Critical care nclex

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The nurse is caring for a client who is 1 day postoperative extensive abdominal surgery for ovarian cancer. The client is receiving IV Ringer's lactate at 100 mL/hr and continual epidural morphine for pain control. The Foley catheter urine output has decreased to <20 mLhr over the past 2 hours. The postoperative hematocrit is 36% (0.36), and the hemoglobin is 12 gIdL (120 g/L). Which action should the nurse carry out first? 1. Assess vital signs 2. Increase the IV rate to 125 ml/hr 3. Notify the health care provider 4. Perform a bladder scan

1 Third-spacing can occur following extensive abdominal surgery and can lead to hypovolemia, decreased cardiac output, hypotension and tachycardia, and decreased urine output. Monitoring vital signs and urine output, and maintaining IV fluids are appropriate interventions to prevent prerenal failure and hypovolemic shock. Additional Information Physiological Adaptation NCSBN Client Need

Emergency medical service personnel are transporting a near-drowning victim who is currently hypothermic. Based on anticipated vital signs, the nurse needs to prepare for which interventions? Select all that apply. 1. Covering client with warm blankets 2. Logrolling the client from side to side frequently 3. Mechanical ventilation 4. Warmed blood administration 5. Warmed IV fluids

1,3,5 Emergency department care of near-drowning victims includes advanced airway management, aggressive oxygenation (warm humidified O2, intubation, mechanical vent..) establishing IV access, and administering IV fluids (warmed if hypothermic), and monitoring for cardiac arrhythmias and fluid imbalances. cover client with warm blanket

A client with a bowel obstruction has been treated with gastric suctioning for 4 days. The nurse notices an increase in nasogastric drainage. Which acid-base imbalance does the nurse correctly identify? Click the exhibit button for more information. Exhibit pH 7.50 PaCO2 45 mm Hg (5.98 kPa) PaO: 90 mm Hg (12 kPa) HCO3 32 mEq/L (32 mmol/L) 1. Metabolic alkalosis, compensated 2. Metabolic alkalosis, uncompensated 3. Respiratory alkalosis; compensated 4. Respiratory alkalosis, uncompensated

2 Loss of acid through suctioning of gastric contents creates a state of metabolic alkalosis. Compensatory hypoventilation may regulate the pH by retaining carbon dioxide (acid).

The nurse is admitting a client with a possible diagnosis of Guillain-Barre syndrome. When collecting data to develop a plan of care for the client, the nurse should give priority to which of the following items? 1. Orthostatic blood pressure changes 2. Presence or absence of knee reflexes 3. Pupil size and reaction to light 4. Rate and depth of respirations

4 The most serious complication to monitor for in new-onset Guillain-Barré syndrome is respiratory compromise from the paralysis ascending into the thoracic region. Monitoring for rate/depth of respirations and measuring serial bedside vital capacity (spirometry) help to detect this early in the disease course. Additional Information Physiological Adaptation NCSBN Client Need

The nurse in the intensive care unit is caring for a client who is postoperative from a cardiac surgery. The client has a mediastinal chest tube. During assessment, the nurse notes bubbling in the suction control chamber. Which nursing action is appropriate'? 1. Assess the insertion site for presence of subcutaneous emphysema 2. Notify the surgeon of a large air leak 3. Take no action as the chest tube is functioning appropriately 4. Turn down the wall suction until the bubbling disappears

3

The nurse is caring for a client with a pulmonary contusion. Assessment reveals restlessness, chest pain on inspiration, diminished breath sounds, and oxygen saturation of 86%. Which acid-base imbalance does the nurse correctly identify? Click on the exhibit button for more information. Exhibit: Laboratory results pH 7.31 Pa02 76 mm Hg (10.11 kPa) PaCO2 54 mm Hg (7.18 kPa) HCO3 24 mEq/L (24 mmol/L) 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

3

The nurse is caring for client with sepsis and acute respiratory failure, who was intubated and prescribed mechanical ventilation 3 days ago. The nurse assesses for which adverse effect associated with the administration of positive pressure ventilation (PPV)? 1. Dehydration 2. Hypokalemia 3. Hypotension 4. Increased cardiac output

3

There has been an explosion at a local chemical plant. A private car arrives at the emergency department with 4 victims whose clothes are saturated with a strong-smelling liquid. The victims are wheezing. The nurse should implement which intervention first? 1. Assessing the clients' respiratory systems 2. Decontaminating the clients 3. Donning personal protective equipment 4. Providing oxygen by nasal cannula

3

To obtain accurate continuous blood pressure readings via a radial arterial catheter, the nurse places the air-filled interface of the stopcock at the phlebostatic axis. Where is it located? 1. Angle of Louis at 2nd intercostal space (ICS) to left of sternal border 2. Aortic area at 2nd ICS to right of sternal border 3. Level of atria at 4th ICS, 1/2 anterior-posterior (AP) diameter 4. 5th ICS at mid clavicular line (MCL)

