Gero Exam #3

The nurse is caring for a patient who has just had a cerebral angiogram. Which intervention should be part of the nursing management plan? a. Ensuring that the patient is adequately hydrated b. Maintaining the patient on an NPO status c. Administering antibiotics to the patient d. Keeping the patient flat in bed for 24 hours

a. Ensuring that the patient is adequately hydrated After the cerebral angiogram, adequate hydration is necessary to assist the kidneys in clearing the heavy dye load. Inadequate hydration may lead to renal dysfunction and renal shutdown.

Considering anatomic location, which cranial nerve will be affected first by downward pressure onto the infratentorial structures? a. III b. VI c. IX d. X

a. III With the location of the oculomotor nerve (cranial nerve [CN] III) at the notch of the tentorium, pupil size and reactivity play a key role in the physical assessment of intracranial pressure changes and herniation syndromes. In addition to CN III compression, changes in pupil size occur for other reasons. Large pupils can result from the instillation of cycloplegic agents, such as atropine or scopolamine, or can indicate extreme stress. Extremely small pupils can indicate narcotic overdose, lower brainstem compression, or bilateral damage to the pons.

What sites can be used for monitoring intracranial pressure (ICP)? (Select all that apply.) a. Intraventricular space b. Epidural space c. Jugular veins d. Subdural space e. Parenchyma

a. Intraventricular space b. Epidural space d. Subdural space e. Parenchyma The five sites for monitoring intracranial pressure are (1) the intraventricular space, (2) the subarachnoid space, (3) the epidural space, (4) the subdural space, and (5) the parenchyma.

The nurse is caring for a patient who has sustained a traumatic head injury. The practitioner has asked the nurse to test the patient's oculocephalic reflex. What must the nurse verity prior to performing the test? a. The absence of cervical injury b. The depth and rate of respiration c. The patient's ability to swallow d. The patient's ability to follow a verbal command

a. The absence of cervical injury In an unconscious patient, assessment of ocular function and innervation of the medial longitudinal fasciculus (MLF) is performed by eliciting the doll's eyes reflex. If the patient is unconscious as a result of trauma, the nurse must ascertain the absence of cervical injury before performing this examination.

Which statements are correct regarding the assessment of motor function in the neurologically impaired patient? (Select all that apply.) a. The presence of a Babinski reflex is an abnormal finding in an adult. b. Lower extremity muscle tone is assessed by asking the patient to push or pull his or her foot against resistance. c. When using noxious stimuli to elicit a motor response, each limb is tested separately. d. The presence of abnormal extension indicates a less positive outcome for the patient than abnormal flexion. e. The evaluation of deep tendon reflexes is an essential part of the nursing neurologic assessment.

a. The presence of a Babinski reflex is an abnormal finding in an adult. c. When using noxious stimuli to elicit a motor response, each limb is tested separately. d. The presence of abnormal extension indicates a less positive outcome for the patient than abnormal flexion. The presence of a Babinski response in an adult is indicative of neurologic dysfunction, pushing or pulling against resistance tests muscle strength not tone, and deep tendon reflexes are not routinely checked by the critical care nurse during assessment.

A patient is undergoing a preoperative evaluation for carotid arteries. What two test should the nurse expect to see ordered for the patient? a. Ultrasound and magnetic resonance angiography b. Conventional angiography and evoked potential c. Computed tomography (CT) and magnetic resonance angiography d. Transcranial Doppler and extracranial Doppler

a. Ultrasound and magnetic resonance angiography Magnetic resonance angiography of the carotid arteries has become an established complement to preoperative ultrasound evaluation. It helps determine the area of salvageable tissue (or penumbra) after acute stroke and head injury.

Indications for the use of electroencephalography (EEG) include (Select all that apply.) a. cerebral infarct. b. metabolic encephalopathy. c. confirmation of brain death. d. altered consciousness. e. all head injuries.

a. cerebral infarct. b. metabolic encephalopathy. c. confirmation of brain death. d. altered consciousness. Indications for the use of electroencephalography include suspected seizure activity, cerebral infarct, metabolic encephalopathies, altered consciousness, infectious disease, some head injuries, and confirmation of brain death.

How often should lubricating eye drops be administered to a patient in a coma to prevent corneal epithelial breakdown? a.2 hours b.4 hours c.8 hours d.12 hours

a.2 hours Instillation of saline or methylcellulose drops every 2 hours prevents corneal breakdown in the coma patient. In addition, taping a polyethylene film over the eyes, extending from beyond the orbit to over the eyebrow, creates a moisture chamber and has been effective in keeping the eyes moist.

The patient is ordered a computed tomography (CT) scan with contrast. Which question should the nurse ask the conscious patient before the procedure? a. "Are you allergic to penicillin?" b. "Are you allergic to iodine-based dye?" c. "Are you allergic to latex?" d. "Are you allergic to eggs?"

b. "Are you allergic to iodine-based dye?" If the patient is scheduled to receive contrast for computed tomography (CT) scanning, questions about possible sensitivity to iodine-based dye must be asked beforehand, if possible. During infusion of the dye and for 10 to 30 minutes afterward, the patient is observed closely for an anaphylactic reaction. Fewer than 1% of all patients undergoing contrast-enhanced CT have severe anaphylactic reactions, shock, or cardiac arrest.

A patient has been admitted with acute confusion and other focal neurologic signs. The practitioner orders magnetic resonance imaging (MRI). The nurse knows in certain situations an MRI is superior to computed tomography (CT). What is one those situations? a. Brain death determination b. Detection of central nervous system infection c. Estimation of intracranial pressure d. Identification of subarachnoid hemorrhage

b. Detection of central nervous system infection Magnetic resonance imaging (MRI) produces images with greater detail than computed tomography (CT) and provides views of several planes (sagittal, coronal, axial, and oblique) that are not possible with CT. MRI with contrast is the preferred study for detection of infectious and inflammatory processes of the central nervous system (CNS). MRI can detect areas of cerebral infarct within a few hours of the incident and can identify small areas of plaque in patients with multiple sclerosis. MRI with contrast is the preferred study for detection of infectious and inflammatory processes of the CNS, malignancy, and metastatic lesions; cervical spine imaging; and postoperative evaluation of tumor recurrence. MRI also is the diagnostic study of choice in the evaluation of spinal cord injury.

The nurse is caring for a patient immediately after a craniotomy. When assessing the size and shape of the patient's pupils the nurse notes the patient's left pupil is oval. What does this finding indicate? a. Cortical dysfunction b. Intracranial hypertension c. Hydrocephalus d. Metabolic coma

b. Intracranial hypertension Pupil shape is also noted in the assessment of pupils. Although the pupil is normally round, an irregularly shaped or oval pupil may be noted in patients with eye surgery. Initial stages of cranial nerve III compression from elevated intracranial pressure can also cause the pupil to have an oval shape.

Which of the following statements best describes assessment of arousal? a. It measures content of consciousness and is a higher-level function. b. It is an evaluation of the reticular activating system and its connection with the thalamus and the cerebral cortex. c. It becomes a valid parameter when the patient is able to respond to verbal stimuli, such as squeezing the hands on command. d. Noxious stimuli are not to be used as an assessment parameter.

b. It is an evaluation of the reticular activating system and its connection with the thalamus and the cerebral cortex. Assessment of the arousal component of consciousness is an evaluation of the reticular activating system and its connection with the thalamus and the cerebral cortex. Arousal is the lowest level of consciousness, and observation centers on the patient's ability to respond to verbal or noxious stimuli in an appropriate manner.

The nurses are admitting a neurologically impaired patient. The patient's family is present. How comprehensive should the initial history be? a. It should be limited to the chief complaint and personal habits. b. It should be all-inclusive, including events preceding hospitalization. c. It should be confined to current medications and family history. d. It should be restricted to only information that the patient can provide.

b. It should be all-inclusive, including events preceding hospitalization. The one factor common to all neurologic assessment is the need to obtain a comprehensive history of events preceding hospitalization.

The nurse is precepting a nursing student. The student asks about testing of extraocular eye movements. What should the nurse tell the student? a. It tests the pupillary response to light. b. It tests function of the three cranial nerves. c. It tests the ability of the eyes to accommodate to a closer moving object. d. It tests the oculocephalic reflex.

b. It tests function of the three cranial nerves. Control of eye movements occurs with interaction of three cranial nerves: oculomotor (III), trochlear (IV), and abducens (VI).

The nurse is caring for a patient with a head injury who is obtunded. The nurse is going to use noxious stimuli to elicit a response. What is an acceptable method? a. Nipple pinch b. Nail bed pressure c. Supraorbital pressure d. Sternal rub

b. Nail bed pressure Nail bed pressure and trapezius pinch are acceptable methods of noxious stimulation. Nail bed pressure allows evaluation of individual extremity function. Trapezius pinch is difficult to perform on large or obese adults. Repeated sternal rub can cause the sternum to become excoriated, open, and infected. Supraorbital pressure must be avoided in patients with head injuries, frontal craniotomies, or facial surgery. Nipple and testicle pinching are inappropriate and unnecessary.

A patient has developed acute kidney injury (AKI) secondary to cardiogenic shock. Which laboratory value would the nurse find helpful in evaluating patient's renal status? a. Serum sodium b. Serum creatinine c. Serum potassium d. Urine potassium

b. Serum creatinine In the acutely ill patient, small changes in the serum creatinine level and urine output may signal important declines in the glomerular filtration rate and kidney function

The practitioner has ordered a carotid Doppler study for a patient. The patient asks the nurse what the test is for. How should the nurse respond? a. The test evaluates blood flow in the anterior, middle, or posterior cerebral arteries. b. The test estimates blood flow velocity thought the carotid arteries. c. The test assesses arteriovenous circulation in the intracranial space. d. The test gauges global cerebral blood flow.

b. The test estimates blood flow velocity thought the carotid arteries. Ultrasound technology, although not an absolute measure of cerebral blood flow, uses a noninvasive technique to provide information about the flow velocity of blood through carotid vessels. Carotid duplex studies are used as a routine screening procedure for intraluminal narrowing of the common and internal carotid arteries as a result of atherosclerotic plaques.

The nurse is caring for a severely head injured comatose patient who is dying. The nurse knows the patient has entered the late stages of intracranial hypertension when the nurse observes which signs? a. Pupils are equal and reactive b. Widening pulse pressure c. Eupnea d. Decreased intracranial pressure

b. Widening pulse pressure Attention must also be paid to the pulse pressure because widening of this value may occur in the late stages of intracranial hypertension. With the loss of autoregulation as blood pressure increases, cerebral blood flow (CBF) and cerebral blood volume increase and intracranial pressure (ICP) therefore increases. The mean arterial pressure must be maintained at a level sufficient to produce adequate CBF in the presence of elevated ICP.

The patient's intracranial pressure (ICP) reading has gradually climbed from 15 to 23 mm Hg. The nurse's primary action is to: a. drain off 7 mm of cerebrospinal fluid (CSF) from the catheter. b. notify the physician. c. place the patient in a high Fowler position to decrease the pressure. d. check level of consciousness.

b. notify the physician. Under normal physiologic conditions, mean intracranial pressure (ICP) is maintained below 15 mm Hg. An increase in ICP can decrease blood flow to the brain, causing brain damage. Persistent ICP elevation above 20 mm Hg remains the most significant factor associated with a fatal outcome.

Which assessment finding in a patient in coma 10 to 12 hours after cardiopulmonary arrest is indicative of unlikely survival? a.Decorticate posturing b.Absent pupillary light reflexes c.Decerebrate posturing d.Central hyperventilation

b.Absent pupillary light reflexes Much research has been directed toward identifying the prognostic indicators for the patient in coma after a cardiopulmonary arrest. In a meta-analysis, the best predictors of poor outcome after cardiac arrest were lack of corneal or papillary response at 24 hours and lack of motor movement at 72 hours. However, regardless of the cause or duration of coma, the outcome for an individual cannot be predicted with 100% accuracy.

While caring for a comatose patient with intracranial hypertension, the nurse observes the patient's ICP fall from 65 to 12 mm Hg. After troubleshooting the monitoring system and finding no issues, the nurse suspects the cause of this change is which situation? a.A seizure b.Brain herniation c.Resolving cerebral d.Excessive dehydration

b.Brain herniation Herniation of intracerebral contents results in the shifting of tissue from one compartment of the brain to another and places pressure on cerebral vessels and vital function centers of the brain. If unchecked, herniation rapidly causes death as a result of the cessation of cerebral blood flow and respirations. Signs of brain herniation include fixed and dilated pupils, flaccidity, and respiratory arrest. The intracranial pressure drops as the pressure is relieved by shifting the intracranial components downward.

A patient has been admitted with a stroke. The nurse anticipates a practitioner's order for which diagnostic study before initiating therapy? a.Magnetic resonance imaging b.Noncontrast computed tomography c.Contrast computed tomography d.Lumbar puncture

b.Noncontrast computed tomography Confirmation of the diagnosis of ischemic stroke is the first step in the emergent evaluation of these patients. Differentiation from intracranial hemorrhage is vital. Noncontrast computed tomography (CT) scanning is the method of choice for this purpose, and it is considered the most important initial diagnostic study. Magnetic resonance imaging (MRI) can demonstrate infarction of cerebral tissue earlier than can CT but is less useful in the emergent differential diagnosis. Lumbar puncture is performed only if subarachnoid hemorrhage is suspected and the CT scan findings are normal.

A patient has been on complete bed rest for 3 days. The practitioner has left orders to get the patient out of bed for meals. The patient complains of feeling dizzy and faint while sitting at the bedside. The nurse suspects that the patient is experiencing what problem? a.Orthostatic hypertension b.Orthostatic hypotension c.Hypervolemia d.Electrolyte imbalance

b.Orthostatic hypotension Orthostatic hypotension produces subjective feelings of weakness, dizziness, or faintness. Orthostatic hypotension occurs with hypovolemia or prolonged bed rest or as a side effect of medications that affect blood volume or blood pressure.

Percussion of kidneys is usually done to assess what parameter? a.Size and shape of the kidneys b.Presence of pain in the renal area c.Presence of a fluid wave d.Patient's overall fluid status

b.Presence of pain in the renal area Percussion is performed to detect pain in the area of a kidney or to determine excess accumulation of air, fluid, or solids around the kidneys. Percussion of the kidneys also provides information about kidney location, size, and possible problems

A patient has been admitted in acute heart failure. Which parameter would indicate to the nurse that the patient is fluid overloaded? a.Central venous pressure of 4 mm Hg b.Pulmonary artery occlusion pressure (PAOP) of 18 mm Hg c.Cardiac index of 2.5 L/min/m2 d.Mean arterial pressure of 40 mm Hg

b.Pulmonary artery occlusion pressure (PAOP) of 18 mm Hg The pulmonary artery occlusion pressure (PAOP) represents the left atrial pressure required to fill the left ventricle. When the left ventricle is full at the end of diastole, this represents the volume of blood available for ejection. It is also known as left ventricular preload and is measured by the PAOP. The normal PAOP is 5 to 12 mm Hg. In fluid volume excess, PAOP rises. In fluid volume deficit, PAOP is low.

The nurse is caring for a patient who is going to have digital subtraction angiography. The patient asks what is the difference between conventional and digital subtraction angiography. What should the nurse tell the patient? a. Digital subtraction angiography has fewer complications. b. Digital subtraction angiography is noninvasive. c. Digital subtraction angiography uses significantly less dye. d. Digital subtraction angiography is done through the femoral vein.

c. Digital subtraction angiography uses significantly less dye. Digital subtraction angiography uses significantly less dye than arterial angiography. Dye is injected in the venous or arterial system. The patient must remain motionless during the procedure. Complications are the same as those for cerebral angiography.

The nurse is precepting a new graduate nurse. The new graduate asks about the difference between electroencephalography and evoked potentials. What should the nurse tell the new graduate? a. Evoked potentials measure and record electric and muscle activity in response to noxious stimuli. b. Electroencephalography measures cerebral blood flow and oxygen extraction. c. Evoked potentials measure cerebral electrical impulses generated in response to sensory stimuli. d. Electroencephalography measures the biochemical changes in the brain to assess metabolic activity.

c. Evoked potentials measure cerebral electrical impulses generated in response to sensory stimuli. Evoked potentials involve the recording of electrical impulses generated by a sensory stimulus as it travels through the brainstem and into the cerebral cortex. Electroencephalography (EEG) records electric impulses, commonly called brain waves, generated by the brain.

