PCC4 Final

A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing acute respiratory distress syndrome? (Select all that apply.) A. A client who experienced a near-drowning incident B. A client following coronary artery bypass graft surgery C. A client who has a hemoglobin of 15.1 mg/dL D. A client who has dysphagia E. A client who experienced a drug overdose

A. A client who experienced a near-drowning incident B. A client following coronary artery bypass graft surgery D. A client who has dysphagia E. A client who experienced a drug overdose

A nurse is caring for a client who experienced a cervical spine injury 3 months ago. The nurse should plan to implement which of the following types of bladder management methods? A. Condom catheter B. Intermittent urinary catheterization C. Credé's method D. Indwelling urinary catheter

A. Condom catheter

A nurse is caring for a client following a thoracentesis. Which of the following manifestations should the nurse recognize as risks for complications? (Select all that apply) A. Dyspnea B. Localized bloody drainage on the dressing C. Fever D. Hypotension E. Report of pain at the puncture site

A. Dyspnea C. Fever D. Hypotension

A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? (Select all that apply.) A. Encourage the client to cough every 2 hr. B. Check for continuous bubbling in the suction chamber. C. Strip the drainage tubing every 4 hr. D. Clamp the tube once a day. E. Obtain a chest x-ray.

A. Encourage the client to cough every 2 hr. B. Check for continuous bubbling in the suction chamber. E. Obtain a chest x-ray.

A nurse is caring for a client who is receiving vecuronium for acute respiratory distress syndrome. Which of the following medications should the nurse anticipate administering with this medication? (Select all that apply.) A. Fentanyl B. Furosemide C. Midazolam D. Famotidine E. Dexamethasone

A. Fentanyl C. Midazolam

A nurse in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP? (Select all that apply.) A. Headache B. Dilated pupils C. Tachycardia D. Decorticate posturing E. Hypotension

A. Headache B. Dilated pupils D. Decorticate posturing

A nurse is caring for a client who was recently admitted to the emergency department following a head-on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, and has a laceration on his forehead that is bleeding. Which of the following is the priority nursing action at this time? A. Keep neck stabilized. B. Insert nasogastric tube. C. Monitor pulse and blood pressure frequently. D. Establish IV access and start fluid replacement.

A. Keep neck stabilized.

A nurse is preparing to care for a client following chest tube placement. Which of the following items should be available in the client's room? (Select all that apply.) A. Oxygen B. Sterile water C. Enclosed hemostat clamps D. Indwelling urinary catheter E. Occlusive dressing

A. Oxygen B. Sterile water C. Enclosed hemostat clamps E. Occlusive dressing

A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure are in the client's room? (Select all that apply.) A. Oxygen equipment B. Incentive spirometer C. Pulse oximeter D. Sterile dressing E. Suture removal kit

A. Oxygen equipment C. Pulse oximeter D. Sterile dressing

A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take? A. Position the client in an upright position, leaning over the bedside table. B. Explain the procedure. C. Obtain ABGs. D. Administer benzocaine spray

A. Position the client in an upright position, leaning over the bedside table.

A nurse is planning care for a client who has a spinal cord injury (SCI) involving a T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. Which of the following should be the nurse's highest priority? A. Prevention of further damage to the spinal cord B. Prevention of contractures of the lower extremities C. Prevention of skin breakdown of areas that lack sensation D. Prevention of postural hypotension when placing the client in a wheelchair

A. Prevention of further damage to the spinal cord

A nurse is assessing a client following gunshot wound to the chest. For which of the following findings should the nurse monitor to detect a pneumothorax? (Select all that apply) A. Tachypnea B. Deviation of the trachea C. Bradycardia D. Decreased use of accessory muscles E. Pleuritic pain

A. Tachypnea B. Deviation of the trachea E. Pleuritic pain

When caring for a patient, the nurse assesses tachypnea, a cough, and restlessness. The lung sounds have fine, scattered crackles, and the chest x-ray shows new bilateral interstitial and alveolar infiltrates. The nurse is aware that the patient may have an acute lung injury (ALI). In what order does the nurse expect the physiologic changes of acute respiratory distress syndrome (ARDS) to occur if it happens with this patient? (Answer with a letter followed by a comma and a space (e.g. A, B, C, D...).) a. Atelectasis b. Interstitial edema c. Refractory hypoxemia d. Surfactant dysfunction e. Increased inflammatory response f. Decreased gas exchange surface area

B, D, A, C, E, F b. Interstitial edema d. Surfactant dysfunction a. Atelectasis c. Refractory hypoxemia e. Increased inflammatory response f. Decreased gas exchange surface area In the injury or exudative phase of ARDS (1-7 days after acute lung injury), there is interstitial edema and surfactant dysfunction that lead to atelectasis. Widespread atelectasis decreases lung compliance, hyaline membranes form, and refractory hypoxemia occurs. In the reparative or proliferative phase (1-2 weeks after acute lung injury), there is an increased inflammatory response which worsens hypoxia. In the fibrotic phase (2-3 weeks after acute lung injury), the lung tissue is remodeled by collagen and fibrous tissue, which decreases the available surface area for gas exchange.

A nurse is orienting a newly licensed nurse who is caring for a client who is receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements by the newly licensed nurse indicates an understanding of PSV? A. "It keeps the alveoli open and prevents atelectasis." B. "It allows preset pressure delivered during spontaneous ventilation." C. "It guarantees minimal minute ventilation." D." It delivers a preset ventilatory rate and tidal volume to the client."

B. "It allows preset pressure delivered during spontaneous ventilation."

A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the following actions should the nurse take first? A. Obtain a chest x-ray. B. Apply sterile gauze to the insertion site. C. Place tape around the insertion site. D. Assess respiratory status.

B. Apply sterile gauze to the insertion site.

A nurse in the emergency department is assessing a client who has a suspected flail chest. Which of the following findings should the nurse expect? (Select all that apply.) A. Bradycardia B. Cyanosis C. Hypotension D. Dyspnea E. Paradoxic chest movement

B. Cyanosis C. Hypotension D. Dyspnea E. Paradoxic chest movement

A nursing is caring for a client who has a closed-head injury with ICP readings ranging from 16 to 22 mm Hg. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP? (Select all that apply.) A. Suction the endotracheal tube frequently B. Decrease the noise level in the client's room C. Elevate the client's head on two pillows. D. Administer a stool softener. E. Keep the client well hydrated.

B. Decrease the noise level in the client's room D. Administer a stool softener.

A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? (Select all that apply.) A. Continuous bubbling in the water seal chamber B. Gentle constant bubbling in the suction control chamber C. Rise and fall in the level of water in the water seal chamber with inspiration and expiration D. Exposed sutures without dressing E. Drainage system upright at chest level

B. Gentle constant bubbling in the suction control chamber C. Rise and fall in the level of water in the water seal chamber with inspiration and expiration

A nurse is caring for a client who has increased ICP and a new prescription for mannitol. For which of the following adverse effects should the nurse monitor? A. Hyperglycemia B. Hyponatremia C. Hypervolemia D. Oliguria

B. Hyponatremia

A nurse is reviewing the prescriptions for a client who has a pneumothorax. Which of the following actions should the nurse perform first? A. Assess the client's pain. B. Obtain a large-bore IV needle for decompression. C. Administer lorazepam. D. Prepare for chest tube insertion.

