Mrs V final (SATA sole chaptes 1,2,9,14,19,7,8,),

You are providing patient education with active hepatitis B. What will you include in the discharge instructions. -eat large meals that are spread out throughout the day. -follow a diet low in fat and high in carbs -do not share razors, utilences, touthbrushes and other types of personal hygine -perform aerobic excerises daily -acetaminophene

ANS--follow a diet low in fat and high in carbs ANS-do not share razors, utilences, touthbrushes and other types of personal hygine

Which code drugs can be given safely through an endotracheal tube? (Select all that apply) a. Adenosine b. Atropine c. Epinephrine d. Vasopressin e. Amiodarone

ANS: B, C, D Medications that can be administered through the endotracheal tube until IV access is established are atropine, epinephrine, lidocaine, and vasopressin.

The nurse provider cares for a patient with carbon monoxide poisoning the nurse expects what findings.SATA -hyperglycemia -excessive salivation -dyspena SOB -abdominal pain -confusion

Answer- SOB, Confusion

Which statements concerning licensure as a registered nurse are correct? (Select all that apply.) a. Nurses who graduate from different types of nursing education programs are granted different types of licenses, those with a baccalaureate degree having the most expanded role. b. A nursing license cannot be revoked, only suspended. c. Each nurse practice act describes requirements for initial licensure. d. It is illegal for states to ask about the mental or physical status of an applicant. e. Students who graduate in the top 10% of their class are exempt from taking the NCLEX-RN for licensure. f. Candidates for licensure must present proof of graduation as required by the state.

ANS c. Each nurse practice act describes requirements for initial licensure. f. Candidates for licensure must present proof of graduation as required by the state.

32. SATA Which clinical manifestations of inflammatory bowel syndrome are common to patients with both ulcerative colitis and chrones disease. -dirrheal stools -cramping and abdomal pain -lesions that penetrate the intestion -strictiors are common -restricted to rectum

ANS -dirrheal stools ANS--cramping and abdomal pain

SATA- The nurse is caring for a patient with chronic pancreatitis. Which assessment findings are related to this disease process. -dirrhea -polyphagia -jaundic -weight gain -polydipisia

ANS -polyphagia ANS-jaundic ANS-polydipisia

42. Which of the following medications would not be administered to a patient experiencing pancreatitis. -Protein pumpinhibitors -histamin 2 blockers -insulin -chlorinergics -dextrose

ANS-Insulin ANS- Dextrose

SATA- The nurse is caring for a patient with colorectal cancer.Which assessment finding indicates the possibility of metastasis -elevated hemoglobin level -lower back pain -elevated bilirubin level -dry mouth -Ascities

ANS-lower back pain ANS-elevated bilirubin level ANS-Ascities

31. SATA The nurse is caring for a patient who is a recent recipient of a kidney transplant. Which intervention should the nurse perform in the immediate post op period. SATA -record central venous pressure -report for urine output more than 500 ml -notify the health care provider of a sudden decrease in urine output -monitor pt for hyponaturemia and hypokalemia -replace urine output with fluids for the first 5 hours

ANS-record CVP ANS-monitor pt for hyponaturemia and hypokalemia

You are providing education to a patient with CKD about calcium acetate. what statement made by the patient indicates they understood your teaching about the medication -Its important to consume high amounts of oatmeal, fish and deer -take this med with meals or immediately after -this med will help keep my calcium levels normal -this med will help prevent my phosphate level from increasing

ANS-the med will help prevent my phosphate level from increasing ANS--take this med with meals or immediately after

Postresuscitation goals include which of the following? (Select all that apply) a. Control dysrhythmias b. Maintain airway c. Maintain blood pressure d. Wean off oxygen e. Early ambulation

ANS: A, B, C Postresuscitation goals include optimizing tissue perfusion by airway, blood pressure maintenance, oxygenation, and control of dysrhythmias. Weaning off oxygen and early ambulation are good actions when possible but are not goals of postresuscitation care.

A patient is admitted to the hospital with multiple trauma and extensive blood loss. The nurse assesses vital signs to be BP 80/50 mm Hg, heart rate 135 beats/min, respirations 36 breaths/min, cardiac output (CO) of 2 L/min, systemic vascular resistance of 3000 dynes/sec/cm-5, and a hematocrit of 20%. The nurse anticipates administration of which the following therapies or medications? a. Blood transfusion b. Furosemide c. Dobutamine infusion d. Dopamine hydrochloride infusion

ANS: A Both hemodynamic parameters and the reported hematocrit value indicate hypovolemia and blood loss requiring volume resuscitation with blood products. Furosemide administration will worsen fluid volume status. Inotropic agents will not correct the underlying fluid volume deficit and anemia. Vasoconstrictors are contraindicated in a volume-depleted state.

A patient's ventilator settings are adjusted to treat hypoxemia. The fraction of inspired oxygen is increased from 0.6 to 0.7, and the positive end-expiratory pressure is increased from 10 to 15 cm H2O. Shortly after these adjustments, the nurse notes that the patient's blood pressure drops from 120/76 mm Hg to 90/60 mm Hg. What is the most likely cause of this decrease in blood pressure? a. Decrease in cardiac output b. Hypovolemia c. Increase in venous return d. Oxygen toxicity

ANS: A Positive end-expiratory pressure increases intrathoracic pressure and may result in decreased venous return. Cardiac output decreases as a result, and is reflected in the lower blood pressure. It is essential to assess the patient to identify optimal positive end-expiratory pressure—the highest amount that can be applied without compromising cardiac output. Although hypovolemia can result in a decrease in blood pressure, there is no indication that this patient has hypovolemia. As noted, higher levels of positive end-expiratory pressure may cause a decrease, not an increase, in venous return. Oxygen toxicity can occur in this case secondary to the high levels of oxygen needed to maintain gas exchange; however, oxygen toxicity is manifested in damage to the alveoli.

The patient tells the nurse, "I didn't think I was having a heart attack because the pain was in my neck and back." The nurse explains: (Select all that apply.) a. "Pain can occur anywhere in the chest, neck, arms, or back. Don't hesitate to call the emergency medical services if you think it's a heart attack." b. "For many people chest pain from a heart attack occurs in the center of the chest, behind the breastbone." c. "The sooner the patient can get medical help, the less damage is likely to occur in case of a heart attack." d. "You need to make sure it's a heart attack before you call the emergency response personnel." e. "Often symptoms can be treated with nitroglycerin, so be sure to take several before calling 911."

ANS: A, B, C Angina may occur anywhere in the chest, neck, arms, or back, but the most commonly described is pain or pressure behind the sternum. The pain often radiates to the left arm but can also radiate down both arms and to the back, the shoulder, the jaw, and/or the neck. In the statement about treating symptoms with nitroglycerin, the word "several" is vague.

Select the strategies for preventing deep vein thrombosis (DVT) and pulmonary embolus (PE). (Select all that apply.) a. Graduated compression stockings b. Heparin or low-molecular weight heparin for patients at risk c. Sequential compression devices d. Strict bed rest e. Leg massage

ANS: A, B, C Graduated compression stockings, sequential compression devices, and anticoagulation can reduce the risk for DVT. Physical activity can also reduce the risk; bed rest increases the risk. Leg massage is not recommended.

The nurse is caring for a patient in acute respiratory failure and understands that the patient should be positioned (Select all that apply.) a. high Fowler's. b. side lying with head of bed elevated. c. sitting in a chair. d. supine with the bed flat. e. Trendelenburg.

ANS: A, B, C Patients in respiratory distress are unable to tolerate a flat position. Trendelenburg would also be contraindicated as the weight of the organs on the lungs would inhibit movement. High Fowler's is appropriate. Side lying with head of bed elevated, sitting in a chair, and high Fowler's position are all appropriate ways to position the patient to facilitate gas exchange and comfort.

