Chapter 55: PrepU - Nursing Management: Critical Care

A nurse is providing care to a client who is to receive a tube feeding. A nasogastric tube has been inserted. Which method would the nurse anticipate as being used to confirm placement? 1- radiography 2- pH determination of gastric aspirate 3- auscultation of instilled air over stomach 4- evaluation of marking on tube

1

A client is being cared for in the ED. The client is assigned to the triage category of "urgent." How often must the nurse reassess the client? 1- Every 15 minutes 2- Every 30 minutes 3- Every 60 minutes 4- Every 120 minutes

2

A male patient is being treated for acute respiratory distress syndrome (ARDS) in the intensive care unit. The patient has responded favorably to treatment but remains intubated. What nursing action should the nurse take in order to promote his coping ability? 1- Perform education about the etiology of his disease and about future prevention measures. 2- Encourage the patient's participation in decisions around care and treatment. 3- Emphasize positive assessment findings when discussing the patient's health status with him. 4- Perform passive range of motion exercises frequently throughout each shift.

2

A nurse is providing care to an older adult client who has frostbite of the feet. Which action would be least appropriate? 1- Providing an analgesic for pain 2- Massaging the feet 3- Restricting ambulation 4- Placing sterile cotton between the toes after rewarming

2

A patient is brought to the emergency department following an overdose of a selective serotonin reuptake inhibitor (SSRI). While assessing the patient, the nurse suspects that the patient may be developing serotonin syndrome based on which of the following? 1- Hypotension 2- Seizures 3- Lack of perspiration 4- Lethargy

2

When caring for patients with respiratory system failure, the critical care nurse understands that a major health disorder caused by hypoxemic respiratory failure is: 1- Acute respiratory distress syndrome. 2- Pulmonary edema. 3- Chronic bronchitis. 4- Emphysema.

1

The nurse is caring for a client who has been prescribed total parental nutrition (TPN). After several days of receiving TPN, the nurse notes the client is producing increased amount of urinea nd reporting increased thirst and blurred vision. What should be the nurse's initial action? 1- Check the client's blood pressure 2- Assess the client's blood glucose level 3- Ascultate the client's chest 4- Dip the client's urine for urinalysis

2

A patient was bitten by a tick 3 months ago and is now having muscle aches as well as joint pain and swelling. The patient is having difficulty with self care and requires assistance with activities of daily living (ADLs). What stage of Lyme disease does the nurse recognize the patient is in? 1- Stage I 2- Stage II 3- Stage III 4- Stage IV

3

A patient with a brain tumor has been admitted to the critical care unit after developing syndrome of inappropriate antidiuretic hormone hypersecretion (SIADH). In light of this patient's endocrine disorder, what assessments should the nurse prioritize? 1- Potassium levels, blood urea nitrogen (BUN), creatinine 2- Abdominal girth, lung auscultation 3- Sodium levels, urine output 4- Arterial blood gases, level of consciousness

3

The nurse is caring for a client suffering from carbon monoxide poisoning. The nurse will expect the client to exhibit which manifestation? 1- Severe hypertension 2- Hyperactivity 3- Intoxication 4- Cherry red skin coloring

3

A patient in the intensive care unit has had blood work drawn several times over the past 24 hours and the nurse notes that the patient's serum lactic acid level is trending upward. The most recent level is elevated at 5.3 mEq/L. What interpretation should the nurse draw from this assessment finding? 1- The patient is experiencing increased intracranial pressure. 2- Intracellular contents are being released into the patient's vascular space. 3- The patient has developed a systemic infection. 4- The patient is experiencing a deficit in oxygen supply.