B. Obtain a large-bore IV needle for decompression.

A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? (Select all that apply.) A. Confusion B. Pale skin C. Bradycardia D. Hypotension E. Elevated blood pressure

B. Pale skin E. Elevated blood pressure

A nurse is planning care for a client who has severe acute respiratory distress system (SARS). Which of the following actions should be included in the plan of care for this client? (Select all that apply.) A. Administer antibiotics. B. Provide supplemental oxygen. C. Administer antiviral medications. D. Administer of bronchodilators. E. Maintain ventilatory support.

B. Provide supplemental oxygen. D. Administer of bronchodilators. E. Maintain ventilatory support.

A nurse is reviewing ABG laboratory results of a client who is in respiratory distress. The results are pH 7.47, PaCO2 32 mm Hg, HCO3 22 mm Hg. The nurse should recognize that the client is experiencing which of the following acid-base imbalances? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

B. Respiratory alkalosis

A nurse is caring for a client who has a spinal cord injury who reports a severe headache and is sweating profusely. Vital signs include blood pressure 220/110 mm Hg and apical heart rate 54/min. Which of the following actions should the nurse take first? A. Notify the provider. B. Sit the client upright in bed. C. Check the urinary catheter for blockage. D. Administer antihypertensive medication.

B. Sit the client upright in bed.

A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following modes of ventilation that increases the effort of the client's respiratory muscles should the nurse include in the plan of care? (Select all that apply.) A. Assist-control B. Synchronized intermittent mandatory ventilation C. Continuous positive airway pressure D. Pressure support ventilation E. Independent lung ventilation

B. Synchronized intermittent mandatory ventilation C. Continuous positive airway pressure D. Pressure support ventilation (all require that the client generate force to take spontaneous breaths)

A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client? A. Nonrebreather mask B. Venturi mask C. Nasal cannula D. Simple face mask

B. Venturi mask

A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a client who has acute respiratory distress syndrome (ARDS). Which of the following statements by the newly licensed nurse indicates understanding of the teaching? A. "This medication is given to treat infection." B."This medication is given to facilitate ventilation." C."This medication is given to decrease inflammation. D."This medication is given to reduce anxiety."

B."This medication is given to facilitate ventilation."

A Nurse in the emergency department is assessing a client who was in a motor vehicle crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6° C (101.4° F), and SaO2 92% on room air. Which of the following actions should the nurse take first? A. Obtain a chest x-ray. B. Prepare for chest tube insertion. C. Administer oxygen via a high-flow mask. D. Initiate IV access.

C. Administer oxygen via a high-flow mask.

A nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. Which of the following is the priority assessment? A. Glasgow Coma Scale B. Cranial nerve function C. Oxygen saturation D. Pupillary response

C. Oxygen saturation

A nurse is planning care of a client following placement of a chest tube 1hr ago. Which of the following actions should the nurse include in the plan of care? A. Clamp the chest tube if there is continuous bubbling in the water seal chamber B. Keep the chest tube drainage system at the level of the right atrium C. Tape all connections between the chest tube and drainage system D. Empty the collection chamber and record the amount of drainage every 8 hr

C. Tape all connections between the chest tube and drainage system

A nurse is reviewing discharge instructions for a client who experienced a pneumothorax. Which of the following statements should the nurse use when teaching the client? A. "Notify your provider if you experience weakness. B. "You should be able to return to work in 1 week." C. "You need to wear a mask when in crowded areas." D."Notify your provider if you experience a productive cough."

D."Notify your provider if you experience a productive cough."

The nurse notes tidaling of the water level in the tube submerged in the water-seal chamber in a patient with closed chest tube drainage. The nurse should a. continue to monitor the patient. b. check all connections for a leak in the system. c. lower the drainage collector further from the chest. d. clamp the tubing at progressively distal points away from the patient until the tidaling stops.

a. continue to monitor the patient.

The most common early clinical manifestations of ARDS that the nurse may observe are a. dyspnea and tachypnea. b. cyanosis and apprehension. c. hypotension and tachycardia. d. respiratory distress and frothy sputum.

a. dyspnea and tachypnea.

A 70-year-old male patient has multiple myeloma. His wife calls to report that he sleeps most of the day, is confused when awake, and complains of nausea and constipation. Which complication of cancer is this most likely caused by? a. hypercalcemia b. tumor lysis syndrome c. spinal cord compression d. superior vena cava syndrome

a. hypercalcemia

All the following are signs of fluid overload except: a. increased urine output b. tachycardia c. crackles in lungs d. edema

a. increased urine output

A nurse is caring for aclient who is receiving mechanical ventilation and develops acute respiratory distress. Which of the following actions should the nurse take first? a. initiate bag-valve-mask ventilation b. provide the client with a communication board c. obtain a blood sample for ABG analysis d. document the ventilator settings

a. initiate bag-valve-mask ventilation

During admission of a patient with a severe head injury to the emergency department, the nurse places the highest priority on assessment for a. patency of airway. b. presence of a neck injury. c. neurologic status with the Glasgow Coma Scale. d. cerebrospinal fluid leakage from the ears or nose.

a. patency of airway.

A nurse is caring for a patient who has a TBI and assumes a decerebrate posture in response to noxious stimuli. Which of the following reactions should the nurse anticipate when drawing a blood sample? a. rigid extension of arms b. internal flexion of wrists c. curling into a fetal position d. internal rotation of legs

a. rigid extension of arms A Client who exhibits a decerebrate posture rigidly extends and pronates the 4 extremities and externally rotates the wrists. Decerebrate posturing indicates a severe brain stem injury and late neurological decline

A nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching? A. Apply a vest restraint if self-extubation is attempted. B. Monitor ventilator settings every 8 hr. C. Document tube placement in centimeters at the angle of jaw. D. Assess breath sounds every 1 to 2 hr

D. Assess breath sounds every 1 to 2 hr

A nurse is caring for a client who experienced a cervical spine injury 24 hr ago. Which of the following types of prescribed medications should the nurse clarify with the provider? A. Glucocorticoids B. Plasma expanders C. H2 antagonists D. Muscle relaxants

D. Muscle relaxants

A nurse is assisting a provider with the removal of a chest tube. Which of the following should the nurse instruct the client to do? A. Lie on his left side. B. Use the incentive spirometer. C. Cough at regular intervals. D. Perform the Valsalva maneuver.

