Critical Care Final Exam Practice Questions

d

Decerebrate posturing (abnormal extension) indicates dysfunction in which area of the central nervous system? a. Cerebral cortex b. Thalamus c. Cerebellum d. Brainstem

b,d

During a physical assessment, a client was diagnosed with increased temperature due to an increased basal metabolic rate (BMR). Which hormonal imbalances may the client have? (Select all that apply). a. Cortisol b. Thyroid c. Estrogen d. Testosterone e. Progesterone

c

Four clients who sustained head injuries are presented below. Which client has the least score on the Glasgow coma scale? a. Client A b. Client B c. Client C d. Client D

a

How much of a size difference between the two pupils is still considered normal? a. 1 mm b. 1.5 mm c. 2 mm d. 2.5 mm

1,3,4,5

In assessing the priority of client needs in an emergency situation, the nurse performs primary assessment first and then secondary assessment. What subjective and objective data are obtained by the nurse in a secondary assessment? Select all that apply. 1.Pain assessment 2.Airway assessment 3.Client medical history 4.Vital sign measurements 5.Neurological assessment 6.Cervical spine assessment

b

Motor vehicle crashes (MVCs) and falls are the greatest cause of a. spinal shock. b. blunt thoracic trauma. c. maxillofacial injuries d. penetrating thoracic injuries.

c

Signs and symptoms associated with a flail chest include a. tracheal deviation toward the unaffected side. b. jugular venous distention. c. paradoxical respiratory movement. d. respiratory alkalosis.

d

Studies have shown that the intraparenchymal catheter has a better result than the intraventricular catheter. Identify the answer that supports this statement. a. The intraparenchymal catheter allows for CSF drainage. b. The intraparenchymal catheter has increased monitoring time. c. The intraparenchymal catheter has a longer insertion time for monitoring ICP. d. The intraparenchymal catheter has decreased device-related complications.

d

The Code of Ethics for Nursing provides a framework for the nurse in ethical decision making and a. is usurped by state or federal laws. b. allows the nurse to focus on the good of society rather than the uniqueness of the client. c. was recently adopted by the American Nurses Association. d. provides society with a set of expectations of the profession.

d

The GCS is an invalid measure for the patient with a. hemiplegia. b. Parkinson disease. c. mental retardation. d. intoxication.

1

The client arrives at the emergency department, and emergency response personnel inform the nurse that the client is a victim from a burning building. Which assessment finding is a priority for the nurse to address? 1.Singed nasal hair with a hoarse voice 2.Moist, reddened skin that blanches on the face 3.Dry, reddened skin on legs, reporting pain of 10 4.Heart rate 110 beats/min, blood pressure 140/90 mm Hg

4

The client is brought from a burning building and has hard, leathery, black skin over the entire chest and both arms. What is the client's primary need in the emergency department? 1.Analgesics 2.Debridement 3.Tetanus immunization 4.Intravenous (IV) fluids

3

The family of a client with a spinal cord injury rushes to the nursing station, saying that the client needs immediate help. On entering the room, the nurse notes that the client is diaphoretic with a flushed face and neck and is complaining of a severe headache. The pulse rate is 40 beats/minute, and the blood pressure is 230/100 mm Hg. The nurse acts quickly, suspecting that the client is experiencing which condition? 1.Spinal shock 2.Pulmonary embolism 3.Autonomic dysreflexia 4.Malignant hyperthermia

4

The nurse assigned to the pediatric unit finds an infant unresponsive and without respirations or a pulse. What is the nurse's next action after calling for help? 1.Check for carotid pulse. 2.Call anesthesia for intubation. 3.Begin rescue breathing with head tilt-chin lift. 4.Perform compressions at 100 to 120 times per minute.

2

The nurse caring for a client with a chest tube turns the client to the side and the chest tube accidentally disconnects from the water seal chamber. Which initial action should the nurse take? 1.Call the health care provider (HCP). 2.Place the tube in a bottle of sterile water. 3.Replace the chest tube system immediately. 4.Place a sterile dressing over the disconnection site.

2

A client is being weaned from parenteral nutrition (PN) and is expected to begin taking solid food today. The ongoing solution rate has been 100 mL/hour. The nurse anticipates that which prescription regarding the PN solution will accompany the diet prescription? 1.Discontinue the PN. 2.Decrease PN rate to 50 mL/hour. 3.Start 0.9% normal saline at 25 mL/hour. 4.Continue current infusion rate prescriptions for PN.

4

A client who sustained a smoke inhalation injury arrives in the emergency department. On assessment, the nurse notes that the client is very confused and combative. The nurse determines that the client is experiencing which problem? 1.Pain 2.Fear 3.Anxiety 4.Hypoxia

c

A client who was in a motor bike accident has a severe neck injury. Which priority nursing care is most needed? a. Assessing for crepitus b. Assessing for bleeding c. Maintaining a patent airway d. Performing neurologic assessment

a

The nurse is providing postprocedure care to a client who had a cardiac catheterization. The client begins to manifest signs and symptoms associated with embolization. Which action should the nurse take? a. Notify the primary healthcare provider immediately b. Apply a warm, moist compress to the incision site c. Increase the intravenous fluid rate by 20 mL/hr d. Monitor vital signs more frequently

1

The nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead, there are fibrillatory waves before each QRS complex. How should the nurse correctly interpret the client's heart rhythm? 1.Atrial fibrillation 2.Sinus tachycardia 3.Ventricular fibrillation 4.Ventricular tachycardia

d

The nurse notes that the client's drainage has decreased from 50 to 5 mL/hr 12 hours after chest tube insertion for hemothorax. What is the best initial action for the nurse to take?Select an option, then click Submit. A.Document this expected decrease in drainage. B.Clamp the chest tube while assessing for air leaks. C.Milk the tube to remove any excessive blood clot buildup. D.Assess for kinks or dependent loops in the tubing.

c

In assessing a client with an arteriovenous (AV) shunt who is scheduled for dialysis today, the nurse notes the absence of a thrill or bruit at the shunt site. What action should the nurse take?Select an option, then click Submit. A.Advise the client that the shunt is intact and ready for dialysis as scheduled. B.Encourage the client to keep the shunt site elevated above the level of the heart. C.Notify the health care provider of the findings immediately. D.Flush the site at least once with a heparinized saline solution.

a

In the ethical decision-making process, after the identification of alternative options has been established, a. an outcome for each action must be predicted. b. the team must determine which options to present to the patient or family. c. the choice of one option compromises the option not chosen. d. "no action" is not an option in this step of the decision-making process.

2

A cardiac monitor alarm sounds, and the nurse notes a straight line on the monitor screen. The nurse should take which action first? 1.Call a code. 2.Assess the client. 3.Call the primary health care provider. 4.Obtain a rhythm strip from the monitor device.

b

A 25-year-old client was admitted yesterday after a motor vehicle collision. Neurodiagnostic studies have shown a basal skull fracture in the middle fossa. Assessment on admission revealed both halo and Battle signs. Which new symptom indicates that the client is likely to be experiencing a common life-threatening complication associated with a basal skull fracture?Select an option, then click Submit. A.Bilateral jugular venous distention B.Oral temperature of 102° F C.Intermittent focal motor seizures D.Intractable pain in the cervical region

d

A nurse is caring for a client who sustained a transection of the spinal cord with no other injuries. The nurse continually monitors this client for which medical emergency? a. Hemorrhage b. Hypovolemic shock c. Gastrointestinal atony d. Autonomic hyperreflexia

a

A patient with multisystem trauma has been in the ICU for 6 days after sustaining a closed head injury, a right-sided pneumothorax, right rib fractures, a grade IV liver laceration, a pancreatic contusion, and a right acetabular fracture. The patient is still intubated and mechanically ventilated and has a chest tube, Foley catheter, and two abdominal drains. The patient's hemodynamic assessment reveals the following values: BP, 94/66 mm Hg; HR, 118 beats/min; T, 38.7° C; CVP, 5 cm H2O; wedge pressure, 6 mm Hg; cardiac index, 6.1; and systemic vascular resistance, 450 dynes/sec. What is the most likely cause of this hemodynamic picture? a. Septic shock b. Hemorrhagic shock c. Cardiogenic shock d. Neurogenic shock

c

A score of 6 on the Glasgow Coma Scale (GCS) indicates a. a vegetative state. b. paraplegia. c. coma. d. obtundation.

b

An oval pupil is indicative of a. cortical dysfunction. b. intracranial hypertension. c. hydrocephalus. d. metabolic coma.

a

Before performing the doll's eye or oculocephalic reflex, the nurse must verify a. the absence of cervical injury. b. the depth and rate of respiration. c. a physician's order to perform the maneuver. d. the patient's ability to follow a verbal command.

a

During assessment of a client in the intensive care unit, the nurse notes that the client's breath sounds are clear on auscultation, but jugular vein distention and muffled heart sounds are present. Which intervention should the nurse implement?Select an option, then click Submit. A.Prepare the client for a pericardial tap. B.Administer intravenous furosemide (Lasix). C.Assist the client to cough and breathe deeply. D.Instruct the client to restrict oral fluid intake.

