354Qw/exp mainly critical care? (does contain CC hemo and resp)

A client with acute kidney injury is receiving a fluid challenge of 500 mL of normal saline over 1 hour. With a drop factor of 20 drops/mL, how many drops per minute does the nurse infuse?

167 drops/min 20 gtt × 500 mL = 10,000/60 min = 167 drops/min

The nurse is teaching a client about induction therapy for acute leukemia. Which client statement indicates a need for additional education? A "After this therapy, I will not need to have any more." B "I will need to avoid people with a cold or flu." C "I will probably lose my hair during this therapy." D "The goal of this therapy is to put me in remission."

A "After this therapy, I will not need to have any more. Induction therapy is not a cure for leukemia, it is a treatment; therefore, the client needs more education to understand this. Because of infection risk, clients with leukemia should avoid people with a cold or flu. Induction therapy will most likely cause the client with leukemia to lose his or her hair. The goal of induction therapy is to force leukemia into remission.

The nurse is teaching a client with newly diagnosed anemia about conserving energy. What does the nurse tell the client? (Select all that apply.) A "Allow others to perform your care during periods of extreme fatigue." Correct B "Drink small quantities of protein shakes and nutritional supplements daily." Correct C "Perform a complete bath daily to reduce your chance of getting an infection." D "Provide yourself with four to six small, easy-to-eat meals daily." Correct E "Perform your care activities in groups to conserve your energy." F "Stop activity when shortness of breath or palpitations are present."

A "Allow others to perform your care during periods of extreme fatigue." B "Drink small quantities of protein shakes and nutritional supplements daily." D "Provide yourself with four to six small, easy-to-eat meals daily." F "Stop activity when shortness of breath or palpitations are present." It is critical to have others help the anemic client who is extremely tired. Although it may be difficult for him or her to ask for help, this practice should be stressed to the client. Drinking small protein or nutritional supplements will help rebuild the client's nutritional status. Having four to six small meals daily is preferred over three large meals; this practice conserves the body's expenditure of energy used in digestion and assimilation of nutrients. Stopping activities when strain on the cardiac or respiratory system is noted is critical. A complete bath should be performed only every other day; on days in between, the client can be taught to take a "mini" sponge bath, which will conserve energy and still be safe in preventing the risks for infection. Care activities should be spaced every hour or so rather than in groups to conserve energy; the time just before and after meals should be avoided.

A distant family member arrives to visit a female client recently diagnosed with leukemia. The family member asks the nurse, "What should I say to her?" Which responses does the nurse suggest? (Select all that apply.) A "Ask her how she is feeling." Correct B "Ask her if she needs anything." Correct C "Tell her to be brave and to not cry." D "Talk to her as you normally would when you haven't seen her for a long time." Correct E "Tell her what you know about leukemia."

A "Ask her how she is feeling." B "Ask her if she needs anything." D "Talk to her as you normally would when you haven't seen her for a long time." Asking the client how she is feeling is a broad general opening and would be nonthreatening to the client. Asking if she needs anything is a therapeutic communication of offering self and would be considered to be therapeutic and helpful to the client. The family member should talk to her as she normally would when she hasn't seen her in a long time. There is no need to act differently with the client. If she wants to offer her feelings, keeping a normal atmosphere facilitates that option. Acting as if things are "different" because she has cancer takes the control of the situation from the client. Telling her to be brave and not to cry is callous and unfeeling; if the client is feeling vulnerable and depressed, telling her to "be brave" shuts off any opportunity for her to express her feelings. There is no need to inform the client about her disease, unless she asks about it. Opening the conversation with discussion about leukemia should be the client's prerogative.

A client has sustained a fracture of the left tibia. The extremity is immobilized using an external fixation device. Which postoperative instruction does the nurse include in this client's teaching plan? A "Use pain medication as prescribed to control pain." B "Clean the pin site when any drainage is noticed." C "Wear the same clothing that is normally worn." D "Apply bacitracin (Neosporin) if signs or symptoms of infection develop around pin sites."

A "Use pain medication as prescribed to control pain." The client should be taught the correct use of prescribed pain medication to control pain adequately. Pin sites must be cleaned at least every 8 hours and as needed to reduce the risk for infection, not when any drainage is noticed. The client will have to adjust the type of clothing worn while the fixation device is in place. If signs and symptoms of infection develop around the pin sites, the client must notify the health care provider immediately. Infection at the pin sites places the client at risk for osteomyelitis.

Which client is at greatest risk for having a hemolytic transfusion reaction? A A 34-year-old client with type O blood B A 42-year-old client with allergies C A 58-year-old immune-suppressed client D A 78-year-old client

A A 34-year-old client with type O blood Hemolytic transfusion reactions are caused by blood type or Rh incompatibility. When blood that contains antigens different from the client's own antigens is infused, antigen-antibody complexes are formed in the client's blood. Type O is considered the universal donor, but not the universal recipient. The client with allergies would be most susceptible to an allergic transfusion reaction. The immune-suppressed client would be most susceptible to a transfusion-associated graft-versus-host disease. The older adult client would be most susceptible to circulatory overload.

Which clinical manifestation indicates the need for increased fluids in a client with kidney failure? A Increased blood urea nitrogen (BUN) B Increased creatinine level C Pale-colored urine D Decreased sodium level

A Increased blood urea nitrogen (BUN An increase in BUN can be an indication of dehydration, and an increase in fluids is needed. Increased creatinine indicates kidney impairment. Urine that is pale in color is diluted; an increase in fluids is not necessary. Sodium is increased, not decreased, with dehydration.

An RN from pediatrics has "floated" to the medical-surgical unit. Which client is assigned to the float nurse? A A 42-year-old with sickle cell disease receiving a transfusion of packed red blood cells B A 50-year-old with pancytopenia needing assessment of risk factors for aplastic anemia C A 55-year-old with folic acid deficiency anemia caused by alcohol abuse who needs counseling D A 60-year-old with newly diagnosed polycythemia vera who needs teaching about the disease

A A 42-year-old with sickle cell disease receiving a transfusion of packed red blood cells Because sickle cell disease is commonly diagnosed during childhood, the pediatric nurse will be familiar with the disease and with red blood cell transfusion; therefore, he or she should be assigned to the client with sickle cell disease. Aplastic anemia, folic acid deficiency, and polycythemia vera are problems more commonly seen in adult clients who should be cared for by nurses who are more experienced in caring for adults.

Which finding in the first 24 hours after kidney transplantation requires immediate intervention? A Abrupt decrease in urine output B Blood-tinged urine C Incisional pain D Increase in urine output

A Abrupt decrease in urine output An abrupt decrease in urine output may indicate complications such as rejection, acute kidney injury, thrombosis, or obstruction. Blood-tinged urine, incisional pain, and an increase in urine output are expected findings after kidney transplantation.

A rock climber has sustained an open fracture of the right tibia after a 20-foot fall. The nurse plans to assess the client for which potential complications? (Select all that apply.) A Acute compartment syndrome (ACS) B Fat embolism syndrome (FES) C Congestive heart failure D Urinary tract infection (UTI) E Osteomyelitis

A Acute compartment syndrome (ACS) B Fat embolism syndrome (FES) E Osteomyelitis ACS is a serious condition in which increased pressure within one or more compartments reduces circulation to the area. A fat embolus is a serious complication in which fat globules are released from yellow bone marrow into the bloodstream within 12 to 48 hours after the injury. FES usually results from long bone fracture or fracture repair, but is occasionally seen in clients who have received a total joint replacement. Bone infection, or osteomyelitis, is most common in open fractures. Congestive heart failure is not a potential complication for this client; pulmonary embolism is a potential complication of venous thromboembolism, which can occur with fracture. The client is at risk for wound infection resulting from orthopedic trauma, not a UTI.

A client's left arm is placed in a plaster cast. Which assessment does the nurse perform before the client is discharged? A Assess that the cast is dry. B Ensure that the client has 4 × 4 gauze to take home for placement between the cast and the skin. C Check the fit of the cast by inserting a tongue blade between the cast and the skin. D Ensure that the capillary refill of the left fingernail beds is longer than 3 seconds.

A Assess that the cast is dry. The cast must be dry and free of cracking and crumbling before the client is discharged. The client should not place anything between the cast and the skin. In assessing fit, one finger should easily fit between the cast and the skin. Capillary refill longer than 3 seconds indicates impairment of the circulation in the extremity and requires the health care provider's immediate attention.

A client with chronic kidney disease reports chest pain. The nurse notes tachycardia and low-grade fever. Which additional assessment is warranted? A Auscultate for pericardial friction rub. B Assess for crackles. Incorrect C Monitor for decreased peripheral pulses. D Determine if the client is able to ambulate.

A Auscultate for pericardial friction rub. The client with uremia is prone to pericarditis; symptoms include inspiratory chest pain, low-grade fever, and ST-segment elevation. Crackles and tachycardia are symptomatic of fluid overload; fever is not present. Although the nurse will monitor pulses, and ambulation is important to prevent weakness and deep vein thrombosis, these are not pertinent to the constellation of symptoms of pericarditis that the client presents with.

A client with a recently created vascular access for hemodialysis is being discharged. In planning discharge instructions, which information does the nurse include? A Avoiding venipuncture and blood pressure measurements in the affected arm B Modifications to allow for complete rest of the affected arm C How to assess for a bruit in the affected arm D How to practice proper nutrition

A Avoiding venipuncture and blood pressure measurements in the affected arm Compression of vascular access causes decreased blood flow and may cause occlusion; if this occurs, dialysis will not be possible. The arm should be exercised to encourage venous dilation, not rested. The client can palpate for a thrill; a stethoscope is not needed to auscultate the bruit at home. The nurse should take every opportunity to discuss nutrition, even as it relates to wound healing, but loss of the graft or fistula by compression or occlusion must take priority because lifesaving dialysis cannot be performed.

What are the risk factors for the development of leukemia? (Select all that apply.) A Bone marrow hypoplasia Correct B Chemical exposure Correct C Down syndrome Correct D Ionizing radiation Correct E Multiple blood transfusions F Prematurity at birth

A Bone marrow hypoplasia B Chemical exposure C Down syndrome D Ionizing radiation Reduced production of blood cells in the bone marrow is one of the risk factors for developing leukemia. Exposure to chemicals through medical need or by environmental events can also contribute. Certain genetic factors contribute to the development of leukemia; Down syndrome is one such condition. Radiation therapy for cancer or other exposure to radiation, perhaps through the environment, also contributes. There is no indication that multiple blood transfusions are connected to clients who have leukemia. Although some genetic factors may influence the incidence of leukemia, prematurity at birth is not one of them.

A 56-year-old client admitted with a diagnosis of acute myelogenous leukemia is prescribed IV cytosine arabinoside for 7 days and an infusion of daunorubicin for the first 3 days. What is the major side effect of this therapy? A Bone marrow suppression B Liver toxicity C Nausea D Stomatitis

A Bone marrow suppression

A client with a compound fracture of the left femur is admitted to the emergency department after a motorcycle crash. Which action is most essential for the nurse to take first? A Check the dorsalis pedis pulses. B Immobilize the left leg with a splint. C Administer the prescribed analgesic. D Place a dressing on the affected area.

A Check the dorsalis pedis pulses. The first action should be to assess the circulatory status of the leg because the client is at risk for acute compartment syndrome, which can begin as early as 6 to 8 hours after an injury. Severe tissue damage can also occur if neurovascular status is compromised. Immobilization will be needed, but the nurse must assess the client's condition first. Administering an analgesic and placing a dressing on the affected area should both be done after the nurse has assessed the client.

The RN has just received change-of-shift report. Which of the assigned clients should be assessed first? A Client with chronic kidney failure who was just admitted with shortness of breath B Client with kidney insufficiency who is scheduled to have an arteriovenous fistula inserted C Client with azotemia whose blood urea nitrogen and creatinine are increasing D Client receiving peritoneal dialysis who needs help changing the dialysate bag

A Client with chronic kidney failure who was just admitted with shortness of breath The dyspnea of the client with chronic kidney failure may indicate pulmonary edema and should be assessed immediately. The client with kidney insufficiency is stable and assessment can be performed later. The client with azotemia requires assessment and possible interventions, but is not at immediate risk for life-threatening problems. The client receiving peritoneal dialysis can be seen last because it is a slow process and the client has no urgent needs.

To prevent pre-renal acute kidney injury, which person is encouraged to increase fluid consumption? A Construction worker B Office secretary C Schoolteacher D Taxicab driver

A Construction worker Physical labor and working outdoors, especially in warm weather, cause diaphoresis and place the construction worker at risk for dehydration and pre-renal azotemia. The office secretary and schoolteacher work indoors and, even without air conditioning, will not lose as much fluid to diaphoresis as someone performing physical labor. The taxicab driver, even without air conditioning, will not experience diaphoresis and fluid loss like the construction worker.

The nurse is teaching a client with vitamin B12 deficiency anemia about dietary intake. Which type of food does the nurse encourage the client to eat? A Dairy products B Grains C Leafy vegetables D Starchy vegetables

A Dairy products Dairy products such as milk, cheese, and eggs will provide the vitamin B12 that the client needs. Grains, leafy vegetables, and starchy vegetables are not a source of vitamin B12.

When assisting with dietary protein needs for a client on peritoneal dialysis, the nurse recommends that the client select which food? A Eggs B Ham C Eggplant D Macaroni

A Eggs Suggested protein-containing foods for a client on peritoneal dialysis are milk, meat, and eggs. Although a protein, ham is high in sodium, which should be avoided. Vegetables and pasta contain mostly carbohydrates. Peritoneal dialysis clients are allowed 1.2 to 1.5 g of protein/kg/day because protein is lost with each exchange.

Which clients are at risk for acute kidney injury (AKI)? (Select all that apply.) A Football player in preseason practice Correct B Client who underwent contrast dye radiology Correct C Accident victim recovering from a severe hemorrhage Correct D Accountant with diabetes E Client in the intensive care unit on high doses of antibiotics Correct F Client recovering from gastrointestinal influenza

A Football player in preseason practice B Client who underwent contrast dye radiology C Accident victim recovering from a severe hemorrhage E Client in the intensive care unit on high doses of antibiotics F Client recovering from gastrointestinal influenza To prevent AKI, all people should be urged to avoid dehydration by drinking at least 2 to 3 liters of fluids daily, especially during strenuous exercise or work associated with diaphoresis, or when recovering from an illness that reduces kidney blood flow, such as influenza. Contrast media may cause acute renal failure, especially in older clients with reduced kidney function. Recent surgery or trauma, transfusions, or other factors that might lead to reduced kidney blood flow may cause AKI. Certain antibiotics may cause nephrotoxicity. Diabetes may cause acute kidney failure superimposed on chronic kidney failure.

The nurse teaches a client who is recovering from acute kidney disease to avoid which type of medication? A Nonsteroidal anti-inflammatory drugs (NSAIDs) B Angiotensin-converting enzyme (ACE) inhibitors C Opiates D Calcium channel blockers

A Nonsteroidal anti-inflammatory drugs (NSAIDs) NSAIDs may be nephrotoxic to a client with acute kidney disease, and should be avoided. ACE inhibitors are used for treatment of hypertension and to protect the kidneys, especially in the diabetic client, from progression of kidney disease. Opiates may be used by clients with kidney disease if severe pain is present; however, excretion may be delayed. Calcium channel blockers can improve the glomerular filtration rate and blood flow within the kidney.

The nurse is assessing a newly admitted client with thrombocytopenia. Which factor needs immediate intervention? A Nosebleed B Reports of pain C Decreased urine output D Increased temperature

A Nosebleed The client with thrombocytopenia has a high risk for bleeding. The nosebleed should be attended to immediately. The client's report of pain, decreased urine output, and increased temperature are not the highest priority.

A client has undergone an elective below-the-knee amputation of the right leg as a result of severe peripheral vascular disease. In postoperative care teaching, the nurse instructs the client to notify the health care provider if which change occurs? A Observation of a large amount of serosanguineous or bloody drainage B Mild to moderate pain controlled with prescribed analgesics C Absence of erythema and tenderness at the surgical site D Ability to flex and extend the right knee

A Observation of a large amount of serosanguineous or bloody drainage A large amount of serosanguineous or bloody drainage may indicate hemorrhage or, if an incision is present, that the incision has opened. This requires immediate attention. Mild to moderate pain controlled with prescribed analgesics would be a normal finding for this client. Absence of erythema and tenderness of the surgical site would also be normal findings for this client. The client should be able to flex and extend the right knee (limb) after surgery.

While managing care for a client with chronic kidney disease, which actions does the registered nurse (RN) plan to delegate to unlicensed assistive personnel (UAP)? (Select all that apply.) A Obtain the client's pre-hemodialysis weight. Correct B Check the arteriovenous (AV) fistula for a thrill and bruit. C Document the amount the client drinks throughout the shift. Correct D Auscultate the client's lung sounds every 4 hours. E Explain the components of a low-sodium diet.

A Obtain the client's pre-hemodialysis weight. C Document the amount the client drinks throughout the shift. Obtaining the client's weight and documenting oral fluid intake are routine tasks that can be performed by UAP. Assessment skills (checking the AV fistula and auscultating lung sounds) and client education (explaining special diet) require more education and are in the legal scope of practice of the RN.

The nurse anticipates providing collaborative care for a client with a traumatic amputation of the right hand with which health care team members? (Select all that apply.) A Occupational therapist Correct B Physical therapist Correct C Psychologist Correct D Respiratory therapist E Speech therapist

A Occupational therapist B Physical therapist C Psychologist An occupational therapist and a physical therapist will help to enable the client to become more independent in performing activities of daily living. An amputation can be traumatic to the client; loss of a body part should not be underestimated because the client may experience an altered self-concept, so counseling support with a psychologist should be made available to the client. The client does not have a respiratory condition that warrants collaborative care with a respiratory therapist. A speech therapist is not indicated because the client does not have speech impairment.

The nurse assists a client with acute kidney injury (AKI) to modify the diet in which ways? (Select all that apply.) A Restricted protein B Liberal sodium C Restricted fluids D Low potassium E Low fat

A Restricted protein C Restricted fluids D Low potassium Breakdown of protein leads to azotemia and increased blood urea nitrogen. Fluid is restricted during the oliguric stage. Potassium intoxication may occur, so dietary potassium is also restricted. Sodium is restricted during AKI because oliguria causes fluid retention. Fats may be used for needed calories when proteins are restricted.

An older adult client has had an open reduction and internal fixation of a fractured right hip. Which intervention does the nurse implement for this client? A. Keep the client's heels off the bed at all times. B. Re-position the client every 3 to 4 hours. C. Administer preventive pain medication before deep-breathing exercises. D. Prohibit the use of antiembolic stockings.

A. Keep the client's heels off the bed at all times. Because the client is an older adult and is more at risk for skin breakdown because of impaired circulation and sensation, the client's heels must be kept off the bed at all times to avoid constant pressure on this sensitive area. Re-positioning the older adult client must be done every 2 hours, not every 3 to 4 hours, to prevent skin breakdown and to inspect the skin for any signs of breakdown. Pain medication would not be administered for deep-breathing exercises because this client typically would not experience pain upon breathing. Antiembolic stockings are not contraindicated for older adults; rather, they help prevent deep vein thrombosis.

Which intervention does the nurse suggest to a client with a leg amputation to help cope with loss of the limb? A. Talking with an amputee close to the client's age who has had the same type of amputation B Drawing a picture of how the client sees him- or herself C Talking with a psychiatrist about the amputation D Engaging in diversional activities to avoid focusing on the amputation

A. Talking with an amputee close to the client's age who has had the same type of amputation Meeting with someone of a comparable age who has gone through a similar experience will help the client cope better with his or her own situation. Drawing a picture is not therapeutic and may cause more harm than good. Unless the client is having serious maladjustment problems or has a coexisting psychological disorder, meeting with a psychiatrist should not be necessary. Diversional activities do not help the client deal with loss of the limb.

The nurse is assisting with endotracheal intubation of the patient and recognizes that the procedure will be done in what order: _______________, _______________, _______________, _______________, _______________? (Put a comma and space between each answer choice.) A. Assess balloon on endotracheal tube for symmetry and leaks. B. Assess lung fields for bilateral expansion. C. Inflate balloon of endotracheal tube. D. Insert endotracheal tube with laryngoscope and blade. E. Suction oropharynx.

ANS: A, E, D, C, B Intubation is done systematically by the physician, therapist, or anesthetist. Equipment is gathered and assessed (e.g., balloon/cuff on endotracheal tube). The patient is hyperoxygenated and secretions are suctioned from the oropharynx to visualize the vocal cords. The tube is inserted, and the balloon is inflated once the tube is in place. The position of the tube is assessed after intubation through auscultation of breath sounds, carbon dioxide testing, and chest x-ray.

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 actions: _______________, _______________, _______________, _______________? (Put a comma and space between each answer choice.) 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 must quickly assess the patient and determine possible causes of the alarm. If the cause is not assessed within seconds, the nurse must manually ventilate the patient and secure assistance in troubleshooting the problem. Once the problem has been corrected, the patient must be reassessed.

The correct priority order of actions in prehospital primary survey for burn injuries is: _______________, _______________, _______________, _______________. (Put a comma and space between each answer choice.) a. Assess ABCs and cervical spine. b. Provide oxygen therapy if smoke inhalation is suspected. c. Make rapid head-to-toe assessment to rule out additional trauma. d. Stop the burning process and prevent further injury.

