat, cold, and guided imagery may enhance the opiate effects. Patient-controlled analgesia (PCA) pumps should be set with appropriate doses and limits.

A client with Guillain-Barré syndrome is admitted to the hospital. The nurse plans caregiving priority to interventions that address which priority client problem? a. Anxiety b. Low fluid volume c. Inadequate airway d. Potential for skin breakdown

ANS: C Airway takes priority. Anxiety is probably present, but a physical diagnosis takes priority over a psychosocial one. The client has no reason to have low fluid volume unless he or she has been unable to drink for some time. If present, airway problems take priority over a circulation problem. An actual problem takes precedence over a risk for a problem.

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

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

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

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

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

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

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

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

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

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

A client is receiving plasmapheresis. What action by the nurse best prevents infection in this client? a. Giving antibiotics prior to treatments b. Monitoring the client's vital signs c. Performing appropriate hand hygiene d. Placing the client in protective isolation

ANS: C Plasmapheresis is an invasive procedure, and the nurse uses good hand hygiene before and after client contact to prevent infection. Antibiotics are not necessary. Monitoring vital signs does not prevent infection but could alert the nurse to its possibility. The client does not need isolation.

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

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

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

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

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

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

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

ANS: C, E Neither heparin nor pressure bags nor pressurized flush systems are used for ICP monitoring setups. ICP is recorded as a mean value with the transducer system zero referenced at the level of the foramen of Munro. Manually flushing the device may result in an increase in ICP.

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

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

31. 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

ANS: D A hyperacute rejection occurs within hours or days of the transplanted organ. An implanted renal transplant that becomes cyanotic upon reperfusion represents a hyperacute rejection. A cardiac transplant patient with a 3-month history of shortness of breath represents an acute rejection. Small pustules that follow a dermatome most likely represent herpes zoster. Several small lumps under the skin may indicate squamous cell carcinoma.

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

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

30. 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."

ANS: D An altruistic living donor is an individual who makes a decision to donate an organ or part of an organ to a stranger. The nurse can help the patient navigate the donation process. Living donors may be related or unrelated to the potential recipient. In general, living donors are usually between the ages of 18 and 60 years. All transplant centers coordinate the living donation process.

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

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

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

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

The nurse is teaching a client who is receiving carbamazepine (Tegretol) for chronic trigeminal neuralgia. Which statement indicates that the client correctly understands the teaching? a. "This drug will prevent seizures, which can occur because of trigeminal disease." b. "I expect to have surgery soon, so I can stop taking this drug now." c. "This medication is very successful in relieving pain. I am glad to be taking it." d. "I will avoid drinking alcohol because it can add to the side effects of this medicine."

ANS: D Carbamazepine is thought to interfere with the transmission of pain through slow fibers. It may decrease the paroxysmal afferent impulse that causes trigeminal pain. Trigeminal disease does not cause seizures. Drowsiness, dizziness, confusion, and risk for falls are adverse effects of this medication. Alcohol consumption increases these risks; therefore the client should not drink alcohol when taking this medication. Seizure disorders may occur in clients who stop taking this medication. The dose should be decreased gradually. Pain relief varies with the person; some people find that this medication provides at least some relief.

23. 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? a. Daily weight b. Fingerstick glucose c. Lung sound auscultation d. Urine osmolality

ANS: D Diabetes insipidus may result from traumatic brain injury. It results in passage of large volumes of dilute urine. Urine osmolality is low in individuals with diabetes insipidus, and urine specific gravity assessments should be incorporated into the care of at-risk patients. Even though daily weight monitoring is important in the assessment of fluid balance disorders, it is not specific in determining cause. Urine specific gravity measuring would be a more specific means of identifying diabetes insipidus. Blood glucose values would be abnormal in diabetes mellitus but not diabetes insipidus. Changes in breath sounds accompany fluid overload states such as SIADH. Diabetes insipidus is a hypovolemic condition.

2. Which of the following patients is at the highest risk for hyperosmolar hyperglycemic syndrome? a. An 18-year-old college student with type 1 diabetes who exercises excessively b. A 45-year-old woman with type 1 diabetes who forgets to take her insulin in the morning c. A 75-year-old man with type 2 diabetes and coronary artery disease who has recently started on insulin injections d. An 83-year-old, long-term care resident with type 2 diabetes and advanced Alzheimer's disease who recently developed influenza

ANS: D Hyperosmolar hyperglycemic syndrome is more common in type 2 diabetes; influenza is a stressor that would result in further increases in blood sugar. Some individuals with advanced Alzheimer's disease cannot communicate thirst needs and may be incontinent, making hypertonic fluid loss more difficult to estimate. Uncontrolled type 1 diabetes is associated with diabetic ketoacidosis. Interruption of insulin delivery related to a missed insulin dose in type 1 diabetes creates a situation of absolute insulin deficiency in type 1 diabetes and is associated with diabetic ketoacidosis. A patient with type 2 diabetes who is new to insulin is at risk for hypoglycemia.

10. 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

ANS: D Hypoglycemia may indicate a poorly functioning liver and requires immediate action. Postoperative pain level of 3/10 in a renal transplant patient, a lung transplant patient with a productive cough, and a heart transplant recipient with a cardiac output of 4 L/min are normal or expected findings requiring no immediate action.

12. 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? a. Lower serum glucose, lower osmolality, and greater ketosis b. Lower serum glucose, lower osmolality, and milder ketosis c. Higher serum glucose, higher osmolality, and greater ketosis d. Higher serum glucose, higher osmolality, and no ketosis

ANS: D In patients with hyperosmolar hyperglycemic syndrome (HHS), glucose is higher; osmotic diuresis is greater, resulting in higher osmolality; and ketosis is usually absent. Glucose values in HHS are typically higher than those of diabetic ketoacidosis and are not typically accompanied by ketosis.

A client with trigeminal neuralgia is about to undergo surgery for pain relief. The client asks, "How will this surgery relieve my pain?" How does the nurse respond? a. "The surgeon will cut the connection between the cranial nerves." b. "The surgeon will use an electrode to bypass the trigeminal nerve conduction." c. "An incision is made into the nerve itself, and an anesthetic is applied to the area." d. "A small artery compressing the nerve will be relocated."

ANS: D In some clients, a small artery compresses the nerve as it enters the pons. By relocating this nerve, pain relief is obtained and sensation is spared. The other responses do not answer the client's question appropriately.

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

ANS: D In this scenario, the patient's temperature is elevated, which increases metabolic demands. Increases in metabolic demands increase cerebral blood flow and contribute to increased intracranial pressure (ICP). Cooling measures should be implemented. Insertion of an oral airway in an alert patient is contraindicated. While maintaining neutral head position and ensuring adequate periods of rest between nursing interventions are appropriate actions for patients with elevated ICP, treatment of the fever is of higher priority.

26. 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: a. 0200. b. 0400. c. 0800. d. peakless.

ANS: D Insulin glargine (Lantus) is a long-acting insulin that has no specific peak in action. The remaining times are associated with peaks of other short-acting and intermediate-acting insulin products.

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

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

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

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

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

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

14. 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 body's 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.

ANS: D Nerves of the autonomic nervous system are severed during lung transplant surgery. This results in denervation of the lung and loss of the cough reflex. Loss of this reflex places the patient at greater risk for infection because of the potential inability to clear secretions effectively. Although immunosuppressant medications reduce the body's ability to fight infections, this is a general explanation for all increased risk of infection in transplant recipients. Atelectasis decreases oxygenation. The primary reason for pulmonary hygiene is to expectorate secretions. Primary graft dysfunction is caused by ischemia, surgical trauma, or denervation and is similar to acute respiratory distress syndrome.

9. In the management of diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome, when is an intravenous (IV) solution that contains dextrose started? a. Never; normal saline is the only appropriate solution in diabetes management b. When the blood sugar reaches 70 mg/dL c. When the blood sugar reaches 150 mg/dL d. When the blood glucose reaches 250 mg/dL

ANS: D Normal saline is the best initial fluid choice for management of hyperglycemic states. However, when the glucose reaches about 250 mg/dL, solutions containing dextrose are added to prevent hypoglycemia. Hypotonic solutions are required to replace intracellular fluid deficits, and dextrose is required to prevent hypoglycemia later when glucose levels reach initial targets. A glucose level of 70 mg/dL is suggestive of hypoglycemia and would require oral glucose replacement, a 50% dextrose bolus, or glucagon administration.

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

ANS: D Osmotic diuretics draw water from normal brain cells, decreasing ICP and increasing CPP and urine output. An ICP of 10 mm Hg and CPP of 70 mm Hg are within normal limits. A GCS score of 5, while not optimum indicates a slight improvement. A CVP of 2 mm Hg indicates hypovolemia. To ensure adequate cerebral perfusion, further action on the part of the nurse is necessary.

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

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

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

ANS: D Patient assessment findings are indicative of a skull fracture. The presence of straw-colored nasal draining may be indicative of a CSF leak. Drainage should be monitored and allowed to flow freely. Application of a nasal drip pad is the most appropriate action. Monitoring airway patency and maintaining the head in a neutral position are not priorities in a patient who is awake and alert. Insertion of bilateral ear plugs is not standard of care.

11. 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: a. adrenal crisis. b. diabetes insipidus. c. myxedema coma. d. syndrome of inappropriate secretion of antidiuretic hormone (SIADH).

ANS: D SIADH may be induced by ectopic sources of antidiuretic hormone, including small cell lung carcinoma. The clinical presentation of a dilutional hypervolemia is consistent with SIADH. Adrenal crisis is characterized by fluid loss if secondary to decreased cortisol and aldosterone levels resulting in sodium loss. Diabetes insipidus is characterized by increased urine output and is not typically caused by lung tumors. Myxedema coma, although characterized by facial and peripheral edema, does not result from small cell lung carcinoma.

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

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

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

ANS: D Sustained increases in ICP lasting longer than 5 minutes should be avoided. This is accomplished by spacing nursing care activities to allow for rest between activities. All other nursing actions are a part of the patient's plan of care; however, spacing out interventions is the priority.

20. 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? a. Adrenal crisis b. Myxedema coma c. Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) d. Thyroid storm

ANS: D Tachycardia, vascular collapse, rapid cardiac rhythms, congestive heart failure, and severe hyperthermia are consistent with the clinical manifestations of the hypermetabolic state of thyroid storm. Adrenal insufficiency presents with weakness, fatigue, weight loss, anorexia, abdominal pain, and hyperpigmentation. Myxedema coma is an extreme form of hypothyroidism and is characterized by signs of hypometabolism, including bradycardia, hypotension, hypothermia, cold intolerance, and neurological sluggishness. SIADH is characterized by fluid retention, hyponatremia, and hemodilution. Heat intolerance and atrial fibrillation are not typical characteristics of the condition.

he nurse is assessing laboratory results for a client with myasthenia gravis (MG). Which results does the nurse correlate with this disease process? a. Elevated serum calcium level b. Decreased thyroid hormone level c. Decreased complete blood count d. Elevated acetylcholine receptor antibody levels

ANS: D Testing for acetylcholine receptor (AChR) antibodies is important because 80% to 90% of clients with the disease have elevated AChR antibody levels. The other laboratory results are not associated with myasthenia gravis.

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

ANS: D The charge nurse should assess the patient with an ICP of 20 mm Hg and a temperature of 104° F as this is an abnormal finding and should be investigated further. A patient with a GCS of 6 being mechanically ventilated has a secure airway and there is no indication of distress. Photophobia is an expected finding with meningitis and droplet precautions are appropriate for a patient with bacterial meningitis.

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

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

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

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

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

ANS: D These are classic symptoms of epidural and acute subdural hematomas: injury, lucid period, and progressive deterioration. The physician must be notified of this neurological emergency so appropriate interventions can be implemented. Although elevating the head of the bed, continuously monitoring the patient and applying stimulation as necessary to assess neurological response are appropriate interventions, notification of the physician is a priority given the severity in change of neurological status.

19. 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? a. Elevated adrenocorticotropic hormone b. Elevated cortisol levels c. Elevated T3 and T4 d. Elevated thyroid-stimulating hormone

ANS: D Thyroid hormones are low in myxedema. Thyroid-stimulating hormone is usually high in relation to the feedback mechanisms for hormone regulation if myxedema is caused by primary hypothyroidism. Elevated adrenocorticotropic hormone may be seen in pituitary conditions or adrenal insufficiency. Elevated cortisol levels accompany Cushing's syndrome. Elevated T3 and T4 levels are consistent with hyperthyroidism.

8. 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: a. the patient's blood glucose is 110 mg/dL. b. the patient maintains a core body temperature of 98.2° F (36.8° C). c. the patient's urine specific gravity decreases. d. 2 liters of urine are produced in a 24-hour period.

ANS: D Vasopressin is administered to replace antidiuretic hormone following a hypophysectomy. Other life-sustaining hormones such as cortisol and thyroid hormone that involve a feedback system between the pituitary gland and the target gland also must be replaced. Vasopressin produces elevation of blood pressure, causes retention of fluid, and reduces urine output. The result is a decrease in serum sodium and serum osmolality secondary to hemodilution and increase in urine specific gravity. Blood glucose control is not affected by vasopressin; cortisol would directly affect blood glucose. Core body temperature would be most directly affected by thyroid hormone. Urine specific gravity would increase, not decrease, following vasopressin administration.

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

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

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

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

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

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

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

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

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

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

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

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

client with myasthenia gravis has the priority client problem of inadequate nutrition. What assessment finding indicates that the priority goal for this client problem has been met? a. Ability to chew and swallow without aspiration b. Eating 75% of meals and between-meal snacks c. Intake greater than output 3 days in a row d. Weight gain of 3 pounds in 1 month

ANS: D Weight gain is the best indicator that the client is receiving enough nutrition. Being able to chew and swallow is important for eating, but adequate nutrition can be accomplished through enteral means if needed. Swallowing without difficulty indicates an intact airway. Since the question does not indicate what the client's meals and snacks consist of, eating 75% may or may not be adequate. Intake and output refers to fluid balance.

A client is being evaluated for signs associated with myasthenic crisis or cholinergic crisis. Which symptoms lead the nurse to suspect that the client is experiencing a cholinergic crisis?

Abdominal cramps, blurred vision, facial muscle twitching The nurse suspects a cholinergic crisis when the client experiences abdominal cramps, blurred vision, and facial muscle twitching. These are signs of an acute exacerbation of muscle weakness symptoms of cholinergic crisis caused by overmedication with cholinergic (anticholinesterase) drugs.Bowel and bladder incontinence, pallor, cyanosis, increased pulse, anoxia, and decreased urine output are symptoms indicating a myasthenic crisis. Restlessness, increased salivation and tearing, and dyspnea are symptoms indicating a mixed myasthenic-cholinergic crisis.

The nurse is caring for a patient who has just been admitted to the hospital. Labs are drawn and sent to the lab. The nurse gets a call later in the day that the patient has a neutrophil count of 88% and a band level of 10%. How should the nurse interpret this? Acute bacterial infection Acute viral infection Malignancies Anaphylactic reaction

Acute bacterial infection Neutrophils are the most numerous of the granulocytes. Band neutrophils, which are immature neutrophils, constitute only about 3% to 5%. The phrase "a shift to the left" refers to an increased number of "bands," or band neutrophils, compared with mature neutrophils on a complete blood count (CBC) report. This finding generally indicates an acute bacterial infectious process. Basophils are elevated in acute systemic allergic reactions and inflammatory responses. Lymphocytes are responsible for surveillance and destruction of virus-infected and malignant cells

After receiving 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 last hour. Given this report, the nurse obtains orders for treatment that include which of the following? Select all that apply. Administer infusion of 500 mL 0.9% normal saline every 4 hours as needed if the CVP is <5 mm Hg. Increase supplemental oxygen therapy to 60% Venturi mask. Administer 40 mg furosemide (Lasix) intravenously as needed if the urine output is less than 30 mL/hr. Administer acetaminophen (Tylenol) 650 mg suppository per rectum as needed to treat temperature >101° F.