2

The nurse has developed a nursing care plan for a client with a burn injury to implement during the emergent phase. Which priority intervention should the nurse include in the plan of care? 1.Monitor vital signs every 4 hours. 2.Monitor mental status every hour. 3.Monitor intake and output every shift. 4.Obtain and record weight every other day.

2

The client has a T3 spinal cord injury and is brought to the emergency department. The nursing assessment reveals blood pressure 70/40 mm Hg, pulse 50 beats/min, and respirations 18 breaths/min, and the nurse suspects neurogenic shock. The client's skin is warm, dry, and pink. What action should the nurse prepare to take first? 1.Assess cranial nerves X and XI. 2.Administer intravenous isotonic fluids. 3.Place the client in Trendelenburg's position. 4.Perform a Glasgow Coma Scale assessment.

3

The client is admitted to hospital with unstable angina. The nurse who is monitoring the client's cardiac rhythm notes this rhythm on the cardiac monitor. Refer to Figure. The client is anxious and reports tight chest pain that radiates to the left arm and jaw. Which as-needed prescribed medication should the nurse plan to administer first? 1.Metoprolol 2.Alprazolam 3.Nitroglycerin 4.Morphine sulfate

1

The client with a spinal cord injury at level C4 is brought to the emergency department. What is the priority nursing assessment? 1.Respiratory effort 2.Rectal temperature 3.Level of intact sensation 4.Glasgow Coma Scale (GCS) score

1

The nurse reviews the assessment data on a client with a head injury and notes that the client's intracranial pressure reading is 10 mm Hg. Based on this finding, the nurse determines that the client's intracranial pressure reading indicates which finding? 1.Is normal 2.Is elevated 3.Requires primary health care provider notification 4.Needs to be reduced with aggressive treatment measures

2

The unstable client in the cardiac care unit has sustained runs of a cardiac dysrhythmia. When cardioversion fails to normalize the rhythm (refer to figure), the nurse most appropriately prepares to assist in the administration of which medication? Refer to Figure. 1.Digoxin, a cardiac glycoside 2.Amiodarone, a class III antidysrhythmic medication 3.Propranolol, a class II antidysrhythmic medication and beta blocker 4.Verapamil, a class IV antidysrhythmic medication and calcium channel blocker

a,b,e

The nurse is caring for a client who was just admitted to the hospital with the diagnosis of head trauma. Which clinical indicators should the nurse consider as evidence of increasing intracranial pressure? (Select all that apply). a. Vomiting b. Irritability c. Hypotension d. Increased respirations e. Decreased level of consciousness

b

The nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which is the priority concern of the nurse when caring for this client? a. Fluid volume b. Skin integrity c. Physical mobility d. Urinary elimination

a

The nurse is caring for a client with a spinal cord injury. Which assessment findings alert the nurse that the client is developing autonomic hyperreflexia (autonomic dysreflexia)? a. Hypertension and bradycardia b. Flaccid paralysis and numbness c. Absence of sweating and pyrexia d. Escalating tachycardia and shock

b

The nurse is caring for different clients in a mass casualty event. Which client is assigned the lowest priority for care? a. Client with red tag b. Client with black tag c. Client with green tag d. Client with yellow tag

a,b,c

The nurse is teaching a client who underwent a hypophysectomy for hyperpituitarism about self-management. Which actions performed by the client could cause complications on the second post-operative day? (Select all that apply). a. Nose blowing b. Teeth brushing c. Bending forward d. Breathing through the mouth e. Lying in a semi-Fowler's position

d

The oculovestibular reflex, or cold caloric test, a. should not be performed on an unconscious patient because of the risk of aspiration. b. has an abnormal response of rapid nystagmus-like deviation to the side of the body that is tested. c. is a routine test of the nursing neurologic examination. d. is one of the final clinical assessments of brainstem function.

a

The osmotic diuretic that has been most effective in the reduction of increased ICP is a. mannitol. b. furosemide (Lasix). c. urea. d. glycerol.

b

The patient is ordered a CT scan with contrast. Which question should the nurse ask the conscious patient before the procedure? a. Are you allergic to penicillin? b. Are you allergic to iodine-based dye? c. Are you allergic to latex? d. Are you allergic to eggs?

b

The patient's ICP reading has gradually climbed from 15 to 23 mm Hg. The nurse's primary action is to: a. drain off 7 mm of CSF from the catheter. b. notify the physician. c. place the patient in a high Fowler position to decrease the pressure. d. check level of consciousness.

d

The target range for PaCO2 when using hyperventilation to lower ICP is a. 25 to 30 mm Hg. b. 25 to 35 mm Hg. c. 35 to 40 mm Hg. d. 35 ± 2 mm Hg.

2

The nurse notes this cardiac rhythm on a client's monitor and prepares for which action first? Refer to Figure. 1.Checks for breathing 2.Defibrillates the client 3.Palpates for a carotid pulse 4.Checks for patency of the airway

4

A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client? 1.100% oxygen via an aerosol mask 2.Oxygen via nasal cannula at 6 L/minute 3.Oxygen via nasal cannula at 15 L/minute 4.100% oxygen via a tight-fitting, nonrebreather face mask

b

Which of the following is the most common complication after high-dose barbiturate therapy? a. Hypothermia b. Hypotension c. Myocardial depression d. Decreased CVP

c

A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. Which are the priority nursing assessments? a. Level of consciousness and pupil size b. Characteristics of pain and blood pressure c. Quality of respirations and presence of pulses d. Observation of abdominal contusions and other wounds

d

Which nursing action is necessary for the client with a flail chest?Select an option, then click Submit. A.Withhold prescribed analgesic medications. B.Percuss the fractured rib area with light taps. C.Avoid implementing pulmonary suctioning. D.Encourage coughing and deep breathing.

d

A 74-year-old male client is admitted to the intensive care unit (ICU) with a diagnosis of respiratory failure secondary to pneumonia. Currently, he is ventilator-dependent, with settings of tidal volume (VT) of 750 mL and an intermittent mandatory ventilation (IMV) rate of 10 breaths/min. Arterial blood gas (ABG) results are as follows: pH, 7.48; PaCO2, 30 mm Hg; PaO2, 64 mm Hg; HCO3, 25 mEq/L; and FiO2, 0.80. Which intervention should the nurse implement first?Select an option, then click Submit. A.Increase the ventilator VT to 850 mL. B.Decrease the ventilator IMV to a rate of 8 breaths/min. C.Reduce the FiO2 to 0.70 and redraw ABGs. D.Add 5 cm positive end-expiratory pressure (PEEP).

b

A patient is admitted to the ICU with a C5-C6 subluxation fracture. He is able to move his legs better than he can move his arms. Caring for the patient would include which of the following interventions? a. Keeping the room cool, dark, and quiet b. Administering intravenous methylprednisolone for the first 24 hours after the injury c. Elevating the head of the bed 45 degrees d. Resuscitating low blood pressure by only using intravenous fluid

d

A patient is admitted to the ICU with a C5-C6 subluxation fracture. He is able to move his legs better than he can move his arms. Which of the following statements is true about his spinal cord injury? a. He is likely to be in supraventricular tachycardia. b. Hyperthermia is common in patients with spinal cord injury. c. These patients do not usually require mechanical ventilation. d. The patient has a central cord syndrome.

a

A patient is admitted to the critical care unit with a subdural hematoma. The GCS is used to assess his level of consciousness. In assessing the patient's best motor response, the movement that receives the lowest score is a. decerebrate posturing. b. localizing pain. c. withdrawing from pain. d. decorticate posturing.

a

A patient was thrown 30 feet from an open-top Jeep and straddled a row of mailboxes before she landed on the ground. She has an open pelvic fracture. The nurse admitting the patient into the ICU knows that a. aggressive fluid and blood replacement will probably be needed. b. the patient will probably be able to walk as soon as she is hemodynamically stable. c. she will probably not need surgery to stabilize her fracture. d. there is little likelihood of damage to the genitourinary or gastrointestinal tracts.

a

A patient who was an unrestrained driver in a high-speed, head-on motor vehicle collision presents with dyspnea, tachycardia, hypotension, jugular venous distention, tracheal deviation to the left, and decreased breath sounds on the right side. What is the most likely diagnosis? a. Tension pneumothorax b. Cardiac tamponade c. Simple pneumothorax d. Ruptured diaphragm

c

Critical care nurses can best enhance the principle of autonomy by a. presenting only the information to prevent relapse in a patient. b. assisting with only tasks that cannot be done by the patient. c. providing the patient with all of the information and facts. d. guiding the patient toward the best choices for care.

a

During assessment of a patient who is new to the critical unit, the nurse observes perianal ecchymosis. The nurse suspects the patient has a a. pelvic fracture. b. bladder trauma. c. rectal laceration. d. spleen laceration.

a

Fidelity includes faithfulness and promise-keeping to clients, and it incorporates the added concepts of a. confidentiality and privacy. b. truth and reflection. c. autonomy and paternalism. d. beneficence and nonmaleficence.