4

The nurse is caring for a client who has been in the intensive care unit for 5 days. The nurse is preparing the client to ambulate by having the client sit at the edge of the bed. The nurse notes the client is unable lift the front of the foot and toes upward. What nursing intervention is appropriate based on this assessment? 1- Encourage to the client to stand up and stretch out the foot 2- Massage the anterior surface and toes of the foot 3- Provide the client with an assistive device and encourage ambulation within the room 4- Promote dorsiflexion with a footboard and request a physiotherapy consult

4

A patient is admitted to the ED for the treatment of a large wound to his right leg. After determining that his injuries did not pose an immediate threat to life, the nurse's next priority in treating the wound would be to: 1- Inspect the wound to assess the extent of damage to underlying structures. 2- Cleanse the wound and the surrounding area. 3- Splint the wound in a functional position. 4- Administer tetanus prophylaxis.

1

Which phase of the psychological reaction to rape is characterized by fear and flashbacks? 1- Heightened anxiety phase 2- Acute disorganization phase 3- Denial phase 4- Reorganization phase

1

What is a common source of airway obstruction in an unconscious client? 1- A foreign object 2- Saliva or mucus 3- The tongue 4- Edema

3

A nurse is providing care to the family of a client who was brought to the emergency department and suddenly died. Which of the following would be appropriate for the nurse to do? Select all that apply. 1- Talk with the family about the client having "passed on." 2- Provide sedation to family members as needed. 3- Ask the family if they would like to view the body. 4- Provide a private place for the family to be together. 5- Allow the family to express their emotions freely.

3,4,5

A nurse is establishing a patient's airway. Which action would the nurse perform first? 1- Giving abdominal thrusts 2- Using the jaw-thrust maneuver 3- Inserting an artificial airway 4- Repositioning the patient's head

4

The nurse is caring for a an older adult client recovering from respiratory failure in the intensive care unit. The nurse anticipates the client's will require a diet high in protein due to the risk of which problem related to critical illness? 1- Nitrogen wasting 2- Hypokalemia 3- Renal insufficiency 4- Constipation

1

Which of the following statements would most lead a nurse to suspect that a patient is experiencing food poisoning? 1- "I've been feeling sick to my stomach for about 3 or 4 days now." 2- "The food I ate seemed to look and taste like it should." 3- "My brother got sick like me after eating the same food." 4- "I have a pain in my left side, down low near my groin."

3

A nurse is caring for a client who is experiencing alcohol withdrawal. Which statement best indicates that the client understands the need for long-term treatment? 1- The client agrees to attend supportive counseling. 2- The client agrees to involve his family in psychotherapy. 3- The client agrees to ongoing participation in one or more support groups. 4- The client agrees to detoxification, rehabilitation, and participation in an aftercare program.

4

A patient is being treated in the critical care unit for urosepsis. The patient's level of consciousness has decreased over the past 12 hours, but the nurse is continuing to conduct regularly scheduled pain assessments in the knowledge that: 1- Pain is associated with a consequent decrease in renal function. 2- Pain blunts the patient's awareness of other important signs and symptoms. 3- Pain contributes to hyperglycemia and hypoglycemia. 4- Pain increases the patient's cardiac workload.

4

An 85-year-old client is admitted to the ED. Heat stroke is suspected. The client's core temperature is 106.2°F (41.2°C), blood pressure (BP) 90/60 mm Hg, and pulse 102 bpm. The nurse understands that the primary treatment measure for the client will include 1- administration of sodium supplements. 2- IV hydration with normal saline solution. 3- endotracheal intubation with mechanical ventilation. 4- immersion of the client in a cold-water bath.

4

A critical care nurse should be able to quickly assess a patient's mean arterial pressure (MAP) when monitoring cardiac status. Using the standard formula, estimate the MAP of a patient whose blood pressure is 110/70 mm Hg. 1- 63 mm Hg 2- 73 mm Hg 3- 83 mm Hg 4- 93 mm Hg

3

A nurse is providing care to a critically ill client and is checking the client's urine output every hour. Which measurement would the nurse immediately report to the health care provider? 1- 42 mL 2- 38 mL 3- 30 mL 4- 20 mL

4

A client presents to the ED reporting choking on a chicken bone. The client is breathing spontaneously. The nurse applies oxygen and suspects a partial airway obstruction. Which action should the nurse do next? 1- Encourage the client to cough forcefully. 2- Insert a nasopharyngeal airway. 3- Prepare the client for a bronchoscopy. 4- Insert an oropharyngeal airway.

