Only For The 1% Nurses

The nurse recognizes that the patient on which mode of mechanical ventilation is at greatest risk for developing respiratory alkalosis? 7 1. Assist-control 2. Intermittent mandatory ventilation 3. Synchronized intermittent mandatory ventilation 4.Pressure support

1. Assist-control - The disadvantage of assist-control mode is that in the hyperventilating patient, respiratory alkalosis can develop if the respiratory rate increases above a normal rate because the ventilator continues to deliver a preset volume with each initiated breath.

The nurse is providing care to a patient who is mechanically ventilated. Which nursing action is most effective in decreasing the risk for aspiration? 7 1. Elevate the head of the bed between 30 to 45 degrees - Unless contraindicated, any patient who is mechanically ventilated should have the head of the bed elevated at 30 to 45 degrees to decrease the risk for aspiration. 2. Limit each suctioning event to no more than 10 seconds 3. Perform chest physiotherapy as prescribed by the practitioner 4.Ensure an NPO status is maintained for the length of the prescribed treatment

1. Elevate the head of the bed between 30 to 45 degrees - Unless contraindicated, any patient who is mechanically ventilated should have the head of the bed elevated at 30 to 45 degrees to decrease the risk for aspiration.

The nurse correlates which mechanical ventilator setting as placing a patient at greatest risk for barotrauma? 27 1. CPAP 3 cm H2O 2. FIO2 0.30 3. PEEP 7 cm H2O 4.Low tidal volumes

3. PEEP 7 cm H2O - Positive end-expiratory pressure (PEEP) values greater than 5 cm H2O increase the risk of barotrauma.

The nurse is providing care to a patient who is being weaned from mechanical ventilation. Which finding would necessitate the continuation of mechanical ventilation if noted during the weaning process? 7 1. An FIO2 less than or equal to 0.4 to 0.5 2. A positive end-expiratory pressure (PEEP) less than or equal to 5 to 8 cm H2O 3. A pH greater than 7.25 during spontaneous ventilation 4.Decreased blood pressure

4. Decreased blood pressure - Hemodynamic instability, such as a decreased blood pressure to a hypotensive state, indicates the patient is not a candidate for being weaned from mechanical ventilation.

A patient comes to the community clinic complaining of having a fever. Which clinical manifestations does the nurse correlate with a possible diagnosis of meningitis? Select all that apply. 1. Eye tearing 2. Photophobia 3. Opisthotonos 4. Nuchal rigidity 5.Auditory hallucinations

ANS 2, 3, 4

In the patient diagnosed with multiple organ dysfunction syndrome (MODS), the nurse identifies the nursing diagnosis of Ineffective Peripheral Tissue Perfusion as being most relevant. Which assessment provides the most specific data to support this nursing diagnosis? 1. Monitor urine output 2. Assess character of stool 3. Assess temperature 4.Monitor pupil reactions

ANS: 1

The nurse conducts a neurological assessment for a patient. Which finding correlates to a parasympathetic stimulation of the autonomic nervous system (ANS)? 1. Pupils that are constricted 2. Blood glucose is increased 3. A heart rate that is increased 4.A decrease in saliva production

ANS: 1

The nurse correlates a low level of thyroid-stimulating hormone (TSH) to which effect on the musculoskeletal system? 1. Reduces bone growth 2. Initiates the growth of bone 3. Slows the rate of bone destruction 4.Promotes the number of osteoblasts

ANS: 1

The nurse correlates damage to which area of the heart in patients who experience an inferior wall myocardial infarction (MI)? 1. Sinoatrial (SA) node 2. Atrioventricular (A V) node 3. Purkinje fibers 4. Ventricles

ANS: 1

The nurse is concerned that a patient is at risk for pulseless electrical activity. What information from the assessment did the nurse use to make this clinical decision? 1. Blood pH 7.30 2. Temperature 100.5°F 3. Serum glucose level 170 mg/dL 4.Serum potassium level 4.1 mEq/L

ANS: 1

The nurse is providing care to a patient who is mechanically ventilated. The high-pressure alarm is activated, and the nurse notes a collection of moisture in the ventilator tubing. Which action by the nurse is appropriate? 1. Emptying the water from the ventilator tubing 2. Suctioning as needed 3. Inserting an oral airway 4.Assessing for asymmetrical chest rise