4

The nurse monitors the client receiving parenteral nutrition (PN) for complications of the therapy and should assess the client for which manifestations of hyperglycemia? 1.Fever, weak pulse, and thirst 2.Nausea, vomiting, and oliguria 3.Sweating, chills, and abdominal pain 4.Weakness, thirst, and increased urine output

d

Initially after a stroke, a client's pupils are equal and reactive to light. Later, the nurse assesses that the right pupil is reacting more slowly than the left and that the systolic blood pressure is beginning to rise. What complication should the nurse consider that the client is developing? a. Spinal shock b. Hypovolemic shock c. Transtentorial herniation d. Increasing intracranial pressure

b

Institutional ethics committees (IECs) review ethical cases that are problematic for the practitioner. Major functions of IECs include a. consultation with purely binding recommendations. b. support and education to health care providers. c. conflict resolution for moral dilemmas. d. recommendations that are binding in all cases.

1

The nurse is developing a nursing care plan for a client with a circumferential burn injury of the right arm. What is the nurse's priority action? 1.Monitor the radial pulse every hour. 2.Keep the extremity in a dependent position. 3.Document any changes that occur in the pulse. 4.Place pressure dressings and wraps around the burn sites.

1,3,5

The client is scheduled for coronary artery bypass grafting (CABG) in 7 days. The nurse should discuss with the cardiac surgeon the continued administration of which medications if prescribed for preoperative clients? Select all that apply. 1.Clopidogrel 2.Torsemide 3.Enoxaparin 4.Propranolol 5.Acetylsalicylic acid

1

The nurse is developing a plan of care for a client who sustained an inhalation burn injury. Which nursing intervention should the nurse include in the plan of care for this client? 1.Elevate the head of the bed. 2.Monitor oxygen saturation levels every 4 hours. 3.Encourage coughing and deep breathing every 4 hours. 4.Assess respiratory rate and breath sounds every 4 hours.

2

The client with full-thickness burns over 50% of the total body surface is brought to the emergency department. Rapid infusion of intravenous normal saline is started. What is the best indication that the client has adequate hydration? 1.Presence of tears 2.Urine output of 40 mL/hr 3.Moist mucous membranes 4.Capillary refill less than 2 seconds

a

The difference between ethics and morals is that ethics a. is more concerned with the "why" of behavior. b. provides a framework for evaluation of the behavior. c. is broader in scope than morals. d. concentrates on the right or wrong behavior based on religion and culture values.

4

The emergency department nurse is assessing a client who sustained a blunt chest injury and suspects the presence of flail chest. Which specific characteristic finding would the nurse note in this condition? 1.Anxiety 2.Loss of consciousness 3.Slow deep respirations 4.Asymmetrical chest movement

a

The most clinically significant ICP waveform is a. A waves. b. B waves. c. C waves. d. D waves.

b

The nurse observes ventricular fibrillation on telemetry and, on entering the client's bathroom, finds the client unconscious on the floor. Which intervention should the nurse implement first?Select an option, then click Submit. A.Administer an antidysrhythmic medication. B.Start cardiopulmonary resuscitation. C.Prepare for mechanical ventilation. D.Assess the client's pulse oximetry.

3

The nurse overhears a health care provider (HCP) stating that a client diagnosed with disseminated intravascular coagulation (DIC) requires a transfusion. Which blood product should the nurse anticipate that the HCP will write a prescription for? 1.Albumin 2.Platelets 3.Cryoprecipitate 4.Packed red blood cells

4

The nurse performs an electrocardiogram (ECG) on a client and notes this cardiac rhythm (see figure). The nurse further analyzes the rhythm and notes a regular R-R interval, a rate of 65 beats/min, and a P-R interval of 0.20 second. How should the nurse identify this rhythm? Refer to Figure. 1.Atrial fibrillation 2.Sinus tachycardia 3.Sinus bradycardia 4.Normal sinus rhythm

a

The nurse uses the Glasgow Coma Scale to assess a client with a head injury. Which Glasgow Coma Scale score indicates that the client is in a coma? a. 6 b. 9 c. 12 d. 15

c

Values clarification can assist the client to clarify his or her own values to facilitate effective decision making. Which of the following nursing activities is incorporated into this intervention? a. Avoid the use of open-ended questions. b. Use multiple sessions to cross-examine the client to ensure he or she is clear about personal values. c. Use appropriate questions to assist the client in reflecting on the situation and what is personally important. d. Encourage members of the health care team to relate how they would make the decision.

c

When a nurse assesses a client receiving total parenteral nutrition (TPN), which laboratory value is most important for the nurse to monitor regularly?Select an option, then click Submit. A.Albumin B.Calcium C.Glucose D.Alkaline phosphatase

c

Which of the following statements is true about a patient with a blunt cardiac injury/cardiac contusion? a. It will probably be diagnosed by pericardiocentesis. b. Hemodynamic parameters will most likely show a low cardiac output and low systemic vascular resistance. c. Treatment can require insertion of a temporary pacemaker for conduction control. d. The only accurate way to evaluate cardiac contusion is to check the creatine phosphokinase fraction.

d

Which of the following will cause a nurse to suspect that a patient's pulmonary contusion is worsening? a. A pulmonary artery catheter showing a central venous pressure of 6 cm H2O and a wedge pressure of 8 mm Hg b. An increased need for pain medication c. An arterial blood gas value that demonstrates respiratory alkalosis d. Increased peak airway pressures on the ventilator

c

Which patient position is optimal to prevent elevated ICP pressures? a. The head of the bed elevated 30 to 40 degrees b. Supine with the patient's neck in a neutral alignment c. Individualized head position to maximize cerebral perfusion pressure and minimize ICP measurements d. The head of the bed elevated with flexion of the hips

a

Which statement best reflects the concept of allocation of resources within the critical care setting? a. Limitations of resources force reexamination of goals of critical care for clients. b. Care is provided equally to all those who need the resources. c. Equal access is available for those with the same condition or diagnosis. d. Technologic advances are available to most of those in a given community.

d

While starting an intravenous line on the right hand of an unconscious patient, the patient reaches over with his left hand and tries to remove the noxious stimuli. This response is called a. decorticate posturing. b. decerebrate posturing. c. withdrawal. d. localization.

b

With an intact oculocephalic reflex, the a. patient's eyes move in the same direction the head is turned. b. patient's eyes move in the opposite direction to the movement of the patient's head. c. patient's eyes remain midline. d. doll's eye reflex is absent.

A 76-year-old right-handed patient has been admitted to the critical care unit with an intracerebral hemorrhage. A CT of her head reveals a large left parietal area bleed. Patient assessment includes T 98.7°F, P 98 beats/min and thready, R 8 breaths/min, and BP 168/100 mm Hg. The patient's initial treatment plan should involve a. placing her in the Trendelenburg position. b. administering an antihypertensive agent. c. initiating induced hypertensive therapy. d. intubation to support airway and breathing.

d

3

he nurse is caring for an adult client with a burn injury. Which descriptor is related to the rehabilitative phase? 1.Focus is on prevention of infection. 2.Lasts until partial wound closure occurs. 3.May last months to years, depending on severity of injury. 4.Only major organs are involved in the physiologic response of injury greater than 20% of total body surface area (TBSA).

a,d,e

What interventions should the nurse implement in caring for a client with diabetes insipidus (DI) following a head injury? (Select all that apply). a. Providing adequate fluids within easy reach b. Reporting an increasing urine specific gravity c. Administering prescribed erythromycin d. Assessing for and reporting changes in neurological status e. Monitoring for constipation, weight loss, hypotension, and tachycardia

c

What is the correct location for placement of the hands for manual chest compressions during cardiopulmonary resuscitation (CPR) on the adult client?Select an option, then click Submit. A.Just above the xiphoid process, on the upper third of the sternum B.Below the xiphoid process, midway between the sternum and the umbilicus C.Just above the xiphoid process, on the lower third of the sternum D.Below the xiphoid process, midway between the sternum and the first rib