1

A client undergoes a total abdominal hysterectomy. When assessing the client 10 hours later, the nurse identifies which finding as an early sign of shock? 1- Confusion 2- Pale, warm, dry skin 3- Heart rate of 110 beats/minute 4- Urine output of 30 ml/hour

1

A clinical nurse specialist is conducting an in-service education program for a group of critical care nurses about ways to reduce the incidence of ventilator-associated pneumonia. The nurse specialist determines that the teaching was effective when the group identifies which intervention as being most important? 1- hand washing 2- strict aseptic technique 3- monitoring ETT cuff pressure 4- oral care every shift

1

A critical care nurse is providing care to a client being mechanically ventilated. The low pressure alarm sounds. The nurse would assess for which situation? 1- disconnection from the ventilator 2- biting of the endotracheal tube 3- kinking of the tubing 4- evidence of bronchospasm

1

The nurse has received a client into care who was admitted with a heroin overdose. The client has a 5-year history of illicit substance use with cocaine, heroine and oxycodone. The client develops a sudden onset of wheezing, restlessness and a cough that produces a frothy, pink sputum. The nurse suspects the client has most likely developed which complication of opioid overdose? 1- Pulmonary edema 2- Pneumonia 3- Congestive heart failure 4- Panic attack

1

The nurse is caring for a client who is intubated and receiving mechanical ventilation. The nurse responds to an alarm on the volume-cycled ventilator and finds the high pressure alarm is ringing. Which problem should the nurse expect to find when assessing the patient and equipment? 1- There is a kink in the ventilator tubing. 2- The tubing has disconnected from the machine. 3- The client airway has been displaced. 4- The tubing has disconnected from the endotracheal tube.

1

The nurse is caring for a client with septic shock in the intensive care unit. The nurse assessed a blood pressure of 80/50 mm Hg and heart rate of 48 bpm. Which intravenous medication should the nurse expect will be administered to this client? 1- Dopamine 2- Amiodarone 3- Esmolol 4- Nitroprusside

1

The nurse is caring for a victim of a sexual assault. The client is fearful and experiencing flashbacks. The nurse recognizes that the client is experiencing which phase of the psychological reaction to rape? 1- Heightened anxiety phase 2- Acute disorganization phase 3- Denial phase 4- Reorganization phase

1

The nurse in the hospital emergency department is assessing a patient who fell while intoxicated with alcohol. The nurse is using the Clinical Institute Withdrawal Assessment-Alcohol (CIWA-A) scale to assess the patient's need for a benzodiazipine medication. In order to assess for auditory disturbances, which question should the nurse ask the patient? 1- "Are you hearing anything that is disturbing you?" 2- "Are you experiencing any burning or numbness?" 3- "Are you finding the light is too harsh or bothering your eyes?" 4- "Does it feel like there is a tight band around your head?"

1

The nurse is caring for a client who is agitated and confused. The client is persistently trying to get out of bed and attempted to remove the peripheral IV. The nurse has attempted to re-orient the client; however, this was not effective in de-escalating the client's agitation. The client yells, "I am going to punch you in the face!" What is the nurse's next action? 1- Call security personnel to assist 2- Adminster antipsychotic medication 3- Apply physical restraints 4- Move out of the client's view

1

The nurse has been caring for a client in the intensive care unit for the past three days. The nurse notes the client has progressed to -3 on the Richmond Agitation and Sedation Scale (RASS). Which observation would lead the nurse to document this score? 1- The client opens his eyes when the nurse calls his name 2- The client appears alert but calm 3- The client moves slightly when the nurse rubs his chest 4- The client is trying to remove the peripheral intravenous line

1

The nurse has come on shift to find that a client newly admitted to the ICU is confused and persistently trying to get out of bed despite being comforted and re-oriented by the nurse. The client begins to pull on the peripheral intravenous line in the hand and speaking in non-sensical terms. The client's history indicates a sudden onset of neurological symptoms after developing a bacterial infection. The nurse anticipates providing care for which health problem? 1- Delirium 2- Pain 3- Anxiety 4- Fever