ANS: 1

The nurse is providing care to a patient who is mechanically ventilated. The high-pressure alarm sounds and the nurse notes a mucous plug in the endotracheal (ET) tube. Which action by the nurse is indicated? 1. Suctioning as needed 2. Inserting an oral airway 3. Assessing for asymmetrical chest rise 4.Emptying water from the ventilator tubing

ANS: 1

The nurse monitors for which clinical manifestation in the patient diagnosed with trigeminal neuralgia? 1. Acute onset of pain 2. Impaired swallowing 3. Visual disturbances 4.Impaired extraocular movements

ANS: 1

The nurse monitors for which finding in the patient admitted in neurogenic shock? 1. Bradycardia 2. Increased central venous pressure 3. Increased cardiac output 4.Hyperventilation

ANS: 1

The nurse requests an occupational therapy consultation for a patient with bilateral carpal tunnel syndrome to assist the patient with which behavior? 1. Evaluate work environment 2. Instruct on hand exercises 3. Instruct on the use of splints 4. Review the action of NSAIDs

ANS: 1

The nurse suspects that a patient sustained a meniscus tear while playing basketball. The nurse makes this determination based on which clinical manifestations? 1. Knee pops when bent 2. Weak peripheral pulses 3. Reduced muscle tone of the thigh 4.Calf cramping with the knees bent

ANS: 1

The nurse teaches a patient the importance of wearing sunglasses when outside to decrease the risk of which disorder? 1. Cataracts 2. Glaucoma 3. Detached retina 4.Corneal abrasions

ANS: 1

What should the nurse conclude if constant bubbling is noted in the water-seal chamber of a closed chest drainage system? 1. The system has an air leak 2. The chest tube is obstructed 3. The system is functioning normally. 4. The patient's lung has re-expanded.

ANS: 1

Which prescribed medication for the patient recovering from a traumatic amputation does the nurse correlate to the treatment of phantom limb pain? 1. Gabapentin 2. Ibuprofen 3. Opioids 4.Muscle relaxants

ANS: 1

The nurse correlates which assessment data to the patient experiencing early respiratory distress? Select all that apply. 1. Dyspnea 2. Restlessness 3. Tachycardia 4. Confusion 5.Cyanosis

ANS: 1, 2, 3

The nurse monitors for which clinical manifestations in the patient experiencing an ischemic stroke of the basilar artery? Select all that apply. 1. Ataxia 2. Nausea 3. Dysphasia 4. Inability to swallow 5.Difficulty with speech

ANS: 1, 2, 3, 4, 5

The nurse correlates the actions of which hormones to bone health? Select all that apply. 1. Calcitonin 2. Estrogen 3. Parathyroid hormone 4. Triiodothyronine 5.Thyroid-stimulating hormone

ANS: 1, 2, 3, 5

The nurse monitors for which clinical manifestations of neurovascular compromise in the patient with an injured ankle? Select all that apply. 1. Pain 2. Pressure 3. Paralysis 4. Purulence 5.Pulselessness

ANS: 1, 2, 3, 5

Which intervention does the nurse include in the plan of care for a patient being mechanically ventilated who is receiving care based on a ventilator bundle focused on reducing the risk of ventilator-associated pneumonia? Select all that apply. 1. Elevating the head of the bed 2. Ensuring a sedation vacation each day 3. Minimizing ambulation 4. Administering a prescribed peptic ulcer prophylactic regimen 5.Restricting family visitation

ANS: 1, 2, 4

A patient with an ischemic stroke is being considered for recombinant tissue plasminogen activator (rt-PA). The nurse recognizes which factors as contraindications to this treatment? Select all that apply. 1. Age 83 years 2. Symptoms present for 45 minutes 3. Computed tomography (CT) scan demonstrates area of ischemia 4. 10-year history of type 2 diabetes mellitus 5.Takes warfarin sodium for atrial fibrillation

ANS: 1, 4, 5

The nurse provides care to a patient who is intubated and receiving mechanical ventilation. Which actions are appropriate for the nurse to implement if the high-pressure alarm sounds? Select all that apply. 1. Inserting an oral airway 2. Assessing the ventilator connections 3. Checking the patient's cuff pressure 4. Suctioning the patient's endotracheal tube 5.Emptying water from the ventilator tubing

