Complex Care Final Exam

A nurse is assessing an adolescent who experienced blunt force trauma to the abdomen. What finding is the nurse's priority -BP 92/50 -HR 72/min -Abdominal pain 4/10

-BP 92/50

In an unconscious patient, eye movements are tested by the oculocephalic response. Which statements regarding the testing of this reflex are true?

-Doll's eyes absent indicate a disruption in normal brainstem processing -Doll's eyes present indicate brainstem activity -Eye movement in the opposite direction as the head when turned indicates an intact reflex -increased ICP is a contraindication to the assessment of this reflex -presence of cervical injuries is a contraindication to the assessment of this reflex

A nurse in the ED is monitoring a client who has a cervical spinal cord injury form a fall. The nurse should monitor the client for which complications?

-Hypotension -absence of bowel sounds -Weakened gag reflex

Fluid resuscitation is an important component of managing the trauma patient. What statements are true regarding the care of a trauma patient?

-IV fluid may need to be warmed to prevent hypothermia -massive transfusions should be avoided to improve patient outcomes -Type O blood can be administered in emergency situations

Trauma patients are at high risk for multiple complications not only due to the mechanism of the injury bur also due to the patients' long-term management. What statements apply to trauma patients?

-Indwelling urinary catheters are a source of infection -Patients often develop infection and sepsis secondary to central line catheters -Pneumonia is often an adverse outcome of mechanical ventilation

Nursing priorities to prevent ineffective coagulation include which of the following?

-Prevention of hypothermia -Administration of fresh frozen plasma as ordered -Administration of calcium as ordered

The nurse is preparing to monitor ICP with a fluid-filled monitoring system. The nurse understands which principles and/or concepts to be essential when implementing ICP monitoring?

-Recording ICP as a "mean" value -Zero referencing the transducer system

During the assessment of a patient after a high-speed motor vehicle crash, which findings would increase the nurse's suspicion of pulmonary contusion?

-chest wall ecchymosis -pink-tinged or blood secretions -signs of hypoxia on room air -fractured ribs

Hypothermia is associated with...

-coagulopathies -dysrhythmias -myocardial dysfunction -reduced tissue perfusion

Which of the following patients would require greater amounts of fluid resuscitation to prevent acute kidney injury associated with rhabdomyolysis?

-crush injury to right arm -lightening strike of the left arm and chest -second degree burns to 40% of the body

Which interventions can the nurse implement to assist the patient's family in coping with the traumatic event

-establish a family spokesperson -ask the family about their normal coping mechanisms -coordinate a family conference -provide an effective communication system between staff and family

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?

-make frequent neurological assessments -maintain MAP less than 130 mm Hg

Which of the following findings require immediate nursing interventions related to the assessment of a patient with a TBI

-mean arterial pressure 48 mm Hg -non-reactive pupils -respiratory rate of 10 breaths per min

Treatment and/or prevention of rhabdomyolysis in at-risk include aggressive fluid resuscitation to achieve how much urine output?

100 mL/hr

Which patient has the greatest risk of developing acute respiratory distress syndrome (ARDS) after a traumatic injury?

A patient who has received large volumes of fluid and/or blood replacement

The nurse receives a patient from the emergency department following a closed head injury. After insertion of an ventriculostomy, the nurse assess the following vital signs: Blood pressure 100/60 mmHg, heart rate 52 beats/min, respiratory rate 24 breaths/min, oxygen saturation 97% on supplemental oxygen at 45% via Venturi mask, GCS score of 4, and intracranial pressure of 18 mm Hg. Which order should the nurse institute first? A. Mannitol 1g intravenous B. Portable chest X-ray C. Seizure precautions D. Ancef 1g intravenous

A. Mannitol 1g intravenous

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 GCS 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 BP of 190/100

A. a patient with a complete spinal injury at the C5 dermatome level ~ risk for ineffective breathing patterns

The nurse is to administer 100mg Phenytoin IV. Vital signs assessed by the nurse include BP 90/60, HR 52, RR 18, O2 99% on supplemental oxygen at 3 L/min by cannula. To prevent complications, what is the best action by the nurse?

Administer over 5 minuets

Which statement best defines the term traumatic injury

Alcohol consumption, drug abuse, or other substance abuse contribute to traumatic events

A nurse in the ED is assessing a newly admitted client who has facial trauma. What is the nurses priority assessment?