1

A male patient who presented to the emergency department with severe headache and visual disturbances has been found to be experiencing a hypertensive emergency and has been admitted to the critical care unit. The critical care unit should anticipate the administration of which of the following medications? 1- Epinephrine 2- Dopamine 3- Nitroprusside 4- Dobutamine

3

A client is in hypovolemic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's: 1- blood pressure. 2- hemoglobin level. 3- temperature. 4- heart rate.

1

A client present to the ED following a work-related injury to the left hand. The client has an avulsion of the left ring finger. Which correctly describes an avulsion? 1- Tissue tearing away from supporting structures 2- Incision of the skin with well-defined edges, usually long rather than deep 3- Skin tear with irregular edges and vein bridging 4- Denuded skin

1

A homeless client presents to the ED. Upon assessment, the client is experiencing hypothermia. The nurse will plan to complete which priority intervention during the rewarming process? 1- Attach a cardiac monitor 2- Insert a Foley urinary catheter 3- Assist with endotracheal intubation 4- Administer inotropic drugs

1

A client in the ICU is at risk for developing acute kidney injury. Which laboratory test result would the nurse monitor closely for this client? Select all that apply. 1- serum creatinine 2- BUN 3- creatinine clearance 4- LDH 5- AST

1,2,3

The nurse is caring for a client who has just been intubated and started on mechanical ventilation in the intensive care unit. The nurse recognizes that it is possible to inadvertently intubate the right lung only. What nursing assessment and monitoring is required to determine if this complication has occured? Select all that apply. 1- Auscultate both sides of the chest 2- Mark the endotracheal tube at the corner of the mouth and nose 3- Monitor for both high and low pressure alarms 4- Apply suctioning to clear the airway 5- Re-set the ventilator rate as needed

1,2,3

An elderly man has sustained multiple bee stings on his arms, neck, and chest. He went to the ED because of the presence of hives and swelling, which got worse over time. Using the triage system with five levels, his care would be considered: 1- Resuscitative. 2- Emergent. 3- Urgent. 4- Minor.

2

The nurse in the ED is triaging patients during the shift. What does the nurse know is the first priority in treating any patient in the ED? 1- Controlling hemorrhage. 2- Establishing an airway. 3- Obtaining consent for treatment. 4- Restoring cardiac output.

2

A high school football player is brought to the emergency department after collapsing at practice in extremely hot and humid weather. Which of the following would lead the nurse to suspect that the client is experiencing heat stroke? 1- Temperature of 101 degrees F (38 degrees C) 2- Diaphoresis 3- Delirium 4- Bradycardia

3

A nurse is assessing a patient who is suspected of having a partial airway obstruction. Which of the following would the nurse expect to find? 1- Spontaneous coughing 2- High-pitched noises on inhalation 3- Severe respiratory distress 4- Cyanosis

1

A nurse is providing care to a client in the critical care unit who has been on prolonged bed rest. When assessing the client, the nurse notes that the client is unable to lift the anterior surface of the foot and toes upward. The nurse documents this as: 1- footdrop 2- contracture 3- ICU-acquired weakness 4- nitrogen wasting

1

A nurse is providing care to a client in the emergency department and walks into the hallway to get equipment. All of a sudden, gunshots are heard. Which of the following would be the nurse's priority? 1- Protecting himself or herself 2- Securing the area 3- Gaining control of the situation 4- Providing care to the injured

1

A critical care nurse knows to assess the cardiac system for the probable cause of heart disease subsequent to trauma. Which of the following is a major concern? 1- Heart block 2- Pericarditis 3- Cardiac tamponade 4- Mitral regurgitation

3

The nurse is planning care for a ventilated client. When planning interventions to prevent deep vein thrombosis, what should the nurse include? Select all that apply. 1- Administer antiplatelet medications as prescribed 2- Apply compression boots intermittently 3- Dedicate time for passive range-of-motion exercise 4- Discourage visitors to promote bed rest 5- Elevate head of the bed to 30 degrees

