LP 3: Critical Care (burns, shock, ventilation, heart surgery)
After open-heart surgery a client develops a temperature of 102*F. The nurse notifies the physician, because elevated temperatures: a. Increase the cardiac output b. May indicate cerebral edema c. May be a forerunner of hemorrhage d. Are related to diaphoresis and possible chilling
a. Increase the cardiac output Temperatures of 102*F or greater lead to an increased metabolism and cardiac workload.
A patient who has been severely burned in an accident is brought to the emergency department. The physician orders a regimen to begin fluid resuscitation. Which type of fluid would the nurse most likely use as part of fluid resuscitation following a burn injury? a. Lactated Ringer's solution b. 0.9% Normal saline c. D10W d. D5 ½ NS with KCl
a. Lactated Ringer's solution
The nurse is caring for a patient who was just placed on mechanical ventilation and is observing the patient's vital signs because positive-pressure ventilation can lead to: Select all that apply. a. decreased cardiac output. b. decreased venous return. c. increased renal function. d. decreased intracranial pressure. e. increased hepatic function.
a. decreased cardiac output. b. decreased venous return. d. decreased intracranial pressure. 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 CO. As a secondary consequence, hepatic and renal dysfunction may occur. In addition, positive-pressure ventilation impairs cerebral venous return. In patients with impaired autoregulation, positive-pressure ventilation can result in increased intracranial pressure. Cognitive Level: Application Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation
Which of the following blood gases would be indicative of acute respiratory failure - ventilation failure? a. pH 7.22, PaCO2 54, PaO2 68 mmHg; HCO3 28 meq/L b. pH 7.22, PaCO2 28, PaO2 78 mmHg; HCO3 18 meq/L c. pH 7.22, PaCO2 44, PaO2 58 mmHg; HCO3 36 meq/L d. pH 7.56, PaCO2 28, PaO2 98 mmHg; HCO3 30 meq/L
a. pH 7.22, PaCO2 54, PaO2 68 mmHg; HCO3 28 meq/L
The nurse is suctioning a patients endotracheal tube and notices that the heart rate is dropping from 100 to 52 beats/min. What is the priority action? a. Increase the oxygen on the ventilator. b. Stop suctioning and give the patient some extra breaths. c. Administer atropine 0.5 mg intravenously (IV) per protocol. d. Increase the patient's IV fluids.
b. Stop suctioning and give the patient some extra breaths. The patient is experiencing a vagal response to suctioning. The procedure should be stopped immediately, and the patient should be provided extra breaths either manually or on the ventilator. Extra breaths will hyperoxygenate the patient and hopefully reverse the vagal response. Atropine is appropriate only if the patient is symptomatic and hyperoxygenation fails to reverse the bradycardia. Increasing IV fluids may or may not have any effect on the situation. Because the ventilator is already on 100% FiO
Mr. A is placed on a ventilator after cardiac arrest. Which statement is correct regarding endotracheal tube cuff management? a. The cuff should be deflated every 2 hours to minimize tissue damage to the trachea. b. The minimal leak technique is commonly used to determine proper cuff inflation. c. Cuff pressures between 40 and 50 mm Hg are necessary to maintain a proper seal. d. Cuff pressure should be monitored at least every 24 hours.
b. The minimal leak technique is commonly used to determine proper cuff inflation. The minimal leak technique is commonly used to determine proper cuff pressure. In a patient requiring positive end-expiratory pressure or at high risk for aspiration, the minimal occlusion volume technique can be used. Cuff pressure should be monitored at least every shift and kept at no higher than 25 mm Hg. Routine cuff deflation is not done because of the high risk of aspiration in intubated patients.
A patient is admitted to the intensive care unit with an acute myocardial infarction. Upon assessment, the patient is noted to be confused. The nurse suspects that the confusion is most likely attributable to: a. early onset of dementia. b. low cardiac output. c. anxiety over chest pain. d. poor oxygen exchange.
b. low cardiac output. When assessing a patient with an altered cardiac function, confusion is most likely because of a decrease in cardiac output, hypotension, or hypoxemia. There is no indication from the patient's history to support a consideration of dementia. Anxiety may cause distraction, but confusion is uncommon.