Administer infusion of 500 mL 0.9% normal saline every 4 hours as needed if the CVP is <5 mm Hg. Administer acetaminophen (Tylenol) 650 mg suppository per rectum as needed to treat temperature >101° F. Fluid volume resuscitation is a priority in patients with severe sepsis to maintain circulating blood volume and end organ perfusion and oxygenation. A 500-mL IV bolus of 0.9% normal saline is appropriate given the patient's CVP of 2 mm Hg and hourly urine output of 10 mL/hr. There is no evidence to support the need to increase supplemental oxygen. Administration of furosemide (Lasix) in the presence of a fluid volume deficit is contraindicated. The fever may need to be treated.

What is the best understanding of mixed venous oxygen saturation by the nurse? An overall picture of oxygen delivery and oxygen consumption The amount of oxygen attached to each hemoglobin molecule The amount of oxygen perfusion taking place within the myocardium The amount of oxygen the lungs are able to mix with the blood

An overall picture of oxygen delivery and oxygen consumption Clinical determination of mixed venous oxygen saturation can be measured hemodynamically and provides a picture of the overall oxygen utilization by organs and tissues. Mixed venous oxygen saturation is the percentage of hemoglobin saturation in the central venous circulation, and it provides an assessment of the amount of oxygen used by the tissues.

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

B

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

B

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

B

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

B

Family assessment can be challenging, and each nurse may obtain additional information regarding family structure and dynamics. What is the best way to share this information from shift to shift? A. Create an informal family information sheet that is kept on the bedside clipboard. That way, everyone can review it quickly when needed. B. Develop a standardized reporting form for family information that is incorporated into the patient's medical record and updated as needed. C. Require that the charge nurse have a detailed list of information about each patient and family member. Thus, someone on the unit is always knowledgeable about potential issues. D. Try to remember to discuss family structure and dynamics as part of the change-of-shift report.

B

The nurse is assigned to care for a patient who is a non-native English speaker. What is the best way to communicate with the patient and family to provide updates and explain procedures? A. Conduct a Google search on the computer to identify resources for the patient and family in their native language. Print these for their use. B. Contact the hospital's interpreter service for someone to translate. C. Get in touch with one of the residents who you know is fluent in the native language and ask him if he can come up to the unit. D. Use the patient's 8-year-old child who is fluent in both English and the native language to translate for you.

B

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

B

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

B

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

B

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

B

Which intervention is appropriate to assist the patient in coping with admission to the critical care unit? A. Allowing unrestricted visiting by several family members at one time B. Explaining all procedures in easy-to-understand terms C. Providing back massage and mouth care D. Turning down the alarm volume on the cardiac monitor

B

Which nursing interventions would best support the family of a critically ill patient? A. Encourage family members to stay all night in case the patient needs them. B. Give a condition update each morning and whenever changes occur. C. Limit visitation from children into the critical care unit. D. Provide beverages and snacks in the waiting room.

B

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

B

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

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

Patients with burns may have mesh grafts or sheet grafts. Which of the following sites is most likely to have a sheet graft applied? a) Arm b) Face c) Leg d) Chest

B A sheet graft is more likely to be used on the face and hands because the cosmetic effects are more optimal. Meshed grafts are more commonly used elsewhere on the body (e.g., arm, leg, chest).

The patient is receiving neuromuscular blockade. Which nursing assessment indicates a target level of paralysis? a. Glasgow Coma Scale score of 3 b. Train-of-four yields two twitches c. Bispectral index of 60 d. CAM-ICU positive

B A train-of-four response of two twitches using a peripheral nerve stimulator indicates adequate paralysis. The Glasgow Coma Scale does not assess paralysis; it is an indicator of consciousness. The Bispectral Index provides an assessment of sedation. The CAM-ICU is a tool to assess delirium.

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

B Analysis of urinary sediment and electrolyte levels is helpful in distinguishing among the various causes of acute kidney injury. Postrenal conditions may present with stones, crystals, sediment, bacteria, and clots from the obstruction.

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

B Assessed vital signs and hemodynamic values indicate decreased circulating volume. The patient has not responded appropriately to therapy aimed at increasing circulating volume. Additional intervention is needed because response to therapy is not appropriate, values are abnormal, and timely intervention is critical for a patient with low circulating blood volume.

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

B Azotemia refers to increases in BUN and serum creatinine.

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 a) acute delirium b) PTSD c) suicidal intentions d) bipolar disorder

B Burn-injured patients experience psychologically devastating injuries in addition to physical injuries. Burn patients who demonstrate changes in behavior, anxiety, insomnia, regression, and acting out should be evaluated for posttraumatic stress disorder.

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 a) altered nutrition, less than body requirements b) body image disturbance c) decreased CO d) fluid volume deficit

B Burns, scarring, and skin grafting can all affect appearance. Body image disturbances may result.

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

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

The nurse is assessing the patient's pain using the Critical Care Pain Observation Tool. Which of the following assessments would indicate the greatest likelihood of pain and need for nursing intervention? a. Absence of vocal sounds b. Fighting the ventilator c. Moving legs in bed d. Relaxed muscles in upper extremities

B Fighting the ventilator is rated with the greatest number of points for compliance with the ventilator, and could indicate pain or anxiety. Absence of vocal sounds (e.g., no crying) and relaxed muscles do not indicate pain and are not given a point value. The patient may be moving the legs as a method of range of motion, not necessarily in response to pain. The patient needs to be assessed for restlessness if the movement is excessive.

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

B Fluid resuscitation with large volumes of crystalloid results in hemodilution of red blood cells and plasma proteins. Hemoglobin and hematocrit results indicate hemodilution.

The nurse wishes to assess the quality of a patient's pain. Which of the following questions is appropriate to obtain this assessment if the patient is able to give a verbal response? a. "Is the pain constant or intermittent?" b. "Is the pain sharp, dull, or crushing?" c. "What makes the pain better? Worse?" d. "When did the pain start?"

B If the patient can describe the pain, the nurse can assess quality, such as sharp, dull, or crushing. The other responses relate to continuous or intermittent presence (A), what provides relief (C), and duration (D).

An elderly individual from an assisted-living facility (ALF) 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? a) Ask the caregiver at what temperature the water heater is set in the home. b) Ask the caregiver to step out while examining the patient's burn injury. c) Immediately contact the police to report the suspected elder abuse. d) Ask the caregiver to describe exactly how the injury occurred.

B In cases of suspected abuse, especially in vulnerable patients such as children, elderly, and mentally impaired, it is important to assess the injured patient separately from the caregiver.

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? a) Carbon monoxide poisoning always occurs when soot is visible. b) Inhalation injury above the glottis may cause significant edema that obstructs the airway. c) The patient will have a copious amount of mucus that will need to be suctioned. d) The singed hairs and soot in the nostrils will cause dysfunction of cilia in the airways.

B In inhalation injury, the airway may become edematous quickly, making intubation difficult. Early intubation is recommended to protect the airway.

The patient is admitted to the unit with the diagnosis of rhabdomyolysis. The patient is started on intravenous (IV) fluids and IV mannitol. What action by the nurse is best? a) Assess the patient's hearing b) Assess the patient's lungs c) Decrease IV fluids once the diuretic has been administered d) Give extra doses before giving radiologic contrast agents

B Mannitol, an osmotic diuretic often used in acute kidney injury caused by rhabdomyolysis, increases plasma volume. Patients may be at risk for the development of pulmonary edema due to the rapid expansion of intravascular volume triggered by mannitol.

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? a) Maintain a closed wound system to decrease the risk of infection b) Remove excessive wound fluid and promote moist wound healing c) Increase patient mobility w/ large burn wounds d) Quantify wound drainage amount for more accurate output assessment

B Negative-pressure wound therapy can be used to treat grafts or partial-thickness burns by decompressing edematous interstitial spaces that enhance local perfusion, optimizing wound healing. This therapy also provides a moist wound-healing environment.

The nurse is assisting the patient to select foods from the menu that will promote wound healing. Which statement indicates the nurse's knowledge of nutritional goals? a) "Avoid foods that have saturated fats. Fats interfere with the ability of the burn wound to heal." b) "Choose foods that are high in protein, such as meat, eggs, and beans. These help the burns to heal." c) "It is important to choose foods such as bread and pasta that are high in carbohydrates. These foods will give you energy and help you to heal faster." d) "Select foods that have lots of fiber, such as whole grains and fruits. These will promote removal of toxins from the body that interfere with healing."

B Nutritional therapy must be instituted immediately after burn injury to meet the high metabolic demands of the body. Oral diets should be high in calories and high in protein to meet the demands of the body.

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

B Peritoneal dialysis is the removal of solutes and fluid by diffusion through a patient's own semipermeable membrane (the peritoneal membrane) with a dialysate solution that has been instilled into the peritoneal cavity.

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

B Routine replacement of hemodialysis catheters to prevent infection is not recommended. The decision to remove or replace the catheter is based on clinical need and/or signs and symptoms of infection.

The nurse is caring for an elderly patient who was admitted with renal insufficiency. An expected laboratory finding for this patient may be a) an increased GFR b) a normal serum creatinine level c) increased ability to excrete drugs d) hypokalemia

B Serum creatinine levels may remain the same in the elderly patient, even with a declining GFR, because of decreased muscle mass and hence decreased creatinine production.

The nurse is caring for a patient who has circumferential full-thickness burns of his forearm. A priority in the plan of care is a) to keep the extremity in a dependent position b) active or passive ROM exercises every hour c) to prepare for a escharotomy as a prophylactic measure d) to splint the forearm

B Special attention is given to circumferential (completely surrounding a body part) full-thickness burns of the extremities. Pressure from bands of eschar or from edema that develops as resuscitation proceeds may impair blood flow to underlying and distal tissue. Therefore, extremities are elevated to reduce edema. Active or passive range-of-motion (ROM) exercises are performed every hour for 5 minutes to increase venous return and to minimize edema.

The critical care nurse knows that in critical ill patients, renal dysfunction: a) is a very rare problem b) affects nearly two thirds of patients c) has a low mortality rate once renal replacement therapy has been initiated d) has little effect on morbidity, mortality, or quality of life

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

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

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

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

B The patient is complaining of chest pain and has an elevated systemic vascular resistance (SVR). To reduce afterload, ease the workload of the heart, and dilate the coronary arteries, improving oxygenation to the heart muscle, initiation of a nitroglycerin infusion is most appropriate.

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

B This scenario indicates hypovolemia from the nausea and vomiting, requiring volume replacement. Hypovolemia resulting from large urine or gastrointestinal losses often requires the administration of a hypotonic solution, such as 0.45% saline.

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

B Vasoconstrictive agents should not be administered for hypotension in the presence of circulation fluid volume deficit, which this patient displays. The nurse should question the use of the dopamine infusion.

Nursing strategies to help families cope with the stress of critical illness include: (Select all that apply.) A.. Asking the family to leave during the morning bath to promote the patient's privacy. B. Encouraging family members to make notes of questions they have for the physician during family rounds. C. If possible, providing continuity of nursing care. D. Providing a daily update of the patient's condition to the family spokesperson. E. Ensuring that a waiting room stocked with snacks is nearby.

B, C, D

Which of the following factors increase the burn patient's risk for venous thromboembolism? (Select all that apply.) a) Burn injury less than 10% b) Bed rest c) Burns to lower extremities d) Electrical burn injury e) Delayed fluid resuscitation

B, C, E Venous thromboembolism (VTE) is a significant risk for patients who have thermal injury, venous stasis associated with immobility/bed rest, hypercoagulability seen with burn injuries greater than 10% TBSA, and hypovolemia associated with delayed fluid resuscitation. Burns to lower extremities will limit mobility and use of sequential compression devices, increasing the potential risk for VTE. Electrical burn injury may pose a risk for VTE; however, VTE is more closely associated with thermal injuries greater than 10% TBSA.

The nurse is listening to a lecture on increased-risk organ donors. Which statement by the nurse indicates that teaching has been effective? A. "Increased-risk donors are those who have been declared brain dead" B. "Increased-risk donors are those who have a recent history of illicit drug use" C. "Increased-risk donors are those who donate after withdrawal from life-support" D. "Increased-risk donors are those who have suffered intracranial hemorrhage"

B. "Increased-risk donors are those who have a recent history of illicit drug use"

The nurse has just listened to a lecture on how nociceptors differ from other nerve receptors in the body. Which statement by the nurse indicates that teaching has been effective? A. "Nociceptors adapt readily to the pain response to allow the body to adjust" B. "Nociceptors adapt very little to the pain response" C. "Nociceptors release histamine to help increase oxygenation" D. "Nociceptors secrete serotonin to help ease pain and inflammation"

B. "Nociceptors adapt very little to the pain response"

Which statements best describe functions of an organ procurement organization? (SATA) A. Declaration of brain death B. Consent for organ donation C. Management of organ donor D. Evaluation of transplant candidate E. Surgical retrieval of organs

B. Consent for organ donation, C. Management of organ donor, D. Evaluation of transplant candidate

The nurse is participating on a committee to remodel the critical care unit and recommends which features to enhance care delivery and the patient-family experience? (SATA) A. Headwall systems that look like regular furniture B. Designated space for staff, administration, and education C. Rooms at least 100 sq. ft. in area D. Space for the family within the patient room

B. Designated space for staff, administration, and education, D. Space for the family within the patient room

The nurse is on a committee related to family visitation in the critical care unit and discusses evidence to help in the planning. Which statement reflects evidence? A. Allowing children to visit is stressful for the patient and the child B. Family presence during procedures promotes adaptation C. Restricted visitation prevents family exhaustion D. Visitation shapes the critical care experience for the family but not the nurse

B. Family presence during procedures promotes adaptation

The nurse is caring for a client diagnosed with delirium. How should the nurse focus the patient assessment? A. Focus on keeping the patient medicated until transfer B. Focus on keeping the patient safe C. Focus on maintaining patency of the artificial airway D. Focus on maximizing conversations with health care providers

B. Focus on keeping the patient safe

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

C

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

C

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

C

Family assessment is essential to meet family needs. Which of the following must be assessed first to assist the nurse in providing family-centered care? A. Assessment of patient and family's developmental stages and needs B. Description of the patient's home environment C. Identification of immediate family, extended family, and decision makers D. Observation and assessment of how family members function with each other

C

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

C

Many critically ill patients experience anxiety. The nurse can reduce anxiety with which approach? A. Ask family members to limit their visitation to 2-hour periods in morning, afternoon, and evening. B. Explain the unit routine. C. Explain procedures before and while you are doing them. D. Suction Mr. J.'s endotracheal tube immediately when he starts to cough.

C

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

C

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

C

The provider prescribes a pulmonary artery occlusive pressure reading (PAOP) for a patient being monitored with a pulmonary artery catheter. Immediately after obtaining an occlusive pressure, the nurse notes the change in waveform indicated on the strip below. What are the best actions by the nurse? A. Turn the patient to the left side; obtain a stat portable chest x-ray. B. Place the patient supine; repeat zero referencing of the system. C. Document the wedge pressure; continue to monitor the patient. D. Perform an immediate dynamic response test; obtain a chest x-ray.