3

The emergency department nurse is assessing a client who was involved in a motor vehicle accident during which the client's head was hit. The client reports neck pain. Which actions are essential for the nurse to perform at this time? Select all that apply. 1. Apply a hard cervical collar 2. Assess neck range of motion 3. Determine if client has rectal tone 4. Position client on firm surface 5. Use logrolling if moving the client

1,4,5

While caring for a postoperative client with an invasive arterial line, the nurse identifies a large discrepancy between the arterial line reading and the manual cuff pressure. Arterial line reading: 100.62 mm Hg; manual cuff reading: 120.76 mm Hg. What interventions should the nurse take to facilitate accurate functioning of the arterial line? Select all that apply. 1. Perform a square wave test on the monitor 2. Position the client flat for all blood pressure (BP) readings 3. Recheck and compare with an automatic BP machine 4. Verify that the zero reference stopcock is leveled with the client's phlebostatic axis 5. Zero balance the system

1,4,5

In the intensive care unit, the nurse cares for a client who is being treated for hypotension with a continuous infusion of dopamine. Which assessment finding indicates that the infusion rate may need to be adjusted for the client? 1. Central venous pressure (CVP) is 6 mm Hg 2. Heart rate is 120 beats per minute (bpm) 3. Mean arterial pressure (MAP) is 78 mm Hg 4. Systemic vascular resistance (SVR) is 900 dynes/sec/cm-5

2 Dopamine is a sympathomimetic inotropic agent that increases heart rate, blood pressure, cardiac output, and urine output. Vital signs should be monitored closely in these clients as a higher dose can result in dangerous tachycardia and tachyarrhythmias. Normal central venous pressure is 2-8 mm Hg; normal mean arterial pressure ([systolic blood pressure + (2 x diastolic blood pressure)]/3) is 70-105 mm Hg; and normal systemic vascular resistance is 800-1200 dynes/sec/cm-5.

Which client event would be considered an adverse event and would require completion of an incident/event/irregular occurrence/variance report? Select all that apply. 1. Administered 9:00 AM medication at 9:30 AM 2. Developed worsening cellulitis after missing antibiotics for 1 day 3. Has a seizure and a history of epilepsy 4. Slides off the edge of the bed and ends up sitting on the floor 5. Waits 4 hours to be transported for STAT diagnostic CT scan

2,4,5

Which client incident would be classified as an adverse event that requires an incident/event/irregular occurrence/variance report? Select all that apply. 1. Client admitted with white blood cell count of 28,000 mm3 (28.0 × 109/L) and dies from sepsis 2. Client receives 1 mg morphine instead of prescribed 0.5 mg morphine 3. Client refuses pneumonia vaccination and contracts pneumonia 4. Nurse did not report client's new hemoglobin result of 6 g/dL (60 g/L) to oncoming nurse 5. Provider was not notified of client's positive blood culture results

2,4,5

An unrestrained, intoxicated client accidentally drives into a steel post by the hospital emergency department door. The client's head hits the windshield, splintering the glass, and the client loses consciousness. What action is a priority for the emergency department nurse? 1. Assess client for a carotid pulse 2. Open client's airway with a head tilt, chin lift maneuver 3. Place hard cervical collar on client 4. Remove client from car onto a backboard

3

The flight nurse assesses an alert and oriented client at an industrial accident scene who was impaled in the abdomen by a pair of scissors. Which nursing action is the immediate priority on arrival at the scene? 1. Insert a large-bore V line and infuse normal saline 2. Obtain blood for type and crossmatch and hemoglobin 3. Remove constrictive clothing to enhance circulation 4. Stabilize the scissors with sterile bulky dressings

4 An impaled object should not be manipulated or removed at the scene as further trauma and bleeding of soft tissue and surrounding organs may occur. The embedded object is stabilized on scene to allow for initial client assessment and later transport to a health care facility where skilled trauma care is available.

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A 13-year-old is brought to the emergency department (ED) after being in a motor vehicle collision. The client was struck in the face by the airbag and reports black spots floating in the field of vision. What intervention should the ED nurse complete first? 1. Cover both eyes with patches 2. Make client NPO 3. Notify the health care provider 4. Place client on bed rest

1

A client with acute respiratory distress syndrome is receiving positive pressure mechanical ventilation with 15 cm H2O (11 mm Hg) positive end-expiratory pressure (PEEP). The nurse should assess for which complication associated with PEEP? 1. Barotrauma 2. Decreased oxygen saturation 3. Hypertension 4. Oxygen toxicity

1

During assessment of a client who had major abdominal surgery a week ago, the nurse notes that the incision has dehisced and evisceration has occurred. The nurse stays with the client while another staff member gets sterile gauze and saline. How should the nurse position the client while waiting to cover the wound? 1. Low Fowler's position with knees bent 2. Prone to prevent further evisceration 3. Side-lying lateral position 4. Supine with head of the bed flat

