ICU practic NCLEX
An adult client arrives in the emergency department with burns to both legs and perineal area. Using the rule of nines, the nurse would determine that approximately what percentage of the client's body surface has been burned? ___%
Answer Key: 37 Feedback: The most rapid method used to calculated the size of a burn injury in adult clients whose weights are in normal proportion to their heights is the rule of nines. This method divides the body into areas that are multiples of 9% except the perineum (which is 1%). Each leg is 18%, each arm is 9%, and the head is 9%, the trunk is 36%. Both legs and perineal area equal 37%.
The nurse is caring for a client with a spinal cord injury who has spinal shock. The nurse performs an assessment on the client, knowing that which assessment will provide the best information about recovery from spinal shock? A. Reflexes B. Pulse rate C. Temperature D. Blood Pressure
Answer Key: A Feedback: Good Job! Areflexia characterizes spinal shock; therefore reflexes would provide the best information about recovery. Vital sign changes (options b, c, and d) are not consistently affected by spinal shock. Because vital signs are affected by many factors, they do not give reliable information about spinal shock recovery. Blood pressure would provide good information about recovery from other types of shock, but not spinal shock.
Which of the following measures should the nurse implement to prevent ventilator-associated pneumonia (VAP) in the client who is intubated and on mechanical ventilation? A. Practice meticulous hand hygiene. B. Maintain the head of the bed elevation at 10 degrees. C. Perform suctioning of oral cavity secretions every 6 hours D. Have the respiratory therapist change the ventilator circuit tubing every 24 hours.
Answer Key: A Feedback: Good Job! Because normal upper airway defenses are bypassed, clients who are intubated with mechanical ventilation are at risk for VAP. Prevention includes effective handwashing before and after suctioning, when touching ventilator equipment, and when in contact with respiratory secretions.
The nurse evaluates a client following treatment for carbon monoxide poisoning. The nurse would document that the treatment was effective if which of the following were present? A. The client is sleeping soundly B. The client is awake and talking C. The heart monitor shows sinus tachycardia D. Carboxyhemoglobin levels are less than 5%
Answer Key: D Feedback: Normal carboxyhemoglobin levels are less than 5% for an adult (0.05%-2.5% for a nonsmoker and 5-10% for a heavy smoker). Clients can be awake and talking with abnormally high levels. The symptoms of carbon monoxide poisoning are tachycardia, tachypnea, and central nervous system depression.
An anxious client presents to the emergency room seeking treatment for a laceration of the finger. The client's vital signs are pulse 106 beats per minute, blood pressure 158/88mmHg, and respirations 28 breaths per minute. After cleansing the injury and reassuring the client, the nurse rechecks vital signs and notes a pulse of 82 beats per minute, BP 130/80mmHg, and respirations 20 breaths per minute. The nurse determines that the change in vital signs is caused by:Incorrect A. Cooling effects of the cleansing agent B. Clients adaptation to the air conditioning C. Early clinical indicators of shock D. Fall in sympathetic nervous system discharge
Answer Key: D Feedback: Physical or emotional stress triggers sympathetic nervous system stimulation which causes tachycardia, high blood pressure, and tachypnea. Stress reduction returns these parameters to baseline. Tips: Remove the two that are alike: "cooling action" and "air conditioning"
A nurse is caring for a client who had an allogenic liver transplant and is receiving tacrolimus (Prograf) daily. Which finding indicates to the nurse that the client is experiencing and adverse reaction to the medication? A. Hypotension B. Photophobia C. Profuse sweating D. Decrease in urine output
Answer Key: D Feedback: Tacrolimus is an immunosuppressant medication used in the prophylaxis of organ rejection in clients receiving allogenic liver transplants. Frequent side effects include headache, tremor, insomnia, paresthesia, diarrhea, nausea, constipation, vomiting, abdominal pain, and hypertension. Adverse reactions and toxic effects include nephrotoxicity and pleural effusion. Nephrotoxicity is characterized by an increasing serum creatinine level and a decrease in urine output.