2

What is the most important nursing action for the nurse to take after observing a pulsating abdominal mass in a client's left upper abdomen? 1.Assess for the presence of frequent diarrhea. 2.Follow up for possible abdominal aortic aneurysm. 3.Determine last menstrual period to rule out ectopic pregnancy. 4.Palpate the mass to determine if there is positive rebound tenderness.

a

When assessing a client's fluid and electrolyte status, the nurse recalls that the regulator of extracellular osmolarity is what? a. Sodium b. Potassium c. Chloride d. Calcium

b,c

When caring for a client with a head injury that may have involved the medulla, the nurse bases assessments on the knowledge that the medulla controls a variety of functions. Which functions will the nurse assess? (Select all that apply). a. Balance b. Breathing c. Pulse rate d. Fat metabolism e. Temperature regulation

1,5,6

When creating a mechanically ventilated client's plan of care for prevention of ventilator-associated pneumonia (VAP), the nurse should include which measures in the plan? Select all that apply. 1.Suction the oral cavity whenever needed. 2.Apply topical antibiotics to the oral cavity. 3.Change the ventilator circuit tubing every 2 hours. 4.Maintain the client in a supine position at all times. 5.Practice frequent oral hygiene, including teeth brushing. 6.Wear gloves when suctioning or handling the endotracheal tube.

a

When opening the airway of an unresponsive trauma patient in the emergency department, which of the following considerations is correct? a. Airway assessment must incorporate cervical spine immobilization. b. Hyperextension of the neck is the only acceptable technique. c. Flexion of the neck protects the patient from further injury. d. Airway patency takes priority over cervical spine immobilization.

2,3,4

Which assessment findings in a client with an endotracheal tube indicate that placement of the tube may need to be further evaluated? Select all that apply. 1.Bilateral chest rise and fall noted 2.Chest rise noted on the right side only 3.Breath sounds audible over the epigastrium 4.Breath sounds audible only on the right side 5.Breath sounds audible with bibasilar crackles 6.Breath sounds audible and decreased throughout

b

Which color tag will be given by the triage nurse to a client assigned to class IV, during a mass casualty situation? a. Red b. Black c. Green d. Yellow

d

Which of the following ethical principles is most important when soliciting informed consent from a client? a. Nonmaleficence b. Fidelity c. Beneficence d. Veracity

18

An adult client is admitted to the emergency department after a burn injury. The client's upper half of the anterior torso is burned, and there are circumferential burns to the lower half of both arms. Using the rule of nines, what percent of the body is burned? Fill in the blank.

a

A client diagnosed with angina pectoris complains of chest pain while ambulating in the hallway. Which action should the nurse implement first?Select an option, then click Submit. A.Support the client to a sitting position. B.Ask the client to walk slowly back to the room. C.Administer a sublingual nitroglycerin tablet. D.Provide oxygen via nasal cannula.

1,3,4

A client being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious and the nurse suspects air embolism. What are the priority nursing actions? Select all that apply. 1.Administer oxygen to the client. 2.Continue dialysis at a slower rate after checking the lines for air. 3.Notify the health care provider (HCP) and Rapid Response Team. 4.Stop dialysis, and turn the client on the left side with head lower than feet. 5.Bolus the client with 500 mL of normal saline to break up the air embolus.

2,5

A client had a recent coronary artery bypass graft (CABG). Which assessment findings should alert the nurse of the complication of cardiac tamponade? Select all that apply. 1.Fine crackles noted in both lung bases 2.Clear lung sounds with distended jugular veins 3.Noted shivering with client temperature at 97° F (36.1° C) 4.Sudden increase in systolic blood pressure in client receiving nitroprusside 5.Sudden decrease of drainage from the mediastinal chest tube previously with heavy drainage

1

A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of which condition? 1.Right pneumothorax 2.Pulmonary embolism 3.Displaced endotracheal tube 4.Acute respiratory distress syndrome

4

A client in sinus bradycardia, with a heart rate of 45 beats/minute, complains of dizziness and has a blood pressure of 82/60 mm Hg. Which prescription should the nurse anticipate will be prescribed? 1.Administer digoxin. 2.Defibrillate the client. 3.Continue to monitor the client. 4.Prepare for transcutaneous pacing.

4

A client in the intensive care unit shows ventricular fibrillation (VF) on the monitor, which is verified by client assessment. What is the nurse's priority action? 1.Prepare for cardioversion. 2.Initiate a lidocaine drip, and titrate. 3.Administer a bolus dose of lidocaine. 4.Initiate cardiopulmonary resuscitation (CPR).

4

A client is admitted to the hospital after a high-voltage electrical burn injury. The client has dark-colored urine, and urinalysis results are positive for myoglobin. The nurse should place priority on which nursing action? 1.Ambulate the client frequently. 2.Reassure the client that the injury will resolve without residual effects. 3.Obtain a nasogastric (NG) tube and lubricant from the supply area in preparation for insertion. 4.Monitor the urine output and examine the urine for color, odor, and the presence of particulate matter.

1

A client is admitted to the hospital with a diagnosis of neurogenic shock after a traumatic motor vehicle collision. Which manifestation best characterizes this diagnosis? 1.Bradycardia 2.Hyperthermia 3.Hypoglycemia 4.Increased cardiac output

4

A client is brought to the emergency department immediately after a smoke inhalation injury. The initial nursing action would be to prepare the client to receive which treatment? 1.A sedative 2.Pain medication 3.Endotracheal intubation 4.100% humidified oxygen via a face mask

2,3,5

A client is brought to the emergency department with deep partial-thickness burns to the face, neck, arms, and chest after trying to put out a car fire. Which are the priority nursing actions for this client? Select all that apply. 1.Restrict fluids. 2.Assess for airway patency. 3.Administer oxygen as prescribed. 4.Place a cooling blanket on the client. 5.Elevate extremities if no fractures are present. 6.Prepare to give oral pain medication as prescribed.

2

A client is diagnosed with atrial fibrillation, and the health care provider prescribes medication therapy. Prior to initiating medication therapy, which cardiac rhythm would the nurse expect to note on the cardiac monitor? Click on the image to indicate your answer.

1

A client is in the intensive care unit (ICU) on a ventilator for respiratory failure. The cardiac monitor alarm sounds, and the rhythm shows asystole. Which identifies the priority actions of the nurse? 1.Assess the client; assess the lead wires; call a code; start CPR. 2.Assess the lead wires; call a code; assess the client; start CPR. 3.Get a crash cart; call a code; provide Ambu bag respirations; start CPR. 4.Assess the ventilator; call a code; assess the client; start cardiopulmonary resuscitation (CPR).

3

A client is taking warfarin for atrial fibrillation and has just been discharged home. The home health nurse should include which criteria in the teaching plan for this client regarding the length of therapy? 1.Therapy on warfarin will last 1 year. 2.Therapy on warfarin will last 6 months. 3.Therapy on warfarin will last long term or be indefinite. 4.Therapy on warfarin will last short term or 2 to 3 weeks.

b

A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid ventricular response. Based on this finding, the nurse anticipates assisting the physician with which treatment?Select an option, then click Submit. A.Administer lidocaine, 75 mg intravenous push. B.Perform synchronized cardioversion. C.Defibrillate the client as soon as possible. D.Administer atropine, 0.4 mg intravenous push.

1

A client receiving total parenteral nutrition (TPN) experiences sudden development of chest pain, dyspnea, tachycardia, cyanosis, and a decreased level of consciousness. What should the nurse suspect as a complication of the TPN? 1.Air embolism 2.Hyperglycemia 3.Catheter-related sepsis 4.Allergic reaction to the catheter

14,940

A client sustained a burn injury at 7:00 a.m. The client's spouse states that before the burn, the client's body weight was 198 lbs. The health care provider has estimated that the total body surface area (BSA) burned is 83%. Using the Parkland (Baxter) formula (4 mL × kilograms of body mass × percent total BSA), the nurse determines that the total amount of intravenous lactated Ringer's solution that the client will receive by 3 p.m. of the same day on which the burn occurred is which value? Fill in the blank.

4

A client with a spinal cord injury suddenly complains of a severe, pounding headache. The nurse quickly checks the client and notes that the client is diaphoretic and has an elevated blood pressure and a drop in heart rate. The nurse suspects that the client is experiencing autonomic dysreflexia, elevates the head of the client's bed, and should immediately perform which action? 1. Notify the primary health care provider. 2. Increase the rate of intravenous fluids. 3. Check to see if the client has a prescription for an antihypertensive. 4. Check the client's bladder for distention and the rectum for impaction.

1,4,2,3,5,6

A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client's vital signs, the nurse takes the following actions. Arrange the actions in the order they should be performed. All options must be used. Drag the text in the left column to the correct order in the right column. 1. Raise the head of the bed. 2. Check for bladder distention. 3. Contact the health care provider (HCP). 4. Loosen tight clothing on the client. 5. Administer an antihypertensive medication. 6. Document the occurrence, treatment, and response.