Altered respirations

The nurse is caring for a patient admitted to the ED following 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 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 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 responds to a high alert alarm for a patient in the neurological intensive care unit. The nurse arrived 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 caring for a patient admitted with a subarachnoid hemorrhage following surgical repair of the aneurysm. Assessment by the nurse notes BP 90/60, HR 115, RR 28, O2 99% on supplemental oxygen at 3 L/min by cannula, a GCS score of 4, and a CVP of 2mmHG. After reviewing the orders, which order is the highest priority? A. furosemide 20mg IV push as needed B. 500 mL albumin intravenous infusion C. Decadron 10mg IV push D. Dilantin 50mg IV push

B. 500 mL albumin intravenous infusion

Which following injury would result in a greater likelihood of internal organ damage and risk for infection? A. A fall from a 6-foot ladder onto the grass B. A gunshot wound to the abdomen C. A knife wound to the right chest D. A motor vehicle crash in which the driver hits the steering wheel

B. A gunshot wound to the abdomen

The nurse is caring for a patient 5 days following clipping of an anterior communicating artery aneurysm for a subarachnoid hemorrhage. The nurse assess the patient to be more lethargic than the previous hour with a BP 95/50 mm Hg, heart rate 110 beats/min, respiratory rate 20 beats/min, oxygen saturation 95% on 3 L/min oxygen via nasal cannula, and a temperature of 101.5F. Which order should the nurse institute first? A. Blood cultures for temperature >101F B. Acetaminophen 650mg per rectum C. 500mL albumin infusion intravenously D. Decadron 20mg IV push every 4 hours

C. 500mL albumin infusion intravenously ~albumin will allow for volume expansion and prevent vasospasm and ensure cerebral perfusion

The nurse is caring for a patient with an intercranial pressure ICP of 18mm Hg and a GCS score of 3. Following the administration of mannitol, which assessment finding by the nurse requires further action?

CVP of 2 mm Hg

The nurse is preparing to administer a routine dose of phenytoin. The primary care provider orders phenytoin 500mg IV every 6 hours. What is the best action by the nurse?

Contact the pcp to discuss the order

After receiving the hand-off report form 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 vented patient with a GCS of 6 C. A patent with bacterial meningitis on droplet precautions D. A patient with an ICP of 20mmHg and an oral temp of 104F

D. A patient with an ICP of 20mmHg and an oral temp of 104F

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 to assure effective care?

Determine the time of symptom onset

What statement about mass casualty triage during a disaster is true?

Disaster victims with the greatest chances for survival receive priority for treatment

The nurse in trauma unit has received report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?

Evaluate chest expansion

A nurse is caring for a client who has multiple long bone fractures caused by a motor-vehicle crash that happened 24hr ago. The client tells the nurse he is short of breath and experiencing chest pain. The nurse should assess the client further for which of the following potential complications?

Fat embolism syndrome

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 F. The patient is lethargic, responds to voice but falls asleep readily when not stimulated. Which nursing action is the most important to include in this patient's plan of care?

Frequent neurological assessments

A 24-year-old unrestrained driver who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60mm Hg at the scene. What should the primary survey of this patient upon arrival to the ED include?

Getting a baseline assessment and establish priorities

A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in what finding as an indication of adequate fluid replacement?

Heartrate

A nurse is caring for a client who has fractures of the symphysis pubis and pelvis. The nurse should monitor the client for which of the following findings of a common complication of pelvic fractures?

Hematuria

A nurse in the ED is reviewing the medical record of a client who has an extensive burn injury. Which lab result should the nurse expect?

Hyperkalemia ~due to the release of potassium from damages cells

In the trauma unit, what is the most common cause of symptoms of decreased cardiac output?

Hypovolemia

A nurse is caring for a client who has a femur fracture. The nurse suspects that the client has fat embolism syndrome. Which finding should the nurse identify as an early manifestation?

Hypoxemia

While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mm Hg and a CPP of 85mm Hg. What is the best interpretation by the nurse?

ICP is high; CPP is normal

The nurse is caring for a patient admitted with bacterial meningitis. Vital signs assessed by the nurse include BP 110/70, HR 110, RR 30, O2 sat 95% on supplemental oxygen at 3 L/min and a temp of 103.5F. What is the priority nursing action?

Implement seizure precautions

The nurse is caring for 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

A nurse in an emergency room is caring for a client who has sustained partial-thickness burns to bot lower legs, chest, face, and both forearms. What priority action should the nurse take?

Inspect the mouth for signs of inhalation injuries

An 18-year old unrestrained passenger who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60mm Hg at the scene. This patient should be treated at which level trauma center?

Level I

A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nursed priority when assessing the severity of the client's burns?