A patient admitted with sepsis has a pulmonary artery catheter placed that also measures SvO2. During a routine assessment, the nurse notes that the patient's SvO2 is 56%. The nurse knows that this indicates: a. oxygen supply is not equal to demand. b. oxygen supply is equal to demand. c. oxygen saturation is not accurate. d. oxygen is not being extracted by the tissues.
b. oxygen supply is not equal to demand.
Which statement is true regarding the use of prone positioning in a patient with acute lung injury (ALI)? a. It can be used safely in all patients. b. A strict schedule of turning every 2 hours must be adhered to for greatest success. c. Prone positioning improves perfusion to less damaged areas of the lung. d. It is not useful in mobilizing secretions.
c. Prone positioning improves perfusion to less damaged areas of the lung. In ALI, the dependent areas of lung tissue are most affected. The prone position allows perfusion of the healthier tissue. It is contraindicated in patients with head and spinal trauma and may cause edema. Care must be taken to keep the eyes moist and taped shut while the patient is prone to avoid corneal ulcerations.
During a cardiac catherization blood samples from the right atrium, right ventricle, and pulmonary artery are analyzed for their oxygen content. Normally: a. All contain less CO2 than does pulmonary vein blood b. All contain more oxygen than does pulmonary vein blood c. The samples of blood all contain about the same amount of oxygen d. Pulmonary artery blood contains more oxygen than the other samples
c. The samples of blood all contain about the same amount of oxygen Blood samples from the right atrium, right ventricle, and pulmonary artery would all be about the same with regard to oxygen concentration. Such blood contains slightly less oxygen than does systemic arterial blood.
What statement best describes what happens to the alveoli in ARDS? a. They are over expanded b. They have increased perfusion c. They are filled with fluid d. They have improved gas exchange
c. They are filled with fluid
A 2 year-old is being monitored after cardiac surgery. What data represents a decrease in cardiac output? a. Hypertension b. Increased urine output c. Weak peripheral pulses d. Capillary refill < 2 sec
c. Weak peripheral pulses
Strategies to prevent ventilator associated pneumonia include: a. rotating the patient's position every 2 hours with HOB at 10 degrees. b. daily oral care with peroxide. c. peptic ulcer disease prophylaxis. d. biweekly assessment of readiness to extubate.
c. peptic ulcer disease prophylaxis. Strategies to prevent VAP ("VAP bundle") include elevation of the head of the bed, daily "sedation vacations," assessment of readiness to extubate, peptic ulcer disease prophylaxis, deep venous thrombosis prophylaxis, and daily oral care with chlorhexidine.
The nurse is caring for a patient admitted with severe sepsis. Her blood pressure is 80/50 mm Hg, heart rate 120 bpm and temperature 102 degrees Fahrenheit. Assuming physician orders, which intervention should the nurse carry out first? a. Acetaminophen suppository b. Blood cultures obtained from two different sites c. Broad spectrum antibiotics d. Isotonic fluid challenge
d. Isotonic fluid challenge
The nurse prepares the client for insertion of a pulmonary artery catheter (Swan-Ganz catheter). The nurse teaches the client that the catheter will be inserted to provide information about: a. Stroke volume b. Cardiac output c. Venous pressure d. Left ventricular functioning
d. Left ventricular functioning The catheter is placed in the pulmonary artery. Information regarding left ventricular function is obtained when the catheter balloon is inflated.
A woman with severe mitral stenosis and mitral regurgitation has a pulmonary artery catheter inserted. The physician orders pulmonary artery pressure monitoring, including pulmonary capillary wedge pressures. The purpose of this is to help assess the: a. Degree of coronary artery stenosis b. Peripheral arterial pressure c. Pressure from fluid within the left ventricle d. Oxygen and carbon dioxide concentration is the blood
d. Oxygen and carbon dioxide concentration is the blood The pulmonary artery pressures are used to assess the heart's ability to receive and pump blood. The pulmonary capillary wedge pressure reflects the left ventricle end-diastolic pressure and guides the physician in determining fluid management for the client. The degree of coronary artery stenosis is assessed during a cardiac catherization. The peripheral arterial pressure is assessed with an arterial line.