2

A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client's breath sounds? 1.Stridor 2.Crackles 3.Scattered rhonchi 4.Diminished breath sounds

1

A client with parenteral nutrition (PN) infusing has disconnected the tubing from the central line catheter. The nurse assesses the client and suspects an air embolism. The nurse should immediately place the client in which position? 1.On the left side, with the head lower than the feet 2.On the left side, with the head higher than the feet 3.On the right side, with the head lower than the feet 4.On the right side, with the head higher than the feet

4

A client with subarachnoid hemorrhage will be taking nimodipine. How should the nurse describe this medication to the client and spouse? 1.A vasodilator that will dilate cerebral blood vessels 2.A β-adrenergic blocker that will decrease blood pressure 3.An angiotensin-converting enzyme that will reduce the blood pressure 4.A calcium channel blocker that will decrease spasm in cerebral blood vessels

2

A client with unstable ventricular tachycardia has a prescription to receive amiodarone intravenously. During administration of this medication, the nurse assisting in the care of the client should monitor which priority item? 1.Blood pressure 2.Cardiac rhythm 3.Peripheral pulses 4.Skin color and dryness

a

A patient has sustained an epidural hematoma after a 10-foot fall from a roof. Which of the following is true about epidural hematomas? a. They are usually arterial in nature. b. They typically have a worse mortality rate than subdural hematomas. c. They are associated with a permanent loss of consciousness. d. Clinical signs and symptoms include bilateral pupil dilation.

b

A patient is admitted to the ICU for observation of his grade II splenic laceration. Which of the following signs and symptoms would suggest that he has had a delayed rupture of his splenic capsule and is now in hemorrhagic shock? a. BP, 110/70 mm Hg; HR, 120 beats/min; Hct, 42 mg/dL; UO, 40 mL/hr; skin that is pink, warm, and dry with capillary refill of 3 seconds b. BP, 90/70 mm Hg; HR, 140 beats/min; Hct, 21 mg/dL; UO, 10 mL/hr; pale, cool, clammy skin; confused c. BP, 100/60 mm Hg; HR, 100 beats/min; Hct, 35 mg/dL; UO, 30 mL/hr; pale, cool, dry skin; alert and oriented d. BP, 110/60 mm Hg; HR, 118 beats/min; Hct, 38 mg/dL; UO, 60 mL/hr; flushed, warm, diaphoretic skin; agitated and confused

b

A patient with multisystem trauma has been in the ICU for 6 days after sustaining a closed head injury, a right-sided pneumothorax, right rib fractures, a grade IV liver laceration, a pancreatic contusion, and a right acetabular fracture. The patient is still intubated and mechanically ventilated and has a chest tube, Foley catheter, and two abdominal drains. The patient's hemodynamic assessment reveals the following values: BP, 94/66 mm Hg; HR, 118 beats/min; T, 38.7° C; CVP, 5 cm H2O; wedge pressure, 6 mm Hg; cardiac index, 6.1; and systemic vascular resistance, 450 dyns/sec. The patient is at the greatest risk to develop a. respiratory failure. b. infection. c. venous thromboembolism d. fat embolism syndrome.

a

A patient's condition has deteriorated. Changes in condition include trachea shift, absence of breath sounds on the left side, and hypotension. A chest tube was inserted on the left side with 1800 mL of blood removed. The nurse expects that the patient will be taken to surgery for a a. thoracotomy. b. cardiac tamponade. c. splenectomy. d. pneumothorax.

b

A patient's condition has deteriorated. Changes in condition include trachea shift, absence of breath sounds on the left side, and hypotension. The nurse suspects that the patient has developed a(n) a. cardiac tamponade. b. hemothorax. c. open pneumothorax. d. ruptured diaphragm.

d

A strategy to minimize secondary brain injury in head-injured patients is a. hyperventilation to keep PCO2 less than 30. b. fluid restriction to keep central venous pressure less than 6 cm H2O. c. maintaining body temperature more than 37.5° C. d. fluid resuscitation as needed to keep the systolic blood pressure greater than 90 mm Hg.

b

Which condition should the nurse anticipate as a potential problem in a female client with a neurogenic bladder?Select an option, then click Submit. A.Stress incontinence B.Infection C.Painless gross hematuria D.Peritonitis

3,4,5

Which clinical manifestations of a tension pneumothorax should be of immediate concern to the nurse? Select all that apply. 1.Bradypnea 2.Flattened neck veins 3.Decreased cardiac output 4.Hyperresonance to percussion 5.Tracheal deviation to the opposite side

a

Ethical decisions are best made by a. following the guidelines of a framework or model. b. having the client discuss alternatives with the physician or nurse. c. prioritizing the greatest good for the greatest number of persons. d. careful consideration by the Ethics Committee after all diagnostic data are reviewed.

4

The nurse is documenting information in a client's chart when the electrocardiogram telemetry alarm sounds, and the nurse notes that the client is in ventricular tachycardia (VT). The nurse rushes to the client's bedside and should perform which assessment first? 1.Heart rate 2.Blood pressure 3.Respiratory rate 4.Check responsiveness

a

The nurse is assessing the client with subdural hematoma after a fall. The client was admitted for observation with a normal neurologic assessment on admission. Upon entering the room the nurse finds the client exhibiting seizure activity. Which is the first action the nurse should take? a. Assess the client's airway. b. Place pads on the side rails. c. Notify the healthcare provider. d. Leave and obtain the crash cart.

3

The emergency department nurse is caring for a client who was in a motor vehicle crash and is told by the paramedics that the client hit a tree, was not wearing a seatbelt, and his head hit the windshield. What is a priority action for the nurse? 1.Insert a second intravenous (IV) line. 2.Assess for the presence of Doll's eyes. 3.Leave on the hard immobilization collar. 4.Obtain a Glasgow Coma Scale (GCS) score.

3

The low-pressure alarm sounds on a ventilator. The nurse assesses the client and then attempts to determine the cause of the alarm. If unsuccessful in determining the cause of the alarm, the nurse should take what initial action? 1.Administer oxygen. 2.Check the client's vital signs. 3.Ventilate the client manually. 4.Start cardiopulmonary resuscitation.

d

The most important aspect of a secondary survey is to a. check circulatory status. b. check electrolyte profile. c. insert a urinary catheter. d. obtain patient history.

d

The nurse assesses a client who has been prescribed furosemide (Lasix) for cardiac disease. Which electrocardiographic change would be a concern for a client taking a diuretic?Select an option, then click Submit. A.Tall, spiked T waves B.A prolonged QT interval C.A widening QRS complex D.Presence of a U wave

1,2,3,4

The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles and the nurse suspects pulmonary edema. The nurse immediately asks another nurse to contact the health care provider and prepares to implement which priority interventions? Select all that apply. 1.Administering oxygen 2.Inserting a Foley catheter 3.Administering furosemide 4.Administering morphine sulfate intravenously 5.Transporting the client to the coronary care unit 6.Placing the client in a low Fowler's side-lying position

a

The nurse initiates neurologic checks for a client who is at risk for neurologic compromise. Which manifestation typically provides the first indication of altered neurologic function?Select an option, then click Submit. A.Change in level of consciousness B.Increasing muscular weakness C.Changes in pupil size bilaterally D.Progressive nuchal rigidity

3

The nurse is assessing a 1-hour postoperative client after a right pulmonary wedge resection. The nurse notes the presence of 200 mL of bloody drainage in the client's collection chamber of the chest tube drainage system. Which action by the nurse is most appropriate? 1.Contact the surgeon. 2.Irrigate the chest tube. 3.Document the findings. 4.Lower the amount of suction being applied.

1

The nurse is assessing a client who is exhibiting signs of autonomic dysreflexia. What is the priority action the nurse must take for this client? 1.Raise the head of the bed. 2.Obtain an oxygen saturation. 3.Document the occurrence, treatment, and response. 4.Insert a Foley catheter, per as-needed (prn) prescription.

1

The nurse is assessing the client's family for understanding of the client's craniectomy, scheduled for the next day. Which statement best indicates the family understands this procedure? 1."Our father will have a piece of his skull removed to allow for the swelling on his brain to decrease." 2."Our father will have the blood removed from his brain and be able to come home at the end of the day." 3."Our father will have an opening in the head made by a drill to allow the fluid to be removed from his brain." 4."We will not be able to see our father for 48 hours because his surgery needs for him to remain in isolation."

2

The nurse is assigned the care of a client who experienced a myocardial infarction and is being monitored by cardiac telemetry. The nurse notes the sudden onset of this cardiac rhythm on the monitor. The nurse should immediately take which action? Refer to Figure. 1.Take the client's blood pressure. 2.Initiate cardiopulmonary resuscitation (CPR). 3.Place a nitroglycerin tablet under the client's tongue. 4.Continue to monitor the client for 1 minute and then contact the health care provider (HCP).