ANS: D, A, B, C Early care has a positive impact on recovery. The first priority is to stop the burning process and prevent further injury. At this point, you initiate the primary survey, which is to assess the ABCs and cervical spine. Oxygen therapy follows the ABCs. The secondary survey includes further assessment for additional injuries.

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

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

The nurse is caring for a 100-kg patient being monitored with a pulmonary artery catheter. The nurse assesses a blood pressure of 90/60 mm Hg, heart rate 110 beats/min, respirations 36/min, oxygen saturation of 89% on 3 L of oxygen via nasal cannula. Bilateral crackles are audible upon auscultation. Which hemodynamic value requires immediate action by the nurse? a. Cardiac index (CI) of 1.2 L/min/m3 b. Cardiac output (CO) of 4 L/min c. Pulmonary vascular resistance (PVR) of 80 dynes/sec/cm-5 d. Systemic vascular resistance (SVR) of 1800 dynes/sec/cm-5

ANS: A A cardiac index of 1.2 L/min/m3 combined with the identified clinical assessment findings indicate a low cardiac output with fluid overload (bilateral crackles) requiring intervention. The remaining hemodynamic values are within normal limits: cardiac output of 4 L/min; pulmonary vascular resistance of 80 dynes/sec/cm-5; and the systemic vascular resistance of 1800 dynes/sec/cm-5.

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

ANS: A A cardiac output of 2.0 L/min in a patient with cardiogenic shock warrants immediate assessment. A PAP of 20 mm Hg, CVP of 6 mm Hg, and a PAOP of 10 mm Hg are all within normal limits.

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

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

A patient with a history of type 1 diabetes and an eating disorder is found unconscious. In the emergency department, the following lab values are obtained: Glucose: 648 mg/dL pH: 6.88 PaCO2: 20 mm Hg PaO2: 95 mm Hg HCO3¯: undetectable Anion gap: >31 Na+: 127 mEq/L K+: 3.5 mEq/L Creatinine: 1.8 mg/dL After the patient's airway and ventilation have been established, the next priority for this patient is: a. administration of a 1-L normal saline fluid bolus. b. administration of 0.1 unit of regular insulin IV push followed by an insulin infusion. c. administration of 20 mEq KCl in 100 mL. d. IV push administration of 1 amp of sodium bicarbonate.

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

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

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

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

ANS: A An arterial lactate level of 1.0 mEq/L is within normal limits and is indicative of normal oxygen delivery to the tissues. The cardiac output, mixed venous saturation, and cardiac index values are all below normal limits indicating inadequate cardiac output sufficient to provide oxygen delivery to the organs and tissues.

The nurse is caring for a patient with a chemical burn injury. The priority nursing intervention is to: a. remove the patient's clothes and flush the area with water. b. apply saline compresses. c. contact a poison control center for directions on neutralizing agents. d. remove all jewelry.

ANS: A As long as the chemical remains in contact with the skin, burn damage will result. Priority interventions are to remove the patient's clothes, brush loose chemical away from the skin and apply water for at least 30 minutes. Water needs to washed away from the body, not be applied as compresses. Contacting poison control may be helpful in obtaining more information on the systemic effects of the chemical, but it is not a priority intervention. Jewelry should be removed, but this is not as high a priority as removing the chemical and stopping the chemical burning process through continuous flushing with water.

The nurse is caring for a patient admitted with hypovolemic shock. The nurse palpates thready brachial pulses but is unable to auscultate a blood pressure. What is the best nursing action? a. Assess the blood pressure by Doppler. b. Estimate the systolic pressure as 60 mm Hg. c. Obtain an electronic blood pressure monitor. d. Record the blood pressure as "not assessable."

ANS: A Auscultated blood pressures in shock may be significantly inaccurate due to vasoconstriction. If blood pressure is not audible, the approximate value can be assessed by palpation or ultrasound. If brachial pulses are palpable, the approximate measure of systolic blood pressure is 80 mm Hg. This action has the potential to delay further assessment of a compromised patient in shock. Documenting a blood pressure as not assessable is not appropriate without further attempts using different modalities.

A patient is admitted to the hospital with multiple trauma and extensive blood loss. The nurse assesses vital signs to be BP 80/50 mm Hg, heart rate 135 beats/min, respirations 36 breaths/min, cardiac output (CO) of 2 L/min, systemic vascular resistance of 3000 dynes/sec/cm-5, and a hematocrit of 20%. The nurse anticipates administration of which the following therapies or medications? a. Blood transfusion b. Furosemide (Lasix) c. Dobutamine (Dobutrex) infusion d. Dopamine hydrochloride (Dopamine) infusion

ANS: A Both hemodynamic parameters and the reported hematocrit value indicate hypovolemia and blood loss requiring volume resuscitation with blood products. Furosemide administration will worsen fluid volume status. Inotropic agents will not correct the underlying fluid volume deficit and anemia. Vasoconstrictors are contraindicated in a volume-depleted state.

The nurse is caring for a patient who suffered a head trauma following a fall. The patient's heart rate is 112 beats/min and blood pressure is 88/50 mm Hg. The patient has poor skin turgor and dry mucous membranes. The patient is confused and restless. The following laboratory values are reported: serum sodium is 115 mEq/L; blood urea nitrogen (BUN) 50 mg/dL; and creatinine 1.8 mg/dL. The findings are consistent with which disorder? a. Cerebral salt wasting b. Diabetes insipidus c. Syndrome of inappropriate secretion of antidiuretic hormone d. Thyroid storm

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

The nurse is caring for a patient who is mechanically ventilated. As part of the nursing care, the nurse understands that: a. communication with intubated patients is often difficult. b. controlled ventilation is the preferred mode for most patients. c. patients with chronic obstructive pulmonary disease wean easily from mechanical ventilation. d. wrist restraints are applied to all patients to avoid self-extubation.

ANS: A Communication difficulties are common because of the artificial airway. Restraints must be determined individually. Patients with chronic obstructive pulmonary disease often have difficulty weaning. Synchronized intermittent mandatory ventilation and assist/control ventilation are the commonly used modes.

The nurse is caring for a patient following insertion of an intraaortic balloon pump (IABP) for cardiogenic shock unresponsive to pharmacotherapy. Which hemodynamic parameter best indicates an appropriate response to therapy? a. Cardiac index (CI) of 2.5 L/min/m2 b. Pulmonary artery diastolic pressure of 26 mm Hg c. Pulmonary artery occlusion pressure (PAOP) of 22 mm Hg d. Systemic vascular resistance (SVR) of 1600 dynes/sec/cm-5

ANS: A Desired outcomes for a patient in cardiogenic shock with an IABP include decreased SVR, diminished symptoms of myocardial ischemia (chest pain, ST-segment elevation), increased stroke volume, and increased cardiac output and cardiac index. A cardiac index of 2.5 L/min is within normal limits. All other values are high and would not indicate an appropriate response to therapy.

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

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

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

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

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

ANS: A Diminished breaths sounds over the lung field on the same side of the line insertion site may be indicative of a pneumothorax. A pneumothorax, which can develop slowly, is a major complication following insertion of central lines when the subclavian route is used. Localized pain at catheter insertion site is not the immediate priority in this scenario. A measured central venous pressure of 5 mm Hg is normal. Slight bloody drainage at the insertion site soon after the procedure does not require immediate action.

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

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

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

ANS: A Duration of the catheter is an independent risk factor for CRBSI, and removal of the catheter when not needed to guide treatment is associated with a reduction in mortality. Maintaining of the insertion site should be guided by institutional guidelines and is best accomplished with chlorhexidine skin antisepsis. Minimizing the number of times the flush system is opened by changing tubing no more frequently than every 72 to 96 hours reduces the risk of CRBSI. Maintaining a pressure of 300 mm Hg on the flush solution bag helps maintain the integrity of the invasive line and does not reduce the risk of infection.

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

ANS: A Ensuring a patent IV site prevents complications associated with infiltration of the medication (soft tissue necrosis). Mixing the drug with normal saline prevents crystallization of the medication and would be noticed prior to administration. Evaluating the serum K+ is not required prior to administration. The dose of phenytoin (Dilantin) ordered can be safely administered IV push over 2 minutes and does not require an infusion pump.

Which of the following devices is best suited to deliver 65% oxygen to a patient who is spontaneously breathing? a. Face mask with non-rebreathing reservoir b. Low-flow nasal cannula c. Simple face mask d. Venturi mask

ANS: A Face masks with reservoirs (partial rebreathing and non-rebreathing reservoir masks) provide oxygen concentration of 60% or higher. The addition of the reservoir increases the amount of oxygen available to the patient during inspiration and allows for the delivery of concentrations of 35% to 60% (partial rebreather) or 60% to 80% (non-rebreather) depending on the flowmeter setting, the fit of the mask, and the patient's respiratory pattern. The high-flow nasal cannula, not the traditional low-flow models, can provide higher flows. The simple face mask can deliver flows up to 60%. The Venturi mask allows better regulation of oxygen concentration and generally does not deliver more than 60% oxygen.

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

ANS: A Fluid volume resuscitation is the priority in patients with severe sepsis to maintain circulating blood volume and end-organ perfusion and oxygenation. A 500-mL IV bolus of 0.9% normal saline is appropriate given the patient's CVP of 2 mm Hg and hourly urine output of 10 mL/hr. There is no evidence to support the need to increase supplemental oxygen. Administration of furosemide (Lasix) in the presence of a fluid volume deficit is contraindicated

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

ANS: A Given the patient's diagnosis, laboratory results, and supporting vital signs, restoring circulating blood volume is a priority and can be accomplished following insertion of an appropriate gauge IV (18) to facilitate blood and fluid administration. Universal precautions, fall precautions, and application of heel protectors are appropriate interventions but are not the immediate priority.

A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL. The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best? a. "High glucose is common in shock and needs to be treated." b. "Some of the medications we are giving are to raise blood sugar." c. "The IV solution has lots of glucose, which raises blood sugar." d. "The stress of this illness has made your spouse a diabetic."

ANS: A High glucose readings are common in shock, and best outcomes are the result of treating them and maintaining glucose readings in the normal range. Medications and IV solutions may raise blood glucose levels, but this is not the most accurate answer. The stress of the illness has not "made" the client diabetic.

A patient is admitted to the cardiac care unit with an acute anterior myocardial infarction. The nurse assesses the patient to be diaphoretic and tachypneic, with bilateral crackles throughout both lung fields. Following insertion of a pulmonary artery catheter by the physician, which hemodynamic values is the nurse most likely to assess? a. High pulmonary artery diastolic pressure and low cardiac output b. Low pulmonary artery occlusive pressure and low cardiac output c. Low systemic vascular resistance and high cardiac output d. Normal cardiac output and low systemic vascular resistance

ANS: A In cardiogenic shock, cardiac output and cardiac index decrease. Right atrial pressure, pulmonary artery pressures, and pulmonary artery occlusion pressure increase and volume backs up into the pulmonary circulation and the right side of the heart. Pulmonary artery occlusion pressure increases in cardiogenic shock. Systemic vascular resistance is high and cardiac output is low in cardiogenic shock. Cardiac output is low and systemic vascular resistance is high in cardiogenic shock.

A patient presents to the emergency department with suspected thyroid storm. The nurse should be alert to which of the following cardiac rhythms while providing care to this patient? a. Atrial fibrillation b. Idioventricular rhythm c. Junctional rhythm d. Sinus bradycardia

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

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

ANS: A Interventions that have been associated with a reduction in CLABSI include timely removal of unnecessary central lines. Documentation of the line insertion date will assist in monitoring this measure. Elevation of the head of the bed, assessment for weaning readiness, and appropriate sedation management are appropriate interventions to reduce the risk of ventilator-acquired pneumonia.

The nurse is caring for patient who has been struck by lightning. Because of the nature of the injury, the nurse assesses the patient for which of the following? a. Central nervous system deficits b. Contractures c. Infection d. Stress ulcers

ANS: A Lightning injury frequently causes cardiopulmonary arrest. However, of those patients who survive, 70% will have transient central nervous system deficits. Contractures, infection, and stress ulcer risks are no greater than with other causes of burn injury.

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

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

A client is receiving norepinephrine (Levophed) for shock. What assessment finding best indicates a therapeutic effect from this drug? a. Alert and oriented, answering questions b. Client denial of chest pain or chest pressure c. IV site without redness or swelling d. Urine output of 30 mL/hr for 2 hours

ANS: A Normal cognitive function is a good indicator that the client is receiving the benefits of norepinephrine. The brain is very sensitive to changes in oxygenation and perfusion. Norepinephrine can cause chest pain as an adverse reaction, so the absence of chest pain does not indicate therapeutic effect. The IV site is normal. The urine output is normal, but only minimally so.

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

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

A patient has been on daily, high-dose glucocorticoid therapy for the treatment of rheumatoid arthritis. His prescription runs out before his next appointment with his physician. Because he is asymptomatic, he thinks it is all right to withhold the medication for 3 days. What is likely to happen to this patient? a. He will go into adrenal crisis. b. He will go into thyroid storm. c. His autoimmune disease will go into remission. d. Nothing; it is appropriate to stop the medication for 3 days.

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

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

ANS: A Patients with toxic epidermal necrolysis, Stevens-Johnson Syndrome (SJS), and erythema multiforme present with acute onset fever and flulike symptoms, with erythema and blisters developing within 24 to 96 hours, skin and mucous membranes slough, resulting in a significant and painful partial-thickness injury. Staphylococcal scalded skin syndrome presents predominantly in children. Necrotizing soft tissue infection results from rapidly invasive bacterial infections. Graft versus host disease is not logical given the clinical information provided.

A patient's ventilator settings are adjusted to treat hypoxemia. The fraction of inspired oxygen is increased from .60 to .70, and the positive end-expiratory pressure is increased from 10 to 15 cm H2O. Shortly after these adjustments, the nurse notes that the patient's blood pressure drops from 120/76 mm Hg to 90/60 mm Hg. What is the most likely cause of this decrease in blood pressure? a. Decrease in cardiac output b. Hypovolemia c. Increase in venous return d. Oxygen toxicity

ANS: A Positive end-expiratory pressure increases intrathoracic pressure and may result in decreased venous return. Cardiac output decreases as a result, and is reflected in the lower blood pressure. It is essential to assess the patient to identify optimal positive end-expiratory pressure—the highest amount that can be applied without compromising cardiac output. Although hypovolemia can result in a decrease in blood pressure, there is no indication that this patient has hypovolemia. As noted, higher levels of positive end-expiratory pressure may cause a decrease, not an increase, in venous return. Oxygen toxicity can occur in this case secondary to the high levels of oxygen needed to maintain gas exchange; however, oxygen toxicity is manifested in damage to the alveoli.

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

ANS: A Positive inotropic agents (e.g., dobutamine) are given to increase the contractile force of the heart. As contractility increases, cardiac output and index increase and improve tissue perfusion. Administration of furosemide will assist only in managing fluid volume overload. Phenylephrine administration enhances vasoconstriction, which may increase afterload and further reduce cardiac output. Sodium nitroprusside is given to reduce afterload. There is no evidence to support a need for afterload reduction in this scenario.

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

ANS: A The IABP improves coronary artery perfusion, reduces afterload, and improves perfusion to vital organs. An IABP acts through counterpulsation, augmenting the pumping action of the heart, displacing blood to improve both forward and backward blood flow. It does not "beat" for the damaged heart. An IABP does not filter blood impurities. An IABP is designed as a temporary therapy for use when pharmacological interventions alone are not effective. It is indicated for short-term use, not as a bridge to transplant.

While monitoring a patient for signs of shock, the nurse understands which system assessment to be of priority? a. Central nervous system b. Gastrointestinal system c. Renal system d. Respiratory system

ANS: A The central nervous system experiences decreased perfusion first. The patient will have central nervous system changes early during the course of shock, such as changes in the level of consciousness. Although the gastrointestinal, renal, and respiratory systems also experience changes during shock, changes in the central nervous system provide the earliest indication of decreased perfusion.

A patient's endotracheal tube is not secured tightly. The respiratory care practitioner assists the nurse in taping the tube. After the tube is retaped, the nurse auscultates the patient's lungs and notes that the breath sounds over the left lung fields are absent. The nurse suspects that: a. the endotracheal tube is in the right mainstem bronchus. b. the patient has a left pneumothorax. c. the patient has aspirated secretions during the procedure. d. the stethoscope earpiece is clogged with wax.

ANS: A The endotracheal tube can become dislodged during repositioning and is likely in the right mainstem bronchus. It is important to reassess breath sounds after the retaping procedure. A pneumothorax would also result in diminished or absent breath sounds; however, it is not associated with repositioning the endotracheal tube. Aspiration may occur during the procedure but would be manifested in changes in chest x-ray, hypoxemia, etc. The stethoscope is not a factor.

The nurse is caring for an 18-year-old athlete with a possible cervical spine (C5) injury following a diving accident. The nurse assesses a blood pressure of 70/50 mm Hg, heart rate 45 beats/min, and respirations 26 breaths/min. The patient's skin is warm and flushed. What is the best interpretation of these findings by the nurse? a. The patient is developing neurogenic shock. b. The patient is experiencing an allergic reaction. c. The patient most likely has an elevated temperature. d. The vital signs are normal for this patient.

ANS: A The most profound feature of neurogenic shock is bradycardia with hypotension from the decreased sympathetic activity. There is no evidence to support an allergic reaction in this scenario. Hypothermia, not an elevated temperature, can develop from uncontrolled heat loss associated with vasodilation in neurogenic shock. Vital signs are not normal given the clinical situation.

A client in shock is apprehensive and slightly confused. What action by the nurse is best? a. Offer to remain with the client for awhile. b. Prepare to administer antianxiety medication. c. Raise all four siderails on the client's bed. d. Tell the client everything possible is being done.

ANS: A The nurse's presence will be best to reassure this client. Antianxiety medication is not warranted as this will lower the client's blood pressure. Using all four siderails on a hospital bed is considered a restraint in most facilities, although the nurse should ensure the client's safety. Telling a confused client that everything is being done is not the most helpful response.

A client has been brought to the emergency department after being shot multiple times. What action should the nurse perform first? a. Apply personal protective equipment. b. Notify local law enforcement officials. c. Obtain "universal" donor blood. d. Prepare the client for emergency surgery.

ANS: A The nurse's priority is to care for the client. Since the client has gunshot wounds and is bleeding, the nurse applies personal protective equipment (i.e., gloves) prior to care. This takes priority over calling law enforcement. Requesting blood bank products can be delegated. The nurse may or may not have to prepare the client for emergency surgery.

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

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

The nurse gets the hand-off report on four clients. Which client should the nurse assess first? a. Client with a blood pressure change of 128/74 to 110/88 mm Hg b. Client with oxygen saturation unchanged at 94% c. Client with a pulse change of 100 to 88 beats/min d. Client with urine output of 40 mL/hr for the last 2 hours

ANS: A This client has a falling systolic blood pressure, rising diastolic blood pressure, and narrowing pulse pressure, all of which may be indications of the progressive stage of shock. The nurse should assess this client first. The client with the unchanged oxygen saturation is stable at this point. Although the client with a change in pulse has a slower rate, it is not an indicator of shock since the pulse is still within the normal range; it may indicate the client's pain or anxiety has been relieved, or he or she is sleeping or relaxing. A urine output of 40 mL/hr is only slightly above the normal range, which is 30 mL/hr.

The nurse is caring for a patient in septic shock. The nurse assesses the patient to have a blood pressure of 105/60 mm Hg, heart rate 110 beats/min, respiratory rate 32 breaths/min, oxygen saturation (SpO2) 95% on 45% supplemental oxygen via Venturi mask, and a temperature of 102° F. The physician orders stat administration of an antibiotic. Which additional physician order should the nurse complete first? a. Blood cultures b. Chest x-ray c. Foley insertion d. Serum electrolytes

ANS: A Timely identification of the causative organism through blood cultures and the initiation of appropriate antibiotics following obtaining blood cultures improve the survival of patients with sepsis or septic shock. A chest x-ray, Foley insertion, and measurement of serum electrolytes may be included in the plan of care but are not the priority in this scenario.

Upon entering the room of a patient with a right radial arterial line, the nurse assesses the waveform to be slightly dampened and notices blood to be backed up into the pressure tubing. What is the best action by the nurse? a. Check the inflation volume of the flush system pressure bag. b. Disconnect the flush system from the arterial line catheter. c. Zero reference the transducer system at the phlebostatic axis. d. Reduce the number of stopcocks in the flush system tubing.

ANS: A To maintain the patency of the arterial line, the inflation volume of the flush system pressure bag should be inflated to 300 mm Hg to ensure a constant flow of fluid through the system, preventing backward flow of blood into the system tubing. Disconnecting the flush system from the arterial line is not appropriate and could increase the risk of infection to the patient. Zero referencing the system will not help clear the blood from the system tubing. Reducing the number of stopcocks helps reduce the risk of a disconnection that could lead to excessive blood loss.

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

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

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

ANS: A, B, C Options A, B, and C are required to ensure proper functioning of the arterial line. There is no need to restrain all extremities. Depending on the patient's level of sedation, the right hand may need gentle restraint.

Which of the following statements about the pain management of a burn victim are true? (Select all that apply.) a. Additional pain medication may be needed because of rapid body metabolism. b. Pain medication should be given before procedures such as debridement, dressing changes, and physical therapy. c. Patients with a history of drug and alcohol abuse will require higher doses of pain medication. d. The intramuscular route is preferred for pain medication administration.