ANS: 1, 4, 5

The nurse monitors for which clinical manifestations in the patient suspected of having cardiac tamponade? Select all that apply. (Hoffman 30) 1. Hypotension 2. Pulsus paradoxus 3. Muffled heart sounds 4. Jugular vein distention 5.Lower extremity edema

ANS: 1,2,3,4

Which intervention does the nurse include in the plan of care for a patient being mechanically ventilated who is receiving care based on a ventilator bundle focused on reducing the risk of ventilator-associated pneumonia? Select all that apply. 7 1. Elevating the head of the bed 2. Ensuring a sedation vacation each day 3. Minimizing ambulation 4. Administering a prescribed peptic ulcer prophylactic regimen 5.Restricting family visitation

ANS: 1,2,4

A patient is diagnosed with a small meniscus tear of the right knee. For which interventions does the nurse prepare the patient? Select all that apply. 1. Ice 2. Limited rest 3. Physical therapy for a month 4. Total immobility for several weeks 5.Use of nonsteroidal anti-inflammatory drugs (NSAIDs)

ANS: 1,2,5

A patient is being prepared for a Tensilon test. What does the nurse ensure is available before the beginning of this test? 1. Oxygen 2. Atropine sulfate 3. Dexamethasone 4.Epinephrine

ANS: 2

A patient who had a segmental left lung resection for treatment of a lung carcinoma returns from surgery with a left posterolateral chest tube attached to a disposable water-seal chest drainage system. Which signs would indicate that the drainage system is working properly? 1. Air is bubbling in the water-seal chamber. 2. The fluid level in the water-seal chamber fluctuates. 3. The fluid level in the drainage chamber remains constant. 4.The bubbling in the suction chamber is intermittent.

ANS: 2

A patient with bilateral carpal tunnel syndrome (CTS) does not want to have surgery. The nurse teaches the patient that this increases the risk of which complication? 1. Infection 2. Chronic pain 3. Decreased circulation 4.Hematoma formation

ANS: 2

A patient with myasthenia gravis is experiencing sweating and pallor. After administering edrophonium (Tensilon), which finding suggests the patient is experiencing a cholinergic crisis? 1. Improved muscle strength 2. Fasciculations 3. Strong hand grasps 4.Equal shoulder shrugs

ANS: 2

The nurse correlates electrocardiogram (ECG) lead changes in leads II, III, and aVF to which type of myocardial infarction? 1. Anterior wall 2. Inferior wall 3. Lateral wall 4. Posterior wall

ANS: 2

The nurse is monitoring the electrocardiogram (ECG) of a patient who has an internal ventricular pacemaker. Which pacer spike indicates the pacemaker is functioning properly? 1. The pacer spike occurs before the P wave 2. The pacer spike occurs before the QRS 3. Two pacer spikes occur before the QRS 4.Two pacer spikes occur before the T wave

ANS: 2

The nurse is providing care to a patient who is admitted with neurogenic shock. The nurse administers the prescribed atropine with no results. The nurse prepares to initiate which prescription at this time? 1. Low-dose dopamine 2. Transcutaneous pacing 3. Cardiac defibrillation 4.Morphine

ANS: 2

The nurse is providing care to a patient who is mechanically ventilated. The high-pressure alarm sounds and the nurse notes the patient is biting down on the endotracheal (ET) tube. Which action by the nurse is appropriate? 1. Suctioning as needed 2. Inserting an oral airway 3. Assessing for asymmetrical chest rise 4.Emptying water from the ventilator tubing

ANS: 2

The nurse is reviewing postoperative instructions with a patient recovering from carpal tunnel syndrome (CTS) surgery. Which statement by the patient indicates the need for further teaching? 1. "I should take the pain medication as prescribed." 2. "I should expect my hand to feel numb for a few weeks." 3. "I should perform hand exercises as directed by the therapist." 4."I should stop any activity that causes hand numbness or pain."