A client's ABG results are : pH 7.56, PaCO2 22 mmHg; PaO 86 mmHg; HCO3 26 mEq/L; O2 98%. The ABG results represent: a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory Acidosis d. Respiratory Alkalosis
d. Respiratory Alkalosis
For the first 24 hours after a burn injury, a standard fluid resuscitation formula is 4 mL/kg/% burn of intravenous (IV) fluid for the first 24 hours. What is the total amount of fluid that will be administered to a 70-kg man with a burn injury that covers 50% of his body surface area?
14,000 mL
Which question is appropriate for the nurse to ask to determine the quality of the patient's chest pain? a. "How long does it last?" b. "How severe is it?" c. "What is it like?" d. "When did it begin?
a. "What is it like?" "What is it like?" is an open-ended question that allows the patient to describe the quality of the chest pain. "How severe is it?" and "How long does it last?" are questions related to the quantity of the chest pain. "When did it begin?" will elicit a reply that refers to the chronology of the chest pain.
A patient is brought into the emergency department after suffering from third degree burns in an explosion. The patient has burns on approximately 40 percent of his body. The nurse weighs the patient and notes that he weighs 170 lbs. Calculate the volume of IV fluid this patient must receive in the first 24 hours using the Parkland formula. a. 12 L b. 4 L c. 8 L d. 16 L
a. 12 L
A client has just arrived to the Emergency Department and has sustained burns on the front and back of the right arm and leg a. 27% b. 18% c. 36% d. 9%
a. 27%
A 2 year old comes in with burns from the bath tub to both legs, what percentage of body is this? a. 15% b. 30% c. 9.50% d. 19%
b. 30%
Mr. G requires neuromuscular blockade to facilitate mechanical ventilation. Which is not a true statement when providing nursing care to paralyzed patients? a. Because patients under neuromuscular blockade are unable to react to the environment, special safety precautions are not needed. b. Pain medication is required because neuromuscular blocking agents do not have an analgesic effect. c. Patients under the influence of neuromuscular blocking agents are fully aware of activity around them. d. The nurse must be alert for complications of immobility such as deep vein thrombosis, pressure ulcers, and atelectasis.
a. Because patients under neuromuscular blockade are unable to react to the environment, special safety precautions are not needed. Neuromuscular blocking agents only halt skeletal muscle movement and do not inhibit pain or awareness; they must be administered together with a sedative or anxiolytic agent. Pain medication is administered if the patient has a pain-producing illness or surgery. Providing reorientation and explanations for all procedures is critical because patients can still hear but cannot move or see. These patients are also at high risk for developing the complications of immobility, so interventions related to the prevention of skin breakdown, atelectasis, and deep vein thrombosis are also implemented. Patient safety is another concern because these patients cannot react to the environment. Special precautions are taken to protect patients at all times.
A client has the diagnosis of left ventricular failure and a high pulmonary capillary wedge pressure (PCWP). The physician orders dopamine to improve ventricular function. The nurse will know the medication is working if the client's: a. Blood pressure rises b. Blood pressure decreases c. Cardiac index falls d. PCWP rises
a. Blood pressure rises If dopamine as a positive effect, it will cause vasoconstriction peripherally, but increase renal perfusion and the blood pressure will rise. The cardiac index will also rise and the PCWP should decrease.