A nurse is caring for a client after a supratentorial craniotomy. The nurse places a sign above the client's bed stating that the client should be maintained in which of the following positions? A. Prone B. Supine C. Semi-Fowlers D. Dorsal recumbent
C Semi-Fowlers After supratentorial surgery (surgery above the brain's tentorium), the client's head is usually elevated to 30 degrees to promote venous outflow through the jugular veins and modulate intracranial pressure (ICP). Options a,b, and d are incorrect positions after this surgery because they are likely to increase ICP.
Above was question 10.
q
A nurse is assessing a client with a brainstem injury. In addition to performing the Glascow Coma Scale, the nurse plans to: A. Perform Arterial Blood Gases and pulse oximetry B. Assist with a lumbar puncture and assess deep tendon reflexes C. Perform a pulmonary wedge pressure using a Swan-Ganz line D. Check cranial nerve functioning and respiratory rate and rhythm
Answer Key: D Feedback: Great Job! Assessment should be specific to the area of the brain involved. Assessing the respiratory status and cranial nerve function is a critical component of the assessment process in a client with a brain stem injury because the respiratory center is located in the brainstem. Options a,b, and c are not necessary based on the data in the question.
A client with a spinal cord injury is at risk of developing footdrop. The nurse should use which of the following as the effective preventative measure? A. Foot board B. Heel protectors C. Posterior splints D. Pneumatic boots
Answer Key: C Feedback: The most effective means of preventing footdrop is the use of posterior splints or high-top sneakers. A foot board prevents plantar flexion, but also places the client more at risk for developing pressure ulcers of the feet. Heel protectors protect the skin, but do not prevent footdrop. Pneumatic boots prevent deep vein thrombosis, but not foot drop.
A nurse is caring for a client with hypertension receiving torsemide (Demedex) 5mg orally daily. Which of the following would indicate to the nurse that the client might be experiencing a side effect related to the medication? A. A chloride level of 98mEq/L B. A sodium level of 135 mEq/L C. A potassium level of 3.1 mEq/L D. A blood urea nitrogen (BUN) of 15mg/dL
Answer Key: C Feedback: Torsemide is a loop diuretic. It is common for this medication to cause hypokalemia. The medication can produce acute, profound water loss, volume and electrolyte depletion, dehydration, decreased blood volume, and circulatory collapse. Potassium is the only option that indicates electrolyte depletion, the other values are WDL.
The nurse is caring for a client with a thoracic spinal cord injury. As part of the nursing care plan, the nurse monitors for spinal shock. In the event that spinal shock occurs, the nurse anticipates that the most likely intravenous (IV) fluid to be prescribed would be: A. Dextran B. 0.9% normal saline C. 5% dextrose in water D. 5% dextrose in 0.9% normal saline
Answer Key: B Feedback: Good Job! Normal saline is an isotonic solution that primarily remains in the intravascular space, increasing intravascular volume. This IV fluid would increase the client's blood pressure. Dextran is rarely used in spinal shock because isotonic fluid administration usually suffices. Additionally Dextran has potential adverse effects, like bleeding. Dextrose 5% in water is a hypotonic solution that pulls fluid out of the intravascular space and is not indicated for shock. Dextrose 5% in normal saline 0.9% is hypertonic and may be indicated for shock resulting from burns or hemorrhage.
An adult client has undergone a lumbar puncture to obtain cerebrospinal fluid (CSF) for analysis. The nurse assesses for which of the following values that should be negative if the CSF is normal? A. Protein B. Glucose C. Red blood cells D. White blood cells
Answer Key: C Feedback: The adult with normal CSF has no red blood cells in the CSF. The client may have small levels of white blood cells (0-8 cells/mm3). Protein (15-45mg/dL), and glucose (45-74mg/dL) are normally present in CSF
A client with significant flail chest has arterial blood gases (ABGs) that reveal a PaO2 of 68 and a PaCO2 of 51. Two hours ago the PaO2 was 82 and the PaCO2 was 44. Based on these changes the nurse obtains which of the following items? A. Intubation tray B. Chest tube insertion set C. Portable chest x-ray machine D. Injectable lidocaine (Xylocaine)
Answer Key: A Feedback: Good Job! Flail chest occurs from a blunt trauma to the chest. The loose segment from the chest wall becomes paradoxical to the expansion and contraction of the rest of the chest wall. The client with flail chest has painful rapid shallow respirations while experiencing severe dyspnea. The effort of breathing and the paradoxical chest movement have the net effect of producing hypoxia and hypercapnia. The client develops respiratory failure and frequently requires intubation and mechanical ventilation, usually with positive end expiratory pressure (PEEP); therefore an intubation tray is necessary.
