critical care pt. 2

An unconscious patient with a traumatic head injury has a blood pressure of 126/72 mm Hg, and an intracranial pressure of 18 mm Hg. The nurse will calculate the cerebral perfusion pressure as ____________________.

(126 + (2)x 62) - ICP = 72

Which of the following values is considered normal for ICP? 0 to 15 mm Hg 25 mm Hg 35 to 45 mm Hg 120/80 mm Hg

0-15 mmHg

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

An airplane crash results in mass casualties The nurse is directing personnel to tag all victims. Which information should be placed on the tag? SATA 1. triage priority 2. identifying information when possible (such as name, age, address) 3 medications and treatments administered 4 presence of jewelry 5. next of kin

1, 2, 3

An explosion at a chemical plant produces flames and smoke. more than 20 people have burn injuries. Which victims, all adults, should be transported to a burn center? SATA 1. The victim with chemical spills on both arms 2. The victim with 3rd degree burns of both legs 3. The victim with 1st degree burns of both hands 4. The victim in respiratory distress 5. The victim who inhaled smoke

1, 2, 4, 5

The nurse is monitoring a client with increased intracranial pressure (ICP). What indicators are the most critical for the nurse to monitor? Select all that apply. 1. Systolic blood pressure. 2. Urine output. 3. Breath sounds. 4. Cerebral perfusion pressure. 5. Level of pain.

1, 4.

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

anterior and posterior trunk rule of nines

18% each

The patient is admitted with injuries that were sustained in a fall. During the nurse's first assessment upon admission, the findings are: blood pressure 90/60 (as compared to 136/66 in the emergency department), flaccid paralysis on the right, absent bowel sounds, zero urine output, and palpation of a distended bladder. These signs are consistent with which of the following? 1. paralysis 2. spinal shock 3. high cervical injury 4. temporary hypovolemia

2

12 A client is experiencing an allergic response. The nurse should perform the actions in which order from first to last? 1. assess for urticaria 2. assess the airway, and breathing pattern 3. Notify the HCP 4. Activate the rapid response team

2, 1, 4 ,3

The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for a client who had a craniotomy 12 hours ago. What should the nurse do? Select all that apply. 1. Encourage the client to cough to expectorate secretions. 2. Elevate the head of the bed 15 to 30 degrees. 3. Contact the health care provider if ICP is greater than 20 mm Hg. 4. Monitor neurologic status using the Glasgow Coma Scale. 5. Stimulate the client with active range-of- motion exercises.

2,3,4

1 A client is admitted to the ED with a headache, weakness, and slight confusion. The HCP diagnoses carbon monoxide poisoning. What should the nurse do first? 1. Initiate gastric lavage 2. Maintain body temp 3. Admin 100% O2 by mask 4. Obtain a psychiatric referral

3

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 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

What should the nurse do first when a client with a head injury begins to have clear drainage from his nose? 1. Compress the nares. 2. Tilt the head back. 3. Give the client tissues to collect the fluid. 4. Administer an antihistamine for postnasal drip.

3

Problems with memory and learning would relate to which of the following lobes? Frontal Occipital Parietal Temporal

4

The nurse is assessing a client with increas- ing intracranial pressure (ICP). The nurse should notify the health care provider about which of the following changes in the client's condition? ■ 1. Widening pulse pressure. ■ 2. Decrease in the pulse rate. ■ 3. Dilated, fixed pupils. ■ 4. Decrease in level of consciousness (LOC).

4

Which information obtained by the nurse when caring for a patient who has cardiogenic shock indicates that the patient may be developing multiple organ dysfunction syndrome (MODS)? A) The patient's serum creatinine level is elevated. B) The patient complains of intermittent chest pressure. C) The patient has crackles throughout both lung fields. D) The patient's extremities are cool and pulses are weak.

A

21. The nurse is inspecting the groin site of a patient 2 hours after IABP insertion. Which of the following would the nurse include in her assessment? Select all that apply. A) Hourly urine output B) Quality of pulses C) Bleeding at the insertion site D) Infection E) Head of the bed less than 30 degrees

A, B, C, E

A patient was in a serious motor vehicle crash. At the scene, what is the highest priority of care? A) Extrication from the vehicle B) Cervical spine protection C) Establishing two large-bore intravenous lines D) Collecting information about the crash

B

Dobutamine (Dobutrex) is used to treat a client experiencing cardiogenic shock. Nursing intervention includes: a.) Monitoring for fluid overload. b.) Monitoring for cardiac dysrhythmias. c.) Monitoring respiratory status. d.) Monitoring for hypotension.