D. Perform the Valsalva maneuver.

A nurse is caring for a client who has a C4 spinal cord injury. The nurse should recognize the client is at greatest risk for which of the following complications? A. Neurogenic shock B. Paralytic ileus C. Stress ulcer D. Respiratory compromise

D. Respiratory compromise

A nurse is reviewing the lab results of a client who has metabolic alkalosis. Which of the following lab values should the nurse expect? A. pH 7.31, HCO3-22 mEq/L, PaCO2 50 mmHg B. pH 7.48, HCO3-23 mEq/L, PaCO2 25 mmHg C. pH 7.32, HCO3-18 mEq/L, PaCO2 40 mmHg D. pH 7.49, HCO3-32 mEq/L, PaCO2 40 mmHg

D. pH 7.49, HCO3-32 mEq/L, PaCO2 40 mmHg

A patient experienced head trauma in a car crash. There are many steps in the pathophysiology of the progression from injury to severe increased intracranial pressure (ICP) and death. In which order do the listed events occur? (Answer with a letter followed by a comma and a space (e.g. A, B, C, D).) a. Decreased cerebral blood flow b. Increased ICP with brainstem compression c. Increased ICP from increased blood volume d. Compression of ventricles and blood vessels e. Tissue edema from initial insult

E, F, D, A, B, C e. Tissue edema from initial insult d. Compression of ventricles and blood vessels a. Decreased cerebral blood flow b. Increased ICP with brainstem compression c. Increased ICP from increased blood volume After initial insult to the brain, there is tissue edema, which causes an initial increase in ICP, then compression of ventricles and blood vessels, which decreases cerebral blood flow, thus decreasing O2 and causing death of brain cells. Edema occurs around this necrotic tissue, and ICP is increased with compression of the brainstem and respiratory center leading to accumulation of CO2. ICP is further increased from increased blood volume that leads to death.

For a 65-year-old woman who has lived with a T1 spinal cord injury for 20 years, which health teaching instructions should the nurse emphasize? a. A mammogram is needed every year b. Bladder function tends to improve with age c. Heart disease is not common in people with spinal cord injury. d. As a person ages, the need to change body position is less important

a. A mammogram is needed every year

A patient is in acute respiratory distress syndrome (ARDS) as a result of sepsis. Which measure would be implemented to maintain cardiac output? a. Administer crystalloid fluids. b. Position the patient in the Trendelenburg position. c. Place the patient on fluid restriction and administer diuretics. d. Perform chest physiotherapy and assist with staged coughing.

a. Administer crystalloid fluids. Low cardiac output may necessitate crystalloid fluids in addition to lowering positive end-expiratory pressure (PEEP) or administering inotropes. The Trendelenburg position (not recommended to treat hypotension) and chest physiotherapy are unlikely to relieve decreased cardiac output, and fluid restriction and diuresis would be inappropriate interventions.

The nurse is providing care for an older adult patient who is experiencing low partial pressure of oxygen in arterial blood (PaO2) as a result of worsening left-sided pneumonia. Which intervention should the nurse use to help the patient mobilize his secretions? a. Augmented coughing or huff coughing b. Positioning the patient side-lying on his left side c. Frequent and aggressive nasopharyngeal suctioning d. Application of noninvasive positive pressure ventilation (NIPPV)

a. Augmented coughing or huff coughing Augmented coughing and huff coughing techniques may aid the patient in the mobilization of secretions. If positioned side-lying, the patient should be positioned on his right side (good lung down) for improved perfusion and ventilation. Suctioning may be indicated but should always be performed cautiously because of the risk of hypoxia. NIPPV is inappropriate in the treatment of patients with excessive secretions.

Which clinical manifestation would the nurse interpret as a manifestation of neurogenic shock in a patient with acute spinal cord injury? a. Bradycardia b. Hypertension c. Neurogenic spasticity d. Bounding pedal pulses

a. Bradycardia Neurogenic shock is caused by the loss of vasomotor tone after injury and is characterized by bradycardia and hypotension. Loss of sympathetic innervation causes peripheral vasodilation, venous pooling, and decreased cardiac output. Thus hypertension, neurogenic spasticity, and bounding pedal pulses are not seen in neurogenic shock.

A patient with a gunshot wound to the right side of the chest arrives in the emergency department exhibiting severe shortness of breath with decreased breath sounds on the right side of the chest. Which action should the nurse take immediately? a. Cover the chest wound with a nonporous dressing taped on three sides. b. Pack the chest wound with sterile saline soaked gauze and tape securely. c. Stabilize the chest wall with tape and initiate positive pressure ventilation. d. Apply a pressure dressing over the wound to prevent excessive loss of blood.

a. Cover the chest wound with a nonporous dressing taped on three sides. The patient has a sucking chest wound (open pneumothorax). Air enters the pleural space through the chest wall during inspiration. Emergency treatment consists of covering the wound with an occlusive dressing that is secured on three sides. During inspiration, the dressing pulls against the wound, preventing air from entering the pleural space. During expiration, the dressing is pushed out and air escapes through the wound and from under the dressing.

Which signs and symptoms differentiate hypoxemic respiratory failure from hypercapnic respiratory failure (select all that apply)? a. Cyanosis b. Tachypnea c. Morning headache d. Paradoxical breathing e. Use of pursed-lip breathing

a. Cyanosis b. Tachypnea d. Paradoxical breathing

Which assessment findings would alert the nurse that the patient has entered the diuretic phase of acute kidney injury (AKI) (select all that apply.)? a. Dehydration b. Hypokalemia c. Hypernatremia d. BUN increases e. Urine output increases f. Serum creatinine increases

a. Dehydration b. Hypokalemia e. Urine output increases

The patient has pulmonary fibrosis and experiences hypoxemia during exercise but not at rest. To plan patient care, the nurse should know the patient is experiencing which physiologic mechanism of respiratory failure? a. Diffusion limitation b. Intrapulmonary shunt c. Alveolar hypoventilation d. Ventilation-perfusion mismatch

a. Diffusion limitation The patient with pulmonary fibrosis has a thickened alveolar-capillary interface that slows gas transport, and hypoxemia is more likely during exercise than at rest. Intrapulmonary shunt occurs when alveoli fill with fluid (e.g., acute respiratory distress syndrome, pneumonia). Alveolar hypoventilation occurs when there is a generalized decrease in ventilation (e.g., restrictive lung disease, central nervous system diseases, neuromuscular diseases). Ventilation-perfusion mismatch occurs when the amount of air does not match the amount of blood that the lung receives (e.g., chronic obstructive pulmonary disease, pulmonary embolus).

What nursing intervention should be implemented for a patient experiencing increased intracranial pressure (ICP)? a. Monitor fluid and electrolyte status carefully. b. Position the patient in a high Fowler's position. c. Administer vasoconstrictors to maintain cerebral perfusion. d. Maintain physical restraints to prevent episodes of agitation.

a. Monitor fluid and electrolyte status carefully. Fluid and electrolyte disturbances can have an adverse effect on ICP and must be monitored vigilantly. The head of the patient's bed should be kept at 30 degrees in most circumstances, and physical restraints are not applied unless absolutely necessary. Vasoconstrictors are not typically administered in the treatment of ICP.

Which manifestations in a patient with a thoracic spinal cord injury (T4) should alert the nurse to possible autonomic dysreflexia? a. Headache and rising blood pressure b. Irregular respirations and shortness of breath c. Decreased level of consciousness or hallucinations d. Abdominal distention and absence of bowel sounds

a. Headache and rising blood pressure Manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic), a throbbing headache, bradycardia, and diaphoresis. Respiratory changes, decreased level of consciousness, and gastrointestinal complaints are not characteristic manifestations.

