471 Final -- LAST ONE!

8. A client arrives in the emergency department after being in a car crash with fatalities. The client has a nearly amputated leg that is bleeding profusely. What action by the nurse takes priority? a. Apply direct pressure to the bleeding. b. Ensure the client has a patent airway. c.. Obtain consent for emergency surgery. d. Start two large-bore IV catheters.

B Airway is the priority, followed by breathing and circulation (IVs and direct pressure). Obtaining consent is done by the physician. DIF: Applying/Application REF: 740 KEY: Critical rescue| shock| primary survey

37. Which question will the nurse ask a patient who has been admitted with a benign occipital lobe tumor to assess for functional deficits? a. "Do you have difficulty in hearing?" b. "Are you experiencing visual problems?" c. "Are you having any trouble with your balance?" d. "Have you developed any weakness on one side?"

B Because the occipital lobe is responsible for visual reception, the patient with a tumor in this area is likely to have problems with vision. The other questions will be better for assessing function of the temporal lobe, cerebellum, and frontal lobe. DIF: Cognitive Level: Apply (application) REF: 1334 TOP: Nursing Process: Assessment

28. A patient reports dizziness and shortness of breath for several days. During heart monitoring in the emergency department (ED), the nurse obtains the following electrocardiographic (ECG) tracing. The nurse interprets this heart rhythm as a. junctional escape rhythm. b. accelerated idioventricular rhythm. c. third-degree atrioventricular (AV) block. d. sinus rhythm with premature atrial contractions (PACs).

C The inconsistency between the atrial and ventricular rates and the variable PR interval indicate that the rhythm is third-degree AV block. Sinus rhythm with PACs will have a normal rate and consistent PR intervals with occasional PACs. An accelerated idioventricular rhythm will not have visible P waves. DIF: Cognitive Level: Apply (application) REF: 768 TOP: Nursing Process: Assessment

25. The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Assess the patient's gag and cough reflexes. b. Determine when the stroke symptoms began. c. Administer the prescribed short-acting insulin. d. Infuse the prescribed IV metoprolol (Lopressor).

C Administration of subcutaneous medications is included in LPN/LVN education and scope of practice. The other actions require more education and scope of practice and should be done by the registered nurse (RN). DIF: Cognitive Level: Apply (application) REF: 1359 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

15. What is the priority nursing assessment when caring for a patient who has just arrived in the emergency department after suffering an electrical burn from exposure to a high-voltage current? a. Oral temperature b. Peripheral pulses c. Extremity movement d. Pupil reaction to light

C All patients with electrical burns should be considered at risk for cervical spine injury, and assessments of extremity movement will provide baseline data. The other assessment data also are necessary but not as essential as determining cervical spine status. DIF: Cognitive Level: Application REF: 474 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

9. A patient with dilated cardiomyopathy has an atrial fibrillation that has been unresponsive to drug therapy for several days. The nurse anticipates that the patient may need teaching about a. electrical cardioversion. b. IV adenosine (Adenocard). c. anticoagulant therapy with warfarin (Coumadin). d. insertion of an implantable cardioverter-defibrillator (ICD).

C Atrial fibrillation therapy that has persisted for more than 48 hours requires anticoagulant treatment for 3 weeks before attempting cardioversion; this is done to prevent embolization of clots from the atria. Adenosine is not used to treat atrial fibrillation. Cardioversion may be done after several weeks of Coumadin therapy. ICDs are used for patients with recurrent ventricular fibrillation. DIF: Cognitive Level: Application REF: 827-828 TOP: Nursing Process: Planning

34. Which information about a patient who has been receiving fibrinolytic therapy for an acute myocardial infarction (AMI) is most important for the nurse to communicate to the health care provider? a. No change in the patient's chest pain b. A large bruise at the patient's IV insertion site c. A decrease in ST segment elevation on the electrocardiogram (ECG) d. An increase in cardiac enzyme levels since admission

A Continued chest pain suggests that the fibrinolytic therapy is not effective and that other interventions such as percutaneous coronary intervention (PCI) may be needed. Bruising is a possible side effect of fibrinolytic therapy, but it is not an indication that therapy should be discontinued. The decrease of the ST segment elevation indicates that fibrinolysis is occurring and perfusion is returning to the injured myocardium. An increase in cardiac enzyme levels is expected with reperfusion and is related to the washout of enzymes into the circulation as the blocked vessel is opened. DIF: Cognitive Level: Application REF: 782-783 OBJ: Special Questions: Prioritization TOP: Nursing Process: Evaluation

13. A nurse prepares to discharge a client with cardiac dysrhythmia who is prescribed home health care services. Which priority information should be communicated to the home health nurse upon discharge? a. Medication reconciliation b. Immunization history c. Religious beliefs d. Nutrition preferences

A The home health nurse needs to know current medications the client is taking to ensure assessment, evaluation, and further education related to these medications. The other information will not assist the nurse to develop a plan of care for the client. DIF: Applying/Application REF: 673 KEY: Hand-off communication

12. Which action by a new nurse who is caring for a patient who has just had an implantable cardioverter-defibrillator (ICD) inserted indicates a need for more education about care of patients with ICDs? a. The nurse assists the patient to do active range of motion exercises for all extremities. b. The nurse assists the patient to fill out the application for obtaining a Medic Alert ID and bracelet. c. The nurse gives atenolol (Tenormin) to the patient without consulting first with the health care provider. d. The nurse teaches the patient that sexual activity usually can be resumed once the surgical incision is healed.

A The patient should avoid moving the arm on the ICD insertion site until healing has occurred in order to prevent displacement of the ICD leads. The other actions by the new nurse are appropriate for this patient. DIF: Cognitive Level: Application REF: 833-835 TOP: Nursing Process: Evaluation

10. When assisting with insertion of a pulmonary artery (PA) catheter, the nurse identifies that the catheter is correctly placed when the a. monitor shows a typical PAWP tracing. b. PA waveform is observed on the monitor. c. systemic arterial pressure tracing appears on the monitor. d. catheter has been inserted to the 22-cm marking on the line.

A The purpose of a PA line is to measure PAWP, so the catheter is floated through the pulmonary artery until the dilated balloon wedges in a distal branch of the pulmonary artery, and the PAWP readings are available. After insertion, the balloon is deflated and the PA waveform will be observed. Systemic arterial pressures are obtained using an arterial line. The length of catheter needed for insertion will vary with patient size. DIF: Cognitive Level: Comprehension REF: 1693 TOP: Nursing Process: Assessment

11. When prone positioning is used for a patient with acute respiratory distress syndrome (ARDS), which information obtained by the nurse indicates that the positioning is effective? a. The patient's PaO2 is 89 mm Hg, and the SaO2 is 91%. b. Endotracheal suctioning results in clear mucous return. c. Sputum and blood cultures show no growth after 48 hours. d. The skin on the patient's back is intact and without redness.

A The purpose of prone positioning is to improve the patient's oxygenation as indicated by the PaO2 and SaO2. The other information will be collected but does not indicate whether prone positioning has been effective. DIF: Cognitive Level: Apply (application) REF: 1625 TOP: Nursing Process: Evaluation

9. Which assessment finding by the nurse when caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP) indicates that the PEEP may need to be decreased? a. The patient has subcutaneous emphysema. b. The patient has a sinus bradycardia with a rate of 52. c. The patient's PaO2 is 50 mm Hg and the SaO2 is 88%. d. The patient has bronchial breath sounds in both the lung fields.

A The subcutaneous emphysema indicates barotrauma caused by positive pressure ventilation and PEEP. Bradycardia, hypoxemia, and bronchial breath sounds are all concerns and will need to be addressed, but they are not indications that PEEP should be reduced. DIF: Cognitive Level: Application REF: 1760-1761 TOP: Nursing Process: Assessment

16. An employee spills industrial acids on both arms and legs at work. What action should the occupational health nurse take first? a. Remove nonadherent clothing and wristwatch. b. Apply an alkaline solution to the affected area. c. Place a cool compress on the area of exposure. d. Cover the affected area with dry, sterile dressings.

A With chemical burns, the initial action is to remove the chemical from contact with the skin as quickly as possible. Remove nonadherent clothing, shoes, watches, jewelry, glasses, or contact lenses (if the face was exposed). Flush the chemical from the wound and surrounding area with copious amounts of saline solution or water. Covering the affected area or placing cool compresses on the area will leave the chemical in contact with the skin. Application of an alkaline solution is not recommended. DIF: Cognitive Level: Apply (application) REF: 429 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

13. The nurse admitting a patient who has a right frontal lobe tumor would expect the patient may have a. expressive aphasia. c. right-sided weakness. b. impaired judgment. d. difficulty swallowing.

B The frontal lobe controls intellectual activities such as judgment. Speech is controlled in the parietal lobe. Weakness and hemiplegia occur on the contralateral side from the tumor. Swallowing is controlled by the brainstem. DIF: Cognitive Level: Apply (application) REF: 1336 TOP: Nursing Process: Assessment

13. Which action should the nurse perform when preparing a patient with supraventricular tachycardia for cardioversion who is alert and has a blood pressure of 110/66 mm Hg? a. Turn the synchronizer switch to the "off" position. b. Give a sedative before cardioversion is implemented. c. Set the defibrillator/cardioverter energy to 360 joules. d. Provide assisted ventilations with a bag-valve-mask device.

B When a patient has a nonemergency cardioversion, sedation is used just before the procedure. The synchronizer switch is turned "on" for cardioversion. The initial level of joules for cardioversion is low (e.g., 50). Assisted ventilations are not indicated for this patient. DIF: Cognitive Level: Apply (application) REF: 772 TOP: Nursing Process: Implementation

34. A patient being admitted with bacterial meningitis has a temperature of 102.5° F (39.2° C) and a severe headache. Which order should the nurse implement first? a. Administer ceftizoxime (Cefizox) 1 g IV. b. Give acetaminophen (Tylenol) 650 mg PO. c. Use a cooling blanket to lower temperature. d. Swab the nasopharyngeal mucosa for cultures.

D Antibiotic therapy should be instituted rapidly in bacterial meningitis, but cultures must be done before antibiotics are started. As soon as the cultures are done, the antibiotic should be started. Hypothermia therapy and acetaminophen administration are appropriate but can be started after the other actions are implemented. DIF: Cognitive Level: Analyze (analysis) REF: 1340 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

15. A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a right pneumothorax. Which collaborative action will the nurse anticipate next? a. Increase the tidal volume and respiratory rate. b. Decrease the fraction of inspired oxygen (FIO2). c. Perform endotracheal suctioning more frequently. d. Lower the positive end-expiratory pressure (PEEP).

D Because barotrauma is associated with high airway pressures, the level of PEEP should be decreased. The other actions will not decrease the risk for another pneumothorax. DIF: Cognitive Level: Apply (application) REF: 1624 TOP: Nursing Process: Planning

9. A patient with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. Teaching for this patient would include information about a. anticoagulant therapy. c. emergency cardioversion. b. permanent pacemakers. d. IV adenosine (Adenocard).

A Atrial fibrillation therapy that has persisted for more than 48 hours requires anticoagulant treatment for 3 weeks before attempting cardioversion. This is done to prevent embolization of clots from the atria. Cardioversion may be done after several weeks of anticoagulation therapy. Adenosine is not used to treat atrial fibrillation. Pacemakers are routinely used for patients with bradydysrhythmias. Information does not indicate that the patient has a slow heart rate. DIF: Cognitive Level: Apply (application) REF: 766 TOP: Nursing Process: Planning

3. The nurse caring frequently for older adults in the hospital is aware of risk factors that place them at a higher risk for shock. For what factors would the nurse assess? (Select all that apply.) a. Altered mobility/immobility b. Decreased thirst response c. Diminished immune response d. Malnutrition e. Overhydration

A, B, C, D Immobility, decreased thirst response, diminished immune response, and malnutrition can place the older adult at higher risk of developing shock. Overhydration is not a common risk factor for shock. DIF: Remembering/Knowledge REF: 752 KEY: Shock| older adult| nursing process assessment

8. A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority? a. Ensure the client has adequate sedation. b. Find another provider to intubate. c. Interrupt the procedure to give oxygen. d. Monitor the client's oxygen saturation.

C Each intubation attempt should not exceed 30 seconds (15 is preferable) as it causes hypoxia. The nurse should interrupt the intubation attempt and give the client oxygen. The nurse should also have adequate sedation during the procedure and monitor the client's oxygen saturation, but these do not take priority. Finding another provider is not appropriate at this time. DIF: Applying/Application REF: 615 KEY: Respiratory system| intubation| oxygenation

11. A patient with a neck fracture at the C5 level is admitted to the intensive care unit. During initial assessment of the patient, the nurse recognizes the presence of neurogenic shock on finding a. hypotension, bradycardia, and warm extremities. b. involuntary, spastic movements of the arms and legs. c. hyperactive reflex activity below the level of the injury. d. lack of movement or sensation below the level of the injury.

A Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of spinal cord injury. Lack of movement and sensation indicate spinal cord injury, but not neurogenic shock. DIF: Cognitive Level: Comprehension REF: 1549-1550 TOP: Nursing Process: Assessment

9. A client has a small-bore feeding tube (Dobhoff tube) inserted for continuous enteral feedings while recovering from a traumatic brain injury. What actions should the nurse include in the client's care? (Select all that apply.) a. Assess tube placement per agency policy. b. Keep the head of the bed elevated at least 30 degrees. c. Listen to lung sounds at least every 4 hours. d. Run continuous feedings on a feeding pump. e. Use blue dye to determine proper placement.

A, B, C, D All of these options are important for client safety when continuous enteral feedings are in use. Blue dye is not used because it can cause lung injury if aspirated. DIF: Applying/Application REF: 955 KEY: Neurologic disorders| enteral feedings

5. A nursing student planning to teach clients about risk factors for coronary artery disease (CAD) would include which topics? (Select all that apply.) a. Advanced age b. Diabetes c. Ethnic background d. Medication use e. Smoking

A, B, C, E Age, diabetes, ethnic background, and smoking are all risk factors for developing CAD; medication use is not. DIF: Remembering/Knowledge REF: 760 KEY: Coronary artery disease| pathophysiology| patient education

3. A nurse is teaching a client with premature ectopic beats. Which education should the nurse include in this client's teaching? (Select all that apply.) a. Smoking cessation b. Stress reduction and management c. Avoiding vagal stimulation d. Adverse effects of medications e. Foods high in potassium

A, B, D A client who has premature beats or ectopic rhythms should be taught to stop smoking, manage stress, take medications as prescribed, and report adverse effects of medications. Clients with premature beats are not at risk for vasovagal attacks or potassium imbalances. DIF: Remembering/Knowledge REF: 673 KEY: Patient education

4. A nurse cares for an older client with burn injuries. Which age-related changes are paired appropriately with their complications from the burn injuries? (Select all that apply.) a. Slower healing time - Increased risk for loss of function from contracture formation b. Reduced inflammatory response - Deep partial-thickness wound with minimal exposure c. Reduced thoracic compliance - Increased risk for atelectasis d. High incidence of cardiac impairments - Increased risk for acute kidney injury e. Thinner skin - May not exhibit a fever when infection is present

A, C, D Slower healing time will place the older adult client at risk for loss of function from contracture formation due to the length of time needed for the client to heal. A pre-existing cardiac impairment increases risk for acute kidney injury from decreased renal blood flow, and reduced thoracic compliance places the client at risk for atelectasis. Reduced inflammatory response places the client at risk for infection without a normal response, including fever. Clients with thinned skin are at greater risk for deeper wounds from minimal exposure. DIF: Remembering/Knowledge REF: 474 KEY: Older adult

18. Which of these actions should the nurse take first when a patient arrives in the emergency department with facial and chest burns caused by a house fire? a. Infuse the ordered IV solution. b. Auscultate the patient's lung sounds. c. Determine the extent and depth of the burns. d. Administer the ordered opioid pain medications.