B

A patient is brought to the ED by ambulance with a gunshot wound to the abdomen. The nurse knows that the most common hollow organ injured in this type of injury is what? A) Liver B) Small bowel C) Stomach D) Large bowel

B) Small bowel

A client develops acute renal failure (ARF) after receiving I.V. therapy with a nephrotoxic antibiotic. Because the client's 24-hour urine output totals 240 ml, the nurse suspects that the client is at risk for: a) dehydration. b) paresthesia. c) cardiac arrhythmia. d) pruritus.

C As urine output decreases, the serum potassium level rises; if it rises sufficiently, hyperkalemia may occur, possibly triggering a cardiac arrhythmia. Hyperkalemia doesn't cause paresthesia (sensations of numbness and tingling). Dehydration doesn't occur during this oliguric phase of ARF, although typically it does arise during the diuretic phase. In the client with ARF, pruritus results from increased phosphates and isn't associated with hyperkalemia.

A patient is experiencing respiratory insufficiency and cannot maintain spontaneous respirations. The nurse suspects that the physician will perform which of the following actions? A) Insert an oropharyngeal airway. B) Perform the jaw thrust maneuver. C) Perform endotracheal intubation. D) Perform a cricothyroidotomy.

C Endotracheal tubes are used in cases when the patient cannot be ventilated with an oropharyngealairway, which is used in patients who are breathing spontaneously. The jaw thrust maneuver does notestablish an airway and cricothyroidotomy would be performed as a last resort.

A patient has experienced excessive losses of bicarbonate and has subsequently developed an acidbase imbalance. How will this lost bicarbonate be replaced? A) The kidneys will excrete increased quantities of acid. B) Bicarbonate will be released from the adrenal medulla. C) Alveoli in the lungs will synthesize new bicarbonate. D) Renal tubular cells will generate new bicarbonate.

D

The nurse is caring for a patient who has a fluid volume deficit. When evaluating this patients urinalysis results, what should the nurse anticipate? A) A fluctuating urine specific gravity B) A fixed urine specific gravity C) A decreased urine specific gravity D) An increased urine specific gravity

D

When assessing a patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider? a. The patient has a positive Kernig's sign. b. The patient complains of having a stiff neck. c. The patient's temperature is 101° F (38.3° C). d. The patient's blood pressure is 86/42 mm Hg.

D

Which nursing action will the home health nurse include in the plan of care for a patient with paraplegia in order to prevent autonomic dysreflexia? a. Assist with selection of a high protein diet. b. Use quad coughing to assist cough effort. c. Discuss options for sexuality and fertility. d. Teach the purpose of a prescribed bowel program.

D Fecal impaction is a common stimulus for autonomic dysreflexia. The other actions may be included in the plan of care but will not reduce the risk for autonomic dysreflexia.

A patient with acute kidney injury (AKI) has an arterial blood pH of 7.30. The nurse will assess the patient for a. vasodilation. b. poor skin turgor. c. bounding pulses. d. rapid respirations.

D This is done to blow off excess CO2

18. What are some patient priorities during the emergent phase of burn management?

Fluid volume and respiratory status

The nurse uses topical gentamicin sulfate (Garamycin) on a client's burn injury. Which laboratory value will the nurse monitor?

Gentamicin is nephrotoxic and sufficient amounts can be absorbed through burn wounds to affect kidney function. Any client receiving gentamicin by any route should have kidney function monitored. In burn patients, the systemic absorption of topical gentamicin may be enhanced, and one should be watchful for the potential repercussions.

What is the most life-threatening effect of renal failure for which the nurse should monitor the patient?

Hyperkalemia

The nurse is caring for a patient in the oliguric phase of AKI. What does the nurse know would be the daily urine output?