Which of the following actions is an important part of oral care for an intubated patient? Select all that apply. a. Brushing the teeth and tongue with a soft-bristled toothbrush b. Using lemon glycerin swabs on the patient's lips and gums c. Using alcohol-based mouthwash every 2 hours d. Using a tonsil suction to keep secretions cleared out of the mouth e. Providing lip moisturizer as needed
a. Brushing the teeth and tongue with a soft-bristled toothbrush Oral care consists of brushing the patient's teeth with a soft toothbrush to reduce plaque, brushing the patient's tongue and gums with a foam swab to stimulate the tissue, and performing deep oropharyngeal suction to remove any secretions that have pooled above the patient's cuff. Lemon glycerin swabs and alcohol-based mouthwashes dry out the mouth and lips and are not recommended. Cognitive Level: Analysis Nursing Process: Implementation Client Need: Physiological Integrity: Physiological Adaptation d. Using a tonsil suction to keep secretions cleared out of the mouth Oral care consists of brushing the patient's teeth with a soft toothbrush to reduce plaque, brushing the patient's tongue and gums with a foam swab to stimulate the tissue, and performing deep oropharyngeal suction to remove any secretions that have pooled above the patient's cuff. Lemon glycerin swabs and alcohol-based mouthwashes dry out the mouth and lips and are not recommended. Cognitive Level: Analysis Nursing Process: Implementation Client Need: Physiological Integrity: Physiological Adaptation e. Providing lip moisturizer as needed Oral care consists of brushing the patient's teeth with a soft toothbrush to reduce plaque, brushing the patient's tongue and gums with a foam swab to stimulate the tissue, and performing deep oropharyngeal suction to remove any secretions that have pooled above the patient's cuff. Lemon glycerin swabs and alcohol-based mouthwashes dry out the mouth and lips and are not recommended. Cognitive Level: Analysis Nursing Process: Implementation Client Need: Physiological Integrity: Physiological Adaptation
Which of the following descriptions are accurate regarding full-thickness wounds? Select all that apply. a. Dry b. Wet c. Painful d. Painless e. Black f. White
a. Dry d. Painless e. Black f. White
A 12-year-old boy has been brought into the emergency room after suffering a burn injury while helping his dad in the garage. The nurse performs a rapid initial assessment of the wounds and checks for signs of inhalation injury. Which of the following signs or symptoms would indicate an inhalation injury in this child? a. Elevated carboxyhemoglobin level b. Burns to the neck and chest c. Burned hair and eyebrows d. Respiratory rate of 24/min
a. Elevated carboxyhemoglobin level
Which hemodynamic changes are associated with mitral stenosis? a. Elevated left atrial pressure, pulmonary artery occlusive pressure, and pulmonary artery diastolic pressure; normal left ventricular end-diastolic pressure b. Elevated left atrial pressure, pulmonary artery occlusive pressure, and left ventricular end-diastolic pressure; normal pulmonary artery diastolic pressure c. Elevated pulmonary artery occlusive pressure, pulmonary artery diastolic pressure, and left ventricular end-diastolic pressure; normal left atrial pressure d. Elevated left atrial pressure, pulmonary artery diastolic pressure, and left ventricular end-diastolic pressure; normal pulmonary artery occlusive pressure
a. Elevated left atrial pressure, pulmonary artery occlusive pressure, and pulmonary artery diastolic pressure; normal left ventricular end-diastolic pressure In mitral valve stenosis, left atrial pressure and pulmonary artery occlusive pressure are increased and cause pulmonary congestion; however, these elevated values do not reflect the left ventricular end-diastolic pressure (LVEDP) because a stenotic mitral valve decreases normal blood flow from the left atrium to the left ventricle, decreasing left ventricular preload and consequently lowering LVEDP. The other options do not accurately describe the hemodynamic effects of mitral stenosis.
For a client who excretes excessive amounts of calcium during the postoperative period after open heart surgery, which of the following measures should the nurse institute to help prevent complications associated with excessive calcium excretion? a. Ensure a liberal fluid intake b. Provide an alkaline-ash diet c. Prevent constipation d. Enrich the client's diet with dairy products
a. Ensure a liberal fluid intake In an immobilized client, calcium leaves the bone and concentrates in the ECF fluid. When a large amount of calcium passes through the kidneys, calcium can precipitate and form calculi. Nursing interventions that help prevent calculi include ensuring a liberal fluid intake (unless contraindicated). A diet rich in acid should be provided to keep the urine acidic, which increases the solubility of calcium. Preventing constipation is not associated with excessive calcium excretion. Limiting foods rich in calcium, such as dairy products, will help on preventing renal calculi.
A nurse is assessing the neurovascular of a client who has returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is: a. Normal because of increased blood flow through the leg b. Slightly deteriorating and should be monitored for another hour c. Moderately impaired, and the surgeon should be called d. Adequate from an arterial approach, but venous complications are arising.
a. Normal because of increased blood flow through the leg An expected outcome of surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow.
