Critical Care EAQs

The nurse is assessing clients who have sustained submersion injuries. Which are most likely to be the nurse's assessment findings? Select all that apply. 1 Ronchi 2 Areflexia 3 Hypertension 4 Fixed, dilated pupils 5 Cough with pink-frothy sputum

5 Ronchi and cough with pink-frothy sputum are common pulmonary assessment findings in submersion victims. The absence of reflexes is associated with hypothermia, not necessarily submersion. Hypotension, not hypertension, is a common assessment finding associated with submersion injuries. Fixed, dilated pupils are associated with victims of hypothermia.

The nurse is caring for a client with injuries from a bomb blast. Which emergency assessments are performed by the nurse in a primary survey? Select all that apply. 1 Airway 2 Breathing 3 Circulation 4 Focused adjuncts 5 Identify deformities 6 Give comfort measures

1,2,3,5 The primary survey focuses on airway, breathing, circulation (ABC), disability, and exposure or environmental control. Airway, breathing, circulation, and identifying deformities are performed in a primary survey to identify life-threatening conditions to analyze the appropriate interventions. Assessing focused adjuncts and giving comfort measures are performed during a secondary survey.

A client with tongue occlusion has loss of gag reflex and alterations in level of consciousness. The blood gas test shows oxygen saturation as 40mm Hg and carbon dioxide saturation as 75 mm Hg. Which type of support provides immediate relief to the client? 1 Tracheotomy 2 Laryngeal repair 3 Abdominal thrust maneuver 4Autotitrating positive airway pressure

1 Upper airway obstruction may occur with tongue occlusion, which is associated with loss of gag reflex and alterations in the level of consciousness. The client suffering from severe hypoxia (O2 saturation of 40mm Hg) and who is hypercapnic (CO2 saturation of 75 mm Hg) requires an emergency tracheotomy for relief within 2 minutes. Laryngeal repair is performed to prevent laryngealstenosis and to cover exposed cartilage. The abdominal thrust maneuver clears upper airway obstruction caused by a foreign body. Autotitrating positive airway pressure resets the pressure throughout the breathing cycle in a client with severe sleep apnea.

The nurse is caring for a client with peritonitis who had surgery two hours ago due to a ruptured appendix. Which clinical findings should the nurse expect to observe when assessing this client? Select all that apply. 1 Fever 2 Hyperactivity 3 Extreme hunger 4 Urinary retention 5 Abdominal muscle rigidity

1,4,5 The nurse is assessing a client with peritonitis who is also recovering from surgery that occurred two hours ago for a ruptured appendix. The nurse should expect to observe a fever and abdominal muscle rigidity from peritonitis and urinary retention as a complication of surgical anesthesia. A fever is associated with peritoneal membrane inflammation and a moderate fever is also a common post-surgical assessment finding. Abdominal rigidity over the affected area is a classic sign of peritonitis. Malaise, fatigue (not hyperactivity), and nausea (not hunger) are the expected findings with peritonitis and during surgical recovery.

The nurse is performing a rewarming procedure on a client with severe hypothermia by administering warmed intravenous fluids. The nurse carefully monitors the client's core temperature while performing this procedure. What is the lowest temperature at which the nurse will stop the rewarming? 1 86° F (30°C) 2 91.4° F (33°C) 3 96.8° F (36°C) 4 100.4° F (38°C)

2 A rewarming procedure should be performed carefully, because it places the client at risk for after drop, a further drop in core temperature. This can lead to hypotension and dysrhythmias. So, active rewarming should be discontinued once the core temperature reaches 89.6° F to 93.2° F (32° to 34° C). Administering warmed intravenous fluids is a type of active rewarming. Therefore, the nurse will stop this procedure when client's core temperature reaches 92.4° F (33°C). A core temperature of 86° F (30°C) indicates that moderate to severe hypothermia is present. The nurse would continue the rewarming procedure at this temperature. A core temperature of 96.8° F (36°C) is outside the recommended range till which active rewarming should be performed. At this temperature, the client is mildly hypothermic, and an active rewarming procedure is not required. However, this is not the lowest temperature at which the nurse would the active rewarming procedure. A core temperature of 100.4° F (38°C) is in the normal range; the nurse would have stopped the active rewarming procedure long before this temperature is reached.

The nurse is interpreting the client's rhythm strip and finds that the P and QRS waves are consistent, with a P wave preceding every QRS complex. The PR interval is 0.26 seconds long. The rate is 64 beats per minute. How should the nurse interpret this rhythm? 1 Complete heart block 2 Normal sinus rhythm (NSR) 3 Sinus rhythm with first degree AV block 4Sinus rhythm with second degree atrioventricular (AV) block

3 In first degree block, P and QRS waves are consistent in shape. A P wave precedes every QRS complex, which is followed by a T wave. PR interval is prolonged and is greater than 0.20 seconds. NSR reflects normal conduction of the sinus impulse through the atria and ventricles; PR interval is 0.12 to 0.20 seconds. In second degree AV block, QRS may be normal or widened and have at least one or more nonconducted QRS complexes. In third degree AV block, QRS has no relationship with P waves.

A nurse is inserting a gastric tube and arranging for diagnostic studies for a client who sustained injuries after a bus accident. Which type of emergency assessment is being performed? 1 Disability 2 Breathing 3 Focused adjuncts 4 Giving comfort measures

3 Emergency assessment of focused adjuncts is performed in a secondary survey. Inserting a gastric tube and arranging for diagnostic studies are included in this type of assessment. Emergency assessment of disability is performed in a primary survey to identify a client's level of consciousness. Emergency assessment of breathing is performed in a primary survey to identify respiratory distress or any need for mechanical ventilation. Giving comfort measures is performed during the secondary survey to provide emotional support to the client and caregiver.STUDY TIP: Remember that intelligence plays a vital role in your ability to learn. However, being smart involves more than just intelligence. Being practical and applying common sense are also part of the learning experience.