The patient has rapidly progressing glomerular inflammation. Weight has increased and urine output is steadily declining. What is the priority nursing intervention? a. Monitor the patient's cardiac status. b. Teach the patient about hand washing. c. Obtain a serum specimen for electrolytes. d. Increase direct observation of the patient.

a. Monitor the patient's cardiac status. The nurse's priority is to monitor the patient's cardiac status. With the rapidly progressing glomerulonephritis, renal function begins to fail and fluid, potassium, and hydrogen retention lead to hypervolemia, hyperkalemia, and metabolic acidosis. Excess fluid increases the workload of the heart, and hyperkalemia can lead to life-threatening dysrhythmias. Teaching about hand washing and observation of the patient are important nursing interventions but are not the priority. Electrolyte measurement is a collaborative intervention that will be done as ordered by the health care provider.

The nurse in the cardiac care unit is caring for a patient who has developed acute respiratory failure. Which medication is used to decrease patient pulmonary congestion and agitation? a. Morphine b. Albuterol c. Azithromycin d. Methylprednisolone

a. Morphine For a patient with acute respiratory failure related to the heart, morphine is used to decrease pulmonary congestion as well as anxiety, agitation, and pain. Albuterol is used to reduce bronchospasm. Azithromycin is used for pulmonary infections. Methylprednisolone is used to reduce airway inflammation and edema.

Which descriptions characterize acute kidney injury (select all that apply)? a. Primary cause of death is infection. b. It almost always affects older people. c. Disease course is potentially reversible. d. Most common cause is diabetic nephropathy. e. Cardiovascular disease is most common cause of death.

a. Primary cause of death is infection. c. Disease course is potentially reversible.

A nurse in the emergency department is assessing a client for closed pneumothorax and significant bruising of the left chest following a motor-vehicle crash. The client reports severe left chest pain on inspiration. The nurse should assess the client for which of the following manifestations of pneumothorax? a. absence of breath sounds b. expiratory wheezing c. inspiratory stridor d. rhonchi

a. absence of breath sounds

A nurse is assessing a client with a closed head injury who has received mannitol for manifestations of ICP. Which of the following findings indicates the medication is having a therapeutic effect. a. serum osmolality is 310mOsm/L b. pupils are dilated c. HR is 56/min d. client is restless

a. serum osmolality is 310mOsm/L Mannitol is an osmotic diuretic used to reduce cerebral edema by drawing water out of the brain tissue. A serum osmolarity of 310 mOsm/L is desired. A decrease in cerebral edema should result in a decrease in ICP

A nurse is caring for a client following a right pleural thoracentesis. The nurse measures a total of 35 mL of purulent drainage. Which of the following findings should the nurse recognize as an indication of a tension pneumothorax? (Select all that apply) a. tracheal deviation to the left b. temperature of 38.8 C (102 F) c. absent breath sounds on the Rt side d. neck vein distention e. bradypnea

a. tracheal deviation to the left c. absent breath sounds on the Rt side d. neck vein distention

A nurse is assessing a client who sustained a recent head injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure? a. widened pulse pressure b. tachycardia c. periorbital edema d. decrease in urine output

a. widened pulse pressure

A 19-yr-old woman is hospitalized for a frontal skull fracture from a blunt force head injury. Thin bloody fluid is draining from the patient's nose. What action by the nurse is most appropriate? a. Test the drainage for the presence of glucose. b. Apply a loose gauze pad under the patient's nose. c. Place the patient in a modified Trendelenburg position. d. Ask the patient to gently blow the nose to clear the drainage.

b. Apply a loose gauze pad under the patient's nose. Cerebrospinal fluid (CSF) rhinorrhea (clear or bloody drainage from the nose) may occur with a frontal skull fracture. A loose collection pad may be placed under the nose, and if thin bloody fluid is present, the blood will coalesce and a yellow halo will form if CSF is present. If clear drainage is present, testing for glucose would indicate the presence of CSF. Mixed blood and CSF will test positive for glucose because blood contains glucose. If CSF rhinorrhea occurs, the nurse should inform the physician immediately. The head of the bed may be raised to decrease the CSF pressure so that a tear can seal. The nurse should not place a dressing or tube in the nasal cavity, and the patient should not sneeze or blow the nose.

When caring for older adult patients with respiratory failure, the nurse will add which intervention to individualize care? a. Position the patient in the supine position primarily. b. Assess frequently for signs and symptoms of delirium. c. Provide early endotracheal intubation to reduce complications. d. Delay activity and ambulation to provide additional healing time.

b. Assess frequently for signs and symptoms of delirium. Older adult patients are more predisposed to factors such as delirium, health care associated infections, and polypharmacy. Individualizing the older patient's care plan to address these factors will improve care. Older adult patients are not required to remain in a supine position only and should increase activity as soon as stability is determined. Endotracheal intubation is not provided early, and noninvasive positive pressure ventilation may be considered as an alternative. The nurse should consider that the aging process leads to decreased lung elastic recoil, weakened lung muscles and reduced gas exchange, which may make the patient difficult to wean from the ventilator.

The nurse is caring for a patient admitted with a subdural hematoma after a motor vehicle accident. What change in vital signs would the nurse interpret as a manifestation of increased intracranial pressure (ICP)? a. Tachypnea b. Bradycardia c. Hypotension d. Narrowing pulse pressure

b. Bradycardia Bradycardia could indicate increased ICP. Changes in vital signs (known as Cushing's triad) occur with increased ICP. They consist of increasing systolic pressure with a widening pulse pressure, bradycardia with a full and bounding pulse, and irregular respirations.

During the oliguric phase of AKI, the nurse monitors the patient for (select all that apply) a. hypotension. b. ECG changes c. hypernatremia. d. pulmonary edema. e. urine with high specific gravity

b. ECG changes d. pulmonary edema.

The nurse is caring for a patient admitted to the hospital with a head injury who requires frequent neurologic assessment. Which components are assessed using the Glasgow Coma Scale (GCS) (select all that apply.)? a. Judgment b. Eye opening c. Abstract reasoning d. Best verbal response e. Best motor response f. Cranial nerve function

b. Eye opening d. Best verbal response e. Best motor response

A patient with a T4 spinal cord injury experiences neurogenic shock as a result of sympathetic nervous system dysfunction. What would the nurse recognize as characteristic of this condition? a. Tachycardia b. Hypotension c. Increased cardiac output d. Peripheral vasoconstriction

b. Hypotension

A nurse on a medical unit is caring for a client who aspirated gastric contents prior to admission. The nurse administers 100% oxygen by nonrebreather mask after the client reports severe dyspnea. Which of the following findings is a clinical manifestation of acute respiratory distress syndrome (ARDS)? a. tympanic temperature 38 celcius (100.4 F) b. PaO2 50 mmHg c. Rhonchi d. Hypopnea

b. PaO2 50 mmHg

When caring for a patient with acute respiratory distress syndrome (ARDS), which finding indicates therapy is appropriate? a. pH is 7.32. b. PaO2 is greater than or equal to 60 mm Hg. c. PEEP increased to 20 cm H2O caused BP to fall to 80/40. d. No change in PaO2 when patient is turned from supine to prone position

b. PaO2 is greater than or equal to 60 mm Hg. The overall goal in caring for the patient with ARDS is for the PaO2 to be greater than or equal to 60 mm Hg with adequate lung ventilation to maintain a normal pH of 7.35 to 7.45. PEEP is usually increased for ARDS patients, but a dramatic reduction in BP indicates a complication of decreased cardiac output. A positive occurrence is a marked improvement in PaO2 from perfusion better matching ventilation when the anterior air-filled, nonatelectatic alveoli become dependent in the prone position.