What hemodynamic finding would be most indicative of ARDS? a. PAWP - 8 mmHg b. Cardiac index of 2.3 L/min (per body surface area) c. CVP - 16 mmHg d. Systemic vascular resistance of 400 dynes/sec2.
a. PAWP - 8 mmHg
Which type of shock has the following hemodynamic manifestations: increased cardiac output (CO), increased cardiac index (CI), decreased right atrial pressure (RAP), decreased systemic vascular resistance (SVR), and decreased pulmonary artery occlusion pressure (PAOP)? a. Septic b. Cardiogenic c. Anaphylactic d. Neurogenic
a. Septic Clinical manifestations of septic shock include increased CO and CI, decreased SVR, decreased RAP, and decreased PAOP.
A 35-year-old male was knifed in the street fight, admitted through the ER, and is now in the ICU. An assessment of his condition reveals the following symptoms: respirations shallow and rapid, CVP 15 cm H2O, BP 90 mm Hg systolic, skin cold and pale, urinary output 60-100 mL/hr for the last 2 hours. Analyzing these symptoms, the nurse will base a nursing diagnosis on the conclusion that the client has which of the following conditions? a. Hypovolemic shock b. Cardiac tamponade c. Wound dehiscence d. Atelectasis
b. Cardiac tamponade All of the client's symptoms are found in both cardiac tamponade and hypovolemic shock except the increase in urinary output.
Which signs cause the nurse to suspect cardiac tamponade after a client has cardiac surgery? Check all that apply. a. Tachycardia b. Hypertension c. Increased CVP d. Increased urine output e. Jugular vein distention
a. Tachycardia c. Increased CVP e. Jugular vein distention Blood in the pericardial sac compresses the heart so the ventricles cannot fill; this leads to a rapid thready pulse. Tamponade causes hypotension and a narrowed pulse pressure. As the tamponade increases, pressure on the heart interferes with the ejection of blood from the left ventricle, resulting in an increased pressure in the right side of the heart and the systemic circulation. As the heart because more inefficient, there is a decrease in kidney perfusion and therefore urine output. The increased venous pressure caused JVD.
A triage nurse takes a call from a patient who tells her that he has been burned while trying to do some electrical wiring. The nurse asks the client for more information. Which data from the patient would indicate that he has suffered a 2nd-degree burn? a. The skin is dark red, glossy, and has blisters b. The skin is light red and swollen c. The skin is light red with a small amount d. The skin is dark, leathery, and dry
a. The skin is dark red, glossy, and has blisters
Which of the following statements made by a patient with extensive burns would require further teaching? SELECT ALL THAT APPLY. a. "I will move my burned arm as much as possible." b. "I will limit my fluid intake until after my wounds stop draining." c. "I will eat four large meals a day if my stomach does not feel upset." d. "I will take the prescribed pain medication after my dressing changes."
b. "I will limit my fluid intake until after my wounds stop draining." d. "I will take the prescribed pain medication after my dressing changes."
What is the most important nursing action when measuring a pulmonary capillary wedge pressure (PCWP)? a. Have the client bear down when measuring the PCWP b. Deflate the balloon as soon as the PCWP is measured c. Place the client in a supine position before measuring the PCWP d. Flush the catheter with heparin solution after the PCWP is determined.
b. Deflate the balloon as soon as the PCWP is measured While the balloon must be inflated to measure the capillary wedge pressure, leaving the balloon inflated will interfere with blood flow to the lung. Bearing down will increase intrathoracic pressure and alter the reading. While a supine position is preferred; it is not essential. Agency protocols relative to flushing of unused ports must be followed.