Less than 400 ml

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

a

1. A 65 year old male patient has experienced full-thickness electrical burns on the legs and arms. As the nurse you know this patient is at risk for the following:

acute kidney injury dysrhythmia iceberg effect bone fractures

when should the IABP inflate

during onset of diastole, dicrotic notch

S/S of hypoxemia/hypoxia

dyspnea, altered mental status, increased BP, dysrhythmias,

Characteristic of autonomic dysreflexia

elevated BP

t or f: tidaling in the water seal chamber is okay

false

resuscitative phase

first 48 hours focus on maintaining an adequate hemodynamic status

The _____________ layer of the skin helps regulate our body temperature.

hypodermis

Four days after surgery for internal fixation of a C3 to C4 fracture, a nurse is moving a client from the bed to the wheelchair. The nurse is checking the wheelchair for correct features for this client. Which of the following features of the wheelchair are appropriate for the needs of this client? Select all that apply. ■ 1. Back at the level of the client's scapula. ■ 2. Back and head that are high. ■ 3. Seat that is lower than normal. ■ 4. Seat with firm cushions. ■ 5. Chair controlled by the client's breath.

2 , 3, 5 The client with a C3 to C4 fracture has neck control but may tire easily using sore muscles around the incision area to hold up his head. There- fore, the head and neck of his wheelchair should be high. The seat of the wheelchair should be lower than normal to facilitate transfer from the bed to the wheelchair. When a client can use his hands and arms to move the wheelchair, the placement of the back to the client's scapula is necessary. This client cannot use his arms and will need an electric chair with breath, chin, or voice control to manipulate movement of the chair. A firm or hard cushion adds pressure to bony prominences; the cushion should instead be padded to reduce the risk of pressure ulcers.

Which of the following signs and symptoms of increased ICP after head trauma would appear first? Bradycardia Large amounts of very dilute urine Restlessness and confusion Widened pulse pressure

3

A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons? To reduce intraocular pressure To prevent acute tubular necrosis To promote osmotic diuresis to decrease ICP To draw water into the vascular system to increase blood pressure

3 Mannitol promotes osmotic diuresis by increasing the pressure gradient, drawing fluid from intracellular to intravascular spaces. Although mannitol is used for all the reasons described, the reduction of ICP in this client is a concern.

8 The nurse notices a fire in a wastebasket in a clients room. in which order of priority from first to last should the nurse perform the actions? 1. confine the fire by closing the door to the clients room 2. extinguish the fire 3. remove the client from the room 4. pull the fire alarm at the alarm pull station

3, 4, 1, 2

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

Which of the following is the most sensitive indicator of renal function? a) Serum creatinine of 1.5 mg/dL b) Creatinine clearance of 90 mL/min c) Urinary protein level of 150 mg/24h. d) BUN of 20 mg/dLb

A As glomerular filtration decreases, the serum creatinine and BUN levels increase and the creatinine clearance decreases. Serum creatinine is the more sensitive indicator of renal function because of its constant production in the body. The BUN is affected not only by renal disease but also by protein intake in the diet, tissue catabolism, fluid intake, parenteral nutrition, and medications such as corticosteroids.

Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation (DIC)? a.) Hemorrhagic skin rash b.) Edema c.) Cyanosis d.) Dyspnea on exertion

A Rationale: DIC is characterized by skin petechiae and a purpuric skin rash caused by spontaneous bleeding into the tissues. An abnormal coagulation phenomenon causes the condition.

A patient arrives to the ER due to experiencing burns while in an enclosed warehouse. Which assessment findings below demonstrate the patient may have experienced an inhalation injury? A. Carbonaceous sputum B. Hair singeing on the head and nose C. Lhermitte's Sign D. Bright red lips E. Hoarse voice F. Tachycardia

A, B, D, E, F

A client has been diagnosed with sepsis. The nurse will most likely find which of the following when assessing this client: Select all that apply: a.) Rapid shallow respirations. b.) Severe hypotension. c.) Mental status changes. d.) Elevated temperature. e.) Lactic acidosis. f.) Oliguria.

A, D

complications of burns

ARF, paralytic ileus, shock, compartment syndrome, acute respiratory failure.

The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising? a.) Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. b.) Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. c.) Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. d.) Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.

B

For a client in the oliguric phase of acute renal failure (ARF), which nursing intervention is the most important? a) Providing pain-relief measures b) Limiting fluid intake c) Encouraging coughing and deep breathing d) Promoting carbohydrate intake

B) During the oliguric phase of ARF, urine output decreases markedly, possibly leading to fluid overload. Limiting oral and I.V. fluid intake can prevent fluid overload and its complications, such as heart failure and pulmonary edema. Encouraging coughing and deep breathing is important for clients with various respiratory disorders. Promoting carbohydrate intake may be helpful in ARF but doesn't take precedence over fluid limitation. Controlling pain isn't important because ARF rarely causes pain.