Why is assessment of level of conscious (LOC) the most important aspect of the neurologic examination? a. The LOC is the most prognostic indicator of the patient's outcome. b. The LOC is generally limited to the Glasgow Coma Scale making it the quickest part of the assessment. c. In most situations the LOC deteriorates before any other neurologic changes are noted. d. The LOC is the easiest part of the neurologic exam and thus is generally performed first.

c. In most situations the LOC deteriorates before any other neurologic changes are noted. Assessment of the level of consciousness is the most important aspect of the neurologic examination.

The nurse is caring for a patient with an intracranial pressure-monitoring device that provides access to cerebrospinal fluid (CSF) for sampling. What type of device does the patient have? a. Subarachnoid bolt b. Epidural catheter c. Intraventricular catheter d. Fiber-optic catheter

c. Intraventricular catheter An intraventricular catheter allows accurate intracranial pressure (ICP) measurement and provides access to cerebrospinal fluid (CSF) for drainage or sampling. A subarachnoid bolt, epidural catheter, and fiber-optic catheter provide no access for CSF sampling.

The nursing management plan for a patient undergoing a water-based contrast myelogram should include intervention? a. Maintain the patient flat in bed for 4 to 6 hours b. Observe the puncture sight every 15 minutes for 2 hours for signs of bleeding c. Keep the patient's head elevated 30 to 45 degrees for 8 hours d. Administer a sedative to keep the patient from moving around

c. Keep the patient's head elevated 30 to 45 degrees for 8 hours Postprocedure care includes keeping the patient's head elevated 30 to 45 degrees for 8 hours, monitoring neurologic status, and encouraging oral fluids.

The practitioner wishes to evaluate the functional integrity of cerebral motor pathways in a brain-injured patient. Which test should the nurse anticipate the practitioner will order? a. Electroencephalography b. Xenon computed tomography (CT) c. Motor-evoked potentials d. Emission tomography

c. Motor-evoked potentials Motor-evoked potentials assess the functional integrity of descending motor pathways. The motor cortex is stimulated via direct high-voltage electric stimulation through the scalp or use of a magnetic field to induce an electrical current within the brain.

The nurse is caring for a patient with a closed head injury with a Glasgow Coma Scale (GCS) score of 6. What does this score indicate about the patient's neurologic status? a. Patient is in a vegetative state. b. Patient is a paraplegic. c. Patient is in a coma. d. Patient is able to obey commands.

c. Patient is in a coma. The best possible score on the Glasgow Coma Scale (GCS) is 15, and the lowest score is 3. Generally, a score of 7 or less on the GCS indicates coma. Originally, the scoring system was developed to assist in general communication concerning the severity of neurologic injury.

An elderly patient is in a motor vehicle accident and sustains a significant internal hemorrhage. The nurse knows the patient is at risk for developing what type of acute kidney injury (AKI)? a. Intrinsic b. Postrenal c. Prerenal d. Intrarenal

c. Prerenal Any condition that decreases blood flow, blood pressure, or kidney perfusion before arterial blood reaches the renal artery that supplies the kidney may be anatomically described as prerenal acute kidney injury (AKI). When arterial hypoperfusion caused by low cardiac output, hemorrhage, vasodilation, thrombosis, or other cause reduces the blood flow to the kidney, glomerular filtration decreases, and consequently urine output decreases.

The nurse is caring for a critically injured patient who can only be aroused by vigorous external stimuli. Which category should the nurse use to document the patient's level of consciousness? a. Lethargic b. Obtunded c. Stuporous d. Comatose

c. Stuporous Stuporous means the patient can be aroused only by vigorous and continuous external stimuli. Motor response is often withdrawal or localizing to stimulus. Obtunded means the patient displays dull indifference to external stimuli, and response is minimally maintained. Questions are answered with a minimal response. Lethargic means the patient displays a state of drowsiness or inaction in which the patient needs an increased stimulus to be awakened. Comatose means vigorous stimulation fails to produce any voluntary neural response in the patient.

A patient has been admitted in a coma of unknown cause. Structural causes have been ruled out. The nurse suspects the patient may be experiencing which cause of coma? a.Trauma b.Ischemic stroke c.Drug overdose d.Intracerebral hemorrhage

c.Drug overdose Causes of metabolic coma include drug overdose, infectious diseases, endocrine disorders, and poisonings. Structural causes of coma include ischemic stroke, intracerebral hemorrhage, trauma, and brain tumors.

Nursing actions for the patient with increased intracranial pressure (ICP) should include which activity? a.Elevate the head of the bed 30 to 40 degrees. b.Place the patient supine with the neck in a neutral alignment. c.Individualize the patient's head position to minimize ICP. d.Elevate the patient's head and knees while flexing the hips.

c.Individualize the patient's head position to minimize ICP. The recent trend is to individualize the head position to maximize cerebral perfusion pressure and minimize intracranial pressure measurements. Head elevation has long been advocated as a conventional nursing intervention to control ICP, presumably by increasing venous return; however, this may decrease CPP.

A patient has been admitted with acute confusion and other focal neurologic signs. The practitioner is going to perform a lumbar puncture. What is an abnormal finding in the cerebrospinal fluid? a. Clear and colorless b. Glucose of 60 mg/dL c. Protein of 20 mg/dL d. 30 red blood cells

d. 30 red blood cells Cerebrospinal fluid is normally a clear, colorless, odorless solution that contains 50 to 75 mg/dL of glucose, 5 to 25 mg/dL of protein, and no red blood cells.

A patient is admitted with an anoxic brain injury. The nurse notes abnormal extension of both extremities to noxious stimuli. This finding indicates dysfunction in which area of the central nervous system? a. Cerebral cortex b. Thalamus c. Cerebellum d. Brainstem

d. Brainstem Abnormal extension occurs with lesions in the area of the brainstem. Abnormal flexion occurs with lesions above the midbrain in the region of the thalamus or cerebral hemispheres.

Cerebral infarction is a serious complication of which procedure? a. Extracranial Doppler b. Evoked potential testing c. Myelography d. Cerebral angiography

d. Cerebral angiography Complications associated with cerebral angiography include cerebral embolus caused by the catheter dislodging a segment of atherosclerotic plaque in the vessel, hemorrhage or hematoma formation at the insertion site, vasospasm caused by the irritation of catheter placement, thrombosis of the extremity distal to the injection site, and allergic or adverse reaction to the contrast medium.

The nurse is caring for a patient with a head injury and observes a rhythmic increase and decrease in the rate and depth of respiration followed by brief periods of apnea. What should the nurse document under breathing pattern? a. Central neurogenic hyperventilation b. Apneustic breathing c. Ataxic respirations d. Cheyne-Stokes respirations

d. Cheyne-Stokes respirations Cheyne-Stokes respirations have a rhythmic crescendo and decrescendo of rate and depth of respiration, including brief periods of apnea. These respirations are usually seen with bilateral deep cerebral lesions or some cerebellar lesions. Central neurogenic hyperventilations are very deep, very rapid respirations with no apneic periods. They are usually seen with lesions of the midbrain and upper pons. Apneustic breathing includes clusters of irregular, gasping respirations separated by long periods of apnea. They are usually seen in lesions of the lower pons or upper medulla. Ataxic respirations are irregular, random patterns of deep and shallow respirations with irregular apneic periods. They are usually seen in lesions of the medulla.

The nurse is caring for a comatose patient with a brain tumor. When the nurse touches the palm of the patient's hand, the patient grasps the nurse's hand. What is this sign indicative of? a. There is damage to the brainstem. b. It's a normal finding. c. The patient is getting better. d. Cortical damage is present.

d. Cortical damage is present. The grasp reflex is present when tactile stimulation of the palm of the hand produces a grasp response that is not a conscious voluntary act. The grasp reflex is a primitive reflex that normally disappears with maturational development; thus, the presence of the grasp reflex in the adult indicates cortical damage.

One therapeutic measure for treating hyperkalemia is the administration of dextrose and regular insulin. Which description regarding how this treatment works is accurate? a. Forces potassium out of the serum into the lymphatic space. b. Promotes higher excretion of potassium in the urine. c. Binds with potassium lowering available amounts. d. Forces potassium out of the serum into the cells.

d. Forces potassium out of the serum into the cells. Acute hyperkalemia can be treated temporarily by intravenous administration of insulin and glucose. An infusion of 50 mL of 50% dextrose accompanied by 10 units of regular insulin forces potassium out of the serum and into the cells.

A patient is being prepared for a neurologic work-up. The practitioner is getting ready to perform a lumbar puncture. What is the best position for the nurse to place the patient in for the procedure? a. Prone b. Reverse Trendelenburg c. High Fowler d. Lateral recumbent position with knees and head slightly tucked.

d. Lateral recumbent position with knees and head slightly tucked. Patients undergoing a lumbar puncture are placed either in the lateral recumbent position, with the knees and head tightly tucked, or in the sitting position, leaning over a bedside table or some other support.

The nurse is starting a peripheral intravenous catheter in the right hand of an unconscious patient. During the procedure the patient reaches over with his left hand and tries to remove the noxious stimuli. How would the nurse document this response? a. Decorticate posturing b. Decerebrate posturing c. Withdrawal d. Localization

d. Localization Localization occurs when the extremity opposite to the extremity receiving pain crosses the midline of the body in an attempt to remove the noxious stimulus from the affected limb.

While the Glasgow Coma Scale (GCS) is part of the routine neurologic assessment, the nurse knows that it is not a valid measure for certain types of patients. In which patient is the GCS not valid? a. Patient with hemiplegia b. Patient with Parkinson disease c. Patient with dyslexia d. Patient who is intoxicated

d. Patient who is intoxicated Several points should be kept in mind when the Glasgow Coma Scale is used for serial assessment. It provides data about level of consciousness only, and it should never be considered a complete neurologic examination. Additionally, it is not a sensitive tool for evaluation of an altered sensorium, and it does not account for possible aphasia or mechanical intubation. It is also a poor indicator of lateralization of neurologic deterioration

The nurse is precepting a new graduate nurse. The new graduate asks about testing the oculovestibular reflex. What should the nurse tell the new graduate? a. The test should not be performed on an unconscious patient because of the risk of aspiration. b. An abnormal response is manifested by conjugate, slow, tonic nystagmus deviating toward the irrigated ear. c. This test should be included in the nursing neurologic examination of a patient with a head injury. d. This test is one of the final clinical assessments of brainstem function.

d. This test is one of the final clinical assessments of brainstem function. The oculovestibular reflex is one of the final clinical assessments of brainstem function and is only performed by a practitioner. After confirmation that the tympanic membrane is intact, the head is raised to a 30-degree angle. Then 20 to 100 mL of ice water is injected into the external auditory canal. In a normal response, eye movement is in the direction of the injection site. An abnormal response is disconjugate eye movement, which indicates a brainstem lesion, or no response, which indicates little to no brainstem function.

Which patient problem has the highest priority in the patient management plan for a patient with Guillain-Barré syndrome? a.Nutritional deficient due to lack of exogenous nutrients or increased metabolic demand b.Acute pain due to transmission and perception of cutaneous, visceral, muscular, or ischemic impulses c.Increased probability of aspiration due to impaired swallowing d.Abnormal breathing pattern due to musculoskeletal fatigue or neuromuscular impairment

d.Abnormal breathing pattern due to musculoskeletal fatigue or neuromuscular impairment The most common cause of death of patients with GBS is respiratory arrest; thus, the highest nursing priority for a patient with Guillain-Barré syndrome is directed toward providing ventilatory support and maintaining surveillance for complications. Facilitating nutritional support, providing comfort and emotional support, and educating the patient and family are important but rank lower than issues with the respiratory system.

A patient is admitted with an acute head injury after a motor vehicle accident. The patient is intubated and ventilated, and a ventriculostomy is placed. In addition to monitoring of intracranial pressure, what treatment can be provided with the ventriculostomy? a.Instillation of mannitol b.Drainage of subdural hematoma c.Brain tissue sampling d.Cerebrospinal fluid drainage

d.Cerebrospinal fluid drainage Advantages of a ventriculostomy include access for cerebrospinal fluid drainage and sampling, access for determination of volume-pressure curves, direct measurement of pressure, and access for medication instillation.

In a patient with a distended abdomen differentiating ascites from solid bowel contents is accomplished by performing what assessment? a.Auscultation of bowel sounds b.Palpation of the liver margin c.Measuring abdominal girth d.Eliciting a fluid wave

d.Eliciting a fluid wave Differentiating ascites from distortion by solid bowel contents is accomplished by producing what is called a fluid wave. The fluid wave is elicited by exerting pressure to the abdominal midline while one hand is placed on the right or left flank. Tapping the opposite flank produces a wave in the accumulated fluid that can be felt under the hands.

The practitioner has ordered dialysis for a patient with acute heart failure who is unresponsive to diuretics. Which type of dialysis would the nurse anticipate being started on this patient? a. Intermittent ultrafiltration b. Continuous venovenous hemofiltration (CVVH) c. Continuous venovenous hemodialysis (CVVHD) d. Continuous venovenous hemodiafiltration (CVVHDF

ANS: A Intermittent ultrafiltration using a peripheral venous catheter is more likely to be used to remove excess volume from patients with acute decompensated heart failure when the kidneys are unresponsive to diuretics.

A patient presents moderately short of breath and dyspneic. A chest radiographic examination reveals a large right pleural effusion with significant atelectasis. Which procedure would the practitioner be most likely to prescribe? a. Thoracentesis b. Bronchoscopy c. Ventilation-perfusion (V/Q) scan d. Repeat chest radiograph

ANS: A Thoracentesis is a procedure that can be performed at the bedside for the removal of fluid or air from the pleural space. It is used most often as a diagnostic measure; it may also be performed therapeutically for the drainage of a pleural effusion or empyema. No evidence is present that would necessitate a V/Q scan. A bronchoscopy cannot assist in fluid removal. A problem with this chest radiograph is not indicated.

A patient is admitted with respiratory failure and is being mechanically ventilated. The nurse understands there is a significant association between acute kidney injury and respiratory failure. How does mechanical ventilation alter kidney function? (Select all that apply.) a. Decreases blood flow to the kidney. b. Decreases glomerular filtration rate (GFR). c. Damages the kidney tubular endothelium. d. Decreases urine output. Hinders flow of urine from the kidneys

ANS: A B D Mechanical ventilation can alter kidney function. Positive-pressure ventilation reduces blood flow to the kidney, lowers the GFR, and decreases urine output. These effects are intensified with the addition of positive end-expiratory pressure (PEEP)

Nursing management of a patient undergoing a diagnostic procedure entails what nursing actions? (Select all that apply.) a. Positioning the patient for the procedure b. Monitoring the patient's responses to the procedure c. Obtaining consent for the procedure d. Teaching the patient about the procedure e. Medicating the patient before and after procedure

ANS: A, B, D, E Preparing the patient includes teaching the patient about the procedure, answering any questions, and positioning the patient for the procedure. Monitoring the patient's responses to the procedure includes observing the patient for signs of pain and anxiety and monitoring vital signs, breath sounds, and oxygen saturation. Assessing the patient after the procedure includes observing for complications of the procedure and medicating the patient for any postprocedural discomfort. Obtaining consent for the procedure is not a nursing responsibility

The nursing management plan for the patient with a urinary drainage catheter would include which interventions to prevent catheter-associated UTI (CAUTI)? (Select all that apply.) a. Insert urinary catheters using aseptic techniques. b. Change the urinary catheter daily. c. Review the need for the urinary catheter daily and remove promptly. d. Flush the urinary catheter q8 hours to maintain patency. e. Avoid unnecessary use of indwelling urinary catheters.

ANS: A,C,E The key components of CAUTI prevention are to avoid unnecessary use of urinary catheters, insert urinary catheters using aseptic technique, adopt evidence-based standards for maintenance of urinary catheters, review the need for the urinary catheter daily, and remove the catheter promptly.

The practitioner has ordered continuous renal replacement therapy (CRRT) for a patient with acute kidney injury. The patient needs both the removal of fluids and a moderate amount of solutes. Which type of CRRT would the nurse anticipate being started on this patient? a. Slow continuous ultrafiltration (SCUF) b. Continuous venovenous hemofiltration (CVVH) c. Continuous venovenous hemodialysis (CVVHD) d. Continuous venovenous hemodiafiltration (CVVHDF)

ANS: B CVVH is indicated when the patient's clinical condition warrants removal of significant volumes of fluid and solutes. Fluid is removed by ultrafiltration in volumes of 5 to 20 mL/min or up to 7 to 30 L/24 hr. Removal of solutes such as urea, creatinine, and other small non-protein-bound toxins is accomplished by convection

For which situation does a patient with acute lung failure require a bronchodilator? a. Excessive secretions b. Bronchospasms c. Thick secretions d. Fighting the ventilator

ANS: B Bronchodilators aid in smooth muscle relaxation and are of particular benefit to patients with airflow limitations. Bronchospasms are a form of airflow limitation. The patient with excessive secretions requires suctioning. The patient with thick secretions requires increased hydration. The patient fighting the ventilator needs further assessment and possibly an anxiolytic or sedative.