Ten minutes following administration of an antibiotic, the nurse assesses a patient to have edematous lips and expiratory stridor. Vital signs are blood pressure 70/40, heart rate 130 and respirations 36/min. What is the priority intervention? a. Diphenhydramine (Benadryl) IV b. Epinephrine (Adrenalin) IV c. 1-liter 0.9% NaCl bolus d. Arterial blood gases
b. Epinephrine (Adrenalin) IV
A patient has been brought in to the emergency department with 2nd and 3rd degree burns over 40 percent of his body. The effects of the burn on the cardiovascular system include which of the following? Select all that apply. a. Increased mean arterial pressure b. Fluid volume deficit c. ECG changes d. Hypovolemic shock e. Myocardial infarction
b. Fluid volume deficit c. ECG changes d. Hypovolemic shock e. Myocardial infarction
A post CABG client has rales bilaterally, a gallop not present preop and the following hemodynamic measures: Cardiac index 1.4; PAP 42/25mmHg; CVP 14 mmHg; PAWP 15 mmHg. The BP has trended down from 120 systolic to 90. The nurse would question which order? a. Start dobutamine drip b. Increase the IV rate to 125 mm/hr c. Administer lasix 80mg d. Administer Nitroprusside
b. Increase the IV rate to 125 mm/hr
The nurse has just completed an infusion of 1-L of normal saline in a patient with severe sepsis. One hour later, which laboratory result requires immediate nursing action? a. Creatinine 1.4 mg/dL b. Lactate 6 mmol/L c. Sodium 140 mEq/L d. Albumin 2.5 mEq/L
b. Lactate 6 mmol/L
A nurse is caring for a patient who has been severely burned and who is in the ICU. According to Maslow's hierarchy of needs, which of the following actions demonstrates that the nurse is meeting the patient's highest priority needs? Select all that apply. a. Keeping the room quiet and dark b. Maintaining the ventilator settings c. Suctioning the patient's airway as needed d. Using a hemodynamic monitor e. Contacting the patient's family so they can visit
b. Maintaining the ventilator settings c. Suctioning the patient's airway as needed d. Using a hemodynamic monitor
A 3 year old is experiencing distress after cardiac surgery. What data indicates cardiac tamponade? a. Hypertension b. Muffled heart sounds c. Widened pulse pressures d. Increased chest tube drainage
b. Muffled heart sounds
Atherosclerosis impedes coronary blood flow by which of the following mechanisms? a. Plaques obstruct the vein b. Plaques obstruct the artery c. Blood clots form outside the vessel wall d. Hardened vessels dilate to allow blood to flow through
b. Plaques obstruct the artery Arteries, not veins, supply the coronary arteries with oxygen and other nutrients. Atherosclerosis is a direct result of plaque formation in the artery. Hardened vessels can't dilate properly and, therefore, constrict blood flow.
A client is rushed to the emergency room after having a 500 pound steel container fall onto their left side, spilling hazardous material all over the clients face. The chemical is burning the clients face and the client is losing their airway. The nurse gowns up into the hazmat suit and makes sure it is safe to enter the hazmat room. What is the nurses priority at this time? a. Maintain the clients airway b. Pour water over the client and remove all hazardous material c. Get a set of vital signs d. Give the patient oxygen
b. Pour water over the client and remove all hazardous material
Which laboratory value provides information regarding the severity of impaired perfusion and helps determine the adequacy of therapies in the patient with septic shock and multiple organ dysfunction syndrome (MODS)? a. Serum glucose b. Serum lactate c. Serum albumin d. Serum creatinine
b. Serum lactate Serum lactate levels provide information regarding the severity of impaired perfusion and the presence of lactic acidosis. The values differ significantly in MODS survivors and nonsurvivors.
Which of the following statements made by a patient with an intra-aortic balloon pump would require further education? a. "The device will increase the blood flow to my heart." b. "The machine will allow my heart to not work quite as hard." c. "I should perform leg exercises frequently to prevent blood clots." d. "I should use the call light and ask for help if I need to have a bowel movement."
c. "I should perform leg exercises frequently to prevent blood clots."