A client with renal failure is receiving epoetin alfa (Epogen) to support erythropoiesis. The nurse questions the client about compliance with taking which of the following medications that supports red blood cell (RBC) production? A. Iron supplement B. Zinc supplement C. Calcium supplement D. Magnesium supplement
Answer Key: A Feedback: Good Job! Iron is needed for RBC production; otherwise the body cannot produce sufficient erythrocytes. in either case the client is not receiving the full benefit of epoetin alfa therapy if iron is not taken. Options b, c, and d are not necessary for RBC production.
A nurse has just finished assisting the physician in placing a central intravenous (IV) line. Which of the following is a priority intervention after central line insertion? A. Prepare the client for a chest radiograph B. Assess the client's temperature to monitor for infection. C. Label the dressing with the date and time of catheter insertion. D. Monitor the blood pressure (BP) to assess for fluid volume overload
Answer Key: A Feedback: Great Job! A major risk associated with central line placement is the possibility of a pneumothorax developing from an accidental puncture of the lung. Assessing the results of a chest radiograph is one of the best methods to determine if this complication has occurred and verify catheter tip placement before initiating intravenous therapy.
A client without history of respiratory disease has experienced sudden onset of chest pain and dyspnea and is diagnosed with pulmonary embolus. The nurse immediately implements which expected prescription for this client? A. Semi-fowler's position, oxygen, and morphine sulfate intravenously (IV) B. Supine position, oxygen, and meperidine hydrochloride (Demerol) intramuscularly (IM) C. High Fowler's position, oxygen, meperidine hydrochloride (Demerol) intravenously (IV) D. High Fowler's position, oxygen, and two tablets of acetaminophen with codeine (Tylenol #3)
Answer Key: A Feedback: Standard therapeutic intervention for the client with pulmonary embolus includes proper positioning, oxygen and intravenous analgesics. the head of the bed is placed in semi-Fowler's position. High Fowler's is avoided because extreme hip flexure slows venous return from the legs and increases the risk of new thrombi. The supine position will increase the dyspnea that occurs with pulmonary embolism. The usual analgesic of choice is morphine sulfate administered IV. The medication reduces pain, relieves anxiety, and can diminish congestion of blood in the pulmonary vessels because it causes peripheral venous dilation
A client was admitted to the nursing unit with a closed head injury 6 hours ago. During initial assessment, the nurse finds that the client has vomited, is confused, and complains of dizziness and headache. Based on these data, which of the following is the most important nursing action? A. Notify the physician B. Administer an antiemetic C. Reorient the client to surroundings D. Change the client's gown and bed linens
Answer Key: A Feedback: The client with a closed head injury is at risk of developing increased intracranial pressure (ICP). Increased ICP is evidenced by signs and symptoms such as headache, dizziness, confusion, weakness, and vomiting. Because of the implications of the client's manifestations, the most important nursing intervention is to notify the physician. Other nursing actions that are appropriate include physical care of the client and reorientation of surroundings.
A client in renal failure is at risk for hyperkalemia. The nurse monitors for which of the following clinical manifestations of hyperkalemia? A. Tall peaked T waves B. Flattened P waves C. Prominent U wave on EKG D. Widened QRS
Answer Key: A, B, D Feedback: Tall peaked T waves, flattened P waves, and widened QRS are signs and symptoms of hyperkalemia. U waves are present in hypokalemia.
The nurse plans care for a client diagnosed with end-stage renal disease (ESRD). Which findings does the nurse expect to find in the client's medical record? Select all that apply. A. Edema B. Anemia C. Hypotension D. Bradycardia E. Hypocalcemia
Answer Key: A, B, E Feedback: The manifestations of ESRD are the result of impaired renal function. Three main functions of the kidney include fluid balance, erythropoietin production, and vitamin D activation. Anemia, Edema and Hypocalcemia are common. Hypertension, not hypotension is common. Bradycardia is not a common findings in ESRD.