C

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? a) 2800 mL b) 7000 mL c) 14 L d) 28 L

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

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

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

The patient is admitted with complaints of general malaise and fatigue, along with a decreased urinary output. The patient's urinalysis shows coarse, muddy brown granular casts and hematuria. The nurse determines that the patient has: a) AKI from a prerenal condition b) AKI from postrenal obstruction c) intrarenal disease, probably ATN d) a UTI

C Analysis of urinary sediment and electrolyte levels is helpful in distinguishing among the various causes of acute kidney injury. Coarse, muddy brown granular casts are classic findings in ATN. Microscopic hematuria and a small amount of protein also may be seen.

In patients with extensive burns, edema occurs in both burned and unburned areas because of a) catecholamine-induced vasoconstriction b) decreased GFR c) increased capillary permeability d) loss of integument barrier

C Capillary permeability is altered in burns beyond the area of tissue damage, resulting in significant shift of proteins, fluid, and electrolytes resulting in edema (third-spacing).

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

C Continuous venovenous hemodialysis (CVVHD) is similar to CVVH in that ultrafiltration removes plasma water. It differs in that dialysate solution is added around the hemofilter membranes to facilitate solute removal by the process of diffusion.

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

C Dialysis disequilibrium syndrome often occurs after the first or second dialysis treatment or in patients who have had sudden, large decreases in BUN and creatinine levels as a result of the hemodialysis. Because of the blood-brain barrier, dialysis does not deplete the concentrations of BUN, creatinine, and other uremic toxins in the brain as rapidly as it does those substances in the extracellular fluid. An osmotic concentration gradient established in the brain allows fluid to enter until the concentration levels equal those of the extracellular fluid. The extra fluid in the brain tissue creates a state of cerebral edema for the patient, which results in severe headaches, nausea and vomiting, twitching, mental confusion, and occasionally seizures.

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

C Dobutamine is used to stimulate contractility and heart rate while causing vasodilation in low cardiac output states, improving overall cardiac performance. The patient's cardiac index is well above normal limits, so the rate of infusion of the medication should be reduced so as not to overstimulate the heart.

The optimal measurement of intravascular fluid status during the immediate fluid resuscitation phase of burn treatment is a) BUN b) daily weight c) hourly intake and urine output d) serum potassium

C During initial fluid resuscitation, urine output helps guide fluid resuscitation needs. Measuring hourly intake and output is most effective in determining the needs for additional fluid infusion than is urine output alone.

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 Excessive external loss of fluid may occur through the gastrointestinal tract via vomiting and diarrhea, which may lead to hypovolemia.

The nurse is caring for four patients on the progressive care unit. Which patient is at greatest risk for developing delirium? a. 36-year-old recovering from a motor vehicle crash; being treated with an alcohol withdrawal protocol. b. 54-year-old postoperative aortic aneurysm resection with an elevated creatinine level c. 86-year-old from nursing home, postoperative from colon resection d. 95-year-old with community-acquired pneumonia; family has brought in eyeglasses and hearing aid

C From this list, the elderly, postoperative, nursing home resident is at greatest risk. The 96-year-old has been provided eyeglasses and a hearing aid, which will decrease the risk of delirium. Renal failure is a risk for delirium, but an elevated BUN does not always indicate renal failure. The 36-year-old is receiving medications as part of an alcohol withdrawal protocol, which should decrease the risk for delirium.

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

C Given the acute nature of the patient's blood loss, the nurse should titrate the rate of the blood transfusion to an improvement in the patient's blood pressure.

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

C Hypothermia can develop in neurogenic shock from uncontrolled heat loss; therefore, a patient should be rewarmed slowly to avoid further vasodilation.

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

C Inadequate collateral circulation past the fistula or graft may result in loss of this pulse. The physician is notified immediately if no bruit is auscultated, no thrill is palpated, or the distal pulse is absent. Loss of bruit and thrill indicate a loss of blood flow, most likely due to clotting. The patient will need to return to surgery as soon as possible for declotting.

The nurse is caring for a patient admitted to the critical care unit 48 hours ago with a diagnosis of severe sepsis. As part of this patient's care plan, what intervention is most important for the nurse to discuss with the multidisciplinary care team? a) Frequent turning b) Monitoring I&O c) Enteral feedings d) Pain management

C Initiation of enteral feedings within 24 to 48 hours of admission is critical in reducing the risk of infection by assisting in maintaining the integrity of the intestinal mucosa.

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 a) AKI b) ARDS c) intra-abdominal hypertension d) DIC disorder

C Intra-abdominal hypertension (IAH) is a serious complication caused by circumferential torso burn injuries or edema from aggressive fluid resuscitation. Signs and symptoms of IAH include tense abdomen, decreased urine output, and worsening pulmonary function.

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? a) "Do you live alone?" b) "Do you have any drug or food allergies?" c) "Do you have a heart condition or heart failure?" d) "Have you had any surgeries?"

C Many variables influence the outcome of elderly burn patient mortality, including preinjury hydration status, nutritional status, and comorbid diseases, especially heart failure. Assessment questions should include, as a priority, information about the patient's cardiovascular status, including heart failure.

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

C Metabolic acidosis is the primary acid-base imbalance seen in acute kidney injury. Treatment of metabolic acidosis depends on its severity. Patients with a serum bicarbonate level of less than 15 mEq/L and a pH of less than 7.20 are usually treated with IV sodium bicarbonate. The goal of treatment is to raise the pH to a value greater than 7.20.

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

C Tenderness at the insertion site, swelling, erythema, or drainage should be reported to the physician.

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 nurse's best response would be: a) "Unfortunately, an autograft skin is a temporary graft and a second surgery will be needed to close the wound." b) "An autograft is a biological dressing that will eventually be replaced by your body generating new tissue." c) "Yes, an autograft will transfer your own skin from one area of your body to cover the burn wound." d) "Unfortunately, autografts frequently do no adhere to burn wounds and a xenograft will be necessary to close the wound."

C The autograft is the only permanent method of grafting, and it uses the patient's own tissue to cover the burn wound.

Tissue damage from burn injury activates an inflammatory response that increases the patient's risk for a) AKI b) ARDS c) infection d) stress ulcers

C The loss of skin as the primary barrier against microorganisms and activation of the inflammatory response cascades results in immunosuppression, placing the patient at an increased risk of infection.

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

C The patient is experiencing symptoms of hypovolemic shock. Isotonic crystalloids, such as normal saline and lactated Ringer's solutions, are the priority intervention.

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

C The scenario indicates retention of fluid; therefore, the nurse must assess for symptoms of fluid overload, for example, by auscultating the lung fields.

The assessment of pain and anxiety is a continuous process. When critically ill patients exhibit signs of anxiety, the nurse's first priority is to: a. administer antianxiety medications as ordered. b. administer pain medication as ordered. c. identify and treat the underlying cause. d. reassess the patient hourly to determine whether symptoms resolve on their own.

C When patients exhibit signs of anxiety or agitation, the first priority is to identify and treat the underlying cause, which could be hypoxemia, hypoglycemia, hypotension, pain, or withdrawal from alcohol and drugs. Treatment is not initiated until assessment is completed. Medication may not be needed if the underlying cause can be resolved

Nonpharmacological approaches to pain and/or anxiety that may best meet the needs of critically ill patients include: (Select all that apply.) a. anaerobic exercise. b. art therapy. c. guided imagery. d. music therapy.

C, D Guided imagery is a powerful technique for controlling pain and anxiety, especially that associated with painful procedures. Similar to guided imagery, a music therapy program offers patients a diversionary technique for pain and anxiety relief. Anaerobic exercise is not a nonpharmacological approach for managing pain and anxiety. Most critically ill patients are not able to participate in art therapy.

The nurse has listened to a lecture on the management of pain in patients with a history of substance abuse. Which of the following statements by the nurse indicates that teaching has been effective? A. "Folic acid and thiamine administration may potentiate the action of pain medications" B. "Pain medications should be withheld to avoid addiction to the medications" C. "Patients may have a higher-than-normal dosage threshold to achieve therapeutic effects" D. "Withdrawal symptoms from drugs or alcohol do not occur if the patient is mechanically ventilated"

C. "Patients may have a higher-than-normal dosage threshold to achieve therapeutic effects"

The nurse is meeting with family members of a critically ill patient. Which statement best addresses the psychological needs of the family members? A. "I'm adjusting the alarms on the monitor to reduce the noise level in the room" B. "It would help the patient if you can spend the night in the waiting room" C. "The team has just made rounds on the patient. We are going to begin weaning the patient from the ventilator today since the patient's oxygen is improving" D. "There are coffee and cookies in the waiting room. Why don't you take a short break?"

C. "The team has just made rounds on the patient. We are going to begin weaning the patient from the ventilator today since the patient's oxygen is improving"

Which assessment findings should the nurse anticipate in a client who has been declared brain dead? A. Pupils are PERRLA B. Presence of gag reflex C. Absence of ocular movement D. Intact corneal reflex

C. Absence of ocular movement

The nurse is making rounds on a busy orthopedic floor. Which statement about pain does the nurse use to guide in pain assessments of patients? A. Anxiety can cause an increase in pain level, whereas pain has no effect on anxiety B. Anxiety can occur without increasing pain C. Anxiety is not associated with tissue injury D. Pain can occur without increasing anxiety

C. Anxiety is not associated with tissue injury

Which intervention is important in meeting the needs of family members of critically ill patients? A. Allow a minister to meet with the family only in the waiting room B. Allow the family to visit the patient in large groups whenever they wish C. Encourage family members to participate in small activities of patient care, such as range-of-motion exercises D. Tell the family that "everything will be ok. The patient has the best team in the hospital"

C. Encourage family members to participate in small activities of patient care, such as range-of-motion exercises

As part of the nursing assessment, the nurse asks the family spokesperson, "Since you have such a large family, can you tell me how well everyone gets along?" This question is part of which assessment? A. Cultural assessment B. Developmental assessment C. Functional assessment D. Structural assessment

C. Functional assessment

Pleasant sensory stimuli in the critical care unit can be promoted by which interventions? (SATA) A. Conversing with another nurse about another patient's condition B. Discussing other patients' conditions within hearing range C. Moving the patient's bed to facilitate looking out the window D. Providing a clock, calendar, and family pictures in the room E. Asking, "Do you know what day it is?"

C. Moving the patient's bed to facilitate looking out the window, D. Providing a clock, calendar, and family pictures in the room

Which statement best represents immunosuppressant therapy in organ transplant recipients? A. Immunosuppressive therapy in renal transplant patients requires steroids B. Effective immunosuppressant therapy requires a minimum of four medications C. The use of an mTOR inhibitor is contraindicated in early postoperative lung transplants D. Medication trough levels provide information on immune system suppression

C. The use of an mTOR inhibitor is contraindicated in early postoperative lung transplants

Which statements related to the management of unstable angina are true? Select all that apply. Aspirin is given at the onset of each chest pain episode. Calcium channel blockers help to reduce symptoms. Early revascularization (e.g., angioplasty) may be helpful. It is best treated with rest and nitroglycerin.

Calcium channel blockers help to reduce symptoms. Early revascularization (e.g., angioplasty) may be helpful. It is best treated with rest and nitroglycerin. Unstable angina can be treated by conservative management or early intervention with percutaneous intervention or surgical revascularization. Conservative intervention for the patient experiencing angina includes the administration of nitrates, beta-adrenergic blocking agents, and/or calcium channel blocking agents. Angioplasty, stenting, and bypass surgery are approaches to revascularization. Rest and nitroglycerin are treatments for stable angina. Aspirin is not a typical treatment for unstable angina.

The nurse is monitoring a patient's intracranial pressuere (ICP). While the nurse is providing hygiene measures, she observes that the ICP reading is sustained at 18 mm Hg. What is the priority nursing action? Cease stimulating the patient. Continue with hygiene measures. Lower the head of the bed to 10 degrees. Open the ICP monitor to continuous drainage.

Cease stimulating the patient. Sustained increases in ICP should be avoided. Nursing care activities should be spaced to prevent an increase in ICP. Actions that cause a sustained elevation in ICP should be avoided until ICP returns to baseline resting values. Elevating the head of the bed to 30 degrees or more can help reduce ICP. Continuous drainage of CSF fluid will result in herniation.

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

Central herniation A downward shift of the cerebral hemispheres, basal ganglia, and diencephalon through the tentorial notch causes central herniation, which compresses the vital centers of the brainstem. This results in a shift of one cerebral hemisphere under the falx cerebri to the other cerebral hemisphere. Cerebellar tonsils are displaced through the foramen magnum, causing fatal damage to the respiratory and cardiac centers. Uncal herniation compresses the midbrain, causing dysfunction of the ipsilateral third nerve, resulting in unilateral pupil dilation.

The nurse is caring for a patient admitted with severe sepsis. The physician orders include the administration of large volumes of isotonic saline solution as part of early goal-directed therapy. Which of the following best represents a therapeutic end point for goal-directed fluid therapy? Central venous pressure >8 mm Hg Heart rate >60 beats/min Mean arterial pressure >50 mm Hg Serum lactate level >6 mEq/L

Central venous pressure >8 mm Hg Early goal-directed therapy includes administration of IV fluids to keep the central venous pressure at 8 mm Hg or greater. Additional therapeutic end points include a heart rate at less than 110 beats/min and a mean arterial blood pressure at 65 mm Hg or greater. Serum lactate levels are elevated in sepsis; target levels should be <2.2 mEq/L.

The nurse is caring for a patient with a ruptured cerebral aneurysm. During initial assessment, the nurse notes that the cerebrospinal fluid draining into a ventriculostomy system is blood tinged. What is the best interpretation of this finding by the nurse? Cerebral aneurysms commonly rupture in the subarachnoid space. This assessment finding is indicative of developing cerebral meningitis. Patient movement has resulted in dislodgment of the catheter. Normal cerebral spinal fluid contains a small amount of visible blood.

Cerebral aneurysms commonly rupture in the subarachnoid space. Cerebral aneurysms commonly rupture in the subarachnoid space, resulting in cerebral spinal fluid that is blood tinged. Cerebral spinal fluid is cloudy in the presence of meningitis. Ventriculostomy drains are typically sutured into place; a change in ICP waveform would be indicative of dislodgment of the catheter. Normal cerebrospinal fluid is clear.

The nurse is managing the blood pressure of a patient with a traumatic brain injury. When planning the care of this patient, which statement best represents appropriate blood pressure management? Cerebral perfusion pressure (CPP) should be sustained at least 70 mm Hg. Hypertension greater than 160 mm Hg is necessary to achieve adequate perfusion. Nimodipine reduces blood pressure through its effect on cerebral vessels. Nitrates are the vasopressors of choice with increased ICP.

Cerebral perfusion pressure (CPP) should be sustained at least 70 mm Hg. To achieve adequate cerebral blood flow, cerebral perfusion pressure (CPP = MAP-ICP) should be at least 70 mm Hg. While hypotension may compromise cerebral blood flow, in the setting of increased intracranial pressure, hypertension (>160 mm Hg) can worsen cerebral edema by increasing microvascular pressure. Nimodipine is a calcium channel blocker that does not affect cerebral vasculature and is effective in providing quick, tight control of blood pressure.

The charge nurse is reviewing the patients on the critical care floor. Which patients does the charge nurse anticipate as benefiting from noninvasive positive pressure ventilation? Select all that apply. Acute respiratory distress syndrome Chronic obstructive pulmonary disease exacerbation Obstructive sleep apnea Pulmonary edema

Chronic obstructive pulmonary disease exacerbation Obstructive sleep apnea Pulmonary edema Noninvasive ventilation is not appropriate for management of acute respiratory distress syndrome. The other conditions are often treated initially with noninvasive ventilation.