After cardiac surgery, a client's blood pressure measures 126/80. The nurse determines that the mean arterial pressure (MAP) is which of the following? a. 46 mm Hg b. 80 mm Hg c. 95 mm Hg d. 90 mm Hg
c. 95 mm Hg
Which of the following is at greatest risk of developing hypovolemic shock? a. A patient admitted with abdominal pain and an elevated white blood cell count. b. A patient with a temperature of 102 degrees Fahrenheit and a general dermal rash. c. A patient with a 2-day history of nausea, vomiting and diarrhea d. A patient with slight rectal bleeding from hemorrhoids
c. A patient with a 2-day history of nausea, vomiting and diarrhea
Which client would be most appropriate for pressure support ventilation? a. C2 spinal fracture 1 week ago b. A patient that breathing only at the set respiratory rate of 12 breaths per minute on a volume control ventilation setting. c. A post coronary artery bypass patient that is following commands d. A 16-year old patient requiring 80% oxygen to keep sats greater than 92%
c. A post coronary artery bypass patient that is following commands
The most important assessment for the nurse to make after a client has had a femeropopiteal bypass for peripheral vascular disease would be: a. Incisional pain b. Pedal pulse rate c. Capillary refill time d. Degree of hair growth
c. Capillary refill time Checking capillary refill provides data about current perfusion of the extremity. While the presence and quality of the pedal pulse provide data about peripheral circulation, it is not necessary to count the rate.
Which of the following are clinical manifestations of cardiogenic shock? a. Decreased pulmonary artery occlusion pressure b. Decreased right atrial pressure c. Decreased cardiac index to less than 2.2 L/min/m2 d. Decreased systemic vascular resistance
c. Decreased cardiac index to less than 2.2 L/min/m2 Initially, clinical manifestations reflect the decline in cardiac output. Clinical manifestations include cardiac index less than 2.2 L/min/m
A client is experiencing cardiogenic shock as a result of a myocardial infarction. His blood pressure is 80/40 and has a low urine output. Which of the following orders would be most appropriate for the patient? a. 1-L lactated Ringer's bolus b. Furosemide (Lasix) IV c. Epinephrine (Adrenaline) infusion d. Nitroglycerin infusion
c. Epinephrine (Adrenaline) infusion
In patients with extensive burns, edema occurs in both burned and unburned areas because of: a. Catecholamine-induced vasoconstriction b. Decreased glomerular filtration c. Increased capillary permeability d. Loss of integument barrier
c. Increased capillary permeability
Ms. P's SaO2 drops every time you suction her tracheostomy. Which of the following interventions would NOT be helpful in preventing desaturation? a. Provide a few seconds of 100% oxygen before suctioning. b. Provide two to three large breaths before suctioning. c. Instill 5 to 10 mL of sterile saline before suctioning. d. Limit suction passes to less than 15 seconds.
c. Instill 5 to 10 mL of sterile saline before suctioning. A side effect of suctioning is desaturation. Providing 100% oxygen or hyperventilating before suctioning can reduce this effect. Limiting the length of time for each suction pass is also helpful. Instillation of saline is contraindicated because it has not proved to be of any benefit and may actually contribute to hypoxemia, lower airway colonization, and VAP.
Which of the following statements is true regarding complications of noninvasive ventilation (NIV)? a. Masks should allow moderate air leaks for patient comfort. b. Agitation while undergoing NIV should be treated aggressively with sedation. c. When using a full face mask, the patient's hands should not be restrained. d. Placement of a nasogastric tube is contraindicated.
c. When using a full face mask, the patient's hands should not be restrained. Insufflation of the stomach places the patient at risk for aspiration. A nasogastric tube is placed for decompression as necessary. Heavy sedation should be avoided. A patient who requires noninvasive ventilation with a face mask should never be restrained. The patient must be able to remove the mask if it becomes displaced or if the patient vomits. A properly fitted mask minimizes air leakage and discomfort for the patient.
A physician is planning to insert an arterial catheter into a patient. Before the catheter is inserted, the nurse should: a. check the patient's platelets for indication of heparin-induced thrombocytopenia. b. obtain a 100-mL bag of 0.9% saline for the flush system. c. perform an Allen test to confirm adequate arterial blood flow. d. set up a double transducer tubing system.
c. perform an Allen test to confirm adequate arterial blood flow. The major advantage of the radial artery is the supply of collateral circulation to the hand provided by the ulnar artery through the palmar arch in most people. Before radial artery cannulation, collateral circulation must be assessed by using Doppler flow or by the modified Allen test according to institutional protocol. In the Allen test, the radial and ulnar arteries are compressed simultaneously. The patient is asked to clench and unclench the hand until it blanches. One of the arteries is then released, and the hand should immediately flush from that side. The same procedure is repeated for the remaining artery.