1

Four clients were involved in a major highway motor vehicle accident. Which client requires priority care? 1. Client with blood pressure of 90/70 mm Hg and deviated trachea 2. Client with concussion who was unconscious for 5 minutes 3. Client with grossly swollen upper thigh and blood pressure of 80/60 mm Hg 4. Client with pain at the thoracic spine and complete paralysis of both legs

1

The client is brought to the emergency department after falling off a roof and landing on his back. A T1 spinal fracture is diagnosed. The client's blood pressure is 74/40 mm Hg, pulse is 50/min, and skin is pink and dry. What nursing action is a priority? 1. Administer IV normal saline 2. Determine if urinary occult blood is present 3. Perform a neurological assessment 4. Verify that there is no stool impaction

1

The nurse notes a change in the condition of a client in septic shock with an infected leg ulcer and positive blood cultures for methicillin-resistant Staphylococcus aureus. Which assessment finding is most important for the nurse to report to the health care provider? 1. Cold and clammy skin 2. Oxygen saturation of 92% 3. Sinus tachycardia of 118/min 4. Urine output of 0.5 mL/kg/hr

1

The oncoming nurse is receiving report on 4 clients. Which should be the priority assessment? 1. Client who had a carotid endarterectomy that day with a blood pressure of 160/88 mm Hg 2. Client who is 1 day post bowel resection with absent bowel sounds 3. Client with a pulse of 109/min who has a history of atrial fibrillation 4. Client with pancreatitis whose total parenteral nutrition is almost finished

1

A client with hypothermia has just arrived in the emergency department via ambulance. The client is being rewarmed with blankets, and the IV fluids are being changed over to warmed fluids. What additional intervention is a priority? 1. Attaching the cardiac monitor 2. Covering the client's head 3. Drawing blood for electrolytes and glucose 4. Placing an additional large-bore IV catheter

1 Cardiac monitoring and gentle handling of the client are a high priority with hypothermia. The cold myocardium is extremely irritable and prone to dysrhythmias. The nurse should anticipate defibrillation in these clients.

The nurse is preparing to defibrillate a client who suddenly went into ventricular fibrillation. Which steps are essential prior to delivering a shock? Select all that apply. 1. Apply defibrillator pads 2. Call out and look around to ensure that everyone is "all clear" 3. Continue chest compressions until ready to deliver shock 4. Ensure adequate IV sedation has been given 5. Ensure that the synchronization button is turned on

1,2,3

A nurse in the intensive care unit (ICU) is caring for a client with sepsis who is on a mechanical ventilator (MV). The client is exposed to the noise of the MV, monitoring equipment, and infusion pump alarms during the day and night. What should the nurse identify as the priority nursing diagnosis (ND)? 1. Anxiety 2. Disturbed sleep pattern 3. Powerlessness 4. Risk for acute confusion

2

When caring for a client with a left radial artery catheter, which assessment data obtained by the nurse indicates the need to take immediate action? 1. Capillary refill of less than 3 seconds 2. Left hand cooler than right 3. Mean arterial pressure of 65 mm Hg 4. Pressure bag at 300 mm Hg

2

The nurse is caring for a client who had a near-drowning accident in cold weather. Which assessment finding indicates the most severe injury? 1. Decreased body temperature 2. Toes pointed straight down 3. Weak and thready pulse 4. Wheezing on auscultation

2 Decerebrate posturing (arms and legs straight out, toes pointed down: toe pointed straight down, head/neck arched back) usually indicates severe brain injury

A client is admitted to the intensive care unit with diabetic ketoacidosis. The client is most likely to exhibit which of the following arterial blood gas results? 1. pH 7.26, PaCO2 56 mm Hg (7.5 kPa), HCO3 23 mEq/L (23 mmol/L) 2. pH 7.30, PaCO2 30 mm Hg (4.0 kPa), HCO3 15 mEq/L (15 mmol/L) 3. pH 7.40, PaCO2 40 mm Hg (5.3 kPa), HCO3 24 mEq/L (24 mmol/L) 4. pH 7.58, PaCO2 48 mm Hg (6.4 kPa), HCO3 44 mEq/L (44 mmol/L)

2 The arterial blood gas result most consistent with the diagnosis of diabetic ketoacidosis is metabolic acidosis or partially compensated metabolic acidosis (pH ≤7.30 and HCO3 ≤18 mEq/L [18 mmol/L]). Respiratory compensation may raise pH to near-normal values, but the PCO2 will be dramatically lower than normal (PCO2 ≤30 mm Hg [4.0 kPa]). metabolic acidosis (low pH and low HCO3).