The nurse is caring for a 68-yr-old man who had coronary artery bypass surgery 3 weeks ago. During the oliguric phase of acute kidney disease, which action would be appropriate to include in the plan of care? a. Provide foods high in potassium. b. Restrict fluids based on urine output. c. Monitor output from peritoneal dialysis. d. Offer high-protein snacks between meals.

b. Restrict fluids based on urine output. Fluid intake is monitored during the oliguric phase. Fluid intake is determined by adding all losses for the previous 24 hours plus 600 mL. Potassium and protein intake may be limited in the oliguric phase to avoid hyperkalemia and elevated urea nitrogen. Hemodialysis, not peritoneal dialysis, is indicated in acute kidney injury if dialysis is needed.

A 25-year-old man was recently diagnosed with leukemia. He is admitted to the hospital for further evaluation and chemotherapy initiation. He only complains of fatigue and malaise. Laboratory evaluation reveals pancytopenia, hyperkalemia (K 6.8), uric acid 13, hyperphosphatemia (12), and elevated lactate dehydrogenase (LDH). What is the most likely cause of his electrolyte abnormalities? a. Laboratory error b. Tumor lysis syndrome c. Hypercalcemia d. Acute renal failure

b. Tumor lysis syndrome

Vasogenic cerebral edema increases intracranial pressure by a. shifting fluid in the gray matter b. altering the endothelial lining of cerebral capillaries c. leaking molecules from the intracellular fluid to the capillaries. d. altering the osmotic gradient flow into the intravascular component

b. altering the endothelial lining of cerebral capillaries

The most common early symptom of a spinal cord tumor is a. urinary incontinence. b. back pain that worsens with activity. c. paralysis below the level of involvement d. impaired sensation of pain, temperature, and light touch.

b. back pain that worsens with activity.

A nurse is caring for a client who is in the oliguric-anuric stage of acute kidney injury. The client reports diarrhea, a dull headache, palpitations, and muscle tingling and weakness. Which of the following actions should the nurse take first? a. administer an analgesic b. check the electrolyte values c. measure the client's weight d. restrict the client's protein intake

b. check the electrolyte values

An ER nurse is assessing a client who sustained a fall off a roof. Which of the following findings should the nurse identify as an indication of a basilar skull fracture? a. depressed fracture of forehead b. clear fluid coming from nares c. black and blue discoloration around eyes d. bleeding from top of scalp

b. clear fluid coming from nares

A nurse plans care for the patient with increased intracranial pressure with the knowledge that the best way to position the patient is to a. keep the head of the bed flat. b. elevate the head of the bed to 30 degrees. c. maintain patient on the left side with the head supported on a pillow. d. use a continuous-rotation bed to continuously change patient position

b. elevate the head of the bed to 30 degrees.

The nurse is caring for a patient receiving an initial dose of chemotherapy to treat a rapidly growing metastatic colon cancer. The nurse is aware that the patient is at risk for tumor lysis syndrome (TLS) and will monitor for which abnormality associated with this oncologic emergency? a. hypokalemia b. hypocalcemia c. hypouricemia d. hypophosphatemia

b. hypocalcemia TLS is a metabolic complication characterized by rapid release of intracellular components in response to chemotherapy. This can rapidly lead to acute renal injury. The hallmark signs of TLS are hyperuricemia, hyperphosphatemia, hyperkalemia, and hypocalcemia.

A nurse is preparing an in-service about the stages of acute kidney injury. Which of the following pieces of information should the nurse include about prerenal azotemia? a. prerenal azotemia begins prior to the onset of symptoms b. interference with renal perfusion causes prerenal azotemia c. prerenal azotemia is irreversible, even in the early stages d. infections and tumors cause prerenal azotemia

b. interference with renal perfusion causes prerenal azotemia

A client is admitted to the emergency department following a motorcycle crash. The nurse notes a crackling sensation upon palpation of the right side of the client's chest. After notifying the provider, the nurse should document this finding as which of the following? a. friction rub b. crackles c. crepitus d. tactile fremitus

c. crepitus

The nurse is caring for a client who is experiencing autonomic dysreflexia due to a C5 spinal cord injury. After checking the client's VS, which of the following actions should be performed next? a. administer nifedipine b. place the client in high-Fowler's position c. check for urinary retention d. check for a fecal impaction

b. place the client in high-Fowler's position According to evidence-based practice, the nurse should first place the client in a high-Fowler's position to decrease the client's blood pressure and reduce the risk of end-organ damage from the sudden rise in blood pressure.

A nurse is caring for client who has a brainstem injury. Which of the following physiological functions should the nurse monitor? a. understanding speech b. respiratory effort c. decision-making ability d. temperature control

b. respiratory effort

The nurse is admitting a 45-yr-old patient with asthma in acute respiratory distress. The nurse auscultates the patient's lungs and notes cessation of the inspiratory wheezing. The patient has not yet received any medication. What should this finding suggest to the nurse? a. Spontaneous resolution of the acute asthma attack b. An acute development of bilateral pleural effusions c. Airway constriction requiring immediate interventions d. Overworked intercostal muscles resulting in poor air exchange

c. Airway constriction requiring immediate interventions When a patient in respiratory distress has inspiratory wheezing and then it ceases, it is an indication of airway obstruction. This finding requires emergency action to restore airway patency. Cessation of inspiratory wheezing does not indicate spontaneous resolution of the acute asthma attack, bilateral pleural effusion development, or overworked intercostal muscles in this asthmatic patient that is in acute respiratory distress.

A 22-yr-old woman with paraplegia after a spinal cord injury tells the home care nurse she experiences bowel incontinence two or three times each day. Which action by the nurse is most appropriate? a. Insert a rectal stimulant suppository. b. Teach the patient to gradually increase intake of high-fiber foods. c. Assess bowel movements for frequency, consistency, and volume. d. Instruct the patient to avoid all caffeinated and carbonated beverages.

c. Assess bowel movements for frequency, consistency, and volume. The nurse should establish baseline bowel function and explore the patient's current knowledge of an appropriate bowel management program after spinal cord injury. To prevent constipation, caffeine intake should be limited but need not be eliminated. After stabilization, creation of a bowel program including a rectal stimulant, digital stimulation, or manual evacuation at the same time each day will regulate bowel elimination. Instruction on high-fiber foods is indicated if the patient has a knowledge deficit.