The nurse is caring for a mechanically ventilated patient and responds to a high inspiratory pressure alarm. Recognizing possible causes for the alarm, the nurse assesses for which of the following? (Select all that apply.) a. Coughing or attempting to talk b.Disconnection from the ventilator c.Kinks in the ventilator tubing d.Need for suctioning e.Spontaneous breathing

ANS: A, C, D Coughing, kinks, and mucus in the airway can cause the inspiratory pressure to increase; ventilator disconnects result in low-volume alarms. A disconnection from the ventilator would result in a low exhaled volume alarm, not a high-pressure alarm. Spontaneous breathing does not trigger alarms.

In caring for the patient who has a coagulopathy, the nurse should (Select all that apply.) a. assess fluids for occult blood. b. observe for oozing and bleeding and remove clots that form. c. limit invasive procedures. d. take temperatures rectally to increase accuracy. e. weigh dressings to assess blood loss.

ANS: A, C, E Nursing interventions specific to the patient with a coagulopathy include the following: weigh dressings to assess blood loss, assess fluids for occult blood, observe for oozing and bleeding from skin and mucous membranes, and leave clots undisturbed. Precautions such as limiting invasive procedures, including indwelling urinary catheters or rectal temperature measurement, are also important.

The nurse is caring for a patient admitted with shock. The nurse understands which assessment findings best assess tissue perfusion in a patient in shock? (Select all that apply.) a. Blood pressure b. Heart rate c. Level of consciousness d. Pupil response e. Respirations f. Urine output

ANS: A, C, F The level of consciousness assesses cerebral perfusion, urine output assesses renal perfusion, and blood pressure is a general indicator of systemic perfusion. Heart rate is not an indicator of perfusion. Pupillary response and respirations do not assess perfusion.

The first critical care units were (Select all that apply.) a.burn units. b.coronary care units. c.recovery rooms. d.neonatal intensive care units. e.high-risk OB units.

ANS: B, C Recovery rooms and coronary care units were the first units designated to care for critically ill patients. Burn, neonatal intensive care, and high-risk OB units were established as specialty units evolved.

8. Which nursing interventions would be appropriate after angioplasty? (Select all that apply.) a. Elevate the head of the bed by 45 degrees for 6 hours. b. Assess pedal pulses on the involved limb every 15 minutes for 1 to 2 hours. c. Monitor the vascular hemostatic device for signs of bleeding. d. Instruct the patient to bend his or her knee every 15 minutes while the sheath is in place. e. Maintain NPO status for 12 hours.

ANS: B, C The head of the bed must not be elevated more than 30 degrees, and the patient should be instructed to keep the affected leg straight. Bed rest is 6 to 8 hours in duration, unless a vascular hemostatic device is used. The nurse observes the patient for bleeding or swelling at the puncture site and frequently assesses adequacy of circulation to the involved extremity. NPO status does not need to be maintained after the patient is fully alert.

A college student was admitted to the emergency department after being found unconscious by a roommate. The roommate informs emergency medical personnel that the student has diabetes and has been experiencing flulike symptoms, including vomiting, since yesterday. The patient had been up all night studying for exams. The patient used the last diabetes testing supplies 3 days ago and has not had time to go to the pharmacy to refill prescription supplies. Based upon the history, which laboratory findings would be anticipated in this client? (Select all that apply.) a.Blood glucose: 43 mg/dL b.Blood glucose: 524 mg/dL c.HCO3—: 10 mEq/L d.PaCO2: 37 mm Hg e.pH: 7.23

ANS: B, C, E The patient is presenting with laboratory evidence of diabetic ketoacidosis. Diabetic ketoacidosis is characterized by hyperglycemia and low bicarbonate levels, low CO2, and low pH. A blood glucose of 43 mg/dL is indicative of hypoglycemia. The reported carbon dioxide level is normal and is not consistent with acute DKA, for which compensatory tachypnea would be expected along with a low PaCO2.

A mode of pressure-targeted ventilation that provides positive pressure to decrease the workload of spontaneous breathing through the endotracheal tube is a. continuous positive airway pressure. b. positive end-expiratory pressure. c. pressure support ventilation. d. T-piece adapter.

ANS: C Pressure support (PS) is a mode of ventilation in which the patient's spontaneous respiratory activity is augmented by the delivery of a preset amount of inspiratory positive pressure. Positive end-expiratory pressure provides positive pressure at end expiration during mechanical breaths, and continuous positive airway pressure provides positive pressure during spontaneous breaths. The T-piece adapter is used to provide oxygen with spontaneous, unassisted breaths.

Which scenarios contribute to effective handoff communication at change of shift? (Select all that apply.) a.The nephrology consultant physician is making rounds and asks you for an update on the patient's status and to assist in placing a central line for hemodialysis. b.The noise level is high because twice as many staff members are present and everyone is giving report in the nurses' station. c.The unit has decided to use a standardized checklist/tool for change-of-shift reports and patient transfers. d.You and the oncoming nurse conduct a standardized report at the patient's bedside and review key assessment findings. e.The off-going nurse is giving the patient medications at the same time as giving handoff report to the oncoming nurse.

ANS: C, D A reporting tool and bedside report improve handoff communication by ensuring standardized communication and review of assessment findings. Conducting report at the bedside also reduces noise that commonly occurs at the nurses' station during a change of shift. The nephrologist has created an interruption that can impede handoff with the next nurse. Likewise, noise in the nurses' station can cause distractions that can impair concentration and listening. Giving medications at the same time as handoff report could lead to serious errors both in medication administration and in the report itself.

Acute myocardial infarction (AMI) can be classified as which of the following? (Select all that apply.) a. Angina b. Nonischemic c. Non-Q wave d. Q wave e. Frequent PVCs

ANS: C, D AMI can be classified as Q wave or non-Q wave.

The nurse is caring for a patient with an admitting diagnosis of congestive heart failure. While attempting to obtain a pulmonary artery occlusion pressure in the supine position, the patient becomes anxious and tachypneic. What is the best action by the nurse? a. Limit the patient's supine position to no more than 10 seconds. b. Administer antianxiety medications while recording the pressure. c. Encourage the patient to take slow, deep breaths while supine. d. Elevate the head of the bed 45 degrees while recording pressures.

ANS: D Hemodynamic parameters can be accurately measured and trended with the head of the bed elevated to 45 degrees as long as the zeroing stopcock is properly leveled to the phlebostatic axis. Elevating the head of the bed to 45 degrees would be the optimum position to obtain a pulmonary artery occlusion pressure for a patient who becomes anxious and tachypneic when flat. Administering antianxiety medications is not standard of care for obtaining hemodynamic pressures. Encouraging slow, deep breaths while supine may inappropriately alter hemodynamic readings by altering intrathoracic pressure.

The nurse is caring for a mechanically ventilated patient. The providers are considering performing a tracheostomy because the patient is having difficulty weaning from mechanical ventilation. Related to tracheostomy, the nurse understands which of the following? a. Patient outcomes are better if the tracheostomy is done within a week of intubation. b. Percutaneous tracheostomy can be done safely at the bedside by the respiratory therapist. c. Procedures performed in the operating room are associated with fewer complications. d. The greatest risk after a percutaneous tracheostomy is accidental decannulation.

ANS: D Optimal timing of tracheostomy is not yet known. Percutaneous procedures done at the bedside are not associated with any higher risks than those done in the operating room. Trained physicians safely perform percutaneous tracheostomies at the bedside. The greatest risk for percutaneous tracheostomy is accidental decannulation because the trachea is not surgically attached.

A patient has been admitted with muscle trauma and crush injuries. The nurse understands that this patient is at high risk for the development of acute kidney injury secondary to rhabdomyolysis. Which findings would suggest the patient is developing this complication? (Select all that apply.) a. Dark tea-colored urine b. Decreased urine output c. Hypoxemia d. Diminished pulses e. Increased serum creatine kinase level

ANSWERS -Dark tea colored urine -increased serum creatine kinase level -decreased urine output

A patient with a 10-year history of heart failure presents to the emergency department reporting severe shortness of breath. Assessment reveals crackles throughout the lung fields and labored breathing. The patient takes beta blockers, ACE inhibitors, and diuretics as directed. What treatment strategies does the nurse plan to implement for immediate short-term management? (Select all that apply.) a. Dobutamine b. Intraaortic balloon pump c. Nesiritide d. Ventricular assist device e. Biventricular pacemaker

ANS: A, B, C This patient is showing signs and symptoms of an acute exacerbation of heart failure. Dobutamine and nesiritide are medications administered for acute short-term management; mechanical assist with an intraaortic balloon pump or insertion of a biventricular pacemaker also may be warranted as long-term therapy, but neither is appropriate for this acute exacerbation.