The nurse is teaching a client about the risk factors of restless legs syndrome. Which statement by the client indicates a correct understanding of the nurse's instruction?

Cigarettes and alcohol must be avoided." The correct statement about the risks of restless legs syndrome is cigarettes and alcohol must be avoided. Clients with restless legs syndrome need to avoid as many risk factors as possible or make lifestyle modifications. Examples include avoiding caffeine and alcohol, quitting smoking, and losing weight.Clients with RLS need to be encouraged to exercise but not engage in strenuous activity within 2-3 hours before bedtime. Use of over-the-counter drugs is not contraindicated for clients with restless legs syndrome.

The nurse is caring for a patient admitted with a spinal cord injury. Upon assessment, the nurse notes a complete loss of motor and sensory function below the patient's nipple line. What is the best interpretation of this assessment finding by the nurse? Anterior cord lesion Central cord lesion Complete cord lesion Brown-Sequard syndrome

Complete cord lesion A complete cord lesion results in loss of motor and sensory function below the level of spinal cord injury. Assessment findings associated with anterior cord lesion include loss of motor function, pain, and temperature sensation while touch, proprioception, and sense of vibration remain intact. Assessment findings with central cord injury include impairment in the arms and hands and to a lesser extent in the legs. The brain's ability to send and receive signals to and from parts of the body below the site of injury is reduced but not entirely blocked. Assessment findings with Brown-Sequard syndrome include loss of motor function, proprioception, vibration, and light touch on the same side as the injury while on the side opposite the injury, there is a loss of pain, temperature, and crude touch sensations.

A client's spouse expresses concern that the client, who has Guillain-Barré syndrome (GBS), is becoming very depressed and will not leave the house. What is the nurse's best response?

Contact the Guillain-Barré Syndrome Foundation International for resources. Here is their contact information." The nurse's best response to a client's spouse about the client with GBS being depressed is referring the client to the GBS Foundation for resources. The Guillain-Barré Syndrome Foundation International (www.gbs-cidp.org) provides resources and information for clients and their families. The Foundation may be able to help the spouse and family find local support groups to assist the family with the transition.Inviting one close friend over is appropriate, but more than one might overwhelm the client. Telling the spouse to let the client say alone and that the behavior is normal is not helpful and inappropriate. Although depression is expected initially, some action does need to be taken to prevent further deterioration.

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

D

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

D

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

D

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

D

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

D

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

D

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

D

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

D

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

D

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

D

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

D

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

D

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 A reduction in blood pressure leads to an increase in catecholamine release, resulting in an increase in heart rate and contractility to improve cardiac output.

The nurse is administering both crystalloid and colloid IV 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 I&O c) Adequate pain management d) Urine output of 0.5 mL/kg/hr

D Adequate urine output of at least 0.5 mL/kg/hr indicates adequate perfusion to the kidneys following administration of fluid to enhance circulating blood volume.

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

D Advantages of peritoneal dialysis include that the equipment is assembled easily and rapidly, the cost is relatively inexpensive, the danger of acute electrolyte imbalances or hemorrhage is minimal, and dialysate solutions can be individualized.

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

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

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 CO b) High systemic vascular resistance and low CO c) Low pulmonary artery occlusive pressure and low CO d) Low systemic vascular resistance and high CO

D As a consequence of the massive vasodilation associated with septic shock, in the early stages, cardiac output is high with low systemic vascular resistance.

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 mmHg, 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 As shock progresses along the continuum, acidosis ensues, caused by metabolic acidosis, hypoxia, and anaerobic metabolism. A pH 7.30, CO2 45 mm Hg, HCO3 18 indicates metabolic acidosis and progression to a late stage of shock.

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

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

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

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

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

D Early goal-directed therapy in severe sepsis includes administration of IV fluids to keep RAP/CVP at 8 mm Hg or greater (but not greater than 15 mm Hg) and heart rate less than 110 beats/min. Fluid resuscitation to restore perfusion is the immediate priority.

The nurse has been administering 0.9% normal saline intravenous fluids in a patient with severe sepsis. To evaluate the effectiveness of fluid therapy, which physiological parameters would be most important for the nurse to assess? a) Breath sounds and capillary refill b) BP and oral temperature c) Oral temperature and capillary refill d) RAP and urine output

D Early goal-directed therapy includes administration of IV fluids to keep central venous pressure at 8 mm Hg or greater. Combined with urine output, fluid therapy effectiveness can be adequately assessed.

The nurse is managing the pain of a patient with burns. The provider has prescribed opiates to be given intramuscularly. The nurse contacts the provider to change the prescription to IV administration because a) IM injections cause additional skin disruption b) burn pain is so severe it required relief by the fastest route available c) hypermetabolism limits effectiveness of medications administered IM d) tissue edema may interfere w/ drug absorption of injectable routes

D Edema and impaired circulation of the soft tissue interfere with absorption of medications administered subcutaneously or intramuscularly

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

D If a reliable 24-hour urine collection is not possible, the Cockcroft and Gault formula may be used to determine the creatinine clearance from a serum creatinine value.

The 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 a) hypervolemia from burn resuscitation b) increased incidence of ureteral stones c) nephrotoxic antibiotics for prevention of infection d) release of myoglobin from injured tissues

D Myoglobin is released during electrical injury and is a risk factor for rhabdomyolysis and acute kidney injury.

The nurse is caring for a patient who requires administration of a neuromuscular blocking agent to facilitate ventilation with non-traditional modes. The nurse understands that neuromuscular blocking agents provide: a. antianxiety effects. b. complete analgesia. c. high levels of sedation. d. no sedation or analgesia.

D Neuromuscular blocking (NMB) agents do not possess any sedative or analgesic properties. Patients who receive NMBs must also receive a sedative agent.

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

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

The nurse is planning care to meet the patient's 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 provider best indicates the nurse's knowledge of pain management for this patient? a) "Can we ask the music therapist to come by each morning to see if that will help the patient's pain?" b) "The patient's pain is often unrelieved. I suggest that we also add benzodiazepines to the opioids around the clock." c) "The patient's pain is often unrelieved. It would be best if we can schedule the opioids around the clock." d) "The patient's pain varies depending on the treatment given. Can we try patient-controlled analgesia to see if that helps the patient better?"

D Patient-controlled analgesia allows the patient with burns to self-medicate for pain, thus providing independence with pain management strategies. Nonpharmacological pain strategies may provide helpful adjuncts to pain interventions. Scheduled pain medications and anxiolytic agents, although helpful, do not put the control of pain management with the patient.

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

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

The nurse is concerned that the patient will pull out the endotracheal tube. As part of the nursing management, the nurse obtains an order for: a. a Posey-type vest. b. a higher dosage of lorazepam. c. propofol. d. soft wrist restraints.

D Restraints are associated with an increased incidence of agitation and delirium. Therefore, the least restrictive methods of restraint are recommended, which is the soft wrist restraints. The Posey-type vest will not prevent self-extubation. The least amount of sedation is also recommended; therefore, neither increasing the dosage of lorazepam nor adding propofol is indicated and would likely prolong mechanical ventilation.

The nurse is caring for a patient receiving benzodiazepine intermittently. The nurse understands that the best way to administer such drugs is to: a. administer around the clock, rather than as needed, to ensure constant sedation. b. administer the medications through the feeding tube to prevent complications. c. give the highest allowable dose for the greatest effect. d. titrate to a predefined endpoint using a standard sedation scale.

D The best approach for administering benzodiazepines (and all sedatives) is to administer and titrate to a desired endpoint using a standard sedation scale. Administering around the clock as well as giving the highest allowable dose without basing it on an assessment target may result in excessive sedation. For greatest effect, most benzodiazepines are given intravenously

The nurse is concerned about the risk of alcohol withdrawal syndrome in a 45-year- old postoperative patient. Which statement indicates her understanding of management of this patient? a. "Alcohol withdrawal is common; we see it all of the time in the trauma unit." b. "There is no way to assess for alcohol withdrawal." c. "This patient will require less pain medication." d. "We have initiated the alcohol withdrawal protocol."

D The most important treatment of alcohol withdrawal syndrome is prevention. Many units have protocols that are initiated early to prevent the syndrome. Alcohol withdrawal syndrome is common; however, this statement does not indicate knowledge of management. The patient experiencing alcohol withdrawal may exhibit a variety of symptoms, such as disorientation, agitation, and tachycardia. Patients with substance abuse require increased dosages of pain medications.

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

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

The best way to monitor agitation and effectiveness of treating it in the critically ill patient is to use a/the: a. Confusion Assessment Method (CAM-ICU). b. FACES assessment tool. c. Glasgow Coma Scale. d. scale such as Richmond Agitation Sedation Scale.

D Various sedation scales are available to assist the nurse in monitoring the level of sedation and assessing response to treatment. The Richmond Agitation Sedation Scale is a commonly used tool that has been validated. The CAM-ICU assesses for delirium. The FACES scale assesses pain. The Glasgow Coma Scale assesses neurological status.

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 Vital signs and hemodynamic values assessed collectively include classic signs and symptoms of hypovolemia. Both urine output and chest drainage values are high, contributing to the hypovolemia.

The correct priority order of actions in prehospital primary survey for burn injuries is: a) assess ABCs and cervical spine b) provide oxygen therapy if smoke inhalation is suspected c) make rapid head-to-toe assessment to rule out additional trauma d) stop the burning process and prevent further injury

D, A, B, C Early care has a positive impact on recovery. The first priority is to stop the burning process and prevent further injury. At this point, you initiate the primary survey, which is to assess the ABCs and cervical spine. Oxygen therapy follows the ABCs. The secondary survey includes further assessment for additional injuries.

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

D, E, F In the event of a reaction, the transfusion is stopped, the patient is assessed, and both the physician and laboratory are notified. All transfusion equipment (bag, tubing, and remaining solutions) and any blood or urine specimens obtained are sent to the laboratory according to hospital policy.

Which statement best describes the role of the acute care nurse in the organ donation process? A. Approach the family for consent for organ donation once brain death has been determined B. Implement donor management procedures once brain death has been determined C. Obtain consent from the next-of-kin for withdrawal of life support D. Notify the organ procurement organization (OPO) in cases of impending death

D. Notify the organ procurement organization (OPO) in cases of impending death

Which interventions are components of the ventilator bundle of care? Select all that apply. Daily assess the readiness for weaning/extubation. Elevate the head of the bed at least 30 degrees. Provide prophylaxis for deep vein thrombosis. Provide stress ulcer prophylaxis. Provide therapeutic paralysis.

Daily assess the readiness for weaning/extubation. Elevate the head of the bed at least 30 degrees. Provide prophylaxis for deep vein thrombosis. Provide stress ulcer prophylaxis. Therapeutic paralysis is not part of the ventilator bundle. The other responses, along with oral care, are part of the ventilator bundle.

The nurse is caring for a mechanically ventilated patient with acute respiratory failure. Which intervention is most beneficial in reducing the duration of mechanical ventilation and its complications? Administration of neuromuscular blockade Daily interruption of sedation and assessment of readiness to wean/extubate Frequent turning and early mobility, including ambulation if possible Regular and frequent oral care

Daily interruption of sedation and assessment of readiness to wean/extubate Daily assessment of readiness to extubate is the best approach for determining readiness to wean and for assisting in decreased duration of mechanical ventilation. Neuromuscular blockade prolongs mechanical ventilation. Turning and mobility are important interventions to prevent complications, but they do not necessarily affect duration of ventilation.

Which of the following statements is correct regarding burn classification? Deep partial-thickness injuries involve destruction of epidermis and most of the dermis. Full-thickness burns involve all layers of the skin down to the bone. Partial-thickness burns involve injury to the dermal layer. Superficial burns involve only the epidermis.

Deep partial-thickness injuries involve destruction of epidermis and most of the dermis. Partial-thickness burns involve injury to the dermal layer. Superficial burns involve only the epidermis. Deep partial-thickness burns involve the epidermis and most of the dermis. Partial-thickness burns may extend to varying depths of the dermis. Superficial burns involve only the epidermis. Full-thickness injuries do not necessarily involve the bone but do involve deeper structures such as subcutaneous fat, fascia, and muscle.

The nursing instructor asks a nursing student to compare Bell's palsy and trigeminal neuralgia. Which statement by the nursing student is correct?

Difficulty chewing may occur in both disorders." The correct statement about Bell's palsy and trigeminal neuralgia is that problems with chewing can happen in both disorders. Both Bell's palsy and trigeminal neuralgia can affect cranial nerve V, which affects facial expressions and chewing.Both Bell's Palsy and trigeminal neuralgia are disorders of the cranial nerves. Facial twitching can be a sign of trigeminal neuralgia, whereas Bell's palsy causes a unilateral facial paralysis. Bell's palsy is caused by the herpes simplex virus, unlike trigeminal neuralgia, which is thought to be caused by excessive firing of irritated nerve fibers in the trigeminal nerve.

The patient presents to the emergency department after having crushing chest pain for the past 5 hours. The ECG and laboratory work confirm suspicions of an acute myocardial infarction (AMI). Which findings would be the most conclusive that the patient is having an AMI? Select all that apply. ECG changes with ST-elevation Elevated CK-MB isoenzymes Elevated serum troponin levels Elevated urinary myoglobin level

ECG changes with ST-elevation Elevated CK-MB isoenzymes Elevated serum troponin levels ST-segment elevation and elevated cardiac enzymes are seen in Q-wave MI. Serum Troponin may assist in diagnosis of AMI.

A client will be receiving plasmapheresis for treatment of Guillain-Barre'syndrome (GBS). Which posttreatment test will the nurse anticipate to be ordered?

Electrolyte panel For the client receiving plasmapheresis for treatment of GBS, the nurse expects that an electrolyte panel will be ordered. Electrolytes will be checked since citrate-induced hypocalcemia is a complication of plasmapheresis.An electroencephalogram evaluates brain waves and is useful in detecting seizure activity. It would not be beneficial in this situation. A lumbar puncture might have been performed as part of the diagnostic process initially but not as part of posttreatment. There is no role for a urinalysis after plasmapheresis.

Which of the following are nursing interventions to prevent ventilator-associated pneumonia (VAP)? Select all that apply. Elevate the head of bed to at least 30 degrees. Intubate the patient with an endotracheal tube with continuous subglottic aspiration of secretions. Maintain a deep level of sedation. Provide regular oral care, including the use of chlorhexidine.

Elevate the head of bed to at least 30 degrees. Provide regular oral care, including the use of chlorhexidine. Maintaining the head of bed at 30 to 45 degrees and providing oral care are two interventions to prevent VAP that the nurse can implement. The special endotracheal tube reduces the risk for VAP; however, this is not a nursing intervention. The patient should be sedated based on specific targets. Deep sedation should be avoided because it prolongs time on mechanical ventilation, increasing the patient's risk for VAP.

The nurse needs to obtain a cardiac output measurement from a patient who has just had a pulmonary artery catheter inserted. What are important interventions for ensuring accurate pressure and cardiac output measurements? Select all that apply. Ensure rapid injection of fluid through the injectate port. Zero reference the transducer system at the phlebostatic axis. Inflate the pulmonary artery catheter balloon with 5 mL air. Use lactated Ringer's solution for the injectate.

Ensure rapid injection of fluid through the injectate port. Zero reference the transducer system at the phlebostatic axis. To ensure accurate measurement, zero referencing of the transducer system is a priority action. Rapid injection of the appropriate solution will ensure more accurate readings. Inflating the pulmonary artery catheter balloon with 5 mL of air is likely to result in rupture of the balloon, as this volume of air is too high. Normal saline or 5% dextrose in water solutions are used for obtaining thermodilution cardiac output measurements.