ANS: A, B, C The rapid metabolism associated with burn injury may require additional pain medication. Many of the procedures associated with burn wounds are painful, such as dressing changes. Adequate pain medication should be given prior to the procedures. Edema in burned patients alters the absorption of medications that are injected intramuscularly; therefore, drugs must be administered by the IV route.

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

ANS: A, B, C, D During insertion of a pulmonary artery catheter (PAC/Swan-Ganz), the nurse should allay the patient's anxiety, ensure that the sterile field is maintained to decrease the risk of infection, inflate the balloon upon request of the physician to assist in catheter placement, and monitor for dysrhythmias that may occur as the catheter passes through the right ventricle. Informed consent may be witnessed by the nurse, but it is obtained by the physician and should occur before the procedure begins.

The nurse caring frequently for older adults in the hospital is aware of risk factors that place them at a higher risk for shock. For what factors would the nurse assess? (Select all that apply.) a. Altered mobility/immobility b. Decreased thirst response c. Diminished immune response d. Malnutrition e. Overhydration

ANS: A, B, C, D Immobility, decreased thirst response, diminished immune response, and malnutrition can place the older adult at higher risk of developing shock. Overhydration is not a common risk factor for shock.

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

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

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

ANS: A, B, D Autograft skin will allow for faster healing with less scar formation and a shorter hospitalization.

The nurse is caring for a patient with burns to the hands, feet, and major joints. The nurse plans care to include which of the following? (Select all that apply.) a. Applying splints that maintain the extremity in an extended position b. Implementing passive or active range-of-motion exercises c. Keeping the limbs as immobile as possible d. Wrapping fingers and toes individually with bandages

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

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

ANS: A, B, D To obtain an accurate pulmonary artery occlusion pressure (PAOP), the transducer system should be zero referenced and leveled to ensure accurate readings, and the balloon should be inflated with enough air, for no more than 8 to 10 seconds until a change in waveform is noted. The volume of air necessary to inflate the balloon should be documented. Maintaining the balloon in the inflated position can lead to pulmonary infarction.

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

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

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

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

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

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

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

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

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

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

The nurse is caring for a client with suspected severe sepsis. What does the nurse prepare to do within 3 hours of the client being identified as being at risk? (Select all that apply.) a. Administer antibiotics. b. Draw serum lactate levels. c. Infuse vasopressors. d. Measure central venous pressure. e. Obtain blood cultures.

ANS: A, B, E Within the first 3 hours of suspecting severe sepsis, the nurse should draw (or facilitate) serum lactate levels, obtain blood cultures (or other cultures), and administer antibiotics (after the cultures have been obtained). Infusing vasopressors and measuring central venous pressure are actions that should occur within the first 6 hours.

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

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

The student nurse studying shock understands that the common manifestations of this condition are directly related to which problems? (Select all that apply.) a. Anaerobic metabolism b. Hyperglycemia c. Hypotension d. Impaired renal perfusion e. Increased perfusion

ANS: A, C The common manifestations of shock, no matter the cause, are directly related to the effects of anaerobic metabolism and hypotension. Hyperglycemia, impaired renal function, and increased perfusion are not manifestations of shock.

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

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

The nurse is caring for a mechanically ventilated patient and responds to a high inspiratory pressure alarm. Recognizing possible causes for the alarm, the nurse assesses for which of the 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

ANS: A, C, D Coughing, kinks, and mucus in the airway can cause the inspiratory pressure to increase; ventilator disconnects result in low-volume alarms. A disconnection from the ventilator would result in a low exhaled volume alarm, not a high-pressure alarm.

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

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

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

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

The nurse caring for hospitalized clients includes which actions on their care plans to reduce the possibility of the clients developing shock? (Select all that apply.) a. Assessing and identifying clients at risk b. Monitoring the daily white blood cell count c. Performing proper hand hygiene d. Removing invasive lines as soon as possible e. Using aseptic technique during procedures

ANS: A, C, D, E Assessing and identifying clients at risk for shock is probably the most critical action the nurse can take to prevent shock from occurring. Proper hand hygiene, using aseptic technique, and removing IV lines and catheters are also important actions to prevent shock. Monitoring laboratory values does not prevent shock but can indicate a change.

Which of the following infection control strategies should the nurse implement to decrease the risk of infection in the burn-injured patient? (Select all that apply.) a. Apply topical antibacterial wound ointments/dressings. b. Change indwelling urinary catheter every 7 days. c. Daily assess the need for central IV catheters. d. Restrict family visitation. e. Maintain strict aseptic technique during burn wound management.

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

The nurse is caring for a young adult patient admitted with shock. The nurse understands which assessment findings best assess tissue perfusion in a patient in shock? (Select all that apply.) a. Blood pressure b. Heart rate c. Level of consciousness d. Pupil response e. Respirations f. Urine output

ANS: A, C, F The level of consciousness assesses cerebral perfusion, urine output assesses renal perfusion, and blood pressure is a general indicator of systemic perfusion. Heart rate is not an indicator of perfusion. Pupillary response does not assess perfusion. Respirations do not assess perfusion.

A client is in the early stages of shock and is restless. What comfort measures does the nurse delegate to the nursing student? (Select all that apply.) a. Bringing the client warm blankets b. Giving the client hot tea to drink c. Massaging the client's painful legs d. Reorienting the client as needed e. Sitting with the client for reassurance

ANS: A, D, E The student can bring the client warm blankets, reorient the client as needed to decrease anxiety, and sit with the client for reassurance. The client should be NPO at this point, so hot tea is prohibited. Massaging the legs is not recommended as this can dislodge any clots present, which may lead to pulmonary embolism.

The nurse is preparing to obtain a right atrial pressure (RAP/CVP) reading. What are the most appropriate nursing actions? (Select all that apply.) a. Compare measured pressures with other physiological parameters. b. Flush the central venous catheter with 20 mL of sterile saline. c. Inflate the balloon with 3 mL of air and record the pressure tracing. d. Obtain the right atrial pressure measurement during end exhalation. e. Zero reference the transducer system at the level of the phlebostatic axis.

ANS: A, D, E To obtain an accurate right atrial pressure (RAP/CVP) reading, the transducer system should be zero referenced and leveled with the phlebostatic axis to ensure accurate readings; the value should be obtained during end exhalation, and any obtained measure should be evaluated in light of the patient's physiological parameters and physical assessment. The catheter does not need to be flushed before measurement because continuous saline flush is part of the RAP system. There is no balloon with a right atrial pressure (RAP/CVP) catheter.

A nurse is caring for several clients at risk for shock. Which laboratory value requires the nurse to communicate with the health care provider? a. Creatinine: 0.9 mg/dL b. Lactate: 6 mmol/L c. Sodium: 150 mEq/L d. White blood cell count: 11,000/mm3

ANS: B A lactate level of 6 mmol/L is high and is indicative of possible shock. A creatinine level of 0.9 mg/dL is normal. A sodium level of 150 mEq/L is high, but that is not related directly to shock. A white blood cell count of 11,000/mm3 is slightly high but is not as critical as the lactate level.

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

ANS: B A pulmonary artery catheter provides hemodynamic measurements that guide interventions that include appropriate fluid therapy. Even though a pulmonary catheter provides multiple intravenous access sites, this is not the primary purpose of the catheter. Although the catheter is positioned in the pulmonary artery, positioning is not the purpose of the catheter. The primary purpose of the catheter is not to aid in the healing of the heart but to guide therapy.

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

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

A patient admitted with severe burns to his face and hands is showing signs of extreme agitation. The nurse should explore the mechanism of burn injury possibly related to: a. excessive alcohol use. b. methamphetamine use. c. posttraumatic stress disorder. d. subacute delirium.

ANS: B A vague or inconsistent injury history, burns to the face and hands, and signs of agitation or substance withdrawal should alert the nurse to a potential methamphetamine-related injury.

A client arrives in the emergency department after being in a car crash with fatalities. The client has a nearly amputated leg that is bleeding profusely. What action by the nurse takes priority? a. Apply direct pressure to the bleeding. b. Ensure the client has a patent airway. c. Obtain consent for emergency surgery. d. Start two large-bore IV catheters.

ANS: B Airway is the priority, followed by breathing and circulation (IVs and direct pressure). Obtaining consent is done by the physician.

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

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

A client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery. The client's sternal wound has not yet healed. What statement by the client most indicates a higher risk of developing sepsis after discharge? a. "All my friends and neighbors are planning a party for me." b. "I hope I can get my water turned back on when I get home." c. "I am going to have my daughter scoop the cat litter box." d. "My grandkids are so excited to have me coming home!"

ANS: B All these statements indicate a potential for leading to infection once the client gets back home. A large party might include individuals who are themselves ill and contagious. Having litter boxes in the home can expose the client to microbes that can lead to infection. Small children often have upper respiratory infections and poor hand hygiene that spread germs. However, the most worrisome statement is the lack of running water for handwashing and general hygiene and cleaning purposes.

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

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

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

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

The nurse has just completed administration of a 1000-L bolus of 0.9% normal saline. The nurse assesses the patient to be slightly confused, with a mean arterial blood pressure (MAP) of 50 mm Hg, a heart rate of 110 beats/min, urine output of 10 mL for the past hour, and a central venous pressure (CVP/RAP) of 3 mm Hg. What is the best interpretation of these results by the nurse? a. Patient response to therapy is appropriate. b. Additional interventions are indicated. c. More time is needed to assess response. d. Values are normal for the patient condition.

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

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

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

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

ANS: B Avoiding infusing vasoactive agents into the port used to obtain the thermodilution cardiac output (TdCO) measurement prevents the patient from receiving a bolus of these agents during rapid infusion of the injectate solution. Ensuring zero referencing of the transducer, maintaining 300 mm Hg pressure of the system pressure bag, and limiting the length of the pressure tubing help to ensure the obtained measures are accurate and do not influence safety.

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

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

A burn patient in the rehabilitation phase of injury is increasingly anxious and unable to sleep. The nurse should consult with the provider to further assess the patient for: a. acute delirium. b. posttraumatic stress disorder. c. suicidal intentions. d. bipolar disorder.

ANS: B Burn-injured patients experience psychologically devastating injuries in addition to physical injuries. Burn patients that demonstrate changes in behavior, anxiety, insomnia, regression, and acting out should be evaluated for posttraumatic stress disorder. Acute delirium is more likely to occur during the acute phase of injury. Suicidal ideations should always be addressed if the patient expresses or shows signs of suicidal thoughts. Burn-injured patients may have an underlying mental health disorder that requires treatment, such as bipolar disorder or schizophrenia.

The nurse is caring for a patient who has undergone skin grafting of the face and arms for burn wound treatment. A primary nursing diagnosis is: a. altered nutrition, less than body requirements. b. body image disturbance. c. decreased cardiac output. d. fluid volume deficit.

ANS: B Burns, scarring, and skin grafting can all affect appearance. Body image disturbances may result. Nutritional support is started early in management of the patient with burns, and there is no indication that this patient has a nutritional deficit. Nursing care plan priorities would also continue to focus on nutritional needs to optimize healing. Decreased cardiac output and fluid volume deficit should not be priority concerns during the wound closure phase of burn wound management by grafting.

One of the early signs of the effect of hypoxemia on the nervous system is: a. cyanosis. b. restlessness. c. tachycardia. d. tachypnea.

ANS: B Decreased oxygenation to the nervous system may result in restlessness and agitation—early signs of hypoxemia. Cyanosis is a late sign. Tachycardia and tachypnea may occur, but CNS changes tend to occur earlier.

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

ANS: B Fluid resuscitation with large volumes of crystalloid results in hemodilution of red blood cells and plasma proteins. Hemoglobin and hematocrit results indicate hemodilution. Given the clinical scenario, there is no evidence to support the need for a blood transfusion and no evidence of fluid overload. Although administration of large volumes of crystalloid can result in hemodilution of plasma proteins leading to third spacing of fluid, this fact does not support the hemoglobin and hematocrit results.

A patient with type 1 diabetes who is receiving a continuous subcutaneous insulin infusion via an insulin pump contacts the clinic to report mechanical failure of the infusion pump. The nurse instructs the patient to begin monitoring for signs of: a. adrenal insufficiency. b. diabetic ketoacidosis. c. hyperosmolar, hyperglycemic state. d. hypoglycemia.

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

An elderly individual from an assisted living facility presents with severe scald burns to the buttocks and back of the thighs. The caregiver from the ALF accompanies the patient to the emergency department and states that the bath water was "too hot" and that the "patient sat in the water too long." What should the nurse do? a. Ask the caregiver at what temperature the water heater is set in the home. b. Ask the caregiver to step out while examining the patient's burn injury. c. Immediately contact the police to report the suspected elder abuse. d. Ask the caregiver to describe exactly how the injury occurred.

ANS: B In cases of suspected abuse, especially in vulnerable patients such as children, elderly, and mentally impaired, it is important to assess the injured patient separately from the caregiver. While obtaining safety information on the temperature of the water heater is important, it is not a priority assessment question. The nurse should follow the hospital protocol for contacting appropriate authorities concerning suspected abuse, which may include contacting the police or social services. Asking the caregiver to describe how the injury occurred is important (e.g., there may be discrepancies in the physical assessment and reported mechanism of burn injury); however, examining the patient away from the caregiver is a priority.

When paramedics notice singed hairs in the nose of a burn patient, it is recommended that the patient be intubated. What is the reasoning for the immediate intubation? a. Carbon monoxide poisoning always occurs when soot is visible. b. Inhalation injury above the glottis may cause significant edema that obstructs the airway. c. The patient will have a copious amount of mucus that will need to be suctioned. d. The singed hairs and soot in the nostrils will cause dysfunction of cilia in the airways.

ANS: B In inhalation injury, the airway may become edematous quickly, making intubation difficult. Early intubation is recommended to protect the airway. Carbon monoxide poisoning may be present, but singed nose hairs are neither a symptom nor a reason for early intubation. Management of secretions is not an indication for intubation. Singed hairs and soot are more commonly symptoms of injury above the glottis rather than lower airway, below-the-glottis, signs and symptoms that will interfere with oxygenation and ventilation.

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

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

The nurse has just completed an infusion of a 1000 mL bolus of 0.9% normal saline in a patient with severe sepsis. One hour later, which laboratory result requires immediate nursing action? a. Creatinine 1.0 mg/dL b. Lactate 6 mmol/L c. Potassium 3.8 mEq/L d. Sodium 140 mEq/L

ANS: B Lactate level has been used as an indicator of decreased oxygen delivery to the cells, adequacy of resuscitation in shock, and as an outcome predictor. All other listed values are within normal limits and do not require additional follow-up.

The nursing 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 Loose connections in hemodynamic monitoring tubing can lead to hemorrhage, a major complication of arterial pressure monitoring. Application of a pressure dressing is required only upon arterial line removal. Blood return is adequate confirmation of arterial line placement; x-ray studies are not performed to confirm arterial line placement. Neutral positioning of the extremity and use of an arm board, without limb restraint, is the standard of care.

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

ANS: B Low pulmonary artery occlusion pressures usually indicate volume depletion, so intravenous fluids would be indicated. Administration of diuretics would worsen the patient's volume status. Negative inotropes would not improve the patient's volume status. Vasopressors will increase blood pressure but are contraindicated in a low volume state.

A student is caring for a client who suffered massive blood loss after trauma. How does the student correlate the blood loss with the client's mean arterial pressure (MAP)? a. It causes vasoconstriction and increased MAP. b. Lower blood volume lowers MAP. c. There is no direct correlation to MAP. d. It raises cardiac output and MAP.

ANS: B Lower blood volume will decrease MAP. The other answers are not accurate.

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

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

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

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

The nurse understands that negative-pressure wound therapy may be used in the treatment of partial-thickness burn wounds to do which of the following? a. Maintain a closed wound system to decrease the risk of infection. b. Remove excessive wound fluid and promote moist wound healing. c. Increase patient mobility with large burn wounds. d. Quantify wound drainage amount for more accurate output assessment.

ANS: B Negative-pressure wound therapy can be used to treat grafts or partial-thickness burns by decompressing edematous interstitial spaces that enhance local perfusion, optimizing wound healing. This therapy also provides a moist wound-healing environment. The system is closed and may reduce the risk of infection but may not prevent infection. Patients are less mobile because the system needs an electrical source to function. Wound drainage is quantified by using the negative-pressure wound therapy system, but this is not a primary indication for the therapy.

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

ANS: B Numbness and tingling in the left hand, which is the location of an arterial catheter, indicates possible neurovascular compromise and requires immediate action. A dampened waveform can indicate problems with arterial line patency but is not an emergent situation. Slight bloody drainage at the subclavian insertion site is not an unusual finding. Slight redness at the insertion site, while of concern, does not require immediate action.

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

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

Oxygen saturation (SaO2) represents: a. alveolar oxygen tension. b. oxygen that is chemically combined with hemoglobin. c. oxygen that is physically dissolved in plasma. d. total oxygen consumption.

ANS: B Oxygen saturation value reflects the saturation of the hemoglobin.

A PaCO2 of 48 mm Hg is associated with: a. hyperventilation. b. hypoventilation. c. increased absorption of O2. d. increased excretion of HCO3.

ANS: B PaCO2 rises in patients with hypoventilation. Hyperventilation results in a decrease in PaCO2. PaCO2 does not affect oxygen absorption. Increased excretion of bicarbonate would result in metabolic acidosis.

A patient is receiving hydrocortisone sodium succinate for adrenal crisis. What other medication does the nurse prepare to administer? a. Regular insulin b. A proton pump inhibitor c. Canagliflozin d. Propranolol

ANS: B Patients receiving hydrocortisone sodium succinate need to be on a regime to prevent GI bleeding. A proton pump inhibitor would be a good choice. Insulin is used in the treatment of diabetes or for glycemic control in acutely ill nondiabetics. Canagliflozin is an oral anti-hyperglycemic medication. Propranolol is a beta blocker often used in thyroid storm to blunt the effects of sympathetic nervous system stimulation.

The nurse is caring for a patient who underwent pituitary surgery 12 hours ago. The nurse will give priority to monitoring the patient carefully for which of the following? a. Congestive heart failure b. Hypovolemic shock c. Infection d. Volume overload

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

A nurse works at a community center for older adults. What self-management measure can the nurse teach the clients to prevent shock? a. Do not get dehydrated in warm weather. b. Drink fluids on a regular schedule. c. Seek attention for any lacerations. d. Take medications as prescribed.

ANS: B Preventing dehydration in older adults is important because the age-related decrease in the thirst mechanism makes them prone to dehydration. Having older adults drink fluids on a regular schedule will help keep them hydrated without the influence of thirst (or lack of thirst). Telling clients not to get dehydrated is important, but not the best answer because it doesn't give them the tools to prevent it from occurring. Older adults should seek attention for lacerations, but this is not as important an issue as staying hydrated. Taking medications as prescribed may or may not be related to hydration.

The nurse is assisting with endotracheal intubation and understands correct placement of the endotracheal tube in the trachea would be identified by which of the following? (Select all that apply.) a. Auscultation of air over the epigastrium b. Equal bilateral breath sounds upon auscultation c. Position above the carina verified by chest x-ray d. Positive detection of carbon dioxide (CO2) through CO2 detector devices

ANS: B, C, D The position of the tube is assessed after intubation through auscultation of breath sounds, carbon dioxide testing, and chest x-ray. Auscultation of air over the epigastrium indicates placement in the esophagus rather than the trachea.

A nurse is caring for a client after surgery. The client's respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since they were last assessed 4 hours ago. What action by the nurse is best? a. Ask if the client needs pain medication. b. Assess the client's tissue perfusion further. c. Document the findings in the client's chart. d. Increase the rate of the client's IV infusion.

ANS: B Signs of the earliest stage of shock are subtle and may manifest in slight increases in heart rate, respiratory rate, or blood pressure. Even though these readings are not out of the normal range, the nurse should conduct a thorough assessment of the client, focusing on indicators of perfusion. The client may need pain medication, but this is not the priority at this time. Documentation should be done thoroughly but is not the priority either. The nurse should not increase the rate of the IV infusion without an order.

Silver is used as an ingredient in many burn dressings because it: a. stimulates tissue granulation. b. is effective against a wide spectrum of wound pathogens. c. provides topical pain relief. d. stimulates wound healing.

ANS: B Silver is an ingredient in many dressings because it helps prevent infection against a wide spectrum of common pathogens. Silver does not stimulate tissue granulation; nor does it provide pain relief or stimulate wound healing processes.

The nurse is caring for a patient who has circumferential full-thickness burns of his forearm? A priority in the plan of care is : a. Keeping the extremity in a dependent position b. Active and passive range of motion every hour. c. Preparing for an escharotomy as a prophylactic measure d. Splinting the forearm

ANS: B Special attention is given to circumferential (completely surrounding a body part) full thickness burns of the extremities. Pressure from bands of eschar or from edema that develops as resuscitation proceeds may impair blood flow to underlying and distal tissue. Therefore, extremities are elevated to reduce edema. Active or passive range-of-motion (ROM) exercises are performed every hour for 5 minutes to increase venous return and to minimize edema. Peripheral pulses are assessed every hour, especially in circumferential burns of the extremities, to confirm adequate circulation. If signs and symptoms of compartment syndrome are present on serial examination, preparation is made for an escharotomy to relieve pressure and to restore circulation

A patient with newly diagnosed type 1 diabetes is being transitioned from an infusion of intravenous (IV) regular insulin to an intensive insulin therapy regimen of insulin glargine and insulin aspart. How should the nurse manage this transition in insulin delivery? a. Administer the insulin glargine and continue the IV insulin infusion for 24 hours. b. Administer the insulin glargine and discontinue the IV infusion in several hours. c. Discontinue the IV infusion and administer the insulin aspart with the next meal. d. Discontinue the IV infusion and administer the Lantus insulin at bedtime.