Based on the progress note documentation, which priority intervention does the nurse anticipate? Click on the exhibit button for additional information. Exhibit Progress notes 2000 Client admitted to CCU #4, reporting vise-like chest pain and shortness of breath. Pulmonary artery (PA) catheter inserted by the health care provider via right internal jugular vein without difficulty. Central venous pressure (CVP) 18 mm Hg, pulmonary artery wedge pressure (PAWP) 25 mm Hg and coarse crackles auscultated bilaterally. ______________, RN 1. 0.9% sodium chloride, 500 mL intravenous bolus 2. Furosemide, 40 mg intravenous push 3. Metoprolol, 5 mg intravenous push 4. Vancomycin, 1 g intravenously every 12 hours

2 The client's central venous pressure (CVP) is elevated (normal value 2-8 mm Hg), indicating increased systemic circulation volume and increased right ventricular preload. Pulmonary artery wedge pressure (PAWP) is also elevated (normal value 6-12 mm Hg), indicating increased left ventricular preload. In the presence of increased CVP and PAWP, coarse crackles indicate left-sided failure. The treatment goal is to decrease fluid volume and preload. Furosemide is a loop diuretic that will decrease both left- and right-sided preload.

A large-scale community disaster occurs and clients must share hospital rooms due to the rapid influx of new victims. Which room assignments are appropriate in this situation? Select all that apply. 1. 2 clients on contact isolation, one with vancomycin-resistant enterococci infection and another with methicillin-resistant Staphylococcus infection 2. 2 clients with Clostridium difficile infection, one in the stool and the other in a wound 3. A client in sickle cell disease crisis and a client with streptococcal pneumonia 4. A client who had abdominal surgery today and a client with universal precautions 5. A young client in Buck's traction with an elderly client with Parkinson's disease

2,4,5

The intensive care nurse is caring for a client who has just been extubated. Which interventions are appropriate at this time? Select all that apply. 1. Administer prescribed oral narcotics for throat pain 2. Administer warmed, humidified oxygen via facemask 3. Give the client ice chips to moisten the mouth 4. Provide mouth care with oral sponges 5. Start the client on incentive spirometer

2,4,5

A client in cardiac arrest has pulseless electrical activity (PEA) and is not responding to resuscitation or medication. What should the nurse consider to help identify known, treatable causes of PEA? Select all that apply. 1. Arterial blood gas shows pH 6.9 2. Breath sounds are present on only one side 3. Capillary glucose is 310 mg/dL (17.2 mmol/L) 4. Muffled heart sounds with hypotension 5. Temperature is 102.2 F (39 C)

1,2,4

The nurse is caring for an 11 month-old child in the pediatric hospital. Which of these child's findings would be a common criterion to activate the rapid response team? Select all that apply. 1. New-onset right-sided paralysis of extremities 2. Pulse rate sustained at 120/min 3. Respirations continued at 38/min 4. Sudden inability to be aroused to an awake state 5. Temperature of 101 _3 F (38.5 C)

1, 4 Rapid response teams are formed as a means to get critical care specialists to the bedside of clients who are not in a critical care unit when acute, significant changes occur in their condition. Each institution sets its own criteria, but it usually includes acute changes in heart rate, systolic blood pressure, respiratory rate, oxygen saturation, level of consciousness, and/or urine output. Although strokes occur more commonly in adults, they can occur in children. Symptoms found in both groups can be similar, such as unilateral paralysis, which is usually found with vessel abnormalities or a hematologic complication (eg, sickle cell, cancer) (Option 1). Just as in adults, emergency treatment for children should be activated. A sudden loss of consciousness is emergent in any client (Option 4). (Option 2) Normal heart rate for an infant (1-12 months) is 100-160/min. (Option 3) Normal respiration rate for an infant (1-12 months) is 30-60/min. (Option 5) A fever is ordinarily not an emergency situation that meets the criteria to activate the rapid response team. It can signal a serious condition in infants who are age <1 month or in children age <2 years who have a temperature >104 F (40 C) without a localized source (due to an immature immune system). However, in this case, it would probably be more effective to call a health care provider to prescribe appropriate diagnostic tests (eg, complete blood count, cultures) and treatment (eg, antibiotics). A fever does not usually require immediate life-saving intervention. Educational objective: Rapid response teams are formed as a means to get critical care assistance to the bedside of clients (not in intensive care) with acute significant changes in their condition. Common criteria include sudden, significant changes in pulse rate, respiration rate, systolic blood pressure, oxygen saturation, level of consciousness, and/or urine output.

Upon arrival in the post-anesthesia care unit (PACU), the nurse performs the initial assessment of a client who had surgery under general anesthesia. Which assessment finding prompts the nurse to notify the health care provider (HCP) immediately? 1. Difficult to arouse 2. Muscle stiffness 3. Pinpoint pupils 4. Temperature 96 F (35.6 C)

2 Malignant hyperthermia (MH) is a rare, life-threatening inherited muscle abnormality that is triggered by certain drugs used to induce general anesthesia. The most specific characteristic signs and symptoms of MH include hypercapnia, muscle rigidity, and hyperthermia.