Numbers of white blood cells (WBCs) are increased in circumstances of (Select all that apply.) a.inflammation. b.allergy. c.invasion by pathogenic organisms. d.malnutrition. e.immune diseases.

ANS: A, B, C WBCs play a key role in the defense against infectious organisms and foreign antigens. Numbers of WBCs are increased in circumstances of inflammation, tissue injury, allergy, or invasion with pathogenic organisms. Numbers of WBCs are diminished in conditions of malnutrition, advancing age, and immune diseases.

Accepted treatments for disseminated intravascular coagulation (DIC) may require (Select all that apply.) a. platelet infusions. b. administration of fresh frozen plasma. c. cryoprecipitate. d. packed RBCs. e. heparin.

ANS: A, B, C, D Administration of platelets is the highest priority for transfusion because they provide the clotting factors needed to establish an initial platelet plug from any bleeding site. Fresh frozen plasma is administered for fibrinogen replacement. It contains all clotting factors and antithrombin III; however, factor VIII is often inactivated by the freezing process, thus necessitating administration of concentrated factor VIII in the form of cryoprecipitate. Transfusions of packed RBCs are given to replace cells lost in hemorrhage. Although heparin's antithrombin activity prevents further clotting, it may increase the risk of bleeding and may cause further problems. Its use is controversial when it is administered to patients with DIC.

he possible P waveforms that are associated with junctional rhythms include which of the following? (Select all that apply.) a. No P wave b. Inverted P wave c. Shortened PR interval d. P wave after the QRS complex e. Normal P wave and PR interval

ANS: A, B, C, D Because of the location of the AV node—in the center of the heart—impulses generated may be conducted forward, backward, or both. With the potential of forward, backward, or bidirectional impulse conduction, three different P waveforms may be associated with junctional rhythms: When the AV node impulse moves forward, P waves may be absent because the impulse enters the ventricle first. The atria receives the wave of depolarization at the same time as the ventricles; thus, because of the larger muscle mass of the ventricles, there is no P wave. When the AV node impulse is conducted backward, the impulse enters the atria first. When depolarization occurs backward, an inverted P wave is created. Once the atria have been depolarized, the impulse moves down the bundle of His and depolarizes both ventricles normally. A short PR interval (<0.12 second) is noted. When the impulse is conducted both forward and backward, P waves may be present after the QRS complex. TERM ENGLISH

Which of the following are documented as part of the cardiopulmonary arrest record? (Select all that apply) a. Medication administration times b. Defibrillation times, joules, outcomes c. Rhythm strips of cardiac rhythm(s) noted d. Signatures of recorder and other personnel e. Model of defibrillator used.

ANS: A, B, C, D Documentation includes the time the code is called, the time CPR is started, any actions that are taken, and the patient's response (e.g., presence or absence of a pulse, heart rate, blood pressure, cardiac rhythm). Intubation and defibrillation (and the energy used) must be documented, along with the patient's response. The time and sites of IV initiations, types and amounts of fluids administered, and medications given to the patient must be accurately recorded. Rhythm strips are recorded to document events and response to treatment. Signatures of those involved in the code effort, including the recorder, are essential.

The nurse is preparing for insertion of a pulmonary artery catheter (PAC). During insertion of the catheter, what are the priority nursing actions? (Select all that apply.) a. Allay the patient's anxiety by providing information about the procedure. b. Ensure that a sterile field is maintained during the insertion procedure. c. Inflate the balloon during the procedure when indicated by the provider. d. Monitor the patient's cardiac rhythm throughout the procedure. e. Obtain informed consent by informing the patient of procedural risks.

ANS: A, B, C, D During insertion of a pulmonary artery catheter (PAC/Swan-Ganz), the nurse should allay the patient's anxiety, ensure that the sterile field is maintained to decrease the risk of infection, inflate the balloon upon request of the provider to assist in catheter placement, and monitor for dysrhythmias that may occur as the catheter passes through the right ventricle. Informed consent may be witnessed by the nurse, but it is obtained by the provider and should occur before the procedure begins.

A patient is admitted with an acute myocardial infarction (AMI). The nurse monitors for which potential complications? (Select all that apply.) a.Cardiac dysrhythmias b.Heart failure c. Pericarditis d.Ventricular rupture e.Chest pain

ANS: A, B, C, D Dysrhythmias, heart failure, pericarditis and ventricular rupture are potential complications of AMI. Chest pain is a possible symptom of AMI.

Which of the following are components of the Institute for Healthcare Improvement's (IHI's) ventilator bundle? (Select all that apply.) a. Interrupt sedation each day to assess readiness to extubate. b. Maintain head of bed at least 30 degrees of elevation. c. Provide deep vein thrombosis prophylaxis. d. Provide prophylaxis for peptic ulcer disease. e. Swab the mouth with foam swabs every 2 hours.

ANS: A, B, C, D Options A, B, C, and D are components of the IHI ventilator bundle. Oral care with chlorhexidine has recently been added to the IHI bundle. Swabbing alone provides comfort care.

Sinus bradycardia is a symptom of which of the following? (Select all that apply.) a. Calcium channel blocker medication b. Beta blocker medication c. Athletic conditioning d. Hypothermia e. Hyperthyroidism

ANS: A, B, C, D Vasovagal response; medications such as digoxin or AV nodal blocking agents, including calcium channel blockers and beta blockers; myocardial infarction; normal physiological variant in the athlete; disease of the sinus node; increased intracranial pressure; hypoxemia; and hypothermia may cause sinus bradycardia. Hyperthyroidism is a cause of sinus tachycardia.

Which of the following are physiological effects of positive end-expiratory pressure (PEEP) used in the treatment of ARDS? (Select all that apply.) a. Increases functional residual capacity b. Prevents collapse of unstable alveoli c. Improves arterial oxygenation d. Opens collapsed alveoli e. Improves carbon dioxide retention

ANS: A, B, C, D Ventilatory support for ARDS typically includes PEEP to restore functional residual capacity, open collapsed alveoli, prevent collapse of unstable alveoli, and improve arterial oxygenation. PEEP does not improve CO2 retention.

36. (sole 4, SATA question #5). When providing palliative care, the nurse must keep in mind that the family may include which of the following? (Select all that apply.) a. Unmarried life partners of same sex b. Unmarried life partners of opposite sex c. Roommates d. Close friends e. Parents

ANS: A, B, C, D, E (she put that roommates were also considered) The definition of family varies and may include unmarried life partners of the same or opposite sex, close friends, and other close individuals who have no legal relationship with the patient.

Which of the following nursing activities demonstrates implementation of the AACN Standards of Professional Performance? (Select all that apply.) a.Attending a meeting of the local chapter of the American Association of Critical-Care Nurses in which a continuing education program on sepsis is being taught b.Collaborating with a pastoral services colleague to assist in meeting spiritual needs of the patient and family c.Participating on the unit's nurse practice council d.Posting an article from Critical Care Nurse on the management of venous thromboembolism for your colleagues to read e.Using evidence-based strategies to prevent ventilator-associated pneumonia

ANS: A, B, C, D, E All answers are correct. Attending a program to learn about sepsis—Acquires and maintains current knowledge and competency in patient care. Collaborating with pastoral services—Collaborates with the health care team to provide care in a healing, humane, and caring environment. Posting information for others—Contributes to the professional development of peers and other health care providers. Nurse practice council—Provides leadership in the practice setting. Evidence-based practices—Uses clinical inquiry in practice.

Benefits of having the family present during resuscitation include which of the following? (Select all that apply) a. Facilitates the grief process b. Lets the family see that everything is being done c. Sustains patient-family relationships d. Allows the staff easy access to ask for organ transplant e. Provides a sense of closure

ANS: A, B, C, E Families who have been present during a code describe the benefits as knowing that everything possible was being done for their loved one, feeling supportive and helpful to the patient and staff, sustaining patient-family relationships, providing a sense of closure on a life shared together, and facilitating the grief process.

