CC Exam 2
The nurse is caring for a patient who is being evaluated clinically for brain death by a primary care provider. Which assessment findings by the nurse support brain death? A. Absence of a corneal reflex B. Unequal, reactive pupils C. Withdrawal from painful stimuli D. Core temperature of 100.8F
A. Absence of a corneal reflex Rationale: Absence of a corneal reflex indicates altered brainstem activity and is a component used in the clinical evaluation of brain death. Reactive pupils, withdrawal reaction to painful stimuli, and the ability to maintain core temperature indicate brainstem activity.
The patient diagnose with acute respiratory distress disorder syndrome (ARDS) would exhibit which symptom? A. Decreasing PaO2 levels despite increased FiO2 administration B. Elevated alveolar surfactant levels C. Increased lung compliance with increased FiO2 administration D. Respiratory acidosis associated with hyperventilation
A. Decreasing PaO2 levels despite increased FiO2 administration Rationale: Patients with ARDS often have hypoxemia refractory to treatment. Surfactant levels are often diminished in ARDS. Compliance decreases in ARDS. In early ARDS, hyperventilation may occur along with respiratory alkalosis.
The family of a critically ill patient has asked to discuss organ donation with the patient's nurse. When preparing to answer the family's questions, the nurse understands which concern(s) most often influence a family's decision to donate? (select all that apply). A. Donor disfigurement influences on funeral care B. Fear of inferior medical care provided to donor C. Age and location of all possible organ recipients D. Concern that donated organs will not be used E. Fear that the potential donor may not be deceased F. Concern over financial costs associated with donation
A. Donor disfigurement influences on funeral care B. Fear of inferior medical care provided to donor E. Fear that the potential donor may not be deceased F. Concern over financial costs associated with donation Rationale: Common fears and concerns that can influence a family's decision to donate include fears of disfigurement of the donor, fear of inferior medical care being provided to the donor in order to hasten the process, fear that the donor may not really be deceased, and concern that the family of the donor
The patient is a 60-year-old with pneumonia. He is admitted with dyspnea, fever, and chills. His blood gas is below: pH: 7.28 paCO2: 56 HCO3: 25 O2sat: 89% What are the treatment goals for this patient? A. Improve both ventilation and oxygenation with bronchodilators and oxygen therapy B. Fluid, antiemetics, and management of electrolyte disorders C. This is a stable condition and requires no treatment D. Treatment would consist of control of diarrhea and bowel rest, as well as IV hydration and electrolytes
A. Improve both ventilation and oxygenation Rationale: The patient has uncompensated respiratory acidosis with mild hypoxemia as a result of his pneumonia. This is due to inadequate ventilation and perfusion. Ventilation may improve with the use of bronchodilators and pulmonary hygiene. If not, the patient may require CPAP, BIPAP, or intubation and mechanical ventilation. Oxygen therapy should consist of only the minimal amount necessary to increase oxygen saturation to >95%.
Which of the following are physiological effects of positive end-expiratory pressure (PEEP) used in the treatment of acute respiratory distress syndrome (ARDS)? (select all that apply). A. Increase functional residual capacity B. Prevent collapse of unstable alveoli C. Improve arterial oxygenation D. Open collapsed alveoli E. Improve venous oxygenation
A. Increase functional residual capacity B. Prevent collapse of unstable alveoli C. Improve arterial oxygenation D. Open collapsed alveoli Rationale: Ventilatory support for ARDS typically includes PEEP to restore functional residual capacity, open collapsed alveoli, prevent collapse of unstable alveoli, and improve arterial NOT venous oxygenation.
The nurse caring is caring for a client with advanced metastatic cancer that has not responded to treatment. The healthcare provider prescribes palliative care only. Which intervention should the nurse withhold? A. Intubation with mechanical ventilation. B. Around-the-clock pain medication. C. Regular diet as tolerated. D. Bronchodilators for shortness of breath.
A. Intubation with mechanical ventilation. Rationale: Palliative care provides clients with comfort measures as they near the end of life. When the healthcare provider prescribes palliative care only, the nurse should withhold life-saving interventions, such as intubation with mechanical ventilation.
The nurse is analyzing an arterial blood gas of a client who is mechanically ventilated. The ABG results are pH 7.32; paCO2 50 mmHg; HCO3 30mEq/liter. How should the nurse interpret this blood gas? A. Partially compensated respiratory acidosis. B. Partially compensated respiratory alkalosis. C. Partially compensated metabolic acidosis. D. Partially compensated metabolic alkalosis.
A. Partially compensated respiratory acidosis. Rationale: The normal arterial blood gas (ABG) levels are pH: 7.35-7.45; paCO2: 35-45 mmHg; HCO3: 22-26 mEq/liter. In partially compensated respiratory acidosis because the pH is not within normal limits, compensation is attempting to correct the pH. In compensation, the opposite of the disorder compensates to bring the pH to normal range. In this case, the HCO3 is elevated to compensate for the paCO2.