A client is brought to the emergency department after his face slammed into a brick wall during a gang fight. Which client assessment finding is most important for the nurse to consider before inserting a nasogastric tube? 1 An ecchymotic area on the forehead 2. Frontal headache rated as 10 on a 1-10 scale 3. Nasal drainage on gauze has a red spot surrounded by serous fluid 4. Small amount of bright red blood oozing from cheek laceration

3 Cerebrospinal fluid (CSF) rhinorrhea (or CSF otorrhea) can confirm that a skull fracture has occurred and transversed the dura. If the drainage is clear, dextrose testing can determine if it is CSF. However, the presence of blood would make this test unreliable as blood also contains glucose. In this case, the halo/ring test should be performed by adding a few drops of the blood-tinged fluid to gauze and assessing for the characteristic pattern of coagulated blood surrounded by CSF. Identification of this pattern is very important as CSF leakage places the client at risk for infection. The client's nose should not be packed. No nasogastric or oral gastric tube should be inserted blindly when a basilar skull fracture is suspected as there is a risk of penetrating the skull through the fracture site and having the tube ascend into the brain. These tubes are placed under fluoroscopic guidance in clients with such fractures. (Option 1) A bruise is an expected finding after direct trauma. It would be a concern if the ecchymosis were around the eyes (periorbital, "raccoon eyes") or postauricular (Battle's sign) as this generally indicates a basilar skull fracture, a tear in the dura, and a potential CSF leak. (Option 2) A headache is an expected finding after trauma. It would be a concern if it were unrelieved by non-narcotic analgesics or accompanied by signs of increased intracranial pressure. (Option 4) The head is highly vascular and it is not unusual to have blood oozing after trauma. This is not as concerning as a potential CSF leak. However, it can become a problem if the nurse is unable to eventually stop the bleeding as substantial total blood loss is a concern. Educational objective:A nasogastric tube should not be inserted when a basilar skull fracture is suspected. CSF leakage is an indication of this and can be evidenced by a positive halo/ring test of the blood-tinged nasal drainage (coagulated blood surrounded by CSF). Additional Information Reduction of Risk Potential NCSBN Client Need

The emergency department nurse receives a client with extensive injuries to the head and upper back. The nurse will perform what action to allow the best visualization of the airway? 1. Head-tilt chin-lift in the supine position on a backboard 2. Head-tilt chin-lift in the Trendelenburg position 3. Jaw-thrust maneuver in semi-Fowler's position 4. Jaw-thrust maneuver in the supine position on a backboard

4 Clinical situations involving trauma should follow ABC: Airway, Breathing, and Circulation. Airway assessment is particularly critical in clients with injuries to the head, neck, and upper back. Injury to the upper back should be treated as spinal trauma until the client has been cleared by an Advanced Trauma Life Support-qualified health care provider. Until the spine is appropriately assessed, the client should be placed on a backboard and stabilized. The nurse should use the jaw-thrust maneuver to avoid movement of an unstable spine. One provider should stabilize the cervical vertebra allowing the second provider to articulate the jaw independently of the spinal column. (Option 1) Although use of the backboard is appropriate, the head-tilt chin-lift should not be used as it involves manipulation of the neck without proper stabilization. If the cervical vertebrae are fractured, the spinal cord could be badly damaged. (Option 2) The head-tilt chin-lift does not stabilize the alignment of the head and neck and can cause spinal cord damage. In addition, the Trendelenburg position causes the abdominal organs to shift toward the diaphragm, which increases the work of breathing. (Option 3) The jaw-thrust maneuver is appropriate, but stabilization of the spine is best performed in the supine position, such as on the flat, hard surface of a backboard. Educational objective: If there is any suspicion of spinal injury, the jaw-thrust maneuver should be used for airway assessment to avoid any shifting of unstable vertebrae and subsequent spinal cord damage.

A client with a blood pressure (BP) of 250/145 mm Hg is admitted for hypertensive crisis. The health care provider prescribes a continuous IV infusion of nitroprusside sodium. Which of these is the priority goal in initial management of hypertensive crisis? 1. Decrease mean arterial pressure (MAP) by no more than 25% 2. Keep blood pressure at or below 120/80 mm Hg 3. Maintain heart rate (HR) of 60-100/min 4. Maintain urine output of at least 30 mL/hr

1

A client's wife is panic-stricken at the thought of withdrawing all life support from her husband, who is dying from end-stage chronic obstructive pulmonary disease and sepsis. She asks the nurse what he will experience when mechanical ventilation is stopped. Which statement made by the nurse is most appropriate at this time? 1. "The healthcare provider will prescribe a continuous intravenous infusion of morphine to make him more comfortable." 2. "To maintain blood flow to his heart and lungs, we will continue norepinephrine, the vasopressor, but discontinue all other medications." 3. "To prevent aspiration, we will discontinue his feeding tube and begin total parenteral nutrition to meet his nutritional needs." 4. "We will continue basic care, such as monitoring his vital signs, giving nutrition, and monitoring laboratory tests."