A client has Guillain-Barré syndrome. Which interdisciplinary health care team members does the nurse plan to collaborate with to help prevent pressure ulcers related to immobility in this client?

Family members,Dietitian,Occupational therapist (OT), Social worker The nurse plans to collaborate with family members, the dietician, and OT to help prevent pressure ulcers in the client with GBS. Family members would help to develop interventions to prevent these ulcers, because the family will mostly likely be directly involved in the client's care. Malnutrition puts the client at greater risk for pressure ulcers, so the dietitian must be included as well. The OT can provide assistive devices that will help prevent ulcers.The certified hospital chaplain and the social worker can assist with providing additional psychosocial support but would not be involved with direct prevention of ulcers. The social worker would also assist with the discharge plan and reintegration into the community.

The nurse is caring for a patient with a head injury. If autoregulation is lost, what should the nurse be most concerned for? Occurrence of central venous engorgement. Unchanged cerebral blood flow. Hypertension increasing cerebral blood flow. Shunting of cerebrospinal fluid (CSF) blockage.

Hypertension increasing cerebral blood flow. Autoregulation is the ability of the cerebral vessels to adjust their diameter in response to arterial pressure changes within the brain. If mean arterial blood pressure rises, cerebral vessels will constrict to prevent excessive distension of the cerebral arteries. When autoregulation is lost, cerebral vessels are no longer able to regulate diameter and as a result hypertension increases cerebral perfusion pressure. Cerebral vessels may become engorged as a result of the loss of autoregulation. Cerebral blood flow is affected with the loss of autoregulation. Loss of autoregulation does not block CSF flow.

A client newly diagnosed with myasthenia gravis (MG) is being discharged, and the nurse is teaching about proper medication administration. Which statement by the client demonstrates a need for further teaching?

I can continue to take over-the-counter drugs like before." Further teaching about medication administration is indicated when the client with MG says that he/she can still take over-the-counter drugs. Clients with MG must not take any over-the-counter medications without checking with their primary health care provider first.The client's medication schedule may be posted in the home for the benefit of family members. An extra supply of medication should be kept in the client's car or workplace to maintain therapeutic levels in case a dose was missed. The client may wear a watch with an alarm as a medication reminder to maintain therapeutic levels.

A client with myasthenia gravis (MG) is receiving cholinesterase inhibitor drugs to improve muscle strength. The nurse is educating the family about this therapy. Which statement by a family member indicates a correct understanding of the nurse's instruction?

I will call 911 if a sudden increase in weakness occurs." The statement about cholinesterase inhibitors that shows a correct understanding of the nurse's instructions is that the family member will call 911 if there is a sudden increase in weakness. A potential adverse effect of cholinesterase inhibitors is cholinergic crisis. Sudden increases in weakness and the inability to clear secretions, swallow, or breathe adequately indicate that the client is experiencing crisis. The family member must call 911 for emergency assistance.The dose of cholinesterase inhibitors would never be increased without provider supervision. The client needs to eat meals 45-60 minutes after taking cholinesterase inhibitors to avoid aspiration. Cholinesterase inhibitors must be taken with a small amount of food to help alleviate GI side effects.

In a patient with increased intracranial pressure (ICP), which of the following cranial nerves should the nurse assess for consensual light response, elevation of the eyelids, and eye movement? I, IX, X II, V, VII II, VI, X III, IV, VI

III, IV, VI Cranial nerve III is responsible for the consensual light response, elevation of the eyelids, and eye movements. In addition, cranial nerves III, IV, and VI affect extraocular eye movements.

The nurse prepares to suction the endotracheal tube of an intubated patient. Which action is important for the nurse to take? Set the suction vacuum as high as possible. Instill normal saline before the procedure. Avoid hyperoxygenation during the procedure. Keep suction time to less than 10 to 15 seconds.

Keep suction time to less than 10 to 15 seconds. To prevent hypoxemia, suction time must not exceed 10 to 15 seconds. The vacuum is set between 80 and 120 mm Hg. Normal saline is not recommended. To prevent hypoxemia, all patients should be hyperoxygenated before suctioning.

The nurse is caring for a patient with hypovolemia. Which large volume crystalloid solution should the nurse anticipate the health care provider to order? Select all that apply. 5% dextrose Albumin Lactated Ringer's (LR) Normal saline

Lactated Ringer's (LR) Normal saline LR solution and 0.9% normal saline are isotonic solutions that are commonly infused to treat hypovolemia. Solutions of 5% dextrose in water and 0.45% normal saline are hypotonic and are not used for fluid resuscitation. Hypotonic solutions rapidly leave the intravascular space, causing interstitial and intracellular edema. A systematic review of 30 randomized controlled trials found no benefit in giving colloids (e.g., albumin) over crystalloids and recommended against the administration of colloids in most patient populations.

The nurse is caring for a patient in shock. Which is a priority action by the nurse? Ensure adequate cellular hydration. Maintain adequate tissue perfusion. Prevent third-spacing of fluids. Support mechanical ventilation.

Maintain adequate tissue perfusion. Care of a patient in shock is directed toward correcting or reversing the altered circulatory component and reversing tissue hypoxia. Restoring circulating intravascular volume is the priority in improving tissue perfusion and oxygen delivery.

The nurse is caring for a patient who has blood pooling in the capillary bed and arterial blood pressure too low to support perfusion of vital organs. Which symptoms should the nurse assess for? Acute respiratory distress syndrome (ARDS) Disseminated intravascular coagulation (DIC) Increased cerebral perfusion pressure Multisystem organ failure and/or dysfunction

Multisystem organ failure and/or dysfunction Maldistribution of blood flow refers to the uneven distribution of flow to various organs and pooling of blood in the capillary beds. This impaired blood flow leads to impaired tissue perfusion and a decreased oxygen supply to the cells, all of which contribute to multiple organ failure. Damage to the type II pneumocytes leads to ARDS. Consumption of clotting factors may cause DIC. Low arterial blood pressure leads to decreased cerebral perfusion pressure.

A client arrives in the emergency department with new-onset ptosis, diplopia, and dysphagia. The nurse anticipates that the client will be tested for which neurologic disease?

Myasthenia gravis (MG) The nurse expects the client with these signs/symptoms will be tested for MG. Sudden-onset ptosis, diplopia, and dysphagia are classic signs/symptoms of MG. Laboratory studies and a cholinesterase inhibitor test (e.g., Tensilon challenge test) most likely will be done to confirm the diagnosis.Signs/symptoms of Bell's palsy include facial paralysis; the face appears masklike and sags. Signs/symptoms of GBS typically begin in the legs and spread to the arms and upper body. Trigeminal neuralgia is characterized by sharp, intense facial pain that is usually not associated with sensory or motor deficits.

A client with new-onset Bell's palsy is being dismissed from the hospital. Which statement made by the client demonstrates a need for further teaching by the nurse?

Narcotics will be needed for pain relief." Mild analgesics, not narcotics, are used for pain associated with Bell's palsy.Further teaching about Bell's palsy is needed when the client says that narcotics are needed for pain. Artificial tears need to be taken at least 4 times a day and taping the affected eye at night protects the cornea from drying out and potentially ulcerating. Drying out of the eyes occurs because of the eye's inability to close. Mastication is often impaired with Bell's palsy, so soft foods are indicated.

A patient is complaining of midsternal chest discomfort radiating down the right arm. The discomfort has been present for about 5 minutes. The patient is also asthmatic and allergic to calcium channel blockers. The nurse anticipates an order from the health care provider for which medication? Isoptin Metoprolol Nifedipine Nitroglycerin sublingual

Nitroglycerin sublingual These are symptoms of angina. Administration of nitrates is indicated as a first-line treatment.

The patient is admitted with the diagnosis of "Junctional Rhythm." The nurse places the patient on the cardiac monitor expecting to see: Select all that apply. P waves with a PR interval of 0.16 seconds. P waves with a PR interval less than 0.12 seconds. no P waves but a narrow QRS complex. P waves coming after the QRS complex. no P waves but a wide QRS complex.

P waves with a PR interval less than 0.12 seconds. no P waves but a narrow QRS complex P waves coming after the QRS complex Because of the location of the AV node—in the center of the heart—impulses generated may be conducted forward, backward, or both, creating three different P waveforms that may be associated with junctional rhythms: When the AV node impulse moves forward, P waves may be absent because the impulse enters the ventricle first. The atria receive the wave of depolarization at the same time as the ventricles; thus, because of the larger muscle mass of the ventricles, there is no P wave. QRS complex is normal. When the AV node impulse is conducted backward, the impulse enters the atria first. Conduction back toward the atria allows for at least partial depolarization of the atria. A short PR interval (<0.12 second) is noted. When the impulse is conducted both forward and backward, P waves may be present after the QRS complex. In this type of conduction, the impulse first moves into the ventricles, depolarizing them and creating a QRS complex. Because the impulse is also conducted backward, some atrial depolarization occurs, and a late P wave is noted after the QRS complex. In normal sinus rhythm, the PR interval is 0.12 to 0.20 seconds. Ventricular dysrhythmias arise from ectopic foci in the ventricles. Because the stimulus depolarizes the ventricles in a slower, abnormal way, the QRS complex appears widened and has a bizarre shape. The QRS complex is wider than 0.12 seconds and often wider than 0.16 seconds. Depolarization from abnormal ventricular beats rarely activates the atria in a retrograde fashion. Therefore, most ventricular dysrhythmias have no apparent P waves.

The nurse is drawing labs on a patient with COPD in the critical care unit. Which baseline arterial blood gases (ABGs) should the nurse expect for this patient? PaO2 50 mm Hg and PaCO2 35 mm Hg PaO2 55 mm Hg and PaCO2 55 mm Hg PaO2 80 mm Hg and PaCO2 50 mm Hg PaO2 75 mm Hg and PaCO2 40 mm Hg

PaO2 55 mm Hg and PaCO2 55 mm Hg The patient with COPD typically has hypoxemia and an elevated carbon dioxide level.

In which circumstances should the nurse anticipate that patients should be transferred to specialized burn center for treatment? Partial-thickness and full-thickness burns greater than 10% TBSA in patients over the age of 50 Burns involving the face, eyes, ears, hands, feet, perineum, major joints Inhalation injury Electrical burns, including lightning injury Burn patients with concomitant trauma

Partial-thickness and full-thickness burns greater than 10% TBSA in patients over the age of 50 Burns involving the face, eyes, ears, hands, feet, perineum, major joints Inhalation injury Electrical burns, including lightning injury Burn patients with concomitant trauma According to the American Burn Association, patients meeting the following criteria should be transferred to a burn referral center for optimal patient outcomes. 1. Partial-thickness and full-thickness burns greater than 10% of the total body surface area (TBSA) in patients under 10 years or over 50 years of age. 2. Partial-thickness and full-thickness burns greater than 20% BSA in other age groups. 3. Partial-thickness and full-thickness burns involving the face, eyes, ears, hands, feet, genitalia, or perineum or those that involve skin overlying major joints. 4. Electrical burns, including lightning injury (significant volumes of tissue beneath the surface may be injured and result in acute renal failure and other complications). 5. Significant chemical burns. 6. Inhalation injury. 7. Burn injury in patients with preexisting illness that could complicate management, prolong recovery, or affect mortality. 8. Any burn patient in whom concomitant trauma poses an increased risk of morbidity or mortality may be treated initially in a trauma center until stable before transfer to a burn center. 9. Children with burns seen in hospitals without qualified personnel or equipment for their care should be transferred to a burn center with these capabilities. 10. Burn injury in patients who will require special social and emotional or long-term rehabilitative support, including cases involving suspected child abuse and neglect

The nurse is preparing to admit a patient from the ED who has sustained a complete spinal cord lesion at the C5 level. When planning the patient's care, which nursing intervention is most important? Perform hourly incentive spirometry. Apply warming devices as needed. Give small, frequent feedings. Assist with passive range-of-motion.

Perform hourly incentive spirometry. A patient with a C5 spinal cord injury will have intact diaphragmatic breathing with varying impairment of intercostal and abdominal muscle function. It is most important for the nurse to perform hourly incentive spirometry to ensure the patient's lungs adequately expand, optimizing oxygenation. Applying warming devices, providing frequent feedings, and assisting with passive range-of-motion are all a part of the care of a patient with spinal cord injury; however, in a patient with C5 injury, interventions that support oxygenation, airway patency, and pulmonary toilet are of the highest priority.

What is the best action by the nurse to level and zero a hemodynamic monitoring system transducer? Level the air-fluid interface of the zeroing transducer at the height of the patient's mattress. Position the air-fluid interface of the zeroing transducer at the fifth intercostal space,midclavicular line. Position the air-fluid interface of the zeroing transducer at the phlebostatic axis (fourth intercostal space, midaxillary line). Level the air-fluid interface of the zeroing transducer at the second intercostal space, anterior-axillary line.

Position the air-fluid interface of the zeroing transducer at the phlebostatic axis (fourth intercostal space, midaxillary line). To obtain accurate hemodynamic values, the transducer system must be positioned at the level of the atria and pulmonary artery, commonly termed the phlebostatic axis (fourth intercostal space, midaxillary line). The transducer must be leveled at the phlebostatic axis. The transducer must be placed at the level of the fourth intercostal space, midaxillary line.

What is the best action by the nurse to accurately record a thermodilution cardiac output (CO)? Place the patient prone, enter the computation constant, and obtain four successive measurements. Place the patient prone, elevate the backrest 30 degrees, and obtain three successive measurements. Place the patient supine, enter the computation constant, and obtain one value with the head of the bed elevated at 45 degrees. Position the patient supine, obtain three values within 10% of each other, and calculate the average cardiac output.

Position the patient supine, obtain three values within 10% of each other, and calculate the average cardiac output. The average of three cardiac output measurements, all within 10% of each other, is obtained to accurately assess a cardiac output. To obtain accurate cardiac output measurements, a patient must be in the supine position with a backrest elevation of 0 to 30 degrees. Three successive measurements are taken and the average cardiac output calculated.

A client with myasthenia gravis is admitted with generalized fatigue, a weak voice, and dysphagia. Which client problem has the highest priority?

Potential for aspiration related to difficulty with swallowing The client problem that has the highest priority for a client with MG is the risk for aspiration due to difficulty swallowing. The potential for aspiration is the highest priority client problem because the client's ability to maintain airway patency is compromised.Although important, an inability to tolerate everyday activities, an inability to communicate verbally related to vocal weakness, and an inability to care for oneself related to muscle weakness are not the nurse's highest priority.

A client is admitted with an exacerbation of Guillain-Barré syndrome (GBS), presenting with dyspnea. Which intervention does the nurse perform first?

Raises the head of the bed to 45 degrees The nurse's first action for a client with an exacerbation of GBS who now has dyspnea is to raise the head of the bed to 45 degrees. The head of the client's bed must be elevated to allow for increased lung expansion. This action helps improve the client's ability to breathe.Calling the RRT for intubation may be necessary if dyspnea is severe or oxygen saturation does not respond to oxygen therapy. Close monitoring of respiratory status is indicated because of the acute stages of GBS. Instructing the client on how to cough effectively is not the priority in this case. The client would be suctioned as needed but cautiously to avoid vagal stimulation.

The nurse is caring for a patient who is being monitored with a central venous catheter. In preparing to record a right atrial pressure reading, what is most important for the nurse to keep in mind when recording an accurate value? Record the pressure at the end of expiration. Low pressures indicate ventricular dysfunction. High pressures are likely to indicate hypovolemia. Zero referencing is not needed before every recording.