B A patient with facial and chest burns is at risk for inhalation injury, and assessment of airway and breathing is the priority. The other actions will be completed after airway management is assured. DIF: Cognitive Level: Application REF: 487 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

12. Which assessment information will the nurse collect to determine whether a patient is developing postconcussion syndrome? a. Muscle resistance b. Short-term memory c. Glasgow coma scale d. Pupil reaction to light

B Decreased short-term memory is one indication of postconcussion syndrome. The other data may be assessed but are not indications of postconcussion syndrome. DIF: Cognitive Level: Application REF: 1440 TOP: Nursing Process: Assessment

16. A client with a traumatic brain injury is agitated and fighting the ventilator. What drug should the nurse prepare to administer? a. Carbamazepine (Tegretol) b. Dexmedetomidine (Precedex) c. Diazepam (Valium) d. Mannitol (Osmitrol)

B Dexmedetomidine is often used to manage agitation in the client with traumatic brain injury. Carbamazepine is an antiseizure drug. Diazepam is a benzodiazepine. Mannitol is an osmotic diuretic. DIF: Remembering/Knowledge REF: 955 KEY: Neurologic disorders| sedatives| mechanical ventilation

2. The emergency department team is performing cardiopulmonary resuscitation on a client when the client's spouse arrives at the emergency department. Which action should the nurse take first? a. Request that the client's spouse sit in the waiting room. b. Ask the spouse if he wishes to be present during the resuscitation. c. Suggest that the spouse begin to pray for the client. d. Refer the client's spouse to the hospital's crisis team.

B If resuscitation efforts are still under way when the family arrives, one or two family members may be given the opportunity to be present during lifesaving procedures. The other options do not give the spouse the opportunity to be present for the client or to begin to have closure. DIF: Applying/Application REF: 114 KEY: Death| emergency nursing

2. While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient's oxygen saturation (SpO2) from 94% to 88%. Which action should the nurse take? a. Suction the patient's oropharynx. b. Increase the prescribed O2 flow rate. c. Instruct the patient to cough and deep breathe. d. Help the patient to sit in a more upright position.

B Increasing O2 flow rate will usually improve O2 saturation in patients with ventilation-perfusion mismatch, as occurs with pulmonary embolism. Because the problem is with perfusion, actions that improve ventilation, such as deep breathing and coughing, sitting upright, and suctioning, are not likely to improve oxygenation. DIF: Cognitive Level: Apply (application) REF: 1609 TOP: Nursing Process: Implementation

27. A patient who is being admitted to the emergency department with intermittent chest pain gives the following list of daily medications to the nurse. Which medication has the most immediate implications for the patient's care? a. captopril c. furosemide (Lasix) b. sildenafil (Viagra) d. warfarin (Coumadin)

B The nurse will need to avoid giving nitrates to the patient because nitrate administration is contraindicated in patients who are using sildenafil because of the risk of severe hypotension caused by vasodilation. The other home medications should also be documented and reported to the health care provider but do not have as immediate an impact on decisions about the patient's treatment. DIF: Cognitive Level: Analyze (analysis) REF: 716 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

17. A nurse is teaching a client about warfarin (Coumadin). What assessment finding by the nurse indicates a possible barrier to self-management? a.. Poor visual acuity b. Strict vegetarian c. Refusal to stop smoking d. Wants weight loss surgery

B Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors. Foods high in vitamin K thus interfere with its action and need to be eaten in moderate, consistent amounts. A vegetarian may have trouble maintaining this diet. The nurse should explore this possibility with the client. The other options are not related. DIF: Applying/Application REF: 607 KEY: Anticoagulants| patient education| medication safety

4. A client is 1 day postoperative after a coronary artery bypass graft. What nonpharmacologic comfort measures does the nurse include when caring for this client? (Select all that apply.) a. Administer pain medication before ambulating. b. Assist the client into a position of comfort in bed. c. Encourage high-protein diet selections. d. Provide complementary therapies such as music. e. Remind the client to splint the incision when coughing.

B, D, E Nonpharmacologic comfort measures can include positioning, complementary therapies, and splinting the chest incision. Medications are not nonpharmacologic. Food choices are not comfort measures. DIF: Applying/Application REF: 781 KEY: Coronary artery disease| nonpharmacologic comfort measures

3. A nurse is caring for a client after a stroke. What actions may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assess neurologic status with the Glasgow Coma Scale. b. Check and document oxygen saturation every 1 to 2 hours. c. Cluster client care to allow periods of uninterrupted rest. d. Elevate the head of the bed to 45 degrees to prevent aspiration. e. Position the client supine with the head in a neutral midline position.

B, E The UAP can take and document vital signs, including oxygen saturation, and keep the client's head in a neutral, midline position with correct direction from the nurse. The nurse assesses the Glasgow Coma Scale score. The nursing staff should not cluster care because this can cause an increase in the intracranial pressure. The head of the bed should be minimally elevated, up to 30 degrees. DIF: Applying/Application REF: 938 KEY: Neurologic disorders| stroke| delegation| unlicensed assistive personnel (UAP)

30. Which information about a patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse? a. Intracranial pressure of 15 mm Hg b. Cerebrospinal fluid (CSF) drainage of 15 mL/hour c. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg d. Cardiac monitor shows sinus tachycardia, with a heart rate of 126 beats/min

C The PbtO2 should be 20 to 40 mm Hg. Lower levels indicate brain ischemia. An intracranial pressure (ICP) of 15 mm Hg is at the upper limit of normal. CSF is produced at a rate of 20 to 30 mL/hour. The reason for the sinus tachycardia should be investigated, but the elevated heart rate is not as concerning as the decrease in PbtO2. DIF: Cognitive Level: Application REF: 1430-1432 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

7. A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first? a. Initiate oxygen via a nasal cannula. b. Place the client in a supine position. c. Palpate the bladder for distention. d. Administer a prescribed beta blocker.

C The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic injury. Precipitating conditions should be eliminated and the physician notified. The other actions would not be appropriate. DIF: Applying/Application REF: 899 KEY: Spinal cord/back injury

4. During the change of shift report, a nurse is told that a patient has an occluded left posterior cerebral artery. The nurse will anticipate that the patient may have a. dysphasia. c. visual deficits. b. confusion. d. poor judgment.

C Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle cerebral artery involvement. Cognitive deficits and changes in judgment are more typical of anterior cerebral artery occlusion. DIF: Cognitive Level: Apply (application) REF: 1350 TOP: Nursing Process: Assessment

14. Which of these snacks will be best for the nurse to offer to a patient with burns covering 40% total body surface area (TBSA) who is in the acute phase of burn treatment? a. Strawberry gelatin b. Whole wheat bagel c. Chunky applesauce d. Chocolate milkshake

D A patient with a burn injury needs high protein and calorie food intake, and the milkshake is the highest in these nutrients. The other choices are not as nutrient-dense as the milkshake. DIF: Cognitive Level: Application REF: 486 TOP: Nursing Process: Planning

29. When caring for a patient who has just arrived on the medical-surgical unit after having cardiac catheterization, which nursing action should the nurse delegate to an LPN/LVN? a. Perform the initial assessment of the catheter insertion site. b. Teach the patient about the usual postprocedure plan of care. c. Check the rate on the infusion pump used to administer heparin. d. Administer the scheduled aspirin and lipid-lowering medication.

D Administration of oral medications is within the scope of practice for LPNs/LVNs. The initial assessment of the patient, patient teaching, and administration of intravenous anticoagulant medications should be done by the RN. DIF: Cognitive Level: Application REF: 793 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

13. When administering IV nitroglycerin (Tridil) to a patient with a myocardial infarction (MI), which action will the nurse take to evaluate the effectiveness of the medication? a. Check blood pressure. b. Monitor apical pulse rate. c. Monitor for dysrhythmias. d. Ask about chest discomfort.

D The goal of IV nitroglycerin administration in MI is relief of chest pain by improving the balance between myocardial oxygen supply and demand. The nurse also will monitor heart rate and BP and observe for dysrhythmias, but these parameters will not indicate whether the medication is effective. DIF: Cognitive Level: Application REF: 784-785 TOP: Nursing Process: Evaluation

5. A nurse prepares to discharge an older adult client home from the emergency department (ED). Which actions should the nurse take to prevent future ED visits? (Select all that apply.) a. Provide medical supplies to the family. b. Consult a home health agency. c. Encourage participation in community activities. d. Screen for depression and suicide. e. Complete a functional assessment.

D, E Due to the high rate of suicide among older adults, a nurse should assess all older adults for depression and suicide. The nurse should also screen older adults for functional assessment, cognitive assessment, and risk for falls to prevent future ED visits. DIF: Understanding/Comprehension REF: 112 KEY: Discharge planning| older adult

2. A nurse triages clients arriving at the hospital after a mass casualty. Which clients are correctly classified? (Select all that apply.) a. A 35-year-old female with severe chest pain: red tag b. A 42-year-old male with full-thickness body burns: green tag c. A 55-year-old female with a scalp laceration: black tag d. A 60-year-old male with an open fracture with distal pulses: yellow tag e. An 88-year-old male with shortness of breath and chest bruises: green tag

A, D Red-tagged clients need immediate care due to life-threatening injuries. A client with severe chest pain would receive a red tag. Yellow-tagged clients have major injuries that should be treated within 30 minutes to 2 hours. A client with an open fracture with distal pulses would receive a yellow tag. The client with full-thickness body burns would receive a black tag. The client with a scalp laceration would receive a green tag, and the client with shortness of breath would receive a red tag. DIF: Analyzing/Analysis REF: 141 KEY: Triage| emergency nursing

28. Which assessment finding by the nurse caring for a patient who has had coronary artery bypass grafting using a right radial artery graft is most important to communicate to the health care provider? a. Complaints of incisional chest pain b. Pallor and weakness of the right hand c. Fine crackles heard at both lung bases d. Redness on both sides of the sternal incision

B The changes in the right hand indicate compromised blood flow, which requires immediate evaluation and actions such as prescribed calcium channel blockers or surgery. The other changes are expected or require nursing interventions. DIF: Cognitive Level: Analyze (analysis) REF: 729 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

10. For a patient who had a right hemisphere stroke, the nurse anticipates planning interventions to manage a. impaired physical mobility related to right-sided hemiplegia. b. risk for injury related to denial of deficits and impulsiveness. c. impaired verbal communication related to speech-language deficits. d. ineffective coping related to depression and distress about disability.

B The patient with right-sided brain damage typically denies any deficits and has poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability. DIF: Cognitive Level: Apply (application) REF: 1350 TOP: Nursing Process: Diagnosis

10. A patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse expect to take? a. Administer IV furosemide (Lasix). b. Prepare the patient for craniotomy. c. Initiate high-dose barbiturate therapy. d. Type and crossmatch for blood transfusion.

B The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation. If intracranial pressure is elevated after surgery, furosemide or high-dose barbiturate therapy may be needed, but these will not be of benefit unless the hematoma is removed. Minimal blood loss occurs with head injuries, and transfusion is usually not necessary. DIF: Cognitive Level: Apply (application) REF: 1329 TOP: Nursing Process: Planning

20. Eight hours after a thermal burn covering 50% of a patient's total body surface area (TBSA), the nurse assesses the patient. The patient weighs 92 kg (202.4 lb). Which information would be a priority to communicate to the health care provider? a. Blood pressure is 95/48 per arterial line. b. Urine output of 41 mL over past 2 hours. c. Serous exudate is leaking from the burns. d. Heart monitor shows sinus tachycardia of 108.

B The urine output should be at least 0.5 to 1.0 mL/kg/hr during the emergent phase, when the patient is at great risk for hypovolemic shock. The nurse should notify the health care provider because a higher IV fluid rate is needed. BP during the emergent phase should be greater than 90 mm Hg systolic and the pulse rate should be less than 120 beats/min. Serous exudate from the burns is expected during the emergent phase. DIF: Cognitive Level: Analyze (analysis) REF: 434 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

3. A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the client's O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best? a. Administer oxygen at 2 L/min. b. Allow continued bathroom privileges. c. Obtain a bedside commode. d. Suggest the client use a bedpan.

B This client's physiologic parameters did not exceed normal during and after activity, so it is safe for the client to continue using the bathroom. There is no indication that the client needs oxygen, a commode, or a bedpan. DIF: Applying/Application REF: 769 KEY: Coronary artery disease| activity intolerance| vital signs| nursing assessment

6. A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred? a. Hemoglobin: 14.2 g/dL b. Platelet count: 82,000/L c. Red blood cell count: 4.8/mm3 d. White blood cell count: 8.7/mm3

B This platelet count is low and could indicate heparin-induced thrombocytopenia. The other values are normal for either gender. DIF: Applying/Application REF: 609 KEY: Anticoagulants| laboratory values

28. A young adult patient who is in the rehabilitation phase 6 months after a severe face and neck burn tells the nurse, "I'm sorry that I'm still alive. My life will never be normal again." Which response by the nurse is best? a. "Most people recover after a burn and feel satisfied with their lives." b. "It's true that your life may be different. What concerns you the most?" c. "Why do you feel that way? It will get better as your recovery progresses." d. "It is really too early to know how much your life will be changed by the burn."

B This response acknowledges the patient's feelings and asks for more assessment data that will help in developing an appropriate plan of care to assist the patient with the emotional response to the burn injury. The other statements are accurate but do not acknowledge the anxiety and depression that the patient is expressing. DIF: Cognitive Level: Apply (application) REF: 447 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

24. Which information about the patient who has had a subarachnoid hemorrhage is most important to communicate to the health care provider? a. The patient complains of having a stiff neck. b. The patient's blood pressure (BP) is 90/50 mm Hg. c. The patient reports a severe and unrelenting headache. d. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).

B To prevent cerebral vasospasm and maintain cerebral perfusion, BP needs to be maintained at a level higher than 90 mm Hg systolic after a subarachnoid hemorrhage. A low BP or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP. An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider. DIF: Cognitive Level: Analyze (analysis) REF: 1350 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

26. Which nursing action can the registered nurse (RN) delegate to experienced unlicensed assistive personnel (UAP) working as telemetry technicians on the cardiac care unit? a. Decide whether a patient's heart rate of 116 requires urgent treatment. b. Observe heart rhythms for multiple patients who have telemetry monitoring. c. Monitor a patient's level of consciousness during synchronized cardioversion. d. Select the best lead for monitoring a patient admitted with acute coronary syndrome.

B UAP serving as telemetry technicians can monitor heart rhythms for individuals or groups of patients. Nursing actions such as assessment and choice of the most appropriate lead based on ST segment elevation location require RN-level education and scope of practice. DIF: Cognitive Level: Apply (application) REF: 760 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

7. A patient with deep partial-thickness and full-thickness burns of the face and chest is having the wounds treated with the open method. Which nursing action will be included in the plan of care? a. Restrict all visitors to prevent cross-contamination of wounds. b. Wear gowns, caps, masks, and gloves during all care of the patient. c. Turn the room temperature up to at least 68° F (20° C) during dressing changes. d. Administer prophylactic antibiotics to prevent bacterial colonization of wounds.