4

The nurse is assisting in caring for a client with an intracranial pressure (ICP) monitoring device that is placed in the subarachnoid space. The nurse should understand that which reading is abnormal and requires primary health care provider notification? 1. 7 mm Hg 2. 12 mm Hg 3. 15 mm Hg 4. 21 mm Hg

1

The nurse is caring for a client immediately after removal of the endotracheal tube. The nurse should report which sign immediately if experienced by the client? 1.Stridor 2.Occasional pink-tinged sputum 3.Respiratory rate of 24 breaths/minute 4.A few basilar lung crackles on the right

1

The nurse is caring for a client who is mechanically ventilated. The nurse should assess the client's need for suctioning a minimum of how often? 1.Every 2 hours 2.Every 3 hours 3.Every 4 hours 4.Every 6 hours

3,4,5

The nurse is caring for a client who is pulseless and experiencing this dysrhythmia. Which interventions should the nurse anticipate implementing in collaboration with the health care provider (HCP)? Select all that apply. Refer to Figure. 1.Prepare for cardioversion. 2.Prepare to administer digoxin 3.Prepare to administer amiodarone. 4.Prepare to administer epinephrine. 5.Provide cardiopulmonary resuscitation (CPR).

3

The nurse is caring for a client who received lidocaine to treat a ventricular dysrhythmia. The nurse should monitor which items closely after administering the medication? 1. Skin temperature and turgor 2. Visual acuity and liver function laboratory results 3. Vital signs, electrocardiogram pattern, and neurological status 4. Kidney function laboratory results and gastrointestinal function

4

The nurse is caring for a client who sustained a burn injury to the anterior arms and anterior chest area from a fire. Which assessment finding would indicate that the client sustained a respiratory injury as a result of the burn? 1.Fear and anxiety 2.Complaints of pain 3.Clear breath sounds 4.Use of accessory muscles for breathing

2

The nurse is caring for a client who sustained a thermal burn caused by the inhalation of steam 24 hours ago. The nurse determines that the priority nursing action is to assess which item? 1.Pain level 2.Lung sounds 3.Ability to swallow 4.Laboratory results

4

The nurse is caring for a client with a T4 spinal cord injury. Which assessment finding is a priority to address? 1.Subjective statements of depression 2.Stage 2 pressure ulcers on both heels 3.Urine output for 8 hours of 480 mL, cloudy 4.Blood pressure 200/100 mm Hg, throbbing headache

1

The nurse is caring for a client with a chest tube drainage system. During repositioning of the client, the chest tube accidentally pulls out of the pleural cavity. Which is the initial nursing action? 1.Apply an occlusive dressing. 2.Reinsert the chest tube quickly. 3.Contact the respiratory therapist. 4.Contact the health care provider (HCP).

a

The nurse is caring for a client with a chest tube to water seal drainage that was inserted 10 days ago because of a ruptured bullae and pneumothorax. Which finding should the nurse report to the health care provider before the chest tube is removed?Select an option, then click Submit. A.Tidaling of water in water seal chamber B.Bilateral muffled breath sounds at bases C.Temperature of 101° F D.Absence of chest tube drainage for 2 days

2

The nurse is caring for a client with a diagnosis of angina who is receiving metoprolol XL. The nurse looks at the cardiac monitor and notes this cardiac rhythm. How should the nurse interpret this rhythm? Refer to Figure. 1.Sinus tachycardia 2.Sinus bradycardia 3.Normal sinus rhythm 4.Ventricular fibrillation

2

The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which finding occurs? 1.Suctioning is required frequently. 2.Aspiration of gastric contents occurs during suctioning. 3.The client's skin and mucous membranes are light pink. 4.Excessive secretions are suctioned from a tracheostomy.

4

The nurse is caring for a client with an internal arteriovenous fistula who is receiving hemodialysis. The nurse expects to note which finding if the fistula is patent? 1.Lack of a bruit at the site of the fistula 2.White fibrin specks noted in the fistula 3.Warmth and redness at the site of the fistula 4.Palpation of a thrill over the site of the fistula

2

The nurse is listing goals for a client with a thoracic 4 (T4) vertebral spinal cord injury to prevent autonomic dysreflexia. Which goal is most appropriate to prevent this life-threatening complication? 1. The client wears elastic support stockings at all times. 2. The client performs self-catheterization every 6 hours. 3. The client turns, coughs, and deep breathes every 2 hours. 4. The client takes medication to relieve muscle spasms daily.

4

The nurse is monitoring a client with a head injury for signs of increased intracranial pressure (ICP). Which finding indicates an early sign of increased ICP? 1.Decrease in pulse rate 2.Shallow, slow respirations 3.Rise in systolic blood pressure 4.Decreasing level of consciousness

1

The nurse is monitoring a client with a tracheostomy tube for complications related to the tube. The nurse suspects tracheoesophageal fistula if which finding is noted? 1.Abdominal distention 2.Excess mucus production 3.Abnormal skin and mucous membrane color 4.Use of accessory muscles to assist with breathing

1

The nurse is performing a cardiovascular assessment on a client with heart failure. Which item should the nurse check to gain the best information about the client's left-sided heart function? 1. Breath sounds 2. Peripheral edema 3. Hepatojugular reflux 4. Jugular vein distention

3

The nurse is performing an assessment on a client admitted to the nursing unit who has sustained an extensive burn injury involving 45% of total body surface area. When planning for fluid resuscitation, the nurse should consider that fluid shifting to the interstitial spaces is greatest during which time period? 1.Immediately after the injury 2.Within 12 hours after the injury 3.Between 18 and 24 hours after the injury 4.Between 42 and 72 hours after the injury

3

The nurse is performing an assessment on a client who sustained circumferential burns of both legs. Which assessment would be the initial priority in caring for this client? 1.Assessing heart rate 2.Assessing respiratory rate 3.Assessing peripheral pulses 4.Assessing blood pressure (BP)

a

The nurse is performing hourly neurologic checks for a client with a head injury. Which new assessment finding warrants immediate intervention by the nurse?Select an option, then click Submit. A.A unilateral pupil that is dilated and nonreactive to light B.Client cries out when awakened by a verbal stimulus C.Client demonstrates a loss of memory of the events leading up to the injury D.Onset of nausea, headache, and vertigo

2,3,4

The nurse is preparing discharge instructions for a client who has been treated for premature ventricular contractions (PVCs). Which instructions are essential elements of the discharge plan? Select all that apply. 1.Avoid straining during a bowel movement. 2.Take potassium supplements as prescribed. 3.Learn ways to cope with stress and avoid getting an infection. 4.Avoid caffeinated beverages and over-the-counter energy drinks. 5.Review procedures for use of automatic external defibrillator (AED) and cardiopulmonary resuscitation (CPR).

4

The nurse is preparing to assist a primary health care provider with insertion of a central venous catheter in a client with a diagnosis of malnutrition. The nurse should place the client in which position? 1.Sims' with the head turned toward the site of insertion 2.Left lateral with the head turned toward the site of insertion 3.Low-Fowler's with the head turned away from the site of insertion 4.Trendelenburg's with the head turned away from the site of insertion

3

The nurse is providing care for a client who sustained burns over 30% of the body from a fire. On assessment, the nurse notes that the client is edematous in both burned and unburned body areas. The client's wife asks why her husband "looks so swollen." What is the nurse's best response? 1."Constricted blood vessels have caused a loss of protein in the blood." 2."Leaking blood vessels have led to increased protein amounts in the blood." 3."Leaking blood vessels have led to decreased protein amounts in the blood." 4."Constricted blood vessels have led to increased protein amounts in the blood."

3

The nurse is providing care to a client with increased intracranial pressure (ICP). Which approach is least likely to be beneficial in controlling the client's increased ICP? 1.Reducing environmental noise 2.Maintaining a quiet environment 3.Clustering nursing activities to be done all at one time 4.Maintaining the client's head elevated in a midline neutral position

4

The nurse is providing discharge instructions to a client who had a permanent pacemaker inserted. Which instruction should the nurse provide to the client? 1.Be cautious when participating in contact sports. 2.The use of a cellular phone will never affect a pacemaker. 3.Avoid lifting more than 25 pounds (11.3 kg) until cleared by the primary health care provider. 4.Notify the primary health care provider if the radial pulse is outside of the range programmed in the pacemaker.

1

The nurse is providing morning care to a client who has a closed chest tube drainage system to treat a pneumothorax. When the nurse turns the client to the side, the chest tube is accidentally dislodged from the chest. The nurse immediately applies sterile gauze over the chest tube insertion site. Which is the nurse's next action? 1.Call the health care provider. 2.Replace the chest tube system. 3.Obtain a pulse oximetry reading. 4.Place the client in a Trendelenburg's position.