1

The nurse performs admission assessments on 4 clients. Which client assessment information is most concerning and needs priority care? 1. 17-year-old with suspected meningococcal meningitis who has a fever of 103 F (39.4 C), headache with photophobia, and stiff neck 2. 36-year-old who is an IV drug user with cellulitis of the arm, a fever of 103.2 F (39.6 C), and foul-smelling drainage from self-injection sites 3. 45-year-old with diabetes mellitus and osteomyelitis of the foot who has a fever of 100.9 F (38.3 C) and a serum glucose of 295 mg/dL (16.4 mmoll) 4. 76-year-old with chronic bronchitis who has a fever of 101 F (38.3 C) and a productive cough of thick green mucus

1

A client who is 2 hours post aortic valve replacement is in the intensive care unit (ICU). The low pressure alarm for the client's radial arterial line sounds. Which action should the nurse take first? 1. Check for bleeding at tube connection sites 2. Perform a fast flush of the arterial line system 3. Re-level the transducer to the phlebostatic axis 4. Zero and re-balance the monitor and system

1 A low pressure alarm for an arterial line can indicate the presence of hypotension or disconnected tubing. Hemorrhage can rapidly occur with a disconnected arterial catheter line. The nurse should check the client for the presence of hypotension and its causes before troubleshooting the system. Additional Information Physiological Adaptation NCSBN Client Need

A client with blunt trauma undergoes an exploratory laparotomy to repair the intraabdominal injury. After 24 hours, the client has a nasogastric tube attached to continual low suction, 2 Hemovac closed-wound suction abdominal drains, and is receiving IV Ringer's lactate and continual epidural morphine. The client now develops hypotension, tachycardia, oliguria, and severe nausea. What is the client's priority nursing diagnosis (ND) at this time? 1. Deficient fluid volume 2. Impaired urinary elimination 3. Nausea 4. Risk for infection

1 Deficient fluid volume, nausea, and risk for infection are appropriate NDs for a client who has undergone surgery for repair of a blunt trauma intraabdominal hemorrhagic injury. However, the priority ND addresses the highest level of risk to a client: airway, breathing, circulation (eg, hypovolemia, cardiac output), and vital signs (eg, hypotension, tachycardia).

Yesterday, the client was weaned from the mechanical ventilator and an intravenous infusion of lorazepam. The client has been alert and oriented for 24 hours but is now experiencing confusion. The nurse now evaluates new-onset confusion by assessing the client's sense of place and time, difficulty focusing, short-term memory loss, and increasing lethargy. The nurse suspects which condition in this client? 1 Amnesia 2. Delirium 3. Dementia 4 Psychosis

2

The nurse is caring for a newly admitted client with worsening cerebral edema from increased intracranial pressure (ICP). The client is intubated and is on mechanical ventilation. Which of the following nursing interventions may help reduce ICP? Select all that apply. 1. Hyperventilate before and after suctioning 2. Maintain a quiet environment 3. Maintain neutral midline head positioning 4. Perform as many nursing interventions as possible together 5. Suction for 30 (is 10) seconds to remove endotracheal tube secretions at regular intervals

1,2,3 Nursing activities can increase intracranial pressure (ICP) and should be limited and spread throughout the day. The goal is to reduce ICP while managing basic needs. Nursing interventions include elevating the head of the bed, administering stool softeners, managing pain and fever, and maintaining a calm environment.

A client with acute exacerbation of chronic obstructive pulmonary disease is intubated for mechanical ventilation. Which intervention is important in the prevention of ventilator-associated pneumonia? Select all that apply. 1. 30-45 degree elevation of the head of the bed 2. Avoid gastric over-distension 3. Maintain an endotracheal cuff pressure of at least 20 cm H2O (15 mm Hg) 4. Perform in-line endotracheal suctioning every hour 5. Perform oral care with chlorhexidine

1,2,3,5 Prevention of ventilator-associated pneumonia General -->Hand hygiene -->Noninvasive ventilation when possible -->Daily sedation vacation & weaning protocols -->Orogastric tubes Prevent aspiration -->Semirecumbent position (30°-45° angle)à semi Fowler position Aspiration of subglottic secretions -->Endotracheal tube cuff pressure >20 cm H2O -->Reduce colonization -->Oral antisepticsà chlorhexidine mouthwash -->Routine prophylaxis not recommended -->Avoid proton pump inhibitors & histamine receptor-blocking agents, if possible

Which nursing interventions are appropriate for managing the care of a client receiving mechanical ventilation and continuous IV sedation? Select all that apply. 1. Maintain the head of the bed at 30-45 degrees 2. Mute ventilator alarms at night to allow the client to rest 3. Pause sedation daily to assess weaning readiness 4. perform Oral care with chlorhexidine solution 5. Place a manual resuscitation bag at the bedside

1,3,4,5 When caring for a client requiring mechanical ventilation, the nurse should monitor respiratory status and airway patency (eg, breath sounds, insertion depth of endotracheal tube), maintain an appropriate level of sedation, assess for weaning readiness, prevent ventilator-associated infection (eg, oral care with chlorhexidine, head of the bed at 30-45 degrees), and implement safety measures (eg, emergency equipment at bedside, ventilator alarms on).