When auscultating a patient's lungs, the nurse hears sounds that sound like popping in the small airways. What should the nurse document under breath sounds in the patient's record? a. Sonorous wheezes b. Crackles c. Sibilant wheezes d. Pleural friction rub

ANS: B Crackles or rales are short, discrete, popping, or crackling sounds produced by fluid in the small airways or alveoli.

The patient's arterial blood gas (ABG) values on room air are PaO2, 40 mm Hg; pH, 7.10; PaCO2, 44 mm Hg; and HCO3-, 16 mEq/L. What is the interpretation of the patient's ABG? a. Uncompensated respiratory acidosis b. Uncompensated metabolic acidosis c. Compensated metabolic acidosis d. Compensated respiratory acidosis

ANS: B The pH is below normal range (7.35 to 7.45), so this is uncompensated acidosis. The PaCO2 normal and the HCO3- is markedly low. This indicates uncompensated metabolic acidosis. Uncompensated metabolic acidosis values include a pH below 7.35, PaCO2 of 35 to 45 mm Hg, and HCO - below 22 mEq/L. Uncompensated respiratory acidosis values include a pH below 7.35, PaCO 32 above 45 mm Hg, and HCO3- of 22 to 26 mEq/L. Compensated metabolic acidosis values include a pH of 7.35 to 7.39, PaCO2 below 35 mm Hg, and HCO3- below 22 mEq/L. Compensated respiratory acidosis values include a pH of 7.35 to 7.35, PaCO2 above 45 mm Hg, and HCO3- above 26 mEq/L.

The patient's arterial blood gas (ABG) values on room air are PaO2, 70 mm Hg; pH, 7.31; PaCO2, 52 mm Hg; and HCO3-, 24 mEq/L. What is the interpretation of the patient's ABG? a. Uncompensated metabolic alkalosis b. Uncompensated respiratory acidosis c. Compensated respiratory acidosis d. Compensated respiratory alkalosis

ANS: BThe pH is closer to the acidic level, so the primary disorder is acidosis. Uncompensated respiratory acidosis values include a pH below 7.35, PaCO2 above 45 mm Hg, and HCO3- of 22 to 26 mEq/L. Compensated respiratory acidosi3s values include a pH of 7.35 to 7.39, PaCO2 greater than 45 mm Hg, and HCO - greater than 26 mEq/L. Compensated respiratory alkalosis values include a pH of 7.41 to 7.45, PaCO2 below 35 mm Hg, and HCO3- below 22 mEq/L. Uncompensated metabolic alkalosis values include a pH above 7.45, PaCO2 of 35 to 45 mm Hg, and HCO3- above 26 mEq/L

To assess whether or not an arteriovenous fistula is functioning, what must the nurse do and why? a. Palpate the quality of the pulse distal to the site to determine whether a thrill is present; auscultate with a stethoscope to appreciate a bruit to assess the quality of the blood flow. b. Palpate the quality of the pulse proximal to the site to determine whether a thrill is present; auscultate with a stethoscope to appreciate a bruit to assess the quality of the blood flow. c. Palpate gently over the site of the fistula to determine whether a thrill is present; listen with a stethoscope over this site to appreciate a bruit to assess the quality of the blood flow. d. Palpate over the site of the fistula to determine whether a thrill is present; check whether the extremity is pink and warm

ANS: C The nurse frequently assesses the quality of blood flow through the fistula. A patent fistula has a thrill when palpated gently with the fingers and a bruit when auscultated with a stethoscope. The extremity should be pink and warm to the touch. No blood pressure measurements, intravenous infusions, or laboratory phlebotomy is performed on the arm with the fistula

A patient with a history of chronic obstructive pulmonary disease requires oxygen therapy at 28%. Which oxygen administration device should the patient be placed on to accomplish this? a. Simple mask b. Nasal cannula c. Air-entrainment mask d. Partial rebreathing mask

ANS: C An air-entrainment mask is used in patients requiring the delivery of a precise low FiO2. A simple mask, partial rebreathing mask, and nasal cannula are not able to provide as precise level of oxygen as an air-entrainment mask.

What chest wall deformity is characterized by an increase in anteroposterior (AP) diameter with displacement of the sternum forward and the ribs outward? a. Funnel chest b. Pigeon breast c. Barrel chest d. Harrison's groove

ANS: C Normal ratio of anteroposterior diameter to lateral diameter ranges from 1:2 to 5:7. A barrel chest is characterized by displacement of the sternum forward and the ribs outward and is suggestive of chronic obstructive pulmonary disease. Funnel chest, pectus excavatum, creates a pit-shaped depression. Pigeon chest, pectus carinatum, causes an increase in anteroposterior diameter. Both are related to restrictive pulmonary disease. Harrison's groove, a rib deformity, is a result of rickets.

The nurse is caring for a patient with respiratory failure. The nurse notes the patient's diaphragmatic excursing is 8 cm. What coexisting conditions could account for this finding? a. Asthma and emphysema b. Hepatomegaly and ascites c. Atelectasis and pleural effusion d. Pneumonia and pneumothorax

ANS: CNormal diaphragmatic excursion is 3 to 5 cm and is part of the percussion component of the physical examination. Diaphragmatic excursion is increased in pleural effusion, and disorders that elevate the diaphragm, such as atelectasis or paralysis. Diaphragmatic excursion is decreased in disorders such as ascites, pregnancy, hepatomegaly, and emphysema.

On admission, a patient presents with a respiratory rate of 24 breaths/min, pursed-lip breathing, heart rate of 96 beats/min in sinus tachycardia, and a blood pressure of 110/68 mm Hg. The patient's arterial blood gas (ABG) values on room air are PaO2, 70 mm Hg; pH, 7.38; PaCO2, 52 mm Hg; and HCO3-, 34 mEq/L. Which diagnoses would be most consistent with the above arterial blood gas values? a. Acute pulmonary embolism b. Acute myocardial infarction c. Acute heart failure d. Chronic obstructive pulmonary disease

ANS: D The fact that the HCO - level has increased enough to compensate for the increased pCO level 32 indicates that this is not an acute condition because the kidneys can take several days to adjust. The other choices would present with a lower HCO3- level. The values indicate respiratory acidosis, and one of the potential causes is chronic obstructive pulmonary disease. Potential causes for respiratory alkalosis are pulmonary embolism, acute myocardial infarction, and acute heart failure.

Which procedures provide information about the patient's ventilation status? (Select all that apply.) a. Lung biopsy b. Exercise testing c. Pulse oximetry d. Capnography e. Arterial blood gas analysis

ANS: D, E Measurement of the patient's carbon dioxide (CO2) level provides information about the patient's ventilation status. Both capnography and arterial blood gas analysis provide information about the patient's CO2 level. Pulse oximetry provides information about the patient's oxygenation status, not ventilation status. Exercise testing provides information about the patient' s oxygenation status to help differentiate cardiac and pulmonary disease. A lung biopsy provides information about the patient's lung tissue.

How does the patient history assist the nurse in developing the management plan? (Select all that apply.) a. Provides direction for the rest of the assessment b. Exposes key clinical manifestations. c. Aids in developing the plan of care d. The degree of the patient's distress determines the extent of the interview. e. Determines length of stay in the hospital setting.

Answer: A, B, C, D Rationale: The initial presentation of the patient determines the rapidity and direction of the interview. For a patient in acute distress, the history should be curtailed to just a few questions about the patient's chief complaint and precipitating events.

Which conditions will commonly reveal breath sounds with inspiration greater than expiration on assessment? (Select all that apply.) a. Normal lung. b. Bronchiectasis. c. Emphysema. d. Acute bronchitis. e. Diffuse pulmonary fibrosis.

Answer: A, B, D Rationale: The normal lung, bronchiectasis, and acute bronchitis will commonly present with an inspiration greater than expiration ratio. Acute bronchitis can also have inspiration that equals expiration ratio as also seen with emphysema, diffuse pulmonary fibrosis, and consolidating pneumonia. Noting that many conditions present with the same findings affirms the need for further assessment and evaluation.

Deviation of the trachea occurs in which conditions? (Select all that apply.) a. Pneumothorax. b. Pulmonary fibrosis. c. Chronic obstructive pulmonary disease. d. Emphysema e. Pleural effusion

Answer: A, B, E Rationale: Assessment of tracheal position assists in the diagnosis of pneumothorax, unilateral pneumonia, pulmonary fibrosis, and pleural effusion.

A patient just involved in a motor vehicle accident has sustained blunt chest trauma as part of his injuries. The nurse notes absent breath sounds on the left side. A left-sided pneumothorax is suspected and is further validated when assessment of the trachea reveals what finding? a. A shift to the right. b. A shift to the left. c. No deviation d. Subcutaneous emphysema.

Answer: a. A shift to the right. Rationale: With a pneumothorax, the trachea shifts to the opposite side of the problem; with atelectasis, the trachea shifts to the same side as the problem. Subcutaneous emphysema is more commonly related to a pneumomediastinum and is not specifically related to the trachea but to air trapped in the mediastinum and general neck area.

The nurse performs inspection of the oral cavity as part of a focused pulmonary assessment to check for evidence of what condition? a. Hypoxia b. Dyspnea c. Dehydration d. Malnutrition

Answer: a. Hypoxia Rationale: Severe hypoxia will be manifested by central cyanosis, which is evident in the oral and circumoral areas. Although dehydration and nutritional status can both be partially assessed by oral cavity inspection, this information is not as vital as determining hypoxia. Dyspnea means difficulty breathing.

The nurse is performing a pulmonary assessment on a patient with a pleural effusion. Which finding is unexpected? a. Increased diaphragmatic excursion. b. Decreased tactile fremitus. c. Dull percussion tones. d. Pleural friction rub.

Answer: a. Increased diaphragmatic excursion. Rationale: Assessment findings associated with pleural effusion include dullness on percussion, decreased tactile fremitus, pleural friction rub, and decreased diaphragmatic excursion. Increased diaphragmatic excursion is not associated with acute bronchitis.

When assessing a patient, the use of observation is referred to as what technique? a. Inspection b. Palpation c. Percussion d. Auscultation

Answer: a. Inspection Rationale: Inspection is the process of looking intently at the patient. Palpation is the process of touching the patient to judge the size, shape, texture, and temperature of the body surface or underlying structures. Percussion is the process of creating sound waves on the surface of the body to determine abnormal density of any underlying areas. Auscultation is the process of concentrated listening with a stethoscope to determine characteristics of body functions.

In what condition are bronchophony, egophony, and whispering pectoriloquy increased? a. Pneumonia with consolidation b. Pneumothorax c. Asthma d. Bronchiectasis

Answer: a. Pneumonia with consolidation Rationale: Voice sounds are increased in pneumonia with consolidation because there is increased vibration through material. Bronchophony and whispering pectoriloquy are heard as clear transmission of sounds on auscultation; egophony is heard as an "a" sound when the patient is saying "e."

A patient is admitted with diminished to absent breath sounds on the right side, tracheal deviation to the left side, and asymmetric chest movement. These findings are indicative of which disorder? a. Tension pneumothorax b. Pneumonia c. Pulmonary fibrosis d. Atelectasis

Answer: a. Tension pneumothorax Rationale: Diminished to absent breath sounds on the right side, tracheal deviation to the left side, and asymmetric chest movement are indicative of tension pneumothorax.

The nurse is performing a pulmonary assessment on a patient with acute bronchitis. Which finding is unexpected? a. Rasping productive cough. b. Decreased tactile fremitus. c. Resonant percussion tones. d. Crackles and wheezes.

Answer: b. Decreased tactile fremitus. Rationale: Assessment findings associated with acute bronchitis include rasping productive cough, resonance on percussion, crackles and wheezes, and normal to increased tactile fremitus. Decreased tactile fremitus is not associated with acute bronchitis.

A patient is admitted with acute lung failure secondary to emphysema. Percussion of the lung fields will predictably exhibit which tone? a. Resonance b. Hyperresonance c. Tympany d. Dullness

Answer: b. Hyperresonance Rationale: The percussion tone of hyperresonance is heard with emphysema related to overinflation of the lung. Resonance can be found in normal lungs or with the diagnosis of bronchitis. Tympany occurs with the diagnosis of large pneumothorax and emphysematous blebs. Dullness occurs with the diagnosis of atelectasis, pleural effusion, pulmonary edema, pneumonia, and a lung mass.

When assessing a patient, the use of touch to judge the character of the body surface and underlying organs is known as what technique? a. Inspection b. Palpation c. Percussion d. Auscultation

Answer: b. Palpation Rationale: Palpation is the process of touching the patient to judge the size, shape, texture, and temperature of the body surface or underlying structures. Inspection is the process of looking intently at the patient. Percussion is the process of creating sound waves on the surface of the body to determine abnormal density of any underlying areas. Auscultation is the process of concentrated listening with a stethoscope to determine characteristics of body functions.

While conducting a physical assessment on a patient with chronic obstructive pulmonary disease (COPD), the nurse notes that the patient's breathing is rapid and shallow. What is this type of breathing pattern called? a. Hyperventilation. b. Tachypnea. c. Obstructive breathing. d. Bradypnea.

Answer: b. Tachypnea. Rationale: Tachypnea is manifested by an increase in the rate and decrease in the depth of ventilation. Hyperventilation is manifested by an increase in both the rate and depth of ventilation. Obstructive breathing is characterized by progressively shallower breathing until the patient actively and forcefully exhales. Bradypnea is a slow respiratory rate characterized as less than 12 breaths/min in an adult.

While palpating a patient's lungs the nurse notes fremitus over the patient's trachea but not the lung periphery. What do these findings indicate? a. Bilateral pleural effusion. b. Bronchial obstruction. c. A normal finding. d. Apical pneumothorax.

Answer: c. A normal finding. Rationale: Fremitus is described as normal, decreased, or increased. With normal fremitus, vibrations can be felt over the trachea but are barely palpable over the periphery. With decreased fremitus, there is interference with the transmission of vibrations. Examples of disorders that decrease fremitus include pleural effusion, pneumothorax, bronchial obstruction, pleural thickening, and emphysema.

A patient presents with chest trauma from a motor vehicle accident. Upon assessment, the nurse documents that the patient is complaining of dyspnea, shortness of breath, tachypnea, and tracheal deviation to the right. In addition, the patient's tongue is blue-gray. Based on this assessment data, what additional assessment findings would the nurse expect to find? a. Kussmaul breathing pattern. b. Absent breath sounds in the right lower lung fields. c. Absent breath sounds in the left lung fields. d. Diminished breath sounds in the right upper lung fields.

Answer: c. Absent breath sounds in the left lung fields. Rationale: The clinical picture described is most consistent with left pneumothorax. This would cause the trachea to deviate to the right, away from the increasing pressure of the left. A pneumothorax this severe would completely collapse the left lung, thus causing absent breath sounds in that lung. The right lung fields would not be affected. Kussmaul breathing pattern is rapid, deep and labored.

A patient is admitted in respiratory distress secondary to pneumonia. The nurse knows that obtaining a history is very important. What is the appropriate intervention at this time for obtaining this data? a. Collect an overview of past medical history, present history, and current health status. b. Do not obtain any history at this time. c. Curtail the history to just a few questions about the patient's chief complaint and precipitating events. d. Complete the history and then provide measures to assist the patient to breathe easier.

Answer: c. Curtail the history to just a few questions about the patient's chief complaint and precipitating events. Rationale: The initial presentation of the patient determines the rapidity and direction for the interview. For a patient in acute distress, the history should be curtailed to just a few questions about the patient's chief complaint and the precipitating events.

The nurse is performing a pulmonary assessment on a patient with pulmonary fibrosis. Which finding is unexpected? a. Diminished thoracic expansion. b. Tracheal deviation to the most affected side. c. Hyperresonant percussion tones. d. Decreased breath sounds.

Answer: c. Hyperresonant percussion tones. Rationale: Assessment findings associated with pulmonary fibrosis include diminished thoracic expansion, tracheal deviation to the most affected side, decreased or absent breath sounds, and resonance or dullness on percussion. Hyperresonance is not an expected finding in pulmonary fibrosis.

A patient is admitted with an exacerbation of chronic obstructive pulmonary disease (COPD). The nurses notes that the patient has difficulty getting breath out. Which phrase best describes the patient's breathing pattern? a. Deep sighing breaths without pauses. b. Rapid, shallow breaths. c. Normal breathing pattern interspersed with forced expirations. d. Irregular breathing pattern with both deep and shallow breaths.