The nurse is caring for an elderly patient who is being admitted for anemia of unknown cause. The patient has been on multiple medications at home for various ailments. In assessing the patient's medication list, the nurse notes medications that may alter hemostasis, including which of the following: (Select all that apply.) a. aminoglycosides. b. antiplatelet agents. c. cephalosporins. d. vasoconstrictors. e. sulfonamides.

ANS: A, B, C, E Medications that may alter hemostasis include aminoglycosides, anticoagulants, antiplatelet agents, cephalosporins, histamine blockers, nitrates, sulfonamides, sympathomimetics, and vasodilators.

Which nursing actions are most important for a patient with a right radial arterial line? (Select all that apply.) a. Checking the circulation to the right hand every 2 hours b. Maintaining a pressurized flush solution to the arterial line setup c. Monitoring the waveform on the monitor for dampening d. Restraining all four extremities with soft limb restraints e. Ensuring all junctions remain tightly connected

ANS: A, B, C, E Options A, B, C, and E are required to ensure proper functioning of the arterial line. There is no need to restrain all extremities. Depending on the patient's level of sedation, the right hand may need gentle restraint.

The nurse is caring for a patient with cystic fibrosis (CF) and understands that treatment consists of which of the following? (Select all that apply.) a. Airway clearance therapies b. Antibiotic therapy c. Nutritional support d. Tracheostomy e. Lung transplant

ANS: A, B, C, E The three cornerstones of care for a patient with CF are antibiotic therapy, airway clearance, and nutritional support. Lung transplant is a treatment modality for those who can get a match and who do not have current respiratory failure. A tracheostomy is not a standard treatment for CF.

When dealing with hematological malignancies, therapies that have significant management roles include which of the following: (Select all that apply.) a. chemotherapy. b. biotherapy. c. bone marrow transplantation. d. surgery. e. radiation.

ANS: A, B, C, E Therapy commonly includes chemotherapy and biotherapy. Bone marrow transplantation is used in selected cases. Surgery may be performed to establish a pathological diagnosis by excisional or incisional biopsy but has no other significant role in the management of hematological malignancies. Radiation may be used to treat lymphoma when the disease is limited to single nodes or node groups.

In an unconscious patient, eye movements are tested by the oculocephalic reflex. Which statements regarding the testing of this reflex are true? (Select all that apply.) a. Doll's eyes absent indicate a disruption in normal brainstem processing. b. Doll's eyes present indicate brainstem activity. c. Eye movement in the opposite direction as the head when turned indicates an intact reflex. d. Eye movement in the same direction as the head when turned indicates an intact reflex. e. Increased intracranial pressure (ICP) is a contraindication to the assessment of this reflex. f. Presence of cervical injuries is a contraindication to the assessment of this reflex.

ANS: A, B, C, E, F In unconscious patients with stable cervical spine, assess oculocephalic reflex (doll's eye): turn the patient's head quickly from side to side while holding the eyes open. Note movement of eyes. The doll's eye reflex is present if the eyes move bilaterally in the opposite direction of the head movement

40.(sole 6, SATA #1). Which statement(s) about total parenteral nutrition is (are) true? (Select all that apply.) a. Assessing fluid volume status and preventing infection are important nursing considerations. b. Fingerstick glucose levels are assessed every 6 hours and prn. c. Total parenteral nutrition is administered through a feeding tube and pump. d. Total parenteral nutrition, with added lipids, provides adequate levels of protein, carbohydrates, and fats. e. (somthing about soy based lipids)

ANS: A, B, D All are correct except administration via a feeding tube and pump. A tube and pump are used to deliver enteral nutrition.

Which of the following are common causes of sinus tachycardia? (Select all that apply.) a. Hyperthyroidism b. Hypovolemia c. Hypothyroidism d. Heart Failure e. Sleep

ANS: A, B, D Common causes of sinus tachycardia include hyperthyroidism, hypovolemia, heart failure, anemia, exercise, use of stimulants, fever, and sympathetic response to fear or pain and anxiety. Hypothyroidism and sleep tend to slow the heart rate.

The nurse is caring for a mechanically ventilated patient. The nurse understands that strategies to prevent ventilator-associated pneumonia include which of the following? (Select all that apply.) a. Drain condensate from the ventilator tubing away from the patient. b. Elevate the head of the bed 30 to 45 degrees. c. Instill normal saline as part of the suctioning procedure. d. Perform regular oral care with chlorhexidine. e. Awaken the patient daily to determine the need for continued ventilation.

ANS: A, B, D Condensate should be drained away from the patient to avoid drainage back into the patient's airway. Prevention guidelines recommend elevating the head of bed at 30 to 45 degrees. Regular antiseptic oral care, with an agent such as chlorhexidine, reduces oropharyngeal colonization. Daily "sedation holidays" help determine the need to continue mechanical ventilation. Normal saline is not recommended as part of the suctioning procedure, and it may increase the risk for infection.

Identify the priority interventions for managing symptoms of an acute myocardial infarction (AMI) in the ED. (Select all that apply.) a. Administration of morphine b. Administration of nitroglycerin (NTG) c. Dopamine infusion d. Oxygen therapy e. Transfusion of packed red blood cells

ANS: A, B, D The initial pain of AMI is treated with morphine sulfate administered intravenously. NTG may be given to reduce the ischemic pain of AMI. NTG increases coronary perfusion because of its vasodilatory effects. Oxygen administration is important for assisting the myocardial tissue to continue its pumping activity and for repairing the damaged tissue around the site of the infarct. Transfusion is not required except in the setting of severe anemia, which may limit oxygen delivery to the heart. Dopamine infusion is usually used to treat hypotension but causes tachycardia which would be deleterious for the patient having an AMI because it increases the heart's workload and demand for oxygen.

When performing an initial pulmonary artery occlusion pressure (PAOP), what are the best nursing actions? (Select all that apply.) a. Inflate the balloon for no more than 8 to 10 seconds while noting the waveform change. b. Inflate the balloon with air, recording the volume necessary to obtain a reading. c. Maintain the balloon in the inflated position for 8 hours following insertion. d. Zero reference and level the air-fluid interface of the transducer at the level of the phlebostatic axis. e. Inflate and deflate the balloon on an hourly schedule

ANS: A, B, D To obtain an accurate pulmonary artery occlusion pressure (PAOP), the transducer system should be zero referenced and leveled to ensure accurate readings, and the balloon should be inflated with enough air, for no more than 8 to 10 seconds until a change in waveform is noted. The volume of air necessary to inflate the balloon should be documented. Maintaining the balloon in the inflated position can lead to pulmonary infarction. There is no reason to inflate and deflate the catheter's balloon unless measurements are being obtained.

What psychosocial factors may potentially contribute to the development of diabetic ketoacidosis? (Select all that apply.) a.Altered sleep/rest patterns b.Eating disorder c.Exposure to influenza d.High levels of stress e.Lack of financial resources

ANS: A, B, D, E Psychosocial factors may lead to changes in diabetes self-management practices that precipitate diabetic ketoacidosis. Eating disorders may complicate 20% of recurrent cases of DKA in young women. Changes in sleep patterns and psychosocial stressors may lead to increased insulin demands in the face of declining self-care practices. Financial and time limitations may affect the ability to monitor for changes in control. Exposure to influenza is a physiological factor; it would not be a psychosocial factor associated with DKA.

28. (Sole 17, SATA #3).(this question on the test only showed the correct answers with 2 blank spaces) When caring for the patient with upper GI bleeding, the nurse assesses for which of the following? (Select all that apply.) a. Severity of blood loss b. Hemodynamic stability c. Vital signs every 30 minutes d. Signs of hypervolemic shock e. Necessity for fluid resuscitation

ANS: A, B, E Initial evaluation of the patient with upper GI bleeding involves a rapid assessment of the severity of blood loss, hemodynamic stability and the necessity for fluid resuscitation, and frequent monitoring of vital signs and assessments of body systems for signs of hypovolemic shock. Vital signs should be monitored at least every 15 minutes.