A client is due in hydrotherapy for a burn dressing change. To ensure that the procedure is most tolerable for the client, the nurse takes which of the following actions? A. Ensures that the client has a robe and slippers B. Administers an analgesic 20 minutes before therapy C. Sends dressing supplies with the client to hydrotherapy D. Administers the intravenous antibiotic 30 minutes before therapy
Answer Key: B The client should receive pain medication approximately 20 minutes before a burn dressing change. This will help the client tolerate an otherwise painful procedure.
A client is admitted to the cardiac intensive care unit after coronary artery bypass graft surgery. The nurse notes that in the first hour after admission, the mediastinal chest tube drainage was 75ml. During the second hour, the drainage had dropped to 5ml. The nurse interprets that: A. This is normal B. The tube may be occluded C. The lung has fully expanded D. The client needs to cough and deep breathe
Answer Key: B Feedback: After coronary artery bypass surgery, chest tube drainage should not exceed 100-150ml per hour during the first two hours postoperatively, and approximately 500 ml of drainage is expected in the first 24 hours after coronary artery bypass graft surgery. The sudden drop in drainage between the first and second hour indicates that the tube is possibly occluded. The other options are incorrect interpretations.
Skin closure with heterograft will be performed on a client with a burn injury, and the client asks the nurse about the meaning of a heterograft. the nurse tells the client that a heterograft is skin from: A. A cadaver B. Another species C. The burned client D. A synthetic source
Answer Key: B Feedback: Biologic dressings can be heterograft, homograft, synthethic or autograft. Heterograft is skin from another species. The most common type of heterograft is pig skin because of its availability and its relative compatibility with human skin. Homograft is skin from another human which is usually obtained from a cadaver and is provided through a skin bank. Autograft is skin from the client. Synthetic dressings are also available for covering burn wounds.
The nurse is evaluating the effectiveness of antimicrobial therapy for a client with infective endocarditis. The nurse determines that which finding documented in the client's health record is the least reliable indicator of effectiveness. A. Clear breath sounds B. Systolic heart murmur C. Temperature of 98.8F D. Negative blood cultures
Answer Key: B Feedback: Good Job! A systolic heart murmur, once present in the client, will not resolve spontaneously and is therefore the least reliable indicator. Clear breath sounds are a normal finding, and in this instance could mean resolution of heart failure, if that was accompanying the endocarditis. Negative blood cultures and normothermia indicate resolution of infection.
The nurse is planning care for a client with a T3 spinal cord injury. The nurse includes which intervention in the plan to prevent autonomic dysreflexia (hyperreflexia). A. Administer dexamethasone (Decadron) as per the physician's prescription B. Assist the client to develop a daily bowel routine to prevent constipation C. Teach the client that this condition is relatively minor with few symptoms D. Assess vital signs and observe for hypotension, tachycardia, and tachypnea.
Answer Key: B Feedback: Good Job! Autonomic dysreflexia is a potentially life-threatening condition and may be triggered by bladder distention, bowel distention, visceral distention or stimulation of pain receptors in the skin. A daily bowel program eliminates this trigger. A client with autonomic dysreflexia would be hypertensive and bradycardic. Removal of the stimulus results in prompt resolution of the signs and symptoms. Option a is unrelated tho this specific condition. Autonomic dysreflexia is a neurological emergency and must be treated immediately to prevent a hypertensive stroke.
A client with a burn injury receives a prescription for a regular diet. Which is the best meal for the nurse to provide to the client to promote wound healing? A. Peanut butter and jelly sandwich, apple, tea B. Chicken breast, broccoli, strawberries, milk C. Veal chop, boiled potatoes, Jell-O, orange juice D. Pasta with tomato sauce, garlic bread, ginger ale
Answer Key: B Feedback: The meal with the best potential to promote wound healing includes nutrient-rich food choices including protein, such as chicken and milk, and vitamin C, such as broccoli and strawberries. The remaining options include one or more items with a low nutritional value especially the tea, jelly, Jell-O, and ginger ale. Another important consideration is that depending on the extent of the injury, the basal metabolic rate is 40-100 times higher than normal in a client with a burn.