Answer: c. Normal breathing pattern interspersed with forced expirations. Rationale: Difficulty getting breath out is indicative of air trapping. Air trapping is described as a normal breathing pattern interspersed with forced expirations. As the patient breathes, air becomes trapped in the lungs, and ventilations become progressively shallower until the patient actively and forcefully exhales.

What assessment technique uses the creation of sound waves across the body surface to determine abnormal densities? a. Inspection b. Palpation c. Percussion d. Auscultation

Answer: c. Percussion Rationale: Percussion is the process of creating sound waves on the surface of the body to determine abnormal density of any underlying areas. Palpation is the process of touching the patient to judge the size, shape, texture, and temperature of the body surface or underlying structures. Inspection is the process of looking intently at the patient. Auscultation is the process of concentrated listening with a stethoscope to determine characteristics of body functions.

A patient is admitted with acute lung failure secondary to chronic obstructive pulmonary disease (COPD). Upon inspection of the patient, the nurse observes that the patient's fingers appear discolored. What does this finding indicate the presence of? a. Clubbing. b. Central cyanosis. c. Peripheral cyanosis d. Chronic tuberculosis.

Answer: c. Peripheral cyanosis Rationale: Discoloration of the fingers is an indication of peripheral cyanosis. Central cyanosis occurs when the unsaturated hemoglobin of arterial blood exceeds 5 g/dL and is considered a life-threatening situation. Clubbing refers to an abnormality of the fingers caused by chronically low blood levels of oxygen often related to a heart or lung disease.

The nurse is observing a new graduate listen to a patient's lungs. Which action by the new graduate indicates a need to review auscultation skills? a. The nurse starts at the apices and moves to the bases. b. The nurse compares breath sounds from side to side. c. The nurse listens during inspiration. d. The nurse listens posteriorly, laterally, and anteriorly.

Answer: c. The nurse listens during inspiration. Rationale: Breath sounds are assessed during both inspiration and expiration. Auscultation is done in a systematic sequence: side-to-side, top-to-bottom, posteriorly, laterally, and anteriorly.

What assessment technique involves having the patient breathe in and out slowly with an open mouth? a. Inspection b. Palpation c. Percussion d. Auscultation

Answer: d. Auscultation Rationale: Percussion is the process of creating sound waves on the surface of the body to determine abnormal density of any underlying areas. Palpation is the process of touching the patient to judge the size, shape, texture, and temperature of the body surface or underlying structures. Inspection is the process of looking intently at the patient. Auscultation is the process of concentrated listening with a stethoscope to determine characteristics of body functions.

Which lung sounds would be most likely heard in a patient experiencing an asthma attack? a. Coarse rales. b. Pleural friction rub. c. Fine crackles. d. Expiratory wheezes.

Answer: d. Expiratory wheezes. Rationale: Wheezes are high-pitched, squeaking, whistling sounds produced by airflow through narrowed small airways. They are heard mainly on expiration but may also be heard throughout the ventilatory cycle. Depending on their severity, wheezes can be further classified as mild, moderate, or severe. Rales are crackling sounds produced by fluid in the small airways or alveoli or by the snapping open of collapsed airways during inspiration. A pleural friction rub is a dry, coarse sound produced by irritated pleural surfaces rubbing together and is caused by inflammation of the pleura.

A patient is admitted with acute respiratory failure secondary to pneumonia. Upon auscultation, the nurse hears creaking, leathery, coarse breath sounds in the lower anterolateral chest area during inspiration and expiration. This finding is indicative of what condition? a. Emphysema. b. Atelectasis. c. Pulmonary fibrosis. d. Pleural effusion.

Answer: d. Pleural effusion. Rationale: A pleural friction rub is the result of irritated pleural surfaces rubbing together and is characterized by a leathery, dry, loud, coarse sound. A pleural friction rub is seen with pleural effusions or pleurisy and is not indicative of emphysema, atelectasis, or pulmonary fibrosis.

Which condition is an example of a disorder with increased tactile fremitus? a. Emphysema b. Pleural effusion c. Pneumothorax d. Pneumonia

Answer: d. Pneumonia Rationale: Examples of disorders that increase tactile fremitus include pneumonia, lung cancer, and pulmonary fibrosis. Emphysema, pleural effusion, and pneumothorax are disorders that decrease fremitus.

What is the sequence for auscultation of the anterior chest? a. Right side, top to bottom, then left side, top to bottom. b. Left side, top to bottom, then right side, top to bottom. c. Side to side, bottom to top. d. Side to side, top to bottom.

Answer: d. Side to side, top to bottom. Rationale: Auscultation should be done in a systematic sequence: side to side, top to bottom, posteriorly, laterally, and anteriorly.

Which of the following conditions is associated between kidney failure and respiratory failure? (Select all that apply.) a. ARDS b. Lower GFR c. Increased urine output d. Decreased urine output e. Decreased blood flow to the kidneys

a. ARDS b. Lower GFR d. Decreased urine output e. Decreased blood flow to the kidneys

The nurse is caring for a severely head injured comatose patient who is dying. The practitioner asks to be notified when the patient starts to exhibit signs of Cushing reflex. The nurse would call the practitioner when the patient starts to show what signs? a. Bradycardia, systolic hypertension, and widening pulse pressure b. Tachycardia, systolic hypotension, and tachypnea c. Headache, nuchal rigidity, and hyperthermia d. Bradycardia, aphasia, and visual field disturbances

a. Bradycardia, systolic hypertension, and widening pulse pressure The Cushing reflex is a set of three clinical manifestations (bradycardia, systolic hypertension, and widening pulse pressure) related to pressure on the medullary area of the brainstem.

Which patient may need sedation before having a magnetic resonance imaging (MRI) scan? a. Claustrophobic patient b. Comatose patient c. Elderly patient d. Patient with a spinal cord injury

a. Claustrophobic patient The magnetic resonance imaging procedure is lengthy and requires the patient to lie motionless in a tight, enclosed space. Mild sedation, a blindfold, or both may be necessary for claustrophobic patients.

What is a continuous venovenous hemodialysis filter permeable to? a. Electrolytes b. Red blood cells c. Protein d. Lipids

a. Electrolytes

A patient is admitted to the critical care unit with a subdural hematoma. The nurse is assessing the patient's Glasgow Coma Scale (GCS) score. Which statement is true concerning the GCS? a. It provides data about level of consciousness only. b. It is considered equivalent to a complete neurologic examination. c. It is a sensitive tool for evaluation of an altered sensorium. d. It is the most critical assessment parameter to account for possible aphasia.

a. It provides data about level of consciousness only. Several points should be kept in mind when the Glasgow Coma Scale is used for serial assessment. It provides data about level of consciousness only, and it should never be considered a complete neurologic examination. Additionally, it is not a sensitive tool for evaluation of an altered sensorium, and it does not account for possible aphasia or mechanical intubation. It is also a poor indicator of lateralization of neurologic deterioration.

Which of the following diuretics maybe combined to work on different parts of the nephron? a. Loop and thiazide diuretics b. Loop and osmotic diuretics c. Osmotic and carbonic anhydrase inhibitor diuretics d. Thiazide and osmotic diuretics

a. Loop and thiazide diuretics

A patient is admitted with acute kidney injury (AKI). Which event from the patient's history was the most probable cause of the patient's AKI? a. Recent computed tomography of the brain with and without contrast b. A recent bout of acute heart failure after an acute myocardial infarction c. Twice-daily prescription of Lasix 40 mg by mouth d. A recent bout of benign prostatic hypertrophy and transurethral resection of the prostate

a. Recent computed tomography of the brain with and without contrast Intravenous contrast media can be nephrotoxic, especially with the patient's preexisting cardiac disease. The other choices, although possible causes, are less likely than the intravenous contrast media

To remove fluid during hemodialysis, a positive hydrostatic pressure is applied to the blood and a negative hydrostatic pressure is applied to the dialysate bath. What is this process called? a. Ultrafiltration b. Hemodialysis c. Reverse osmosis d. Colloid extraction

a. Ultrafiltration To remove fluid, a positive hydrostatic pressure is applied to the blood, and a negative hydrostatic pressure is applied to the dialysate bath. The two forces together, called transmembrane pressure, pull and squeeze the excess fluid from the blood. The difference between the two values (expressed in millimeters of mercury [mm Hg]) represents the transmembrane pressure and results in fluid extraction, known as ultrafiltration, from the vascular space.

A critical care patient is diagnosed with massive head trauma. The patient is receiving brain tissue oxygen pressure (PbtO2) monitoring. The nurse recognized that the goal of this treatment is to maintain PbtO2: a. greater than 20 mm Hg. b. less than 15 mm Hg. c. between 15 and 20 mm Hg. d. between 10 and 20 mm Hg.

a. greater than 20 mm Hg. In a patient with head injury, the goal of treatment is to maintain the PbtO2 greater than 20 mm Hg. Factors that decrease PbtO2 include tissue hypoxia, hypocapnia, hypovolemia, decreased blood pressure, low hemoglobin levels, intracranial hypertension, and hyperthermia. Treatment is directed at the underlying cause.

A nurse is teaching a nursing student about the modes of volume ventilation. Which statement regarding the assist-control (AC) mode indicates the student understood the information? a."It delivers gas at preset volume, at a set rate, and in response to the patient's inspiratory efforts." b."It delivers gas at a preset volume, allowing the patient to breathe spontaneously at his or her own volume." c."It applies positive pressure during both ventilator breaths and spontaneous breaths." d."It delivers gas at preset rate and tidal volume regardless of the patient's inspiratory efforts."

a."It delivers gas at preset volume, at a set rate, and in response to the patient's inspiratory efforts." AC ventilation delivers gas at preset tidal volume in response to patient's inspiratory efforts and initiates breath if patient fails to do so within preset time. The other statements describe other modes of mechanical ventilation.

Which patient has the best prognosis based on the cause of coma? a.A 36-year-old man with closed head injury b.A 50-year-old woman with hepatic encephalopathy c.A 46-year-old woman with subarachnoid hemorrhage d.A 72-year-old man with hypertensive intracerebral hemorrhage

a.A 36-year-old man with closed head injury Prognosis depends on the cause of coma and the length of time unconsciousness persists. Only 15% of patients in nontraumatic coma make a satisfactory recovery. Metabolic coma usually has a better prognosis compared with coma caused by a structural lesion, and traumatic coma usually has a better outcome compared with nontraumatic coma.

A patient has been admitted with an ischemic stroke. The patient received recombinant tissue plasminogen activator (rtPA) in the emergency department. The nurse reviews the medication administration record to make sure the patient does not have which medications for the next 24 hours? (Select all that apply.) a.Aspirin b.Sodium nitroprusside c.Warfarin d.Labetalol e.Any antiplatelet drugs

a.Aspirin c.Warfarin e.Any antiplatelet drugs The major risk and complication of rtPA therapy is bleeding, especially intracranial hemorrhage. Unlike fibrinolytic protocols for acute myocardial infarction, subsequent therapy with anticoagulant or antiplatelet agents is not recommended after rtPA administration in ischemic stroke. Patients receiving fibrinolytic therapy for stroke should not receive aspirin, heparin, warfarin, ticlopidine, or any other antithrombotic or antiplatelet drugs for at least 24 hours after treatment. Sodium nitroprusside and labetalol are used to manage blood pressure after a stroke.

A patient is admitted with acute kidney injury. The nurse would expect to see elevated values in which laboratory results? (Select all that apply.) a.Blood urea nitrogen (BUN) b.Creatinine c.Glucose d.Hemoglobin and hematocrit e.Protein

a.Blood urea nitrogen (BUN) b.Creatinine d. Hgb & Hct With kidney dysfunction, the blood urea nitrogen (BUN) is elevated because of a decrease in the glomerular filtration rate and resulting decrease in urea excretion. Elevations in the BUN can be correlated with the clinical manifestations of uremia; as the BUN rises, symptoms of uremia become more pronounced. Creatinine levels are fairly constant and are affected by fewer factors than BUN. As a result, the serum creatinine level is a more sensitive and specific indicator of kidney function than BUN. Creatinine excess occurs most often in persons with acute kidney injury resulting from impaired excretion. Decreased hematocrit value can indicate fluid volume excess because of the dilutional effect of the extra fluid load. Decreases also can result from anemias, blood loss, liver damage, or hemolytic reactions. In individuals with acute kidney injury, anemia may occur early in the disease.

A patient has just been admitted with head trauma. While awaiting the results of the CT scan, the patient becomes comatose, develops fixed and dilated pupils, and flaccid to noxious stimuli. The nurse knows that these signs are indicative of which type of herniation? a.Central b.Uncal c.Cingulate d.Infratentorial

a.Central Clinical manifestations of central herniation include loss of consciousness; small, reactive pupils progressing to fixed, dilated pupils; respiratory changes leading to respiratory arrest; and abnormal flexion (decorticate) posturing progressing to flaccidity. Clinical manifestations of uncal herniation include ipsilateral pupil dilation, decreased LOC, respiratory pattern changes leading to respiratory arrest, and contralateral hemiplegia leading to abnormal flexion (decorticate) or abnormal extension (decerebrate) posturing

A patient has been admitted with acute kidney injury. The nurse knows the most important consideration for evaluating the patient's fluid status is what parameter? select two a.Daily weights b.Urine and serum osmolality c.Intake and output d.Hemoglobin and hematocrit levels

a.Daily weights One of the most important assessments of kidney and fluid status is the patient's weight. In the critical care unit, weight is monitored for each patient every day and is an important vital signs measurement.

The nurse is caring for a patient who is ventilator-dependent. The patient's plan of care should include interventions to decrease which psychological factors that may be contributing to the patient's condition? (Select all that apply.) a.Fear b.Sensory overload c.Depersonalization d.Depression e.Trust in the staff

a.Fear b.Sensory overload c.Depersonalization d.Depression Psychological factors contributing to long-term mechanical ventilation dependence include a loss of breathing pattern control (anxiety, fear, dyspnea, pain, ventilator asynchrony, lack of confidence in ability to breathe), lack of motivation and confidence (inadequate trust in staff, depersonalization, hopelessness, powerlessness, depression, inadequate communication), and delirium (sensory overload, sensory deprivation, sleep deprivation, pain medications). The plan of care should include interventions to increase the trust in the staff.

A patient with a ruptured cerebral aneurysm has been admitted for monitoring. The nurse knows that incidence of rebleeding is highest during which time periods? a.First 24 hours b.4 to 12 days c.3 to 4 weeks d.3 to 6 months

a.First 24 hours Rebleeding is the occurrence of a second subarachnoid hemorrhage in an unsecured aneurysm or, less commonly, an arteriovenous malformation. The incidence of rebleeding during the first 24 hours after the first bleed is 4%, with a 1% to 2% chance per day for the following month. Mortality with aneurysmal rebleeding is approximately 70%.

A patient was admitted following an aspiration event on the medical-surgical floor. The patient is receiving 40% oxygen via a simple face mask. The patient has become increasingly agitated and confused. The patient's oxygen saturation has dropped from 92% to 84%. The nurse notifies the practitioner about the change in the patient's condition. What interventions should the nurse anticipate? a.Intubation and mechanical ventilation b.Change in antibiotics orders c.Suction and reposition the patient d.Orders for a sedative

a.Intubation and mechanical ventilation Given the significant drop in oxygen saturation, increasing agitation and confusion, the nurse should anticipate the patient will need to be intubated and mechanically ventilated. Administrating antibiotics, suctioning and repositioning, and administering a sedative would not address the development of severe hypoxemia.

The nurse is caring for a patient who has had a head injury and is now having seizures. Which medication should the nurse anticipate being ordered for this patient? a.Lorazepam b.Phenytoin c.Phenobarbital d.Midazolam

a.Lorazepam Lorazepam is a fast-acting, short-duration agent that may be indicated for breakthrough seizures until therapeutic drug levels can be reached. Phenytoin is the recommended medication for seizure prophylaxis. Phenobarbital is a barbiturate whose action produces central nervous system depression and reduces the spread of an epileptic focus.

The nurse is caring for a patient head trauma with increased intracranial pressure who is being mechanically ventilated. The patient management plan should include which intervention? a.Maintain the PaCO2 between 33 and 37 mm Hg. b.Maintain the PaCO2 between 25 and 35 mm Hg. c.Maintain the FiO2 at 80%. d.Maintain the respiratory rate at 20 breaths/min.

a.Maintain the PaCO2 between 33 and 37 mm Hg. The current trend is to maintain PaCO2 levels on the lower side of normal (35 ± 2 mm Hg) by carefully monitoring arterial blood gas measurements and by adjusting ventilator settings. Although hypoxemia must be avoided, excessively high levels of oxygen offer no benefits, and increasing inspired oxygen concentrations to greater than 60% may lead to toxic changes in lung tissue. The patient's respiratory rate should not be preset at a certain level but should be titrated to maintain the PaCO2 between 33 and 37 mm Hg.