Immediately after a patient has been intubated, the nurse assisting with the intubation auscultates over the epigastric area, noting air movement and gurgling. What are the most appropriate interventions? A. Prepare for immediate ET tube removal, hyperoxygenate with 100% oxygen for 3 to 5 minutes, and reattempt intubation because the tube is in the esophagus. B. Immediately pull the tube back 1 to 2 cm, manually bag the patient, and auscultate for bilateral breath sounds because the tube is in the right main stem bronchus. C. Connect the patient to the ventilator after obtaining ventilator settings from the practitioner because the tube is correctly placed. D. Auscultate the chest for bilateral breath sounds, assess for carbon dioxide detection, and order a chest radiograph to confirm the tube is in the correct position.
A. Prepare for immediate ET tube removal, hyperoxygenate with 100% oxygen for 3 to 5 minutes, and reattempt intubation because the tube is in the esophagus. Rationale: Air movement and gurgling over the epigastrium indicate tube placement in the esophagus, which requires immediate removal of the tube and hyperoxygenation to prevent hypoxemia, while preparing for reintubation. Although pulling the tube back corrects right main stem bronchus intubation, the patient will not receive any ventilation or oxygenation if the tube is in the esophagus. Connecting the patient to a ventilator is inappropriate because the patient will not receive any ventilation or oxygenation if the tube is in the esophagus. A tube in the esophagus requires immediate removal of the tube and hyperoxygenation to prevent hypoxemia while preparing for reintubation, which supersedes auscultating for breath sounds, assessing for carbon dioxide detection, and ordering a chest radiograph.
A client in the intensive care unit begins to manifest seizure activity while the unlicensed assistive personnel (UAP) is providing a bedbath. The UAP pulls the emergency call bell and calls for help. Which action by the UAP should the nurse correct? A. Restraining the client's extremities. B. Loosening restrictive clothing. C. Padding the raised side rails. D. Placing the client in a lateral position
A. Restraining the client's extremities. Rationale: A client should be protected as much as possible during seizure activity. The nurse should direct the UAP to refrain from restricting the client's extremities with restraints, which can cause injury to the client and the person who is holding or applying restraints on the client.
The transplant clinic coordinator is evaluating relative of a patient with end-stage renal disease, whose blood type is A positive, for suitability as a living donor for kidney transplantation. Which family member best qualifies for evaluation? A. A 65-year old brother with a history of hypertension; blood type A positive B. A 35-year old female with a history of food allergies; blood type O negative C. A 14-year old son, otherwise healthy with no history; blood type B negative D. A 70-year old mother, with a history of sinus infections; blood type A positive
B. A 35-year old female with a history of food allergies; blood type O negative Rationale: To qualify as a living donor, an individual must be free from hypertension, diabetes, cancer, kidney disease, and heart disease and generally between 18 and 60 years of age. A 35-year old female with a history of food allergies; blood type O negative (universal donor) best qualifies for evaluation. The brother and mother, although blood-type compatible, are outside of acceptable age ranges for living donation. The minor son does not qualify based on blood type.
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 mmHg, heart rate 145 beats/min, respiratory rate 36 breaths/min, oxygen saturation (SpO20 96% on 100% supplemental oxygen by non-rebreather mask. After establishing an intravenous (IV) line, which order should the nurse implement first? A. Obtain stat serum electrolytes B. Administer lorazepam C. Obtain stat portable chest x-ray D. Administer phenytoin
B. Administer lorazepam Rationale: The nurse should administer lorazepam as ordered; lorazepam is the first-line medication for the treatment of status epilepticus. Phenytoin is administered only when lorazepam fails to stop seizure activity or if intermittent seizures persist longer than 20 minutes. Serum electrolytes and chest x-rays are appropriate orders but not in this scenario.
The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine injury who is reporting a severe headache. The nurse assesses a blood pressure of 180/90 mm Hg, heart rate 60 beats/min, respirations 24 breaths/min, and 50 mL of urine via indwelling 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
B. Assess for a kinked urinary catheter and assess for bowel impaction Rationale: 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 infection. Other issues 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. The 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 acute medical nurse is preparing to wean a patient from the ventilator. Which assessment parameter is most important for the nurse to assess? A. Fluid intake for the last 24 hours B. Baseline arterial blood gas (ABG) levels C. Prior outcomes of weaning D. Electrocardiogram (ECG) results
B. Baseline arterial blood gas (ABG) levels Rationale: Before weaning a patient from mechanical ventilation, it is most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the patient is tolerating the procedure. Other assessment parameters are relevant, but less critical. Measuring fluid volume intake and output is always important when a patient is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the patient's record, and the nurse can refer to them before the weaning process begins.
The critical care nurse is providing care for a client diagnosed clinically brain dead and identified as an organ donor. Which are the nurse's priorities in providing care? (Select all that apply.) A. Sustaining a state of hypothermia. B. Maintaining a normal blood pressure. C. Ensuring adequate oxygenation and ventilation. D. Treating any coagulopathy, thrombocytopenia and anemia. E. Monitoring arterial blood gases and serum electrolytes levels.