1,2,3

A client presents to the ED following a motor vehicle collision. The client is suspected of having internal hemorrhage. The nurse assesses the client for signs and symptoms of shock. Which are signs and symptoms of shock? Select all that apply. 1- Cool, moist skin 2- Decreasing blood pressure 3- Increasing heart rate 4- Delayed capillary refill 5- Increasing urine volume

1,2,3,4

The nurse educator is explaining indications for renal dialysis to a group of nursing students. The students are correct in identifying which indications for starting renal dialysis? Select all that apply. 1- Interim management while awaiting renal transplant 2- Pericardial effusion 3- Hypervolemia unresponsive to diuretics 4- Uremic encephalopathy 5- Neurogenic bladder

1,2,3,4

The nurse is providing care for a client who was admitted to the intensive care unit after suffering cardiovascular collapse secondary to a methamphetamine overdose. The client is semi-conscious and has a nasopharyngeal in place. The nurse anticipates this client may require which interventions? Select all that apply. 1- Provide airway support and ventilation 2- Minimize lights and noise disturbances 3- Apply warming blankets 4- Administer antipsychotic medication 5- Follow the unit seizure protocol

1,2,4,5

A nurse is reviewing the medical record of a critically ill client and determines that the client is at risk for pressure ulcers. Which factor would the nurse most likely identify as placing the client at risk? Select all that apply. 1- malnutrition 2- hemodynamic stabilty 3- history of diabetes 4- intact level of consciousness 5- sensory deficit

1,3,5

A patient arrives at the emergency department after taking more than 20 lorazepam tablets. Which of the following would the nurse anticipate that the patient would be given to reverse the effects of the drug? 1- Naloxone 2- Flumazenil 3- Diazepam 4- N-aceytlcysteine

2

A patient is recovering from a motor vehicle accident, which has necessitated mechanical ventilation in the intensive care unit (ICU). The ICU nurse is aware that multiple nursing diagnoses are associated with mechanical ventilation. Which of the following nursing diagnoses is a consequence of mechanical ventilation? 1- Moral Distress 2- Impaired Verbal Communication 3- Acute Confusion 4- Risk for Imbalanced Body Temperature

2

The nurse educator is providing orientation to a group of nurses newly hired to an intensive care unit. The group of nurses are correct in stating which is the most common type of shock managed in critical care? 1- Anaphylactic 2- Hypovolemic 3- Neurogenic 4- Cardiogenic

2

The nurse is caring for a client who is being prepared for the placement of a central intravenous line. The nurse recognizes this client requires this type of intravenous access for which reason? 1- The client will require intravenous access for three days 2- The client requires total parenteral nutrition 3- The client requires infusion of intravenous antibiotics 4- The client requires infusion of a dextrose 5% water (D5W)

2

The nurse is caring for a patient in the ED who is breathing but unconscious. In order to avoid an upper airway obstruction, the nurse is inserting an oropharyngeal airway. How would the nurse insert the airway? 1- At an angle of 90 degrees 2- Upside down and then rotated 180 degrees 3- With the concave portion touching the posterior pharynx 4- With the convex portion facing upward

2

Which guideline is appropriate for a nurse to implement while helping family members cope with the sudden death of a loved one? Inform the family that the client has passed on. 1- Obtain orders for sedation for family members. 2- Show acceptance of the body by touching it, giving the family 3- permission to touch. 4- Provide details of the factors attendant to the sudden death.