29. (Sole 17, SATA #4). Nursing priorities for the management of acute pancreatitis include: (Select all that apply.) a. managing respiratory dysfunction. b. assessing and maintaining electrolyte balance. c. withholding analgesics that could mask abdominal discomfort. d. stimulating gastric content motility into the duodenum. e. utilizing supportive therapies aimed at decreasing gastrin release.

ANS: A, B, E Nursing and medical priorities for the management of acute pancreatitis include several interventions. Managing respiratory dysfunction is a high priority. Fluids and electrolytes are replaced to maintain or replenish vascular volume and electrolyte balance. Analgesics are given for pain control, and supportive therapies are aimed at decreasing gastrin release from the stomach and preventing the gastric contents from entering the duodenum.

Which clinical manifestations are indicative of right ventricular failure? (Select all that apply.) a.Jugular venous distension b.Peripheral edema c.Crackles audible in the lungs d.Weak peripheral pulses e.Hepatomegaly

ANS: A, B, E Jugular venous distension, liver tenderness, hepatomegaly, and peripheral edema are signs of right ventricular failure. Crackles are indicative of left ventricular failure. Weak peripheral pulse are not a manifestation of right ventricular failure. Crackles are indicative of left sided failure.

Factors associated with the development of nephrogenic diabetes insipidus include which of the following? (Select all that apply.) a.Heredity b.Medications c.Meningitis d.Pituitary tumors e.Sickle cell disease

ANS: A, B, E Nephrogenic diabetes insipidus occurs when adequate amounts of antidiuretic hormone are produced with limited renal response. Causative factors for nephrogenic diabetes insipidus are heredity, preexisting renal disease, multisystem diseases such as multiple myeloma and sickle cell disease, chronic electrolyte disturbances, and medications such as phenytoin and lithium carbonate. Meningitis may result in neurogenic diabetes insipidus. Pituitary tumors may result in neurogenic diabetes insipidus.

Which of the following is (are) official journal(s) of the American Association of Critical-Care Nurses? (Select all that apply.) a.American Journal of Critical Care b.Critical Care Clinics of North America c.Critical Care Nurse d.Critical Care Nursing Quarterly e.Critical Care Nursing Management

ANS: A, C American Journal of Critical Care and Critical Care Nurse are two official AACN publications. Critical Care Clinics, Critical Care Nursing Quarterly, and Critical Care Nursing Management are not AACN publications.

Mechanisms for development of diabetes insipidus include which of the following? (Select all that apply.) a. ADH deficiency b.ADH excess c.ADH insensitivity d.ADH replacement therapy e. Water deprivation

ANS: A, C Diabetes insipidus is caused by either a deficiency in ADH production (neurogenic) or impaired renal response to ADH (nephrogenic). ADH excess is characteristic of syndrome of inappropriate secretion of antidiuretic hormone. ADH replacement therapy is a treatment for neurogenic diabetes insipidus. Water deprivation would result in increased ADH secretion and further augment dehydration associated with diabetes insipidus.

Identify diagnostic criteria for ARDS. (Select all that apply.) a. Bilateral infiltrates on chest x-ray study b. Decreased cardiac output c. PaO2/ FiO2 ratio of less than 200 d. Pulmonary artery occlusion pressure (PAOP) of more than 18 mm Hg e. PAOP less than 18 mm Hg

ANS: A, C Diagnostic criteria for ARDS include bilateral infiltrates, or "white out," on chest x-ray study and a low PaO2/FiO2 ratio. Decreased cardiac output and a high PAOP are seen in pulmonary edema associated with cardiac causes. The PAOP description was deleted from the current definition.

Inflammation is initiated by cellular injury and (Select all that apply.) a. is necessary for tissue repair. b. inhibits the process called chemotaxis. c. is harmful when uncontrolled. d. is less efficient when complement proteins are present. e. occurs when mediators cause vasoconstriction.

ANS: A, C Inflammation is initiated by cellular injury, is necessary for tissue repair, and is harmful when uncontrolled. When cellular injury occurs, a process called chemotaxis generates both a mediator and a neutrophil response. Mediator substances (histamine, serotonin, kinins, lysosomal enzymes, prostaglandin, platelet-activating factor, clotting factors, and complement proteins) are released at the site of injury. These mediators cause vasodilation, increase blood flow, induce capillary permeability, and promote chemotaxis and phagocytosis by neutrophils. Inflammatory symptoms such as redness, heat, pain, and swelling are sequelae of these responses. Complement proteins enhance the antibody activity, phagocytosis, and inflammation.

The nurse is caring for a patient admitted with new onset of slurred speech, facial droop, and left-sided weakness 8 hours ago. Diagnostic computed tomography scan rules out the presence of an intracranial bleed. Which actions are most important to include in the patient's plan of care? (Select all that apply.) a. Make frequent neurological assessments. b. Maintain CO2 level at 50 mm Hg. c. Maintain MAP less than 130 mm Hg. d. Prepare for thrombolytic administration. e.Restrain affected limb to prevent injury.

ANS: A, C The goal for ischemic stroke is to keep the systolic blood pressure less than 220 mm Hg and the diastolic blood pressure less than 120 mm Hg. In hemorrhagic stroke, the goal is a mean arterial pressure less than 130 mm Hg. Neurological assessments are compared with the baseline assessments performed in the ED. The elapsed time of 8 hours since onset of symptoms prohibits thrombolytic therapy. The CO2 should be maintained within normal limits; this value is elevated. The elapsed time of 8 hours since onset of symptoms prohibits thrombolytic therapy. Restraints should be avoided.

The normal width of the QRS complex is which of the following? (Select all that apply.) a. 0.06 to 0.10 seconds. b. 0.12 to 0.20 seconds. c. 1.5 to 2.5 small boxes. d. 3.0 to 5.0 small boxes. e. 0.04 seconds or greater.

ANS: A, C The waveform that initiates the QRS complex (whether it is a Q wave or an R wave) marks the beginning of the interval. The normal width of the QRS complex is 0.06 to 0.10 seconds. This width equals 1.5 to 2.5 small boxes. The normal PR interval is 0.12 to 0.20 seconds, three to five small boxes wide; not the QRS interval. A pathological Q wave has a width of 0.04 seconds and a depth that is greater than one fourth of the R wave amplitude; therefore, the QRS complex would be wider than that.

19. (Sole 15, SATA #6). The patient is in the critical care unit and will receive dialysis this morning. The nurse will: (Select all that apply.) a. evaluate morning laboratory results and report abnormal results. b. administer the patient's antihypertensive medications. c. assess the dialysis access site and report abnormalities. d. weigh the patient to monitor fluid status. e. give all medications except for antihypertensive medications.

ANS: A, C, D The patient receiving hemodialysis requires specialized monitoring and interventions by the critical care nurse. Laboratory values are monitored and abnormal results reported to the nephrologist and dialysis staff. The patient is weighed daily to monitor fluid status. On the day of dialysis, dialyzable (water-soluble) medications are not given until after treatment. The dialysis nurse or pharmacist can be consulted to determine which medications to withhold or administer. Supplemental doses are administered as ordered after dialysis. Administration of antihypertensive agents is avoided for 4 to 6 hours before treatment, if possible. Doses of other medications that lower blood pressure (narcotics, sedatives) are reduced, if possible. The percutaneous catheter, fistula, or graft is assessed frequently; unusual findings such as loss of bruit, redness, or drainage at the site must be reported. After dialysis, the patient is assessed for signs of bleeding, hypovolemia, and dialysis disequilibrium syndrome.

Which of the following is a National Patient Safety Goal? (Select all that apply.) a.Accurately identify patients. b.Eliminate the use of patient restraints. c.Reconcile medications across the continuum of care. d.Reduce risks of health care-acquired infection. e.Reduce costs associated with hospitalization.

ANS: A, C, D All except for eliminating the use of restraints and reducing costs are current National Patient Safety Goals. Hospitals have policies regarding the use of restraints and are attempting to reduce the use of restraints; however, this is not a National Patient Safety Goal. Many facilities are actively working on cost reduction, but this is not a National Patient Safety Goal either.