A patient with a history of chronic obstructive pulmonary disease (COPD) requires oxygen therapy. The nurse knows that the practitioner will probably start with a low-flow system and evaluate the patient once the therapy is started. Which device should the nurse anticipate an order for? a.Nasal cannula b.Simple face mask c.Reservoir cannula d.Air-entrainment nebulizer

a.Nasal cannula A low-flow oxygen delivery system provides supplemental oxygen directly into the patient's airway at a flow of 8 L/min or less. Because this flow is insufficient to meet the patient's inspiratory volume requirements, it results in a variable FiO2 as the supplemental oxygen is mixed with room air. A nasal cannula is a low-flow oxygen delivery system.

A patient with pneumonia is on 50% oxygen via a simple mask. The practitioner orders the patient's oxygen to be increased to 70%. Which oxygen administration device should the patient be placed on to accomplish this? a.Nonrebreathing mask b.Nasal cannula c.Partial rebreathing mask d.Simple mask

a.Nonrebreathing mask The patient needs to be placed on a nonrebreathing mask as this is the only device that can provide 70% oxygen. The other devices listed are not able to provide the oxygen therapy at this level.

An exhausted patient has been admitted with status asthmaticus. The nurse anticipates the medical management plan to include which treatments? (Select all that apply.) a.Oxygen therapy b.Bronchodilators c.Corticosteroids d.Antibiotics e.Intubation and mechanical ventilation

a.Oxygen therapy b.Bronchodilators c.Corticosteroids e.Intubation and mechanical ventilation Medical management of a patient with status asthmaticus is directed toward supporting oxygenation and ventilation. Bronchodilators, corticosteroids, oxygen therapy, and intubation and mechanical ventilation are the mainstays of therapy. Indications for mechanical ventilation include cardiac or respiratory arrest, disorientation, failure to respond to bronchodilator therapy, and exhaustion. Antibiotics are not part of the plan unless the patient develops an infection.

A patient is receiving mechanical ventilation via an endotracheal tube. The nurse knows that the patient becomes hypoxemic when suctioned. Which interventions should be included in the patient's plan of care to minimize this complication? (Select all that apply.) a.Oxygenate the patient with 100% oxygen prior to the start of the procedure. b.Oxygenate the patient with 100% after each pass of the suction catheter. c.Limit the duration of each suction pass to 20 seconds. d.Instill 5 to 10 mL of normal saline to facilitate secretion removal. e.Use intermittent suction to avoid damaging tracheal tissue.

a.Oxygenate the patient with 100% oxygen prior to the start of the procedure. b. Oxygenate the patient with 100% after each pass of the suction catheter. To minimize suction-induced hypoxemia, the patient should be oxygenated with 100% oxygen prior to the start of the procedure and after each pass of the suction catheter. The suction pass should be limited to 10 to 15 seconds. There is no evidence to suggest that intermittent suction reduces damage and saline instillation can actually increase the risk for infection.

Patient has been admitted who is severely malnourished. The patient's serum albumin is very low. Which finding would the nurse expect to see in this patient? a.Peripheral edema b.Extra heart sounds c.Hypertension d.Hyponatremia

a.Peripheral edema Decreased albumin levels in the vascular space result in a plasma-to-interstitium fluid shift, creating peripheral edema. A decreased albumin level can occur as a result of protein-calorie malnutrition, which occurs in many critically ill patients in whom available stores of albumin are depleted. A decrease in the plasma oncotic pressure results, and fluid shifts from the vascular space to the interstitial space.

Which nursing intervention should be used to optimize oxygenation and ventilation in the patient with acute lung failure? a.Provide adequate rest time between procedures. b.Position the patient with the good lung up. c.Suction the patient every hour. d.Avoid preoxygenating the patient before suctioning.

a.Provide adequate rest time between procedures. Providing adequate rest and recovery time between various procedures prevents desaturation and optimizes oxygenation. In acute lung failure, the goal of positioning is to place the least affected area of the patient's lung in the most dependent position. Patients with unilateral lung disease should be positioned with the healthy lung in a dependent position. Preoxygenate the patient before suctioning and suction the patient only as needed.

When assessing an intubated patient, the nurse observes normal breath sounds on the right side of the chest and absent breath sounds on the left side of the chest. Which problem should the nurse suspect? a.Right mainstem intubation b.Left pneumothorax c.Right hemothorax d.Gastric intubation

a.Right mainstem intubation The finding of normal breath sounds on the right side of the chest and absent breath sounds on the left side of the chest in a newly intubated patient is probably caused by a right mainstem intubation.

A right-handed patient has been admitted with an intracerebral hemorrhage. A CT of the patient's head reveals a large left parietal area bleed. Based on the type of stroke, which signs and signs might the patient exhibit? a.Right-sided hemiplegia and receptive aphasia b.Left-sided hemiplegia and tactile agnosia c.Decorticate posturing and unequal pupils d.Unilateral neglect and dressing apraxia

a.Right-sided hemiplegia and receptive aphasia Damage to the dominant hemisphere produces problems with speech and language and abstract and analytical skills.

Which weaning methods are used in combination with each other? (Select all that apply.) a.SIMV with CPAP b.SIMV with PSV c.CPAP with PSV d.T-piece and PSV e.PEEP with CPAP

a.SIMV with CPAP b.SIMV with PSV c.CPAP with PSV d.T-piece and PSV A variety of weaning methods are available, but no one method has consistently proven to be superior to the others. These methods include T-tube (T-piece), continuous positive airway pressure (CPAP), pressure support ventilation (PSV), and synchronized intermittent mandatory ventilation (SIMV). One recent multicenter study lends evidence to support the use of PSV for weaning over T-tube or SIMV weaning. Often these weaning methods are used in combination with each other, such as SIMV with PSV, CPAP with PSV, or SIMV with CPAP.

A patient has developed ventilator-associated pneumonia (VAP). The nurse knows that the two pathogens most frequently associated with this condition are which? a.Staphylococcus aureus and Pseudomonas aeruginosa b.Escherichia coli and Haemophilus influenzae c.Acinetobacter baumannii and Haemophilus influenzae d.Klebsiella spp. and Enterobacter spp.

a.Staphylococcus aureus and Pseudomonas aeruginosa Two of the pathogens most frequently associated with VAP are S. aureus and P. aeruginosa.

A patient has been on 100% oxygen for 36 hours. The nurse is aware that the patient is at risk for oxygen toxicity and should be evaluating the patient for which signs and symptoms? (Select all that apply.) a.Substernal chest pain that increases with deep breathing b.Moist cough and tracheal irritation c.Pleuritic pain occurring on inhalation, followed by dyspnea d.Increasing PaCO2 e.Sore throat and eye and ear discomfort

a.Substernal chest pain that increases with deep breathing c.Pleuritic pain occurring on inhalation, followed by dyspnea e.Sore throat and eye and ear discomfort A number of clinical manifestations are associated with oxygen toxicity. The first symptom is substernal chest pain that is exacerbated by deep breathing. A dry cough and tracheal irritation follow. Eventually, definite pleuritic pain occurs on inhalation followed by dyspnea. Upper airway changes may include a sensation of nasal stuffiness, sore throat, and eye and ear discomforts.

A patient who is 2 days postoperative from a hip replacement suddenly develops hypoxemia. The nurse suspects that the patient has developed a pulmonary embolism (PE) when the patient exhibits which signs and symptoms? a.Tachycardia and tachypnea b.Hemoptysis and evidence of deep vein thromboses c.Apprehension and dyspnea d.Right ventricular failure and fever

a.Tachycardia and tachypnea The patient with a pulmonary embolism may have any number of presenting signs and symptoms, with the most common being tachycardia and tachypnea. Additional signs and symptoms that may be present include dyspnea, apprehension, increased pulmonic component of the second heart sound (P1), fever, crackles, pleuritic chest pain, cough, evidence of deep vein thrombosis, and hemoptysis. Syncope and hemodynamic instability can occur as a result of right ventricular failure.

A patient with acute respiratory distress syndrome (ARDS) has continued to deteriorate. The interprofessional team is discussing the initiation of rotation therapy. Which statements made during the discussion are accurate? (Select all that apply.) a.The patient must be turned at least 40 degrees per side, with a total arc of at least 80 degrees, for at least 18 hours a day for the therapy to be effective. b.Kinetic therapy can decrease the incidence of ventilator-acquired pneumonia in patients with neurologic problems and postoperative patients. c.Use of rotational therapy eliminates the need for other pressure ulcer prevention strategies as the rotation takes the place of turning the patient. d.Continuous lateral rotation therapy helps avoid hemodynamic instability secondary to the continuous, gentle turning of the patient. e.Continuous lateral rotation therapy, with a rotation of less than 40 degrees, has been foun

a.The patient must be turned at least 40 degrees per side, with a total arc of at least 80 degrees, for at least 18 hours a day for the therapy to be effective. b.Kinetic therapy can decrease the incidence of ventilator-acquired pneumonia in patients with neurologic problems and postoperative patients. e.Continuous lateral rotation therapy, with a rotation of less than 40 degrees, has been found to be of minimal benefits for critically ill patients. Studies have found that to achieve benefits with rotation therapy, rotation must be aggressive, and the patient must be at least 40 degrees per side, with a total arc of at least 80 degrees for at least 18 hours a day. Kinetic therapy has been shown to decrease the incidence of ventilator-acquired pneumonia, particularly in neurologic and postoperative patients. Complications of the procedure include dislodgment or obstruction of tubes, drains, and lines; hemodynamic instability; and pressure ulcers. Lateral rotation does not replace manual repositioning to prevent pressure ulcers. CLRT has been shown to be of minimal pulmonary benefit for the critically ill patients.

A patient is receiving mechanical ventilation via an endotracheal tube. The plan of care should include monitoring the patient for which complications? (Select all that apply.) a.Tracheoesophageal fistula b.Cricoid abscess c.Tracheal stenosis d.Tube obstruction e.Hemorrhage

a.Tracheoesophageal fistula b.Cricoid abscess c.Tracheal stenosis d.Tube obstruction Complications of endotracheal tubes include tube obstruction, tube displacement, sinusitis and nasal injury, tracheoesophageal fistula, mucosal lesions, laryngeal or tracheal stenosis, and cricoid abscess. Hemorrhage is a complication of tracheostomy tubes.

An alert and oriented patient presents with a pulmonary artery wedge pressure of 4 mm Hg and a cardiac index of 0.8. The BUN is 44 mg/dL, creatinine is 3.2 mg/dL, and BP is 88/36 mm Hg. Urine output is 15 mL/hr. Lungs are clear to auscultation with no peripheral edema noted. Which of the following treatments would the physician most likely order? a. Lasix 40 mg intravenous push b. 0.9% normal saline at 125 mL/hr c. Dopamine 15 μg/kg/min d. Transfuse 1 U of packed red blood cells

b. 0.9% normal saline at 125 mL/hr

What is the recommended nutritional intake of protein to control azotemia in the patient with acute kidney injury? a. 0.5 to 1.0 g/kg/day b. 1.2 to 1.5 g/kg/day c. 1.7 to 2.5 g/kg/day d. 2.5 to 3.5 g/kg/day

b. 1.2 to 1.5 g/kg/day The recommended energy intake is between 20 and 30 kcal/kg/day, with 1.2 to 1.5 g/kg of protein per day to control azotemia (increased blood urea nitrogen level)

A patient has acute kidney injury (previously known as acute tubular necrosis). The following blood work was noted: complete blood count shows a white blood cell count of 11,000 mm3, a hemoglobin of 8 g/dL, and a hematocrit of 30%. His chemistry panel shows serum potassium, 4.5 mg/dL; serum sodium, 135 mg/dL; serum calcium, 8.5 mg/dL; BUN, 20 mg/dL; and creatinine, 1.5 mg/dL. What laboratory value(s) need(s) to be treated most immediately and why? a. Administration of 5% dextrose in water and insulin because the patient is hyperkalemic and needs this level reduced b. Administration of Epogen to treat anemia c. Administration of a broad-spectrum antibiotic to treat the elevated blood cell count d. Administration of a calcium supplement for low calcium

b. Administration of Epogen to treat anemia

The patient is a gravida 6, para 1. She is admitted after a cesarean section after an amniotic embolus. Her heart rate (HR) is more than 150 beats/min with a systolic BP less than 80 mm Hg. Her temperature is 38°C, and her condition has caused her to develop prerenal azotemia. The patient was fluid resuscitated through a double-lumen catheter, which was placed into her right femoral access, and started on vasopressors with a fair response (BP, 80/50 mm Hg; HR, 122 beats/min). Because of her diagnosis and a concern regarding fulminating sepsis, the patient was begun on CVVH. Which of the statements best describes CVVH? a. Complete renal replacement therapy requiring large volumes of ultrafiltrate and filter replacement b. Complete renal replacement therapy that allows removal of solutes and modification of the volume and composition of extracellular fluid to occur evenly over time c. Involves the introduction of ster

b. Complete renal replacement therapy that allows removal of solutes and modification of the volume and composition of extracellular fluid to occur evenly over time

A patient with a serious head injury has been admitted. The nurse knows that certain neurologic findings can indicate the prognosis for the patient. Which finding denotes the most serious prognosis? a. Decorticate posturing b. Decerebrate posturing c. Absence of Babinski reflex d. Glasgow Coma Scale (GCS) score of 14

b. Decerebrate posturing Outcome studies indicate that abnormal flexion or decorticate posturing has a less serious prognosis than does extension, or decerebrate posturing. Onset of posturing or a change from abnormal flexion to abnormal extension requires immediate physician notification. The Babinski reflex is a pathologic finding; absence of this reflex is a normal neurologic finding in adults. The range of scores for the Glasgow Coma Scale is 3 to 15. A score of 14 denotes a minimal deficit.

Which of the following medications is considered a loop diuretic? a. Acetazolamide (Diamox) b. Furosemide (Lasix) c. Mannitol d. Metolazone (Zaroxolyn)

b. Furosemide (Lasix)

. A patient has been hospitalized for a subtotal gastrectomy. After the procedure, an infection developed that eventually had to be treated with gentamicin, an aminoglycoside antibiotic. After 3 days of administration, oliguria occurred, and subsequent laboratory values indicated elevated BUN and creatinine levels. The patient is transferred to the critical care unit with acute kidney injury (previously known as acute tubular necrosis). The patient's vital signs are stable. Which dialysis method would be most appropriate for the patient's condition? a. Peritoneal dialysis b. Hemodialysis c. Continuous renal replacement therapy d. Continuous venovenous hemodialysis (CVVH)

b. Hemodialysis As a treatment, hemodialysis separates and removes from the blood excess electrolytes, fluids, and toxins by means of a hemodialyzer. Hemodialysis would be the first choice for managing this patient with medication toxicity.

A patient was admitted with an infection that had to be treated with gentamicin, an aminoglycoside antibiotic. After 3 days of administration, the patient developed oliguria, and an elevated blood urea nitrogen and creatinine levels. The nurse suspects the patient has developed what type of kidney injury? a. Prerenal b. Intrarenal c. Anuric d. Postrenal

b. Intrarenal Any condition that produces an ischemic or toxic insult directly at parenchymal nephron tissue places the patient at risk for development of intrarenal. Ischemic damage may be caused by prolonged hypotension or low cardiac output. Toxic injury reaction may occur in response to substances that damage the kidney tubular endothelium, such as some antimicrobial medications and the contrast dye used in radiologic diagnostic studies.

Which of the following IV solutions is recommended for treatment of prerenal failure? a. Dextrose in water b. Normal saline c. Albumin d. Lactated Ringer solution

b. Normal saline

Which electrolytes pose the most potential hazard if not within normal limits for a person with renal failure? a. Phosphorous and calcium b. Potassium and calcium c. Magnesium and sodium d. Phosphorous and magnesium

b. Potassium and calcium

What is the most common site for short-term vascular access for immediate hemodialysis? a. Subclavian artery b. Subclavian vein c. Femoral artery d. Radial vein

b. Subclavian vein

The nurse is caring for a patient who has sustained a traumatic head injury. The practitioner has asked the nurse to test the patient's oculocephalic reflex. Which findings indicate that the patient has an intact oculocephalic reflex? a. The patient's eyes move in the same direction the head is turned. b. The patient's eyes move in the opposite direction to the movement of the patient's head. c. The patient's eyes rove and move in opposite directions from each other. d. The patient's eyes move up and down and then back and forth.

b. The patient's eyes move in the opposite direction to the movement of the patient's head. To assess the oculocephalic reflex, the nurse holds the patient's eyelids open and briskly turns the head to one side while observing the eye movements and then briskly turns the head to the other side and observes. If the eyes deviate to the opposite direction in which the head is turned, doll's eyes are present, and the oculocephalic reflex arc is intact. If the oculocephalic reflex arc is not intact, the reflex is absent.