Which of the following assessment findings would be a therapeutic response to the oxygen administered after a severe inhalation injury? a. Pulse oximeter of 100% b. Clear breath sounds c. Productive carboneous secretions d. Carboxyhemoglobin level of 3%
d. Carboxyhemoglobin level of 3%
The nurse has been administering 0.9 NaCl fluids as part of a fluid replacement protocol. To evaluate the effectiveness of fluid therapy, which physiological parameters would be most important for the nurse to check? a. Blood pressure and temperature b. Oral temperature and capillary refill c. Bilateral breath sounds and capillary refill d. Central venous pressure and urine output
d. Central venous pressure and urine output
PEEP has what effect on the heart? a. Bradycardia b. Tachycardia c. Increased BP d. Decreased cardiac output
d. Decreased cardiac output
During the initial phase of septic shock. Which is the physiological cause of increased cardiac output? a. Venous vasodilation b. Arterial constriction c. Increased parasympathetic stimulation d. Increased sympathetic stimulation
d. Increased sympathetic stimulation
A paradoxical pulse occurs in a client who had a coronary artery bypass graft (CABG) surgery 2 days ago. Which of the following surgical complications should the nurse suspect? a. Left-sided heart failure b. Aortic regurgitation c. Complete heart block d. Pericardial tamponade
d. Pericardial tamponade A paradoxical pulse (a palpable decrease in pulse amplitude on quiet inspiration) signals pericardial tamponade, a complication of CABG surgery. Left-sided heart failure can cause pulsus alternans (pulse amplitude alternation from beat to beat, with a regular rhythm). Aortic regurgitation may cause bisferious pulse (an increased arterial pulse with a double systolic peak). Complete heart block may cause a bounding pulse (a strong pulse with increased pulse pressure).
You are caring for Ms. Y. She is scheduled to begin weaning from mechanical ventilation today. Which assessment would be the best indicator of her readiness to be weaned? a Minute ventilation greater than 10 L/min b. Respiratory rate at least 30/min c. FiO2 less than 50% d. Rapid shallow breathing index (RSBI)
d. Rapid shallow breathing index (RSBI) The RSBI is calculated using the minute ventilation and respiratory rate. The other parameters alone are not as predictive of weaning success. The RSBI is calculated using the minute ventilation and respiratory rate. The other parameters alone are not as predictive of weaning success. The RSBI is calculated using the minute ventilation and respiratory rate. The other parameters alone are not as predictive of weaning success. The RSBI is calculated using the minute ventilation and respiratory rate. The other parameters alone are not as predictive of weaning success.
Which of the following shock states includes hypotension despite adequate fluid resuscitation along with perfusion abnormalities such as lactic acidosis and oliguria? a. Bacteremia b. Systemic inflammatory response syndrome c. Multiple organ dysfunction syndrome d. Septic shock
d. Septic shock Septic shock includes hypotension despite adequate fluid resuscitation along with the presence of perfusion abnormalities that may include, but are not limited to, lactic acidosis, oliguria, or an acute alteration in mental status. Patients who are receiving inotropic or vasopressor agents may not be hypotensive at the time that perfusion abnormalities are measured.
When preparing a client for discharge after surgery for a CABG, the nurse should teach the client that there will be: a. No further drainage from the incisions after hospitalizations b. A mild fever and extreme fatigue for several weeks after surgery c. Little incisional pain and tenderness after 3 to 4 weeks after surgery d. Some increase in edema in the leg used for the donor graft when activity increases
d. Some increase in edema in the leg used for the donor graft when activity increases The client is up more at home, so dependent edema usually increases. Serosanguineous drainage may persist after discharge.
Collaborative management for the patient with multiple organ dysfunction syndrome includes decreasing oxygen demand with administration of: a. vasoactive and positive inotropic medications. b. diuretics and antidysrhythmic medications. c. crystalloids and antibiotics. d. antipyretics and sedation.
d. antipyretics and sedation. Oxygen demand can be decreased in any of the following ways: administering sedation or paralytics, administering antipyretics and external cooling measures, and administering pain medications. Vasoactives, positive inotropes, crystalloids, and antidysrhythmics are used to support oxygen transport, not decrease oxygen demand.