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

A patient with newly diagnosed type 1 diabetes is being transitioned from an infusion of intravenous (IV) regular insulin to an intensive insulin therapy regimen of insulin glargine (Lantus) and insulin aspart (NovoLog). How should the nurse manage this transition in insulin delivery? a. Administer the insulin glargine and continue the IV insulin infusion for 24 hours. b. Administer the insulin glargine and discontinue the IV infusion in several hours. c. Discontinue the IV infusion and administer the insulin aspart with the next meal. d. Discontinue the IV infusion and administer the Lantus insulin at bedtime.

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

The nurse is administering intravenous norepinephrine (Levophed) at 5 mcg/kg/min via a 20-gauge peripheral intravenous (IV) catheter. What assessment finding requires immediate action by the nurse? a. Blood pressure 100/60 mm Hg b. Swelling at the IV site c. Heart rate of 110 beats/min d. Central venous pressure (CVP) of 8 mm Hg

ANS: B Swelling at the IV site is indicative of infiltration. Infusion of norepinephrine (Levophed) through an infiltrated IV site can lead to tissue necrosis and requires immediate intervention by the nurse. A blood pressure of 100/60 mm Hg, heart rate of 110 beats/min, and a CVP of 8 mm Hg are adequate and do not require immediate intervention.

A 65-year-old patient is admitted to the progressive care unit with a diagnosis of community-acquired pneumonia. The patient has a history of chronic obstructive pulmonary disease and diabetes. A set of arterial blood gases obtained on admission without supplemental oxygen shows pH 7.35; PaCO2 55 mm Hg; bicarbonate 30 mEq/L; PaO2 65 mm Hg. These blood gases reflect: a. hypoxemia and compensated metabolic alkalosis. b. hypoxemia and compensated respiratory acidosis. c. normal oxygenation and partly compensated metabolic alkalosis. d. normal oxygenation and uncompensated respiratory acidosis.

ANS: B The PaO2 of 65 mm Hg is lower than normal range (80-100 mm Hg), indicating hypoxemia. The high PaCO2 indicates respiratory acidosis. The elevated bicarbonate indicates metabolic alkalosis. Because the pH is normal, the underlying acid-base alteration is compensated. Given the patient's history of chronic pulmonary disease and a pH that is at the lower end of normal range, it can be determined that this patient is hypoxemic with fully compensated respiratory acidosis.

A 53-year-old, 80-kg patient is admitted to the cardiac surgical intensive care unit after cardiac surgery. Four hours after admission to the surgical intensive care unit at 4 PM, the patient has stable vital signs and normal arterial blood gases (ABGs) and is placed on a T-piece for ventilatory weaning. During the nurse's 7 PM (1900) assessment, the patient is restless, heart rate has increased to 110 beats/min, respirations are 36 breaths/min, and blood pressure is 156/98 mm Hg. The cardiac monitor shows sinus tachycardia with 10 premature ventricular contractions (PVCs) per minute. Pulmonary artery pressures are elevated. The nurse suctions the patient and obtains pink, frothy secretions. Loud crackles are audible throughout lung fields. The nurse notifies the physician, who orders an ABG analysis, electrolyte levels, and a portable chest x-ray study. In communicating with the physician, which statement indicates the nurse understands what is likely occurring with the patient? a. "May we have an order for cardiac enzymes? This patient is exhibiting signs of a myocardial infarction." b. "My assessment indicates potential fluid overload." c. "The patient is having frequent PVCs that are compromising the cardiac output." d. "The patient is having a hypertensive crisis; what medications would you like to order?"

ANS: B The crackles, high pulmonary artery pressure, and pink, frothy sputum indicate fluid volume overload. There are not any cues to suggest a myocardial infarction. The PVCs may be related to the surgery or hypoxemia; however, the blood pressure indicates adequate perfusion. The blood pressure is high secondary to fluid overload; treatment of the fluid overload will result in a decrease in blood pressure.

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

ANS: B The increase in thoracic pressure that occurs during the inspiration phase of positive pressure ventilation decreases venous return, decreasing systolic blood pressure. A systolic blood pressure variation or decrease of more than 10 mm Hg in a mechanically ventilated patient is indicative of a patient who would respond to fluid resuscitation and improve tissue perfusion. There is no evidence to indicate the ventilator is malfunctioning, the arterial line needs to be replaced, or that the left limb may have reduced perfusion.

A patient is having difficulty weaning from mechanical ventilation. The nurse assesses the patient for a potential cause of this difficult weaning, which includes: a. cardiac output of 6 L/min. b. hemoglobin of 8 g/dL. c. negative sputum culture and sensitivity. d. white blood cell count of 8000.

ANS: B The low hemoglobin level will decrease oxygen-carrying capacity and may make weaning difficult. A cardiac output of 6 L/min is normal. A negative sputum culture indicates absence of lower respiratory infection, which should promote rather than hinder weaning. A white blood cell count of 8000 is normal and indicates absence of infection, which should promote rather than hinder weaning.

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

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

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

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

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

ANS: B The patient is complaining of chest pain and has an elevated systemic vascular resistance (SVR). To reduce afterload, ease the workload of the heart, and dilate the coronary arteries, improving oxygenation to the heart muscle, initiation of a nitroglycerin infusion is most appropriate. Assessment data do not support the initiation of other listed physician order options

An individual with type 2 diabetes who takes glipizide (Glucotrol) to control her blood glucose has begun a formal exercise program at a local gym. While exercising on the treadmill, she becomes pale, diaphoretic, and shaky. She has a headache and feels as though she is going to pass out. What is the individual's priority action? a. Drink additional water to prevent dehydration. b. Eat something with 15 g of simple carbohydrates. c. Go to the first aid station to have glucose checked. d. Take another dose of the oral agent.

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

An individual with type 2 diabetes who takes glipizide has begun a formal exercise program at a local gym. While exercising on the treadmill, the individual becomes pale, diaphoretic, shaky, and has a headache. The individual feels as though she is going to pass out. What is the individual's priority action? a. Drink additional water to prevent dehydration. b. Eat something with 15 g of simple carbohydrates. c. Go to the first-aid station to have glucose checked. d. Take another dose of the oral agent.

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

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

ANS: B The patient is exhibiting signs of anaphylaxis. For anaphylaxis with hypotension, epinephrine 0.3 to 0.5 mg (3 to 5 mL of 1:10,000 solution) is administered intravenously. Diphenhydramine (Benadryl) will help block histamine release, but epinephrine is the drug of choice for anaphylaxis with hypotension. Corticosteroids, such as methylprednisolone (Solu-Medrol), are used to reduce inflammation, but epinephrine is the drug of choice for anaphylaxis with hypotension. Ranitidine (Zantac) will help block histamine release, but epinephrine is the drug of choice for anaphylaxis with hypotension.

A 53-year-old, 80-kg patient is admitted to the cardiac surgical intensive care unit after cardiac surgery. Four hours after admission to the surgical intensive care unit at 4 PM, the patient has stable vital signs and normal arterial blood gases (ABGs), and is placed on a T-piece for ventilatory weaning. During the nurse's 7 PM (1900) assessment, the patient is restless, heart rate has increased to 110 beats/min, respirations are 36 breaths/min, and blood pressure is 156/98 mm Hg. The cardiac monitor shows sinus tachycardia with 10 premature ventricular contractions (PVCs) per minute. Pulmonary artery pressures are elevated. The nurse suctions the patient and obtains pink, frothy secretions. Loud crackles are audible throughout lung fields. The nurse notifies the physician, who orders an ABG analysis, electrolyte levels, and a portable chest x-ray study. How does the nurse interpret the following blood gas levels? pH 7.28 PaCO2 46 mm Hg Bicarbonate 22 mEq/L PaO2 58 mm Hg O2 saturation 88% a. Hypoxemia and compensated respiratory alkalosis b. Hypoxemia and uncompensated respiratory acidosis c. Normal arterial blood gas levels d. Normal oxygen level and partially compensated metabolic acidosis

ANS: B These levels show respiratory acidosis. The bicarbonate is normal; therefore, no compensation has occurred. This patient is also hypoxemic.

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

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

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

ANS: B To ensure accurate measurement, zero referencing of the transducer system is a priority action after moving a patient and should be completed prior to injecting 10 mL of room temperature 0.9% normal saline. A pulmonary artery catheter occlusion pressure should be documented before obtaining a cardiac output, but without zero referencing the system following movement of a patient, the obtained value may be inaccurate. Inflating the pulmonary artery catheter balloon with 1 mL of air, while appropriate, is not a step required prior to obtaining a cardiac output.

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

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

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

ANS: B To ensure that an accurate SvO2 is obtained, calibration of the invasive monitoring system (e.g., PAC) is accomplished upon insertion and requires both a central venous blood sample from the PAC and an arterial blood gas sample. This process is unique to the accuracy of venous oxygen saturation monitoring systems. Zero referencing the transducer at the level of the phlebostatic axis, ensuring patency of the catheter with a pressurized flush system, and using tubing of adequate length ensure accuracy of all hemodynamic monitoring systems.

The physician 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 Upon removal of an invasive arterial line, adequate pressure must be applied for at least 5 minutes to ensure adequate hemostasis. Application of an air occlusion dressing is not standard of care following removal of an arterial line. Elevation of the affected limb following removal of an arterial line is not a necessary intervention. Neutral wrist position is optimum while the catheter is in place and not necessary after catheter discontinuation

A nurse is caring for a client after surgery who is restless and apprehensive. The unlicensed assistive personnel (UAP) reports the vital signs and the nurse sees they are only slightly different from previous readings. What action does the nurse delegate next to the UAP? a. Assess the client for pain or discomfort. b. Measure urine output from the catheter. c. Reposition the client to the unaffected side. d. Stay with the client and reassure him or her.

ANS: B Urine output changes are a sensitive early indicator of shock. The nurse should delegate emptying the urinary catheter and measuring output to the UAP as a baseline for hourly urine output measurements. The UAP cannot assess for pain. Repositioning may or may not be effective for decreasing restlessness, but does not take priority over physical assessments. Reassurance is a therapeutic nursing action, but the nurse needs to do more in this situation.

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

ANS: B Vasoconstrictive agents should not be administered for hypotension in the presence of circulation fluid volume deficit. The nurse should question the use of the dopamine (Intropin) infusion. All other listed orders are appropriate and have potential for use in the treatment of a hypovolemic shock.

Which of the following situations may result in a low cardiac output and low cardiac index? (Select all that apply.) a. Exercise b. Hypovolemia c. Myocardial infarction d. Shock

ANS: B, C, D Hypovolemia, myocardial infarction, and shock often result in a decreased cardiac output. Cardiac output is usually increased with exercise.

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

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

A college student was admitted to the emergency department after being found unconscious by a roommate. The roommate informs emergency medical personnel that the student has diabetes and has been experiencing flulike symptoms, including vomiting, since yesterday. The patient had been up all night studying for exams. The patient used the last diabetes testing supplies 3 days ago and has not had time to go to the pharmacy to refill prescription supplies. Based upon the history, which laboratory findings would be anticipated in this client? (Select all that apply.) a. Blood glucose 43 mg/dL b. Blood glucose 524 mg/dL c. HCO3- 10 mEq/L d. PaCO2 37 mm Hg e. pH 7.23

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

A college student was admitted to the emergency department after being found unconscious by a roommate. The roommate informs emergency medical personnel that the student has diabetes and has been experiencing flulike symptoms, including vomiting, since yesterday. The patient had been up all night studying for exams. The patient used the last diabetes testing supplies 3 days ago and has not had time to go to the pharmacy to refill prescription supplies. Based upon the history, which laboratory findings would be anticipated in this client? (Select all that apply.) a. Blood glucose: 43 mg/dL b. Blood glucose: 524 mg/dL c. HCO3—: 10 mEq/L d. PaCO2: 37 mm Hg e. pH: 7.23

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

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

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

A patient with long-standing type 1 diabetes presents to the emergency department with a loss of consciousness and seizure activity. The patient has a history of renal insufficiency, gastroparesis, and peripheral diabetic neuropathy. Emergency personnel reported a blood glucose of 32 mg/dL on scene. When providing discharge teaching for this patient and family, the nurse instructs on the need to do which of the following? (Select all that apply.) a. Administer glucagon 1 mg intramuscularly any time the blood glucose is less than 70 mg/dL. b. Administer 15 grams of carbohydrate orally for severe episodes of hypoglycemia. c. Discontinue the insulin pump by removing the infusion set catheter. d. Increase home blood glucose monitoring and report patterns of hypoglycemia to the provider. e. Perform blood glucose monitoring before exercising and driving.

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

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

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

A patient with long-standing type 1 diabetes presents to the emergency department with a loss of consciousness and seizure activity. The patient has a history of renal insufficiency, gastroparesis, and peripheral diabetic neuropathy. Emergency personnel reported a blood glucose of 32 mg/dL on scene. When providing discharge teaching for this patient and family, the nurse instructs on the need to do which of the following? (Select all that apply.) a. Administer glucagon 1 mg intramuscularly any time the blood glucose is less than 70 mg/dL. b. Administer 15 grams of carbohydrate orally for severe episodes of hypoglycemia. c. Discontinue the insulin pump by removing the infusion set catheter. d. Increase home blood glucose monitoring and report patterns of hypoglycemia to the provider. e. Perform blood glucose monitoring before exercising and driving.

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

Fifteen minutes after beginning a transfusion of O negative blood to a patient in shock, the nurse assesses a drop in the patient's blood pressure to 60/40 mm Hg, heart rate 135 beats/min, respirations 40 breaths/min, and a temperature of 102° F. The nurse notes the new onset of hematuria in the patient's Foley catheter. What are the priority nursing actions? (Select all that apply.) a. Administer acetaminophen (Tylenol). b. Document the patient's response. c. Increase the rate of transfusion. d. Notify the blood bank. e. Notify the physician. f. Stop the transfusion.

ANS: B, D, E, F In the event of a reaction, the transfusion is stopped, the patient is assessed, and both the physician and laboratory are notified. All transfusion equipment (bag, tubing, and remaining solutions) and any blood or urine specimens obtained are sent to the laboratory according to hospital policy. The events of the reaction, interventions used, and patient response to treatment are documented. Acetaminophen is not warranted in the immediate recognition and treatment of a transfusion reaction. The infusion must be stopped. Increasing the infusion further increases the likelihood of worsening the transfusion reaction.

Select all of the factors that may predispose the patient to respiratory acidosis. a. Anxiety and fear b. Central nervous system depression c. Diabetic ketoacidosis d. Nasogastric suctioning e. Overdose of sedatives

ANS: B, E Central nervous system depression and drug overdose may result in hypoventilation and cause respiratory acidosis. Anxiety is a cause of hyperventilation and respiratory alkalosis. Diabetic ketoacidosis is a cause of metabolic acidosis. Nasogastric suctioning is a cause of metabolic alkalosis

After pulmonary artery catheter insertion, the nurse assesses a pulmonary artery pressure of 45/25 mm Hg, a pulmonary artery occlusion pressure (PAOP) of 20 mm Hg, a cardiac output of 2.6 L/min and a cardiac index of 1.9 L/min/m2. Which physician order is of the highest priority? a. Apply 50% oxygen via venture mask. b. Insert an indwelling urinary catheter. c. Begin a dobutamine (Dobutrex) infusion. d. Obtain stat cardiac enzymes and troponin.

ANS: C The pulmonary pressures are higher than normal, indicating elevated preload, and the cardiac index and output values are low. The priority order for the nurse to implement is to begin a dobutamine (Dobutrex) infusion to improve cardiac output, possibly reducing pulmonary artery occlusion pressures. The other treatments are important, but the dobutamine infusion is the most important at this time.

The nurse is caring for a burn-injured patient who weighs 154 pounds, and the burn injury covers 50% of his body surface area. The nurse calculates the fluid needs for the first 24 hours after a burn injury using a standard fluid resuscitation formula of 4 mL/kg/% burn of intravenous (IV) fluid for the first 24 hours. The nurse plans to administer what amount of fluid in the first 24 hours? a. 2800 mL b. 7000 mL c. 14 L d. 28 L

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

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

ANS: C A high pulmonary artery occlusion pressure of 25 mm Hg combined with low oxygen saturation is indicative of fluid volume overload and warrants priority action because the patient is at risk for hypoxemia. A CVP of 6 mm Hg with 40 mL of hourly urine output are acceptable assessment findings. A patient with a normal blood pressure and with a slightly dampened waveform does not require immediate action. A pulmonary artery pressure of 25/10 mmHg and a normal oxygen saturation does not require immediate treatment.

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

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

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

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

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

ANS: C Balloon inflation should never be forced because the PAC may have migrated further into the pulmonary artery, creating resistance to balloon inflation. Verification of proper line placement is warranted to avoid pulmonary artery rupture. In addition, the PAC waveform should be observed to assist in identifying location of the tip of the PAC. In this scenario, adding additional air to the balloon will further risk pulmonary artery rupture. Advancing a pulmonary artery catheter is not within the nurse's scope of practice. Flushing the distal port with saline may be indicated to ensure patency; however, the balloon of the PAC should never be locked in the inflated position as rupture of the pulmonary artery may occur.

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

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

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.

ANS: C Capillary permeability is altered in burns beyond the area of tissue damage, resulting in significant shift of proteins, fluid, and electrolytes resulting in edema (third spacing). Catecholamine-induced vasoconstriction does not produce edema. Decreased glomerular filtration may cause fluid retention, but it is not responsible for the extensive edema seen after burn injury. Loss of integument barrier does not cause edema.

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

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

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

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

A client in shock has been started on dopamine. What assessment finding requires the nurse to communicate with the provider immediately? a. Blood pressure of 98/68 mm Hg b. Pedal pulses 1+/4+ bilaterally c. Report of chest heaviness d. Urine output of 32 mL/hr

ANS: C Chest heaviness or pain indicates myocardial ischemia, a possible adverse effect of dopamine. While taking dopamine, the oxygen requirements of the heart are increased due to increased myocardial workload, and may cause ischemia. Without knowing the client's previous blood pressure or pedal pulses, there is not enough information to determine if these are an improvement or not. A urine output of 32 mL/hr is acceptable.

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

ANS: C Dobutamine (Dobutrex) is used to stimulate contractility and heart rate while causing vasodilation in low cardiac output states improving overall cardiac performance. The patient's cardiac index is well above normal limits, so the rate of infusion of the medication should be reduced so as not to overstimulate the heart. There is no evidence to support the need for a serum potassium or 12-lead electrocardiogram. Assessment of hourly urine output is important in the care of the patient in cardiogenic shock, but it is not a priority in this scenario.

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

ANS: C During initial fluid resuscitation, urine output helps guide fluid resuscitation needs. Measuring hourly intake and output is most effective in determining the needs for additional fluid infusion than is urine output alone. Blood urea nitrogen may be used to monitor volume status, but it is affected by the hypermetabolic state seen after burns, so it is not the optimal measure of intravascular fluid status. Daily weight measures overall volume status, not just intravascular volume. Serum potassium is released with tissue damage and thus is not the optimum measure of intravascular fluid status.

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

ANS: C Elevation of the head of bed is an important intervention to prevent aspiration and ventilator-associated pneumonia. Patients who require hemodynamic monitoring while receiving tube feedings should have the air-fluid interface of the transducer leveled with the phlebostatic axis while the head of bed is elevated to at least 30 degrees. Readings will be accurate. Supine positioning of a mechanically ventilated patient increases the risk of aspiration and ventilator-associated pneumonia and is contraindicated in this patient. Hemodynamic values can be accurately measured and trended in with the head of the bed elevated as high as 60 degrees. Even though hemodynamic values can be obtained in lateral positions, it is technically difficult and not accurate unless the positioning of the transducer is exact. Regardless, head of bed elevation is indicated for this patient.

Which patient being cared for in the emergency department is most at risk for developing hypovolemic shock? a. A patient admitted with abdominal pain and an elevated white blood cell count b. A patient with a temperature of 102° F and a general dermal rash c. A patient with a 2-day history of nausea, vomiting, and diarrhea d. A patient with slight rectal bleeding from inflamed hemorrhoids

ANS: C Excessive external loss of fluid may occur through the gastrointestinal tract via vomiting and diarrhea, which may lead to hypovolemia. There is no evidence to support significant fluid loss in the remaining patient scenarios.

The nurse is starting to administer a unit of packed red blood cells (PRBCs) to a patient admitted in hypovolemic shock secondary to hemorrhage. Vital signs include blood pressure 60/40 mm Hg, heart rate 150 beats/min, respirations 42 breaths/min, and temperature 100.6° F. What is the best action by the nurse? a. Administer blood transfusion over at least 4 hours. b. Notify the physician of the elevated temperature. c. Titrate rate of blood administration to patient response. d. Notify the physician of the patient's heart rate.