Which patient would be at risk for developing hypoxemic normocapnic respiratory failure (type I)? a.A young adult patient with a recent cervical spinal injury b.An older adult patient with a stroke with swallowing difficulties c.An adult patient with Guillain-Barré syndrome d.A young adult patient admitted with chest trauma and fractured ribs

b.An older adult patient with a stroke with swallowing difficulties While all these patients are at risk for acute lung failure, the patient with a stroke and swallowing difficulties is at risk for aspiration pneumonitis which could result in hypoxemic normocapnic respiratory failure. The other patients are at risk for hypoxemic hypercapnic respiratory failure secondary to alveolar hypoventilation. A cervical spinal injury, Guillain-Barré syndrome, and chest trauma can all interfere with the patient's ability to breath.

The nurse is caring for a patient with pneumonia. The nurse is alerted when pulse oximeter alarm goes off. The monitor reads 82%. Which action should the nurse should perform first? a.Notify the practitioner and get ready to intubate the patient. b.Assess the patient's condition. c.Turn off the alarm and reapply the oximeter sensor. d.Increase the amount of oxygen being administered to the patient.

b.Assess the patient's condition The first nursing action would be to assess the patient to see if there is a change in his or her condition. If the patient is stable, then the nurse should turn off the alarm and reapply the oximeter sensor as indicated. If the patient is unstable, the practitioner should be notified. The amount of oxygen should not be increased without a practitioner's order

For which situation does a patient with acute lung failure require a bronchodilator? a.Excessive secretions b.Bronchospasms c.Thick secretions d.Fighting the ventilator

b.Bronchospasms Bronchodilators aid in smooth muscle relaxation and are of particular benefit to patients with airflow limitations. Bronchospasms are a form of airflow limitation. The patient with excessive secretions requires suctioning. The patient with thick secretions requires increased hydration. The patient fighting the ventilator needs further assessment and possibly an anxiolytic or sedative.

What causes the presence of myoglobin in urine? (Select all that apply.) a.Injection b.Crush injury c.Acidosis d.Rhabdomyolysis e.Intrarenal acute kidney injury

b.Crush injury d.Rhabdomyolysis Myoglobin in the urine may result from a crush injury or rhabdomyolysis. Intrarenal acute kidney injury can result from rhabdomyolysis. Infection and acidosis do not cause myoglobin to appear in the urine.

A patient was admitted with acute lung failure secondary to pneumonia. What is the single most important measure to prevent the spread of infection between staff and patients? a.Place the patient in respiratory isolation. b.Ensure everyone is using proper hand hygiene. c.Use personal protective equipment when touching the patient. d.Initiate prompt administration of antibiotics.

b.Ensure everyone is using proper hand hygiene. Proper hand hygiene is the single most important measure available to prevent the spread of bacteria from person to person.

The patient management plan for a patient receiving oxygen therapy should include which interventions? a.Observing the patient for signs of oxygen-associated hyperventilation b.Ensuring the oxygen device is properly positioned on the patient c.Removal of all oxygen devices when the patient is eating d.Titrating the patient's oxygen at the nurse's discretion

b.Ensuring the oxygen device is properly positioned on the patient The patient management plan should include confirming that the oxygen therapy device is properly positioned and replacing it after removal is important. The patient should be observed for oxygen-associated hypoventilation. The oxygen delivery device should be changed from a mask to nasal prongs during meals as tolerated or per the practitioner's order. Oxygen is also considered a medication and requires a practitioner's order to titrate.

A patient was taken to surgery for a left lung resection. The patient returned to the unit 30 minutes ago. Upon completion of the assessment, the nurse notices that the chest tube has drained 150 mL of red fluid in the past 30 minutes. The nurse contacts the practitioner and suspects that the patient has developed what complication? a.Pulmonary edema b.Hemorrhage c.Acute lung failure d.Bronchopleural fistula

b.Hemorrhage Hemorrhage is an early, life-threatening complication that can occur after a lung resection. It can result from bronchial or intercostal artery bleeding or disruption of a suture or clip around a pulmonary vessel. Excessive chest tube drainage can signal excessive bleeding. During the immediate postoperative period, chest tube drainage should be measured every 15 minutes; this frequency should be decreased as the patient stabilizes. If chest tube loss is greater than 100 mL/hr, fresh blood is noted, or a sudden increase in drainage occurs, hemorrhage should be suspected.

A patient is admitted in acute heart failure secondary to renal insufficiency. The patient reports that over the past few weeks, his urine output has decreased, and he has developed peripheral edema and ascites. Which diagnostic tests would provide the best information about the internal kidney structures, such as the parenchyma, calyces, pelvis, ureters, and bladder? a.Kidney-ureter-bladder (KUB) b.Intravenous pyelography (IVP) c.Renal ultrasonography (ECHO) d.Renal angiography

b.Intravenous pyelography (IVP) Intravenous pyelography allows visualization of the internal kidney parenchyma, calyces, pelvis, ureters, and bladder. Kidney-ureter-bladder flat-plate radiography of the abdomen determines the position, size, and structure of the kidneys, urinary tract, and pelvis. It is useful for evaluating the presence of calculi and masses and is usually followed by additional tests. In ultrasonography, high-frequency sound waves are transmitted to the kidneys and urinary tract, and the image is viewed on an oscilloscope. This noninvasive procedure identifies fluid accumulation or obstruction, cysts, stones or calculi, and masses. It is useful for evaluating the kidneys before biopsy. Angiography is injection of contrast into arterial blood perfusing the kidneys. It allows for visualization of renal blood flow and may also visualize stenosis, cysts, clots, trauma, and infarctions.

A patient with acute lung failure has been mechanically ventilated for 3 days and is being evaluated for a spontaneous breathing trial. The ventilator high-pressure limit alarm keeps alarming. The patient should be evaluated for which problem? a.Leak in the patient's endotracheal tube cuff b.Kink in the ventilator tubing c.Disconnection from the ventilator d.Faulty oxygen filter

b.Kink in the ventilator tubing The high-pressure alarms will sound for a variety of issues including a kink in the ventilator tubing. A leak in the endotracheal tube cuff, disconnection from the ventilator, and a faulty oxygen sensor will not cause the high-pressure alarm to sound

The nurse is caring for a patient who is ventilator-dependent. The interprofessional team feels the patient's main problem is increased ventilatory workload. The patient's collaborative plan of care should include which interventions to address this issue? (Select all that apply.) a.Decrease the respiratory rate on the ventilator. b.Optimize the ventilator settings and trigger sensitivity. c.Position the patient with the head of the bed elevated at least 30 degrees. d.Insert a nasogastric tube to relieve abdominal distention. e.Replace a small endotracheal tube with a larger tube or a tracheostomy.

b.Optimize the ventilator settings and trigger sensitivity. c.Position the patient with the head of the bed elevated at least 30 degrees. d.Insert a nasogastric tube to relieve abdominal distention. e.Replace a small endotracheal tube with a larger tube or a tracheostomy. Physiologic factors that increase ventilatory workload include decreased lung compliance, increased airway resistance, small endotracheal tube size, decreased ventilatory sensitivity, improper positioning, abdominal distention, and dyspnea. All the interventions address the patient's increased ventilatory workload except decreasing the patient's ventilatory rate. Decreasing the rate will make the patient work harder and may potentiate respiratory muscle fatigue.

The practitioner indicates in her notes that the patient has mild adult respiratory distress syndrome (ARDS). The patient is requiring mechanical ventilation and has a PEEP of 5 cm H2O. The nurse would anticipate the patient having which finding? a.Radiologic evidence of bibasilar atelectasis b.PaO2/FiO2 ratio of 220 mm Hg c.Pulmonary artery occlusion pressure greater than 18 mm Hg d.Oxygen saturation of 92%

b.PaO2/FiO2 ratio of 220 mm Hg According to the definition, ARDS is characterized by: · Lung injury of acute onset, within 1 week of an apparent clinical insult and with progression of respiratory symptoms · Bilateral opacities on chest imaging (chest radiograph or CT) not explained by other lung pathology (e.g. effusion, lobar/lung collapse, or nodules) · Respiratory failure not explained by heart failure or volume overload · Decreased PaO2/FiO2 ratio (mild: 201 to 300 mmHg, moderate: 101 to 200 mmHg; severe ARDS: £ 100 mmHg) · Note that the Berlin definition requires a minimum positive end expiratory pressure (PEEP) of 5 cm H2O for consideration of the PaO2/FiO2 ratio.

The patient management plan of a patient with acute lung failure should include which interventions? (Select all that apply.) a.Positioning the patient with the least affected side up b.Providing adequate rest between treatments c.Performing percussion and postural drainage every 4 hours d.Controlling fever e.Pharmaceutical medications to control anxiety

b.Providing adequate rest between treatments d.Controlling fever e.Pharmaceutical medications to control anxiety The goal of positioning is to place the least affected area of the patient's lung in the most dependent position. Other interventions include performing procedures only as needed, preoxygenating the patient before suctioning, providing adequate rest and recovery time between various procedures, and minimizing oxygen consumption. Interventions to minimize oxygen consumption include limiting the patient's physical activity, administering sedation to control anxiety, and providing measures to control fever

The nurse is caring for a patient with massive pulmonary embolus. Which pathophysiologic hemodynamic consequence should the nurse anticipate the patient may develop? a.Increased systemic vascular resistance leading to left heart failure b.Pulmonary hypertension leading to right heart failure c.Portal vein blockage leading to ascites d.Embolism to the internal carotids leading to a stroke

b.Pulmonary hypertension leading to right heart failure The major hemodynamic consequence of a pulmonary embolus is the development of pulmonary hypertension, which is part of the effect of a mechanical obstruction when more than 50% of the vascular bed is occluded. In addition, the mediators released at the injury site and the development of hypoxia cause pulmonary vasoconstriction, which further exacerbates pulmonary hypertension.

A patient with acute lung failure has been mechanically ventilated for 3 days and is being evaluated for a spontaneous breathing trial. Which parameter would indicate that the patient is ready to be weaned? a.Negative inspiratory force of—10 cm H2O b.Rapid shallow breathing index of 95 c.Minute ventilation of 7 L/min d.Vital capacity of 8 mL/kg

b.Rapid shallow breathing index of 95 An RSBI less than 105 is considered predictive of weaning success. The minute ventilation should be greater than 10 L/min. The vital capacity should be greater than 10 mL/kg. The negative inspiratory force should be less than -20 cm H2O.

A patient was admitted with acute kidney injury. Which urinalysis value reflects a decreased ability of the kidneys to concentrate urine? a.pH of 5.0 b.Specific gravity of 1.000 c.No casts d.Urine sodium of 140 mEq/24 hr

b.Specific gravity of 1.000 Specific gravity measures the density or weight of urine compared with that of distilled water. The normal urinary specific gravity is 1.005 to 1.025. For comparison, the specific gravity of distilled water is 1.000. Because urine is composed of many solutes and substances suspended in water, the specific gravity should always be higher than that of water.

A patient with acute lung failure has been mechanically ventilated for 3 days and is being evaluated for a spontaneous breathing trial. When the nurse enters the room, the ventilator inoperative alarm sounds. Which action should the nurse perform FIRST? a.Troubleshoot the ventilator until the problem is found. b.Take the patient off the ventilator and manually ventilate the patient. c.Call the respiratory therapist for help. d.Silence the ventilator alarms until the problem is resolved.

b.Take the patient off the ventilator and manually ventilate the patient. If the ventilator malfunctions, the patient should be removed from the ventilator and ventilated manually with a manual resuscitation bag. Ensure emergency equipment is at bedside at all times (e.g., manual resuscitation bag connected to oxygen, masks, suction equipment, or supplies), including preparations for power failures.

A patient was admitted with acute heart failure a few days ago. Today the patient's urine has a specific gravity of 1.040. What could be the potential cause for this value? a.Volume overload b.Volume deficit c.Acidosis d.Urine ketones

b.Volume deficit Specific gravity ranges from 1.003 to 1.030. Possible causes for increased values include volume deficit, glycosuria, proteinuria, and prerenal acute kidney injury (AKI). Possible causes for decreased values include volume overload and intrarenal AKI.

What is the dose for low-dose dopamine? a. 1 to 2 mcg/kg/min b. 1 to 2 mg/kg/min c. 2 to 3 mcg/kg/min d. 2 to 3 mg/kg/min

c. 2 to 3 mcg/kg/min

According to the 2007 Brain Trauma Foundation guidelines, the recommended CPP range is: a. 10 to 30 mm Hg. b. 30 to 50 mm Hg. c. 50 to 70 mm Hg. d. 70 to 85 mm Hg.

c. 50 to 70 mm Hg. The 2007 Brain Trauma Foundation guidelines now recommend a cerebral perfusion pressure (CPP) in the range of 50 to 70 mm Hg and consideration of cerebral autoregulation status when selecting a CPP target in a specific patient.

The patient is a gravida 6, para 1. She is admitted after a cesarean section after an amniotic embolus. Her heart rate (HR) is more than 150 beats/min with a systolic BP less than 80 mm Hg. Her temperature is 38°C, and her condition has caused her to develop prerenal azotemia. The patient was fluid resuscitated through a double-lumen catheter, which was placed into her right femoral access, and started on vasopressors with a fair response (BP, 80/50 mm Hg; HR, 122 beats/min). Because of her diagnosis and a concern regarding fulminating sepsis, the patient was begun on CVVH. Identify three complications of CVVH therapy. a. Fat emboli, increased ultrafiltration, and hypertension b. Hyperthermia, overhydration, and power surge c. Air embolism, decreased inflow pressure, and electrolyte imbalance d. Blood loss, decreased outflow resistance, and acid-base imbalance

c. Air embolism, decreased inflow pressure, and electrolyte imbalance

A patient has sepsis and is placed on broad-spectrum antibiotics. Her temperature is 37.8°C. Her BUN level is elevated. She continues on vasopressor therapy. What other steps should be taken to protect the patient from inadequate organ perfusion? a. Increase net ultrafiltrate of fluid. b. Discontinue vasopressor support. c. Assess the patient for blood loss and hypotension. d. Notify the physician of access pressures

c. Assess the patient for blood loss and hypotension.

A patient has been admitted with acute confusion and other focal neurologic signs. The practitioner is going to perform a lumbar puncture. What is the most serious complication of lumbar puncture? a. Meningitis b. Dural tear c. Brainstem herniation d. Spinal cord trauma

c. Brainstem herniation Two life-threatening risks associated with lumbar puncture include possible brainstem herniation, if intracranial pressure is elevated, and respiratory arrest associated with neurologic deterioration.

A patient with acute kidney injury (AKI) has been started on continuous venovenous hemodiafiltration (CVVHDF). The nurse understands the patient should be closely monitored for what circuit-related complications of the therapy? a. Hypervolemia, hypothermia, and hyperkalemia b. Access dislodgment, decreased outflow pressures, and bleeding c. Filter clotting, access failure, and air embolism d. Increased overflow pressure, dehydration, and calcium loss

c. Filter clotting, access failure, and air embolism Circuit-related complications of continuous renal replacement therapy include air embolism, clotted hemofilter, poor ultrafiltration, blood leaks, broken filter, disconnection, access failure, and catheter dislodgement.

A patient with acute kidney injury (AKI) has been started on continuous venovenous hemodialysis (CVVHD). The nurse understands the patient should be closely monitored for what patient-related complications of the therapy? a. Air embolism, access failure, and blood leaks b. Decreased inflow pressure, air bubbles, and power surge c. Infection, hypotension, and electrolyte imbalances d. Catheter dislodgement, decreased outflow pressure, and acid-base imbalances

c. Infection, hypotension, and electrolyte imbalances Patient-related complications of continuous renal replacement therapy (CRRT) include dehydration, hypotension, electrolyte imbalances, acid-base imbalances, blood loss, hemorrhage, hypotension, and infection.

A patient is going for digital subtraction angiography. The patient education plan to prepare the patient for the procedure should include which instruction? a. Inform the patient that the procedure is very noisy and earplugs will be provided b. Tell the patient that repositioning will be required at appropriate intervals c. Instruct the patient to remaining motionless during the entire procedure d. Let the patient know he will be expected to swallow frequently during the procedure

c. Instruct the patient to remaining motionless during the entire procedure The major disadvantage of digital subtraction angiography involves the patient's ability to remain motionless during the entire procedure. Even swallowing significantly interferes with the imaging process.