B Use of gowns, caps, masks, and gloves during all patient care will decrease the possibility of wound contamination for a patient whose burns are not covered. Restricting all visitors is not necessary and will have adverse psychosocial consequences for the patient. The room temperature should be kept at approximately 85° F for patients with open burn wounds. Systemic antibiotics are not well absorbed into deep burns because of the lack of circulation. DIF: Cognitive Level: Application REF: 483-485 TOP: Nursing Process: Planning

5. The nurse notes that a patient's heart monitor shows that every other beat is earlier than expected, has no visible P wave, and has a QRS complex that is wide and bizarre in shape. How will the nurse document the rhythm? a. Ventricular couplets b. Ventricular bigeminy c. Ventricular R-on-T phenomenon d. Multifocal premature ventricular contractions

B Ventricular bigeminy describes a rhythm in which every other QRS complex is wide and bizarre looking. Pairs of wide QRS complexes are described as ventricular couplets. There is no indication that the premature ventricular contractions are multifocal or that the R-on-T phenomenon is occurring. DIF: Cognitive Level: Apply (application) REF: 768 TOP: Nursing Process: Assessment

1. A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (Select all that apply.) a. Age b. Hypertension c. Obesity d. Smoking e. Stress

B, C, D, E Hypertension, obesity, smoking, and excessive stress are all modifiable risk factors for coronary artery disease. Age is a nonmodifiable risk factor. DIF: Remembering/Knowledge REF: 760 KEY: Coronary artery disease| lifestyle factors

3. A hospital prepares to receive large numbers of casualties from a community disaster. Which clients should the nurse identify as appropriate for discharge or transfer to another facility? (Select all that apply.) a. Older adult in the medical decision unit for evaluation of chest pain b. Client who had open reduction and internal fixation of a femur fracture 3 days ago c. Client admitted last night with community-acquired pneumonia d. Infant who has a fever of unknown origin e. Client on the medical unit for wound care

B, E The client with the femur fracture could be transferred to a rehabilitation facility, and the client on the medical unit for wound care should be transferred home with home health or to a long-term care facility for ongoing wound care. The client in the medical decision unit should be identified for dismissal if diagnostic testing reveals a noncardiac source of chest pain. The newly admitted client with pneumonia would not be a good choice because culture results are not yet available and antibiotics have not been administered long enough. The infant does not have a definitive diagnosis. DIF: Applying/Application REF: 143 KEY: Triage| emergency nursing

12. A left-handed patient with left-sided hemiplegia has difficulty feeding himself. Which intervention should the nurse include in the plan of care? a. Provide a wide variety of food choices. b. Provide oral care before and after meals. c. Assist the patient to eat with the right hand. d. Teach the patient the "chin-tuck" technique.

C Because the patient has difficulty feeding himself, the appropriate interventions will focus on teaching the patient to use the right hand for self-feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition. DIF: Cognitive Level: Apply (application) REF: 1361 TOP: Nursing Process: Planning

15. A client in shock has been started on dopamine. What assessment finding requires the nurse to communicate with the provider immediately? a. Blood pressure of 98/68 mm Hg b. Pedal pulses 1+/4+ bilaterally c. Report of chest heaviness d. Urine output of 32 mL/hr

C Chest heaviness or pain indicates myocardial ischemia, a possible adverse effect of dopamine. While taking dopamine, the oxygen requirements of the heart are increased due to increased myocardial workload, and may cause ischemia. Without knowing the client's previous blood pressure or pedal pulses, there is not enough information to determine if these are an improvement or not. A urine output of 32 mL/hr is acceptable. DIF: Applying/Application REF: 748 KEY: Shock| vasoconstrictors| critical rescue

16. The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks, "Why do you want to know if I use cocaine?" How should the nurse respond? a. "Substance abuse puts clients at risk for many health issues." b. "The hospital requires that I ask you about cocaine use." c. "Clients who use cocaine are at risk for fatal dysrhythmias." d. "We can provide services for cessation of substance abuse."

C Clients who use cocaine or illicit inhalants are particularly at risk for potentially fatal dysrhythmias. The other responses do not adequately address the client's question. DIF: Remembering/Knowledge REF: 657 KEY: Cardiac electrical conduction| substance abuse

7. To prevent autonomic hyperreflexia, which nursing action will the home health nurse include in the plan of care for a patient who has paraplegia at the T4 level ? a. Support selection of a high-protein diet. b. Discuss options for sexuality and fertility. c. Assist in planning a prescribed bowel program. d. Use quad coughing to strengthen cough efforts.

C Fecal impaction is a common stimulus for autonomic hyperreflexia. Dietary protein, coughing, and discussing sexuality and fertility should be included in the plan of care but will not reduce the risk for autonomic hyperreflexia. DIF: Cognitive Level: Apply (application) REF: 1431 TOP: Nursing Process: Planning

1. A 63-yr-old patient who began experiencing right arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol? (Put a comma and a space between each answer choice [A, B, C, D].) a. Obtain CT scan without contrast. b. Infuse tissue plasminogen activator (tPA). c. Administer oxygen to keep O2 saturation >95%. d. Use National Institute of Health Stroke Scale to assess patient.

C, D, A, B The initial actions should be those that help with airway, breathing, and circulation. Baseline neurologic assessments should be done next. A CT scan will be needed to rule out hemorrhagic stroke before tPA can be administered. DIF: Cognitive Level: Analyze (analysis) REF: 1354 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

17. A patient who has burns on the back and chest from a house fire has become agitated and restless 9 hours after being admitted to the hospital. Which action should the nurse take first? a. Stay at the bedside and reassure the patient. b. Administer the ordered morphine sulfate IV. c. Assess orientation and level of consciousness. d. Use pulse oximetry to check the oxygen saturation.

D Agitation in a patient who may have suffered inhalation injury might indicate hypoxemia, and this should be assessed by the nurse first. Administration of morphine may be indicated if the nurse determines that the agitation is caused by pain. Assessing level of consciousness and orientation also is appropriate but not as essential as determining whether the patient is hypoxemic. Reassurance is not helpful to reduce agitation in a hypoxemic patient. DIF: Cognitive Level: Application REF: 481 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

17. Which laboratory result for a patient whose cardiac monitor shows multifocal premature ventricular contractions (PVCs) is most important for the nurse to communicate to the health care provider? a. Blood glucose 228 mg/dL b. Serum chloride 90 mEq/L c. Serum sodium 133 mEq/L d. Serum potassium 2.8 mEq/L

D Hypokalemia increases the risk for ventricular dysrhythmias such as PVCs, ventricular tachycardia, and ventricular fibrillation; the health care provider will need to prescribe a potassium infusion to correct this abnormality. Although the other laboratory values also are abnormal, they are not likely to be the etiology of the patient's PVCs and do not require immediate correction. DIF: Cognitive Level: Application REF: 823 | 830-831 | 839 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

16. To verify the correct placement of an oral endotracheal tube (ET) after insertion, the best initial action by the nurse is to a. obtain a portable chest x-ray. b. use an end-tidal CO2 monitor. c. auscultate for bilateral breath sounds. d. observe for symmetrical chest movement.

B End-tidal CO2 monitors are currently recommended for rapid verification of ET placement. Auscultation for bilateral breath sounds and checking chest expansion are also used, but they are not as accurate as end-tidal CO2 monitoring. A chest x-ray confirms the placement but is done after the tube is secured. DIF: Cognitive Level: Analyze (analysis) REF: 1570 TOP: Nursing Process: Evaluation

18. A student nurse is preparing to administer enoxaparin (Lovenox) to a client. What action by the student requires immediate intervention by the supervising nurse? a. Assessing the client's platelet count b. Choosing an 18-gauge, 2-inch needle c. Not aspirating prior to injection d. Swabbing the injection site with alcohol

B Enoxaparin is given subcutaneously, so the 18-gauge, 2-inch needle is too big. The other actions are appropriate. DIF: Applying/Application REF: 607 KEY: Anticoagulants| medication administration

20. A home health care nurse is visiting an older client who lives alone after being discharged from the hospital after a coronary artery bypass graft. What finding in the home most causes the nurse to consider additional referrals? a. Dirty carpets in need of vacuuming b. Expired food in the refrigerator c. Old medications in the kitchen d. Several cats present in the home

B Expired food in the refrigerator demonstrates a safety concern for the client and a possible lack of money to buy food. The nurse can consider a referral to Meals on Wheels or another home-based food program. Dirty carpets may indicate the client has no household help and is waiting for clearance to vacuum. Old medications can be managed by the home health care nurse and the client working collaboratively. Having pets is not a cause for concern. DIF: Applying/Application REF: 781 KEY: Home safety| referrals| coronary artery bypass graft

14. A patient with ST segment elevation in several electrocardiographic (ECG) leads is admitted to the emergency department (ED) and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which question should the nurse ask to determine whether the patient is a candidate for fibrinolytic therapy? a. "Do you take aspirin on a daily basis?" b. "What time did your chest pain begin?" c. "Is there any family history of heart disease?" d. "Can you describe the quality of your chest pain?"

B Fibrinolytic therapy should be started within 6 hours of the onset of the myocardial infarction (MI), so the time at which the chest pain started is a major determinant of the appropriateness of this treatment. The other information also will be needed, but it will not be a factor in the decision about fibrinolytic therapy. DIF: Cognitive Level: Application REF: 782-783 TOP: Nursing Process: Assessment

6. A patient has a sinus rhythm and a heart rate of 72 beats/min. The nurse determines that the PR interval is 0.24 seconds. The most appropriate intervention by the nurse would be to a. notify the health care provider immediately. b. document the finding and monitor the patient. c. give atropine per agency dysrhythmia protocol. d. prepare the patient for temporary pacemaker insertion.

B First-degree atrioventricular block is asymptomatic and requires ongoing monitoring because it may progress to more serious forms of heart block. The rate is normal, so there is no indication that atropine is needed. Immediate notification of the health care provider about an asymptomatic rhythm is not necessary. DIF: Cognitive Level: Apply (application) REF: 767 TOP: Nursing Process: Implementation

18. A patient is admitted to the hospital with dysphasia and right-sided weakness that resolves in a few hours. The nurse will anticipate teaching the patient about a. alteplase (tPA). b. aspirin (Ecotrin). c. warfarin (Coumadin). d. nimodipine (Nimotop).

B Following a TIA, patients typically are started on medications such as aspirin to inhibit platelet function and decrease stroke risk. tPA is used for acute ischemic stroke. Coumadin is usually used for patients with atrial fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage. DIF: Cognitive Level: Application REF: 1468-1469 TOP: Nursing Process: Planning

8. A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the client's electrocardiogram. Which action should the nurse take next? a. Administer intravenous diltiazem (Cardizem). b. Assess vital signs and level of consciousness. c. Administer sublingual nitroglycerin. d. Assess capillary refill and temperature.

B In temporary pacing, the wires are threaded onto the epicardial surface of the heart and exit through the chest wall. The pacemaker spike should be followed immediately by a QRS complex. Pacing spikes seen without subsequent QRS complexes imply loss of capture. If there is no capture, then there is no ventricular depolarization and contraction. The nurse should assess for cardiac output via vital signs and level of consciousness. The other interventions would not determine if the client is tolerating the loss of capture. DIF: Applying/Application REF: 664 KEY: Cardiac electrical conduction

1. A student is caring for a client who suffered massive blood loss after trauma. How does the student correlate the blood loss with the client's mean arterial pressure (MAP)? a. It causes vasoconstriction and increased MAP. b. Lower blood volume lowers MAP. c. There is no direct correlation to MAP. d. It raises cardiac output and MAP.

B Lower blood volume will decrease MAP. The other answers are not accurate. DIF: Remembering/Knowledge REF: 740 KEY: Mean arterial blood pressure| shock

9. An emergency department nurse cares for a client who experienced a spinal cord injury 1 hour ago. Which prescribed medication should the nurse prepare to administer? a. Intrathecal baclofen (Lioresal) b. Methylprednisolone (Medrol) c. Atropine sulfate d. Epinephrine (Adrenalin)

B Methylprednisolone (Medrol) should be given within 8 hours of the injury. Clients who receive this therapy usually show improvement in motor and sensory function. The other medications are inappropriate for this client. DIF: Applying/Application REF: 908 KEY: Medication safety| spinal cord/back injury| steroid

1. A 198-lb patient is to receive a dobutamine infusion at 5 mcg/kg/min. The label on the infusion bag states: dobutamine 250 mg in 250 mL of normal saline. When setting the infusion pump, the nurse will set the infusion rate at how many milliliters per hour?

27 To administer the dobutamine at the prescribed rate of 5 mcg/kg/min from a concentration of 250 mg in 250 mL, the nurse will need to infuse 27 mL/hr. DIF: Cognitive Level: Apply (application) REF: 1599 TOP: Nursing Process: Implementation

2. The nurse estimates the extent of a burn using the rule of nines for a patient who has been admitted with deep partial-thickness burns of the anterior trunk and the entire left arm. What percentage of the patient's total body surface area (TBSA) has been injured?

27% When using the rule of nines, the anterior trunk is considered to cover 18% of the patient's body and the anterior (4.5%) and posterior (4.5%) left arm equals 9%. DIF: Cognitive Level: Understand (comprehension) REF: 432 TOP: Nursing Process: Assessment

2. The nurse is estimating the extent of a burn using the rule of nines for a patient who has been admitted with deep partial-thickness burns of the posterior trunk and right arm. What percentage of the patient's total body surface area (TBSA) has been injured? __________________

27% When using the rule of nines, the posterior trunk is considered to cover 18% of the patient's body and each arm is 9%. DIF: Cognitive Level: Comprehension REF: 476 OBJ: Special Questions: Alternate Item Format TOP: Nursing Process: Assessment

2. An emergency room nurse implements fluid replacement for a client with severe burn injuries. The provider prescribes a liter of 0.9% normal saline to infuse over 1 hour and 30 minutes via gravity tubing with a drip factor of 30 drops/mL. At what rate should the nurse administer the infusion? (Record your answer using a whole number and rounding to the nearest drop.) ____ drops/min

333 drops/min 1000 mL divided by 90 minutes, then multiplied by 30 drops, equals 333 drops/min. DIF: Applying/Application REF: 478 KEY: Medication calculation

1. A client in the emergency department is having a stroke and the provider has prescribed the tissue plasminogen activator (t-PA) alteplase (Activase). The client weighs 146 pounds. How much medication will this client receive? (Record your answer using a whole number.) _____ mg

60 mg The dose of t-PA is 0.9 mg/kg with a maximum dose of 90 mg. The client weighs 66.4 kg. 0.9 mg × 66.4 = 59.76 mg, which rounds to 60 mg. DIF: Applying/Application REF: 939 KEY: Neurologic disorders| thrombolytic agents| drug calculation

1. An 80-kg patient with burns over 30% of total body surface area (TBSA) is admitted to the burn unit. Using the Parkland formula of 4 mL/kg/%TBSA, what is the IV infusion rate (mL/hour) for lactated Ringer's solution that the nurse will give during the first 8 hours?

600 mL The Parkland formula states that patients should receive 4 mL/kg/%TBSA burned during the first 24 hours. Half of the total volume is given in the first 8 hours and then the remaining half is given over 16 hours: 4 × 80 × 30 = 9600 mL total volume; 9600/2 = 4800 mL in the first 8 hours; 4800 mL/8 hr = 600 mL/hr. DIF: Cognitive Level: Apply (application) REF: 439 TOP: Nursing Process: Implementation

1. A 242-pound client is being mechanically ventilated. To prevent lung injury, what setting should the nurse anticipate for tidal volume? (Record your answer using a whole number.) ___ mL

660 mL A low tidal volume of 6 mL/kg is used to prevent lung injury. 242 pounds = 110 kg. 110 kg × 6 mL/kg = 660 mL. DIF: Applying/Application REF: 614 KEY: Mechanical ventilation| respiratory system| injury prevention

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

72 mm Hg The formula for calculation of cerebral perfusion pressure is [(Systolic pressure + Diastolic blood pressure × 2)/3] = intracranial pressure. DIF: Cognitive Level: Application REF: 1452-1453 OBJ: Special Questions: Alternate Item Format TOP: Nursing Process: Assessment

1. An unconscious patient with a traumatic head injury has a blood pressure of 130/76 mm Hg and an intracranial pressure (ICP) of 20 mm Hg. The nurse will calculate the cerebral perfusion pressure (CPP) as ____ mm Hg.