Location of the burn

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?

Maintain blood pressure

The nurse admits a patient to the emergency department with a suspected cervical spine injury. What is the priority nursing action?

Maintain proper head and neck alignment

A nurse is caring for a client who has had a traumatic head injury and is exhibiting signs of increasing ICP. What med should the nurse plan to administer?

Mannitol 25%

The nurse assesses a patient with a skull fracture and notes a Glasgow Coma Scale score of 3. Additional vital signs assessed by the nurse include blood pressure 100/70 mm Hg, heart rate of 55 beats/min, respiratory rate of 10 breaths/min, oxygen saturation 94% on oxygen at 3 L per nasal cannula. What is the priority nursing action?

Monitor the patient's airway patency

During the treatment and management of the trauma patient, maintaining tissue perfusion, oxygenation, and nutritional support are strategies to prevent what potential complication?

Multisystem organ dysfunction

The nurse is caring for a patient who sustained rib fractures after hitting the steering wheel of a car. The patient is spontaneously breathing and receiving oxygen via face mask; the oxygen saturation is 95%. During the nurse's assessment, the oxygen saturation drops to 80%. The patient's blood pressure had dropped from 128/76 to 84/60. The nurse assesses that the breath sounds are absent throughout the left lung fields. The nurse notifies the physician and anticipates what prescribed intervention?

Needle thoracostomy and chest tube insertion

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 nor conscious upon arrival at the emergency department with a GCS of 15. One hour later, the nurse assesses a GSC score of 3. What is the priority nursing actions ?

Notify the primary care provider immediately

While caring for a patient with a basilar skull fracture, the nurse assess clear drainage form the patient's left naris. What is the best nursing action?

Place a nasal drip pad under the nose

A nurse is having a difficult time inserting a large caliber intravenous catheter to facilitate fluid resuscitation to a hypotensive trauma patient. The nurse recommends which of the following emergency procedures to facilitate rapid fluid administration?

Placement of an intraosseous catheter

When providing information on trauma prevention, it is important to realize that individuals age 25-44 years are most likely to experience which type of trauma incident?

Poisonings from prescription and/or illegal drugs resulting in unintentional injury

The nurse has admitted a patient to the ED following a fall form a first-floor hotel balcony. The patient, 22 years old and smelling of alcohol, begins to vomit. Which intervention is most appropriate?

Prepare to suction the oropharynx while maintaining cervical spine

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 patent 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 temp of 102F. To reduce the risk of increases intracranial pressure in this patient, what are the priority nursing actions?

Reduce ambient room temperature and administer antipyretics

What is an initial symptom of a suspected compartment syndrome?

Severe, throbbing pain in the affected area

A nurse is teaching a client who has a pelvic fracture about manifestations of fat embolism syndrome. The nurse should include what finding as an early manifestation?

Tachypnea

A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming form the client's right nostril. Which action should the nurse take first?

Test the drainage for glucose

Range-of-motion exercises, early ambulation, and adequate hydration are interventions to prevent this common complication observed in trauma patients

Venous thromboembolism

A nurse is admitting a young client who has suspected bacterial meningitis. The nurse should closely monitor the client for increased ICP as indicated by which finding?

Widened pulse pressure

The nurse is caring for a patient admitted to the emergency department in status epilepticus. Vital signs assessed by the nurse include BP 160/100 mmHg, HR 145 beats/min, RR 36 breaths/min, oxygen saturation 96% on 100% supplemental oxygen by non-rebreather mask. After establishing an 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

administer lorazepam ~fist line med for treatment of status epilepticus

The PCP orders fosphenytoin, 1.5g IV loading dose for a 75kg patient in status epilepticus. What is the most important action by the nurse?

administer the drug at a slow infusion rate

The need for fluid resuscitation can be assessed best in the trauma patient by monitoring and trending which of the following tests? a. Arterial oxygen saturation b. Hourly urine output c. Mean arterial pressure d. Serum lactate levels

d. Serum lactate levels

A nurse is caring for a client who has sustained a TBI. The nurse should monitor the client for which of the following manifestations of increased ICP?

decreased level of consciousness

What is the optimal measurement of intravascular fluid status during the immediate fluid resuscitation phase of burn treatment?

hourly intake and urine output

In patients with extensive burns, what process is responsible for edema occurring in both burned and unburned areas?

increased capillary permeability

The nurse has just received a patient from the ED 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?

initiate droplet precautions upon admission

Which intervention is a strategy to prevent fat embolism syndrome?

stabilize extremity fractures early