A patient with chronic renal failure receives hemodialysis treatments 3 days a week. Every 2 weeks, the patient requires a transfusion of 1 or 2 U of packed red blood cells. What is the probable reason for this patient's frequent transfusion needs? a. Too much blood phlebotomized for tests b. Increased destruction of red blood cells because of the increased toxin levels c. Lack of production of erythropoietin to stimulate red blood cell formation d. Fluid retention causing hemodilution

c. Lack of production of erythropoietin to stimulate red blood cell formation

A patient was admitted with liver failure and acute kidney injury (AKI). Which intravenous solution should the nurse question if it was ordered for this patient? a. D5W b. 0.9% NaCl c. Lactated Ringer solution d. 0.45% NaCl

c. Lactated Ringer solution Lactated Ringer solution is contraindicated for patients with kidney or liver diseases or in lactic acidosis.

The nurse is teaching a new nurse about endotracheal tube cuff management. Which statement by the new nurse would indicate further education is needed? a."The cuff should be deflated every hour to minimize pressure on the trachea." b."A small leak should be heard on inspiration if the cuff has been inflated using the minimal leak technique." c."Cuff pressures should be kept between 20 and 30 cm H2O." d."Cuff pressure monitoring should be done once every 24 hours."

c."Cuff pressures should be kept between 20 and 30 cm H2O." Cuff pressures are monitored at a minimum of every shift and are maintained within 20 to 30 cm H2O because greater pressures decrease blood flow to the capillaries in the tracheal wall and lesser pressures increase the risk of aspiration. Pressures greater than 30 cm H2O should be reported to the practitioner. Cuffs are not routinely deflated because this increases the risk of aspiration. The minimal leak technique is no longer recommended.

A patient at risk for the recurrence of a pulmonary embolism (PE) is being discharged home. The patient asks "How long do I have to remain on warfarin?" Which response from the nurse is the most accurate? a."You only have to take warfarin for 1 month and then you can stop." b."You could be on warfarin for up to 6 months depending on your lab work." c."Depending on your risk, it could be anywhere from 3 to 12 months." d."Most patients have to stay on warfarin for at least 36 months."

c."Depending on your risk, it could be anywhere from 3 to 12 months." The patient should remain on warfarin for 3 to 12 months depending on his or her risk for thromboembolic disease.

A patient was admitted with acute heart failure. The nurse is assessing the patient for peripheral edema. The nurse presses two fingers over the tibial area, and it takes 1 minute before the indention disappears. What would the nurse in the medical record? a.+1 pitting edema b.+2 pitting edema c.+3 pitting edema d.+4 pitting edema

c.+3 pitting edema The pitting edema scale includes +1 = 2-mm depth; +2 = 4-mm depth (lasting up to 15 seconds); +3 = 6-mm depth (lasting up to 60 seconds); and +4 = 8-mm depth (lasting longer than 60 seconds).

A patient with acute respiratory distress syndrome (ARDS) continues to have ongoing problems with hypoxemia. Which therapeutic measure should the nurse anticipate the practitioner will order next? a.Sedating the patient to blunt noxious stimuli b.Increasing the FiO2 on the ventilator c.Administering positive-end expiratory pressure (PEEP) d.Restricting fluids to 500 mL per shift

c.Administering positive-end expiratory pressure (PEEP) The purpose of using positive-end expiratory pressure (PEEP) in a patient with acute respiratory distress syndrome is to improve oxygenation while reducing FiO2 to less toxic levels. PEEP has several positive effects on the lungs, including opening collapsed alveoli, stabilizing flooded alveoli, and increasing functional residual capacity. Thus, PEEP decreases intrapulmonary shunting and increases compliance.

A patient with acute lung failure has been mechanically ventilated for 3 days and has been started on a spontaneous breathing trial. Which parameter would indicate that the patient is not tolerating weaning? a.A decrease in heart rate from 92 to 80 beats/min b.An SpO2 of 92% c.An increase in respiratory rate from 22 to 38 breaths/min d.Spontaneous tidal volumes of 300 to 350 mL

c.An increase in respiratory rate from 22 to 38 breaths/min An increased in respiratory rate from 22 to 38 breaths/min would indicate the patient is not tolerating weaning. The rest of the parameters indicate the patient is tolerating weaning.

As serum osmolality rises, intravascular fluid equilibrium will be maintained by the release of what substance? a.Ketones b.Glucagon c.Antidiuretic hormone d.Potassium

c.Antidiuretic hormone When the serum osmolality level increases, antidiuretic hormone is released from the posterior pituitary gland and stimulates increased water resorption in the kidney tubules. This expands the vascular space, returns the serum osmolality level back to normal, and results in more concentrated urine and an elevated urine osmolality level.

A patient with a history of chronic obstructive pulmonary disease (COPD) requires oxygen therapy. The nurse knows that oxygen therapy places this patient at high risk for the developing which complication? a.Oxygen toxicity b.Absorption atelectasis c.Carbon dioxide retention d.Pneumothorax

c.Carbon dioxide retention In patients with COPD, carbon dioxide retention may occur as a result of administration of oxygen in high concentrations. Because of the risk of CO2 accumulation, all patients who are chronically hypercapnic require careful low-flow oxygen administration. If hypoxemia is corrected by the administration of oxygen, the stimulus to breathe is abolished; hypoventilation develops, resulting in a further increase in the arterial partial pressure of carbon dioxide (PaCO2).

A patient has been admitted for observation after a head injury. The practitioner is concerned that the patient may develop intracranial hypertension. Which sign should the nurse be observing the patient for? a.Bradycardia b.Abnormal extension c.Decrease in level of consciousness d.Increase in pupillary size

c.Decrease in level of consciousness One of the earliest and most important signs of increased intracranial pressure is a decrease in the level of consciousness. The other signs are later signs.

A patient has been admitted with severe shortness of breath and pleuritic chest pain. The practitioner suspects the patient may have a pulmonary embolism (PE). Which finding would confirm this diagnosis? a.Low-probability V/Q scan b.Negative pulmonary angiogram c.High-probability V/Q scan d.Absence of vascular markings on the chest radiograph

c.High-probability V/Q scan A definitive diagnosis of a pulmonary embolism requires confirmation by a high-probability V/Q scan, an abnormal pulmonary angiogram or computed tomography scan, or strong clinical suspicion coupled with abnormal findings on lower extremity deep venous thrombosis studies.

A patient with severe unilateral pneumonia has been admitted with severe hypoxemia. The nurse suspects the underlying cause of the hypoxemia is which pathophysiologic process? a.Alveolar hypoventilation b.Dead space ventilation c.Intrapulmonary shunting d.Physiologic shunting

c.Intrapulmonary shunting The underlying cause of this patient's hypoxemia is probably intrapulmonary shunting. As blood passes through the affected lung, minimal gas exchange is taking place. Intrapulmonary shunting occurs when blood passes through a portion of a lung that is not ventilated. Physiologic shunting is normal and not a cause of hypoxemia.

The patient with a tracheostomy tube is having difficulty communicating while on the ventilator. Before suggesting the Passy-Muir valve, the nurse should evaluate the patient for the presence of which situation would be a contraindication to this therapy? a.Actively weaning b.Minimal secretions c.Laryngeal dysfunction d.Normal pharyngeal function

c.Laryngeal dysfunction The Passy-Muir valve is contraindicated in patients with laryngeal or pharyngeal dysfunction, excessive secretions, or poor lung compliance. The Passy-Muir valve is not contraindicated for a patient who is actively weaning, has minimal secretions, or normal pharyngeal function.

The nurse is developing a plan of care for a patient with an endotracheal tube (ETT). Which interventions should be incorporated into the plan to minimize the complications of suctioning? a.Insert the suction catheter no more than 4 inches into the tube. b.Premedicate the patient with atropine before suctioning. c.Limit the suction pass to less than 15 seconds. d.Increase the vacuum suction to 180 mm Hg before suctioning.

c.Limit the suction pass to less than 15 seconds. The suction pass should be limited to 10 to 15 seconds to minimize hypoxemia, airway trauma, and cardiac dysrhythmias. The patient should not be premedicated with atropine. The vacuum suction should be 150 mm Hg or less. The suction catheter should be inserted at least to the end of the endotracheal tube which would be longer than 4 inches.

The management plan for a patient with a clipped cerebral aneurysm receiving hemodynamic augmentation includes which intervention? a.Administering osmotic diuretics and vasodilator agents b.Providing the patient with a quiet environment c.Maintaining the patient's systolic blood pressure at 150 to 160 mm Hg d.Keeping the patient's central venous pressure at 5 to 8 mm Hg

c.Maintaining the patient's systolic blood pressure at 150 to 160 mm Hg Hemodynamic augmentation therapy involves increasing the patient's blood pressure and cardiac output with vasoactive medications. Systolic blood pressure is maintained between 150 and 160 mm Hg. The increase in pressure forces blood through the vasospastic area at higher pressures.

A patient was admitted with acute heart failure who has been receiving diuretic therapy. The nurse suspects the patient is hypovolemic. What auscultatory parameter would confirm the nurse's suspicion? a.Hypertension b.Third or fourth heart sound c.Orthostatic hypotension d.Vascular bruit

c.Orthostatic hypotension A drop in systolic blood pressure of 20 mm Hg or more, a drop in diastolic blood pressure of 10 mm Hg or more, or a rise in pulse rate of more than 15 beats/min from lying to sitting or from sitting to standing indicates orthostatic hypotension. The drop in blood pressure occurs because a sufficient preload is not immediately available when the patient changes position. The heart rate increases in an attempt to maintain cardiac output and circulation.

A patient was admitted in acute lung failure. The patient is receiving 40% oxygen via a simple face mask. The morning chest radiography study reveals right lower lobe pneumonia. Which test would the nurse expect the practitioner to order to identify the infectious pathogen? a.CBC with differential b.Wound culture of surgical site c.Sputum gram stain and culture d.Urine specimen

c.Sputum gram stain and culture A sputum gram stain and culture are done to facilitate the identification of the infectious pathogen. In 50% of cases, though, a causative agent is not identified. A diagnostic bronchoscopy may be needed, particularly if the diagnosis is unclear or current therapy is not working. In addition, a complete blood count with differential, chemistry panel, blood cultures, and arterial blood gas analysis is obtained.

The nurse is caring for a patient who has been mechanically ventilated via an endotracheal tube for 19 days. Weaning trials have been unsuccessful. During multidisciplinary rounds, the topic of the patient's airway is discussed. Which airway may be more appropriate for this patient at this time? a.Oropharyngeal airway b.Esophageal obturator airway c.Tracheostomy tube d.Endotracheal intubation

c.Tracheostomy tube Although no ideal time to perform the procedure has been identified, it is commonly accepted that if a patient has been intubated or is anticipated to be intubated for longer than 7 to 10 days, a tracheostomy should be performed.

The nurse will be getting a postoperative patient who is having a pneumonectomy. The nurse suspects the patient may have had which condition? a.Peripheral granulomas b.Bronchiectasis c.Unilateral tuberculosis d.Single lung abscess

c.Unilateral tuberculosis A pneumonectomy is the removal of entire lung with or without resection of the mediastinal lymph nodes. Indications include malignant lesions, unilateral tuberculosis, extensive unilateral bronchiectasis, multiple lung abscesses, massive hemoptysis, and bronchopleural fistula.

A patient is admitted in acute kidney injury. The patient reports that over the past few weeks, his urine output has decreased, and he has developed peripheral edema and ascites. The nurse suspects the main cause of ascites is what condition? a.Hypervolemia b.Dehydration c.Volume overload d.Liver damage

c.Volume overload Individuals with acute kidney injury may have ascites caused by volume overload, which forces fluid into the abdomen because of increased capillary hydrostatic pressures. However, ascites may or may not represent fluid volume excess.

The patient is a gravida 6, para 1. She is admitted after a cesarean section after an amniotic embolus. Her heart rate (HR) is more than 150 beats/min with a systolic BP less than 80 mm Hg. Her temperature is 38°C, and her condition has caused her to develop prerenal azotemia. The patient was fluid resuscitated through a double-lumen catheter, which was placed into her right femoral access, and started on vasopressors with a fair response (BP, 80/50 mm Hg; HR, 122 beats/min). Because of her diagnosis and a concern regarding fulminating sepsis, the patient was begun on CVVH. Why would this therapy be chosen for this patient? a. Hyperdynamic patients can better tolerate abrupt fluid and solute changes. b. It is the treatment of choice for patients with diminished renal perfusion who are unresponsive to diuretics. c. It is indicated for patients who require large-volume removal for severe uremia or critical acid-base i

d. It is indicated for hemodynamically unstable patients, who are often intolerant of the abrupt fluid and solute changes that can occur with hemodialysis.

A patient with acute kidney injury (AKI) has been started on continuous venovenous hemodialysis (CVVHD). The nurse understands that this type of continuous renal replacement therapy (CRRT) is indicated for the patient who needs what type of treatment? a. Fluid removal only b. Fluid removal and moderate solute removal c. Fluid removal and maximum solute removal d. Maximum fluid and solute removal

d. Maximum fluid and solute removal Continuous venovenous hemodialysis (CVVHD) is indicated for patients who require large- volume removal of fluid and solutes.

Which nuclear medicine study should the nurse anticipate a practitioner's order for in a patient who is being evaluated for a brain tumor? a. PET b. MRI c. MRA d. SPECT

d. SPECT The single-photon emission computed tomography (SPECT) test differs from positron emission tomography (PET) in that tracer stays in the bloodstream rather than being absorbed by surrounding tissue, thereby limiting the images to areas where blood flows. SPECT is cheaper and more readily available than higher resolution PET. The major clinical uses of SPECT are to detect cerebrovascular disease, seizures, and tumors. Magnetic resonance imaging and magnetic resonance angiography are radiographic imaging examinations.

A patient is admitted with sepsis and acute kidney injury (AKI). The patient is started on continuous renal replacement therapy (CRRT). The nurse knows that fluid removed each hour is charted as what on the CRRT flow sheet? a. Convection b. Diffusion c. Replacement fluid d. Ultrafiltrate

d. Ultrafiltrate The fluid that is removed each hour is not called urine; it is known as ultrafiltrate. Typically, some of the ultrafiltrate is replaced through the continuous renal replacement therapy circuit by a sterile replacement fluid. Diffusion is the movement of solutes along a concentration gradient from a high concentration to a low concentration across a semipermeable membrane. Convection occurs when a pressure gradient is set up so that the water is pushed or pumped across the dialysis filter and carries the solutes from the bloodstream with it.

A patient has been hospitalized for a subtotal gastrectomy. After the procedure, an infection developed that eventually had to be treated with gentamicin, an aminoglycoside antibiotic. After 3 days of administration, oliguria occurred, and subsequent laboratory values indicated elevated BUN and creatinine levels. The patient is transferred to the critical care unit with acute kidney injury (previously known as acute tubular necrosis). The fluid that is removed each hour is not called urine; it is known as a. convection. b. diffusion. c. replacement fluid. d. ultrafiltrate.

d. ultrafiltrate.

To select the correct size of an oropharyngeal airway, the nurse should ensure the airway extends from which area to which area? a.Tip of the nose to the ear lobe b.Middle of the mouth to the ear lobe c.Tip of the nose to the middle of the trachea d.Corner of the mouth to the angle of the jaw

d.Corner of the mouth to the angle of the jaw An oropharyngeal airway's proper size is selected by holding the airway against the side of the patient's face and ensuring that it extends from the corner of the mouth to the angle of the jaw. If the airway is improperly sized, it will occlude the airway. Nasopharyngeal airways are measured by holding the tube against the side of the patient's face and ensuring that it extends from the tip of the nose to the ear lobe.

A patient has been admitted with the diagnosis of acute respiratory distress syndrome (ARDS). Arterial blood gasses (ABGs) revealed an elevated pH and decreased PaCO2. The patient is becoming fatigued, and the practitioner orders a repeat ABG. Which set of results would be indicative of the patient's current condition? a.Elevated pH and decreased PaCO2 b.Elevated pH and elevated PaCO2 c.Decreased pH and decreased PaCO2 d.Decreased pH and elevated PaCO2

d.Decreased pH and elevated PaCO2 Arterial blood gas analysis reveals a low PaO2 despite increases in supplemental oxygen administration (refractory hypoxemia). Initially, the PaCO2 is low as a result of hyperventilation, but eventually the PaCO2 increases as the patient fatigues. The pH is high initially but decreases as respiratory acidosis develops.