74 Calculate the CPP: (CPP = Mean arterial pressure [MAP] - ICP). MAP = DBP + 1/3 (Systolic blood pressure [SBP] - Diastolic blood pressure [DBP]). The MAP is 94. The CPP is 74. DIF: Cognitive Level: Apply (application) REF: 1315 TOP: Nursing Process: Assessment

1. A 70 kg patient with burns over 30% of total body surface area (TBSA) is admitted to the burn unit. Using the Parkland formula, calculate the volume of lactated Ringer's solution that the nursing staff will administer during the first 24 hours. __________________

8400 mL The Parkland formula states that patients should receive 4 mL/kg/%TBSA burned during the first 24 hours. DIF: Cognitive Level: Application REF: 483 OBJ: Special Questions: Alternate Item Format TOP: Nursing Process: Implementation

12. A nurse is caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should the nurse see first? a. Client with a Glasgow Coma Scale score that was 10 and is now is 8 b. Client with a Glasgow Coma Scale score that was 9 and is now is 12 c. Client with a moderate brain injury who is amnesic for the event d. Client who is requesting pain medication for a headache

A A 2-point decrease in the Glasgow Coma Scale score is clinically significant and the nurse needs to see this client first. An improvement in the score is a good sign. Amnesia is an expected finding with brain injuries, so this client is lower priority. The client requesting pain medication should be seen after the one with the declining Glasgow Coma Scale score. DIF: Applying/Application REF: 952 KEY: Neurologic disorders| neurologic assessment| critical rescue

4. Following surgery, a patient's central venous pressure (CVP) monitor indicates low pressures. Which action will the nurse anticipate taking? a. Increase the IV fluid infusion rate. b. Administer IV diuretic medications. c. Elevate the head of the patient's bed to 45 degrees. d. Document the CVP and continue to monitor.

A A low CVP indicates hypovolemia and a need for an increase in the infusion rate. Diuretic administration will contribute to hypovolemia and elevation of the head may decrease cerebral perfusion. Documentation and continued monitoring is an inadequate response to the low CVP. DIF: Cognitive Level: Application REF: 1693-1695 TOP: Nursing Process: Planning

18. A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first? a. Auscultate the patient's lung sounds. b. Determine the extent and depth of the burns. c. Give the prescribed hydromorphone (Dilaudid). d. Infuse the prescribed lactated Ringer's solution.

A A patient with facial and chest burns is at risk for inhalation injury and assessment of airway and breathing is the priority. The other actions will be completed after airway management is assured. DIF: Cognitive Level: Analyze (analysis) REF: 430 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

20. A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the client will need as the priority? a. Alteplase (Activase) b. Enoxaparin (Lovenox) c. Unfractionated heparin d. Warfarin sodium (Coumadin)

A Activase is a "clot-busting" agent indicated in large PEs in the setting of hemodynamic instability. The nurse knows this drug is the priority, although heparin may be started initially. Enoxaparin and warfarin are not indicated in this setting. DIF: Remembering/Knowledge REF: 606 KEY: Pulmonary embolism| thromboembolic event| anticoagulants

29. When caring for a patient who has just arrived on the telemetry unit after having cardiac catheterization, which nursing intervention should the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Give the scheduled aspirin and lipid-lowering medication. b. Perform the initial assessment of the catheter insertion site. c. Teach the patient about the usual postprocedure plan of care. d. Titrate the heparin infusion according to the agency protocol.

A Administration of oral medications is within the scope of practice for LPNs/LVNs. The initial assessment of the patient, patient teaching, and titration of IV anticoagulant medications should be done by the registered nurse (RN). DIF: Cognitive Level: Apply (application) REF: 729 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

28. A 68-yr-old male patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by his spouse. Which action will the nurse take first? a. Check oxygen saturation. b. Assess pupil reaction to light. c. Palpate the head for injuries d. Verify Glasgow Coma Scale (GCS) score.

A Airway patency and breathing are the most vital functions and should be assessed first. The neurologic assessments should be accomplished next and additional assessment after that. DIF: Cognitive Level: Analyze (analysis) REF: 1330 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

28. A patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by the spouse. Which action will the nurse take first? a. Obtain oxygen saturation. b. Check pupil reaction to light. c. Palpate the head for hematoma. d. Assess Glasgow Coma Scale (GCS).

A Airway patency and breathing are the most vital functions and should be assessed first. The neurologic assessments should be accomplished next and the health and medication history last. DIF: Cognitive Level: Application REF: 1435-1437 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

19. A client in the emergency department has several broken ribs. What care measure will best promote comfort? a. Allowing the client to choose the position in bed b. Humidifying the supplemental oxygen c. Offering frequent, small drinks of water d. Providing warmed blankets

A Allow the client with respiratory problems to assume a position of comfort if it does not interfere with care. Often the client will choose a more upright position, which also improves oxygenation. The other options are less effective comfort measures. DIF: Applying/Application REF: 612 KEY: Respiratory system| nonpharmacologic pain management| comfort measures

18. A nurse is caring for a client who is intubated and has an intra-aortic balloon pump. The client is restless and agitated. What action should the nurse perform first for comfort? a. Allow family members to remain at the bedside. b. Ask the family if the client would like a fan in the room. c. Keep the television tuned to the client's favorite channel. d. Speak loudly to the client in case of hearing problems.

A Allowing the family to remain at the bedside can help calm the client with familiar voices (and faces if the client wakes up). A fan might be helpful but may also spread germs through air movement. The TV should not be kept on all the time to allow for rest. Speaking loudly may agitate the client more. DIF: Applying/Application REF: 780 KEY: Intra-aortic balloon pump| nonpharmacologic comfort measures

22. Which patient is most appropriate for the intensive care unit (ICU) charge nurse to assign to a registered nurse (RN) who has floated from the medical unit? a. A 45-yr-old patient receiving IV antibiotics for meningococcal meningitis b. A 35-yr-old patient with intracranial pressure (ICP) monitoring after a head injury c. A 25-yr-old patient admitted with a skull fracture and craniotomy the previous day d. A 55-yr-old patient who has increased intracranial pressure (ICP) and is receiving hyperventilation therapy

A An RN who works on a medical unit will be familiar with administration of IV antibiotics and with meningitis. The patient recovering from a craniotomy, the patient with an ICP monitor, and the patient on a ventilator should be assigned to an RN familiar with the care of critically ill patients. DIF: Cognitive Level: Analyze (analysis) REF: 1341 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning

22. Which of these patients is most appropriate for the intensive care unit (ICU) charge nurse to assign to an RN who has floated from the medical unit? a. A 44-year-old receiving IV antibiotics for meningococcal meningitis b. A 23-year-old who had a skull fracture and craniotomy the previous day c. A 30-year-old who has an intracranial pressure (ICP) monitor in place after a head injury a week ago d. A 61-year-old who has increased ICP and is receiving hyperventilation therapy

A An RN who works on a medical unit will be familiar with administration of IV antibiotics and with meningitis. The postcraniotomy patient, patient with an ICP monitor, and the patient on a ventilator should be assigned to an RN familiar with the care of critically ill patients. DIF: Cognitive Level: Application REF: 1435-1438 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning

28. After a stroke, a client has ataxia. What intervention is most appropriate to include on the client's plan of care? a. Ambulate only with a gait belt. b. Encourage double swallowing. c. Monitor lung sounds after eating. d. Perform post-void residuals.

A Ataxia is a gait disturbance. For the client's safety, he or she should have assistance and use a gait belt when ambulating. Ataxia is not related to swallowing, aspiration, or voiding. DIF: Applying/Application REF: 934 KEY: Neurologic disorders| patient safety

8. After the nurse gives IV atropine to a patient with symptomatic type 1, second-degree atrioventricular (AV) block, which finding indicates that the drug has been effective? a. Increase in the patient's heart rate b. Increase in strength of peripheral pulses c. Decrease in premature atrial contractions d. Decrease in premature ventricular contractions

A Atropine will increase the heart rate and conduction through the AV node. Because the drug increases electrical conduction, not cardiac contractility, the quality of the peripheral pulses is not used to evaluate the drug effectiveness. The patient does not have premature atrial or ventricular contractions. DIF: Cognitive Level: Apply (application) REF: 763 TOP: Nursing Process: Evaluation

8. After the nurse administers IV atropine to a patient with symptomatic type 1, second-degree atrioventricular (AV) block, which finding indicates that the medication has been effective? a. Increase in the patient's heart rate b. Decrease in premature contractions c. Increase in peripheral pulse volume d. Decrease in ventricular ectopic beats

A Atropine will increase the heart rate and conduction through the AV node. Because the medication increases electrical conduction, not cardiac contractility, the quality of the peripheral pulses is not used to evaluate the drug effectiveness. The patient does not have ventricular ectopy or premature contractions. DIF: Cognitive Level: Application REF: 829 TOP: Nursing Process: Evaluation

15. A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a pneumothorax. Which action will the nurse anticipate taking? a. Lower the positive end-expiratory pressure (PEEP). b. Increase the fraction of inspired oxygen (FIO2). c. Suction more frequently. d. Increase the tidal volume.

A Because barotrauma is associated with high airway pressures, the level of PEEP should be decreased. The other actions will not decrease the risk for pneumothorax. DIF: Cognitive Level: Application REF: 1760-1761 TOP: Nursing Process: Planning

33. When admitting a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI) to the intensive care unit, which action should the nurse perform first? a. Attach the heart monitor. c. Assess the peripheral pulses. b. Obtain the blood pressure. d. Auscultate the breath sounds.

A Because dysrhythmias are the most common complication of myocardial infarction (MI), the first action should be to place the patient on a heart monitor. The other actions are also important and should be accomplished as quickly as possible. DIF: Cognitive Level: Analyze (analysis) REF: 718 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

23. Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires action by the nurse? a. No sedative has been ordered for the patient. b. The patient does not respond to verbal stimulation. c. There is no cough or gag reflex when the patient is suctioned. d. The patient's oxygen saturation remains between 90% to 93%.

A Because neuromuscular blockade is extremely anxiety provoking, it is essential that patients who are receiving neuromuscular blockade receive concurrent sedation and analgesia. Absence of response to stimuli is expected in patients receiving neuromuscular blockade. The O2 saturation is adequate. DIF: Cognitive Level: Apply (application) REF: 1619 TOP: Nursing Process: Assessment

23. The urgent care center protocol for tick bites includes the following actions. Which action will the nurse take first when caring for a patient with a tick bite? a. Use tweezers to remove any remaining ticks. b. Check the vital signs, including temperature. c. Give doxycycline (Vibramycin) 100 mg orally. d. Obtain information about recent outdoor activities.

A Because neurotoxic venom is released as long as the tick is attached to the patient, the initial action should be to remove any ticks using tweezers or forceps. The other actions are also appropriate, but the priority is to minimize venom release. DIF: Cognitive Level: Analyze (analysis) REF: 1641 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning

15. A patient with septic shock has a BP of 70/46 mm Hg, pulse of 136 beats/min, respirations of 32 breaths/min, temperature of 104°F, and blood glucose of 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first? a. Give normal saline IV at 500 mL/hr. b. Give acetaminophen (Tylenol) 650 mg rectally. c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL. d. Start norepinephrine to keep systolic blood pressure above 90 mm Hg.

A Because of the decreased preload associated with septic shock, fluid resuscitation is the initial therapy. The other actions also are appropriate, and should be initiated quickly as well. DIF: Cognitive Level: Analyze (analysis) REF: 1600 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

17. The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider? a. Skin cool and clammy c. Blood pressure of 92/56 mm Hg b. Heart rate of 118 beats/min d. O2 saturation of 93% on room air

A Because patients in the early stage of septic shock have warm and dry skin, the patient's cool and clammy skin indicates that shock is progressing. The other information will also be reported, but does not indicate deterioration of the patient's status. DIF: Cognitive Level: Analyze (analysis) REF: 1594 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

21. A client has a brain abscess and is receiving phenytoin (Dilantin). The spouse questions the use of the drug, saying the client does not have a seizure disorder. What response by the nurse is best? a. "Increased pressure from the abscess can cause seizures." b. "Preventing febrile seizures with an abscess is important." c. "Seizures always occur in clients with brain abscesses." d. "This drug is used to sedate the client with an abscess."

A Brain abscesses can lead to seizures as a complication. The nurse should explain this to the spouse. Phenytoin is not used to prevent febrile seizures. Seizures are possible but do not always occur in clients with brain abscesses. This drug is not used for sedation. DIF: Understanding/Comprehension REF: 955 KEY: Neurologic disorders| antiseizure medications

7. An emergency room nurse assesses a client who was rescued from a home fire. The client suddenly develops a loud, brassy cough. Which action should the nurse take first? a. Apply oxygen and continuous pulse oximetry. b. Provide small quantities of ice chips and sips of water. c. Request a prescription for an antitussive medication. d. Ask the respiratory therapist to provide humidified air.

A Brassy cough and wheezing are some of the signs seen with inhalation injury. The first action by the nurse is to give the client oxygen. Clients with possible inhalation injury also need continuous pulse oximetry. Ice chips and humidified room air will not help the problem, and antitussives are not warranted. DIF: Applying/Application REF: 474 KEY: Respiratory distress/failure

14. A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse? a. Mid-sternal chest pain b. Increased urine output c.. Mild orthostatic hypotension d. P wave touching the T wave

A Chest pain, possibly angina, indicates that tachycardia may be increasing the client's myocardial workload and oxygen demand to such an extent that normal oxygen delivery cannot keep pace. This results in myocardial hypoxia and pain. Increased urinary output and mild orthostatic hypotension are not life-threatening conditions and therefore do not require immediate intervention. The P wave touching the T wave indicates significant tachycardia and should be assessed to determine the underlying rhythm and cause; this is an important assessment but is not as critical as chest pain, which indicates cardiac cell death. DIF: Applying/Application REF: 663 KEY: Cardiac electrical conduction

4. A nursing student is caring for a client who had a myocardial infarction. The student is confused because the client states nothing is wrong and yet listens attentively while the student provides education on lifestyle changes and healthy menu choices. What response by the faculty member is best? a. "Continue to educate the client on possible healthy changes." b. "Emphasize complications that can occur with noncompliance." c. "Tell the client that denial is normal and will soon go away." d.. "You need to make sure the client understands this illness."

A Clients are often in denial after a coronary event. The client who seems to be in denial but is compliant with treatment may be using a healthy form of coping that allows time to process the event and start to use problem-focused coping. The student should not discourage this type of denial and coping, but rather continue providing education in a positive manner. Emphasizing complications may make the client defensive and more anxious. Telling the client that denial is normal is placing too much attention on the process. Forcing the client to verbalize understanding of the illness is also potentially threatening to the client. DIF: Understanding/Comprehension REF: 769 KEY: Coronary artery disease| psychosocial response| coping| therapeutic communication

26. A client had an inferior wall myocardial infarction (MI). The nurse notes the client's cardiac rhythm as shown below: What action by the nurse is most important? a. Assess the client's blood pressure and level of consciousness.. b. Call the health care provider or the Rapid Response Team. c. Obtain a permit for an emergency temporary pacemaker insertion. d. Prepare to administer antidysrhythmic medication.

A Clients with an inferior wall MI often have bradycardia and blocks that lead to decreased perfusion, as seen in this ECG strip showing sinus bradycardia. The nurse should first assess the client's hemodynamic status, including vital signs and level of consciousness. The client may or may not need the Rapid Response Team, a temporary pacemaker, or medication; there is no indication of this in the question. DIF: Analyzing/Analysis REF: 769 KEY: Coronary artery disease| dysrhythmias| nursing assessment| hemodynamic status

9. A female patient who had a stroke 24 hours ago has expressive aphasia. An appropriate nursing intervention to help the patient communicate is to a. ask questions that the patient can answer with "yes" or "no." b. develop a list of words that the patient can read and practice reciting. c. have the patient practice her facial and tongue exercises with a mirror. d. prevent embarrassing the patient by answering for her if she does not respond.

A Communication will be facilitated and less frustrating to the patient when questions that require a "yes" or "no" response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond. DIF: Cognitive Level: Apply (application) REF: 1361 TOP: Nursing Process: Implementation

9. A client is in the clinic a month after having a myocardial infarction.. The client reports sleeping well since moving into the guest bedroom. What response by the nurse is best? a. "Do you have any concerns about sexuality?" b. "I'm glad to hear you are sleeping well now." c. "Sleep near your spouse in case of emergency." d. "Why would you move into the guest room?"