ANS: C Given the acute nature of the patient's blood loss, the nurse should titrate the rate of the blood transfusion to an improvement in the patient's blood pressure. Administering the transfusion over 4 hours can lead to a prolonged state of hypoperfusion and end-organ damage. The heart rate will normalize as circulating blood volume is restored. A mildly elevated temperature does not take priority over restoring circulating blood volume.

The nurse is caring for a patient in spinal shock. Vital signs include blood pressure 100/70 mm Hg, heart rate 70 beats/min, respirations 24 breaths/min, oxygen saturation 95% on room air, and an oral temperature of 96.8° F. Which intervention is most important for the nurse to include in the patient's plan of care? a. Administration of atropine sulfate (Atropine) b. Application of 100% oxygen via facemask c. Application of slow rewarming measures d. Infusion of IV phenylephrine (Neo-Synephrine)

ANS: C Hypothermia can develop in neurogenic shock from uncontrolled heat loss; therefore, a patient should be rewarmed slowly to avoid further vasodilation. In shock, a drop in systolic blood pressure to less than 90 mm Hg is considered hypotensive. Atropine is used for symptomatic bradycardia. The patient's oxygen saturation is 95% on room air with an adequate respiratory rate. The application of 100% oxygen via facemask is not indicated. The patient's heart rate is adequate to support a normal blood pressure.

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

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

The nurse is caring for a patient admitted following a motor vehicle crash. Over the past 2 hours, the patient has received 6 units of packed red blood cells and 4 units of fresh frozen plasma by rapid infusion. To prevent complications, what is the priority nursing intervention? a. Administer pain medication. b. Turn patient every 2 hours. c. Assess core body temperature. d. Apply bilateral heel protectors.

ANS: C Hypothermia is anticipated during the rapid infusion of fluids or blood products. Assessment of core body temperature is a priority. While administration of pain management, repositioning the patient every 2 hours, and application of heel protectors should be part of the patient care, given the rapid transfusion of blood products, these interventions are not the priority in this scenario.

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

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

The nurse is assigned to care for a patient who presented to the emergency department with diabetic ketoacidosis. A continuous insulin intravenous infusion is started, and hourly bedside glucose monitoring is ordered. The targeted blood glucose value after the first hour of therapy is a. 70 to 120 mg/dL. b. a decrease of 25 to 50 mg/dL compared with admitting values. c. a decrease of 35 to 90 mg/dL compared with admitting values. d. less than 200 mg/dL.

ANS: C Initial insulin infusions should be administered with a target blood glucose reduction of 35 to 90 mg/dL per hour. Decreases of less than this rate may be associated with inadequate insulin replacement and allow for the persistence of the ketotic state. Rapid reductions of blood glucose may precipitate life-threatening cerebral edema; thus, controlled reduction of glucose is required.

The nurse is assigned to care for a patient who presented to the emergency department with diabetic ketoacidosis. A continuous insulin intravenous infusion is started, and hourly bedside glucose monitoring is ordered. The targeted blood glucose value after the first hour of therapy is: a. 70 to 120 mg/dL. b. a decrease of 25 to 50 mg/dL compared with admitting values. c. a decrease of 50 to 75 mg/dL compared with admitting values. d. less than 200 mg/dL.

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

The nurse is caring for a patient admitted to the critical care unit 48 hours ago with a diagnosis of severe sepsis. As part of this patient's care plan, what intervention is most important for the nurse to discuss with the multidisciplinary care team? a. Frequent turning b. Monitoring intake and output c. Enteral feedings d. Pain management

ANS: C Initiation of enteral feedings within 24 to 48 hours of admission is critical in reducing the risk of infection by assisting in maintaining the integrity of the intestinal mucosa. Monitoring intake and output, frequent turning, and pain management are important aspects of care but are not a critical priority during the first 24 to 48 hours following admission.

A patient with a 60% burn in the acute phase of treatment develops a tense abdomen, decreasing urine output, hypercapnia, and hypoxemia. Based on this assessment, the nurse anticipates interventions to evaluate and treat the patient for: a. acute kidney injury. b. acute respiratory distress syndrome. c. intraabdominal hypertension. d. disseminated intravascular coagulation disorder.

ANS: C Intraabdominal hypertension (IAH) is a serious complication caused by circumferential torso burn injuries or edema from aggressive fluid resuscitation. Signs and symptoms of IAH include tense abdomen, decreased urine output, and worsening pulmonary function. Acute kidney injury will not result from aggressive fluid resuscitation. Acute respiratory distress syndrome would present with signs of hypoxia and hypercarbia, but not a tense abdomen. Disseminated intravascular disorder may present as a tense abdomen if there is active bleeding, but it would not present with pulmonary symptoms.

The nurse is conducting an admission assessment of an 82-year-old patient who sustained a 12% burn from spilling hot coffee on the hand and arm. Which statement is of priority to assist in planning treatment? a. "Do you live alone?" b. "Do you have any drug or food allergies?" c. "Do you have a heart condition or heart failure?" d. "Have you had any surgeries?"

ANS: C Many variables influence the outcome of elderly burn patient mortality, including preinjury hydration status, nutrition status, and comorbid diseases, especially heart failure. Assessment questions should include, as a priority, information about the patient's cardiovascular status, including heart failure. Obtaining food or drug allergy information is also important along with other past medical history, including past surgeries. Information on the patient's living arrangements is an important safety consideration for discharge planning.

Neuromuscular blocking agents are used in the management of some ventilated patients. Their primary mode of action is: a. analgesia. b. anticonvulsant. c. paralysis. d. sedation.

ANS: C Neuromuscular blocking agents cause respiratory muscle paralysis. They do not have sedative, analgesic, or anticonvulsant effects.

A student nurse is caring for a client who will be receiving sodium nitroprusside (Nipride) via IV infusion. What action by the student causes the registered nurse to intervene? a. Assessing the IV site before giving the drug b. Obtaining a programmable ("smart") IV pump c. Removing the IV bag from the brown plastic cover d. Taking and recording a baseline set of vital signs

ANS: C Nitroprusside degrades in the presence of light, so it must be protected by leaving it in the original brown plastic bag when infusing. The other actions are correct, although a "smart" pump is not necessarily required if the facility does not have them available. The drug must be administered via an IV pump, although the programmable pump is preferred for safety.

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

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

The nurse notes that the patient's arterial blood gas levels indicate hypoxemia. The patient is not intubated and has a respiratory rate of 22 breaths/min. The nurse's first intervention to relieve hypoxemia is to: a. call the physician for an emergency intubation procedure. b. obtain an order for bilevel positive airway pressure (BiPAP). c. notify the provider of values and obtain order for oxygen. d. suction secretions from the oropharynx.

ANS: C Oxygen is administered to treat or prevent hypoxemia. Oxygen should be considered a first-line treatment in cases of hypoxemia. Emergency intubation is not warranted at this time. BiPAP may be considered if administration of supplemental oxygen does not correct the hypoxemia. There is no indication that the patient requires suctioning.

A 32-year-old patient is admitted to the critical care unit with a diagnosis of diabetic ketoacidosis. Following aggressive fluid resuscitation and intravenous (IV) insulin administration, the blood glucose begins to normalize. In addition to glucose monitoring, which of the following electrolytes requires close monitoring? a. Calcium b. Chloride c. Potassium d. Sodium.

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

A patient is admitted to the critical care unit with a diagnosis of diabetic ketoacidosis. Following aggressive fluid resuscitation and intravenous (IV) insulin administration, the blood glucose begins to normalize. In addition to glucose monitoring, which of the following electrolytes requires close monitoring? a. Calcium b. Chloride c. Potassium d. Sodium

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

A mode of pressure-targeted ventilation that provides positive pressure to decrease the workload of spontaneous breathing through the endotracheal tube is: a. continuous positive airway pressure. b. positive end-expiratory pressure. c. pressure support ventilation. d. T-piece adapter.

ANS: C Pressure support (PS) is a mode of ventilation in which the patient's spontaneous respiratory activity is augmented by the delivery of a preset amount of inspiratory positive pressure. Positive end-expiratory pressure provides positive pressure at end expiration during mechanical breaths, and continuous positive airway pressure provides positive pressure during spontaneous breaths. The T-piece adapter is used to provide oxygen with spontaneous, unassisted breaths

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

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

The nurse is caring for a patient with an endotracheal tube. The nurse understands that endotracheal suctioning is needed to facilitate removal of secretions and that the procedure: a. decreases intracranial pressure. b. depresses the cough reflex. c. is done as indicated by patient assessment. d. is more effective if preceded by saline instillation to loosen secretions.

ANS: C Suctioning is performed as indicated by patient's assessment. Suctioning is associated with increases in intracranial pressure; therefore, it is important to hyperoxygenate the patient prior to suctioning to reduce this complication. Suctioning can stimulate the cough reflex rather than depress this reflex. Saline instillation is associated with negative physiological outcomes and is not recommended as part of the suctioning procedure; it does not loosen secretions, which is a common misperception.

When assessing the patient for hypoxemia, the nurse recognizes that an early sign of the effect of hypoxemia on the cardiovascular system is: a. heart block. b. restlessness. c. tachycardia. d. tachypnea.

ANS: C Tachycardia can occur as a compensatory mechanism to increase cardiac output and oxygenation. Dysrhythmias may occur; however, they are not an early sign and tend to be premature ventricular contractions. Restlessness is an early neurological sign, whereas tachypnea is an early respiratory sign

The nurse is assessing the exhaled tidal volume (EVT) in a mechanically ventilated patient. The rationale for this assessment is to: a. assess for tension pneumothorax. b. assess the level of positive end-expiratory pressure. c. compare the tidal volume delivered with the tidal volume prescribed. d. determine the patient's work of breathing.

ANS: C The EVT is assessed to determine if the patient is receiving the tidal volume that is prescribed. Volume may be lost because of leaks in the ventilator circuit, around the endotracheal tube cuff, or around a chest tube. The assessment will not detect a pneumothorax and does not assess positive end-expiratory pressure or work of breathing.

The patient asks the nurse if the placement of the autograft over his full-thickness burn will be the only surgical intervention needed to close his wound. The nurse's best response would be: a. "Unfortunately, an autograft skin is a temporary graft and a second surgery will be needed to close the wound." b. "An autograft is a biological dressing that will eventually be replaced by your body generating new tissue." c. "Yes, an autograft will transfer your own skin from one area of your body to cover the burn wound." d. "Unfortunately, autografts frequently do not adhere well to burn wounds and a xenograft will be necessary to close the wound."

ANS: C The autograft is the only permanent method of grafting and it uses the patient's own tissue to cover the burn wound. Autografting is permanent and does not require a second surgery unless the graft fails. A biological or biosynthetic graft or dressing is a temporary wound covering. A xenograft is from an animal, usually pig skin and is a temporary graft.

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

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

A patient with pancreatic cancer has been admitted to the critical care unit with clinical signs consistent with syndrome of inappropriate secretion of antidiuretic hormone. The nurse anticipates that clinical management of this condition will include: a. administration of 3% normal saline. b. administration of exogenous vasopressin. c. fluid restriction. d. low sodium diet.

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

A patient with pancreatic cancer has been admitted to the critical care unit with clinical signs consistent with syndrome of inappropriate secretion of antidiuretic hormone. The nurse anticipates that clinical management of this condition will include a. administration of 3% normal saline. b. administration of exogenous vasopressin. c. fluid restriction. d. low sodium diet.

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

A patient's status worsens and needs mechanical ventilation. The pulmonologist wants the patient to receive 10 breaths/min from the ventilator but wants to encourage the patient to breathe spontaneously in between the mechanical breaths at his own tidal volume. This mode of ventilation is called: a. assist/control ventilation b. controlled ventilation c. intermittent mandatory ventilation d. positive end-expiratory pressure

ANS: C The intermittent mandatory ventilation mode allows the patient to breathe spontaneously between breaths. The patient will receive a preset tidal volume at a preset rate. Any additional breaths that he initiates will be at his spontaneous tidal volume, which will likely be lower than the ventilator breaths. In assist/control ventilation, spontaneous effort results in a preset tidal volume delivered by the ventilator. Spontaneous effort during controlled ventilation results in patient/ventilator dyssynchrony. Positive end-expiratory pressure (PEEP) is application of positive pressure to breaths delivered by the ventilator. PEEP is an adjunct to both intermittent mandatory and assist/control ventilation.

Tissue damage from burn injury activates an inflammatory response that increases the patient's risk for: a. acute kidney injury. b. acute respiratory distress syndrome. c. infection. d. stress ulcers.

ANS: C The loss of skin as the primary barrier against microorganisms and activation of the inflammatory response cascades results in immunosuppression, placing the patient at an increased risk of infection. A systemic inflammatory response (SIRS) also increases the risk of acute kidney injury in the presence of poor tissue perfusion. Acute respiratory distress syndrome is also a potential complication, but the risk of infection is greater because of the loss of the skin barrier. Catecholamine release and gastrointestinal ischemia are the causes of stress ulcers.

A patient is being mechanically ventilated in the synchronized intermittent mandatory ventilation mode at a rate of 4 breaths/min. His spontaneous respirations are 12 breaths/min. He receives a dose of morphine sulfate, and his respirations decrease to 4 breaths/min. Which acid-base disturbance will likely occur? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

ANS: C The morphine caused respiratory depression. As a result, the frequency and depth of respiration is compromised, which can lead to respiratory acidosis.

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

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

A patient is admitted after collapsing at the end of a summer marathon. She is lethargic, with a heart rate of 110 beats/min, respiratory rate of 30 breaths/min, and a blood pressure of 78/46 mm Hg. The nurse anticipates administering which therapeutic intervention? a. Human albumin infusion b. Hypotonic saline solution c. Lactated Ringer's bolus d. Packed red blood cells

ANS: C The patient is experiencing symptoms of hypovolemic shock. Isotonic crystalloids, such as normal saline and lactated Ringer's solutions, are the priority intervention. Albumin and plasma protein fraction (Plasmanate) are naturally occurring colloid solutions that are infused when the volume loss is caused by a loss of plasma rather than blood, such as in burns, peritonitis, and bowel obstruction. Hypotonic solutions rapidly leave the intravascular space, causing interstitial and intracellular edema and are not used for fluid resuscitation. There is no evidence to support a transfusion in the given scenario.

A 53-year-old, 80-kg patient is admitted to the cardiac surgical intensive care unit after cardiac surgery with the following arterial blood gas (ABG) levels. What is the nurse's interpretation of these values? pH 7.4 PaCO2 40 mm Hg Bicarbonate 24 mEq/L PaO2 95 mm Hg O2 saturation 97% Respirations 20 breaths per minute a. Compensated metabolic acidosis b. Metabolic alkalosis c. Normal ABG values d. Respiratory acidosis

ANS: C These are normal values. All parameters are within normal limits.

A nurse caring for a client notes the following assessments: white blood cell count 3800/mm3, blood glucose level 198 mg/dL, and temperature 96.2° F (35.6° C). What action by the nurse takes priority? a. Document the findings in the client's chart. b. Give the client warmed blankets for comfort. c. Notify the health care provider immediately. d. Prepare to administer insulin per sliding scale.

ANS: C This client has several indicators of sepsis with systemic inflammatory response. The nurse should notify the health care provider immediately. Documentation needs to be thorough but does not take priority. The client may appreciate warm blankets, but comfort measures do not take priority. The client may or may not need insulin.

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

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

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

ANS: C Under normal circumstances, a difference of 10 to 20 mm Hg or more between invasive and noninvasive blood pressure is expected, with the invasive value being higher than the noninvasive value. The cuff used for noninvasive measurement should be assessed for proper cuff size. Given that the invasive value is substantially higher, before initiating corrective actions based on a single noninvasive measurement, such as activating the rapid response system, placing the patient in Trendelenburg position, or administering a fluid bolus, further assessment and troubleshooting are necessary.

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

ANS: C X-ray results indicate proper position of the catheter. The tip of the central venous catheter should rest just above the right atrium in the superior vena cava. The central venous catheter is positioned correctly in the superior vena cava. Dysrhythmias occur if the catheter migrates to the right ventricle. Central venous catheters are placed into great vessels of the venous system and not advanced into the pulmonary artery.

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

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

The nurse is caring for a patient with a pulmonary artery catheter. Assessment findings include a blood pressure of 85/40 mm Hg, heart rate of 125 beats/min, respiratory rate 35 breaths/min, and arterial oxygen saturation (SpO2) of 90% on a 50% venturi mask. Hemodynamic values include a cardiac output (CO) of 1.0 L/min, central venous pressure (CVP) of 1 mm Hg, and a pulmonary artery occlusion pressure (PAOP) of 3 mm Hg. The nurse questions which of the following physician's order? a. Titrate supplemental oxygen to achieve a SpO2 > 94%. b. Infuse 500 mL 0.9% normal saline over 1 hour. c. Obtain arterial blood gas and serum electrolytes. d. Administer furosemide (Lasix) 20 mg intravenously.

ANS: D A central venous pressure of 1 mm Hg, pulmonary artery occlusion pressure of 1 mm Hg along with a blood pressure of 85/40 mm Hg and heart rate of 125 are indicative of a low volume state. Infusion of 500 mL of 0.9% normal saline will increase circulating fluid volume. Administration of furosemide (Lasix) is contraindicated and could further reduce circulating fluid volume. Titrating supplemental oxygen, obtaining serum blood gas and electrolyte samples, although not a priority, are appropriate interventions.

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

ANS: D A hemodynamic value not supported by clinical assessment should be treated as questionable. To ensure the accuracy of hemodynamic readings, the catheter transducer system must be leveled at the phlebostatic axis and zero referenced. In this example, the catheter transducer system may be lower than the phlebostatic axis, resulting in erroneously higher pressures. Clinical manifestations do not support increasing supplemental oxygen. Clinical manifestations do not warrant physician intervention; aberrant values should be investigated further. An aberrant value warrants further investigation, which includes zero referencing and checking the level as an initial measure. A chest x-ray study is not warranted at this time.

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

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

During the initial stages of shock, what are the physiological effects of decreased cardiac output? a. Arterial vasodilation b. High urine output c. Increased parasympathetic stimulation d. Increased sympathetic stimulation

ANS: D A reduction in blood pressure leads to an increase in catecholamine release, resulting in an increase in heart rate and contractility to improve cardiac output. Decreased cardiac output leads to arterial vasoconstriction in an effort to increase blood pressure. Low urine output results, as decreased cardiac output reduces blood flow to the kidneys. There is an increase in sympathetic stimulation in response to a decrease in cardiac output.

The nurse is administering both crystalloid and colloid intravenous fluids as part of fluid resuscitation in a patient admitted in severe sepsis. What findings assessed by the nurse indicate an appropriate response to therapy? a. Normal body temperature b. Balanced intake and output c. Adequate pain management d. Urine output of 0.5 mL/kg/hr

ANS: D Adequate urine output of at least 0.5 mL/ kg/hr indicates adequate perfusion to the kidneys following administration of fluid to enhance circulating blood volume. Normal body temperature and adequate pain management are not assessment findings indicating an adequate response to fluid therapy. During fluid resuscitation in severe sepsis, intake and output will not be balanced as circulating fluid volume deficit is restored.

The nurse is caring for a patient in the early stages of septic shock. The patient is slightly confused and flushed, with bounding peripheral pulses. Which hemodynamic values is the nurse most likely to assess? a. High pulmonary artery occlusive pressure and high cardiac output b. High systemic vascular resistance and low cardiac output c. Low pulmonary artery occlusive pressure and low cardiac output d. Low systemic vascular resistance and high cardiac output

ANS: D As a consequence of the massive vasodilation associated with septic shock, in the early stages, cardiac output is high with low systemic vascular resistance. In septic shock, pulmonary artery occlusion pressure is not elevated. In the early stages of septic shock, systemic vascular resistance is low and cardiac output is high. In the early stages of septic shock, cardiac output is high.

The nurse is caring for a patient admitted with the early stages of septic shock. The nurse assesses the patient to be tachypneic, with a respiratory rate of 32 breaths/min. Arterial blood gas values assessed on admission are pH 7.50, CO2 28 mm Hg, HCO3 26. Which diagnostic study result reviewed by the nurse indicates progression of the shock state? a. pH 7.40, CO2 40, HCO3 24 b. pH 7.45, CO2 45, HCO3 26 c. pH 7.35, CO2 40, HCO3 22 d. pH 7.30, CO2 45, HCO3 18

ANS: D As shock progresses along the continuum, acidosis ensues, caused by metabolic acidosis, hypoxia, and anaerobic metabolism. A pH 7.30, CO2 45 mm Hg, HCO3 18 indicates metabolic acidosis and progression to a late stage of shock. All other listed arterial blood gas values are within normal limits.

The physician orders the following mechanical ventilation settings for a patient who weighs 75 kg. The patient's spontaneous respiratory rate is 22 breaths/min. What arterial blood gas abnormality may occur if the patient continues to be tachypneic at these ventilator settings? Settings: Tidal volume: 600 mL (8 mL per kg) FiO2: 0.5 Respiratory rate: 14 breaths/min Mode assist/control Positive end-expiratory pressure: 10 cm H2O a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

ANS: D Assist/control ventilation may result in respiratory alkalosis, especially when the patient is breathing at a high rate. Each time the patient initiates a spontaneous breath—in this case 22 times per minute—the ventilator will deliver 600 mL of volume.