Which of the following statements about defibrillation are correct? (Select all that apply) a. Early defibrillation (if warranted) is recommended before other actions. b. It is not necessary to ensure that personnel are clear of the patient if hands-off defibrillation is used. c. It is not necessary to synchronize the defibrillation shocks. d. Paddles/patches can be placed anteriorly and posteriorly on the chest. e. All models of defibrillators are the same for standardization.

ANS: A, C, D Defibrillation is indicated as soon as possible because early defibrillation and CPR increase the chance of survival. Regardless of the method of defibrillation, all personnel must avoid contact with the patient or bed during the shock delivery. Shocks are delivered without synchronization. Anterior paddle placement is used most often; however, the alternative method is anteroposterior placement. Defibrillators come in many models, and nurses must ensure they are familiar with the model in use on their unit.

The nurse is caring for a patient who has atrial fibrillation. Sequelae that place the patient at greater risk for mortality/morbidity include which of the following? (Select all that apply.) a. Stroke b. Ashman beats c. Pulmonary emboli d. Prolonged PR interval e. Decreased cardiac output

ANS: A, C, E One complication of atrial fibrillation is thromboembolism. The blood that collects in the atria is agitated by fibrillation, and normal clotting is accelerated. Small thrombi, called mural thrombi, begin to form along the walls of the atria. These clots may dislodge, resulting in pulmonary embolism or stroke. The ineffectual contraction of the atria results in loss of "atrial kick." If too many impulses conduct to the ventricles, atrial fibrillation with rapid ventricular response may result and compromise cardiac output. Ashman beats are not clinically significant. No recognizable or discernible P waves are present; therefore, PR interval is absent.

Which strategy is important in addressing issues associated with the aging workforce? (Select all that apply.) a.Allowing nurses to work flexible shift durations b.Encouraging older nurses to transfer to an outpatient setting that is less stressful c.Hiring nurse technicians who are available to assist with patient care, such as turning the patient d.Remodeling patient care rooms to include devices to assist in patient lifting e.Developing a staffing model that accurately reflects the unit's needs.

ANS: A, C, D Modifying the work environment to reduce physical demands is one strategy to assist the aging workforce. Examples include overhead lifts to prevent back injuries. Twelve-hour shifts can be quite demanding; therefore, allowing nurses flexibility in choosing shifts of shorter duration is a good option as well. Adequate staffing, including both registered nurses and nonlicensed assistive personnel to help with nursing and nonnursing tasks, is helpful. Encouraging experienced, knowledgeable critical care nurses to leave the critical care unit is not wise as the unit loses the expertise of this group.

Which of the following are appropriate nursing interventions for the patient in myxedema coma? (Select all that apply.) a. Administer levothyroxine as prescribed. b.Encourage the intake of foods high in sodium. c.Initiate passive rewarming interventions. d.Monitor airway and respiratory effort. e.Monitor urine osmolality.

ANS: A, C, D Myxedema coma is a severe manifestation of hypothyroidism. Treatment entails replacement of thyroid hormone, airway management related to respiratory depression and potential airway obstruction related to tongue edema, thermoregulation, management of edema and congestive heart failure symptoms, and patient education. Edema may accompany myxedema and necessitate use of sodium restriction. Urine osmolality is monitored in conditions that affect antidiuretic hormone levels.

2).SOLE 4 A patient requires pancuronium as part of treatment of refractive increased intracranial pressure. The nursing care for this patient includes: (Select all that apply.) a. administration of sedatives concurrently with neuromuscular blockade. b.dangling the patient's feet over the edge of the bed and assisting the patient to sit up in a chair at least twice each day. c.ensuring that deep vein thrombosis prophylaxis is initiated. d.providing interventions for eye care, oral care, and skin care. e.ensuring good nutrition with frequent feedings throughout the day.

ANS: A, C, D Pancuronium is a neuromuscular blocking agent (NMB) resulting in complete paralysis of the patient. Patients receiving NMB must be provided total care, including eye, skin, and oral care interventions. Patients are at high risk for deep vein thrombosis secondary to drug-induced paralysis and bed rest. Sedatives must be administered concurrently with NMB, because NMBs have no sedative effects. Although many critically ill patients are assisted to the chair, chair activity is not appropriate for patients receiving NMB; passive exercise is most appropriate. Feeding the patient on an NMB orally is not possible.

The nurse should call the rapid response team for which patients? (Select all that apply) a. 53-year-old with pneumonia and severe respiratory distress b. 17-year-old with apnea following a severe head injury c. 24-year-old experiencing a severe asthmatic attack with stridor d. 73-year-old patient with bradycardia of 40 beats per minute e. 52-year-old patient with no palpable pulse

ANS: A, C, D Rapid response teams (RRTs) or medical emergency teams focus on addressing changes in a patient's clinical condition before a cardiopulmonary arrest occurs. The patient without a pulse and the patient with apnea needs the code team activated.

The patient is in third-degree heart block (complete heart block) and is symptomatic. The treatment for this patient is which of the following? (Select all that apply.) a. Transcutaneous pacemaker b. Atropine IV c. Temporary transvenous pacemaker d. Permanent pacemaker e. Amiodarone IV

ANS: A, C, D Treatments include transcutaneous or transvenous pacing and implanting a permanent pacemaker. Atropine reduces vagal tone, but that is not a cause of complete heart block and will produce more P waves, but the P waves will still not be associated with the QRS

Which statements are true regarding the symptoms of an AMI? (Select all that apply.) a. Dysrhythmias are common occurrences. b. Men have more atypical symptoms than women. c. Midsternal chest pain is a common presenting symptom. d. Some patients are asymptomatic. e. Patients may complain of jaw or back pain.

ANS: A, C, D, E Chest pain is a common presenting symptom in AMI. Dysrhythmias are commonly seen in AMI. Some individuals may have ischemic episodes without knowing it, thereby having a "silent" infarction. Women are more likely to have atypical signs and symptoms, such as shortness of breath, nausea and vomiting, and back or jaw pain.

A patient is admitted to the critical care unit with bradycardia at a heart rate of 39 beats/min and frequent premature ventricular contractions. The nurse notes that the patient is lethargic and reports dizziness for the past 12 hours. Which of the following are acceptable initial treatments for this patient? (Select all that apply.) a. Atropine b. Epinephrine c. Lidocaine d. Transcutaneous pacemaker e. Magnesium sulfate infusion

ANS: A, D Administer atropine, 0.5 mg IV every 3 to 5 minutes to a total dose of 3 mg for symptomatic bradycardia. Transcutaneous pacing is also indicated for symptomatic bradycardia unresponsive to atropine. Epinephrine infusion can be used if atropine is not effective but it is not a first-line choice. Lidocaine is contraindicated in bradycardia because it can depress conduction, which would be detrimental with a heart rate of 39 beats/min. Magnesium is not indicated for bradycardia.

Which of the following strategies will assist in creating a healthy work environment for the critical care nurse? (Select all that apply.) a.Celebrating improved outcomes from a nurse-driven protocol with a pizza party b.Implementing a medication safety program designed by pharmacists c.Modifying the staffing pattern to ensure a 1:1 nurse/patient ratio d.Offering quarterly joint nurse-physician workshops to discuss unit issues e.Using the Situation-Background-Assessment-Recommendation (SBAR) technique for handoff communication

ANS: A, D, E Meaningful recognition, true collaboration, and skilled communication are elements of a healthy work environment. Implementing a medication safety program enhances patient safety, but if done without nursing input, it could have negative outcomes. Staffing should be adjusted to meet patient needs and nurse competencies, not have predetermined ratios that are unrealistic and possibly unneeded.

The nurse is preparing to obtain a right atrial pressure (RAP/CVP) reading. What are the most appropriate nursing actions? (Select all that apply.) a. Compare measured pressures with other physiological parameters. b. Flush the central venous catheter with 20 mL of sterile saline. c. Inflate the balloon with 3 mL of air and record the pressure tracing. d. Obtain the right atrial pressure measurement during end exhalation. e. Zero reference the transducer system at the level of the phlebostatic axis.