B. Maintaining a normal blood pressure. C. Ensuring adequate oxygenation and ventilation. D. Treating any coagulopathy, thrombocytopenia and anemia. E. Monitoring arterial blood gases and serum electrolytes levels. Rationale: Once an identified organ donor has been declared clinically brain dead, the primary focus of care changes from preserving life to preserving organ functioning. This is done by maintaining normal blood pressures, fluid levels, electrolytes levels, serum glucose levels, and normothermia. Mechanical ventilation is provided to maintain adequate oxygenation and normal acid-base balance. If needed, pharmaceutical support is provided for the treatment of anemia, coagulopathy, thrombocytopenia, and diabetes insipidus. Physiological changes occur to bodily functions as the result of decreased perfusion within the brain.
The nurse assesses a female client following surgery for a gun shot wound to the abdomen and determined that the dressing is saturated with blood and petechiae on the extremities. Her current BP is 80/40, HR 130 bpm. Which laboratory finding confirms the presence of disseminating intravascular regulation (DIC)? A. Increased levels of BUN B. Positive D-Dimer C. Increased levels of creatinine D. Decreased lactate levels
B. Positive D-Dimer Rationale: D-Dimers are fibrin degradation products or fragments produced during fibrinolysis. A D-dimer will be significantly elevated if a patient is in DIC. Other labs one might consider ordering would include fibrinogen (depressed to normal), platelet count (low), PT/INR (normal to prolonged), and PTT (normal or elevated). Clinical manifestation of organ dysfunction such as Increased levels of creatinine and BUN are indicative of acute tubular necrosis (renal). Decreased level of lactate levels may be a manifestation of lactate acidosis (metabolic).**
A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg.; blood pressure is 144/90 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
C. 90 mm Hg Rationale: CPP = MAP - ICP MAP = (SBP + 2(DBP))/3 In this case, (144 + 2(90))/3 = 108 108 - 18 = 90 CPP = 90 All other calculated answers are incorrect.
What is a strategy for preventing thromboembolism in patients at risk who cannot take anticoagulants? A. Administration of two aspirin tablets every 4 hours B. Infusion of thrombolytics C. Insertion of a vena cava filter D. Subcutaneous heparin administration every 12 hours
C. Insertion of a vena cava filter Rationale: A filter may be inserted as a prevention measure in patients who are at high risk for thromboembolism. Aspirin is not a preventive therapy. Thrombolytics are given to treat, not prevent, pulmonary embolism. Heparin is administered as a prophylaxis in acute care settings. Coumadin is given for long-term prevention in patients at high-risk for VTE.
The client with respiratory failure has been intubated and placed on a ventilator and is requiring 100% oxygen delivery to maintain adequate oxygenation. Twenty-four hours later, the nurse notes new-onset crackles and decreased breath sounds, and the most recent ABGs show a PaO2 level of 95 mm Hg. The ventilator is not set to provide positive end-expiratory pressure (PEEP). Why is the nurse concerned? A. The low PaO2 level may result in oxygen toxicity B. The 100% oxygen delivery requirement indicates immediate extubation C. Lung sounds may indicate absorption atelectasis D. The level of oxygen delivery may indicate absorption atelectasis
C. Lung sounds may indicate absorption atelectasis Rationale: The client's symptoms suggest the development of oxygen toxicity, a condition that can occur when high levels of oxygen (FiO2 > 60%) are administered for prolonged periods (usually more than 24 hours). Oxygen toxicity can lead to the onset of crackles and decreased breath sounds. High levels of oxygen delivery can result in collapsed alveoli and absorption atelectasis. PEEP can help alveoli remain properly inflated. The PaO2 level of 95 mm Hg indicates that the client's oxygenation is adequate, so there is room to decrease the FiO2 level. Lowering the FiO2 level can help prevent further lung damage while still maintaining adequate oxygenation. Extubation is a significant decision that should be based on the client's overall respiratory status, not just the oxygen requirement.
Which acid-base disturbances commonly occurs with the hyperventilation and impaired gas exchange seen in severe exacerbation of asthma and the treatment for acute exacerbation? A. Metabolic Acidosis B. Metabolic Alkalosis C. Respiratory Acidosis D. Respiratory Alkalosis
C. Respiratory Acidosis Rationale: Although the patient with severe exacerbation of asthma hyperventilates, gas exchange is impaired, which causes respiratory acidosis
The nurse is caring for 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 assess 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 primary care provider immediately
D. Notify the primary care provider immediately Rationale: These are classic symptoms of epidural and acute hematomas: injury, lucid period, and progressive deterioration. The primary care provider must be notified of this neurological emergency so appropriate interventions can be implemented. Although elevating the head of the bed, continuous 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
If a patient is accidentally extubated, which of the following actions are appropriate? A. Remain with the patient. B. Assist respirations with bag-valve mask as needed. C. Assess patient for airway patency, spontaneous breathing, and vital signs. D. Prepare for reintubation. E. All of the above
E. All of the above