Record the pressure at the end of expiration. Right atrial pressures are measured at the end of expiration to ensure that pleural pressure changes do not skew the numerical value. Low pressures are generally indicative of hypovolemia, while high pressures are likely to indicate right ventricular dysfunction. Zero referencing is necessary to ensure accurate measurement and should be performed after any position change.

A patient in acute respiratory failure is experiencing carbon dioxide narcosis secondary to increased CO2 retention. What assessment finding should the nurse expect? Nasal flaring Paradoxical respirations Somnolence Suprasternal muscle retractions

Somnolence Somnolence, lethargy, and coma are seen with CO2 retention. Nasal flaring, paradoxical respirations, and muscle retracts are seen with respiratory muscle fatigue (clinical alert).

Which assessment finding indicates a burn injury below the glottis? Hoarseness Red or flushed cheeks Singed nasal hairs Soot particles in lung secretions

Soot particles in lung secretions Carbonaceous secretions suggest inhalation injury below the glottis. Hoarseness suggests inhalation injury above the glottis. Red or flushed cheeks suggests carbon monoxide poisoning. Singed nasal hairs suggest inhalation injury above the glottis

Secondary hematopoietic organs that participate in hematopoietic cell production include the: Select all that apply. bone marrow. spleen. liver. thymus. lymphatic system.

Spleen liver thymus lymphatic system The primary site of hematopoietic cell production is the bone marrow; however, secondary hematopoietic organs that participate in this process include the spleen, liver, thymus, lymphatic system, and lymphoid tissues.

A patient presents to the emergency department in acute respiratory distress. She has a long-standing history of COPD. Which of the following positions should the nurse place this patient in for optimal tissue perfusion? Prone on a stretcher In a recliner, leaning back as far as it will go Side-lying with head of bed at 15 degrees Stretcher with head of bed as high as it will go

Stretcher with head of bed as high as it will go A patient with COPD will be most comfortable in an upright position that facilitates lung expansion. Proning will not be tolerated, and a 15-degree elevation is not high enough. A recliner is sometimes helpful, but not leaning back as far as it will go.

Which of the following statements is true about nonburn injuries? The clinical picture of a nonburn injury is similar to that of a burn injury. Erythema multiforme is the most extensive type of exfoliative disorder. Necrotizing fasciitis is painless because underlying nerves have been destroyed. Staphylococcal scalding syndrome is skin sloughing caused by the staphylococcal toxin. Toxic epidermal necrolysis is most commonly caused by a drug reaction.

The clinical picture of a nonburn injury is similar to that of a burn injury. Staphylococcal scalding syndrome is skin sloughing caused by the staphylococcal toxin. Toxic epidermal necrolysis is most commonly caused by a drug reaction. Severe nonburn injuries present a clinical picture similar to that of burn injuries. Staphylococcal scalding syndrome occurs as intraepidermal splitting with resultant skin sloughing; this response is a reaction to the staphylococcal toxin. Toxic epidermal necrolysis is frequently associated with a drug. Toxic epidermal necrolysis, not erythema multiforme, is the most extensive form of exfoliative disorder. Necrotizing fasciitis presents with pain out of proportion to the lesion.

The nurse is caring for a patient with an assessed Glasgow Coma Scale score of 3. What is the best interpretation of this finding? Coma scale score is a direct result of dysfunction of the cerebellum. Damage to the patient's corpus callosum has led to a comatose state. A Glasgow Coma Scale score of less than 3 indicates a semicomatose state. There is impairment of the reticular activating system (RAS), resulting in coma.

There is impairment of the reticular activating system (RAS), resulting in coma. The reticular activating system (RAS) controls arousal, the sleep-wake cycle, selective attention, and perceptual awareness. The patient with a Glasgow Coma Scale score of 3 has an impaired RAS system. Dysfunction of the cerebellum results in alteration of fine motor movement, muscle tone, balance, and coordination. The corpus callosum consists of fibers that provide connections between the two cerebral hemispheres. A Glasgow Coma Scale score of less than 8 is consistent with coma.

The nurse is caring for a patient who has symptoms of an acute myocardial infarction (AMI). Which lab should the nurse prepare to draw in order to detect myocardial necrosis? CK CK-MB Potassium Troponin I

Troponin I Troponin I has a greater specificity than other tests in the diagnosis of acute myocardial infarction (AMI) at 7 to 14 hours after the onset of chest pain.

In caring for a patient who is intubated with an endotracheal tube, which complication should the nurse assess for? Community-acquired pneumonia Oxygen toxicity Tension pneumothorax Tube placed in the right mainstem bronchus

Tube placed in the right mainstem bronchus Right mainstem bronchus intubation is common; breath sounds are assessed after intubation and a chest x-ray is done to verify placement. Ventilator-associated pneumonia is a common complication of mechanical ventilation. Oxygen toxicity is associated with mechanical ventilation with high oxygen levels. A tension pneumothorax is a rare, but life-threatening, complication of mechanical ventilation.

Assess and interpret the following arterial blood gases: pH 7.48, PaCO2 33 mm Hg, HCO2 20 mEq/L, PaO2 85 mm Hg. Fully compensated metabolic acidosis; normal oxygenation Normal ventilation and oxygenation Partly compensated respiratory acidosis with hypoxemia Uncompensated respiratory alkalosis; normal oxygenation

Uncompensated respiratory alkalosis; normal oxygenation The high pH, low PaCO2, normal bicarbonate, and normal oxygen levels indicate uncompensated respiratory alkalosis.

The nurse is caring for a patient with possible distributive shock. Which should the nurse look for on assessment? Blood loss and actual hypovolemia. Decreased cardiac output. Third-spacing of fluids into peritoneal space. Vasodilation and relative hypovolemia.

Vasodilation and relative hypovolemia. Distributive shock presents with widespread vasodilation and decreased systemic vascular resistance that result in a relative hypovolemia. Blood loss is associated with hypovolemic shock. Decreased cardiac output is a primary cause of cardiogenic shock. Primary internal sequestration of fluids that causes internal fluid loss is associated with hypovolemic shock.

The nurse is assisting in weaning a patient from long-term mechanical ventilation. Which action should the nurse be prepared to take? Slowly wean over several hours using a T-piece. Expect that the patient will not be affected by fever or abdominal distension. Wean the patient by protocol-driven methods. Wean the patient while the patient's family is present in the room.

Wean the patient by protocol-driven methods. Research has shown that protocol-driven methods for weaning facilitate the process and shorten weaning time. T-piece trials are sometimes done as part of the weaning process; however, it is not always an easy process. Fever and abdominal distension are factors that impede weaning attempts. Family members may be able to provide psychological support during the weaning process.

When obtaining report on a trauma pateint, which question would be helpful in determining potential injuries associated with the mechanism of injury? (SATA) a. Was the patient wearing a seat belt? b. Where was the patient in the car? c. Where are the family members? d. Was fluid resuscitation initiated?

a, b

Which interventions are appropriate to consider in the management of the geriatric trauma patient? (SATA) a. Ask the patient if he or she has fallen recently. b. Obtain a detailed medical history. c. Administer intravenous fluids rapidly to maintain blood pressure. d. Frequently assess for signs of acute delirium. e. Observe for signs of infection, primarily elevated temperature. f. Obtain a detailed list of current medications.

a, b, d, f

The nurse is assessing a patient for suspected alcohol withdrawal and identifies which signs and symptoms as suspicious? (SATA) a.Irritable, confused, hallucinations b. Nausea, vomiting, diarrhea c. Hypotension and tachycardia d. Low body temperature e. Seizures f. Somnolent, difficult to arouse

a, b, e

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

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

A restrained patient's status after a motor vehicle crash includes dyspnea, dysphagia, hoarseness, and complaints of severe chest pain. Upon assessment you note that the patient has weak femoral pulses. Which of the following complications and related diagnostic test should be considered? a. Aortic dissection and aortogram b. Cardiac tamponade and pericardiocentesis c. Liver laceration and focused assessment with sonography for trauma (FAST) d. Pulmonary contusion and chest x-ray

a. Aortic dissection and aortogram

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

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

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

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

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

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

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

a. Decreasing PaO2 levels despite increased FiO2 administration

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

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

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

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

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

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

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

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

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

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

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

a. Management and protection of the airway

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

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

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

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

A trauma patient with a fractured forearm complains of extreme, throbbing pain at the fracture site and paresthesia in the fingers. Upon further assessment, you note that the forearm is extremely edematous, and you are now having difficulty palpating a radial pulse. You notify the physician immediately because you suspect: a. compartment syndrome b. fat emboli. c. Hypothermia. d. rhabdomyolysis.

a. compartment syndrome.

The nurse is speaking with the patient when the monitor shows that the patient is in ventricular fibrillation (VF). The nurse should: immediately defibrillate the patient. initiate basic life-support protocols and call for help. assess the patient and check the patient's monitor leads. initiate advanced life-support protocols as soon as possible.

assess the patient and check the patient's monitor leads. Ventricular fibrillation (VF) is a chaotic rhythm characterized by a quivering of the ventricles, which results in total loss of cardiac output and pulse. Because this patient was in the process of speaking with the nurse, there is evidence of cardiac output being present, which would not be the case with VF. Because a loose lead or electrical interference can produce a waveform similar to VF, it is always important to immediately assess the patient for pulse and consciousness. The issue here is more likely a loose lead. Immediate BLS and ACLS interventions would only be required if the patient was truly in VF.

The nurse is caring for an individual who is admitted for chest pain and shortness of breath. The patient states, "I can't believe I'm having chest pain. I'm a marathon runner and in good shape." During the night, the patient develops a sinus bradycardia with a heart rate of 40 beats/min. The nurse should: ignore this rate since the patient is an athlete. assess the patient for signs of decreased cardiac output. take the patient's temperature and expect to find hyperthermia. perform carotid massage (a maneuver to stimulate a vasovagal response).

assess the patient for signs of decreased cardiac output. Bradycardia is defined as a heart rate less than 60 beats/min. Sinus bradycardia may be a normal heart rhythm for some individuals such as athletes, or it may occur during sleep. Although sinus bradycardia may be asymptomatic, it may cause instability in some individuals if it results in a decrease in cardiac output. The key is to assess the patient and determine if the bradycardia is accompanied by signs of instability. Vasovagal response can occur due to: medications such as digoxin or AV nodal blocking agents, including calcium channel blockers and beta blockers; myocardial infarction; normal physiological variant in the athlete; disease of the sinus node; increased intracranial pressure; hypoxemia; and hypothermia. The nurse would not want to perform a vasovagal response, as this would lower the heart rate more.

If the low-exhaled volume alarm is sounding on a mechanical ventilator, the nurse should: assess to see that the ventilator is attached to the endotracheal tube. contact the respiratory therapist to set the tidal volume at a higher level. extubate the patient and ventilate with a bag-valve device. see whether the patient is biting the endotracheal tube.

assess to see that the ventilator is attached to the endotracheal tube. A low-exhaled volume alarm indicates the patient did not get the prescribed tidal volume. Connection of the ventilator tubing to the endotracheal tube should be checked quickly. The nurse should check the patient quickly; the therapist is contacted quickly if the cause of the alarm is not detected. Setting the tidal volume at a higher level will not correct the underlying problem. The patient is extubated only if the tube is in the esophagus. Biting the endotracheal tube results in a high-pressure alarm.

Prevention of hypothermia is crucial in caring for trauma patients. Which treatments are appropriate for preventing hypothermia? (SATA) a. Administer cool humidified oxygen. b. Cover the patient with an external warming device. c. Leave the patient's clothing on, even if wet. d. Warm fluids and blood products before or during administration. e. Warm the room in the emergency department and critical care unit.

b,d,e

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

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

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

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

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

b. A shotgun wound to the abdomen

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

b. Coagulopathies c. Dysrhythmias d. Myocardial dysfunction

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

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

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

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

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

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

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

b. Poisonings from prescription or illegal drugs

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

b. venous thromboembolism.

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

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

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

c. Red blood cells d. Platelets e. Plasma

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

c. Respiratory acidosis

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

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

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

c. determine tissue oxygenation.

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

c. insertion of a vena cava filter.

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

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

Poor patient outcomes after a traumatic injury are associated with a. chest tube placement for treatment of a hemothorax. b. immediate decompression of a tension pneumothorax. c. massive transfusions of blood products. d. intraosseous cannulation for intravenous fluid administration.

c. massive transfusions of blood products.

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

c. neuromuscular blockade.

A 72-year-old patient fractured his pelvis in a motor vehicle crash 2 days ago. He suddenly becomes anxious and short of breath. His respiratory rate is 34 breaths/min, and he is complaining of midsternal chest pain. His oxygen saturation drops to 75%. You suspect a. cardiac tamponade. b. myocardial infarction. c. pulmonary embolus. d. tension pneumothorax.

c. pulmonary embolus.

The patient complains of being lightheaded and feeling a "fluttering" in his chest. The nurse places the patient on the heart monitor and notices an atrial tachycardia at a rate of 160 beats/min. The patient's blood pressure has dropped from 128/76 mm Hg to 92/46 mm Hg but appears stable at the lower pressure. The nurse should: prepare the patient for asynchronized defibrillation. give the patient digitalis IV and then call the provider. call the provider and prepare the patient for medical or electrical cardioversion. withhold beta blockers and calcium channel blockers.

call the provider and prepare the patient for medical or electrical cardioversion. Atrial tachycardia is a rapid rhythm that arises from an ectopic focus in the atria. Because of the fast rate, atrial tachycardia can be a life-threatening dysrhythmia. Causes include digitalis toxicity, electrolyte imbalances, lung disease, ischemic heart disease, and cardiac valvular abnormalities. Treatment is directed at assessing the patient's tolerance of the tachycardia. If the rate is over 150 beats/min and the patient is symptomatic, emergent cardioversion is considered. Cardioversion is the delivery of a synchronized electrical shock to the heart by an external defibrillator. Medications that may be used include adenosine, beta blockers, calcium channel blockers, and amiodarone.

The patient is complaining of midsternal chest discomfort and nausea. The nurse calls for a 12-lead ECG and notices that the ST segment is newly elevated in two related leads. The nurse should: call the provider because the ST segment may indicate myocardial injury. continue to monitor the patient, as the ST segment is nondiagnostic. monitor the patient for increased signs of GI upset. assure the patient that the ST elevations are normal and of no concern.

call the provider because the ST segment may indicate myocardial injury. A displacement in the ST segment can indicate myocardial ischemia or injury. If ST displacement is noted and is a new finding, a 12-lead ECG is performed and the provider notified. The patient is assessed for signs and symptoms of myocardial ischemia.

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

d. Mobility

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

d. Serum lactate levels

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

d. Severe, throbbing pain in the affected area

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

d. Stabilize extremity fractures early.

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

d. Start 2 large bore IVs

Spinal cord injury causes a loss of sympathetic output, resulting in distributive shock with hypotension and bradycardia. Although blood pressure may respond to fluid resuscitation, what other therapy may be required to compensate for loss of sympathetic innervation? a. Colloids b. Glucocorticoids c. Proton pump inhibitors d. Vasopressors

d. Vasopressors

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

d. needle thoracostomy and chest tube insertion.