ANS: A, D, E To obtain an accurate right atrial pressure (RAP/CVP) reading, the transducer system should be zero referenced and leveled with the phlebostatic axis to ensure accurate readings; the value should be obtained during end exhalation, and any obtained measure should be evaluated in light of the patient's physiological parameters and physical assessment. The catheter does not need to be flushed before measurement because continuous saline flush is part of the RAP system. There is no balloon with a right atrial pressure (RAP/CVP) catheter.

27. (Sole 17, question #2) The nurse is caring for a critically ill patient with respiratory failure who is being treated with mechanical ventilation. As part of the patient's care to prevent stress ulcers, the nurse would provide: (Select all that apply.) a. vagal stimulation. b. proton pump inhibitors. c. anticholinergic drugs d. antacids. e. cholinergic drugs.

ANS: B, C, D Administration of antacids and H2-receptor blockers, and the suppression of vagal stimulation with anticholinergic drugs and proton pump inhibitors (PPI) are effective forms of therapy.

Which of the following statements is true regarding oral care for the prevention of ventilator-associated pneumonia (VAP)? (Select all that apply.) a. Tooth brushing is performed every 2 hours for the greatest effect. b. Implementing a comprehensive oral care program is an intervention for preventing VAP. c. Oral care protocols should include oral suctioning and brushing teeth. d. Protocols that include chlorhexidine gluconate have been effective in preventing VAP. e. Using oral swabs or toothettes are just as effective as brushing the teeth.

ANS: B, C, D A comprehensive oral care protocol is an intervention for preventing VAP. It includes oral suction, brushing teeth every 12 hours, and swabbing. Chlorhexidine gluconate has been effective in patients who have undergone cardiac surgery. Actual toothbrushing is vital to the VAP bundle.

Causes of anemia include which of the following: (Select all that apply.) a. hypoxic states. b. blood loss. c. impaired production of red blood cells. d. increased destruction of red blood cells. e. chronic obstructive pulmonary disease.

ANS: B, C, D Causes of anemia include (1) blood loss (acute or chronic), (2) impaired production of RBCs, (3) increased RBC destruction, or (4) a combination of these. Polycythemia, a disorder in which the number of circulating RBCs is increased, is seen less often but can affect hypoxic patients (e.g., those with chronic obstructive pulmonary disease).

Which of the following situations may result in a low cardiac output and low cardiac index? (Select all that apply.) a. Exercise b. Hypovolemia c. Myocardial infarction d. Shock e. Fever

ANS: B, C, D Hypovolemia, myocardial infarction, and shock often result in a decreased cardiac output. Cardiac output is usually increased with exercise and fever.

The nurse is assisting with endotracheal intubation and understands that correct placement of the endotracheal tube in the trachea would be identified by which of the following? (Select all that apply.) a. Auscultation of air over the epigastrium b. Equal bilateral breath sounds upon auscultation c. Position above the carina verified by chest x-ray d. Positive detection of carbon dioxide (CO2) through CO2 detector devices e. Fogging of the endotracheal tube

ANS: B, C, D The position of the tube is assessed after intubation through auscultation of breath sounds, carbon dioxide testing, and chest x-ray. Auscultation of air over the epigastrium indicates placement in the esophagus rather than the trachea. Fogging of the ET tube does not indicate correct placement.

Autoimmunity can result from (Select all that apply.) a. recognition of tissue as "self." b. injury to tissues. c. infection. d. malignancy. e. unknown causes.

ANS: B, C, D, E In autoimmunity, the body abnormally sees self as nonself and an immune response is activated against those tissues. Autoimmunity can result from injury to tissues, infection, or malignancy, although in many cases the cause is not known.

Secondary immunodeficiency involves the loss of a previously functional immune defense system, which can be caused by (Select all that apply.) a. a single gene defect. b. AIDS. c. aging. d. nutritional deficiencies. e. immunosuppressive therapies.

ANS: B, C, D, E In primary immunodeficiency, the dysfunction exists in the immune system. Most primary immunodeficiencies are congenital disorders related to a single gene defect. Secondary or acquired immunodeficiency is the result of factors outside the immune system, is not related to a genetic defect, and involves the loss of a previously functional immune defense system. AIDS is the most notable secondary immunodeficiency disorder caused by an infection. Aging, dietary insufficiencies, malignancies, stressors (emotional, physical), immunosuppressive therapies, and certain diseases such as diabetes or sickle cell disease are additional examples of conditions that may be associated with acquired immunodeficiencies.

The nurse has been assigned the following patients. Which patients require assessment of blood glucose control as a nursing priority? (Select all that apply.) a.18-year-old male who has undergone surgical correction of a fractured femur b.29-year-old female who is undergoing evaluation for pheochromocytoma c.43-year-old male with acute pancreatitis who is receiving total parenteral nutrition (TPN) d.62-year-old morbidly obese female who underwent a hysterectomy for ovarian cancer e.72-year-old female who is receiving intravenous (IV) steroids for an exacerbation of chronic obstructive pulmonary disease (COPD)

ANS: B, C, D, E Risk factors for development of stress-induced hyperglycemia are a prior history of diabetes or hyperglycemia; obesity; pancreatitis; cirrhosis; glucocorticoids; excess epinephrine; advanced age; nutrition support; and various medications. The young male with the fractured femur is at low risk for stress-induced hyperglycemia.

30.(Sole 17, SATA #5). The patient is admitted with end-stage liver disease. The nurse evaluates the patient for which of the following? (Select all that apply.) a. Hypoglycemia b. Malnutrition c. Ascites d. Hypercoagulation e. Disseminated intravascular coagulation

ANS: B, C, E Altered carbohydrate metabolism may result in unstable blood glucose levels. The serum glucose level is usually increased to more than 200 mg/dL. This condition is termed cirrhotic diabetes. Altered carbohydrate metabolism may also result in malnutrition and a decreased stress response. Protein metabolism, albumin synthesis, and serum albumin levels are decreased. Low albumin levels are also thought to be associated with the development of ascites, a complication of hepatic failure. Fibrinogen is an essential protein that is necessary for normal clotting. A low plasma fibrinogen level, coupled with decreased synthesis of many blood-clotting factors, predisposes the patient to bleeding. Clinical signs and symptoms range from bruising and nasal and gingival bleeding to frank hemorrhage. Disseminated intravascular coagulation may also develop.

Exudate formation at the inflammatory site functions to (Select all that apply.) a. opsonize bacteria. b. dilute toxins. c. deliver proteins. d. attach to the target cell. e. carry away toxins.

ANS: B, C, E Exudate formation at the inflammatory site has three functions: dilute toxins produced, deliver proteins and leukocytes to the site, and carry away toxins and debris. Once phagocytes have been attracted to an area by the release of mediators, a process called opsonization occurs, in which antibody and complement proteins attach to the target cell and enhance the phagocyte's ability to engulf the target cell.

A patient has been successfully converted from ventricular tachycardia with a pulse to a sinus rhythm. Upon further assessment, it is noted that the patient is hypotensive. The appropriate treatment for her hypotension may include (Select all that apply) a. adenosine. b. dopamine infusion. c. magnesium. d. normal saline infusion. e. sodium bicarbonate.

ANS: B, D The patient may need fluid resuscitation; dopamine is indicated for hypotension once hypovolemia has been corrected. Adenosine, magnesium, and sodium bicarbonate are not indicated in this situation.

A patient with long-standing type 1 diabetes presents to the emergency department with a loss of consciousness and seizure activity. The patient has a history of renal insufficiency, gastroparesis, and peripheral diabetic neuropathy. Emergency personnel reported a blood glucose of 32 mg/dL on scene. When providing discharge teaching for this patient and family, the nurse instructs on the need to do which of the following? (Select all that apply.) a.Administer glucagon 1 mg intramuscularly any time the blood glucose is less than 70 mg/dL. b.Administer 15 grams of carbohydrate orally for severe episodes of hypoglycemia. c.Discontinue the insulin pump by removing the infusion set catheter. d.Increase home blood glucose monitoring and report patterns of hypoglycemia to the provider. e.Perform blood glucose monitoring before exercising and driving.