A Concerns about resuming sexual activity are common after cardiac events. The nurse should gently inquire if this is the issue. While it is good that the client is sleeping well, the nurse should investigate the reason for the move. The other two responses are likely to cause the client to be defensive. DIF: Applying/Application REF: 781 KEY: Coronary artery disease| sexuality| anxiety| therapeutic communication

9. A client with a stroke has damage to Broca's area. What intervention to promote communication is best for this client? a. Assess whether or not the client can write. b. Communicate using "yes-or-no" questions. c. Reinforce speech therapy exercises. d. Remind the client not to use neologisms.

A Damage to Broca's area often leads to expressive aphasia, wherein the client can understand what is said but cannot express thoughts verbally. In some instances the client can write.. The nurse should assess to see if that ability is intact. "Yes-or-no" questions are not good for this type of client because he or she will often answer automatically but incorrectly. Reinforcing speech therapy exercises is good for all clients with communication difficulties. Neologisms are made-up "words" often used by clients with sensory aphasia. DIF: Applying/Application REF: 943 KEY: Neurologic disorders| stroke| communication

21. A client is on a dopamine infusion via a peripheral line. What action by the nurse takes priority for safety? a. Assess the IV site hourly. b. Monitor the pedal pulses. c. Monitor the client's vital signs. d. Obtain consent for a central line.

A Dopamine should be infused through a central line to prevent extravasation and necrosis of tissue. If it needs to be run peripherally, the nurse assesses the site hourly for problems. When the client is getting the central line, ensuring informed consent is on the chart is a priority. But at this point, the client has only a peripheral line, so caution must be taken to preserve the integrity of the client's integumentary system. Monitoring pedal pulses and vital signs give indications as to how well the drug is working. DIF: Applying/Application REF: 773 KEY: Inotropic agents| adverse effects| medication safety

15. A nurse cares for a client with burn injuries. Which intervention should the nurse implement to appropriately reduce the client's pain? a. Administer the prescribed intravenous morphine sulfate. b. Apply ice to skin around the burn wound for 20 minutes. c. Administer prescribed intramuscular ketorolac (Toradol). d. Decrease tactile stimulation near the burn injuries.

A Drug therapy for pain management requires opioid and nonopioid analgesics. The IV route is used because of problems with absorption from the muscle and the stomach. For the client to avoid shivering, the room must be kept warm, and ice should not be used. Ice would decrease blood flow to the area. Tactile stimulation can be used for pain management. DIF: Applying/Application REF: 480 KEY: Pain management

6. The nurse assesses a client who has a severe burn injury. Which statement indicates the client understands the psychosocial impact of a severe burn injury? a. "It is normal to feel some depression." b. "I will go back to work immediately." c. "I will not feel anger about my situation." d. "Once I get home, things will be normal."

A During the recovery period, and for some time after discharge from the hospital, clients with severe burn injuries are likely to have psychological problems that require intervention. Depression is one of these problems. Grief, loss, anxiety, anger, fear, and guilt are all normal feelings that can occur. Clients need to know that problems of physical care and psychological stresses may be overwhelming. DIF: Applying/Application REF: 489 KEY: Psychosocial response| coping

25. The nurse is caring for a patient who was admitted to the coronary care unit following an acute myocardial infarction (AMI) and percutaneous coronary intervention the previous day. Teaching for this patient would include a. when cardiac rehabilitation will begin. b. the typical emotional responses to AMI. c. information regarding discharge medications. d. the pathophysiology of coronary artery disease.

A Early after an AMI, the patient will want to know when resumption of usual activities can be expected. At this time, the patient's anxiety level or denial will interfere with good understanding of complex information such as the pathophysiology of coronary artery disease. Teaching about discharge medications should be done closer to discharge. The nurse should support the patient by decreasing anxiety rather than discussing the typical emotional responses to myocardial infarction. DIF: Cognitive Level: Apply (application) REF: 726 TOP: Nursing Process: Planning

19. When caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury, which nursing action has the highest priority? a. Assessment of respiratory rate and depth b. Continuous cardiac monitoring for bradycardia c. Application of pneumatic compression devices to both legs d. Administration of methylprednisolone (Solu-Medrol) infusion

A Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function. The other actions also are appropriate but are not as important as assessment of respiratory effort. DIF: Cognitive Level: Application REF: 1550-1551 | 1556-1557 | 1558-1559 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

13. A nurse is caring for a patient who is orally intubated and receiving mechanical ventilation. To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care? a. Elevate head of bed to 30 to 45 degrees. b. Give enteral feedings at no more than 10 mL/hr. c. Suction the endotracheal tube every 2 to 4 hours. d. Limit the use of positive end-expiratory pressure.

A Elevation of the head decreases the risk for aspiration. Positive end-expiratory pressure is frequently needed to improve oxygenation in patients receiving mechanical ventilation. Suctioning should be done only when the patient assessment indicates that it is necessary. Enteral feedings should provide adequate calories for the patient's high energy needs. DIF: Cognitive Level: Apply (application) REF: 1616 TOP: Nursing Process: Planning

6. To maintain adequate nutrition for a patient who has just been admitted with a 40% total body surface area (TBSA) burn injury, the nurse will plan to a. insert a feeding tube and initiate enteral feedings. b. infuse total parenteral nutrition via a central catheter. c. encourage an oral intake of at least 5000 kcal per day. d. administer multiple vitamins and minerals in the IV solution.

A Enteral feedings can usually be initiated during the emergent phase at low rates and increased over 24 to 48 hours to the goal rate. During the emergent phase, the patient will be unable to eat enough calories to meet nutritional needs and may have a paralytic ileus that prevents adequate nutrient absorption. Vitamins and minerals may be administered during the emergent phase, but these will not assist in meeting the patient's caloric needs. Parenteral nutrition increases the infection risk, does not help preserve gastrointestinal function, and is not routinely used in burn patients. DIF: Cognitive Level: Application REF: 486 TOP: Nursing Process: Planning

22. The following interventions are ordered by the health care provider for a patient who has respiratory distress and syncope after eating strawberries. Which will the nurse complete first? a. Give epinephrine. b. Administer diphenhydramine. c. Start continuous ECG monitoring. d. Draw blood for complete blood count (CBC)

A Epinephrine rapidly causes peripheral vasoconstriction, dilates the bronchi, and blocks the effects of histamine and reverses the vasodilation, bronchoconstriction, and histamine release that cause the symptoms of anaphylaxis. The other interventions are also appropriate but would not be the first ones completed. DIF: Cognitive Level: Analyze (analysis) REF: 1599 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

1. During the primary assessment of a trauma victim, the nurse determines that the patient is breathing and has an unobstructed airway. Which action should the nurse take next? a. Observe the patient's respiratory effort. b. Check the patient's level of consciousness. c. Palpate extremities for capillary refill time. d. Examine the patient for any external bleeding.

A Even with a patent airway, patients can have other problems that compromise ventilation, so the next action is to assess the patient's breathing. The other actions also are part of the initial survey but assessment of breathing should be done immediately after assessing for airway patency. DIF: Cognitive Level: Application REF: 1769-1771 TOP: Nursing Process: Assessment

6. The intensive care unit (ICU) charge nurse will determine that teaching about hemodynamic monitoring for a new staff nurse has been effective when the new nurse a. positions the zero-reference stopcock line level with the phlebostatic axis. b. balances and calibrates the hemodynamic monitoring equipment every hour. c. rechecks the location of the phlebostatic axis when changing the patient's position. d. ensures that the patient is lying supine with the head of the bed flat for all readings.

A For accurate measurement of pressures, the zero-reference level should be at the phlebostatic axis. There is no need to rebalance and recalibrate monitoring equipment hourly. Accurate hemodynamic readings are possible with the patient's head raised to 45 degrees or in the prone position. The anatomic position of the phlebostatic axis does not change when patients are repositioned. DIF: Cognitive Level: Application REF: 1687-1689 TOP: Nursing Process: Evaluation

6. A patient who has experienced blunt abdominal trauma during a car accident is complaining of increasing abdominal pain. The nurse will plan to teach the patient about the purpose of a. ultrasonography. b. peritoneal lavage. c. nasogastric (NG) tube placement. d. magnetic resonance imaging (MRI).

A For patients who are at risk for intraabdominal bleeding, focused abdominal ultrasonography is the preferred method to assess for intraperitoneal bleeding. An MRI would not be used. Peritoneal lavage is an alternative, but it is more invasive. An NG tube would not be helpful in diagnosis of intraabdominal bleeding. DIF: Cognitive Level: Application REF: 1773 TOP: Nursing Process: Planning

1. A 78-kg patient with septic shock has a pulse rate of 120 beats/min with low central venous pressure and pulmonary artery wedge pressure. Urine output has been 30 mL/hr for the past 3 hours. Which order by the health care provider should the nurse question? a. Administer furosemide (Lasix) 40 mg IV. b. Increase normal saline infusion to 250 mL/hr. c. Give hydrocortisone (Solu-Cortef) 100 mg IV. d. Titrate norepinephrine to keep systolic blood pressure (BP) above 90 mm Hg.

A Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock. Patients in septic shock require large amounts of fluid replacement. If the patient remains hypotensive after initial volume resuscitation with minimally 30 mL/kg, vasopressors such as norepinephrine may be added. IV corticosteroids may be considered for patients in septic shock who cannot maintain an adequate BP with vasopressor therapy despite fluid resuscitation. DIF: Cognitive Level: Apply (application) REF: 1600 TOP: Nursing Process: Implementation

14. A nurse administers topical gentamicin sulfate (Garamycin) to a client's burn injury. Which laboratory value should the nurse monitor while the client is prescribed this therapy? a. Creatinine b. Red blood cells c. Sodium d. Magnesium

A Gentamicin is nephrotoxic, and sufficient amounts can be absorbed through burn wounds to affect kidney function. Any client receiving gentamicin by any route should have kidney function monitored. Topical gentamicin will not affect the red blood cell count or the sodium or magnesium levels. DIF: Applying/Application REF: 486 KEY: Medication| antibiotic

7. A patient with acute respiratory distress syndrome (ARDS) and acute kidney injury has the following drugs ordered. Which drug should the nurse discuss with the health care provider before giving? a. gentamicin 60 mg IV b. pantoprazole (Protonix) 40 mg IV c. sucralfate (Carafate) 1 g per nasogastric tube d. methylprednisolone (Solu-Medrol) 60 mg IV

A Gentamicin, which is one of the aminoglycoside antibiotics, is potentially nephrotoxic, and the nurse should clarify the drug and dosage with the health care provider before administration. The other drugs are appropriate for the patient with ARDS. DIF: Cognitive Level: Apply (application) REF: 1623 TOP: Nursing Process: Implementation

24. A nurse is providing community screening for risk factors associated with stroke. Which client would the nurse identify as being at highest risk for a stroke? a. A 27-year-old heavy cocaine user b. A 30-year-old who drinks a beer a day c. A 40-year-old who uses seasonal antihistamines d. A 65-year-old who is active and on no medications

A Heavy drug use, particularly cocaine, is a risk factor for stroke. Heavy alcohol use is also a risk factor, but one beer a day is not considered heavy drinking. Antihistamines may contain phenylpropanolamine, which also increases the risk for stroke, but this client uses them seasonally and there is no information that they are abused or used heavily. The 65-year-old has only age as a risk factor. DIF: Remembering/Knowledge REF: 933 KEY: Neurologic disorders| stroke| health screening

5. A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL. The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best? a. "High glucose is common in shock and needs to be treated." b. "Some of the medications we are giving are to raise blood sugar." c. "The IV solution has lots of glucose, which raises blood sugar." d. "The stress of this illness has made your spouse a diabetic."

A High glucose readings are common in shock, and best outcomes are the result of treating them and maintaining glucose readings in the normal range. Medications and IV solutions may raise blood glucose levels, but this is not the most accurate answer. The stress of the illness has not "made" the client diabetic. DIF: Understanding/Comprehension REF: 754 KEY: Shock| patient education| hyperglycemia| insulin| endocrine system

21. A nurse delegates hydrotherapy to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this activity? a.. "Keep the water temperature constant when showering the client." b. "Assess the wound beds during the hydrotherapy treatment." c. "Apply a topical enzyme agent after bathing the client." d. "Use sterile saline to irrigate and clean the client's wounds."

A Hydrotherapy is performed by showering the client on a special shower table. The UAP should keep the water temperature constant. This process allows the nurse to assess the wound beds, but a UAP cannot complete this act. Topical enzyme agents are not part of hydrotherapy. The irrigation does not need to be done with sterile saline. DIF: Applying/Application REF: 482 KEY: Hygiene| delegation| skin lesions/wounds| unlicensed assistive personnel (UAP)

6. The health care provider recommends a carotid endarterectomy for a patient with carotid atherosclerosis and a history of transient ischemic attacks (TIAs). The patient asks the nurse to describe the procedure. Which response by the nurse is appropriate? a. "The carotid endarterectomy involves surgical removal of plaque from an artery in the neck." b. "The diseased portion of the artery in the brain is removed and replaced with a synthetic graft." c. "A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed." d. "A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque."

A In a carotid endarterectomy, the carotid artery is incised and the plaque is removed. The response beginning, "The diseased portion of the artery in the brain is removed" describes an arterial graft procedure. The answer beginning, "A catheter with a deflated balloon is positioned at the narrow area" describes an angioplasty. The final response beginning, "A wire is threaded through the artery" describes the MERCI procedure. DIF: Cognitive Level: Comprehension REF: 1469-1471 TOP: Nursing Process: Implementation

6. A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate? a. "The obstructing plaque is surgically removed from inside an artery in the neck." b. "The diseased portion of the artery in the brain is replaced with a synthetic graft." c. "A wire is threaded through an artery in the leg to the clots in the carotid artery, and the clots are removed." d. "A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque."

A In a carotid endarterectomy, the carotid artery is incised, and the plaque is removed. The response beginning, "The diseased portion of the artery in the brain is replaced" describes an arterial graft procedure. The answer beginning, "A catheter with a deflated balloon is positioned at the narrow area" describes an angioplasty. The final response beginning, "A wire is threaded through the artery" describes the mechanical embolus removal in cerebral ischemia (MERCI) procedure. DIF: Cognitive Level: Understand (comprehension) REF: 1353 TOP: Nursing Process: Implementation

14. A 20-yr-old patient has a mandatory electrocardiogram (ECG) before participating on a college soccer team and is found to have sinus bradycardia, rate 52. Blood pressure (BP) is 114/54 mm Hg, and the student denies any health problems. What action by the nurse is most appropriate? a. Allow the student to participate on the soccer team. b. Refer the student to a cardiologist for further testing. c. Tell the student to stop playing immediately if any dyspnea occurs. d. Obtain more detailed information about the student's family health history.

A In an aerobically trained individual, sinus bradycardia is normal. The student's normal BP and negative health history indicate that there is no need for a cardiology referral or for more detailed information about the family's health history. Dyspnea during an aerobic activity such as soccer is normal. DIF: Cognitive Level: Apply (application) REF: 763 TOP: Nursing Process: Implementation

14. A 19-year-old has a mandatory electrocardiogram (ECG) before participating on a college swim team and is found to have sinus bradycardia, rate 52. BP is 114/54, and the student denies any health problems. What action by the nurse is appropriate? a. Allow the student to participate on the swim team. b. Refer the student to a cardiologist for further assessment. c. Obtain more detailed information about the student's health history. d. Tell the student to stop swimming immediately if any dyspnea occurs.

A In an aerobically trained individual, sinus bradycardia is normal. The student's normal BP and negative health history indicate that there is no need for a cardiology referral or for more detailed information about the health history. Dyspnea during an aerobic activity such as swimming is normal. DIF: Cognitive Level: Application REF: 823-824 TOP: Nursing Process: Implementation

10. While on a camping trip, a nurse cares for an adult client who had a drowning incident in a lake and is experiencing agonal breathing with a palpable pulse. Which action should the nurse take first? a. Deliver rescue breaths. b. Wrap the client in dry blankets. c. Assess for signs of bleeding. d. Check for a carotid pulse.