4

The nurse is transporting a client with a chest tube by stretcher from the client's room to the x-ray department for a prescribed chest x-ray. The nurse should place the chest tube drainage apparatus in which location for transport? 1.On the stretcher in an upright position 2.On its side on the stretcher next to the client 3.Suspended from the IV pole that is on the stretcher 4.Attached to the stretcher so that it hangs below the mattress

3

The nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but more than 140 beats/minute. The nurse determines that the client is experiencing which dysrhythmia? 1.Sinus tachycardia 2.Ventricular fibrillation 3.Ventricular tachycardia 4.Premature ventricular contractions

2

The nurse responds to a client's heart monitor alarm. The nurse makes sure the heart monitor wires are in proper position, determines the client has no pulse and notifies the rapid response team. The nurse initiates cardiopulmonary resuscitation (CPR). The nurse then prepares for which priority action if this electrocardiogram (ECG) rhythm is noted? (Refer to figure.) 1.Notify the primary health care provider on call. 2.Deliver countershock with defibrillator at 200 joules. 3.Connect the external pacer to deliver 80 beats/min. 4.Administer epinephrine intravenous (IV) per protocol.

1

The nurse suctioning a client through an endotracheal tube monitors the client for complications associated with the procedure. Which finding indicates a complication? 1.An irregular heart rate 2.A pulse oximetry level of 95% 3.A blood pressure of 118/78 mm Hg 4.A reddish coloration in the client's face

1,2,4,5

The nurse, caring for a group of adult clients on an acute care medical-surgical nursing unit, determines that which clients would be the most likely candidates for parenteral nutrition (PN)? Select all that apply. 1.A client with extensive burns 2.A client with cancer who is septic 3.A client who has had an open cholecystectomy 4.A client with severe exacerbation of Crohn's disease 5.A client with persistent nausea and vomiting from chemotherapy

c

The nursing care plan of a patient with a diffuse axonal injury (DAI) would involve which of the following considerations? a. Neurologic assessments should be performed only once a shift. b. The patient will need a computed tomography scan for definitive diagnosis of the injury. c. Blood pressure and temperature elevations are common. d. The patient is at risk for volume overload because of syndrome of inappropriate antidiuretic hormone.

4

The paramedics just transported a client whom they found inside a burning building. What assessment finding is most important for the nurse to evaluate on this client? 1.Pulse rate 2.Blood pressure 3.Rectal temperature 4.Level of consciousness (LOC)

b

The patients at highest risk for neurogenic shock are those who have had a. a stroke. b. a spinal cord injury. c. Guillain-Barré syndrome. d. a craniotomy.

3

The primary health care provider's office nurse is assessing a client who has recently had a renal transplantation. The nurse should monitor for which signs of acute graft rejection? 1.Hypotension, graft tenderness, and anemia 2.Hypertension, oliguria, thirst, and hypothermia 3.Fever, hypertension, graft tenderness, and malaise 4.Fever, vomiting, hypotension, and copious amounts of dilute urine

1

To perform cardiopulmonary resuscitation (CPR), the nurse should use the method pictured to open the airway in which situation? Refer to figure. 1.If neck trauma is suspected 2.In all situations requiring CPR 3.If the client has a history of seizures 4.the client has a history of headaches

c

The most serious complication of lumbar puncture in a critically ill patient is a. bacterial meningitis. b. dural tear. c. brainstem herniation. d. spinal cord trauma.

d

A client comes into the emergency department with neurologic deficits after falling off a ladder. Which client assessment will the nurse perform for the Glasgow Coma Scale? a. Breathing patterns b. Deep tendon reflexes c. Eye accommodation to light d. Motor response to verbal commands

d

A client had a craniotomy for excision of a brain tumor. After surgery, the nurse monitors the client for increased intracranial pressure. Which clinical finding supports an increase in intracranial pressure? a. Thready, weak pulse b. Narrowing pulse pressure c. Regular, shallow breathing d. Lowered level of consciousness

85

A client has a mean arterial blood pressure (MAP) of 97 mmHg and an intracranial pressure (ICP) of 12 mmHg. What is the cerebral perfusion pressure (CPP) for this client? Record your answer using a whole number.

b

A client has sustained a spinal cord injury at the T2 level. The nurse assesses for signs of autonomic hyperreflexia (autonomic dysreflexia). What is the rationale for the nurse's assessment? a. The injury results in loss of the reflex arc. b. The injury is above the sixth thoracic vertebra. c. There has been a partial transection of the cord. d. There is a flaccid paralysis of the lower extremities.

a

A client is admitted to the emergency department with head trauma resulting from an accident. The client opens both eyes to painful stimuli, makes incomprehensible sounds, and flexes to pain. Using the Glasgow Coma Scale, which score will the nurse document in the client's medical record? a. 8 b. 9 c. 12 d. 15

b

A client is admitted to the hospital with a head injury sustained while playing soccer. For which early sign of increased intracranial pressure should the nurse monitor this client? a. Nausea b. Lethargy c. Sunset eyes d. Hyperthermia

c

A client is admitted with a head injury. The nurse identifies that the client's urinary catheter is draining large amounts of clear, colorless urine. What does the nurse identify as the most likely cause? a. Increased serum glucose b. Deficient renal perfusion c. Inadequate antidiuretic hormone (ADH) secretion d. Excess amounts of intravenous (IV) fluid

d

A client is admitted with head trauma after a fall. The client is being prepared for a supratentorial craniotomy with burr holes, and an intravenous infusion of mannitol is instituted. The nurse concludes that this medication primarily is given to do what? a. Lower blood pressure b. Prevent hypoglycemia c. Increase cardiac output d. Decrease fluid in the brain

3

A client is admitted with posttraumatic brain injury and multiple fractures. The client's eyes remain closed, and there is no evidence of verbalization or movement when the nurse changes the client's position. What score on the Glasgow Coma Scale (GCS) should the nurse document? Record your answer using a whole number.

a

A client is at risk for increased intracranial pressure (ICP). Which assessment finding reflects an increase in ICP? a. Unequal pupil size b. Decreasing systolic blood pressure c. Tachycardia d. Decreasing body temperature

a

A client is diagnosed with a brain attack (cerebrovascular accident, CVA). The baseline vital signs are a pulse rate of 78 bpm and a blood pressure (BP) of 120/80 mm Hg. The nurse continues to monitor the vital signs and recognizes that which changes in vital signs indicate increased intracranial pressure (ICP)? a. Pulse 50 bpm and BP 140/60 mm Hg b. Pulse 56 bpm and BP 130/110 mm Hg c. Pulse 60 bpm and BP 126/96 mm Hg d. Pulse 120 bpm and BP 80/60 mm Hg

a

A client is scheduled for a computed tomography (CT) of the brain with contrast. When reviewing the client's medical record, what significant finding should the nurse report to the primary healthcare provider before the diagnostic procedure? a. The client takes metformin daily. b. The client has not been nothing by mouth (NPO). c. The client reports an allergy to gadolinium. d. The client was not prescribed a bowel prep.

d

A client reports left-sided chest pain after playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify which finding? a. Dull sound on percussion b. Vocal fremitus on palpation c. Rales with rhonchi on auscultation d. Absence of breath sounds on auscultation

d

A client sustains a crushing injury of the spinal cord above the level of origin of the phrenic nerve. As a result of this injury, the nurse expects what client response? a. Ventricular fibrillation b. Dysfunction of the vagus nerve c. Retention of sensation but paralysis of the lower extremities d. Respiratory paralysis and cessation of diaphragmatic contractions

c

A client who had extensive pelvic surgery 24 hours ago becomes cyanotic, is gasping for breath, and reports right-sided chest pain. What should the nurse do first? a. Obtain vital signs b. Initiate a cardiac arrest code c. Administer oxygen using a face mask d. Encourage the use of an incentive spirometer

d

A client who sustained a closed head injury is being monitored for increased intracranial pressure. Arterial blood gases are obtained, and the results include a PCO 2 of 33 mm Hg. What action is most important for the nurse to take? a. Encourage the client to slow the breathing rate. b. Auscultate the client's lungs and suction if indicated. c. Advise the healthcare provider that the client needs supplemental oxygen. d. Inform the healthcare provider of the results and continue to monitor for signs of increasing intracranial pressure.