When the nurse applies a painful stimulus to the nail beds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as a. flexion withdrawal. b. localization of pain. c. decorticate posturing. d. decerebrate posturing.

C

A patient with hypovolemic shock has a urinary output of 15 ml/hr. The nurse understands that the compensatory physiologic mechanism that leads to altered urinary output is a.) activation of the sympathetic nervous system (SNS), causing vasodilation of the renal arteries. b.) stimulation of cardiac -adrenergic receptors, leading to increased cardiac output. c.) release of aldosterone and antidiuretic hormone (ADH), which cause sodium and water retention. d.) movement of interstitial fluid to the intravascular space, increasing renal blood flow.

C

After receiving 1000 mL of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate the administration of A) nitroglycerine (Tridil). B) drotrecogin alpha (Xigris). C) norepinephrine (Levophed). D) sodium nitroprusside (Nipride).

C

The presence of prerenal azotemia is a probable indicator for hospitalization for CAP. Which of the following is an initial laboratory result that would alert a nurse to this condition? a) BUN of 18 mg/dL. b) Glomerular filtration rate (GFR) of 100 mL/min. c) Blood urea nitrogen (BUN)-to-creatinine ratio (BUN:Cr) >20. d) Serum creatinine of 1.2 mg/dL.

C

Which action is a priority for the nurse to take when the low pressure alarm sounds for a patient who has an arterial line in the left radial artery?a. Fast flush the arterial line.b. Check the left hand for pallor.c. Assess for cardiac dysrhythmias.d. Rezero the monitoring equipment.

C

In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey? A. Complete set of vital signs B. Palpation and auscultation of the abdomen C. Brief neurologic assessment D. Initiation of pulse oximetry

C A brief neurologic assessment to determine level of consciousness and pupil reaction is part of the primary survey. Vital signs, assessment of the abdomen, and initiation of pulse oximetry are considered part of the secondary survey.

The healthcare provider is caring for a patient who has septic shock. Which of these should the healthcare provider administer to the patient first? a.) Antibiotics to treat the underlying infection. b.) Corticosteroids to reduce inflammation. c.) IV fluids to increase intravascular volume. d.) Vasopressors to increase blood pressure.

C Circulation and perfusion are addressed first so IV fluids will be started immediately. After blood cultures are obtained, broad-spectrum antibiotics should be administered without delay. Vasopressors are administered if the patient is not responding to the fluid challenge. Corticosteroids may be considered to address the inflammatory-induced vasodilation and capillary leakage

A patient has an incomplete right spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which nursing action should be included in the plan of care? a. Assessment of the patient for left leg pain b. Assessment of the patient for left arm weakness c. Positioning the patient's right leg when turning the patient d. Teaching the patient to look at the left leg to verify its position

C The patient with Brown-Séquard syndrome has loss of motor function on the ipsilateral side and will require the nurse to move the right leg. Pain sensation will be lost on the patient's left leg. Left arm weakness will not be a problem for a patient with a T7 injury. The patient will retain position sense for the left leg.

You are caring for a victim of frostbite to the feet. Place the following interventions in the correct order. a. Apply a loose, sterile, bulky dressing. b. Give pain medication. c. Remove the victim from the cold environment. d. Immerse the feet in warm water 100o F to 105o F (40.6o C to 46.1o C)

C, B, D, A

Ongoing evaluation of a patient with blunt liver trauma includes serial measurements of which of the following laboratory values? A. hematocrit B. lipase C. troponin D. amylase

a

The patient is receiving intra-aortic balloon pump (IABP) counterpulsation. What is an indication for this therapy? A) Hypotension after ST-elevation myocardial infarction refractory to other therapy

Hypotension after ST- elevation MI refractory to other therapy

An 83-year-old patient is brought in by ambulance from a long-term care facility. The patients symptoms are weakness, lethargy, incontinence, and a change in mental status. The nurse knows that emergencies in older adults may be more difficult to manage. Why would this be true?

Older adults may have an altered response to treatment.

Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndromes (MODS)?

Serum creatnine is elevated

A patient has been brought to the emergency department with a gunshot wound to the abdomen. In obtaining a history of the incident to determine possible injuries, the nurse asksa. "Where did the incident occur?"b. "What direction did the bullet enter the body?"c. "How long ago did the incident happen?"d. "What emergency care was started at the scene?"

What direction did the bullet enter the body