A patient has coronary artery bypass graft surgery and is transported to the surgical intensive care unit at noon. He is placed on mechanical ventilation. Interpret his initial arterial blood gas levels: pH 7.31 PaCO2 48 mm Hg Bicarbonate 22 mEq/L PaO2 115 mm Hg O2 saturation 99% a. Normal arterial blood gas levels with a high oxygen level b. Partly compensated respiratory acidosis, normal oxygen c. Uncompensated metabolic acidosis with high oxygen levels d. Uncompensated respiratory acidosis; hyperoxygenated

ANS: D The high PaO2 level reflects hyperoxygenation; the PaCO2 and pH levels show respiratory acidosis. The respiratory acidosis is uncompensated as indicated by a pH of 7.31 (acidosis) and a normal bicarbonate level. No metabolic compensation has occurred.

The nurse is caring for a patient with head trauma who was admitted to the surgical intensive care unit following a motorcycle crash. What is an important assessment that will assist the nurse in early identification of an endocrine disorder commonly associated with this condition? a. Daily weight b. Fingerstick glucose c. Lung sound auscultation d. Urine osmolality

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

During insertion of a pulmonary artery catheter, the physician asks the nurse to assist by inflating the balloon with 1.5 mL of air. As the physician advances the catheter, the nurse notices premature ventricular contractions on the monitor. What is the best action by the nurse? a. Deflate the balloon while slowly withdrawing the catheter. b. Instruct the patient to cough and deep-breathe forcefully. c. Inflate the catheter balloon with an additional 1 mL of air. d. Ensure lidocaine hydrochloride (IV) is immediately available.

ANS: D During the insertion of the pulmonary artery catheter, ventricular dysrhythmias may occur as the catheter passes through the right ventricle. Treatment with lidocaine hydrochloride may be necessary to suppress the irritated ventricle and should be readily available. Withdrawing of the catheter is not within the scope of practice of the nurse and may not be necessary. Having the patient cough and deep-breathe will not correct the problem. The maximum volume of air necessary to inflate the balloon is 1.5 mL. Any additional volumes added may increase the risk of complications.

The nurse is caring for a patient admitted with severe sepsis. Vital signs assessed by the nurse include blood pressure 80/50 mm Hg, heart rate 120 beats/min, respirations 28 breaths/min, oral temperature of 102° F, and a right atrial pressure (RAP) of 1 mm Hg. Assuming physician orders, which intervention should the nurse carry out first? a. Acetaminophen suppository b. Blood cultures from two sites c. IV antibiotic administration d. Isotonic fluid challenge

ANS: D Early goal-directed therapy in severe sepsis includes administration of IV fluids to keep RAP/CVP at 8 mm Hg or greater (but not greater than 15 mm Hg) and heart rate less than 110 beats/min. Fluid resuscitation to restore perfusion is the immediate priority. Broad-spectrum antibiotics are recommended within the first hour; however, volume resuscitation is the priority in this scenario.

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

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

The nurse has been administering 0.9% normal saline intravenous fluids as part of early goal-directed therapy protocols in a patient with severe sepsis. To evaluate the effectiveness of fluid therapy, which physiological parameters would be most important for the nurse to assess? a. Breath sounds and capillary refill b. Blood pressure and oral temperature c. Oral temperature and capillary refill d. Right atrial pressure and urine output

ANS: D Early goal-directed therapy includes administration of IV fluids to keep central venous pressure at 8 mm Hg or greater. Combined with urine output, fluid therapy effectiveness can be adequately assessed. Evaluation of breath sounds assists with determining fluid overload in a patient but does not evaluate the effectiveness of fluid therapy. Capillary refill provides a quick assessment of the patient's overall cardiovascular status, but this assessment is not reliable in a patient who is hypothermic or has peripheral circulatory problems. Evaluation of oral temperature does not assess the effectiveness of fluid therapy in patients in shock. Evaluation of oral temperature does not assess the effectiveness of fluid therapy in patients in shock. Capillary refill provides a quick assessment of the patient's overall cardiovascular status, but this assessment is not reliable in a patient who is hypothermic or has peripheral circulatory problems.

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

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

The nurse is providing care to manage the pain of a patient with burns. The physician has ordered opiates to be given intramuscularly. The nurse contacts the physician to change the order to intravenous administration because: a. intramuscular injections cause additional skin disruption. b. burn pain is so severe it requires relief by the fastest route available. c. hypermetabolism limits effectiveness of medications administered intramuscularly. d. tissue edema may interfere with drug absorption of injectable routes.

ANS: D Edema and impaired circulation of the soft tissue interfere with absorption of medications administered subcutaneously or intramuscularly. Even though it is true intramuscular injections disrupt tissue, medication absorption is not effective. Burn pain is severe and intravenous administration is desired to relieve pain, but this is not the physiological basis for giving medications intravenously. Hypermetabolism affects medication effectiveness but is not the rationale for administering opioids intravenously.

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

ANS: D Hemodynamic parameters can be accurately measured and trended with the head of the bed elevated to 45 degrees as long as the zeroing stopcock is properly leveled to the phlebostatic axis. Elevating the head of the bed to 45 degrees would be the optimum position to obtain a pulmonary artery occlusion pressure for a patient that becomes anxious and tachypneic when flat. Administering anxiety medications is not standard of care for obtaining hemodynamic pressures. Encouraging slow deep breaths while supine may inappropriately alter hemodynamic readings by altering intrathoracic pressure.

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

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

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

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

In hyperosmolar hyperglycemic syndrome, the laboratory results are similar to those of diabetic ketoacidosis, with three major exceptions. What differences would you expect to see in patients with hyperosmolar hyperglycemic syndrome? a. Lower serum glucose, lower osmolality, and greater ketosis b. Lower serum glucose, lower osmolality, and milder ketosis c. Higher serum glucose, higher osmolality, and greater ketosis d. Higher serum glucose, higher osmolality, and no ketosis

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

In hyperosmolar hyperglycemic syndrome, the laboratory results are similar to those of diabetic ketoacidosis, with three major exceptions. What differences would you expect to see in patients with hyperosmolar hyperglycemic syndrome? a. Lower serum glucose, lower osmolality, and greater ketosis b. Lower serum glucose, lower osmolality, and milder ketosis c. Higher serum glucose, higher osmolality, and greater ketosis d. Higher serum glucose, higher osmolality, and no ketosis

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

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

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

The nurse is providing insulin education for an elderly patient with longstanding diabetes. An order has been written for the patient to take 20 units of insulin glargine (Lantus) at 10 PM nightly. The nurse should instruct the patient that the peak of the insulin action for this agent is: a. 0200. b. 0400. c. 0800. d. peakless.

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

The nurse is providing insulin education for an elderly patient with long-standing diabetes. A prescription has been written for the patient to take 20 units of insulin glargine at 10 PM nightly. The nurse should instruct the patient that the peak of the insulin action for this agent is a. 0200. b. 0400. c. 0800. d. peakless.

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

The nurse is caring for a patient with an electrical injury. The nurse understands that patients with electrical injury are at a high risk for acute kidney injury secondary to: a. hypervolemia from burn resuscitation. b. increased incidence of ureteral stones. c. nephrotoxic antibiotics for prevention of infection. d. release of myoglobin from injured tissues.

ANS: D Myoglobin is released during electrical injury and is a risk factor for rhabdomyolysis and acute kidney injury. Hypervolemia is not a cause of acute kidney injury. Ureteral stones and nephrotoxic antibiotics may cause acute kidney injury but is not associated with the electrical injury.

Current guidelines recommend the oral route for endotracheal intubation. The rationale for this recommendation is that nasotracheal intubation is associated with a greater risk for: a. basilar skull fracture. b. cervical hyperextension. c. impaired ability to "mouth" words. d. sinusitis and infection.

ANS: D Nasotracheal intubation is associated with an increased risk for sinusitis, which may contribute to ventilator-associated infection. Nasal intubation is contraindicated in patients with basilar skull fracture. The procedure is sometimes performed in patients with cervical spine injury; the procedure can be done without hyperextending the neck. Patients with nasotracheal tubes are generally more comfortable and have a greater ability to "mouth words."

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

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

The nurse is caring for a mechanically ventilated patient. The physicians are considering performing a tracheostomy because the patient is having difficulty weaning from mechanical ventilation. Related to tracheostomy, the nurse understands which of the following? a. Patient outcomes are better if the tracheostomy is done within a week of intubation. b. Percutaneous tracheostomy can be done safely at the bedside by the respiratory therapist. c. Procedures performed in the operating room are associated with fewer complications. d. The greatest risk after a percutaneous tracheostomy is accidental decannulation.

ANS: D Optimal timing of tracheostomy is not yet known. Percutaneous procedures done at the bedside are not associated with any higher risks than those done in the operating room. Trained physicians safely perform percutaneous tracheostomies at the bedside. The greatest risk for percutaneous tracheostomy is accidental decannulation because the trachea is not surgically attached.

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

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

Positive end-expiratory pressure (PEEP) is a mode of ventilatory assistance that produces the following condition: a. Each time the patient initiates a breath, the ventilator delivers a full preset tidal volume. b. For each spontaneous breath taken by the patient, the tidal volume is determined by the patient's ability to generate negative pressure. c. The patient must have a respiratory drive, or no breaths will be delivered. d. There is pressure remaining in the lungs at the end of expiration that is measured in cm H2O.

ANS: D PEEP is the addition of positive pressure into the airways during expiration. PEEP is measured in centimeters of water.

The nurse is planning care to meet the patient's pain management needs related to burn treatment. The patient is alert, oriented, and follows commands. The pain is worse during the day when various treatments are scheduled. Which statement to the physician best indicates the nurse's knowledge of pain management for this patient? a. "Can we ask the music therapist to come by each morning to see if that will help the patient's pain? b. "The patient's pain is often unrelieved. I suggest that we also add benzodiazepines to the opioids around the clock." c. "The patient's pain is often unrelieved. It would be best if we can schedule the opioids around the clock." d. "The patient's pain varies depending on the treatment given. Can we try patient-controlled analgesia to see if that helps the patient better?"

ANS: D Patient-controlled analgesia allows the patient with burns to self-medicate for pain, thus providing independence with pain management strategies. Nonpharmacological pain strategies may provide helpful adjuncts to pain interventions. Scheduled pain medications and anxiolytic agents, although helpful, do not put the control of pain management with the patient.

The nurse is caring for a patient whose ventilator settings include 15 cm H2O of positive end-expiratory pressure (PEEP). The nurse understands that although beneficial, PEEP may result in: a. fluid overload secondary to decreased venous return. b. high cardiac index secondary to more efficient ventricular function. c. hypoxemia secondary to prolonged positive pressure at expiration. d. low cardiac output secondary to increased intrathoracic pressure

ANS: D Positive end-expiratory pressure, especially at higher levels, can result in a decreased cardiac output and index secondary to increased intrathoracic pressure, which impedes venous return. Fluid overload is not an expected finding. The cardiac index would likely decrease, not increase, along with cardiac output. PEEP is used to treat hypoxemia; it does not cause it.

The nurse is preparing to obtain a pulmonary artery occlusion pressure (PAOP) reading for a patient who is mechanically ventilated. Ensuring that the air-fluid interface is at the level of the phlebostatic axis, what is the best nursing action? a. Place the patient in the supine position and record the PAOP immediately after exhalation. b. Place the patient in the supine position and document the average PAOP obtained after three measurements. c. Place the patient with the head of bed elevated 30 degrees and document the average PAOP pressure obtained. d. Place the patient with the head of bed elevated 30 degrees and record the PAOP just before the increase in pressures during inhalation.

ANS: D Pressures are highest when measured at end exhalation in the spontaneously breathing patient. In mechanically ventilated patients, pressures increase with inhalation and decrease with exhalation. Measurements are obtained just before the increase in pressure during inhalation. Supine positioning is contraindicated in the mechanically ventilated patient. The head of bed should be elevated to 30 degrees. Pulmonary artery occlusion pressure is not averaged, but measured during inhalation in the mechanically ventilated patient while appropriate positioning is maintained.

The charge nurse has a Vigileo pulse contour cardiac output monitoring system available for use in the surgical intensive care unit. For which patient is use of this device most appropriate? a. A patient with a history of aortic insufficiency admitted with a postoperative myocardial infarction b. A mechanically ventilated patient with cardiogenic shock being treated with an intraaortic balloon pump c. A patient with a history of atrial fibrillation having frequent episodes of paroxysmal supraventricular tachycardia d. A mechanically ventilated patient admitted following repair of an acute bowel obstruction

ANS: D Pulse contour analysis systems provide stroke volume variation and pulse pressure variation data and are better predictors of fluid responsiveness in mechanically ventilated patients. A patient postoperative from repair of an acute bowel obstruction that is mechanically ventilated is an appropriate candidate for this method of monitoring. Aortic insufficiency, intraaortic balloon pump therapy, and the presence of cardiac dysrhythmias are conditions in which pulse contour analysis systems are either inaccurate or contraindicated.

Pulse oximetry measures: a. arterial blood gases. b. hemoglobin values. c. oxygen consumption. d. oxygen saturation.

ANS: D Pulse oximetry measures oxygen saturation in the peripheral tissues. It does not measure arterial blood gases, but it does estimate the PaO2 that is obtained via a blood gas analysis. It does not measure hemoglobin levels or oxygen consumption.

A patient is admitted to the oncology unit with a small cell lung carcinoma. During the admission, the patient is noted to have a significant decrease in urine output accompanied by shortness of breath, edema, and mental status changes. The nurse is aware that this clinical presentation is consistent with: a. adrenal crisis. b. diabetes insipidus. c. myxedema coma. d. syndrome of inappropriate secretion of antidiuretic hormone (SIADH).

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

A patient is admitted to the oncology unit with a small-cell lung carcinoma. During the admission, the patient is noted to have a significant decrease in urine output accompanied by shortness of breath, edema, and mental status changes. The nurse is aware that this clinical presentation is consistent with a. adrenal crisis. b. diabetes insipidus. c. myxedema coma. d. syndrome of inappropriate secretion of antidiuretic hormone (SIADH).

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

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

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

These signs are consistent with which disorder? a. Adrenal crisis b. Myxedema coma c. Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) d. Thyroid storm

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

A patient presents to the emergency department (ED) with the following clinical signs: Pulse: 132 beats/min Blood pressure: 88/50 mm Hg Respiratory rate: 32 breaths/min Temperature: 104.8° F Chest x-ray: Findings consistent with congestive heart failure Cardiac rhythm: Atrial fibrillation with rapid ventricular response These signs are consistent with which disorder? a. Adrenal crisis b. Myxedema coma c. Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) d. Thyroid storm

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

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

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

A patient presents to the emergency department demonstrating agitation and complaining of numbness and tingling in his fingers. His arterial blood gas levels reveal the following: pH 7.51, PaCO2 25, HCO3 25. The nurse interprets these blood gas values as: a. compensated metabolic alkalosis. b. normal values. c. uncompensated respiratory acidosis. d. uncompensated respiratory alkalosis.

ANS: D The low PaCO2 and high pH values show respiratory alkalosis. The bicarbonate level is normal.

A patient is being mechanically ventilated in the synchronized intermittent mandatory ventilation mode at a rate of 4 breaths/min. His spontaneous respirations are 12 breaths/min. He receives a dose of morphine sulfate, and his respirations decrease to 4 breaths/min. What adjustments may need to be made to the patient's ventilator settings? a. Add positive end-expiratory pressure (PEEP). b. Add pressure support. c. Change to assist/control ventilation at a rate of 4 breaths/min. d. Increase the synchronized intermittent mandatory ventilation respiratory rate.

ANS: D The morphine caused respiratory depression. As a result, the frequency and depth of respiration is compromised, which can lead to respiratory acidosis. The respiratory rate on the mechanical ventilator needs to be increased. The patient also may need to have naloxone administered to reverse the effects of the morphine. PEEP is added to improve oxygenation; it does not increase the rate or depth of respirations. Pressure support will not be effective in increasing the rate of spontaneous respiration. Changing to assist/control ventilation is an option; however, the rate needs to be set higher than 4 breaths/min.

The nurse is caring for a mechanically ventilated patient and notes the high pressure alarm sounding. The nurse cannot quickly identify the cause of the alarm and notes the patient's oxygen saturation is decreasing and heart rate and respiratory rate are increasing. The nurse's priority action is to: a. ask the respiratory therapist to get a new ventilator. b. call the rapid response team to assess the patient. c. continue to find the cause of the alarm and fix it. d. manually ventilate the patient while calling for a respiratory therapist.

ANS: D The nurse must quickly assess the patient and determine possible causes of the alarm. If the cause is not assessed within seconds, the nurse must manually ventilate the patient and secure assistance in troubleshooting the problem. The patient must be treated while the causes are being assessed by the nurse and respiratory therapist. Continuing to assess for the cause without manually ventilating the patient can result in patient compromise. The respiratory therapist, not the rapid response team, will assess and remedy the problem. A new ventilator may be needed, but that would be determined after the respiratory therapist has assessed the situation.

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

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

An elderly female patient has presented to the emergency department with altered mental status, hypothermia, and clinical signs of heart failure. Myxedema is suspected. Which of the following laboratory findings support this diagnosis? a. Elevated adrenocorticotropic hormone b. Elevated cortisol levels c. Elevated T3 and T4 d. Elevated thyroid-stimulating hormone

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

The nurse is providing postoperative care to a patient who underwent a transsphenoidal hypophysectomy for a benign pituitary tumor. The nurse administers replacement hydrocortisone, thyroid hormone, and vasopressin. The nurse evaluates that the vasopressin replacement is effective when: a. the patient's blood glucose is 110 mg/dL. b. the patient maintains a core body temperature of 98.2° F (36.8° C). c. the patient's urine specific gravity decreases. d. 2 liters of urine are produced in a 24-hour period.

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

A patient is admitted to the critical care unit following coronary artery bypass surgery. Two hours postoperatively, the nurse assesses the following information: pulse is 120 beats/min; blood pressure is 70/50 mm Hg; pulmonary artery diastolic pressure is 2 mm Hg; cardiac output is 4 L/min; urine output is 250 mL/hr; chest drainage is 200 mL/hr. What is the best interpretation by the nurse? a. The assessed values are within normal limits. b. The patient is at risk for developing cardiogenic shock. c. The patient is at risk for developing fluid volume overload. d. The patient is at risk for developing hypovolemic shock.

ANS: D Vital signs and hemodynamic values assessed collectively include classic signs and symptoms of hypovolemia. Both urine output and chest drainage values are high, contributing to the hypovolemia. Assessed values are not within normal limits. A cardiac output of 4 L/min is not indicative of cardiogenic shock. The patient is at risk for hypovolemia, not volume overload, as evidenced by excessive hourly chest drainage and urine output.

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

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

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

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

The nurse is caring for a patient with a left radial arterial line, and a pulmonary artery catheter inserted into the right subclavian vein. Which action by the nurse best ensures the safety of the patient being monitored with invasive hemodynamic monitoring lines? a. Document all waveform values. b. Limit the pressure tubing length. c. Zero reference the system daily. d. Ensure alarm limits are turned on.

ANS: D When hemodynamic monitoring is being done, it is important to set alarm limits to alert the nurse to changes in the patient's condition. Hemodyanamic values and waveforms are recorded at scheduled intervals and it is important that the tubing not be too long; however, alarm alerts are of highest priority. The lines are zero referenced per hospital policy, more frequently than daily.

The amount of effort needed to maintain a given level of ventilation is termed: a. compliance. b. resistance. c. tidal volume. d. work of breathing.

ANS: D Work of breathing is the amount of effort needed to maintain a given level of ventilation. Compliance is a measure of the distensibility, or stretchability, of the lung and chest wall. Resistance refers to the opposition to the flow of gases in the airways. Tidal volume is the volume of air in a typical breath

Which statement indicates to the nursing instructor that the nursing student understands the normal healing process of bone after a fracture? A "A callus is quickly deposited and transformed into bone." B "A hematoma forms at the site of the fracture." C "Calcium and vascular proliferation surround the fracture site." D "Granulation tissue reabsorbs the hematoma and deposits new bone."

B "A hematoma forms at the site of the fracture." In stage 1, within 24 to 72 hours after a fracture, a hematoma forms at the site of the fracture because bone is extremely vascular. This then prompts the formation of fibrocartilage, providing the foundation for bone healing. Stage 2 of bone healing occurs within 3 days to 2 weeks after the fracture, when granulation tissue begins to invade the hematoma. Stage 3 of bone healing occurs as a result of vascular and cellular proliferation. In stage 4 of a healing fracture, callus is gradually reabsorbed and transformed into bone.

The nurse wishes to reduce the incidence of hospital-acquired acute kidney injury. Which question by the nurse to the interdisciplinary health care team will result in reducing client exposure? A "Should we filter air circulation?" B "Can we use less radiographic contrast dye?" C "Should we add low-dose dobutamine?" D "Should we decrease IV rates?"

B "Can we use less radiographic contrast dye?" Contrast dye is severely nephrotoxic, and other options can be used in its place. Air circulation and low-dose dopamine are not associated with nephrotoxicity. Pre-renal status results from decreased blood flow to the kidney, such as fluid loss or dehydration; IV fluids can correct this.

The nurse is assessing the endurance level of a client in a long-term care facility. What question does the nurse ask to get this information? A "Are your feet or hands cold, even when you are in bed?" B "Do you feel more tired after you get up and go to the bathroom?" C "How much exercise do you get?" D "What is your endurance level?"