2

A nurse is providing care to a client in the ICU and monitors the client's blood glucose levels four times a day. The nurse anticipates administering insulin therapy based on which blood glucose range for the client? 1- 80 to 100 mg/dL (4.44 to 5.55 mmol/L) 2- 100 to 110 mg/dL (5.55 to 6.11 mmol/L) 3- 120 to 140 mg/dL (6.66 to 7.77 mmol/L) 4- 140 to 180 mg/dL (7.77 to 9.99 mmol/L)

4

A nurse is providing care to a client who is critically ill. The client has an indwelling urinary catheter inserted to evaluate urine output hourly. Which strategy would be most important to reduce the client's risk for catheter-associated urinary tract infection? 1- removing the catheter as soon as possible 2- keeping the catheter drainage bag above the bladder 3- dIsconnecting the catheter from the bag to clean it 4- empyting the drainage bag once per shift

1

A patient arrives at the emergency department after sustaining a gunshot wound to the abdomen. When assessing the patient, the nurse pays particular attention to which of the following? 1- Liver 2- Stomach 3- Large intestine 4- Kidneys

1

A patient brought to the ED by the rescue squad after getting off a plane at the airport is complaining of severe joint pain, numbness, and an inability to move the arms. The patient was on a diving vacation and went for a last dive this morning before flying home. What is a priority action by the nurse? 1- Ensure a patent airway and that the patient is receiving 100% oxygen. 2- Send the patient for a chest x-ray. 3- Send the patient to the hyperbaric chamber. 4- Draw labs for a chemistry panel.

1

An intensive care nurse recognizes that there are numerous factors that contribute to a risk of unstable blood glucose levels in the acutely ill patient. When planning care for patients in the ICU, what goal for blood glucose levels is appropriate for the majority of patients? 1- 80 to 110 mg/dL 2- 95 to 115 mg/dL 3- 105 to 130 mg/dL 4- 20 to 145 mg/dL

1

An older adult patient has been admitted to the intensive care unit with urosepsis. As a consequence of this infection, the patient is experiencing low levels of cortisol. What sequela of low cortisol should the nurse anticipate when planning this patient's care? 1- Low body temperature 2- Confusion 3- Hypertension 4- Increased intracranial pressure

1

A nurse is assigned to care for a 75 kg male patient on a high-frequency, volume-cycled ventilator that delivers very small tidal volumes (3 to 6 mL/kg). The nurse is responsible for monitoring the ventilator. What is the correct tidal volume delivery for a 75 kg patient? 1- <200 mL 2- 200 to 400 mL 3- 225 to 450 mL 4- >500 Ml

3

A nurse is caring for a client who has arrived at the emergency department in shock. The nurse intervenes based on the knowledge that which of the following is the most common cause of shock? 1- Anaphylaxis 2- Sepsis 3- Hypovolemia 4- Cardiac dysfunction

3

A patient is brought to the emergency department after being locked outside of her house in the frigid weather for several hours. The nurse suspects that the patient has sustained frostbite of her hand based on which of the following findings? 1- Hand that appears pink with some white spotting 2- Hand that is firm to palpation 3- Hand that is insensitive to touch 4- Hand that is cool with pale nailbeds

3

A patient presented to the emergency room with gunshot wounds to the abdomen and right thigh. The trauma nurse documented a positive Kehr's sign. Based on the diagnosis, the nurse knows to report the possibility of: 1- Acute pancreatitis. 2- Damage to the small bowel. 3- A ruptured spleen. 4- Liver laceration.

3

A patient suffered a brain stem injury in an assault and is currently receiving controlled mandatory ventilation (CMV) in the intensive care unit. When conducting the scheduled assessments of this patient, the nurse should be aware of which of the following characteristics of CMV? 1- The patient breathes spontaneously, but a set tidal volume is delivered. 2- Oxygen supplementation is constantly adjusted by the ventilator in response to the patient's respiratory rate. 3- The patient's tidal volume is determined spontaneously, but the respiratory rate is controlled by CMV. 4- The rate and tidal volume are set, and the patient does not breathe spontaneously.