ANS: 2

The nurse monitors for which clinical manifestations in a patient in the progressive stage of shock? 1. Polyuria 2. Absent bowel sounds 3. Severe metabolic alkalosis 4.Full, bounding pulses

ANS: 2

A patient with Paget's disease is demonstrating manifestations of a fracture. The results of which diagnostic test is most effective in confirming the fracture? 1. X-ray 2. Bone scan 3. Arthroscopy 4.Bone density test

ANS: 2 Arthroscopy is a surgical procedure that allows a practitioner to view the inside of a joint through an instrument called an arthroscope and is not indicated in the diagnosis of fracture.

A patient is being discharged after treatment for an ischemic stroke. Which medications does the nurse correlate with this management of this neurological disorder? Select all that apply. 1. Antibiotics 2. Anticoagulants 3. Antihypertensives 4. Antiplatelet therapy 5.Lipid-lowering agent

ANS: 2, 3, 4, 5

The nurse correlates which disorders as placing a patient at increased risk of acute respiratory failure (ARF) secondary to hypoventilation? Select all that apply. 1. Chronic obstructive pulmonary disorder 2. High spinal cord injury 3. Myasthenia gravis 4. Pulmonary edema 5.Opioid overdose

ANS: 2, 3, 5

The nurse provides care to a patient who is intubated and receiving mechanical ventilation. Which actions are appropriate for the nurse to implement if the low-pressure alarm sounds? Select all that apply. 1. Inserting an oral airway 2. Assessing the ventilator connections 3. Checking the patient's cuff pressure 4. Suctioning the patient's endotracheal tube 5.Assessing the patient's respiratory rate

ANS: 2, 3, 5

A patient is diagnosed with a health problem that causes demyelination of the peripheral nerves. Which cell structure is being affected? 1. Microglia 2. Astrocytes 3. Schwann cells 4.Oligodendrocytes

ANS: 3

A patient with meningitis is prescribed a cooling blanket. Which explanation does the nurse provide to the patient regarding this treatment? 1. Relieves pain 2. Increases cerebral venous outflow 3. Decreases oxygen demand in the brain 4.Reduces the transmission of the infection

ANS: 3

The nurse correlates which data from a patient's history as a risk factor for trigeminal neuralgia? 1. Has a body mass index of 34 2. Takes birth control pills 3. History of hypertension 4.Works as a computer operator

ANS: 3

The nurse instructs a patient recovering from an acute myocardial infarction on the Life's Simple 7 actions. Which patient statement indicates that additional teaching is required? 1. "I will not smoke." 2. "I will eat a heart-healthy diet." 3. "I will walk for at least 30 minutes three times a week." 4. "I will make sure my blood sugar level stays under 100 mg/dL.

ANS: 3

The nurse is preparing to auscultate the heart sounds of a patient with mitral valve regurgitation. Which sound should the nurse expect to hear? 1. Rub 2. Click 3. Murmur 4.Atrial gallop

ANS: 3

The nurse is reviewing medications prescribed for a patient with hypertrophic cardiomyopathy. Which medication does the nurse question as a primary treatment for this condition? 1. Angiotensin-converting enzyme inhibitor (ACE-I) 2. Diuretic 3. Digoxin 4.Beta blocker

ANS: 3

The nurse is reviewing orders for a patient admitted for evaluation of changes in neurological status. Which prescribed medication does the nurse correlate as a treatment for trigeminal neuralgia? 1. Cogentin 2. Compazine 3. Carbamazepine 4.Hydrochlorothiazide

ANS: 3

he nurse monitors for which clinical manifestations in the exudative phase of acute respiratory distress syndrome (ARDS)? Select all that apply. 1. PaCO2 55 mm Hg 2. Blood pressure 88/40 3. Hypoxemia 4. Respiratory alkalosis 5.Respiratory rate 26

ANS: 3, 4, 5

The nurse is providing care to a patient who is exhibiting clinical manifestations of a fluid and electrolyte deficit. Which of the following orders does the nurse implement to address this disorder? Select all that apply. 1. Administer diuretics 2. Administer antibiotics 3. Place the patient in high-Fowler's position 4. Monitor patient's I&O 5.Initiate intravenous therapy

ANS: 3,4,5

A patient has arrived by ambulance at the emergency department after a cervical spinal cord injury. Which assessment is a priority for the nurse to perform at this time? 1. Mental status and blood pressure 2. Heart rate and rhythm 3. Muscle strength and reflexes 4.Respiratory pattern and airway