A In this emergency situation, the nurse should immediately initiate airway clearance and ventilator support measures, including delivering rescue breaths. DIF: Applying/Application REF: 135 KEY: Drowning| environmental emergencies

2. While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient's oxygen saturation (SpO2) from 94% to 88%. The nurse will a. increase the oxygen flow rate. b. suction the patient's oropharynx. c. assist the patient to cough and deep breathe. d. help the patient to sit in a more upright position.

A Increasing oxygen flow rate usually will improve oxygen saturation in patients with ventilation-perfusion mismatch, as occurs with pulmonary embolism. Because the problem is with perfusion, actions that improve ventilation, such as deep-breathing and coughing, sitting upright, and suctioning, are not likely to improve oxygenation. DIF: Cognitive Level: Application REF: 1747-1749 | 1754 TOP: Nursing Process: Implementation

6. When admitting a patient with possible respiratory failure and a high PaCO2, which assessment information should be immediately reported to the health care provider? a. The patient is very somnolent. b. The patient complains of weakness. c. The patient's blood pressure is 164/98. d. The patient's oxygen saturation is 90%.

A Increasing somnolence will decrease the patient's respiratory rate and further increase the PaCO2 and respiratory failure. Rapid action is needed to prevent respiratory arrest. An SpO2 of 90%, weakness, and elevated blood pressure all require ongoing monitoring but are not indicators of possible impending respiratory arrest. DIF: Cognitive Level: Analyze (analysis) REF: 1615 TOP: Nursing Process: Assessment

6. When admitting a patient in possible respiratory failure with a high PaCO2, which assessment information will be of most concern to the nurse? a. The patient is somnolent. b. The patient's SpO2 is 90%. c. The patient complains of weakness. d. The patient's blood pressure is 162/94.

A Increasing somnolence will decrease the patient's respiratory rate and further increase the PaCO2 and respiratory failure. Rapid action is needed to prevent respiratory arrest. An SpO2 of 90%, weakness, and elevated blood pressure all require ongoing monitoring but are not indicators of possible impending respiratory arrest. DIF: Cognitive Level: Application REF: 1751 TOP: Nursing Process: Assessment

26. When a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter, which information obtained by the nurse is most important to communicate to the health care provider? a. Oral temperature 101.6° F b. Apical pulse 102 beats/min c. Intracranial pressure 15 mm Hg d. Mean arterial pressure 90 mm Hg

A Infection is a serious consideration with ICP monitoring, especially with intraventricular catheters. The temperature indicates the need for antibiotics or removal of the monitor. The ICP, arterial pressure, and apical pulse are all borderline high but require only ongoing monitoring at this time. DIF: Cognitive Level: Application REF: 1438-1440 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

26. A patient who has recently started taking pravastatin (Pravachol) and niacin reports several symptoms to the nurse. Which information is most important to communicate to the health care provider? a. Generalized muscle aches and pains b. Dizziness with rapid position changes c. Nausea when taking the drugs before meals d. Flushing and pruritus after taking the drugs

A Muscle aches and pains may indicate myopathy and rhabdomyolysis, which have caused acute kidney injury and death in some patients who have taken the statin medications. These symptoms indicate that the pravastatin may need to be discontinued. The other symptoms are common side effects when taking niacin, and although the nurse should follow-up with the health care provider, they do not indicate that a change in medication is needed. DIF: Cognitive Level: Analyze (analysis) REF: 711 OBJ: Special Questions: Prioritization TOP: Nursing Process: Evaluation

26. A patient who has recently started taking rosuvastatin (Crestor) and niacin (Nicobid) reports all the following symptoms to the nurse. Which is most important to communicate to the health care provider? a. Generalized muscle aches and pains b. Skin flushing after taking the medications c. Dizziness when changing positions quickly d. Nausea when taking the drugs before eating

A Muscle aches and pains may indicate myopathy and rhabdomyolysis, which have caused acute renal failure and death in some patients who have taken the statin medications. These symptoms indicate that the rosuvastatin may need to be discontinued. The other symptoms are common side effects when taking niacin, and although the nurse should follow up with the patient, they do not indicate that a change in medication is needed. DIF: Cognitive Level: Application REF: 768-770 OBJ: Special Questions: Prioritization TOP: Nursing Process: Evaluation

35. A patient who is receiving positive pressure ventilation is scheduled for a spontaneous breathing trial (SBT). Which finding by the nurse is most likely to result in postponing the SBT? a. New ST segment elevation is noted on the cardiac monitor. b. Enteral feedings are being given through an orogastric tube. c. Scattered rhonchi are heard when auscultating breath sounds. d. hydromorphone (Dilaudid) is being used to treat postoperative pain.

A Myocardial ischemia is a contraindication for ventilator weaning. The ST segment elevation is an indication that weaning should be postponed until further investigation and/or treatment for myocardial ischemia can be done. Ventilator weaning can proceed when opioids are used for pain management, abnormal lung sounds are present, or enteral feedings are being used. DIF: Cognitive Level: Apply (application) REF: 1582 TOP: Nursing Process: Assessment

12. A patient arrives in the emergency department (ED) several hours after taking "25 to 30" acetaminophen (Tylenol) tablets. Which action will the nurse plan to take? a. Give N-acetylcysteine. b. Discuss the use of chelation therapy. c. Start oxygen using a non-rebreather mask. d. Have the patient drink large amounts of water.

A N-acetylcysteine is the recommended treatment to prevent liver damage after acetaminophen overdose. The other actions might be used for other types of poisoning, but they will not be appropriate for a patient with acetaminophen poisoning. DIF: Cognitive Level: Understand (comprehension) REF: 1643 TOP: Nursing Process: Planning

9. A client is receiving norepinephrine (Levophed) for shock. What assessment finding best indicates a therapeutic effect from this drug? a. Alert and oriented, answering questions b. Client denial of chest pain or chest pressure c. IV site without redness or swelling d.. Urine output of 30 mL/hr for 2 hours

A Normal cognitive function is a good indicator that the client is receiving the benefits of norepinephrine. The brain is very sensitive to changes in oxygenation and perfusion. Norepinephrine can cause chest pain as an adverse reaction, so the absence of chest pain does not indicate therapeutic effect. The IV site is normal. The urine output is normal, but only minimally so. DIF: Evaluating/Synthesis REF: 748 KEY: Shock| vasoconstrictors| nursing process evaluation| neurologic system

12. After teaching a client with a spinal cord injury, the nurse assesses the client's understanding. Which client statement indicates a correct understanding of how to prevent respiratory problems at home? a. "I'll use my incentive spirometer every 2 hours while I'm awake." b. "I'll drink thinned fluids to prevent choking." c. "I'll take cough medicine to prevent excessive coughing." d. "I'll position myself on my right side so I don't aspirate."

A Often, the person with a spinal cord injury will have weak intercostal muscles and is at higher risk for developing atelectasis and stasis pneumonia. Using an incentive spirometer every 2 hours helps the client expand the lungs more fully and prevents atelectasis. Clients should drink fluids that they can tolerate; usually thick fluids are easier to tolerate. The client should be encouraged to cough and clear secretions. Clients should be placed in high-Fowler's position to prevent aspiration. DIF: Applying/Application REF: 896 KEY: Spinal cord/back injury

11. An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent dysrhythmias. What action by the nurse is most appropriate? a. Assess for any hemodynamic effects of the rhythm. b. Prepare to administer antidysrhythmic medication. c. Notify the provider or call the Rapid Response Team. d. Turn the alarms off on the cardiac monitor.

A Older clients may have dysrhythmias due to age-related changes in the cardiac conduction system. They may have no significant hemodynamic effects from these changes. The nurse should first assess for the effects of the dysrhythmia before proceeding further. The alarms on a cardiac monitor should never be shut off. The other two actions may or may not be needed. DIF: Applying/Application REF: 769 KEY: Coronary artery disease| older adult| pathophysiology| nursing assessment

15. A nurse teaches a client who experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. Which statement should the nurse include in this client's teaching? a. "Minimize or abstain from caffeine." b. "Lie on your side until the attack subsides." c. "Use your oxygen when you experience PACs." d. "Take amiodarone (Cordarone) daily to prevent PACs."

A PACs usually have no hemodynamic consequences. For a client experiencing infrequent PACs, the nurse should explore possible lifestyle causes, such as excessive caffeine intake and stress. Lying on the side will not prevent or resolve PACs. Oxygen is not necessary. Although medications may be needed to control symptomatic dysrhythmias, for infrequent PACs, the client first should try lifestyle changes to control them. DIF: Applying/Application REF: 663 KEY: Patient education| cardiac electrical conduction

7. After the nurse teaches the patient about the use of atenolol (Tenormin) in preventing anginal episodes, which statement by a patient indicates that the teaching has been effective? a. "It is important not to suddenly stop taking the atenolol." b. "Atenolol will increase the strength of my heart muscle." c. "I can expect to feel short of breath when taking atenolol." d. "Atenolol will improve the blood flow to my coronary arteries."

A Patients who have been taking β-blockers can develop intense and frequent angina if the medication is suddenly discontinued. Atenolol (Tenormin) decreases myocardial contractility. Shortness of breath that occurs when taking β-blockers for angina may be due to bronchospasm and should be reported to the health care provider. Atenolol works by decreasing myocardial oxygen demand, not by increasing blood flow to the coronary arteries. DIF: Cognitive Level: Application REF: 775 | 776 TOP: Nursing Process: Evaluation

27. Which action will the nurse include in the plan of care for a patient who has a cauda equina spinal cord injury? a. Catheterize patient every 3 to 4 hours. b. Assist patient to ambulate 4 times daily. c. Administer medications to reduce bladder spasm. d. Stabilize the neck when repositioning the patient.

A Patients with cauda equina syndrome have areflexic bladder, and intermittent catheterization will be used for emptying the bladder. Because the bladder is flaccid, antispasmodic medications will not be used. The legs are flaccid with cauda equina syndrome, and the patient will be unable to ambulate. The head and neck will not need to be stabilized after a cauda equina injury, which affects the lumbar and sacral nerve roots. DIF: Cognitive Level: Apply (application) REF: 1422 TOP: Nursing Process: Planning

16. A patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care? a. Encourage family members to remain at the bedside. b. Apply soft restraints to protect the patient from injury. c. Keep the room well-lighted to improve patient orientation. d. Minimize contact with the patient to decrease sensory input.

A Patients with meningitis and disorientation will be calmed by the presence of someone familiar at the bedside. Restraints should be avoided because they increase agitation and anxiety. The patient requires frequent assessment for complications. The use of touch and a soothing voice will decrease anxiety for most patients. The patient will have photophobia, so the light should be dim. DIF: Cognitive Level: Apply (application) REF: 1326 TOP: Nursing Process: Planning

16. A patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care? a. Encourage family members to remain at the bedside. b. Apply soft restraints to protect the patient from injury. c. Keep the room well-lighted to improve patient orientation. d. Minimize contact with the patient to decrease sensory input.

A Patients with meningitis and disorientation will be calmed by the presence of someone familiar at the bedside. Restraints should be avoided because they increase agitation and anxiety. The patient requires frequent assessment for complications; the use of touch and a soothing voice will decrease anxiety for most patients. The patient will have photophobia, so the light should be dim. DIF: Cognitive Level: Application REF: 1453-1455 TOP: Nursing Process: Planning

6. A nurse teaches a community health class about water safety. Which statement by a participant indicates that additional teaching is needed? a. "I can go swimming all by myself because I am a certified lifeguard." b. "I cannot leave my toddler alone in the bathtub for even a minute." c. "I will appoint one adult to supervise the pool at all times during a party." d. "I will make sure that there is a phone near my pool in case of an emergency."

A People should never swim alone, regardless of lifeguard status. The other statements indicate good understanding of the teaching. DIF: Analyzing/Analysis REF: 135 KEY: Drowning| environmental emergencies

13. A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The client's spouse is very frustrated, stating that the client's personality has changed and the situation is intolerable. What action by the nurse is best? a. Explain that personality changes are common following brain injuries. b. Ask the client why he or she is acting out and behaving differently. c.. Refer the client and spouse to a head injury support group. d. Tell the spouse this is expected and he or she will have to learn to cope.

A Personality and behavior often change permanently after head injury. The nurse should explain this to the spouse. Asking the client about his or her behavior isn't useful because the client probably cannot help it. A referral might be a good idea, but the nurse needs to do something in addition to just referring the couple. Telling the spouse to learn to cope belittles the spouse's concerns and feelings. DIF: Applying/Application REF: 953 KEY: Neurologic disorders| therapeutic communication| psychosocial response| coping

8. A patient develops increasing dyspnea and hypoxemia 2 days after having cardiac surgery. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by left ventricular failure, the nurse will anticipate assisting with a. inserting a pulmonary artery catheter. b. obtaining a ventilation-perfusion scan. c. drawing blood for arterial blood gases. d. positioning the patient for a chest radiograph.

A Pulmonary artery wedge pressures are normal in the patient with ARDS because the fluid in the alveoli is caused by increased permeability of the alveolar-capillary membrane rather than by the backup of fluid from the lungs (as occurs in cardiogenic pulmonary edema). The other tests will not help in differentiating cardiogenic from noncardiogenic pulmonary edema. DIF: Cognitive Level: Application REF: 1753-1754 TOP: Nursing Process: Implementation

7. A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best? a. Assess for other manifestations of hypoxia. b. Change the sensor on the pulse oximeter. c.. Obtain a new oximeter from central supply. d. Tell the client to take slow, deep breaths.

A Pulse oximetry is not always the most accurate assessment tool for hypoxia as many factors can interfere, producing normal or near-normal readings in the setting of hypoxia. The nurse should conduct a more thorough assessment.. The other actions are not appropriate for a hypoxic client. DIF: Applying/Application REF: 605 KEY: Respiratory assessment| respiratory system| oxygen saturation| hypoxia

7. A provider prescribes a rewarming bath for a client who presents with partial-thickness frostbite. Which action should the nurse take prior to starting this treatment? a. Administer intravenous morphine. b. Wrap the limb with a compression dressing. c. Massage the frostbitten areas. d. Assess the limb for compartment syndrome.

A Rapid rewarming in a water bath is recommended for all instances of partial-thickness and full-thickness frostbite. Clients experience severe pain during the rewarming process and nurses should administer intravenous analgesics. DIF: Applying/Application REF: 133 KEY: Cold-related illness| environmental emergencies

3. While family members are visiting, a patient has a cardiac arrest and is being resuscitated. Which action by the nurse is best? a. Ask family members if they wish to remain in the room during the resuscitation. b. Explain to family members that watching the resuscitation will be very stressful. c. Assign a staff member to wait with family members just outside the patient room. d. Escort family members quickly out of the patient room and then remain with them.

A Research indicates that family members want the option of remaining in the room during procedures such as CPR and that this decreases anxiety and facilitates grieving. The other options may be appropriate if the family decides not to remain with the patient. DIF: Cognitive Level: Application REF: 1687 TOP: Nursing Process: Implementation

8. When preparing to rewarm a patient with hypothermia, the nurse will plan to a. attach a cardiac monitor. b. insert a urinary catheter. c. assist with endotracheal intubation. d. have sympathomimetic drugs available.

A Rewarming can produce dysrhythmias, so the patient should be monitored and treated if necessary. Urinary catheterization and endotracheal intubation are not needed for rewarming. Sympathomimetic drugs tend to stimulate the heart and increase the risk for fatal dysrhythmias such as ventricular fibrillation. DIF: Cognitive Level: Application REF: 1776-1778 TOP: Nursing Process: Planning

11. While admitting a patient with a basal skull fracture, the nurse notes clear drainage from the patient's nose. Which of these admission orders should the nurse question? a. Insert nasogastric tube. b. Turn patient every 2 hours. c. Keep the head of bed elevated. d. Apply cold packs for facial bruising.