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

d. restlessness

The trauma patient presenting with left lower rib fractures develops left upper quadrant tenderness, hypotension, and referred pain to the left shoulder. You suspect: a. bowel obstruction. b. cardiac tamponade. c. pulmonary contusion. d. splenic injury

d. splenic injury

The etiology of pulmonary edema in acute respiratory distress syndrome is related to: damage to the alveolar-capillary membrane. decreased cardiac output. tension pneumothorax. volutrauma and hypoxemia.

damage to the alveolar-capillary membrane. Noncardiogenic pulmonary edema is seen in ARDS secondary to damage to the alveolar-capillary membrane. Decreased cardiac output, tension pneumothorax, volutrauma, and hypoxemia are not causes.

The patient is admitted with a platelet count of 15,000/microliter. The nurse is aware that the patient: has a normal platelet count. has hyperactive bone marrow. is facing certain fatal hemorrhage. is at risk for spontaneous bleeding.

is at risk for spontaneous bleeding. Thrombocytopenia is a platelet count of less than 150,000/microliter. A value of 30,000/microliter is considered critically low, and spontaneous bleeding may occur. Fatal hemorrhage is a great risk when the count is less than 10,000/microliter. The pathophysiology may be related to decreased production of platelets by the bone marrow, increased destruction of platelets, or sequestration of platelets (abnormal distribution)

The patient's hematocrit is 26%, and the patient is noted to have significant orthostatic hypotension. The nurse anticipates that the physician will order: cryoprecipitate. fresh frozen plasma. packed red blood cells (RBCs). platelet infusions.

packed red blood cells (RBCs). Decreases in hemoglobin and hematocrit associated with symptoms of hypovolemia (orthostasis) are treated with RBC transfusions. Cryoprecipitate is usually infused if the fibrinogen level is low. Fresh frozen plasma is used to correct deficiencies in clotting factors.

A major complication of an electrical burn injury is acute kidney injury caused by: excessive fluid resuscitation the catabolic effect of the electrical current through the kidneys. the direct effects of the electrical current as it traverses the intima of the kidney. the release of myoglobin, which can cause acute kidney injury.

the release of myoglobin, which can cause acute kidney injury. Myoglobin is released by damaged tissue and causes damage to renal tubules, contributing to acute kidney injury. Fluid resuscitation promotes renal blood flow and does not contribute to acute kidney injury. Catabolism affects the entire body and is not isolated to renal dysfunction.

The nurse encourages a ventilated client with advanced Guillain-Barré syndrome (GBS) to communicate by which simple technique?

Blinking for "yes" or "no" To communicate, a ventilated client with advanced GBS needs to blink for "yes" or "no." A simple technique involving eye blinking or moving a finger to indicate "yes" and "no" is the best way for the ventilated client with GBS to communicate.Moving the lips is difficult to do around an endotracheal tube and is exhausting for the client. Sign language is very time-consuming to learn, unless the client and family already know it. Use of a laptop may prove too challenging for the client in advanced stages of GBS.

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

C

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

C

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

C

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

C

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

C

The nurse is caring for a patient who sustained a head injury and is unresponsive to painful stimuli. Which intervention is most appropriate while bathing the patient? A. Ask a family member to help you bathe the patient, and discuss the family structure with the family member during the procedure. B. Because the patient is unconscious, complete care as quickly and quietly as possible. C. Tell the patient the day and time, and that you are providing a bath. Reassure the patient that you are there. D. Turn the television on to the evening news so that you and the patient can be updated to current events.

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 Hypothermia is anticipated during the rapid infusion of fluids or blood products. Assessment of core body temperature is a priority.

Both the electroencephalogram (EEG) monitor and the Bispectral Index Score (BIS) or Patient State Index (PSI) analyzer monitors are used to assess patient sedation levels in critically ill patients. The BIS and PSI monitors are simpler to use because they: a. can only be used on heavily sedated patients. b. can only be used on pediatric patients. c. provide raw EEG data and a numeric value. d. require only five leads.

C The BIS and PSI have very simple steps for application, and results are displayed as raw EEG data and the numeric value. A single electrode is placed across the patient's forehead and is attached to a monitor. These monitors can be used in both children and adults, and patients with varying levels of sedation.

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

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

The nurse recognizes that which patient is likely to benefit most from patient-controlled analgesia? a. 21-year-old with a C4 fracture and quadriplegia b. 45-year-old with femur fracture and closed head injury c. 59-year-old postoperative elective bariatric surgery d. 70-year-old postoperative cardiac surgery; mild dementia

C The patient undergoing bariatric surgery (an elective procedure) is the best candidate for PCA. The quadriplegic would be unable to operate the PCA pump. The cardiac surgery patient with mild dementia may not understand how to operate the pump. Likewise, the patient with the closed head injury may not be cognitively intact.

Neuromuscular blocking agents are used in the management of some ventilated patients. Their primary mode of action is: a. analgesia. b. anticonvulsant. c. paralysis. d. sedation.

C These agents cause respiratory muscle paralysis. They do not provide analgesia or sedation. They do not have anticonvulsant properties.

The nurse is listening to a lecture on increasing organ donation. Which statement by the nurse indicates that teaching has been effective? A. "Each hospital individually determines if patients meet donation criteria" B. "Hospitals must notify the organ procurement organization of deaths within 48 hours" C. "Hospitals must have an agreement with an organ procurement organization" D. "Hospitals are not responsible for notifying family members of the option to donate organs"

C. "Hospitals must have an agreement with an organ procurement organization"

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

D

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

D

The patient is to receive one unit of platelets to treat his thrombocytopenia. His platelet count is 75,000/microliter. After his transfusion of platelets, the nurse will expect his repeat platelet count to be: 77,000/microliter. 85,000/microliter. 100,000/microliter. 150,000/microliter.

85,000/microliter. For every unit of single-donor platelets, the platelet count should increase by 5000 to 10,000/microliter. A level of 80,000 to 85,000/microliter would be expected after the transfusion.

Sleep often is disrupted for critically ill patients. Which nursing intervention is most appropriate to promote sleep and rest? A. Consult with the pharmacist to adjust medication times to allow periods of sleep or rest between intervals. B. Encourage family members to talk with the patient whenever they are present in the room. C. Keep the television on to provide white noise and distraction. D. Leave the lights on in the room so that the patient is not frightened of his or her surroundings.

A

The nurse is caring for a patient with a chemical burn injury. The priority nursing intervention is to a) remove the patient's clothes and flush the area with water b) apply saline compresses c) contact a poison control center for directions on neutralizing agents d) remove all jewelry

A As long as the chemical remains in contact with the skin, burn damage will result. Priority interventions are to remove the patient's clothes, brush loose chemical away from the skin and apply water for at least 30 minutes. Water needs to washed away from the body, not applied as compresses.

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

A Continuous venovenous hemofiltration (CVVH) is used to remove fluids and solutes through the process of convection.

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

A Renin activates the renin-angiotensin-aldosterone cascade, which ultimately results in angiotensin II production. Angiotensin II causes vasoconstriction and release of aldosterone from the adrenal glands, thereby raising blood pressure and flow and increasing sodium and water reabsorption in the distal tubule and collecting ducts.

The nurse is assessing the critically ill patient for delirium. The nurse recognizes which characteristics that indicate hyperactive delirium? (Select all that apply.) a. Agitation b. Apathy c. Biting d. Hitting e. Restlessness

A, C, D, E All except for apathy are characteristics of hyperactive delirium. Apathy is seen in hypoactive cases.

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

A, C, D, E The most common reasons for initiating dialysis in acute kidney injury include acidosis, hyperkalemia, volume overload, and uremia.

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

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

The nurse is assessing a client who is experiencing a myasthenia crisis. Which diagnostic test does the nurse anticipate being ordered? a. Babinski reflex test b. Tensilon test c. Cholinesterase challenge test d. Caloric reflex test

ANS: B The Tensilon test in an important procedure for a client in myasthenic crisis. Cholinesterase-inhibiting drugs should be withheld because they increase respiratory secretions, which enhance the manifestations of a myasthenic crisis. A Babinski reflex and caloric reflex test would not be appropriate for this client.

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: (Select all that apply.) a. vagal stimulation. b. proton pump inhibitors. c. anticholinergic drugs d. antacids. e. cholinergic drugs.

ANS: B, C, D Administration of antacids and H2-receptor blockers, and the suppression of vagal stimulation with anticholinergic drugs and proton pump inhibitors (PPI) are effective forms of therapy.

A client is admitted with Guillain-Barré syndrome (GBS). What assessment takes priority? a. Bladder control b. Cognitive perception c. Respiratory system d. Sensory functions

ANS: C Clients with GBS have muscle weakness, possibly to the point of paralysis. If respiratory muscles are paralyzed, the client may need mechanical ventilation, so the respiratory system is the priority. The nurse will complete urinary, cognitive, and sensory assessments as part of a thorough evaluation.

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 a) excessive alcohol use b) methamphetamine use c) PTSD d) subacute delirium

B A vague or inconsistent injury history, burns to the face and hands, and signs of agitation or substance withdrawal should alert the nurse to a potential methamphetamine-related injury.

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

B, C, E

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

A

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

A

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

A

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

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

Family presence is encouraged during resuscitation and invasive procedures. Which findings about this practice have been reported in the literature? (Select all that apply.) A. Families benefit by witnessing that everything possible was done. B. Families report reduced anxiety and fear about what is being done to the patient. C. Presence encourages family members to seek litigation for improper care. D. Presence reduces nurses' involvement in explaining things to the family. E. Families report that staff conversations during this time were distressing.

A, B

Identify which substances in the glomerular filtrate would indicate a problem with renal function. (Select all that apply.) a) Protein b) Sodium c) Creatinine d) RBCs e) Uric acid

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

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

A, D, E

Which intervention is most helpful in preventing sensory overload in critically ill patients? A. Encourage family members to assist in the reorientation of the patient B. Increase the amount of noise from equipment in the patient's room C. Move the patient to a semiprivate room with another confused patient D. Place the patient nearer to the nurses' station for observation

A. Encourage family members to assist in the reorientation of the patient

The nurse is discussing organ donation with the family of a patient for whom death is imminent. Which common concern should the nurse anticipate? A. Having to pay for the donation process B. Organizing the funeral care C. Helping the patient's wife notify extended family D. Trying to wean the patient off the ventilator

A. Having to pay for the donation process

he nurse reviews laboratory data for a client who has Guillain-Barré syndrome (GBS). Which result does the nurse correlate with this disease process? a. Increased cerebrospinal fluid (CSF) protein level b. Decreased serum protein electrophoresis results c. Increased antinuclear antibodies d. Decreased immune globulin G (IgG) levels

ANS: A A lumbar puncture is performed to evaluate the CSF. An increased CSF protein level without increased cell count is a distinguishing feature of GBS. The other results are not associated with GBS.

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

ANS: A Ensuring a patent IV site prevents complications associated with infiltration of the medication (soft tissue necrosis). Mixing the drug with normal saline prevents crystallization of the medication and would be noticed prior to administration. Evaluating the serum K+ is not required prior to administration. The dose of phenytoin (Dilantin) ordered can be safely administered IV push over 2 minutes and does not require an infusion pump.

The nurse assesses a client who has myasthenia gravis. Which clinical manifestation does the nurse expect to observe in this client? a. Inability to perform the six cardinal positions of gaze b. Lateralization to the affected side during the Weber test c. Absent deep tendon reflexes d. Impaired stereognosis

ANS: A The most common assessment finding in more than 90% of clients with myasthenia gravis is involvement of the extraocular muscles. The nurse observes for inability or difficulty with tests of extraocular function, such as the cardinal positions of gaze. Ptosis and incomplete eye closure also may be observed. Altered hearing and absent reflexes are not common in myasthenia gravis.

A client has trigeminal neuralgia and has begun skipping meals and not brushing his teeth, and his family believes he has become depressed. What action by the nurse is best? a. Ask the client to explain his feelings related to this disorder. b. Explain how dental hygiene is related to overall health. c. Refer the client to a medical social worker for assessment. d. Tell the client that he will become malnourished in time.

ANS: A Clients with trigeminal neuralgia are often afraid of causing pain, so they may limit eating, talking, dental hygiene, and socializing. The nurse first assesses the client for feelings related to having the disorder to determine if a psychosocial link is involved. The other options may be needed depending on the outcome of the initial assessment.

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

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

The nurse is teaching a client about taking a new prescription for pyridostigmine. Which statements by the nurse indicate correct information about this drug? (Select all that apply.) a. "Avoid opioids and other sedating drugs when taking this medication." b. "Report increased mucous secretions and sweating immediately to the primary health care provider." c. "Take the prescribed medication after meals to increase intestinal absorption." d. "Avoid taking antibiotics, especially neomycin, while on this medication" e. "Maintain the exact same dose of this medication every day."

ANS: A, B, D Choice A and D are correct due to potential drug-drug interactions with pyridostigmine. Choice B suggests possible cholinergic crisis which can occur if the dose of the medication is too high. The drug should be taken before meals to increase muscle tone needed to chew, swallow, and digest food. The drug dosing may vary depending on how the client is performing each day.

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

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

A client has been diagnosed with Bell's palsy. About what drugs should the nurse anticipate possibly teaching the client? (Select all that apply.) a. Acyclovir (Zovirax) b. Carbamazepine (Tegretol) c. Famciclovir (Famvir) d. Prednisone (Deltasone) e. Valacyclovir (Valtrex)

ANS: A, C, D, E Possible pharmacologic treatment for Bell's palsy includes acyclovir, famciclovir, prednisone, and valacyclovir. Carbamazepine is an anticonvulsant and mood-stabilizing drug and is not used for Bell's palsy.

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

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

he nurse assesses a client with Guillain-Barré syndrome during plasmapheresis. Which complication does the nurse monitor for during this procedure? a. Tachycardia b. Hypovolemia c. Hyperkalemia d. Hemorrhage

ANS: B The client undergoing plasmapheresis is at risk for hypovolemia. The nurse monitors fluid status, assesses vital signs, and administers replacement fluid, as indicated. The other manifestations are not complications of plasmapheresis.

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

ANS: B, C, D Vascular sounds such as bruits may be heard and may indicate dilated, tortuous, or constricted vessels. Venous hums are also normally heard from the inferior vena cava. A hum in the periumbilical region in a patient with cirrhosis indicates obstructed portal circulation. Peritoneal friction rubs may also be heard and may indicate infection, abscess, or tumor.

The nurse assesses a client who has Guillain-Barré syndrome. Which clinical manifestation does the nurse expect to find in this client? a. Ophthalmoplegia and diplopia b. Progressive weakness without sensory involvement c. Progressive, ascending weakness and paresthesia d. Weakness of the face, jaw, and sternocleidomastoid muscles

ANS: C The most common clinical pattern of Guillain-Barré syndrome is the ascending variety. Weakness and paresthesia begin in the lower extremities and progress upward. The other manifestations are not associated with Guillain-Barré syndrome.

A client has undergone a percutaneous stereotactic rhizotomy. What instruction by the nurse is most important on discharge from the ambulatory surgical center? a. "Avoid having teeth pulled for 1 year." b. "Brush your teeth with a soft toothbrush." c. "Do not use harsh chemicals on your face." d. "Inform your dentist of this procedure."

ANS: C The affected side is left without sensation after this procedure. The client should avoid putting harsh chemicals on the face because he or she will not feel burning or stinging on that side. This will help avoid injury. The other instructions are not necessary.

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

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

A client with myasthenia gravis is preparing for discharge. Which instructions does the nurse include when educating the client's family members or caregiver? a. Technique for therapeutic massage to the lower extremities b. Administration of morphine sulfate via an IV pump c. Instructions for preparing thin, puréed foods d. Cardiopulmonary resuscitation (CPR)

ANS: D Respiratory compromise is a common occurrence with myasthenia gravis. The client's family members are encouraged to learn CPR and to have resuscitation equipment available in the home. The other interventions are not a priority.