The nurse develops a care plan for a client receiving hemodialysis who has an arteriovenous (AV) fistula in the right arm. The nurse includes which interventions in the plan to ensure protecting the AV fistula? Select all that apply. A. Assess pulses and circulation proximal to the fistula. B. Palpate for thrills and auscultate for a bruit every four hours. C. Check for bleeding and infection at hemodialysis needle insertion sites. D. Avoid taking blood pressures or performing venipunctures in the extremity. E. Instruct the client not to carry heavy objects or anything that compresses the extremity. F. Instruct the client not to sleep in a position that places his or her body weight on top of the extremity.
Answer Key: B, C, D, E, F Feedback: An AV fistula is an internal anastomosis of an artery to a vein and is used as an access for hemodialysis. The nurse should implement the following to protect the fistula: avoid taking blood pressures or performing venipunctures in the extremity, palpate for thrills and auscultate for bruit every 4 hours, assess pulses and circulation distal to the fistula, check for bleeding and infection at hemodialysis needle insertion sites, instruct the client not to carry heavy objects or anything that compresses the extremity, and instruct the client not to sleep in a position that places his or her body weight on top of the extremity.
A client begins to experience a tonic clonic seizure. The nurse should take which of the following actions? Select all that apply. A. Restrain the client B. Turn the client to the side C. Maintain the client's airway D. Place a padded tongue blade into the client's mouth E. Loosen any restrictive clothing that the client is wearing F. Protect the client from injury and guide the client's movements
Answer Key: B, C, E, F Feedback: Good Job! Precautions are taken to prevent a client from sustaining injury during a seizure. The nurse would maintain the client's airway and turn the client to the side. The nurse would also protect the client from injury, guide the client's movements, and loosen any clothing. Restraints are never used because they could injure the client during the seizure. A padded tongue blade or any other object is never placed into the client's mouth after a seizure begins because the jaw may clench down.
A client with an extremity burn injury has undergone fasciotomy to treat compartment syndrome of the leg. The nurse prepares to provide which type of wound care to the fasciotomy site? A. Dry sterile dressings B. Hydrocolloid dressings C. Wet sterile saline dressings D. Half strength Betadine dressings
Answer Key: C Feedback: A fasciotomy is an incision made extending through the subcutaneous tissue and fascia. The fasciotomy site is not sutured but is left open to relieve pressure and edema. The site is covered with wet sterile saline dressings. After 3-5 days, when perfusion is adequate and edema subsides, the wound is debrided and closed. A hydrocolloid dressing is not indicated for use with clean open incisions. The incision is not dirty, so there should be no reason to require Betadine. Additionally Betadine can be irritating to normal tissues.
The nurse is caring for a client who develops compartment syndrome from a severely fractured arm. The client asks the nurse how this can happen. The nurse's response is based on the understanding that: A. A bone fragment has injured the nerve supply in the area. B. An injured artery causes impaired arterial perfusion through the compartment C. Bleeding and swelling cause increased pressure in an area that cannot expand D. The fascia expands with injury, causing pressure on underlying nerves and muscles
Answer Key: C Feedback: Compartment syndrome is caused by bleeding and swelling within an compartment, which is lined by fascia and that does not expand. The bleeding and swelling place pressure on the nerves, muscle, and blood vessels within the compartment, triggering the symptoms. Options a, b, and d are incorrect.
A client is experiencing acute cardiac and cerebral symptoms as a result of excess fluid volume. The nurse should implement which of the following measures to increase the client's comfort until specific therapy is prescribed by the physician. A. Measure urine output on an hourly basis B. Measure intravenous and oral fluid intake C. Elevate the client's head to at least 45 degrees D. Administer oxygen at 4L per minute by nasal cannula
Answer Key: C Feedback: Good Job! Elevating the head of the bed to 45 degrees reduces venous return to the heart from the lower body, thus reducing the volume of blood that is pumped by the heart. It also promotes venous drainage from the brain, reducing cerebral symptoms. The other options may be appropriate will not help the client's immediate symptoms.
A client is being brought into the emergency department after suffering a head injury. the first action by the nurse is to determine the client's: A. level of consciousness B. Pulse and Blood Pressure C. Respiratory rate and depth D. Ability to move extremities
Answer Key: C Feedback: Good Job! The first action of the nurse is to ensure that the client has an adequate airway and respiratory status. In rapid sequence the client's circulatory status is evaluated (b), followed by evaluation of the neurological status (a,d).