A Rhinorrhea may indicate a dural tear with cerebrospinal fluid (CSF) leakage, and insertion of a nasogastric tube will increase the risk for infections such as meningitis. Turning the patient, elevating the head, and applying cold pack are appropriate orders. DIF: Cognitive Level: Application REF: 1440 TOP: Nursing Process: Implementation

9. When planning the response to the potential use of smallpox as a biological weapon, the emergency department (ED) nurse manager will plan to obtain adequate quantities of a. vaccine. c. antibiotics. b. atropine. d. whole blood.

A Smallpox infection can be prevented or ameliorated by the administration of vaccine given rapidly after exposure. The other interventions would be helpful for other agents of terrorism but not for smallpox. DIF: Cognitive Level: Understand (comprehension) REF: 1645 TOP: Nursing Process: Planning

25. A client has a shoulder injury and is scheduled for a magnetic resonance imaging (MRI). The nurse notes the presence of an aneurysm clip in the client's record. What action by the nurse is best? a. Ask the client how long ago the clip was placed. b. Have the client sign an informed consent form. c. Inform the provider about the aneurysm clip. d. Reschedule the client for computed tomography.

A Some older clips are metal, which would preclude the use of MRI. The nurse should determine how old the clip is and relay that information to the MRI staff. They can determine if the client is a suitable candidate for this examination. The client does not need to sign informed consent. The provider will most likely not know if the client can have an MRI with this clip. The nurse does not independently change the type of diagnostic testing the client receives. DIF: Applying/Application REF: 940 KEY: Neurologic disorders| patient safety| communication| nursing assessment

25. The RN observes all of the following actions being taken by a staff nurse who has floated to the unit. Which action requires that the RN intervene? a. The float nurse uses clean latex gloves when applying antibacterial cream to a burn wound. b. The float nurse obtains burn cultures when the patient has a temperature of 95.2° F (35.1° C). c. The float nurse administers PRN fentanyl (Sublimaze) IV to a patient 5 minutes before a dressing change. d. The float nurse calls the health care provider for an insulin order when a nondiabetic patient has an elevated serum glucose.

A Sterile gloves should be worn when applying medications or dressings to a burn. Hypothermia is an indicator of possible sepsis, and cultures are appropriate. Nondiabetic patients may require insulin because stress and high calorie intake may lead to temporary hyperglycemia. Fentanyl peaks 5 minutes after IV administration and should be used just before and during dressing changes for pain management. DIF: Cognitive Level: Application REF: 484 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation

25. The charge nurse observes the following actions being taken by a new nurse on the burn unit. Which action by the new nurse would require immediate intervention by the charge nurse? a. The new nurse uses clean gloves when applying antibacterial cream to a burn wound. b. The new nurse obtains burn cultures when the patient has a temperature of 95.2° F (35.1° C). c. The new nurse gives PRN fentanyl (Sublimaze) IV to a patient 5 minutes before a dressing change. d. The new nurse calls the health care provider when a nondiabetic patient's serum glucose is elevated.

A Sterile gloves should be worn when applying medications or dressings to a burn. Hypothermia is an indicator of possible sepsis, and cultures are appropriate. Nondiabetic patients may require insulin because stress and high calorie intake may lead to temporary hyperglycemia. Fentanyl peaks 5 minutes after IV administration and should be used just before and during dressing changes for pain management. DIF: Cognitive Level: Apply (application) REF: 440 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation

5. The hospital administration arranges for critical incident stress debriefing for the staff after a mass casualty incident. Which statement by the debriefing team leader is most appropriate for this situation? a. "You are free to express your feelings; whatever is said here stays here." b. "Let's evaluate what went wrong and develop policies for future incidents." c. "This session is only for nursing and medical staff, not for ancillary personnel." d. "Let's pass around the written policy compliance form for everyone."

A Strict confidentiality during stress debriefing is essential so that staff members can feel comfortable sharing their feelings, which should be accepted unconditionally. Brainstorming improvements and discussing policies would occur during an administrative review. Any employee present during a mass casualty situation is eligible for critical incident stress management services. DIF: Applying/Application REF: 145 KEY: Psychosocial response| crisis intervention

27. The charge nurse observes an inexperienced staff nurse who is caring for a patient who has had a craniotomy for a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene? a. The staff nurse suctions the patient every 2 hours. b. The staff nurse assesses neurologic status every hour. c. The staff nurse elevates the head of the bed to 30 degrees. d. The staff nurse administers a mild analgesic before turning the patient.

A Suctioning increases intracranial pressure and is done only when the patient's respiratory condition indicates it is needed. The other actions by the staff nurse are appropriate. DIF: Cognitive Level: Application REF: 1430-1431 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation

2. Admission vital signs for a brain-injured patient are blood pressure of 128/68 mm Hg, pulse of 110 beats/min, and of respirations 26 breaths/min. Which set of vital signs, if taken 1 hour later, will be of most concern to the nurse? a. Blood pressure of 154/68 mm Hg, pulse of 56 beats/min, respirations of 12 breaths/min b. Blood pressure of 134/72 mm Hg, pulse of 90 beats/min, respirations of 32 breaths/min c. Blood pressure of 148/78 mm Hg, pulse of 112 beats/min, respirations of 28 breaths/min d. Blood pressure of 110/70 mm Hg, pulse of 120 beats/min, respirations of 30 breaths/min

A Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad. These findings indicate that the intracranial pressure (ICP) has increased, and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process. DIF: Cognitive Level: Apply (application) REF: 1316 TOP: Nursing Process: Assessment

22. A nurse is caring for a patient with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation using synchronized intermittent mandatory ventilation (SIMV). The settings include fraction of inspired oxygen (FIO2) of 80%, tidal volume of 450, rate of 16/minute, and positive end-expiratory pressure (PEEP) of 5 cm. Which assessment finding is most important for the nurse to report to the health care provider? a. O2 saturation of 99% c. Crackles audible at lung bases b. Heart rate 106 beats/minute d. Respiratory rate 22 breaths/minute

A The FIO2 of 80% increases the risk for O2 toxicity. Because the patient's O2 saturation is 99%, a decrease in FIO2 is indicated to avoid toxicity. The other patient data would be typical for a patient with ARDS and would not be the most important data to report to the health care provider. DIF: Cognitive Level: Analyze (analysis) REF: 1616 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

22. A patient with ARDS who is receiving mechanical ventilation using synchronized intermittent mandatory ventilation (SIMV) has settings of fraction of inspired oxygen (FIO2) 80%, tidal volume 500, rate 18, and positive end-expiratory pressure (PEEP) 5 cm. Which assessment finding is most important for the nurse to report to the health care provider? a. Oxygen saturation 99% b. Patient respiratory rate 22 breaths/min c. Crackles audible at lung bases d. Apical pulse rate 104 beats/min

A The FIO2 of 80% increases the risk for oxygen toxicity. Since the patient's O2 saturation is 99%, a decrease in FIO2 is indicated to avoid toxicity. The other patient data would be typical for a patient with ARDS and would not need to be urgently reported to the health care provider. DIF: Cognitive Level: Analysis REF: 1760 | 1761-1762 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

8. A nurse wants to become involved in community disaster preparedness and is interested in helping set up and staff first aid stations or community acute care centers in the event of a disaster. Which organization is the best fit for this nurse's interests? a. The Medical Reserve Corps b. The National Guard c. The health department d. A Disaster Medical Assistance Team

A The Medical Reserve Corps (MRC) consists of volunteer medical and public health care professionals who support the community during times of need. They may help staff hospitals, establish first aid stations or special needs shelters, or set up acute care centers in the community. The National Guard often performs search and rescue operations and law enforcement. The health department focuses on communicable disease tracking, treatment, and prevention. A Disaster Medical Assistance Team is deployed to a disaster area for up to 72 hours, providing many types of relief services. DIF: Remembering/Knowledge REF: 142 KEY: Emergency nursing

1. To determine whether there is a delay in impulse conduction through the atria, the nurse will measure the length of the patient's a. P wave. b. PR interval. c. QT interval. d. QRS complex.

A The P wave represents the depolarization of the atria. The P-R interval represents depolarization of the atria, atrioventricular (AV) node, bundle of His, bundle branches, and the Purkinje fibers. The QRS represents ventricular depolarization. The Q-T interval represents depolarization and repolarization of the entire conduction system. DIF: Cognitive Level: Comprehension REF: 822 TOP: Nursing Process: Assessment

19. The nurse is caring for a patient who arrived in the emergency department with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action? a. The patient's PaO2 is 45 mm Hg. b. The patient's PaCO2 is 33 mm Hg. c. The patient's respirations are shallow. d. The patient's respiratory rate is 32 breaths/min.

A The PaO2 indicates severe hypoxemia and respiratory failure. Rapid action is needed to prevent further deterioration of the patient. Although the shallow breathing, rapid respiratory rate, and low PaCO2 also need to be addressed, the most urgent problem is the patient's poor oxygenation. DIF: Cognitive Level: Analyze (analysis) REF: 1611 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

31. When caring for a patient who has had a head injury, which assessment information requires the most rapid action by the nurse? a. The patient is more difficult to arouse. b. The patient's pulse is slightly irregular. c. The patient's blood pressure increases from 120/54 to 136/62 mm Hg. d. The patient complains of a headache at pain level 5 of a 10-point scale.

A The change in level of consciousness (LOC) is an indicator of increased intracranial pressure (ICP) and suggests that action by the nurse is needed to prevent complications. The change in BP should be monitored but is not an indicator of a need for immediate nursing action. Headache is not unusual in a patient after a head injury. A slightly irregular apical pulse is not unusual. DIF: Cognitive Level: Application REF: 1431-1433 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

11. Which assessment data obtained by the nurse when caring for a patient with a left radial arterial line indicates a need for the nurse to take action? a. The left hand is cooler than the right hand. b. The mean arterial pressure (MAP) is 75 mm Hg. c. The system is delivering only 3 mL of flush solution per hour. d. The flush bag and tubing were last changed 3 days previously.

A The change in temperature of the left hand suggests that blood flow to the left hand is impaired. The flush system needs to be changed every 96 hours. A mean arterial pressure (MAP) of 75 mm Hg is normal. Flush systems for hemodynamic monitoring are set up to deliver 3 to 6 mL/hour of flush solution. DIF: Cognitive Level: Application REF: 1691-1692 TOP: Nursing Process: Assessment

11. Which assessment finding obtained by the nurse when caring for a patient with a right radial arterial line indicates a need for the nurse to take action? a. The right hand feels cooler than the left hand. b. The mean arterial pressure (MAP) is 77 mm Hg. c. The system is delivering 3 mL of flush solution per hour. d. The flush bag and tubing were last changed 2 days previously.

A The change in temperature of the right hand suggests that blood flow to the right hand is impaired. The flush system needs to be changed every 96 hours. A mean arterial pressure (MAP) of 75 mm Hg is normal. Flush systems for hemodynamic monitoring are set up to deliver 3 to 6 mL/hr of flush solution. DIF: Cognitive Level: Apply (application) REF: 1565 TOP: Nursing Process: Assessment

19. During change-of-shift report, the nurse is told that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 4 days. Which finding is most important for the nurse to report to the health care provider? a. New onset of confusion c. Heart rate 112 beats/min b. Decreased bowel sounds d. Pale, cool, and dry extremities

A The changes in mental status are indicative that the patient is in the progressive stage of shock and that rapid intervention is needed to prevent further deterioration. The other information is consistent with compensatory shock. DIF: Cognitive Level: Analyze (analysis) REF: 1597 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

4. An emergency department nurse cares for a middle-aged mountain climber who is confused and exhibits bizarre behaviors. After administering oxygen, which priority intervention should the nurse implement? a. Administer dexamethasone (Decadron). b. Complete a mini-mental state examination. c. Prepare the client for computed tomography of the brain. d. Request a psychiatric consult.

A The client is exhibiting signs of mountain sickness and high altitude cerebral edema (HACE). Dexamethasone (Decadron) reduces cerebral edema by acting as an anti-inflammatory in the central nervous system. The other interventions will not treat mountain sickness or HACE. DIF: Applying/Application REF: 134 KEY: Altitude-related illness| environmental emergencies

9. A patient with circumferential burns of both arms develops a decrease in radial pulse strength and numbness in the fingers. Which action should the nurse take? a. Notify the health care provider. b. Monitor the pulses every 2 hours. c. Elevate both arms above heart level with pillows. d. Encourage the patient to flex and extend the fingers.

A The decrease in pulse in a patient with circumferential burns indicates decreased circulation to the arms and the need for escharotomy. Monitoring the pulses is not an adequate response to the decrease in circulation. Elevating the hands or increasing hand movement will not improve the patient's circulation. DIF: Cognitive Level: Application REF: 480 TOP: Nursing Process: Implementation

14. Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)? a. The patient's serum creatinine level is elevated. b. The patient complains of intermittent chest pressure. c. The patient's extremities are cool and pulses are weak. d. The patient has bilateral crackles throughout lung fields.

A The elevated serum creatinine level indicates that the patient has renal failure as well as heart failure. The crackles, chest pressure, and cool extremities are all symptoms consistent with the patient's diagnosis of cardiogenic shock. DIF: Cognitive Level: Apply (application) REF: 1591 TOP: Nursing Process: Assessment

32. The nurse obtains these assessment findings for a patient who has a head injury. Which finding should be reported rapidly to the health care provider? a. Urine output of 800 mL in the last hour b. Intracranial pressure of 16 mm Hg when patient is turned c. Ventriculostomy drains 10 mL of cerebrospinal fluid per hour d. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg

A The high urine output indicates that diabetes insipidus may be developing and interventions to prevent dehydration need to be rapidly implemented. The other data do not indicate a need for any change in therapy. DIF: Cognitive Level: Application REF: 1434-1435 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

32. The nurse is caring for a patient who has a head injury. Which finding, when reported to the health care provider, should the nurse expect will result in new prescribed interventions? a. Pale yellow urine output of 1200 mL over the past 2 hours. b. Ventriculostomy drained 40 mL of fluid in the past 2 hours. c. Intracranial pressure spikes to 16 mm Hg when patient is turned. d. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg.

A The high urine output indicates that diabetes insipidus may be developing, and interventions to prevent dehydration need to be rapidly implemented. The other data do not indicate a need for any change in therapy. DIF: Cognitive Level: Apply (application) REF: 1325 TOP: Nursing Process: Assessment

7. Emergency medical technicians arrive at the emergency department with an unresponsive client who has an oxygen mask in place. Which action should the nurse take first? a. Assess that the client is breathing adequately. b. Insert a large-bore intravenous line. c. Place the client on a cardiac monitor. d. Assess for the best neurologic response.

A The highest-priority intervention in the primary survey is to establish that the client is breathing adequately. Even though this client has an oxygen mask on, he or she may not be breathing, or may be breathing inadequately with the device in place. DIF: Applying/Application REF: 116 KEY: Primary survey| emergency nursing

22. A patient with respiratory failure has hemodynamic monitoring and is receiving mechanical ventilation with peak end-expiratory pressure (PEEP) of 10 cm H2O. Which information indicates that a change in the ventilator settings may be required? a. The arterial line shows a blood pressure of 90/46. b. The pulmonary artery pressure (PAP) is decreased. c. The cardiac monitor shows a heart rate of 58 beats/min. d. The pulmonary artery wedge pressure (PAWP) is increased.

A The hypotension indicates that the high intrathoracic pressure caused by the PEEP may be decreasing venous return and cardiac output (CO). The other assessment data would not be caused by mechanical ventilation. DIF: Cognitive Level: Application REF: 1710 TOP: Nursing Process: Evaluation

22. A patient with respiratory failure has arterial pressure-based cardiac output (APCO) monitoring and is receiving mechanical ventilation with peak end-expiratory pressure (PEEP) of 12 cm H2O. Which information indicates that a change in the ventilator settings may be required? a. The arterial pressure is 90/46. b. The stroke volume is increased. c. The heart rate is 58 beats/minute. d. The stroke volume variation is 12%.

