Clin Apps Exam #4
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 patients plan of care? (Select all that apply.)
- Make frequent neurological assessments - Maintain MAP less than 130 mm Hg
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?
10,794 mg
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)?
90 mm Hg
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?
Administer drug over 10 minutes
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?
CVP of 2 mm Hg
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?
Monitor BP
The patient is admitted with pancreatitis and has severe ascites. In caring for this patient, the nurse should:
Monitor the patients BP and evaluate for signs of dehydration
The patient is admitted with acute pancreatitis. The nurse should:
evaluate C-reactive protein as a gauge of severity
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?
ICP is high; CPP is normal
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?
Implement droplet precautions upon admission
Pain control is a nursing priority in patients with acute pancreatitis because pain:
Increases pancreatic secretions
The patient is admitted with severe abdominal pain due to pancreatitis. The patient asks the nurse, What causes this? Why does it hurt so much? The nurse should answer:
Injury to certain cells in the pancreas causes it to digest (eat) itself, causing pain
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?
Notify the physician immediately
The patient is admitted with acute pancreatitis and is later diagnosed as having a pseudocyst. The nurse realizes that:
Pseudocysts may resolve spontaneously, so surgery may be delayed
The patient is admitted with acute pancreatitis and is demonstrating severe abdominal pain, vomiting, and ascites. Using the Ranson classification criteria, the nurse determines that this patient:
has a 15% chance of dying
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?
pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg
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.)
- Dolls eyes absent indicate a disruption in normal brainstem processing - Dolls eyes present indicate brainstem activity - Ete movement in the opposite direction as the head when turned indicates an intact reflex - Increased ICP is a CI to the assessment of this reflex - Presence of cervical injuries is a CI to the assessment of this reflex
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.)
- Recording ICP as a mean value - Zero referencing the transducer system
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?
500 mL albumin IV infusion
Trends in nutritional management of the patient with pancreatitis are changing. As a result, the nurse understands that:
Immediate oral feeling in patients with mild pancreatitis may help recovery
The nurse admits a patient to the emergency department (ED) with a suspected cervical spine injury. What is the priority nursing action?
Maintain proper head and neck alignment
While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the patients left naris. What is the best nursing action?
Place a nasal drip pad under the nose
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?
500 mL albumin infusion IV
Which patient being cared for in the emergency department should the charge nurse evaluate first?
A patient with a complete spinal injury at the C5 dermatome level
After receiving the hand-off report from the day shift charge nurse, which patient should the evening charge nurse assess first?
A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104 F
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?
Administer lorazepam (ativan)
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?
Administer over 5 minutes
The nurse is caring for a patient with acute pancreatitis. To provide adequate pain control, the nurse:
Administers pain medication on a routine schedule
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?
Apply a small nasal drip pad
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?
Assess for a kinked urinary catheter and assess for bowel impaction
The nurse is assessing the patient admitted with pancreatitis. In doing so, the nurse:
Assesses symptoms that could indicate involvement of the stomach
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?
Assist the patient to the floor and provide soft head support
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?
Contact the physician
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?
Determine the time of symptom onset
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?
Ensure potency of IV line
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 patients plan of care?
Frequent neurological assessments
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?
Implement seizure precautions
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 patients blood pressure to be 160/90 mm Hg. What is the best action by the nurse?
Increase the does by 2.5 mg/hr
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?
Increased cerebral blood volume due to vessel dilation
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?
Mannitol 1g IV
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?
Monitor the patients airway potency
The nurse is caring for a patient with severe pancreatitis and who is orally intubated and on mechanical ventilation. The patients calcium level this morning was 5.5 mg/dL. The nurse notifies the provider and:
Places the patient on seizure precautions
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?
Provide rest periods between nursing interventions
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)?
Reduce ambient room temperature and administer antipyretics
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?
The patient is exhibiting purposeful movement
