E4

Treatment and/or prevention of rhabdomyolysis in at-risk patients includes aggressive fluid resuscitation to achieve urine output of:

100 mL/hr

The nurse is caring for a patient who is declared brain dead and is an organ donor. The following events occur: 1300 Diagnostic tests for brain death are completed. 1330 Intensivist reviews diagnostic test results and writes in the progress note that the patient is brain dead. 1400 Patient is taken to the operating room for organ retrieval. 1800 All organs have been retrieved for donation. The ventilator is discontinued. 1810 Cardiac monitor shows flatline. What is the official time of death recorded in the medical record?

1330

Which complications may manifest after an electrical injury? (Select all that apply.)

1: Long bone fractures 2: Cardiac dysrhythmias 3: Compartment syndrome of extremities 4: Dark brown urine 5: Acute cataract formation 6: Seizures

A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned?

36%

An emergency room nurse is triaging victims of a multi-casualty event. Which patient would receive care first?

A 26-year-old male who has pale, cool, clammy skin

The nurse is assisting the patient to select foods from the menu that will promote wound healing. Which statement indicates the nurse's knowledge of nutritional goals?

Choose foods that are high in protein, such as meat, eggs, and beans. These help the burns to heal."

The family of your critically ill patient tells you that they have not spoken with the physician in over 24 hours and that they have some questions they want clarified. During morning rounds, you convey this concern to the attending intensivist and arrange a meeting with the family at 4:00 PM. Which competency of critical care nursing does this represent?

Collaboration with patients, families, and team members

A 36-year-old driver was pulled from a car after it collided with a tree and the gas tank exploded. What assessment data suggest the patient suffered tissue damage consistent with a blast injury?

Crackles (rales) on auscultation of bilateral lung fields

Which of the following patients would require greater amounts of fluid resuscitation to prevent acute kidney injury associated with rhabdomyolysis? (Select all that apply.)

Crush injury to right arm Lightning strike of the left arm and chest

The nurse knows that which of the following statements about organ donation is true?

Donation of selected organs after cardiac death is ethically acceptable.

It is important to prevent hypothermia in the trauma patient because hypothermia is associated with which of the following? (Select all that apply.)

Dysrhythmias Coagulopathies Myocardial dysfunction

An emergency department nurse assesses a patient admitted after a lightning strike. Which assessment would the nurse complete first?

Electrocardiogram (ECG)

Warning signs that can assist the critical care nurse in recognizing that an ethical dilemma may exist include which of the following? (Select all that apply.)

Family members are confused about what is happening to the patient. Family members are in conflict as to the best treatment options. They disagree with each other and cannot come to consensus. The family asks that the patient not be told of treatment plans. The patients condition has changed dramatically for the worse and is not responding to conventional treatment. The physician is considering trying a medication that is not approved to treat the patients condition.

The nurse is caring for a critically ill patient with terminal cancer. The monitor alarms and shows a potentially lethal rhythm. The patient has no pulse. The patient does not have a "do not resuscitate" order written on the chart. What is the appropriate nursing action?

Initiate CPR and call a code

Which statement made by a staff nurse identifying guidelines for palliative care would need to be corrected?

Palliative care practices are reserved for the dying client.

The critical care nurse wants a better understanding of when to initiate an ethics consult. After attending an educational program, the nurse understands that the following situation would require an ethics consultation:

Patient with multiple trauma and is not responding to treatment. No family members are known, and the health care team is debating if care is futile.

A nurse working on a cardiac unit delegated taking vital signs to an experienced unlicensed assistive personnel (UAP). Four hours later, the nurse notes that the patient's blood pressure is much higher than previous readings, and the patient's mental status has changed. What action by the nurse would most likely have prevented this negative outcome?

Providing more appropriate supervision of the UAP

The nurse understands that negative-pressure wound therapy may be used in the treatment of partial- thickness burn wounds to do which of the following?

Remove excessive wound fluid and promote moist wound healing

A 63-year-old patient is admitted with new-onset fever; flulike symptoms; blisters over the arms, chest, and neck; and red, painful oral mucous membranes. The patient should be further evaluated for which possible non-burn-injured skin disorder?

Toxic epidermal necrolysis

The main purpose of certification is to

Validate knowledge of critical care nursing

A 75-year-old patient, who suffered a massive stroke 3 weeks ago, has been unresponsive and has required ventilatory support since the time of the stroke. The physician has approached the spouse regarding placement of a permanent feeding tube. The spouse states that the patient never wanted to be kept alive by tubes and personally didn't want what was being done. After holding a family conference with the spouse, the medical team concurs, and the feeding tube is not placed. This situation is an example of

Withholding life support

The nurse is caring for a patient who has been declared brain dead. The patient is considered a potential organ donor. To proceed with donation, the nurse understands that

after brain death has been determined, perfusion and oxygenation of organs is maintained until organs can be removed in the operating room.

A postsurgical patient is on a ventilator in the critical care unit. The patient has been tolerating the ventilator well and has not required any sedation. On assessment, the nurse notes the patient is tachycardic and hypertensive with an increased respiratory rate of 28 breaths/min. The patient has been suctioned recently via the endotracheal tube, and the airway is clear. The patient responds appropriately to the nurse's commands. The nurse should:

assess the patient's level of pain.