The nurse is inserting an oropharyngeal airway into an assigned client. The nurse plans to use which correct insertion procedure? A. Flex the client's neck B. Leave any dentures in place C. Suction the client's mouth once per shift D. Insert the airway with the tip pointed upward
Answer Key: C Feedback: Great Job! The client with uncontrolled atrial fibrillation with a ventricular rate over 100 beats per minute is at risk for low cardiac output caused by loss of atrial kick. The nurse should assess the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins.
The nurse is caring for a client scheduled to have a cardiac catheterization for the first time. The nurse tells the client that the: A. Procedure is performed in the operating room. B. Initial catheter incision is quite painful, after that, there is little or no pain C. Client may feel fatigue and have various aches, because it is necessary to lie quietly on a hard X-ray table for about 4 hours. D. Client may feel certain sensations at various points during the procedure, such as a fluttery feeling, flushed warm feeling, desire to cough, or palpitations.
Answer Key: D Feedback: Cardiac catheterization is an invasive test that involves the insertion of a catheter and the injection of dye into the heart and surrounding vessels to obtain information about the structure and function of the heart chambers, valves, and coronary circulation. Preprocedure teaching points include that the procedure is done in a darkened cardiac catheterization room and that ECG leads are attached to the chest. A local anesthetic is used so there is little to no pain with catheter insertion. The x-ray table is hard and may be tilted periodically. The procedure may take up to 2 hours, and the client may feel various sensations with catheter passage and dye injection.
The nurse is caring for a client with a head injury and is monitoring the client for decerebrate posturing. Which of the following is characteristic of this type of posturing? A. Flexion of the extremities B. Extension of the extremities C. Upper extremity extension with lower extremity flexion D. Upper extremity flexion with lower extremity extension
Answer Key: D Feedback: Decerebrate posturing, which can occur with upper brainstem injury, is characterized by extension of the extremities.
A client has an arteriovenous (AV) fistula in place in the right upper extremity for hemodialysis treatments. When planning care for this client, which of the following measures should the nurse implement to promote client safety. A. Take blood pressures only on the right arm to ensure accuracy B. Use the fistula for all venipunctures and intravenous infusions C. Ensure that small clamps are attached to the AV fistula dressing D. Assess the fistula for the presence of a bruit and thrill every 4 hours
Answer Key: D Feedback: Fistulas should be evaluated for the presence of a thrills (palpate over the area) and bruits (auscultate with a stethoscope) as an assessment of patency.
The nurse assesses the water seal chamber of a closed chest drainage system and notes fluctuations in the chamber. The nurse determines that this finding indicates that: A. The tubing is kinked B. An air leak is present C. The lung has reexpanded D. The system is functioning as expected
Answer Key: D Feedback: Fluctuations (tidaling) in the water seal chamber are normal during inhalation and exhalation until the lung reexpands and the client no longer requires chest drainage. If fluctuations are absent it could indicate occlusion of the tubing or that the lung has re-expanded. Bubbling in the water seal chamber indicates that an air leak is present.
A hospitalized client is dyspneic and has been diagnosed with a left tension pneumothorax by chest x-ray after insertion of a central venous catheter. Which of the following indicates that the pneumothorax is worsening? A. Hypertension B. Flat neck veins C. Pain with respiration D. Tracheal deviation to the right
Answer Key: D Feedback: Good Job! A tension pneumothorax is characterized by distended neck veins, displaced point of maximal impulse (PMI), tracheal deviation to the unaffected side, asymmetry of the thorax, decreased or absent lung sounds, and worsening cyanosis. The increased intrathoracic pressure causes the blood pressure to fall, not rise. The chest could have pain with respiration.
The nurse has developed a plan of care for a client with a diagnosis of anterior cord syndrome A. Change the client's positions slowly B. Assess the client for decreased sensation to touch C. Assess the client for decreased sensation to vibration D. Teach the client about loss of motor function and decreased pain sensation
Answer Key: D Feedback: Good Job! Anterior cord syndrome is caused by damage to the anterior portion of the grey and white matter. Clinical findings related to anterior cord syndrome include loss of motor function, temperature sensation, and pain sensation below the level of injury. The syndrome does not affect sensations of touch, position, and vibration.