ANS: 4

A patient recovering from an ischemic stroke is prescribed verapamil (Calan). The nurse teaches the patient that this medication works by which action? 1. Increases urination 2. Slows the heart rate 3. Lowers blood lipids 4.Decreases blood pressure

ANS: 4

A patient sustained a meniscus injury several months ago and did not seek medical attention. The nurse monitors the patient for the development of which complication? 1. Tendonitis 2. Fractured patella 3. Dependent edema 4.Permanent joint damage

ANS: 4

After insertion of a chest tube for a pneumothorax, a patient becomes hypotensive with neck vein distention, tracheal shift, absent breath sounds, and diaphoresis. The nurse suspects a tension pneumothorax has occurred. The nurse assesses for what potential cause of tension pneumothorax? 1. Continuous bubbling in the suction chamber 2. The pneumothorax has resolved 3. Insufficient chest tube suction 4.Kinked or obstructed tube

ANS: 4

Care of the patient with sepsis requires close monitoring of oxygenation status. The nurse correlates the SvO2 value as measurement of which parameter? 14 1. Arterial oxygenation 2. Oxygen debt 3. Oxygen delivery 4.Venous oxygen consumption

ANS: 4

The nurse assesses a patient's muscle strength, noting full range of motion against some resistance. How does the nurse document this finding? 1. Grade 1 2. Grade 2 3. Grade 3 4.Grade 4

ANS: 4

The nurse monitors for which clinical manifestations in the patient with suspected carpal tunnel syndrome (CTS)? 1. Reduced radial pulses 2. Fingers cool to touch 3. Capillary refill 3 seconds 4. Hand tingling during the night

ANS: 4

The nurse notes that a patient has bilateral lower extremity edema. For which health problem should the nurse assess further? 1. Pericarditis 2. Cardiac tamponade 3. Lymph obstruction 4.Venous insufficiency

ANS: 4

The nurse provides education to a patient who is diagnosed with trigeminal neuralgia. Which patient statement indicates the need for additional teaching? 1. "Baclofen may be prescribed to decrease pain." 2. "I should avoid cold weather as it may trigger increased pain." 3. "I should eat foods that are easily chewed to avoid weight loss." 4."Carbamazepine may be prescribed to decrease my risk for seizure activity."

ANS: 4

The nurse provides instructions to a patient who is being discharged after treatment for a myocardial infarction. Which patient statement indicates a need for additional teaching? 1. "I will take the Lipitor to reduce my cholesterol levels." 2. "I will take the Lopressor to decrease my heart's demand for oxygen." 3. "I will take the Plavix to prevent the platelets from forming new clots." 4."I will take the sublingual nitroglycerin each day to prevent chest pain."

ANS: 4

The nurse provides care for a patient whose blood pressure is 90/60 mm Hg. The nurse documents the mean arterial pressure as ____________________.

ANS: 70 (MAP = [(2 ´ diastolic) + systolic] / 3)

When calculating a patient's heart rate using the cardiac rhythm strip, the nurse notes the presence of four large boxes between the two R waves. What is this patient's heart rate? Record your answer as a whole number. ______

ANS: 75 Feedback: One method to calculate heart rate is to count the number of large boxes between two R waves and divide that number into 300. If four large boxes are present, then 300/4 = 75.

The Nurse is caring for a mechanically ventilated patient and responds to a high inspiratory pressure alarm. Recognizing possible causes for the alarm, the nurse assesses for which ofthe following? (Select all that apply) A. coughing or attempting to talk B. disconnection from the ventilator C. kinks in the ventilator tubing D. need for suctioning E. spontaneous breathing

ANS: A, C, D

Which of the following are components of the Institute for Healthcare Improvement's (IHI's) ventilator bundle? (Select all that apply) a. Interrupt sedation each day to assess readiness to extubate b. Maintain head of bed at least 30 degrees elevation. c. Provide deep vein thrombosis prophylaxis d. Provide prophylaxis for peptic ulcer disease e. Swab the mouth with foam swabs every 2 hours.