The physician orders intracranial pressure (ICP) readings every hour for a 23-yr-old male patient with a traumatic brain injury from a motor vehicle crash. The patient's ICP reading is 21 mm Hg. It is most important for the nurse to take which action? a. Document the ICP reading in the chart. b. Determine if the patient has a headache. c. Assess the patient's level of consciousness. d. Position the patient with head elevated 60 degrees.

c. Assess the patient's level of consciousness. The patient has an increased ICP (normal ICP ranges from 5 to 15 mm Hg). The most sensitive and reliable indicator of neurologic status is level of consciousness. The Glasgow Coma Scale may be used to determine the degree of impaired consciousness.

The nurse is caring for a 37-yr-old female patient with multiple musculoskeletal injuries who has developed acute respiratory distress syndrome (ARDS). Which intervention should the nurse initiate to prevent stress ulcers? a. Observe stools for frank bleeding and occult blood. b. Maintain head of the bed elevation at 30 to 45 degrees. c. Begin enteral feedings as soon as bowel sounds are present. d. Administer prescribed lorazepam (Ativan) to reduce anxiety.

c. Begin enteral feedings as soon as bowel sounds are present. Stress ulcers prevention includes early initiation of enteral nutrition to protect the gastrointestinal (GI) tract from mucosal damage. Antiulcer agents such as histamine (H2)-receptor antagonists, proton pump inhibitors, and mucosal protecting agents are also indicated to prevent stress ulcers. Monitoring for GI bleeding does not prevent stress ulcers. Ventilator-associated pneumonia related to aspiration is prevented by elevation of the head of bed to 30 to 45 degrees Stress ulcers are not caused by anxiety. Stress ulcers are related to GI ischemia from hypotension, shock, and acidosis.

One week after a thoracotomy, a patient with chest tubes (CTs) to water-seal drainage has an air leak into the closed chest drainage system (CDS). Which patient assessment warrants follow-up nursing actions? a. Water-seal chamber has 5 cm of water. b. No new drainage in collection chamber c. Chest tube with a loose-fitting dressing d. Small pneumothorax at CT insertion site

c. Chest tube with a loose-fitting dressing If the dressing at the CT insertion site is loose, an air leak will occur and will need to be sealed. The water-seal chamber usually has 2 cm of water, but having more water will not contribute to an air leak, and it should not be drained from the CDS. No new drainage does not indicate an air leak but may indicate the CT is no longer needed. If there is a pneumothorax, the chest tube should remove the air.

The nurse is caring for a 27-yr-old man with multiple fractured ribs from a motor vehicle crash. Which clinical manifestation, if experienced by the patient, is an early indication that the patient is developing respiratory failure? a. Tachycardia and pursed lip breathing b. Kussmaul respirations and hypotension c. Frequent position changes and agitation d. Cyanosis and increased capillary refill time

c. Frequent position changes and agitation A change in mental status is an early indication of respiratory failure. The brain is sensitive to variations in oxygenation, arterial carbon dioxide levels, and acid-base balance. Restlessness, confusion, agitation, and combative behavior suggest inadequate oxygen delivery to the brain.

The nurse is caring for a patient who is admitted with a barbiturate overdose. The patient is comatose with a blood pressure of 90/60 mm Hg, apical pulse of 110 beats/min, and respiratory rate of 8 breaths/min. Based on the initial assessment findings, the nurse recognizes that the patient is at risk for which type of respiratory failure? a. Hypoxemic respiratory failure related to shunting of blood b. Hypoxemic respiratory failure related to diffusion limitation c. Hypercapnic respiratory failure related to alveolar hypoventilation d. Hypercapnic respiratory failure related to increased airway resistance

c. Hypercapnic respiratory failure related to alveolar hypoventilation The patient's respiratory rate is decreased as a result of barbiturate overdose, which caused respiratory depression. The patient is at risk for hypercapnic respiratory failure due to an obtunded airway causing decreased respiratory rate and thus decreased CO2 elimination. Barbiturate overdose does not lead to shunting of blood, diffusion limitations, or increased airway resistance.

If a patient is in the diuretic phase of AKI, the nurse must monitor for which serum electrolyte imbalances? a. Hyperkalemia and hyponatremia b. Hyperkalemia and hypernatremia c. Hypokalemia and hyponatremia d. Hypokalemia and hypernatremia

c. Hypokalemia and hyponatremia

Arterial blood gas results are reported to the nurse for a 68-yr-old patient admitted with pneumonia: pH 7.31, PaCO2 49 mm Hg, HCO3 26 mEq/L, and PaO2 52 mm Hg. What order should the nurse complete first? a. Administer albuterol inhaler prn. b. Increase fluid intake to 2500 mL per 24 hours. c. Initiate oxygen at 2 liters/minute by nasal cannula. d. Perform chest physical therapy four times per day.

c. Initiate oxygen at 2 liters/minute by nasal cannula. The arterial blood gas results indicate the patient is in uncompensated respiratory acidosis with moderate hypoxemia. Oxygen therapy is indicated to correct hypoxemia secondary to V/Q mismatch. Supplemental oxygen should be initiated at 1 to 3 L/min by nasal cannula, or 24% to 32% by simple face mask or Venturi mask to improve the PaO2. Albuterol would be administered next if needed for bronchodilation. Hydration is indicated for thick secretions, and chest physical therapy is indicated for patients with 30 mL or more of sputum production per day.

The nurse on the clinical unit is assigned to four patients. Which patient should she assess first? a. Patient with a skull fracture whose nose is bleeding b. Older patient with a stroke who is confused and whose daughter is present c. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0-to-10 scale d. Patient who had a craniotomy for a brain tumor and who is now 3 days postoperative and has had continued vomiting

c. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0-to-10 scale

Which intervention is most likely to prevent or limit barotrauma in the patient with ARDS who is mechanically ventilated? a. Decreasing PEEP b. Increasing the tidal volume c. Use of permissive hypercapnia d. Use of positive pressure ventilation

c. Use of permissive hypercapnia

The patient with a brain tumor is being monitored for increased intracranial pressure (ICP) with a ventriculostomy. What nursing intervention is priority? a. Administer IV mannitol b. Ventilator use to hyperoxygenate the patient c. Use strict aseptic technique with dressing changes. d. Be aware of changes in ICP related to leaking cerebrospinal fluid (CSF).

c. Use strict aseptic technique with dressing changes. The priority nursing intervention is to use strict aseptic technique with dressing changes and any handling of the insertion site to prevent the serious complication of infection. IV mannitol or hypertonic saline will be administered as ordered for increased ICP. Ventilators may be used to maintain oxygenation. CSF leaks may cause inaccurate ICP readings, or CSF may be drained to decrease ICP, but strict aseptic technique to prevent infection is the nurse's priority of care.

The nurse is alerted to a possible acute subdural hematoma in the patient who a. has a linear skull fracture crossing a major artery b. has focal symptoms of brain damage with no recollection of a head injury. c. develops decreased level of consciousness and a headache within 48 hours of a head injury. d. has an immediate loss of consciousness with a brief lucid interval followed by decreasing level of consciousness.

c. develops decreased level of consciousness and a headache within 48 hours of a head injury.