A patient has been admitted after the placement of a ventriculoperitoneal shunt. The nurse should monitor the patient for evidence of which condition? a.Hyponatremia b.Cerebrospinal fluid leak c.Ascending paralysis d.Increased intracranial pressure

d.Increased intracranial pressure The patient should be monitored for signs of increased intracranial hypertension secondary to hydrocephalus. If the shunt is not working correctly, cerebrospinal fluid will accumulate and cause increased intracranial pressure.

A patient has been admitted with an intracerebral hemorrhage. A CT of the patient's head reveals a large left parietal area bleed. Patient assessment includes T—98.7°F, P—98 beats/min and thready, R—8 breaths/min, and BP—168/100 mm Hg. Initial management of the patient includes which intervention? a.Placing the patient in the Trendelenburg position b.Administering an antihypertensive agent c.Initiating hemodynamic augmentation therapy d.Intubating and ventilating the patient

d.Intubating and ventilating the patient Intracerebral hemorrhage is a medical emergency. Initial management requires attention to airway, breathing, and circulation. Intubation is usually necessary. Blood pressure management must be based on individual factors. Reduction in blood pressure is usually necessary to decrease ongoing bleeding, but lowering blood pressure too much or too rapidly may compromise cerebral perfusion pressure, especially in a patient with elevated intracranial pressure. National guidelines recommend keeping the mean arterial blood pressure below 130 mm Hg in patients with a history of hypertension by moderate blood pressure reduction to a mean arterial pressure below 110 mm Hg. Vasopressor therapy after fluid replenishment is recommended if systolic blood pressure falls below 90 mm Hg

A patient presents with aphasia, decreased level of consciousness, and right-sided weakness. The patient has a history of heart disease, hyperlipidemia, and transient ischemic attacks. Based on the history, the nurse suspects that the patient has sustained which type of stroke? a.Hemorrhagic stroke b.Intracerebral hemorrhages c.Subarachnoid hemorrhages d.Ischemic stroke

d.Ischemic stroke Ischemic stroke results from interruption of blood flow to the brain and accounts for 80% to 85% of all strokes. The interruption can be the result of a thrombotic or embolic event. Thrombosis can form in large vessels (large-vessel thrombotic strokes) or small vessels (small-vessel thrombotic strokes). Embolic sources include the heart (cardioembolic strokes) and atherosclerotic plaques in larger vessels (atheroembolic strokes). In 30% of the cases, the underlying cause of the stroke is unknown (cryptogenic strokes). Strokes are classified as ischemic and hemorrhagic. Hemorrhagic strokes can be further categorized as subarachnoid hemorrhages and intracerebral hemorrhages.

A patient with unruptured cerebral aneurysm has been admitted for monitoring. The nurse is aware that this condition poses which risk to the patient? a.It shunts blood away from the surrounding tissues. b.It leaks blood into the subarachnoid space. c.It causes damage the middle layer of the arterial wall. d.It places pressure on the surrounding tissues.

d.It places pressure on the surrounding tissues. An unruptured aneurysm may be problematic because it places pressure on the surrounding tissues. The aneurysm becomes clinically significant when the vessel wall becomes so thin that it ruptures, sending arterial blood at a high pressure into the subarachnoid space.

While caring for a patient with severe left-sided pneumonia, the nurse observes that the patient's oxygen saturation varies depending on the patient's position. Given this information the patient would probably benefit from being placed in which position? a.Reverse Trendelenburg b.Supine c.On the left side d.On the right side

d.On the right side Patients with unilateral lung disease should be positioned with the healthy lung in a dependent position. Because gravity normally facilitates preferential ventilation and perfusion to the dependent areas of the lungs, the best gas exchange would take place in the dependent areas of the lungs. Thus, the goal of positioning is to place the least affected area of the patient's lung in the most dependent position. Patients with unilateral lung disease should be positioned with the healthy lung in a dependent position.

The practitioner has ordered the addition of positive end-expiratory pressure (PEEP) to the current mechanical ventilation settings. Which effect will this change have on the patient's hemodynamics? a.PEEP increases intrathoracic pressure, which increases venous return and cardiac output. b.PEEP decreases venous return, which increases preload and cardiac output. c.PEEP increases venous return, which decreases preload and cardiac output. d.PEEP increases intrathoracic pressure, which decreases venous return and cardiac output.

d.PEEP increases intrathoracic pressure, which decreases venous return and cardiac output. Positive-pressure ventilation increases intrathoracic pressure, which decreases venous return to the right side of the heart. Impaired venous return decreases preload, which results in a decrease in cardiac output.

The nurse is developing a patient management plan for an older adult patient who has had a stroke. The patient is unable to adequately swallow and is receiving tube feedings. Which nursing intervention should be incorporated into the plan of care? a.Observing the amount given in the tube feeding b.Assessing the patient's level of consciousness c.Encouraging the patient to cough and to breathe deeply d.Positioning the patient in a semirecumbent position

d.Positioning the patient in a semirecumbent position Semirecumbency has been shown to decrease the risk of aspiration and inhibit the development of hospital-associated pneumonia.

A patient was admitted with multiple trauma who has been volume resuscitated. The nurse suspects the patient is fluid overloaded. Which assessment findings would confirm the nurse's suspicion? a.Venous filling of the hand veins greater than 5 seconds b.Distended neck veins in the supine position c.Presence of orthostatic hypotension d.Presence of a third heart sound

d.Presence of a third heart sound Auscultation of the heart requires not only assessing rate and rhythm but also listening for extra sounds. Fluid overload is often accompanied by a third or fourth heart sound, which is best heard with the bell of the stethoscope.

To limit respiratory muscle fatigue, the practitioner would like to augment the patient's inspiratory effort. The nurse should anticipate the addition of which therapy? a.Positive end-expiratory pressure (PEEP) b.Continuous positive airway pressure (CPAP) c.Pressure control ventilation (PCV) d.Pressure support ventilation (PSV)

d.Pressure support ventilation (PSV) Preset positive pressure used to augment the patient's inspiratory efforts is known as pressure support ventilation. With continuous positive airway pressure, positive pressure is applied during spontaneous breaths; the patient controls rate, inspiratory flow, and tidal volume. Positive end-expiratory pressure is positive pressure applied at the end of expiration of ventilator breaths.

A patient with pneumonia is reporting shortness of breath. The nurse suspects the patient is hypoxemic and may need additional oxygen therapy. Which arterial blood gas (ABG) value would validate the nurse's suspicions? a.PaO2 of 80 mm Hg b.PaCO2 of 35 mm Hg c.HCO3- of 24 mEq d.SaO2 of 87%

d.SaO2 of 87% The amount of oxygen administered depends on the pathophysiologic mechanisms affecting the patient's oxygenation status. In most cases, the amount required should provide an arterial partial pressure of oxygen (PaO2) of greater than 60 mm Hg or an arterial hemoglobin saturation (SaO2) of greater than 90% during both rest and exercise.

A patient was admitted after a left pneumonectomy. The patient is receiving 40% oxygen via a simple face mask. The morning chest radiography study reveals right lower lobe pneumonia. After eating breakfast, the patient suddenly vomits and aspirates. What action should the nurse take next? a.Lavage the airway with normal saline b.Place the patient supine in a semi-Fowler position c.Manually ventilate the patient d.Suction the airway

d.Suction the airway When aspiration is witnessed, emergency treatment should be instituted to secure the airway and minimize pulmonary damage. The patient's head should be turned to the side, and the oral cavity and upper airway should be suctioned immediately to remove the gastric contents.

A patient has been admitted in a coma of unknown cause. The nurse should anticipate the practitioner ordering the rapid intravenous administration of which three agents? a.Epinephrine, hydrocortisone, and Benadryl b.Dopamine, 10% dextrose in distilled water, and calcium chloride c.Mannitol, dexamethasone, and sodium bicarbonate d.Thiamine, glucose, and opioid antagonist

d.Thiamine, glucose, and opioid antagonist The goal of medical management of the patient in coma is identification and treatment of the underlying cause of the condition. Initial medical management includes emergency measures to support vital functions and prevent further neurologic deterioration. Protection of the airway and ventilatory assistance are often needed. Administration of thiamine (at least 100 milligrams [mg]), glucose, and an opioid antagonist is suggested when the cause of coma is not immediately known.

Supplemental oxygen administration is usually effective in treating hypoxemia related to which situation? a.Physiologic shunting b.Dead space ventilation c.Alveolar hyperventilation d.Ventilation/perfusion mismatching

d.Ventilation/perfusion mismatching Supplemental oxygen administration is effective in treating hypoxemia related to alveolar hypoventilation and ventilation/perfusion mismatching. When intrapulmonary shunting exists, supplemental oxygen alone is ineffective. In this situation, positive pressure is necessary to open collapsed alveoli and facilitate their participation in gas exchange. Positive pressure is delivered via invasive and noninvasive mechanical ventilation

The nursing management plan for a patient undergoing an oil-based contrast myelogram should include intervention? a. Maintain the patient flat in bed for 4 to 8 hours. b. Observe the puncture sight every 15 minutes for 2 hours for signs of bleeding. c. Keep the patient's head elevated 30 to 45 degrees for 8 hours. d. Administer a sedative to keep the patient from moving around.

ANS: A Postprocedure care of the patient undergoing an oil-based iophendylate myelogram includes keeping the patient's flat in bed for 4 to 8 hours.

A patient has been experiencing drowsiness, confusion, and slight focal deficits for several days. The initial noncontract CT findings are negative. The patient is being prepared for a lumbar puncture. Which CSF appearance finding should the nurse expect? a. Cloudy b. Bloody c. Xanthochromic d. Clear

ANS: B If the initial computed tomography findings are negative, a lumbar puncture is performed to obtain cerebrospinal fluid (CSF) for analysis. CSF after subarachnoid hemorrhage (SAH) appears bloody and has a red blood cell count greater than 1000 cells/mm3. If the lumbar puncture is performed more than 5 days after the SAH, the CSF fluid is xanthochromic (dark amber) because the blood products have broken down. Cloudy CSF usually indicates some type of infectious process such as bacterial meningitis, not SAH.

A patient with a serious head injury has been admitted. The nurse knows that certain neurologic findings can indicate the prognosis for the patient. Which finding denotes the most serious prognosis? a. Abnormal flexion b. Abnormal extension c. Localization d. Withdrawal

ANS: B Outcome studies indicate that abnormal extension or decerebrate posturing has a more serious prognosis than does abnormal extension or decorticate posturing. Onset of posturing or a change from abnormal flexion to abnormal extension requires immediate physician notification. Localization and withdrawal are abnormal neurologic findings; however, these findings are less serious than abnormal extension.

The nurse is teaching a nursing student about the importance of assessing the patient's level of conscious (LOC). Which statement indicates the nursing student understood the information? a. "The LOC is the most prognostic indicator of the patient's neurologic outcome." b. "The LOC limited to the Glasgow Coma Scale making it the quickest part of the assessment." c. "The LOC is the easiest part of the neurologic exam and thus is generally performed first." d. "In most situations, the LOC deteriorates before any other neurologic changes are observed."

ANS: D Assessment of the level of consciousness is the most important aspect of the neurologic examination.

The nurse and a new graduate nurse are caring for a comatose patient on continuous electroencephalography (cEEG) monitor. The new graduate says "This monitor is great. How come we don't use it on all the neuro patients?" What are the drawbacks to using this type of monitor? (Select all that apply.) A. Size of machine B. Expensive C. Labor-intensive program D. Requires expertise for interpretation E. Artifacts from ICU environment

B. Expensive C. Labor-intensive program D. Requires expertise for interpretation E. Artifacts from ICU environment The drawbacks to the use of continuous electroencephalography (cEEG) are that it is an expensive, labor-intensive program that requires expertise for interpretation, and is subject to artifacts from the intensive care unit environment. More research on cEEG is needed to determine its cost-saving potential and impact on outcome.

The nurse knows that change in pupil size is a significant neurologic finding particularly in the patient with a head injury. How much of a size difference between the two pupils is still considered normal? a. 1 mm b. 1.5 mm c. 2 mm d. 2.5 mm

a. 1 mm Pupil size should be documented in millimeters with the use of a pupil gauge to reduce the subjectivity of description. Most people have pupils of equal size, between 2 and 5 mm. A discrepancy up to 1 mm between the two pupils is normal.

The patient was admitted with a head injury and an intracranial pressure (ICP) monitoring device was placed. The nurse knows to notify the practitioner if what type of wave start to appear on the monitor? a. A waves b. B wave c. C waves d. D waves

a. A waves A waves are the most clinically significant of the three types. They usually occur in an already elevated baseline intracranial pressure (ICP) (>20 mm Hg) and are characterized by sharp increases in ICP of 30 to 69 mm Hg, which plateau for 2 to 20 minutes and then return to baseline. B waves appear to reflect fluctuations in cerebral blood. C waves are small, rhythmic waves that occur every 4 to 8 minutes at normal levels of ICP. They are related to normal fluctuations in respiration and systemic arterial pressure.

A patient is admitted to the critical care unit with a subdural hematoma. The nurse is assessing the patient's Glasgow Coma Scale (GCS) score. When assessing the patient's best motor response, which movement would receive the lowest score? a. Abnormal extension b. Localizing pain c. Withdrawing from pain d. Decorticate posturing

a. Abnormal extension Abnormal extension (decerebrate posturing) receives a score of 2 on the Glasgow Coma Scale (GCS). The only lower score is 1, which is for a flaccid response.

A patient has been admitted in acute kidney failure with a 10-lb weight gain over 5 days. Which findings may be present in the patient? (Select all that apply.) a.S3 or S4 b.Distended neck veins c.Crackles d.Tachycardia with hypotension e.Edema that disappears with elevation of extremity

a.S3 or S4 b.Distended neck veins c.Crackles The patient is in fluid overload. An S3 or S4, distended neck veins, and crackles may be present in the patient. Tachycardia with hypotension is indicative of hypovolemia. Dependent edema that disappears with elevation of the extremity is indicative of poor circulation.

When calculating the anion gap, what is the predominant cation? a.Sodium b.Potassium c.Chloride d.Bicarbonate

a.Sodium The anion gap is a calculation of the difference between the measurable extracellular plasma cations (sodium and potassium) and the measurable anions (chloride and bicarbonate). In plasma, sodium is the predominant cation, and chloride is the predominant anion.

Which procedure is the diagnostic study of choice for acute head injury? a. Magnetic resonance imaging b. Computed tomography c. Transcranial Doppler d. Electroencephalography

b. Computed tomography Computed tomography offers rapid, convenient, noninvasive visualization of structures and is the diagnostic study of choice for an acute head injury.

A patient has been admitted post craniotomy for a brain tumor. The patient management plan should include monitoring the patient for which complications? (Select all that apply.) a.Diabetes mellitus b.Fluid retention c.Intracranial hypotension d.Surgical hemorrhage e.Corneal abrasions

b.Fluid retention d.Surgical hemorrhage e.Corneal abrasions Complications associated with a craniotomy include intracranial hypertension, surgical hemorrhage, fluid imbalance, cerebrospinal fluid leak, deep venous thrombosis, infection, corneal abrasions, and injury from fall or seizures.

A patient is admitted with acute kidney injury. The patient's weight upon admission was 176 lb and the next day it is 184 lb. What is the approximate amount of fluid retained with this weight gain? a.800 mL b.2200 mL c.3600 mL d.8000 mL

c.3600 mL One liter of fluid equals 1 kg, which is 2.2 lb; 8 lb equals 3.6 kg, which is 3.6 liters; 3.6 liters is equal to 3600 mL.

The nurse is caring for a patient who is had transsphenoidal surgery for removal of a pituitary tumor. The nurse observes a large amount of clear drainage from the nose. The practitioner requests the drainage be tested for the presence of glucose. What is the purpose of this intervention? a.To assess for an infection b.To check for a shift in osmolality c.To check for occult blood d.To assess for a cerebrospinal fluid leak

d.To assess for a cerebrospinal fluid leak To differentiate cerebrospinal fluid (CSF) drainage from postoperative serous drainage, a specimen is tested for glucose content. A CSF leak is confirmed by glucose values of 30 mg/dL or greater.

The patient complains of a metallic taste and loss of appetite. The nurse is concerned that the patient has developed what problem? a.Glycosuria b.Proteinuria c.Myoglobin d.Uremia

d.Uremia A history of recent onset of nausea and vomiting or appetite loss caused by taste changes (uremia often causes a metallic taste) may provide clues to the rapid onset of kidney problems. Glycosuria is the presence of glucose in the urine. Proteinuria is the presence of protein in the urine. Myoglobin is the presence of red blood cells in the urine.