A community-based external disaster is initiated after a tornado moved through the city. A nurse from the medical records review department arrives at the emergency department asking how to assist. The best response by a nurse working for the trauma center would be to

assign the nurse administrative duties, such as obtaining patient demographic information.

Which of the following assists the critical care nurse in ensuring that care is appropriate and based on research?

clinical practice guidelines

In the trauma patient, symptoms of decreased cardiac output are most commonly caused by

hypovolemia

The assessment of pain and anxiety is a continuous process. When critically ill patients exhibit signs of anxiety, the nurse's first priority is to

identify and treat the underlying cause.

The nurse is caring for a patient admitted with a traumatic brain injury following a motor vehicle crash. Several weeks later, the patient is still ventilator dependent and unresponsive to stimulation but occasionally takes a spontaneous breath. The physician explains to the family that the patient has severe neurological impairment and is not expected to recover consciousness. The nurse recognizes that this patient is

in a persistent vegetative state.

In patients with extensive burns, edema occurs in both burned and unburned areas because of

increased capillary permeability

A patient with a 60% burn in the acute phase of treatment develops a tense abdomen, decreasing urine output, hypercapnia, and hypoxemia. Based on this assessment, the nurse anticipates interventions to evaluate and treat the patient for

intraabdominal hypertension

An autograft is used to optimally treat a partial- or full-thickness wound that (Select all that apply.)

involves a joint. involves the face, hands, or feet. requires more than 2 weeks for healing.

Silver is used as an ingredient in many burn dressings because it

is effective against a wide spectrum of wound pathogens.

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

needle thoracostomy and chest tube insertion.

A nurse caring for a patient with neurological impairment often must use painful stimuli to elicit the patient's response. The nurse uses subtle measures of painful stimuli, such as nailbed pressure. She neither slaps the patient nor pinches the nipple to elicit a response to pain. In this scenario, the nurse is exemplifying the ethical principle of

nonmaleficence

The AACN Standards for Acute and Critical Care Nursing Practice use what framework to guide critical care nursing practice?

nursing process

The nurse is caring for a patient with an electrical injury. The nurse understands that patients with electrical injury are at a high risk for acute kidney injury secondary to

release of myoglobin from injured tissues.

The nurse is managing the pain of a patient with burns. The provider has prescribed opiates to be given intramuscularly. The nurse contacts the provider to change the prescription to intravenous administration because

tissue edema may interfere with drug absorption of injectable routes.

Patients with musculoskeletal injury are at increased risk for compartment syndrome. What is an initial symptom of a suspected compartment syndrome?

Severe, throbbing pain in the affected area

A patient has been admitted to the emergency department with a massive hemothorax. What action by the nurse takes priority?

Start 2 large bore IVs

When addressing an ethical dilemma, contextual, physiological, and personal factors of the situation must be considered. Which of the following is an example of a personal factor?

The patient has told you what quality of life means and his or her wishes.

A client presents to the emergency department following a burn injury. The client has burns to the abdomen and front of the left leg. Using the rule of nines, the nurse documents the total body surface area percentage as

18%

client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned?

27%

A critically ill patient has a living will in the chart. The patient's condition has deteriorated, but the spouse wants "everything done," regardless of the patient's wishes. Which ethical principle is the spouse violating?

Autonomy

A nurse has been working as a staff nurse in the surgical intensive care unit for 2 years and is interested in certification. Which credential would be most applicable for the nurse to seek?

CCRN

The nurse is caring for patient who has been struck by lightning. Because of the nature of the injury, the nurse assesses the patient for which of the following?

Central nervous system deficits

A client is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The client has been placed in traction until his femur can be rodded in surgery. For what early complications should the nurse monitor this client? Select all that apply.

Deep vein thrombosis Compartment syndrome Fat embolism

What is the primary goal of a triage system used by the nurse with patients presenting to the emergency department?

Determine the acuity of the patient's condition to determine priority of care.

A 25-year-old client comes to the emergency department with excessive bleeding from a cut sustained when cleaning a knife. Blood work shows a prolonged PT but a vitamin K deficiency is ruled out. When assessing the client, areas of ecchymosis are noted on other areas of the body. Which of the following is the most plausible cause of the client's signs and symptoms?

Hepatic dysfunction

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

Multisystem organ dysfunction

An elderly patient who has fallen from a roof is transported to the emergency department by ambulance. The patient was unconscious at the scene but is conscious on arrival and is triaged as urgent. What is the priority assessment the nurse includes during the primary survey of the patient?

Neurological status

You work in an intermediate care unit and have asked to be involved in developing new guidelines to prevent pressure ulcers in your patient population. The nurse manager tells you that you do not yet have enough experience to be on the prevention task force and that your ideas will be rejected by others. This situation is an example of

a work environment that is unhealthy.

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

a. Placement of an intraosseous catheter

The nurse is caring for a patient with severe neurological impairment following a massive stroke. The physician has ordered tests to determine brain death. The nurse understands that criteria for brain death include (Select all that apply.)

absence of cerebral blood flow. absence of brainstem reflexes on neurological examination. flat electroencephalogram

The nurse is caring for a patient who has circumferential full-thickness burns of his forearm. A priority in the plan of care is

active or passive range-of-motion exercises every hour.

Nociceptors differ from other nerve receptors in the body in that they:

adapt very little to continual pain response

The most critical element of effective early end-of-life decision making is

effective communication among the patient, family, and health care team throughout the course of the illness.