A nurse is caring for a client who experienced a TBI. Which of the following findings indicates the client is experiencing ICP? a. Battle's sign b. periorbital edema c. dilated pupils d. Halo sign

c. dilated pupils Dilated pupils can indicate that intracranial pressure is increasing. This finding should be reported to the provider immediately. (A) Battle's sign is bruising behind the ears and lower jaw that can occur from the trauma of a skull fracture. It does not indicate increas intracranial pressure. (B) Periorbital edema is a result of facial trauma. It does not indicate increased intracranial pressure. (D) A halo sign is a clear or yellow ring surrounding a spot of fluid or blood from the nose or ear. The ring indicates leakage of cerebral spinal fluid that can occur with a skull fracture. It does not indicate increased intracranial pressure.

A nurse is caring for a client for whom the respiratory therapist has just removed the ET tube. Which of the following actions should the nurse take first? a. instruct the client to cough b. administer oxygen via face mask c. evaluate the client for stridor d. keep the client in a semi- to high-Fowler's position

c. evaluate the client for stridor

Maintenance of fluid balance in the patient with ARDS involves a. hydration using colloids. b. administration of surfactant. c. fluid restriction and diuretics as necessary d. keeping the hemoglobin at levels above 9 g/dL (90 g/L)

c. fluid restriction and diuretics as necessary

A nurse is assessing a client who has increased ICP and has received IV mannitol. Which of the following findings indicates a therapeutic effect of this medication? a. decreased blood glucose b. decreased bronchospasms c. increased urine output d. increased temperature

c. increased urine output

A nurse is assessing a client who was admitted to the facility for observation following a closed head injury. Which of the following is the priority assessment the nurse should perform to determine a change in the client's neurological status? a. vital signs b. body posture c. level of consciousness d. examination of pupils

c. level of consciousness

A patient with a head injury develops SIADH. Manifestations the nurse would expect to find include: a. hypernatremia and edema b. muscle spasticity and hypertension c. low urine output and hyponatremia d. weight gain and decreased GFR

c. low urine output and hyponatremia

The nurse identifies a flail chest in a trauma patient when a. multiple rib fractures are determined by X-ray. b. a tracheal deviation to the unaffected side is present. c. paradoxical chest movement occurs during respiration. d. there is decreased movement of the involved chest wall.

c. paradoxical chest movement occurs during respiration.

An ER nurse is assessing a client who has a new TBI. The nurse observes extension of the client's arms and legs, pronation of the arms, and plantar flexion of the feet. Which of the following actions is the nurse's priority? a. monitor urinary output b. administer an osmotic diuretic c. provide supplemental oxygen d. initiate seizure precautions

c. provide supplemental oxygen

Frequent monitoring of patients with SIADH is completed in order to prevent which severe complication? a. hypernatremia b. sepsis c. pulmonary edema d. hypothermia

c. pulmonary edema

A nurse is caring for a client who has a closed traumatic brain injury and is experiencing increased ICP. This increase in ICP is due to which of the following? a. decreased cerebral perfusion b. leakage of cerebral spinal fluid c. rigid skull containing cranial contents d. brain herniated into the brainstem

c. rigid skull containing cranial contents

A nurse is caring for a client who is postoperative following a frontal craniotomy. The nurse should place the client in which of the following positions? a. Trendelenburg b. prone c. semi-Fowler's d. Sims'

c. semi-Fowler's

A nurse is assessing the respiratory status of a client who has COPD. Which of the following manifestations should the nurse identify as an indication of impending respiratory failure? a. wheezing b. bradypnea c. tachycardia d. diaphoresis

c. tachycardia

A patient with a C7 spinal cord injury undergoing rehabilitation tells the nurse he must have the flu because he has a bad headache and nausea. The nurse's first priority is to a. call the HCP. b. check the patient's temperature. c. take the patient's blood pressure. d. elevate the head of the bed to 90 degrees.

c. take the patient's blood pressure.

Which patient would most benefit from noninvasive positive pressure ventilation (NIPPV) to promote oxygenation? a. A patient whose cardiac output and blood pressure are unstable b. A patient whose respiratory failure is due to a head injury with loss of consciousness c. A patient with a diagnosis of cystic fibrosis and who is currently producing copious secretions d. A patient who is experiencing respiratory failure as a result of the progression of myasthenia gravis

d. A patient who is experiencing respiratory failure as a result of the progression of myasthenia gravis NIPPV such as continuous positive airway pressure (CPAP) is most effective in treating patients with respiratory failure resulting from chest wall and neuromuscular disease. It is not recommended in patients who are experiencing hemodynamic instability, decreased level of consciousness, or excessive secretions.

Which patient diagnosis or treatment is most consistent with prerenal acute kidney injury (AKI)? a. IV tobramycin b. Incompatible blood transfusion c. Poststreptococcal glomerulonephritis d. Dissecting abdominal aortic aneurysm

d. Dissecting abdominal aortic aneurysm A dissecting abdominal aortic aneurysm is a prerenal cause of AKI because it can decrease renal artery perfusion and therefore the glomerular filtrate rate. Aminoglycoside antibiotic administration, a hemolytic blood transfusion reaction, and post-streptococcal glomerulonephritis are intrarenal causes of AKI.

A 56-yr-old man with acute respiratory distress syndrome (ARDS) is on positive pressure ventilation (PPV). The patient's cardiac index is 1.4 L/min and pulmonary artery wedge pressure is 8 mm Hg. What order by the physician is important for the nurse to question? a. Initiate a dobutamine infusion at 3 mcg/kg/min. b. Administer 1 unit of packed red blood cells over the next 2 hours. c. Change the maintenance intravenous (IV) rate from 75 to 125 mL/hr. d. Increase positive end-expiratory pressure (PEEP) from 10 to 15 cm H2O.

d. Increase positive end-expiratory pressure (PEEP) from 10 to 15 cm H2O. Patients on PPV and PEEP frequently experience decreased cardiac output (CO) and cardiac index (CI). High levels of PEEP increase intrathoracic pressure and cause decreased venous return which results in decreased CO. Interventions to improve CO include lowering the PEEP, administering crystalloid fluids or colloid solutions, and use of inotropic drugs (e.g., dobutamine, dopamine). Packed red blood cells may also be administered to improve CO and oxygenation if the hemoglobin is less than 9 or 10 mg/dL.

When planning care for a patient with a cervical spinal cord injury (C5), which nursing diagnosis has the highest priority? a. Impaired urinary elimination related to tetraplegia b. Risk for impaired tissue integrity related to paralysis c. Disabled family coping related to the extent of trauma d. Ineffective airway clearance related to cervical spinal cord injury

d. Ineffective airway clearance related to cervical spinal cord injury Maintaining a patent airway is the most important goal for a patient with a cervical spinal cord injury. Although all are appropriate nursing diagnoses for a patient with a cervical spinal cord injury, respiratory needs are always the highest priority (ABCs).