A 2-year-old at an outpatient clinic stops breathing and does not have a pulse. CPR is initiated. When the automated external defibrillator (AED) arrives, the nurse notes that it has only adult AED pads. What is the appropriate action at this time? 1. Continue CPR without using the automated external defibrillator (AED) until paramedic arrive 2. Place one AED pad on the chest and the other on the back 3. Place one AED pad on the upper right chest and the other on the lower left side 4. Place one AED pad on the upper right chest and dispose of the other

2 An automated external defibrillator (AED) should be used as soon as it is available. Adult AED pads can be used on a pediatric client if pediatric pads are unavailable. One pad is placed on the chest and the other is placed on the back ("sandwiching the heart").

A nurse in the emergency department is caring for a homeless client just brought in with frostbite to the fingers and toes. The client is experiencing numbness and assessment shows mottled skin. Which interventions should be included in the client's plan of care? Select all that apply. 1. Apply occlusive dressings after rewarming 2. Elevate affected extremities after rewarming 3. Massage the areas to increase circulation 4. Provide adequate analgesia 5. Provide continuous warm soaks

2,4,5

The nurse will anticipate administration of isotonic IV fluids in which clients? Select all that apply. 1. 14-day-old client has urine output of 2 mL/kg/hr with flat fontanel 2. 3-month-old client with diarrhea has a capillary refill of 4 seconds and mottling in lower extremities 3. 8-year-old client has serum sodium of 131 mEq/L (131 mmoll) and blood urea nitrogen of 15 mg/dL (5.4 mmol/L) 4. Client is having contractions every 10 minutes and will be receiving an epidural analgesic 5. Client received a bolus of IV fluid for hyperemesis gravidarum, and urine output is 80 mL/4 hr and pulse is 120/min

2,4,5

A client with diabetes and an infected heel ulcer is transferred to the intensive care unit because of deteriorating condition. Based on the admission assessment, what does the nurse identify as the most likely condition'? Click the exhibit button for additional information Exhibit: Vital signs at 1000 Temperature 102.8 F (39.3 C) Blood pressure 80/60 mm Hg Heart rate 110/min Respirations 36/min. labored Sp02 89% Admission notes 1000 Client is lethargic and difficult to arouse. Large amount of purulent drainage noted from left heel ulcer. Wound culture positive for Staphylococcus aureus and serum lactate level elevated. Second fluid challenge, 0.9% normal saline solution infusing at 1000 mL/hr. CVP 2 mm Hg, PAWP 3 mm Hg. Will continue to monitor. _________________________, RN 1. Multiple organ dysfunction syndrome (MODS) 2. Sepsis 3. Septic shock 4. Systemic inflammatory response syndrome (SIRS)

3

The nurse is caring for a client with surgical complications who requires continuous total parenteral nutrition (TPN). The nurse assists the health care provider with the insertion of a subclavian triple lumen central venous access device. What is the nurse's priority action before initiating the TPN infusion? 1. Attach a filter to the IV tubing 2. Check baseline fingerstick glucose levels 3. Check the results of the portable chest x-ray 4. Program the electronic infusion pump

3 Incorrect placement of a subclavian central venous catheter can result in an iatrogenic pneumothorax or hemothorax. The priority is to check the results of the chest x-ray to verify that the catheter tip has been placed correctly in the superior vena cava. Other appropriate actions include attaching a filter to the IV tubing, monitoring baseline and fingerstick BG levels every 6 hours, and programming the electronic infusion device to ensure an accurate and consistent hourly infusion rate. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

A client undergoing endotracheal intubation received IV sedation and succinylcholine. Shortly after respiratory status has been stabilized, the client becomes flushed, profusely diaphoretic, and has a rigid jaw. Which medication should the nurse prepare to administer? Click the exhibit button for more information. Exhibit: Vital signs Temperature 105 F (40.6 C) Blood pressure 140/90 mm Hg Heart rate 150/min Respirations 28/min O2 saturation 98% 1. IM epinephrine 2. IV atropine 3. IV dantrolene 4. IV glucagon

3 Malignant hyperthermia is a life-threatening hypermetabolic condition triggered by certain drugs used for general anesthesia. Prompt administration of IV dantrolene is critical. Other interventions include cooling the client and treating high potassium levels

An elderly client with acute diverticulitis develops severe sepsis. The nurse is most likely to assess which manifestations of the systemic inflammatory response syndrome (SIRS) associated with sepsis? Select all that apply. 1. Central venous pressure (CVP) 18 mm Hg 2. Mean arterial blood pressure (MAP) 80 mm Hg 3. Respirations 28/min 4. Sinus tachycardia 118/min 5. Temperature 101.2 F (38.4 C) 6. White blood cell count (WBC) 13.000 ɥL with 20% bands