B "Do you feel more tired after you get up and go to the bathroom?" Asking about feeling tired after using the bathroom is pertinent to the client's activity and provides a comparison. The specific activity helps the client relate to the question and provide needed answers. Asking about cold feet or hands does not address the client's endurance. The hospitalized client typically does not get much exercise; this would be a difficult assessment for a client in long-term care facility to make. Asking the client about his or her endurance level is too vague; the client may not know how to answer this question.

The nurse is educating a group of young women who have sickle cell disease (SCD). Which comment from a class member requires correction? A "Frequent handwashing is an important habit for me to develop." B "Getting an annual 'flu shot' would be dangerous for me." C "I must take my penicillin pills as prescribed, all the time." D "The pneumonia vaccine is protection that I need."

B "Getting an annual 'flu shot' would be dangerous for me." The client with SCD should receive annual influenza and pneumonia vaccinations; this helps prevent the development of these infections, which could cause a sickle cell crisis. Handwashing is a very important habit for the client with SCD to develop because it reduces the risk for infection. Prophylactic penicillin is given to clients with SCD orally twice a day to prevent the development of infection.

Which client statement indicates that stem cell transplantation that is scheduled to take place in his home is not a viable option? A "I don't feel strong enough, but my wife said she would help." B "I was a nurse, so I can take care of myself." C "I will have lots of medicine to take." D "We live 5 miles from the hospital."

B "I was a nurse, so I can take care of myself." Stem cell transplantation in the home setting requires support, assistance, and coordination from others. The client cannot manage this type of care on his own. The client must be emotionally stable to be a candidate for this type of care. It is acceptable for the client's spouse to support the client undergoing this procedure. It is not unexpected for the client to be taking several prescriptions. Five miles is an acceptable distance from the hospital, in case of emergency.

The nurse is reinforcing information about genetic counseling to a client with sickle cell disease who has a healthy spouse. What information does the nurse include? A "Sickle cell disease will be inherited by your children." B "The sickle cell trait will be inherited by your children." C "Your children will have the disease, but your grandchildren will not." D "Your children will not have the disease, but your grandchildren could."

B "The sickle cell trait will be inherited by your children." The children of the client with sickle cell disease will inherit the sickle cell trait, but may not inherit the disease. If both parents have the sickle cell trait, their children could get the disease.

A client awaiting kidney transplantation states, "I can't stand this waiting for a kidney, I just want to give up." Which statement by the nurse is most therapeutic? A "I'll talk to the health care provider and have your name removed from the waiting list." B "You sound frustrated with the situation." C "You're right, the wait is endless for some people." D "I'm sure you'll get a phone call soon that a kidney is available."

B "You sound frustrated with the situation." Acknowledging the client's frustration reflects the feelings the client is having and offers assistance and support. Talking to the health care provider and removing the client from the waiting list does not allow the nurse to hear more and perhaps offer therapeutic listening or a solution to the problem. Telling the client that the wait is endless for some people cuts the client off from sharing his or her concerns and accentuates the negative aspects of the situation. The waiting time for kidney matches is increasing due to a shortage of organs; the nurse should not offer false hope by suggesting that the client will get a phone call soon.

The client has sustained a traumatic amputation of the left arm after a machine accident. In what order should the following nursing actions be taken? 1. Apply direct pressure to the amputated site. 2. Elevate the extremity above the client's heart. 3. Assess the client for breathing problems. 4. Examine the amputation site. A 2, 4, 3, 1 B 3, 4, 1, 2 C 1, 4, 3, 2 D 4, 1, 2, 3

B 3, 4, 1, 2 First, the airway must be assessed for breathing problems. Second, the nurse should examine the amputation site. Third, the nurse should apply direct pressure to the amputated site. Finally, the extremity should be elevated above the client's heart to decrease bleeding.

Which client does the nurse assign as a roommate for the client with aplastic anemia? A A 23-year-old with sickle cell disease who has two draining leg ulcers B A 28-year-old with glucose-6-phosphate dehydrogenase (G6PD) deficiency anemia who is receiving mannitol (Osmitrol) C A 30-year-old with leukemia who is receiving induction chemotherapy D A 34-year-old with idiopathic thrombocytopenia who is taking steroids

B A 28-year-old with glucose-6-phosphate dehydrogenase (G6PD) deficiency anemia who is receiving mannitol (Osmitrol) Because clients with aplastic anemia usually have low white blood cell counts that place them at high risk for infection, roommates such as the client with G6PD deficiency anemia should be free from infection or infection risk. The client with sickle cell disease has two draining leg ulcer infections that would threaten the diminished immune system of the client with aplastic anemia. The client with leukemia who is receiving induction chemotherapy and the client with idiopathic thrombocytopenia who is taking steroids are at risk for development of infection, which places the client with aplastic anemia at risk, too.

When caring for a client with a left forearm arteriovenous fistula created for hemodialysis, which actions must the nurse take? (Select all that apply.) A Check brachial pulses daily. B Auscultate for a bruit every 8 hours. Correct C Teach the client to palpate for a thrill over the site. Correct D Elevate the arm above heart level. E Ensure that no blood pressures are taken in that arm.

B Auscultate for a bruit every 8 hours. C Teach the client to palpate for a thrill over the site. E Ensure that no blood pressures are taken in that arm. A bruit or swishing sound, and a thrill or buzzing sensation upon palpation should be present in this client, indicating patency of the fistula. No blood pressure, venipuncture, or compression, such as lying on the fistula, should occur. Distal pulses and capillary refill should be checked, and for a forearm fistula, the radial pulse is checked—the brachial pulse is proximal. Elevating the arm increases venous return, possibly collapsing the fistula.

Which instruction by the nurse will help a client with chronic kidney disease prevent renal osteodystrophy? A Consuming a low-calcium diet Incorrect B Avoiding peas, nuts, and legumes C Drinking cola beverages only once daily D Increasing dairy products enriched with vitamin D

B Avoiding peas, nuts, and legumes Kidney failure causes hyperphosphatemia; this client must restrict phosphorus-containing foods such as beans, peas, nuts (peanut butter), and legumes. Calcium should not be restricted; hyperphosphatemia results in a decrease in serum calcium and demineralization of the bone. Cola beverages and dairy products are high in phosphorus, contributing to hypocalcemia and bone breakdown.

The nurse admits an older adult client who sustained a left hip fracture and is in considerable pain. The nurse anticipates that the client will be placed in which type of traction? A Balanced skin traction B Buck's traction C Overhead traction D Plaster traction

B Buck's traction Buck's traction may be applied before surgery to help decrease pain associated with muscle spasm. Balanced skin traction is indicated for fracture of the femur or pelvis. Overhead traction is indicated for fracture of the humerus with or without involvement of the shoulder and clavicle. Plaster traction is indicated for wrist fracture.

Which signs and symptoms indicate rejection of a transplanted kidney? (Select all that apply.) A Blood urea nitrogen (BUN) 21 mg/dL, creatinine 0.9 mg/dL B Crackles in the lung fields C Temperature of 98.8° F (37.1° C) D Blood pressure of 164/98 mm Hg E 3+ edema of the lower extremities

B Crackles in the lung fields D Blood pressure of 164/98 mm Hg E 3+ edema of the lower extremities Signs and symptoms of fluid retention (e.g., crackles in the lung fields and 3+ edema of the lower extremities) indicate transplant rejection. Increased blood pressure is also a symptom of transplant rejection. Increasing BUN and creatinine are symptoms of rejection; a BUN of 21 mg/dL and a creatinine of 0.9 mg/dL reflect normal values. Fever, not normothermia, is symptomatic of transplant rejection.

What are the typical clinical manifestations of anemia? (Select all that apply.) A Decreased breath sounds B Dyspnea on exertion Correct C Elevated temperature D Fatigue Correct E Pallor Correct F Tachycardia

B Dyspnea on exertion D Fatigue E Pallor F Tachycardia Difficulty breathing—especially with activity—is common with anemia. Lower levels of hemoglobin carry less O2 to the cells of the body. Fatigue is a classic symptom of anemia; lowered O2 levels contribute to a faster pulse (i.e., cardiac rate) and tend to "wear out" a client's energy. Lowered O2 levels deliver less oxygen to all cells, making clients with anemia pale—especially their ears, nail beds, palms, and conjunctivae and around the mouth. Respiratory problems with anemia do not include changes in breath sounds; dyspnea and decreased oxygen saturation levels are present. Skin is cool to the touch, and an intolerance to cold is noted; elevated temperature would signify something additional, such as infection.

Which intervention most effectively protects a client with thrombocytopenia? A Avoiding the use of dentures B Encouraging the use of an electric shaver C Taking rectal temperatures D Using warm compresses on trauma sites

B Encouraging the use of an electric shaver The client with thrombocytopenia should be advised to use an electric shaver instead of a razor. Any small cuts or nicks can cause problems because of the prolonged clotting time. Dentures may be used by clients with thrombocytopenia as long as they fit properly and do not rub. To prevent rectal trauma, rectal thermometers should not be used. Oral or tympanic temperatures should be taken. Ice (not heat) should be applied to areas of trauma.

The nurse is caring for a client with sickle cell disease. Which action is most effective in reducing the potential for sepsis in this client? A Administering prophylactic drug therapy B Frequent and thorough handwashing C Monitoring laboratory values to look for abnormalities D Taking vital signs every 4 hours, day and night

B Frequent and thorough handwashing Prevention and early detection strategies are used to protect the client in sickle cell crisis from infection. Frequent and thorough handwashing is of the utmost importance. Drug therapy is a major defense against infections that develop in the client with sickle cell disease, but is not the most effective way that the nurse can reduce the potential for sepsis. Continually assessing the client for infection and monitoring the daily complete blood count with differential white blood cell count is early detection, not prevention. Taking vital signs every 4 hours will help with early detection of infection, but is not prevention.

A client is receiving immune-suppressive therapy after kidney transplantation. Which measure for infection control is most important for the nurse to implement? A Adherence to therapy B Handwashing C Monitoring for low-grade fever D Strict clean technique

B Handwashing The most important infection control measure for the client receiving immune-suppressive therapy is handwashing. Adherence to therapy and monitoring for low-grade fever are important, but are not infection control measures. The nurse should practice aseptic technique for this client, not simply clean technique.

A 32-year-old client is recovering from a sickle cell crisis. His discomfort is controlled with pain medications and he is to be discharged. What medication does the nurse expect to be prescribed for him before his discharge? A Heparin (Heparin) B Hydroxyurea (Droxia) C Tissue plasminogen activator (t-PA) D Warfarin (Coumadin)

B Hydroxyurea (Droxia) Hydroxyurea (Droxia) has been used successfully to reduce sickling of cells and pain episodes associated with sickle cell disease (SCD). Clients with SCD are not prescribed anticoagulants such as heparin or warfarin (Coumadin). t-PA is used as a "clot buster" in clients who have had ischemic strokes.

The nurse is transfusing 2 units of packed red blood cells to a postoperative client. What post-transfusion electrolyte imbalance does the nurse want to rule out? A Hypercalcemia B Hyperkalemia C Hypomagnesemia D Hyponatremia

B Hyperkalemia During transfusion, some cells are damaged. These cells release potassium, thus raising the client's serum potassium level (hyperkalemia). This complication is especially common with packed cells and whole-blood products. High serum calcium levels, low magnesium levels, or low sodium levels are not expected with blood transfusions.

A recently admitted client who is in sickle cell crisis requests "something for pain." What does the nurse administer? A Intramuscular (IM) morphine sulfate B Intravenous (IV) hydromorphone (Dilaudid) C Oral ibuprofen (Motrin) D Oral morphine sulfate (MS-Contin)

B Intravenous (IV) hydromorphone (Dilaudid) The client needs IV pain relief, and it should be administered on a routine schedule (i.e., before the client has to request it). Morphine is not administered intramuscularly (IM) to clients with sickle cell disease (SCD). In fact, all IM injections are avoided because absorption is impaired by poor perfusion and sclerosed skin. Nonsteroidal anti-inflammatory drugs may be used for clients with SCD for pain relief once their pain is under control; however, in a crisis, this choice of analgesic is not strong enough. Moderate pain may be treated with oral opioids, but this client is in a sickle cell crisis; IV analgesics should be used until his or her condition stabilizes.

Which medication is most effective in slowing the progression of kidney failure in a client with chronic kidney disease? A Diltiazem (Cardizem) B Lisinopril (Zestril) C Clonidine (Catapres) D Doxazosin (Cardura)

B Lisinopril (Zestril) Angiotensin-converting enzyme inhibitors such as lisinopril appear to be the most effective drugs to slow the progression of kidney failure. Calcium channel blockers such as diltiazem may indirectly prevent kidney disease by controlling hypertension, but are not specific to slowing progression of kidney disease. Vasodilators such as clonidine and doxazosin control blood pressure, but do not specifically protect from kidney disease.

What are serious side effects of antiviral agents prescribed for a client with acute myelogenous leukemia? (Select all that apply.) A Cardiomyopathy B Nephrotoxicity Correct C Ototoxicity Correct D Stroke E Diarrhea

B Nephrotoxicity C Ototoxicity Antiviral agents, although helpful in combating severe infection, have serious side effects, especially nephrotoxicity and ototoxicity. Cardiomyopathy and stroke are not serious side effects of antiviral agents. Diarrhea is a mild side effect associated with antibiotic therapy.

The nurse refers a client with an amputation and the client's family to which community resource? A. American Amputee Society (AAS) B. Amputee Coalition of America (ACA) C. Community Workers for Amputees (CWA) D. National Amputee of America Society (NAAS)

B. Amputee Coalition of America (ACA) The ACA is an available resource for clients with amputations and supports them and their families. The AAS, CWA, and NAAS do not exist.

The nurse assesses multiple clients who are receiving transfusions of blood components. Which assessment indicates the need for the nurse's immediate action? A A partial thromboplastin time (PTT) that is 1.2 times normal in a client who received a transfusion of fresh-frozen plasma (FFP) B Respiratory rate of 36 breaths/min in a client receiving red blood cells C Sleepiness in a client who received diphenhydramine (Benadryl) as a premedication D Temperature of 99.1° F (37.3° C) for a client with a platelet transfusion

B Respiratory rate of 36 breaths/min in a client receiving red blood cells An increased respiratory rate indicates a possible hemolytic transfusion reaction; the nurse should quickly stop the transfusion and assess the client further. Because FFP is not usually given until the PTT is 1.5 times above normal, a PTT that is 1.2 times normal indicates that the FFP has had the desired response. Sleepiness is expected when Benadryl is administered. Temperature elevations are not an indication of an allergic reaction to a platelet transfusion, although the nurse may administer acetaminophen (Tylenol) to decrease the fever.

Which information about a client who was admitted with pelvic and bilateral femoral fractures after being crushed by a tractor is most important for the nurse to report to the health care provider? A Thighs have multiple oozing abrasions. B Serum potassium level is 7 mEq/L. C The client is describing pain as level 4 (0-to-10 scale). D Hemoglobin level is 12.0 g/dL.

B Serum potassium level is 7 mEq/L. The elevated potassium level may indicate that the client has rhabdomyolysis and acute tubular necrosis caused by the crush injury. Further assessment and treatment are needed immediately to prevent further kidney damage or cardiac dysrhythmias. Thighs having multiple oozing abrasions with a pain level of 4 are not unusual for a client with this type of injury. A hemoglobin level of 12.0 g/dL is a normal finding.

When caring for a client with acute kidney injury and a temporary subclavian hemodialysis catheter, which assessment finding does the nurse report to the provider? A Mild discomfort at the insertion site B Temperature 100.8° F C 1+ ankle edema D Anorexia

B Temperature 100.8° F Infection is a major complication of temporary catheters. All symptoms of infection, including fever, must be reported to the provider because the catheter may have to be removed. Mild discomfort at the insertion site is expected with a subclavian hemodialysis catheter. During acute injury, oliguria with resulting fluid retention is expected. Rising blood urea nitrogen may result in anorexia, nausea, and vomiting.

A client has a grade III compound fracture of the right tibia. To prevent infection, which intervention does the nurse implement? A. Apply bacitracin (Neosporin) ointment to the site daily with a sterile cotton swab. B. Use strict aseptic technique when cleaning the site. C. Leave the site open to the air to keep it dry. D. Assist the client to shower daily and pat the wound site dry.

B. Use strict aseptic technique when cleaning the site. Using aseptic technique is the best way to prevent infection. Chlorhexidine (Hibiclens), 2 mg/mL solution, is the better cleansing solution for pin site care, not Neosporin ointment. A wound of this type should be kept covered, not left open to the air. The wound site of a compound fracture must not be exposed to a shower; this practice violates maintaining aseptic technique.

The nurse is infusing platelets to a client who is scheduled for a hematopoietic stem cell transplant. What procedure does the nurse follow? A Administer intravenous corticosteroids before starting the transfusion. B Allow the platelets to stabilize at the client's bedside for 30 minutes. C Infuse the transfusion over a 15- to 30-minute period. D Set up the infusion with the standard transfusion Y tubing.

C Infuse the transfusion over a 15- to 30-minute period. The volume of platelets—200 or 300 mL (standard amount)—needs to be infused rapidly over a 15- to 30-minute period. Administering steroids is not standard practice in administering platelets. Platelets must be administered immediately after they are received; they are considered to be quite fragile. A special transfusion set with a smaller filter and shorter tubing is used to get the platelets into the client quickly and efficiently.

A hematology unit is staffed by RNs, LPN/LVNs, and unlicensed assistive personnel (UAP). When the nurse manager is reviewing documentation of staff members, which entry indicates that the staff member needs education about his or her appropriate level of responsibility and client care? A "Abdominal pain relieved by morphine 4 mg IV; client resting comfortably and denies problems. B.C., RN" B "Ambulated in hallway for 40 feet and denies shortness of breath at rest or with ambulation. T.Y., LPN" C "Client reporting increased shortness of breath; oxygen increased to 4 L by nasal cannula. M.N., UAP" D "Vital signs 37.0° C, heart rate 60, respiratory rate 20, blood pressure 110/68, and oximetry 98% on room air. L.D., UAP"

C "Client reporting increased shortness of breath; oxygen increased to 4 L by nasal cannula. M.N., UAP" Determination of the need for oxygen and administration of oxygen should be done by licensed nurses who have the education and scope of practice required to administer it. All other documentation entries reflect appropriate delegation and assignment of care.

A client is scheduled to undergo kidney transplant surgery. Which teaching point does the nurse include in the preoperative teaching session? A "Your diseased kidneys will be removed at the same time the transplant is performed." B "The new kidney will be placed directly below one of your old kidneys." C "It is essential for you to wash your hands and avoid people who are ill." D "You will receive dialysis the day before surgery and for about a week after."

C "It is essential for you to wash your hands and avoid people who are ill." Anti-rejection medications increase the risks for infection, sepsis, and death. Strict aseptic technique and handwashing are essential. Unless severely infected, the client's kidneys are left in place and the graft is placed in the iliac fossa. Dialysis is performed the day before surgery; after the surgery, the new kidney should begin to make urine.

Discharge teaching has been provided for a client recovering from kidney transplantation. Which information indicates that the client understands the instructions? A "I can stop my medications when my kidney function returns to normal." B "If my urine output is decreased, I should increase my fluids." C "The anti-rejection medications will be taken for life." D "I will drink 8 ounces of water with my medications."

C "The anti-rejection medications will be taken for life." Immune-suppressant therapy must be taken for life to prevent organ rejection. Adherence to immunosuppressive drugs is crucial to survival for clients with transplanted kidneys. Lack of adherence can lead to complications such as rejection, graft loss, return to dialysis, and death. Oliguria is a symptom of transplant rejection; the transplant team should be contacted immediately if this occurs. It is not necessary to take anti-rejection medication with 8 ounces of water.

A client with leukemia is being discharged from the hospital. After hearing the nurse's instructions to keep regularly scheduled follow-up provider appointments, the client says, "I don't have transportation." How does the nurse respond? A "A pharmaceutical company might be able to help." B "I might be able to take you." C "The local American Cancer Society may be able to help." D "You can take the bus."

C "The local American Cancer Society may be able to help." Many local units of the American Cancer Society offer free transportation to clients with cancer, including those with leukemia. Suggesting a pharmaceutical company is not the best answer; drug companies typically do not provide this type of service. Although the nurse offering to take the client is compassionate, it is not appropriate for the nurse to offer the client transportation. Telling the client to take the bus is dismissive and does not take into consideration the client's situation (e.g., the client may live nowhere near a bus route).

A 56-year-old client admitted with a diagnosis of acute myelogenous leukemia (AML) is prescribed IV cytosine arabinoside for 7 days and an infusion of daunorubicin for the first 3 days. An infection develops. What knowledge does the nurse use to determine that the appropriate antibiotic has been prescribed for this client? A Evaluating the client's liver function tests (LFTs) and serum creatinine levels B Evaluating the client's white blood cell (WBC) count level C Checking the culture and sensitivity test results to be certain that the requested antibiotic is effective against the organism causing the infection D Recognizing that vancomycin (Vancocin) is the drug of choice used to treat all infections in clients with AML

C Checking the culture and sensitivity test results to be certain that the requested antibiotic is effective against the organism causing the infection Checking the culture and sensitivity test results to be certain that the requested antibiotic is effective against the organism causing the infection is the best action to take. Drug therapy is the main defense against infections that develop in clients undergoing therapy for AML. Agents used depend on the client's sensitivity to various antibiotics for the organism causing the infection. Although LFTs and kidney function tests may be influenced by antibiotics, these tests do not determine the effectiveness of the antibiotic. Although the WBC count is elevated in infection, this test does not influence which antibiotic will be effective in fighting the infection. Vancomycin may not be effective in all infections; culturing of the infection site and determining the organism's sensitivity to a cohort of drugs are needed, which will provide data on drugs that are capable of eradicating the infection in this client.