Silver is used as an ingredient in many burn dressings because it a) stimulates tissue granulation b) is effective against a wide spectrum of wound pathogens c) provide topical pain relief d) stimulates wound healing

B Silver is an ingredient in many dressings because it helps prevent infection against a wide spectrum of common pathogens.

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

B, C, D, E

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

C

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

C

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

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

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

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

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

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

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

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

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

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

A temporary wound cover composed of a graft of skin transplanted from another human, living or dead, is called a(n): alloderm allograft biobrane xenograft

allograft. An allograft is transplanted skin from another human being. Alloderm is an allograft from another human being with cells removed that target the immune response. Biobrane is a nylon mesh dressing embedded with collagen. Xenograft is a skin graft from a different species.

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

b. deep vein thrombosis from lower extremities.

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

b. multisystem organ dysfunction.

Autonomic dysreflexia is characterized by an exaggerated response of the sympathetic nervous system to a variety of stimuli. Common causes of autonomic dysreflexia include: Select all that apply. bladder distension. fecal impaction. sinus bradycardia. urinary tract infection.

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

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

c. Noninvasive positive-pressure ventilation (NPPV)

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

c. pulmonary angiogram.

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

c. taking all asthma medications as prescribed.

The primary priority for the critical care nurse with regard to the trauma patient is which of the following? a. Decrease the patient's risk for multiple organ dysfunction syndrome. b. Ensure adequate fluid resuscitation. c. Increase the physiological reserve of the trauma patient. d. Provide adequate oxygenation and tissue perfusion.

d. Provide adequate oxygenation and tissue perfusion.

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

d. Reposition patient every 2 hours.

The patient is admitted with a heart rate of 144 beats/min and a blood pressure of 88/42 mm Hg. The patient complains of generalized weakness and fatigue. He states, "Just let me sleep." The nurse determines that the presence of the patient's symptoms is due to: decreased cardiac output. the absence of ischemic heart disease. improved cardiac filling time, allowing the patient to relax. increased coronary artery filling time.

decreased cardiac output. The fast heart rhythm may cause a decrease in cardiac output because of the shorter filling time for the ventricles. Vulnerable populations are those with ischemic heart disease who are adversely affected by the shorter time for coronary filling during diastole.

The nurse admits a client with suspected myasthenia gravis (MG). The nurse anticipates that the primary health care provider (PHCP) will request which medication to aid in the diagnosis of MG?

edrophonium chloride (Tensilon) The nurse expects the PHCP to request edrophonium chloride for a newly admitted client suspected of having MG. Edrophonium chloride (Tensilon) and neostigmine bromide (Prostigmin) may be used for testing for MG. Tensilon is used most often because of its rapid onset and brief duration of action. This drug inhibits the breakdown of acetylcholine (ACh) at the postsynaptic membrane, which increases the availability of ACh for excitation of postsynaptic receptors.Atropine has parasympatholytic effects and is the antidote for edrophonium chloride. Methylprednisolone (Solu-Medrol) is a glucocorticoid that is used to treat inflammatory disorders. Ropinirole (Requip) is a dopamine agonist used in the treatment of restless leg syndrome (RLS).

The patient with a pacemaker shows pacemaker spikes that are not followed by a QRS. The nurse interprets this as: failure to capture. failure to pace. failure to sense. demand mode.

failure to capture. When the pacemaker generates an electrical impulse (pacer spike) and no depolarization is noted, it is described as failure to capture. Failure to pace or fire occurs when the pacemaker fails to initiate an electrical stimulus when it should fire. The problem is noted by absence of pacer spikes on the rhythm strip. Failure to sense manifests as pacer spikes that fall too closely to the patient's own rhythm, earlier than the programmed rate. The demand mode paces the heart when no intrinsic or native beat is sensed.

A patient has sustained deep partial-thickness and full-thickness burns over 60% of her body. Shortly after admission, her blood pressure drops rapidly to a systolic pressure of 70 mm Hg. You know this is primarily due to: carbon monoxide poisoning. extreme pain. hypovolemic shock. sepsis.

hypovolemic shock. Hypovolemic shock occurs soon after burn injury as a result of dramatic fluid shift. Carbon monoxide poisoning would present with signs of acute hypoxemia. Extreme pain would cause a sympathetic response and behavioral symptoms. Sepsis is a significant risk factor for burn-injured patients but would not present this quickly after initial injury.

Ischemia to the gastrointestinal system may be caused by redistribution of blood to the brain and heart. The potential physiological effect of this is: anemia ascites ileus hepatic failure

ileus. Ileus is the result of decreased blood flow to the bowel. Redistribution of blood during acute burn shock does not cause anemia, ascites, or hepatic failure.

The patient has been admitted to the critical care unit with a diagnosis of sepsis. His leukocyte (WBC) and neutrophil counts are low, but his temperature is 103°F orally. The patient states that he has been feeling fine but woke up this morning feeling feverish and having chills. The nurse realizes that this patient is probably: showing signs of thrombocytopenia. immunocompromised. suffering from hemolytic anemia. in sickle cell anemia crisis.

immunocompromised. In patients with a low neutrophil count, fatigue or malaise often coincides with the drop in counts and precedes infectious signs and symptoms. Infection must be assessed; signs or symptoms of systemic infection include a rise in temperature from its normal set point, chills, and accompanying tachycardia. Thrombocytopenia is noted by a deficiency of platelets. In sickle cell crisis, the patient often has decreased urine output, peripheral edema, and signs of uremia. Assessment of the patient with hemolytic anemia may reveal jaundice, abdominal pain, and enlargement of the spleen or liver.

The patient, who is being treated for hypercholesterolemia, complains of hot flashes and a metallic taste in the mouth. The nurse educates the patient that this is a side effect of: bile acid resins. clopidogrel. nicotinic acid. statins.

nicotinic acid. Common side effects of nicotinic acid include metallic taste in mouth, flushing, and increased feelings of warmth.

The patient presents to the emergency department with severe substernal chest discomfort. Cardiac enzymes are elevated, and his ECG shows ST-segment depression in V2 and V3. The nurse anticipates a diagnosis of: non-Q-wave myocardial infarction (MI). pulmonary embolism. Q-wave myocardial infarction (MI). right ventricular infarction.

non-Q-wave myocardial infarction (MI). The non-Q-wave MI usually results from a partially occluded coronary vessel, and it is associated with ST-segment depression in two or more leads, along with elevated cardiac enzymes.

The nurse is interpreting a patient's cardiac rhythm and notes that the PR interval is 0.16 seconds long. The nurse determines that this PR interval indicates: slower-than-normal conduction from the SA node through the AV node. normal conduction from the SA node through the AV node. faster-than-normal conduction from the SA node through the AV node. abnormally fast depolarization of the atria and ventricles.

normal conduction from the SA node through the AV node. The interval from the beginning of the P wave to the next deflection from the baseline is called the PR interval. The PR interval measures the time it takes for the impulse to depolarize the atria, travel to the AV node, and dwell there briefly before entering the bundle of His. The normal PR interval is 0.12 to 0.20 seconds, three to five small boxes wide. When the PR interval is longer than normal, the speed of conduction is delayed in the AV node. When the PR interval is shorter than normal, the speed of conduction is abnormally fast.

When an electrical signal in the heart is aimed directly at the positive electrode, the nurse interprets that the deflection seen on the 12-lead ECG or rhythm strip will be: equiphasic. negative. positive. invisible.

positive. When assessing the 12-lead ECG or a rhythm strip, it is helpful to understand that the electrical activity is viewed in relation to the positive electrode of that particular lead. The positive electrode is the "viewing eye" of the camera. When an electrical signal is aimed directly at the positive electrode, an upright inflection is visualized. If the impulse is going away from the positive electrode, a negative deflection is seen, and if the signal is perpendicular to the imaginary line between the positive and negative poles of the lead, the tracing is equiphasic, with equally positive and negative deflection.

Which statement correctly illustrates the commonality between Guillain-Barré syndrome (GBS) and myasthenia gravis (MG)?

the client's respiratory status and muscle function are affected by both diseases. The correct statement about the commonality between GBS and MG is that both diseases affect the respiratory and muscular system. Both GBS and MG affect clients' respiratory status and muscle function.Only MG is an autoimmune disease with ocular symptoms and is characterized by exacerbations and remissions, whereas GBS has three acute stages. GBS causes demyelination of the peripheral neurons.

9. The constant noise of a ventilator, monitor alarms, and infusion pumps predisposes the patient to: A. Anxiety. B. Pain. C. Powerlessness. D. Sensory overload.

D

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

A

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

A, C, E

The nurse has attended a lecture on pain and anxiety. Which statement by the nurse indicates that teaching has been effective? A. "Pain and anxiety are cyclical, with each exacerbating the other" B. "Pain and anxiety are easily controlled with pain medication" C. Pain and anxiety are mutually exclusive; only one can be experienced at a time" D. "Pain and anxiety are treated with sedative medications"

A. "Pain and anxiety are cyclical, with each exacerbating the other"

Which stressors should the nurse anticipate the patient to have during the critical care experience? (SATA) A. Difficult communication B. Pain C. Feelings of dread D. Difficulty sleeping E. Thoughts of death and dying

A. Difficult communication, B. Pain, C. Feelings of dread, E. Thoughts of death and dying

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

B

Family members have a need for information. Which interventions best assist in meeting this need? A.Handing family members a pamphlet that explains all of the critical care equipment B. Providing a daily update of the patient's progress and facilitating communication with the intensivist C. Telling them that you are not permitted to give them a status report but that they can be present at 4:00 PM for family rounds with the intensivist D. Writing down a list of all new medications and doses and giving the list to family members during visitation

B

The nurse has attended a lecture on pain. Which statement by the nurse indicates that teaching has been effective? (SATA) A. "Pain is a state of apprehension" B. "Pain is a strictly physiological experience" C. "Pain is often exacerbated by anxiety" D. "Pain is whatever the experiencing person says it is"

B. "Pain is a strictly physiological experience" C. "Pain is often exacerbated by anxiety" D. "Pain is whatever the experiencing person says it is"

Open visitation policies are expected by many professional organizations. Which statement reflects adherence to current recommendations? A. Allow animals on the unit; however, these can only be "therapy" animals through the hospital's pet therapy program. B. Allow family visitation throughout the day except at change of shift and during rounds. C. Determine, in collaboration with the patient and family, who can visit and when. Facilitate open visitation policies. D. Permit open visitation by adults 18 years of age and older; limit visits of children to 1 hour.

C

Which intervention about visitation in the critical care unit is true? A. The majority of critical care nurses implement restricted visiting hours to allow the patient to rest. B. Children should never be permitted to visit a critically ill family member. C. Visitation that is individualized to the needs of patients and family members is ideal. D. Visiting hours should always be unrestricted.

C

The nurse is caring for a patient who is dying. Which action can the nurse take to establish a relationship with the patient? A. Leave the family alone to grieve B. Ask family to hold questions for the doctor C. Avoid discussing religious perspectives D. Communicate honestly about the patient's prognosis

D. Communicate honestly about the patient's prognosis

The nurse has been caring for a patient who has just had a surgical procedure. Labs are drawn and sent to the lab. Later in the day the nurse gets a call that the patient has a hematocrit level of 6.5%. How should the nurse interpret this lab result? Fluid overload Dehydration Infection Immunosuppression

Dehydration If the hematocrit level increases, it is most likely due to dehydration. Fluid overload would cause an increase in plasma percentage, thereby causing a decrease in the hematocrit percentage. Hematocrit has no direct bearing on infection or immunosuppression.

The nurse educator is presenting a lecture on crystalloid fluid replacement therapy in shock states. Which statement by a nurse indicates that the teaching has been effective? Lactated Ringer's should not be infused if lactic acidosis is severe. 3 mL of crystalloid is administered to replace 10 mL of blood loss. Administration of colloids is preferred over crystalloids. Solutions of 0.45% normal saline are used routinely in shock.

Lactated Ringer's should not be infused if lactic acidosis is severe. LR solutions contain lactate, which the liver converts to bicarbonate. If liver function is normal, this will counteract lactic acidosis. However, LR should not be infused if lactic acidosis is severe. To replace every 1 mL of blood loss, 3 mL of crystalloid is administered. There is no evidence to support colloid administration being more beneficial than crystalloid administration in shock states. Hypotonic solutions such as 0.45% normal saline are not administered in shock states as these solutions rapidly leave the intravascular space, causing interstitial and intracellular edema.

Which of the following treatments should the nurse anticipate administering to a hypoxic patient admitted with exacerbation of COPD? Bag-valve-mask ventilation with oxygen at 15 L/min Continuous positive airway pressure (CPAP) via face mask Non-rebreather mask with 80% oxygen Oxygen via Venturi mask at 40% oxygen

Oxygen via Venturi mask at 40% oxygen The initial treatment of hypoxemia is delivery of oxygen at a low flow rate. The Venturimask allows a designated percentage of oxygen to be delivered. The initial treatment is low-flow oxygen. If the patient fails to respond to this treatment, noninvasive ventilation (CPAP or BiPAP) may be indicated. A non-rebreather mask at 80% delivers a high percentage of oxygen, which may impair the patient's respiratory drive. Bag-valve-mask ventilation is not indicated.

What is the best position for the nurse to place the patient in to obtain a right atrial pressure measurement? Left side-lying with the head of the bed elevated 30 degrees Prone, lying on the abdomen with slight head elevation Right side-lying with the head of the bed elevated 30 degrees Supine, either flat or with the head of the bed no more than 60 degrees

Supine, either flat or with the head of the bed no more than 60 degrees Accurate assessment of a hemodynamic measure is best accomplished with the patient in a supine position with the head of the bed elevated slightly but no more than 60 degrees. The measurement can be obtained in the lateral position, but it is technically difficult because the patient must be positioned at a 30-degree lateral position for this method to be accurate. Hemodynamic measurements are not assessed in the prone position.

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

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

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

a. Placement of an intraosseous catheter

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

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

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

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

An adult patient suffered an anterior wall myocardial infarction (MI) 4 days ago. Today the patient is experiencing dyspnea and sitting straight up in bed. The nurse's assessment includes bibasilar crackles, an S3 heart sound with a heart rate of 125 beats/min. The nurse anticipates a diagnosis of: heart failure. papillary muscle rupture. pericarditis. pulmonary embolism.

heart failure. These are classic signs of fluid overload and heart failure. Presence of a heart murmur, not the S3, might alert the nurse to a papillary muscle rupture. The patient with pericarditis may have chest pain and a pericardial friction rub. The patient with a pulmonary embolism has symptoms including difficulty in breathing, cyanosis, chest pain and possibly death.

The nurse is teaching a class of health care workers about the risks of getting HIV. The nurse should inform the class that HIV: is commonly transmitted through blood transfusion. can be transmitted only when the infected person has advanced disease. transmission to health care workers is low. cannot be transmitted by needlesticks.

transmission to health care workers is low. HIV is transmitted through exposure to infected body fluids, blood, or blood products. Common modes of transmission include rectal or vaginal intercourse with an infected person; intravenous drug use with contaminated equipment; transfusion with contaminated blood or blood products; and accidental exposure through needlesticks, breaks in the skin, gestation, or childbirth (from mother to fetus). Risk of transmission is more likely when the infected person has advanced disease, although transmission of HIV can occur at any time or stage of infection. Since the 1980s, all blood products have been screened for HIV, hepatitis virus, and human T-cell lymphotrophic virus. The risk of HIV transmission to health care workers is low.