A patient sustained a diffuse axonal injury from a traumatic brain injury (TBI). Why are IV fluids being decreased and enteral feedings started? a. Free water should be avoided. b. Sodium restrictions can be managed. c. Dehydration can be better avoided with feedings. d. Malnutrition promotes continued cerebral edema.

d. Malnutrition promotes continued cerebral edema. A patient with diffuse axonal injury is unconscious and, with increased intracranial pressure, is in a hypermetabolic, hypercatabolic state that increases the need for energy to heal. Malnutrition promotes continued cerebral edema, and early feeding may improve outcomes when begun within 3 days after injury. Fluid and electrolytes will be monitored to maintain balance with the enteral feedings. Excess intravenous fluid administration will also increase cerebral edema.

A 72-yr-old woman with aspiration pneumonia develops severe respiratory distress. Her PaO2 is 42 mmHg and FIO2 is 80%. Which intervention should the nurse complete first? a. Stat portable chest radiography b. Administer lorazepam (Ativan) 1 mg IV push c. Place the patient in a prone position on a rotational bed d. Position the patient with arms supported away from the chest

d. Position the patient with arms supported away from the chest The nurse will first position the patient to facilitate ventilation. Additional oxygen support may be necessary. Refractory hypoxemia indicates the patient is not demonstrating acute lung injury but has now developed acute respiratory distress syndrome (ARDS). If the PaO2 is 42 mm Hg on 80% FIO2 (fraction of inspired oxygen; room air is 21% FIO2), then the PaO2/FIO2 ratio is 52.5, indicating ARDS (PaO2/FIO2 ratio<200). Stat portable chest radiography may show worsening infiltrates or "white lung." A rotational bed placing the patient in prone position would be a strategy to use for select patients with ARDS. This patient's age, diagnosis, and comorbidities may indicate appropriateness for this treatment. Administration of lorazepam (Ativan) 1 mg may be harmful to this patient's oxygenation status. Further assessment would be needed to determine safety.

When caring for a patient during the oliguric phase of acute kidney injury (AKI), which nursing action is appropriate? a Weigh patient three times weekly. b. Increase dietary sodium and potassium. c. Provide a low-protein, high-carbohydrate diet. d. Restrict fluids according to previous daily loss.

d. Restrict fluids according to previous daily loss. Patients in the oliguric phase of AKI will have fluid volume excess with potassium and sodium retention. Therefore, they will need to have dietary sodium, potassium, and fluids restricted. Daily fluid intake is based on the previous 24-hour fluid loss (measured output plus 600 mL for insensible loss). The diet also needs to provide adequate, not low, protein intake to prevent catabolism. The patient should also be weighed daily, not just three times each week.

A 75-year-old man with lung cancer was admitted to the hospital with worsening dyspnea. He complains of progressive dyspnea for 2 months. On physical examination, he has distended jugular veins, plethoric face, venous collaterals on his chest wall, and distant heart sounds. What is the most likely diagnosis? a. Pericardial tamponade b. Constrictive pericarditis c. Congestive heart failure d. Superior vena cava (SVC) syndrome

d. Superior vena cava (SVC) syndrome

A patient with intracranial pressure monitoring has a pressure of 12 mm Hg. The nurse understands that this pressure reflects a. a severe decrease in cerebral perfusion pressure. b. an alteration in the production of cerebrospinal fluid. c. the loss of autoregulatory control of intracranial pressure. d. a normal balance between brain tissue, blood, and cerebrospinal fluid.

d. a normal balance between brain tissue, blood, and cerebrospinal fluid.

A nurse is triaging clients during a mass casualty event. Which of the following labels should the nurse assign to a client who has a head injury with fixed, dilated pupils? a. red b. yellow c. green d. black

d. black The nurse should assign a black tag, or a class IV label, to clients who are not expected to live and will be allowed to die naturally Dilated pupils that are fixed or nonreactive to light are a poor prognostic sign and indicate severely increased intracranial pressure. In a mass casualty situation, the overall goal is to provide lifesaving treatment to the greatest number of people possible.

A client comes to the emergency department in severe respiratory distress following left-sided blunt chest trauma. The nurse notes absent breath sounds on the client's left side and a tracheal shift to the right. For which of the following procedures should the nurse prepare the client? a. tracheostomy placement b. thoracentesis c. CT scan of the chest d. chest tube insertion

d. chest tube insertion

A nurse is caring for a client who has lung cancer that has metastasized. Which of the following findings indicates the client is developing superior vena cava syndrome? a. irregular cardiac rhythm b. numbness in the hands c. muscle cramps d. facial edema

d. facial edema SVCS is a medical emergency resulting from partial occlusion of the superior vena cava, leading to decreased blood flow through the vein. Most cases are associated with cancers involving the client's upper chest. Earliest manifestations are facial and upper extremity edema. death can result if the compression is not corrected.

A nurse is caring for a client who has a chest tube. The nurse notes that the chest tube has become disconnected from the chest drainage system. Which of the following actions should the nurse take? a. place the drainage system at the head of the client's bed b. increase the suction to the chest drainage system c. place the client on low-flow oxygen via nasal cannula d. immerse the end of the chest tube in a bottle of sterile water

d. immerse the end of the chest tube in a bottle of sterile water

A nurse in the ER has assessed a client's airway, breathing, and circulation following a head injury from a fall at work. Which of the following actions is the priority for the nurse to perform next? a. question the client's coworkers about the mechanism of injury b. check the client's pupil for equality and reaction to light c. measure the client's alertness using Glasgow Coma Scale d. immobilize the client's cervical spine

d. immobilize the client's cervical spine

The O, delivery system chosen for the patient in acute respiratory failure should a. always be a low-flow device, such as a nasal cannula or face mask. b. administer continuous positive airway pressure ventilation to prevent CO2 narcosis. C. correct the PaO2 to a normal level as quickly as possible using mechanical ventilation. d. maintain the PaO2 at greater than or equal to 60 mm Hg at the lowest O2 concentration possible.

d. maintain the PaO2 at greater than or equal to 60 mm Hg at the lowest O2 concentration possible.

A nurse is assessing a client who has a high-thoracic spinal cord injury. The nurse should identify which of the following findings as a manifestation of autonomic dysreflexia? a. flushing of the lower extremities b. hypotension c. tachycardia d. report of a headache

d. report of a headache Autonomic dysreflexia is a neurological emergency that can occur in clients who have a cervical or thoracic spinal cord injury above the level of T6. Autonomic dysreflexia can be triggered by a full bladder or distended rectum. Manifestations include a severe, throbbing headache; flushing of the face and neck; bradycardia; and extreme hypertension.

A 70-yr-old man who has end-stage lung cancer is admitted to the hospital with confusion and oliguria for 2 days. Which finding would the nurse report immediately to the health care provider? a. weight gain of 6 lbs b. nausea and vomiting c. urine specific gravity of 1.004 d. serum sodium level of 118 mEq/L

d. serum sodium level of 118 mEq/L Lung cancer cells are able to manufacture and release antidiuretic hormone (ADH) with resultant water retention and hyponatremia. Hyponatremia (serum sodium levels less than 135 mEq/L) may lead to central nervous system symptoms such as confusion, seizures, coma, and death. The other options listed are also symptoms of hyponatremia but are not as critical to report to the health care provider.