3,4,5,6

A child is brought to the emergency department after falling and hitting the head while playing. The child was observed in the emergency department for 3 hours and no abnormal findings were noted. Which would be reasons to advocate for the child's admission to the hospital for continued observation? Select all that apply. 1. Child has a history of muscular dystrophy 2. Child reports a constant headache rated "3" out of 10 3. Nurse smells alcohol on the parent's breath 4. Parent does not speak English 5. Parent says the child was unconscious for 5 minutes

3,5

A 75-year-old client is hospitalized with chronic obstructive pulmonary disease (COPD) exacerbation. The health care provider (HCP) initiates noninvasive positive airway pressure ventilation (NIPPV) with a bilevel positive airway pressure (BIPAP) device. Prescribed medications are shown in the exhibit. Which parameter is most important for the nurse to monitor frequently in this client? Click on the exhibit button for additional information. Exhibit Medication prescription Albuterol and ipratropium: nebulizer, every 4 hours as needed Levofloxacin: 750 mg IV once daily Methylprednisolone: 40 mg IV, every 8 hours Enoxaparin: 40 mg subcutaneously, once daily 1. Blood glucose level 2. Capillary refill time 3. Extremity swelling 4. Mental status

4

The charge nurse is evaluating the skills of a new registered nurse (RN) assigned to care for a client with shock. Which action taken by the new RN indicates a need for further education? 1. Administers furosemide to a client with pulmonary artery wedge pressure (PAWP) of 24 mm Hg with cardiogenic shock 2. Increases norepinephrine infusion rate to maintain mean arterial pressure (MAP) ≥65 mm Hg in a client with anaphylactic shock 3. Moves pulse oximeter sensor from the finger to the forehead of a client with septic shock 4. Places the head of the bed (HOB) for a client with hypovolemic shock in high Fowler's position.

4

There has been a major disaster with the collapse of a large building. Hundreds of victims are expected. The emergency department nurse is sent to triage victims. Which client should the nurse tag "red" and send to the hospital first? 1. Client at 8 weeks gestation with spotting; pulse of 90/min 2. Client with bone piercing skin on leg with oozing laceration; pulse of 88/min 3. Client with fixed and dilated pupils and no spontaneous respirations 4. Client with see-saw chest movement with respirations

4

The nurse assesses diminished lung sounds and high-pitched wheezing in a client with acute asthma exacerbation. Arterial blood gas (ABG) findings are shown in the exhibit. Which acid-base imbalance does the nurse correctly identify? Click the exhibit button for more information. Exhibit pH 7.49 PaCO2 30 mm Hg (4 kPa) Pa02 79 mm Hg (10.5 kPa) HCO- 25 mEq/L (25 mmol/L) 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

4 This client's ABG analysis shows respiratory alkalosis. This is likely due to increased loss of acidic carbon dioxide from hyperventilation (rapid respirations). Hyperventilation due to other causes (eg, anxiety, pain) may also induce respiratory alkalosis. This client's ABG has a high pH (alkalosis), low carbon dioxide, and low oxygen level. Carbon dioxide is acidic; therefore, decreased carbon dioxide indicates a more basic (alkalotic) state due to a respiratory cause. (Option 1) In metabolic acidosis, pH is decreased (<7.35) and HCO3- is decreased (<22 mEq/L [22 mmol/L]). (Option 2) In metabolic alkalosis, pH is increased (>7.45) and HCO3- is increased (>26 mEq/L [26 mmol/L]). (Option 3) In respiratory acidosis, pH is decreased (pH <7.35) and PaCO2 is increased (>45 mm Hg [5.98 kPa]). Educational objective:Loss of acidic carbon dioxide from hyperventilation causes an increase in pH, creating a state of respiratory alkalosis.

Which would be the appropriate client criteria for activating a rapid response team at the hospital? Select all that apply. 1. Glasgow coma scale (GCS) score of 9 throughout shift 2. Heart rate remaining at 58 beats/min for more than 1 hour 3. Postoperative pain rated at 10 4. Respiratory rate maintaining an increase to 30 breaths/min 5. Sustained change in level of consciousness for 10 minutes

4,5 Rapid response criteria for unstable clients in a nonacute care setting usually include sudden, significant changes that do not respond to treatment. Recommended criteria to consider according to the Institute for Healthcare Improvement include the following: -->Any provider worried about the client's condition OR -->An acute change in any of the following:Heart rate <40 or >130/min -->Systolic blood pressure <90 mm Hg -->Respiratory rate <8 or >28/min (Option 4) -->Oxygen saturation <90 despite oxygen -->Urine output <50 mL/4 hr -->Level of consciousness (Option 5)