A client with end-stage kidney disease has been put on fluid restrictions. Which assessment finding indicates that the client has not adhered to this restriction? A Blood pressure of 118/78 mm Hg B Weight loss of 3 pounds during hospitalization C Dyspnea and anxiety at rest D Central venous pressure (CVP) of 6 mm Hg

C Dyspnea and anxiety at rest Dyspnea is a sign of fluid overload and possible pulmonary edema; the nurse should assist the client in correlating symptoms of fluid overload with nonadherence to fluid restriction. Nonadherence to fluid restriction results in fluid volume excess and higher blood pressures; 118/78 mm Hg is a normal blood pressure. Excess fluid intake and fluid retention are manifested by an elevated CVP (>8 mm Hg) and weight gain, not weight loss.

A client has sustained a rotator cuff tear while playing baseball. The nurse anticipates that the client will receive which immediate conservative treatment? A Surgical repair of the rotator cuff B Prescribed exercises of the affected arm C Immobilizer for the affected arm D Patient-controlled analgesia with morphine

C Immobilizer for the affected arm The conservative treatment for this client is to place the injured arm in an immobilizer. Surgical intervention is not considered conservative treatment. Exercises are prohibited immediately after a rotator cuff injury. The client with a rotator cuff injury is treated primarily with nonsteroidal anti-inflammatory drugs to manage pain.

A client is in skeletal traction. Which nursing intervention ensures proper care of this client? A Ensure that weights are attached to the bed frame or placed on the floor. B Ensure that pins are not loose, and tighten as needed. C Inspect the skin at least every 8 hours. D Remove the traction weights only for bathing.

C Inspect the skin at least every 8 hours. The client's skin should be inspected every 8 hours for signs of irritation, inflammation, or actual skin breakdown. Weights are not allowed to be placed on the floor; weights should hang freely at all times. Pin sites should be checked for signs and symptoms of infection and for security in their position to the fixation and the client's extremity. However, the nurse does not adjust the pins. Any loose pin site or alteration must be reported to the health care provider. Weights must never be removed without a request from the health care provider.

The nurse is caring for a client with neutropenia who has a suspected infection. Which intervention does the nurse implement first? A Hydrate the client with 1000 mL of IV normal saline. B Initiate the administration of prescribed antibiotics. C Obtain requested cultures. Correct D Place the client on Bleeding Precautions.

C Obtain requested cultures. Obtaining cultures to identify the infectious agent correctly is the priority for this client. Hydrating the client is not the priority. Administering antibiotics is important, but antibiotics should always be started after cultures are obtained. Placing the client on Bleeding Precautions is unnecessary.

A 32-year-old client recovering from a sickle cell crisis is to be discharged. The nurse says, "You and all clients with sickle cell disease are at risk for infection because of your decreased spleen function. For this reason, you will most likely be prescribed an antibiotic before discharge." Which drug does the nurse anticipate the health care provider will request? A Cefaclor (Ceclor) B Gentamicin (Garamycin) C Penicillin V (Pen-V K) D Vancomycin (Vancocin)

C Penicillin V (Pen-V K) Prophylactic therapy with twice-daily oral penicillin reduces the incidence of pneumonia and other streptococcal infections and is the correct drug to use. It is a standard protocol for long-term prophylactic use in clients with sickle cell disease. Cefaclor (Ceclor) and vancomycin (Vancocin) are antibiotics more specific for short-term use and would be inappropriate for this client. Gentamicin (Garamycin) is a drug that can cause liver and kidney damage with long-term use.

A client admitted to the medical unit with a history of vomiting and diarrhea and an increased blood urea nitrogen requires 1 liter of normal saline infused over 2 hours. Which staff member should be assigned to care for the client? A RN who has floated from pediatrics for this shift B LPN/LVN with experience working on the medical unit C RN who usually works on the general surgical unit D New graduate RN who just finished a 6-week orientation

C RN who usually works on the general surgical unit The nurse with experience in taking care of surgical clients will be most capable of monitoring the client receiving rapid fluid infusions, who is at risk for complications such as pulmonary edema and acute kidney failure. The pediatric float RN and the new graduate RN will have less experience in caring for this type of client. The LPN/LVN should not be assigned to a client requiring IV therapy and who is at high risk for complications.

The nurse is to administer packed red blood cells to a client. How does the nurse ensure proper client identification? A Asks the client's name B Checks the client's armband C Reviews all information with another registered nurse D Verifies the client's room number

C Reviews all information with another registered nurse With another registered nurse, verify the client by name and number, check blood compatibility, and note expiration time. Human error is the most common cause of ABO incompatibility reactions, even for experienced nurses. Asking the client's name and checking the client's armband are not adequate for identifying the client before transfusion therapy. Using the room number to verify client identification is never appropriate.

While assisting a client during peritoneal dialysis, the nurse observes the drainage stop after 200 mL of peritoneal effluent drains into the bag. What action should the nurse implement first? A Instruct the client to deep-breathe and cough. B Document the effluent as output. Incorrect C Turn the client to the opposite side. D Re-position the catheter.

C Turn the client to the opposite side. With peritoneal dialysis, usually 1 to 2 L of dialysate is infused by gravity into the peritoneal space. The fluid dwells in the peritoneal cavity for a specified time, then drains by gravity into a drainage bag. The dialyzing fluid is called peritoneal effluent on outflow. The outflow should be a continuous stream after the clamp is completely open. Potential causes of flow difficulty include constipation, kinked or clamped connection tubing, the client's position, fibrin clot formation, and catheter displacement. If inflow or outflow drainage is inadequate, re-position the client to stimulate inflow or outflow. Turning the client to the other side or ensuring that he or she is in good body alignment may help. Instructing the client to deep-breathe and cough will not promote dialysate drainage. Increased abdominal pressure from coughing contributes to leakage at the catheter site. The nurse needs to measure and record the total amount of outflow after each exchange. However, the nurse should re-position the client first to assist with complete dialysate drainage. An x-ray is needed to identify peritoneal dialysis catheter placement. Only the physician re-positions a displaced catheter.

The nurse is mentoring a recent graduate RN about administering blood and blood products. What does the nurse include in the data? A Obtain the client's initial set of vital signs (VS) within the first 10 minutes of the infusion. B Remain with the client who is receiving the blood for the first 5 minutes of the infusion. C Use a 22-gauge needle to obtain venous access when starting the infusion.

C Use a 22-gauge needle to obtain venous access when starting the infusion. All data are checked by two RNs. Human error is the most common cause of ABO incompatibilities in administering blood and blood products. Initial VS should be recorded before the start of infusion of blood, not after it has begun. The nurse remains with the client for the first 15 to 30 minutes (not 5) of the infusion. This is the period when any transfusion reactions are likely to happen. A 20-gauge needle (or a central line catheter) is used; the 22-gauge needle is too small.

Which factor represents a sign or symptom of digoxin toxicity? A Serum digoxin level of 1.2 ng/mL B Polyphagia C Visual changes D Serum potassium of 5.0 mEq/L

C Visual changes Visual changes, anorexia, nausea, and vomiting are symptoms of digoxin toxicity. A digoxin level of 1.2 ng/mL is normal (0.5 to 2.0 ng/mL). Polyphagia is a symptom of diabetes. Although hypokalemia may predispose to digoxin toxicity, this represents a normal, not low, potassium value.

The nurse is instructing a local community group about ways to reduce the risk for musculoskeletal injury. What information does the nurse include in the teaching plan? A. "Avoid contact sports." B. "Avoid rigorous exercise." C. "Wear helmets when riding a motorcycle." D. "Avoid driving in inclement weather."

C. "Wear helmets when riding a motorcycle." Those who ride motorcycles or bicycles should wear helmets to prevent head injury. Telling the general public to avoid contact sports or to avoid driving in inclement weather is not realistic. Telling the general public to avoid rigorous exercise is not only unrealistic, it is also opposed to what many health care professionals recommend to maintain health.

A client with a fracture asks the nurse about the difference between a compound fracture and a simple fracture. Which statement by the nurse is correct? A "Simple fracture involves a break in the bone, with skin contusions." B "Compound fracture does not extend through the skin." C "Simple fracture is accompanied by damage to the blood vessels." D "Compound fracture involves a break in the bone, with damage to the skin."

D "Compound fracture involves a break in the bone, with damage to the skin." A compound fracture involves a break in the bone with damage to the skin. A simple fracture does not extend through the skin. A compound fracture is accompanied by damage to blood vessels.

A client with thrombocytopenia is being discharged. What information does the nurse incorporate into the teaching plan for this client? A "Avoid large crowds." B "Drink at least 2 liters of fluid per day." C "Elevate your lower extremities when sitting." D "Use a soft-bristled toothbrush."

D "Use a soft-bristled toothbrush." Using a soft-bristled toothbrush reduces the risk for bleeding in the client with thrombocytopenia. Avoiding large crowds reduces the risk for infection, but is not specific to the client with thrombocytopenia. Increased fluid intake reduces the risk for dehydration, but is not specific to the client with thrombocytopenia. Elevating extremities reduces the risk for dependent edema, but is not specific to the client with thrombocytopenia.

A client is being treated for kidney failure. Which statement by the nurse encourages the client to express his or her feelings and concerns about the risk for death and the disruption of lifestyle? A "All of this is new. What can't you do?" B "Are you afraid of dying?" C "How are you doing this morning?" D "What concerns do you have about your kidney disease?"

D "What concerns do you have about your kidney disease?" Asking the client about any concerns is open-ended and specific to the client's concerns. Asking the client to explain what he or she can't do implies inadequacy on the client's part. Asking the client if he or she is afraid of dying is too direct and would likely cause the client to be anxious. Asking the client how he or she is doing is too general and does not encourage the client to share thoughts on a specific topic.

A client with multiple myeloma reports bone pain that is unrelieved by analgesics. How does the nurse respond to this client's problem? A "Ask your doctor to prescribe more medication." B "It is too soon for additional medication to be given." C "I'll turn on some soothing classical music for you." D "Would you like to try some relaxation techniques?"

D "Would you like to try some relaxation techniques?" Because most clients with multiple myeloma have local or generalized bone pain, analgesics and alternative approaches for pain management, such as relaxation techniques, are used for pain relief. This also offers the client a choice. Before prescribing additional medication, other avenues should be explored to relieve this client's pain. Even if it is too soon to give additional medication, telling that to the client is not helpful because it dismisses the client's pain concerns. Although music therapy can be helpful, this response does not give the client a choice.

The nurse assesses the client with which hematologic problem first? A A 32-year-old with pernicious anemia who needs a vitamin B12 injection B A 40-year-old with iron deficiency anemia who needs a Z-track iron injection C A 67-year-old with acute myelocytic leukemia with petechiae on both legs D An 81-year-old with thrombocytopenia and an increase in abdominal girth

D An 81-year-old with thrombocytopenia and an increase in abdominal girth An increase in abdominal girth in a client with thrombocytopenia indicates possible hemorrhage; this warrants further assessment immediately. The 32-year-old with pernicious anemia, the 40-year-old with iron deficiency anemia, and the 67-year-old with acute myelocytic leukemia do not indicate any acute complications, so the nurse can assess them after assessing the client with thrombocytopenia.

The nurse prepares to perform a neurovascular assessment on a client with closed multiple fractures of the right humerus. Which technique does the nurse use? A Inspect the abdomen for tenderness and bowel sounds. B Auscultate lung sounds. C Assess the level of consciousness and ability to follow commands. D Assess sensation of the right upper extremity.

D Assess sensation of the right upper extremity. Assessing sensation of the right upper extremity is part of a focused neurovascular assessment for the client with multiple fractures of the right humerus. Inspecting the abdomen and auscultating lung sounds of the client with multiple fractures are not part of a focused neurovascular assessment. Because the client does not have a head injury, assessing the client's level of consciousness and ability to follow commands is not part of a focused neurovascular assessment.

An 82-year-old client with anemia is requested to receive 2 units of whole blood. Which assessment findings cause the nurse to discontinue the transfusion because it is unsafe for the client? (Select all that apply.) A Capillary refill less than 3 seconds B Decreased pallor C Flattened superficial veins D Hypertension Correct E Hypotension Correct F Rapid, bounding pulse

D Hypertension E Hypotension F Rapid, bounding pulse In an older adult receiving a transfusion, hypertension is a sign of overload, low blood pressure is a sign of a transfusion reaction, and a rapid and bounding pulse is a sign of fluid overload. In this scenario, 2 units, or about a liter of fluid, could be problematic. Capillary refill time that is less than 3 seconds is considered to be normal and would not pose a problem. Increased (not decreased) pallor and cyanosis are signs of a transfusion reaction, while swollen (not flattened) superficial veins are present in fluid overload in older adult clients receiving transfusions.

A client who has been newly diagnosed with leukemia is admitted to the hospital. Avoiding which potential problem takes priority in the client's nursing care plan? A Fluid overload (overhydration) B Hemorrhage C Hypoxia D Infection

D Infection The main objective in caring for a newly diagnosed client with leukemia is protection from infection. Fluid overload, hemorrhage, and hypoxia are not priority problems for the client with leukemia.

Which assessment finding represents a positive response to erythropoietin (Epogen, Procrit) therapy? A Hematocrit of 26.7% B Potassium within normal range C Absence of spontaneous fractures D Less fatigue

D Less fatigue Treatment of anemia with erythropoietin will result in increased hemoglobin and hematocrit (H&H) and decreased shortness of breath and fatigue. A hematocrit value of 26.7% is low; erythropoietin should restore the hematocrit to at least 36% to be effective. Erythropoietin causes more red blood cells to be produced, increasing H&H, not potassium. Calcium supplements and phosphate binders prevent renal osteodystrophy; erythropoietin treats anemia.

Which would be an appropriate task to delegate to unlicensed assistive personnel (UAP) working on a medical-surgical unit? A Administering erythropoietin to a client with myelodysplastic syndrome B Assessing skin integrity on an anemic client who fell during ambulation C Assisting a client with folic acid deficiency in making diet choices D Obtaining vital signs on a client receiving a blood transfusion

D Obtaining vital signs on a client receiving a blood transfusion Obtaining vital signs on a client is within the scope of practice for UAP. Administering medication, assessing clients, and assisting with prescribed diet choices are complex actions that should be done by licensed nurses.

An older adult client has multiple tibia and fibula fractures of the left lower extremity after a motor vehicle crash. Which pain medication does the nurse anticipate will be requested for this client? A Cyclobenzaprine (Flexeril) B Ibuprofen (Advil) C Meperidine (Demerol) D Patient-controlled analgesia (PCA) with morphine

D Patient-controlled analgesia (PCA) with morphine Morphine is an opioid narcotic analgesic; given through PCA, it is the most appropriate mode of pain management for this type of acute pain associated with multiple injuries. Muscle relaxants such as cyclobenzaprine are effective for treating pain related to muscle spasms, but they are not adequate for this type of acute pain. Ibuprofen is a nonsteroidal anti-inflammatory drug that is used to treat mild to moderate pain; bone pain is very acute, so ibuprofen would not be sufficient. Meperidine should never be used for older adults because it has toxic metabolites that can cause seizures.

Which problem excludes a client hoping to receive a kidney transplant from undergoing the procedure? A History of hiatal hernia B Presence of diabetes and glycosylated hemoglobin of 6.8% C History of basal cell carcinoma on the nose 5 years ago D Presence of tuberculosis

D Presence of tuberculosis Long-standing pulmonary disease and chronic infection typically exclude clients from transplantation; these conditions worsen with the immune suppressants that are required to prevent rejection. A client with a history of hiatal hernia is not exempt from undergoing a kidney transplant. Good control of diabetes is a positive point, and would not exclude the client from transplantation. Basal cell carcinoma is considered curable and occurred 5 years ago, consistent with appropriate candidates for transplantation.

The nurse is caring for a client who is in sickle cell crisis. What action does the nurse perform first? A Apply cool compresses to the client's forehead. B Encourage the client's use of two methods of birth control. C Increase food sources of iron in the client's diet. D Provide pain medications as needed.

D Provide pain medications as needed. Analgesics are needed to treat sickle cell pain. Warm soaks or compresses can help reduce pain perception. Cool compresses do not help the client in sickle cell crisis. Birth control is not the priority for this client. Increasing iron in the diet is not pertinent for the client in sickle cell crisis.

What is the most important environmental risk for developing leukemia? A Direct contact with others with leukemia B Family history C Living near high-voltage power lines D Smoking cigarettes

D Smoking cigarettes According to the American Cancer Society (ACS), the only proven lifestyle-related risk factor for leukemia is cigarette smoking. Leukemia is not contagious. Genetics is a strong indicator, but it is not an environmental risk factor. According to the ACS, living near high-voltage power lines is not a proven risk factor for leukemia.

A client who is receiving a blood transfusion suddenly exclaims to the nurse, "I don't feel right!" What does the nurse do next? A Call the Rapid Response Team. B Obtain vital signs and continue to monitor. C Slow the infusion rate of the transfusion. D Stop the transfusion.

D Stop the transfusion. The client may be experiencing a transfusion reaction; the nurse should stop the transfusion immediately. Calling the Rapid Response Team or obtaining vital signs is not the first thing that should be done. The nurse should not slow the infusion rate, but should stop it altogether.

When caring for a client who receives peritoneal dialysis (PD), which finding does the nurse report to the provider immediately? A Pulse oximetry reading of 95% B Sinus bradycardia, rate of 58 beats/min C Blood pressure of 148/90 mm Hg D Temperature of 101.2° F (38.4° C)

D Temperature of 101.2° F (38.4° C) Peritonitis is the major complication of PD, caused by intra-abdominal catheter site contamination; meticulous aseptic technique must be used when caring for PD equipment. A pulse oximetry reading of 95% is a normal saturation. Although a heart rate of 58 beats/min is slightly bradycardic, the provider can be informed upon visiting the client. Clients with kidney failure tend to have slightly higher blood pressures due to fluid retention; this is not as serious as a fever.

The nurse is transfusing a unit of whole blood to a client when the health care provider requests the following: "Furosemide (Lasix) 20 mg IV push." What does the nurse do? A Add furosemide to the normal saline that is infusing with the blood. B Administer furosemide to the client intramuscularly (IM). C Piggyback furosemide into the infusing blood. D Wait until the transfusion has been completed to administer furosemide.

D Wait until the transfusion has been completed to administer furosemide. Completing the transfusion before administering furosemide is the best course of action in this scenario. Drugs are not to be administered with infusing blood products; they can interact with the blood, causing risks for the client. Stopping the infusing blood to administer the drug and then restarting it is also not the best decision. Changing the admission route is not a nursing decision.

The nurse is caring for a client with neutropenia. Which clinical manifestation indicates that an infection is present or should be ruled out? A Coughing and deep breathing B Evidence of pus C Fever of 102° F or higher D Wheezes or crackles

D Wheezes or crackles Wheezes or crackles in the neutropenic client may be the first symptom of infection in the lungs. Coughing and deep breathing are not indications of infection, but can help prevent it. The client with leukopenia, not neutropenia, may have a severe infection without pus or with only a low-grade fever.

A client is recovering from an above-the-knee amputation resulting from peripheral vascular disease. Which statement indicates that the client is coping well after the procedure? A. "My spouse will be the only person to change my dressing." B. "I can't believe that this has happened to me. I can't stand to look at it." C. "I do not want any visitors while I'm in the hospital." D. "It will take me some time to get used to this.

D. "It will take me some time to get used to this. Acknowledging that it will take time to get used to the amputation indicates that the client is expressing acceptance and effective coping. Stating that the spouse will change the dressing indicates the client does not want to participate in self-care. Expressing disbelief and disgust over the amputation indicates the client is unwilling to address what has happened. The client who does not want to receive visitors is having difficulty coping with the change in body image.

Which nursing action does the nurse on the orthopedic unit plan to delegate to unlicensed assistive personnel (UAP)? A. Remove the wound drain for a client who had an open reduction of a hip fracture 3 days ago. B. Assess for bruising on a client who is receiving warfarin (Coumadin) to prevent deep vein thrombosis. C. Teach a client with a right ankle fracture how to use crutches when transferring and ambulating. D. Check the vital signs for a client who was admitted after a total knee replacement 3 hours ago.

D. Check the vital signs for a client who was admitted after a total knee replacement 3 hours ago. Correct Vital sign assessment is a skill that is within the role of the UAP. Removing a wound drain, assessment, and client teaching are nursing actions that require broader education and are within the scope of practice of licensed nursing staff.

A client is brought to the emergency department via ambulance after a motor vehicle crash. What condition does the nurse assess for first? A. Bleeding B. Head injury C. Pain D. Respiratory distress

D. Respiratory distress The client should first be assessed for respiratory distress, and any oxygen interventions instituted accordingly. Bleeding is the second assessment priority, head injury is the third assessment priority, and pain is the fourth assessment priority in this case.