4

In order to meet her nutritional needs while being treated for a traumatic brain injury, a patient in the intensive care unit has had a percutaneous endoscopic gastrostomy (PEG) tube placed. What nursing responsibility related to this intervention should the nurse prioritize? 1- Teaching the patient's family to manage the PEG tube and the patient's feedings 2- Administering a hypertonic solution between feedings 3- Aspirating gastric contents 15 minutes after each feeding 4- Confirming tube placement on a regular basis

4

The nurse is caring for a client with diabetes who requires a peripheral intravenous (PIV) line for antibiotic administration and to treat dehydration. The nurse must avoid inserting which type of PIV? 1- Forearm 2- Hand 3- Foot 4- Upper arm

3

In recent days, a female patient on the critical care unit has developed diarrhea and has begun to experience skin breakdown in her perineal area. How should the nurse first respond to this development? 1- Attempt to identify the specific causes of the patient's diarrhea. 2- Advocate for a change in the patient's diet orders. 3- Ask the primary care provider to prescribe loperamide as needed. 4- Obtain an order for a rectal tube.

1

The intensive care unit nurse has just assumed care for an intubated client who has a previous history of gastric stress ulcer. The nurse should expect to see which medication on this client's medication administration record? 1- Ranitidine 2- Loperamide 3- Simethicone 4- Aluminum hydroxide

1

The intensive care unit nurse is assessing a client who is going to require a peripheral intravenous (PIV) line for fluids. The nurse should consider what information in the client's health history when deciding the site for the PIV? 1- The client has had a mastectomy on the right side 2- The client has hypertension 3- The client has a fluid volume restriction 4- The client has a history of falls

1

The intensive care unit nurse is caring for a client who has severe brain injury with no neurolgical drive to breathe. This client would receive which type of mechanical ventilation? 1- Controlled mandatory ventilation (CMV) 2- Assist control (AC) 3- Synchronized intermittent mandatory ventilation 4- High-frequency ventilation (HFV)

1

The nurse is caring for a client in the ED following a sexual assault. The client is hysterical and crying. The client states, "I know I'm pregnant now, maybe I have HIV. Why did this happen to me?" Which is the best response by the nurse? 1- "Let's talk about this. Do you want me to call a support person?" 2- "Do you want to discuss antipregnancy measures?" 3- "Do you want the phone number for the National Sexual Assault Hotline?" 4- "Would you like us to complete HIV testing?"

1

The nurse is providing care to a client who will be ambulating for the first time after being extubated. The client tells the nurse, "I don't want to do this today. It's too soon and I am afraid I am not strong enough." What intervention should the nurse implement first for the client's fear of falling? 1- Explore possible causes of the client's fear 2- Evaluate the client for cognitive impairment 3- Allow the client to remain on bedrest 4- Clear the area around the bed

1

The nurse is admitting a client into the intensive care unit after cardiac surgery. The nurse notes the client has temporary pacemaker wires surgically placed of into the middle lining of the heart. The nurse knows the client has which type of pacemaker? 1- External pacemaker 2- Transvenous pacemaker 3- Epicardial pacemaker 4- Transthoracic cardiac pacemaker

3

Continuous positive airway pressure (CPAP) has been ordered for a patient in the intensive care unit in an effort to defer intubation. The respiratory therapist has set up the patient's CPAP system and the nurse is now responsible for maintaining the system. When assessing the function of the patient's CPAP, the nurse should ensure that: 1- Suction is set between 30 and 45 mm Hg. 2- The patient receives nebulized bronchodilators every 2 to 3 hours. 3- A tight seal exists between the mask and the patient's mouth. 4- The patient is breathing between 30 and 40 breaths per minute.

3

The nurse has commenced a transfusion of fresh frozen plasma (FFP) and notes the client is exhibiting symptoms of a transfusion reaction. After the nurse stops the transfusion, what is the next required action? 1- Remove the peripheral IV line 2- Start a dextrose 5% water infusion 3- Run a normal saline line to keep the vein open 4- Obtain a blood culture from the IV insertion site

3

The nurse is caring for a client who is receiving nutrition through a nasogastric tube. How should the nurse position the client after a bolus feeding has been completed? 1- In a supine position with bedrails raised 2- In a prone position with knees to chest 3- With legs elevated on a 45-degree angle 4- With head of the bed elevated to 30 degrees

4