ANS: A,B,C,D

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

ANS: A,B,C,E

A patient is having difficulty weaning from mechanical ventilation. The nurse assess the patient and notes what potential cause of this difficult weaning? A. cardiac output of 6L/min B. hemoglobin of 8 g/dL C. Negative sputum culture and sensitivity D. white blood cell count of 8000

ANS: B

The nurse admits a patient to the emergency department (ED) with a suspected cervical spine injury. What is the priority nursing action? A. keep the neck in the hyperextended position. B. maintain proper head and neck alignment. C. prepare for immediate endotracheal intubation. D. remove cervical collar upon arrival to the ED.

ANS: B

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

ANS: B

The nurse notices ventricular tachycardia on the heart monitor. When the patient is assessed, the patient is found to be unresponsive with no pulse. The nurse should take what action immediately? A. treat with intravenous amiodarone or lidocaine. B. begin cardiopulmonary resuscitation and advanced life support. C. provide electrical cardioversion D. ignore the rhythm since it is benign.

ANS: B

The patient is receiving neuromuscular blockade. Which nursing assessment indicates a target level of paralysis? A. Glasgow coma scale score of 3 B. Train-of-four yields two twitches C. Bispectral index of 60 D. CAM-ICU positive

ANS: B

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

ANS: B

The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine injury who is reporting a severe headache. The nurse assesses a blood pressure of 180/90 mmHg, heart rate 60 beats/min, respirations 24 breaths/min, and 50mL of urine via indwelling urinary catheter for the past 4 hours. What is the best action by the nurse? A. administer acetaminophen as ordered for the headache. B. assess for a kinked urinary catheter and assess or bowel impaction. C. encourage the patient to take slow, deep breaths. D. notify the physician of the patient's blood pressure.

ANS: B (autonomic dysreflexia)

Which statement is true regarding oral care for the prevention of ventilator-associated pneumonia (VAP)? (Select all that apply) a. Tooth brushing is performed every 2 hours for the greatest effect. b. Implementing a comprehensive oral care program is an intervention for preventing VAP> c. Oral care protocols should include oral suctioning and brushing teeth. d. Protocols that include chlorhexidine gluconate have been effective in preventing VAP. e. Avoid brushing teeth for two hours after chlorhexidine use.

ANS: B,C,D

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

ANS: C

The nurse is caring for a mechanically ventilated patient and is charting outside the patient's room when the ventilator alarm sounds. What is the priority order for the nurse to complete these ations? A. check quickly for possible causes of the alarm that can be fixed. B. after troubleshooting, connect back to mechanical ventilator and reassess patient. C. go to patient's bedside D. manually ventilate the patient while getting respiratory therapist.

ANS: C, A, D, B

The nurse working on the night shift notices sinus bradycardia on the patient's cardiac monitor. What initial action should the nurse take? A. Give atropine to increase heart rate/ B. Begin transcutaneous pacing of the patient. C. Start a dopamine infusion to stimulate heart function D. Assess for hemodynamic instability.

ANS: D

The patient's heart rate is 165 beats per minute and the cardiac monitor shows a rapid rate with narrow QRS complexes. The P waves cannot be seen, but the rhythm is regular. The patient's blood pressure has dropped from 124/62 to 78/30; skin is cold and diaphoretic and the patient is reporting nausea. The nurse prepares the patient for what intervention? A. administration of beta-blockers B. administration of atropine C. transcutaneous pacemaker insertion D. emergent cardioversion

ANS: D

The nurse is caring for a patient with cystic fibrosis and understands that treatment consists of which of the following? (Select all that apply.) A. airway clearance therapies B. Antibiotic therapy C. Nutritional support D. Tracheostomy E. Cardiac monitoring

ANSWER: A, B, C

The QT interval is the total time taken for ventricular depolarization and repolarization. Prolongation of the QT interval will result in what outcome? A. decreased risk of lethal arrhythmias B. Increase in heart rate C. Increase in the risk of lethal dysrhythmias D. Will only be measured with irregular rhythms

ANSWER: C

A patient admitted with smoke inhalation injuries develops clinical manifestations of acute respiratory distress syndrome (ARDS). The nurse prepares to implement which healthcare provider prescription? 1. Intubation and mechanical ventilation 2. Oxygen via a nasal cannula 3. Face mask oxygen administration 4.Continuous positive airway pressure via face mark