The client with chronic renal failure who is scheduled for hemodialysis this morning is due to receive a daily dose of enalapril (Vasotec). The nurse plans to administer this medication: A. During dialysis B. Just before dialysis C. The day after dialysis D. Upon return from dialysis
Answer Key: D Feedback: Good Job! Antihypertensive medications, such as enalapril, are administered to the client after hemodialysis. This prevents the client from becoming hypotensive during dialysis and also from having the medication removed from the bloodstream by dialysis. There is no rationale for waiting a full day to resume the medication. This would lead to ineffective control of the blood pressure.
A client is intubated and receiving mechanical ventilation. The physician has added 7cm of positive end expiratory pressure (PEEP) to the ventilator settings of the client. The nurse assesses for which of the following expected but adverse effects of PEEP? A. Decreased peak pressure on the ventilator B. Increased temperature from 98 to 100 F rectally C. Decreased heart rate from 78 to 64 beats per minute D. Systolic blood pressure decrease from 122 to 98 mmHg
Answer Key: D Feedback: Good Job! PEEP improves oxygenation by enhancing gas exchange and preventing atelectasis. PEEP leads to increased intrathoracic pressure, which in turn leads to decreased cardiac output. This is manifested in the client by decreased blood pressure and increased pulse (compensation). Peak pressures on the ventilator should not be affected, although the pressure at the end of expiration remains positive at the level set for the PEEP. Fever indicates respiratory infection or infection from another source.
A client admitted to the hospital for repair of an unruptured cerebral aneurysm. Before surgery, the nurse performs frequent assessments on the client. Which assessment finding would be noted first if the aneurysm ruptures? A. Widened pulse pressure B. Unilateral motor weakness C. Unilateral slowing of pupil response D. A decline in the level of consciousness
Answer Key: D Feedback: Good Job! Rupture of a cerebral aneurysm usually results in increased intracranial pressure (ICP). The first sign of increased pressure in the brain is a change in the level of consciousness. This change in consciousness can be as subtle as drowsiness or restlessness. Because centers that control blood pressure are located lower in the brain than those that control consciousness, pulse pressure alteration is a later sign. Slowing of pupil response and motor weakness are also late signs.
A client involved in a house fire is experiencing respiratory distress, and an inhalation injury is suspected. The nurse monitors which of the following for the presence of carbon monoxide poisoning? A. Pulse oximetry B. Urine myoglobin C. Sputum carbon levels D. Serum carboxyhemoglobin levels
Answer Key: D Feedback: Good Job! Serum carboxyhemoglobin levels are the most direct measure of carbon monoxide poisoning, provide the level of poisoning, and thus determine the appropriate treatment measures. The carbon monoxide molecule has a 200 times greater affinity for binding with hemoglobin than an oxygen molecule, causing decreased availability of oxygen to the cells. Clients are treated with 100% oxygen Options a,b, and c do not identify carbon monoxide poisoning.
A client who is unresponsive and pulseless and who has a possible neck injury is brought into the emergency department after a motor vehicle crash. Which does the nurse do to open the client's airway? A. Insert an oropharyngeal airway B. Tilt the head and lift the chin C. Place in the recovery position D. Stabilize the skull and push up the jaw
Answer Key: D Feedback: Good Job! The health care team uses the jaw-thrust maneuver to open the air way until a radiograph confirms that the client's cervical spine is clear to avoid potential aggravation of a cervical spine injury. Options a and b require manipulation of the spine to open the airway and option c can be ineffective for opening the airway.
The nurse assists the provider with a liver biopsy performed at the bedside. Which position does the nurse place the client in after the biopsy? A. Supine with the head elevated on one pillow B. Semi-Fowler's with two pillows under the legs C. Left side-lying with a small pillow under the puncture site D. Right side-lying with a folded towel under the puncture site
Answer Key: D Feedback: Great Job! The liver is located on the right side of the body. After a biopsy, the nurse positions the client on the right side with a small pillow or folded towel under the puncture site for 2 hours. This position presses the liver against the chest wall at the biopsy site.