ANS: B, D, E This patient experienced a severe hypoglycemic episode. The patient is at risk for this because of a history of autonomic neuropathy as evidenced by gastroparesis, which causes erratic gastric emptying and glucose absorption, and renal insufficiency, which can result in erratic clearance of insulin. Patients with hypoglycemia unawareness should increase blood glucose monitoring; carry a glucagon emergency kit and instruct a family member or friend on administration; monitor before high-risk activities, such as driving and exercising; and use caution with alcohol ingestion. Glucagon or 50% dextrose is administered for severe hypoglycemic episodes when a patient is unconscious or extremely uncooperative. Oral glucose replacement may be dangerous in a severe reaction because of the risk of aspiration. Mild and moderate hypoglycemic reactions should be managed with oral glucose replacement. Insulin pump therapy may be suspended temporarily during a hypoglycemic episode but should not be discontinued. The infusion set catheter should not be removed during a hypoglycemic episode.

41.(Sole 6, SATA #2). Which intervention(s) is (are) critical during intravenous lipid administration? (Select all that apply). a. Assess glucose levels q6hr b. Change the tubing every 24 hours. c. Hold lipids when administering antibiotics through the same line. d. Monitor triglyceride levels. e.( maintain elevation of the head of the bed )

ANS: B, D, E? Lipids are very good media for bacterial growth; lipid tubing should be changed every 24 hours. Triglyceride levels must be monitored until stable when administering lipids.

Select all of the factors that may predispose the patient to respiratory acidosis. (Select all that apply.) a. Anxiety and fear b. Central nervous system depression c. Diabetic ketoacidosis d. Nasogastric suctioning e. Overdose of sedatives

ANS: B, E Central nervous system depression and drug overdose may result in hypoventilation and cause respiratory acidosis. Anxiety is a cause of hyperventilation and respiratory alkalosis. Diabetic ketoacidosis is a cause of metabolic acidosis. Nasogastric suctioning is a cause of metabolic alkalosis.

Cherry. In orientation, a new graduate is surprised to learn of workplace violence in healthcare agencies and asks, "What kind of violence is common in hospitals?" The educator describes workplace violence as: (Select all that apply.) a. care of patients admitted who are victims of domestic violence. b. experienced nurses withhold pertinent information from coworkers to portray them as incompetent. c. coworkers participate in employee assistance program (EAP) for support to learn more about anger management for adult children living at home. d. care of persons being held for treatment prior to be jailed incarcerated for committing homicide. e. Statements such as "The new nurse has book sense but can't perform an admission physical without the help of everyone on the unit."

ANS: B, E Withholding information from novices or coworkers to purposely cause them to appear inadequate or unskilled is considered workplace violence due to anxiety and stress it produces. This should not be tolerated and should be reported. Such statements that belittle employees lead to job dissatisfaction, lack of teamwork, and burnout and are considered lateral or workplace violence. This should not be tolerated and should be reported. Employees are not involved in the violence but compassion fatigue may result. The employee is seeking help for issues outside work. Care of the inmate with a history of violent behavior occurred prior to admission to the health care agency.

Ventricular fibrillation should initially be treated by which of the following? (Select all that apply) a. Administration of amiodarone, followed by defibrillation at 360 J b. Atropine 1 mg, followed by defibrillation at 200 J c. Defibrillation at 200 J with biphasic defibrillation d. Defibrillation at 360 J with monophasic defibrillation e. Dopamine continuous infusion.

ANS: C, D If a biphasic defibrillator is available, use the dose at which that defibrillator has been shown to be effective for terminating VF (typically 120 to 200 J). If the dose is not known, use 200 J. If a monophasic defibrillator is available, use an initial shock of 360 J and use 360 J for subsequent shocks. Dobutamine is used for hypotension not related to hypovolemia. Amiodarone can be used for ventricular fibrillation not responsive to CPR, defibrillation, and vasopressors. Atropine is not used in this situation.

The nurse is preparing to monitor intracranial pressure (ICP) with a fluid-filled monitoring system. The nurse understands which principles and/or components to be essential when implementing ICP monitoring? (Select all that apply.) a. Use of a heparin flush solution b. Manually flushing the device "prn" c. Recording ICP as a "mean" value d. Use of a pressurized flush system e. Zero referencing the transducer system

ANS: C, E Neither heparin nor pressure bags nor pressurized flush systems are used for ICP monitoring setups. ICP is recorded as a mean value with the transducer system zero referenced at the level of the foramen of Monro. Manually flushing the device may result in an increase in ICP.

Fifteen minutes after beginning a transfusion of O negative blood to a patient in shock, the nurse assesses a drop in the patient's blood pressure to 60/40 mm Hg, heart rate 135 beats/min, respirations 40 breaths/min, and a temperature of 102° F. The nurse notes the new onset of hematuria in the patient's Foley catheter. What are the priority nursing actions? (Select all that apply.) a. Administer acetaminophen. b. Document the patient's response. c. Increase the rate of transfusion. d. Notify the blood bank. e. Notify the provider. f. Stop the transfusion.

ANS: D, E, F In the event of a reaction, the transfusion is stopped, the patient is assessed, and both the physician and laboratory are notified. All transfusion equipment (bag, tubing, and remaining solutions) and any blood or urine specimens obtained are sent to the laboratory according to hospital policy. The events of the reaction, interventions used, and patient response to treatment are documented although this occurs after immediate action has been taken. Acetaminophen is not warranted in the immediate recognition and treatment of a transfusion reaction. The infusion must be stopped. Increasing the infusion further increases the likelihood of worsening the transfusion reaction.

The patient arrives in the ED with burns to the hands and face after handling hydrochloric acid. What action should the nurse perform SATA -remove all the chemical particles on skin -apply ice to the burn area -never wash the burn area -flush affected area with lots of water -remove all clothing

ANSWERS -Flush affected area with lots of water -Remove all chemical particles on skin -Remove all clothing containing the chemical

What duties are assumed by a state's board of nursing? (Select all that apply.) a. Grants nursing licensure. b. Constructs the licensure examination. c. Assigns disciplinary action when the nurse acts in a manner that results in harm to a patient. d. Assures qualified members are appointed to the board. e. Conducts certification examinations for advanced practice nurses.

Answers. A,C,D a. Grants nursing licensure. c. Assigns disciplinary action when the nurse acts in a manner that results in harm to a patient. d. Assures qualified members are appointed to the board.

SARA rn 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: Select all that apply: A. Acute kidney injury B. Dysrhythmia C. Iceberg effect D. Hypernatremia E. Bone fractures F. Fluid volume overload

The answers are A, B, C, and E. Electric burns are due to an electrical current passing through the body that leads to damage to the skin but also the muscles and bones that are underneath the skin. The patient is at risk for AKI (acute kidney injury) because when the muscles become affected they release myoglobin and the red blood cells release hemoglobin in the blood, which can collect in the kidneys leading to injury. In addition, the heart's electrical system can become damaged leading to dysrhythmia. The iceberg effect can present as well because the extent of damage is not clearly visible on the skin (there can be severe damage underneath). In addition, if the electrical current is strong enough it can lead to bone fractures (specifically cervical spine injuries) due to the severe contraction of the muscles involved.

A patient arrives to the ER with full-thickness burns on the front and back of the torso and neck. The patient has no spinal injuries but is disoriented and coughing up black sooty sputum. Vital signs are: oxygen saturation 63%, heart rate 145, blood pressure 80/56, and respiratory rate 39. As the nurse you will: A. Place the patient in High Fowler's positon. B. Prep the patient for escharotomy. C. Prep the patient for fasciotomy. D. Prep the patient for intubation. E. Place a pillow under the patient's neck. F. Obtain IV access at two sites. G. Restrict fluids.

The answers are A, B, D, and F. After reading this scenario the location of the burns and the patient's presentation should be jumping out at you. The patient is at risk for circumferential burns due to the location of the burns and the depth (full-thickness....will have eschar present that will restrict circulation or here in this example the ability of the patient to breathe in and out). Based on the patient's VS, we see that the respiratory effort is compromised majorly AND