Ans: 1

The nurse correlates damage to which area of the heart in the patient who has complete occlusion of the left anterior descending (LAD) artery? 1. Anterior wall 2. Inferior wall 3. Lateral wall 4. Posterior wall

Ans: 1

The nurse monitors for which clinical manifestations in the patient diagnosed with a pulmonary embolism (PE)? Select all that apply. 1. Tachypnea 2. Hypotension 3. Shortness of breath 4. Bilateral lower extremity edema 5. Accessory muscle use

Ans: 1, 3, 5

In triaging patients in the emergency department, the nurse prioritizes the patient with which clinical manifestations? 1. Dyspnea and anxiety 2. Cyanosis and decreased level of consciousness 3. Confusion and pink skin color 4.Restlessness and tachycardia

Ans: 2

The nurse monitors for which clinical manifestations in the patient experiencing intermediate respiratory failure? 1. Dyspnea 2. Lethargy 3. Tachycardia 4.Restlessness

Ans: 2

The nurse provides care to a patient who is intubated and receiving mechanical ventilation. Which actions are appropriate for the nurse to implement if the low-pressure alarm sounds? Select all that apply. 7 1. Inserting an oral airway 2. Assessing the ventilator connections 3. Checking the patient's cuff pressure 4. Suctioning the patient's endotracheal tube 5. Assessing the patient's respiratory rate

Ans: 2,3,5

The nurse caring for a patient admitted with septic shock is aware of the need to assess for the development of acute respiratory distress syndrome (ARDS). Which early clinical manifestation indicates the development of ARDS? 1. Intercostal retractions 2. Cyanosis 3. Tachypnea 4.Tachycardia

Ans: 3

The nurse assists the healthcare provider with a patient intubation. What is the priority action by the nurse? 1. Ensure suction is available. 2. Place the intubation tray at the bedside for the procedure. 3. Explain each step of the procedure to the patient and family. 4.Administer manual breaths to the patient using a resuscitation bag and mask.

Ans: 4

Based on Virchow's Triad, select which patients below are at RISK for the development of deep vein thrombosis? A. A 55-year old male with hyperlipidemia and diabetes B. A 70-year old female with severe sepsis C. A 25-year old male who uses intravenous drugs. D. A 65-year old female who is post-op day 1 after joining replacement surgery.

Answer: B, C, D

Select all the factors regarding a deep vein thrombosis that are included in Virchow's Triad: A. Hypocoagulability B. Atherosclerosis C. Endothelial damage D. Stasis of venous blood E. Excessive coagulability F. Increased venous blood flow

Answer: C, D, E

When do I use a PNS?

Answer: The PNS is to be used to monitor patients who are receiving neuromuscular blocking agents (NMBA). *Examples of NMBA are: Atracurium Besylate, Cisatracurium Besylate & Vecuronium Bromide.

A-a Gradient

Average A-a gradient 5-10 mmHG Calculation is PAO2 - PaO2

Ms. D has a suspected pulmonary embolus. While awaiting a ventilation-perfusion scan, she is placed on a Venturi Mask at an FiO2 of 50%, which is maintaining her PaO2 at approximately 70 mmHg. Which values would indicate significant pulmonary shunting? A. PaO2/FiO2 ratio of 300 B. PaO2/PAO2 ratio of 220 C. Alveolar-arterial (A-a) gradient of 220 mmHg D. PaO2 alone demonstrates significant shunting

C. Alveolar-arterial (A-a) gradient of 220 mmHg [A normal PAO2/FiO2 ratio is greater than 286, PaO2/PAO2 ratio is greater than 60, and A-a gradient is less than 20 mm Hg. The PaO2 cannot by itself indicate the degree of shunting present.]

CaO2 formula (the 97%)

CaO2 (ml/L) = (SaO2 x Hb x 1.34) + (PaO2 x 0.003)

Myasthenic Crisis S/S

Tachycardia, flaccid muscles, and pale and cool skin. often caused by a respiratory infection or viral or bacterial agents

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Hemodynamics - Leveling Transducer

the transducer must be leveled to the mid-chest because the catheter tip is approximately at this level. This will negate the effect of hydrostatic pressure on the measured pressure.