a,d,e,f

A client with a primary brain tumor has developed syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The nurse will expect to see which clinical findings upon assessment? (Select all that apply). a. Nausea and vomiting b. Hyperthermia c. Bradycardia d. Increased weight e. Decreased serum sodium f. Decreased level of consciousness

c

A client's wife has been informed by the physician that her spouse has a permanent C2-C3 spinal injury, which has resulted in permanent quadriplegia. The wife states that she does not want the physician or nursing staff to tell the client about his injury. The client is awake, alert, and oriented when he asks his nurse to tell him what has happened. Based on which ethical principles does the nurse answer the patient's questions? a. Veracity b. Justice c. Autonomy d. Nonmaleficence

b

A client's wife has been informed by the physician that her spouse has a permanent C2-C3 spinal injury, which has resulted in permanent quadriplegia. The wife states that she does not want the physician or nursing staff to tell the client about his injury. The client is awake, alert, and oriented when he asks his nurse to tell him what has happened. The nurse has conflicting emotions about how to handle the situation and is experiencing: a. autonomy. b. moral distress. c. moral doubt. d. moral courage.

c

A construction worker fell off the roof of a two-story building and was taken to the hospital in an unconscious state. During the initial assessment, what clinical finding should the nurse report immediately? a. Reactive pupils b. Depressed fontanel c. Bleeding from the ears d. Increased body temperature

a

A critical care patient is diagnosed with massive head trauma. The patient is receiving brain tissue oxygen pressure (PbtO2) monitoring. The nurse recognized that the goal of this treatment is to maintain PbtO2 a. greater than 20 mm Hg. b. less than 15 mm Hg. c. between 15 and 20 mm Hg. d. between 10 and 20 mm Hg.

a,b

A nurse is caring for a child with a diagnosis of meningitis. What clinical findings indicate an increase in intracranial pressure? (Select all that apply). a. Irritability b. Bradycardia c. Hyperalertness d. Decreased pulse pressure e. Decreased systolic blood pressure

b

A nurse is caring for a client who had a traumatic brain injury with increased intracranial pressure. Which healthcare provider prescription should the nurse question? a. Continue anticonvulsants b. Teach isometric exercises c. Continue osmotic diuretics d. Keep head of bed at 30 degrees

c

A nurse is caring for a client with a spinal cord injury during the immediate postinjury period. Which is the priority focus of nursing care during this immediate phase? a. Inhibiting urinary tract infections b. Preventing contractures and atrophy c. Avoiding flexion or hyperextension of the spine d. Preparing the client for vocational rehabilitation

b

A nurse observes a window washer falling 25 feet (7.6 m) to the ground. The nurse rushes to the scene and determines that the person is in cardiopulmonary arrest. What should the nurse do first? a. Feel for a pulse b. Begin chest compressions c. Leave to call for assistance d. Perform the abdominal thrust maneuver

c

A nurse uses the Glasgow Coma Scale to assess a client's status after a head injury. When the nurse applies pressure to the nail bed of a finger, which movement of the client's upper arm should cause the most concern? a. Flexing b. Localizing c. Extending d. Withdrawing

b

A patient becomes flaccid with fixed and dilated pupils. The patient's ICP falls from 65 to 12 mm Hg. What should the nurse suspect is happening? a. The patient is having a seizure. b. The patient's brain has herniated. c. The patient's cerebral edema is resolving. d. The patient is excessively dehydrated from the mannitol.

b

A patient's ICP is 34 mm Hg, and his cerebral perfusion pressure is 65 mm Hg. Which of the following is the most appropriate intervention? a. These are normal values, and no interventions are required. b. Administer mannitol 1 to 2 g/kg IV. c. Have the patient lie flat in bed. d. Suction the patient to see if improving his airway will help his ICP.

d

After a head injury, a client develops a deficiency of antidiuretic hormone (ADH). What should the nurse consider before assessing the patient about the response to secretion of ADH? a. Serum osmolarity increases b. Urine concentration decreases c. Glomerular filtration decreases d. Tubular reabsorption of water increases

c

According to the 2007 Brain Trauma Foundation guidelines, the recommended CPP range is a. 10 to 30 mm Hg. b. 30 to 50 mm Hg. c. 50 to 70 mm Hg. d. 70 to 85 mm Hg.

d

After an automobile collision, a client who sustained multiple injuries is oriented to person and place but is confused to time. The client complains of a headache and drowsiness, but assessment reveals that the pupils are equal and reactive. Which nursing action takes priority? a. Moving the client as little as possible b. Preparing the client for mannitol administration c. Stimulating the client to maintain responsiveness d. Monitoring the client for increasing intracranial pressure

c

After surgical clipping of a ruptured cerebral aneurysm, a client develops the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). What manifestations are exhibited with excessive levels of antidiuretic hormone? a. Increased blood urea nitrogen (BUN) and hypotension b. Hyperkalemia and poor skin turgor c. Hyponatremia and decreased urine output d. Polyuria and increased specific gravity of urine

d

Initially after a brain attack (stroke, cerebrovascular accident), a client's pupils are equal and reactive to light. Four hours later the nurse identifies that one pupil reacts more slowly than the other. The client's systolic blood pressure is beginning to increase. On which condition should the nurse be prepared to focus care? a. Spinal shock b. Brain herniation c. Hypovolemic shock d. Increased intracranial pressure

b

MRI is superior to CT for which of the following? a. Brain death determination b. Detection of central nervous system infection c. Estimation of intracranial pressure d. Identification of subarachnoid hemorrhage

c

One of the earliest and most important signs of increased ICP is a. Cushing triad. b. decerebrate posturing (abnormal extension). c. a decrease in the level of consciousness. d. an increase in pupillary size.

b

Symptoms of late stages of intracranial hypertension include a. decreased perfusion of cerebral tissue. b. widening pulse pressure values. c. increased perfusion pressure across the blood-brain barrier. d. decreased intracranial pressure.

a

The clinical manifestations of the Cushing reflex are a. bradycardia, systolic hypertension, and widening pulse pressure. b. tachycardia, systolic hypotension, and tachypnea. c. headache, nuchal rigidity, and hyperthermia. d. bradycardia, aphasia, and visual field disturbances.

b

The first step of the ethical decision-making process is a. consulting with an authority. b. identifying the health problem. c. delineating the ethical problem from other types of problems. d. identifying the client as the primary decision maker.

b

The initial history for the neurologically impaired patient needs to be a. limited to the chief complaint. b. comprehensive, including events preceding hospitalization. c. directed to level of consciousness and pupillary reaction. d. information that only the patient can provide.

c

The laboratory reports of a client who underwent a hypophysectomy show an intracranial pressure (ICP) of 20 mmHg. Which action made by the client is responsible for this condition? a. Drinking lots of water b. Eating high-fiber foods c. Bending over at the waist d. Bending knees when lowering body

c

The most important aspect of the neurologic examination is a. medical history. b. physical examination. c. level of consciousness. d. pupillary responses.

a

What action should the nurse take when caring for a client who has a possible skull fracture as a result of trauma? a. Monitor the client for signs of brain injury. b. Check for hemorrhaging from the oral and nasal cavities. c. Elevate the foot of the bed if the client develops symptoms of shock. d. Observe for clinical indicators of decreased intracranial pressure and temperature.

b

When deciding whether to withdraw or withhold treatment, it is important to a. examine one's own beliefs to guide the family to a correct decision. b. approach the family with honesty and provide clear information. c. simply follow the advance directive if available. d. allow the physician to approach the family.

b

Which color of cerebrospinal fluid (CSF) may indicate subarachnoid hemorrhage in the client? a. Hazy b. Yellow c. Brown d. Colorless

c

Which intervention should be considered LAST in treating uncontrolled intracranial hypertension? a. Sedatives b. Analgesics c. Barbiturates d. Hyperventilation

b

Which of the following choices is an acceptable and recommended method of noxious stimulation? a. Nipple pinch b. Nail bed pressure c. Supraorbital pressure d. Sternal rub

b

Which of the following denotes the most serious prognosis? a. Decorticate posturing b. Decerebrate posturing c. Absence of Babinski reflex d. GCS score of 14

b

Which of the following independent nursing measures can assist in reducing increased ICP? a. Decreasing the ventilator rate b. Decreasing noxious stimuli c. Frequent orientation checks d. Administration of loop diuretics

a,c,d

Which of the following is/are criteria for defining an ethical dilemma? (Select all that apply.) a. An awareness of different options b. An issue in which only one viable option exists c. The choice of one option compromises the option not chosen d. An issue that has different options

a

Which of the following patients may need sedation before having an MRI scan? a. Claustrophobic patient b. Comatose patient c. Elderly patient d. Patient with a spinal cord injury

b

Which of the following procedures is the diagnostic study of choice for acute head injury? a. Magnetic resonance imaging b. Computed tomography c. Transcranial Doppler d. Electroencephalography

c

Which type of ICP monitoring device has the most accurate ICP measurement and provides access to CSF for sampling? a. Subarachnoid bolt or screw b. Subdural or epidural catheter c. Intraventricular catheter d. Fiberoptic transducer tipped catheter