A The hypotension suggests that the high intrathoracic pressure caused by the PEEP may be decreasing venous return and (potentially) cardiac output. The other assessment data would not be a direct result of PEEP and mechanical ventilation. DIF: Cognitive Level: Apply (application) REF: 1571 TOP: Nursing Process: Evaluation

19. Which assessment information obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning? a. The respiratory rate is 32 breaths/min. b. The pulse oximeter shows a SpO2 of 93%. c. The patient has not been suctioned for the last 6 hours. d. The lungs have occasional audible expiratory wheezes.

A The increase in respiratory rate indicates that the patient may have decreased airway clearance and requires suctioning. Suctioning is done when patient assessment data indicate that it is needed, not on a scheduled basis. Occasional expiratory wheezes do not indicate poor airway clearance, and suctioning the patient may induce bronchospasm and increase wheezing. An SpO2 of 93% is acceptable and does not suggest that immediate suctioning is needed. DIF: Cognitive Level: Application REF: 1702-1704 TOP: Nursing Process: Assessment

25. When evaluating a patient with a central venous catheter, the nurse observes that the insertion site is red and tender to touch and the patient's temperature is 101.8° F. What should the nurse plan to do? a. Discontinue the catheter and culture the tip. b. Use the catheter only for fluid administration. c. Change the flush system and monitor the site. d. Check the site more frequently for any swelling.

A The information indicates that the patient has a local and systemic infection caused by the catheter, and the catheter should be discontinued to avoid further complications such as endocarditis. Changing the flush system, continued monitoring, or using the line for fluids will not help prevent or treat the infection. DIF: Cognitive Level: Apply (application) REF: 1562 TOP: Nursing Process: Planning

18. A patient arrives in the emergency department after exposure to radioactive dust. Which action should the nurse take first? a. Place the patient in a shower. b. Obtain the patient's vital signs. c. Determine the type of radioactive agent. d. Obtain a baseline complete blood count.

A The initial action should be to protect staff members and decrease the patient's exposure to the radioactive agent by decontamination. The other actions can be done after the decontamination is completed. DIF: Cognitive Level: Application REF: 1783 | 1785 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

32. A patient who is orally intubated and receiving mechanical ventilation is anxious and is "fighting" the ventilator. Which action should the nurse take next? a. Verbally coach the patient to breathe with the ventilator. b. Sedate the patient with the ordered PRN lorazepam (Ativan). c. Manually ventilate the patient with a bag-valve-mask device. d. Increase the rate for the ordered propofol (Diprivan) infusion.

A The initial response by the nurse should be to try to decrease the patient's anxiety by coaching the patient about how to coordinate respirations with the ventilator. The other actions may also be helpful if the verbal coaching is ineffective in reducing the patient's anxiety. DIF: Cognitive Level: Analyze (analysis) REF: 1579 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

24. The nurse is caring for a patient who is intubated and receiving positive pressure ventilation to treat acute respiratory distress syndrome (ARDS). Which finding is most important to report to the health care provider? a. Red-brown drainage from nasogastric tube b. Blood urea nitrogen (BUN) level 32 mg/dL c. Scattered coarse crackles heard throughout lungs d. Arterial blood gases: pH of 7.31, PaCO2 of 50, and PaO2 of 68

A The nasogastric drainage indicates possible gastrointestinal bleeding or stress ulcer and should be reported. The pH and PaCO2 are slightly abnormal, but current guidelines advocating for permissive hypercapnia indicate that these would not indicate an immediate need for a change in therapy. The BUN is slightly elevated but does not indicate an immediate need for action. Adventitious breath sounds are commonly heard in patients with ARDS. DIF: Cognitive Level: Analyze (analysis) REF: 1623 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

12. A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate? a. Assess the cause of the agitation. b. Reassure the client that he or she is safe. c. Restrain the client's hands. d. Sedate the client immediately.

A The nurse needs to determine the cause of the agitation. The inability to communicate often makes clients anxious, even to the point of panic. Pain and confusion can also cause agitation. Once the nurse determines the cause of the agitation, he or she can implement measures to relieve the underlying cause. Reassurance is also important but may not address the etiology of the agitation. Restraints and more sedation may be necessary, but not as a first step. DIF: Applying/Application REF: 618 KEY: Mechanical ventilation| psychosocial response| anxiety| communication| nursing assessment

29. A client in the emergency department is having a stroke and needs a carotid artery angioplasty with stenting. The client's mental status is deteriorating. What action by the nurse is most appropriate? a. Attempt to find the family to sign a consent. b. Inform the provider that the procedure cannot occur. c. Nothing; no consent is needed in an emergency. d. Sign the consent form for the client.

A The nurse should attempt to find the family to give consent. If no family is present or can be found, under the principle of emergency consent, a life-saving procedure can be performed without formal consent. The nurse should not just sign the consent form. DIF: Applying/Application REF: 938 KEY: Neurologic disorders| informed consent| ethics

31. The nurse notes that a patient's endotracheal tube (ET), which was at the 21-cm mark, is now at the 24-cm mark and the patient appears anxious and restless. Which action should the nurse take first? a. Listen to the patient's lungs. b. Offer reassurance to the patient. c. Bag the patient at an FIO2 of 100%. d. Notify the patient's health care provider.

A The nurse should first determine whether the ET tube has been displaced into the right mainstem bronchus by listening for unilateral breath sounds. If so, assistance will be needed to reposition the tube immediately. The other actions also are appropriate, but detection and correction of tube malposition are the most critical actions. DIF: Cognitive Level: Application REF: 1701-1702 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

11. A family in the emergency department is overwhelmed at the loss of several family members due to a shooting incident in the community. Which intervention should the nurse complete first? a. Provide a calm location for the family to cope and discuss needs. b. Call the hospital chaplain to stay with the family and pray for the deceased. c. Do not allow visiting of the victims until the bodies are prepared. d. Provide privacy for law enforcement to interview the family.

A The nurse should first provide emotional support by encouraging relaxation, listening to the family's needs, and offering choices when appropriate and possible to give some personal control back to individuals. The family may or may not want the assistance of religious personnel; the nurse should assess for this before calling anyone. Visiting procedures should take into account the needs of the family. The family may want to see the victim immediately and do not want to wait until the body can be prepared. The nurse should assess the family's needs before assuming the body needs to be prepared first. The family may appreciate privacy, but this is not as important as assessing the family's needs. DIF: Applying/Application REF: 146 KEY: Psychosocial response| crisis intervention

27. A patient who is being admitted to the emergency department with severe chest pain gives the following list of medications taken at home to the nurse. Which of the medications has the most immediate implications for the patient's care? a. sildenafil (Viagra) b. furosemide (Lasix) c. diazepam (Valium) d. captopril (Capoten)

A The nurse will need to avoid giving nitrates to the patient because nitrate administration is contraindicated in patients who are using sildenafil because of the risk of sudden death caused by vasodilation. The other home medications also should be documented and reported to the health care provider but do not have as immediate an impact on decisions about the patient's treatment. DIF: Cognitive Level: Application REF: 773 | 775-776 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

12. When assessing a patient admitted to the emergency department (ED) with a broken arm and facial bruises, the nurse notes multiple additional bruises in various stages of healing. Which statement or question by the nurse is most appropriate? a. "Is someone at home hurting you?" b. "You should not return to your home." c. "Would you like to see a social worker?" d. "I have to report this abuse to the police."

A The nurse's initial response should be to further assess the patient's situation. Telling the patient not to return home may be an option once further assessment is done. The patient, not the nurse, is responsible for reporting the abuse. A social worker may be appropriate once further assessment is completed. DIF: Cognitive Level: Application REF: 1782-1783 TOP: Nursing Process: Implementation

13. A client in shock is apprehensive and slightly confused. What action by the nurse is best? a. Offer to remain with the client for awhile. b. Prepare to administer antianxiety medication. c. Raise all four siderails on the client's bed. d. Tell the client everything possible is being done.

A The nurse's presence will be best to reassure this client. Antianxiety medication is not warranted as this will lower the client's blood pressure. Using all four siderails on a hospital bed is considered a restraint in most facilities, although the nurse should ensure the client's safety. Telling a confused client that everything is being done is not the most helpful response. DIF: Applying/Application REF: 746 KEY: Psychosocial response| communication| caring| shock

11. A client has been brought to the emergency department after being shot multiple times. What action should the nurse perform first? a. Apply personal protective equipment. b. Notify local law enforcement officials. c. Obtain "universal" donor blood. d. Prepare the client for emergency surgery.

A The nurse's priority is to care for the client. Since the client has gunshot wounds and is bleeding, the nurse applies personal protective equipment (i.e., gloves) prior to care. This takes priority over calling law enforcement. Requesting blood bank products can be delegated. The nurse may or may not have to prepare the client for emergency surgery. DIF: Applying/Application REF: 744 KEY: Standard Precautions| infection control

19. Four days after having a myocardial infarction (MI), a patient who is scheduled for discharge asks for assistance with all the daily activities, saying, "I am too nervous to take care of myself." Based on this information, which nursing diagnosis is appropriate? a. Ineffective coping related to anxiety b. Activity intolerance related to weakness c. Denial related to lack of acceptance of the MI d. Social isolation related to lack of support system

A The patient data indicates that ineffective coping after the MI caused by anxiety about the impact of the MI is a concern. The other nursing diagnoses may be appropriate for some patients after an MI, but the data for this patient do not support denial, activity intolerance, or social isolation. DIF: Cognitive Level: Application REF: 788-789 TOP: Nursing Process: Diagnosis

16. A patient who sustained a spinal cord injury a week ago becomes angry, telling the nurse "I want to be transferred to a hospital where the nurses know what they are doing!" Which reaction by the nurse is best? a. Ask for the patient's input into the plan for care. b. Clarify that abusive behavior will not be tolerated. c. Reassure the patient about the competence of the nursing staff. d. Continue to perform care without responding to the patient's comments.

A The patient is demonstrating behaviors consistent with the anger phase of the mourning process, and the nurse should allow expression of anger and seek the patient's input into care. Expression of anger is appropriate at this stage and should be tolerated by the nurse. Reassurance about the competency of the staff will not be helpful in responding to the patient's anger. Ignoring the patient's comments will increase the patient's anger and sense of helplessness. DIF: Cognitive Level: Application REF: 1565 TOP: Nursing Process: Implementation

5. A nurse is caring for an obese patient with right lower lobe pneumonia. Which position will be best to improve gas exchange? a. On the left side c. In the tripod position b. On the right side d. In the high-Fowler's position

A The patient should be positioned with the "good" lung in the dependent position to improve the match between ventilation and perfusion. The obese patient's abdomen will limit respiratory excursion when sitting in the high-Fowler's or tripod positions. DIF: Cognitive Level: Apply (application) REF: 1617 TOP: Nursing Process: Implementation

13. A 32-year-old patient has a stroke resulting from a ruptured aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan? a. Applying intermittent pneumatic compression stockings b. Assisting to dangle on edge of bed and assess for dizziness c. Encouraging patient to cough and deep breathe every 4 hours d. Inserting an oropharyngeal airway to prevent airway obstruction

A The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboemboism (VTE). Activities such as coughing and sitting up that might increase intracranial pressure (ICP) or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate. DIF: Cognitive Level: Application REF: 1477-1479 TOP: Nursing Process: Planning

13. A patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will the nurse include in the plan of care? a. Apply intermittent pneumatic compression stockings. b. Assist to dangle on edge of bed and assess for dizziness. c. Encourage patient to cough and deep breathe every 4 hours. d. Insert an oropharyngeal airway to prevent airway obstruction.

A The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboembolism. Activities such as coughing and sitting up that might increase intracranial pressure or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate. DIF: Cognitive Level: Apply (application) REF: 1359 TOP: Nursing Process: Planning

7. An unconscious patient has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care? a. Keep the head of the bed elevated to 30 degrees. b. Position the patient with the knees and hips flexed. c. Encourage coughing and deep breathing to improve oxygenation. d. Cluster nursing interventions to provide uninterrupted rest periods.

A The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to help reduce ICP. Flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions increases ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic pressure and ICP. DIF: Cognitive Level: Application REF: 1436-1437 TOP: Nursing Process: Implementation

35. A patient with possible viral meningitis is admitted to the nursing unit after lumbar puncture was performed in the emergency department. Which action prescribed by the health care provider should the nurse question? a. Restrict oral fluids to 1000 mL/day. b. Elevate the head of the bed 20 degrees. c. Administer ceftriaxone (Rocephin) 1 g IV every 12 hours. d. Give ibuprofen (Motrin) 400 mg every 6 hours as needed for headache.

A The patient with meningitis has increased fluid needs, so oral fluids should be encouraged. The other actions are appropriate. Slight elevation of the head of the bed will decrease headache without causing leakage of cerebrospinal fluid from the lumbar puncture site. Antibiotics should be administered until bacterial meningitis is ruled out by the cerebrospinal fluid analysis. DIF: Cognitive Level: Apply (application) REF: 1340 TOP: Nursing Process: Implementation

24. A patient whose cardiac monitor shows sinus tachycardia, rate 102, is apneic and no pulses are palpable by the nurse. What is the first action that the nurse should take? a. Start CPR. b. Defibrillate. c. Administer atropine per hospital protocol. d. Give 100% oxygen per non-rebreather mask.

A The patient's clinical manifestations indicate pulseless electrical activity and the nurse should immediately start CPR. The other actions would not be of benefit to this patient. DIF: Cognitive Level: Application REF: 831-833 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

27. An elderly patient who has stabilized after being in the intensive care unit (ICU) for a week is preparing for transfer to the step down unit when the nurse notices that the patient has new onset confusion. The nurse will plan to a. inform the receiving nurse and then transfer the patient. b. notify the health care provider and postpone the transfer. c. administer PRN lorazepam (Ativan) and cancel the transfer. d. obtain an order for restraints as needed and transfer the patient.

A The patient's history and symptoms most likely indicate delirium associated with the sleep deprivation and sensory overload in the ICU environment, and informing the receiving nurse and transferring the patient is appropriate. Postponing the transfer is likely to prolong the delirium. Benzodiazepines and restraints contribute to delirium and agitation. DIF: Cognitive Level: Application REF: 1686 TOP: Nursing Process: Planning

23. A male patient who has possible cerebral edema has a serum sodium level of 116 mEq/L (116 mmol/L) and a decreasing level of consciousness (LOC). He is now complaining of a headache. Which prescribed interventions should the nurse implement first? a. Administer IV 5% hypertonic saline. b. Draw blood for arterial blood gases (ABGs). c. Send patient for computed tomography (CT). d. Administer acetaminophen (Tylenol) 650 mg orally.

A The patient's low sodium indicates that hyponatremia may be causing the cerebral edema. The nurse's first action should be to correct the low sodium level. Acetaminophen (Tylenol) will have minimal effect on the headache because it is caused by cerebral edema and increased intracranial pressure (ICP). Drawing ABGs and obtaining a CT scan may provide some useful information, but the low sodium level may lead to seizures unless it is addressed quickly. DIF: Cognitive Level: Analyze (analysis) REF: 1325 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

13. A triage nurse in a busy emergency department (ED) assesses a patient who complains of 7/10 abdominal pain and states, "I had a temperature of 103.9° F (39.9° C) at home." The nurse's first action should be to a. assess the patient's current vital signs. b. give acetaminophen (Tylenol) per agency protocol. c. ask the patient to provide a clean-catch urine for urinalysis. d. tell the patient that it will be 1 to 2 hours before seeing a health care provider.

A The patient's pain and statement about an elevated temperature indicate that the nurse should obtain vital signs before deciding how rapidly the patient should be seen by the health care provider. A urinalysis may be appropriate, but this would be done after the vital signs are taken. The nurse will not give acetaminophen before confirming a current temperature elevation. DIF: Cognitive Level: Analyze (analysis) REF: 1632 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

14. A triage nurse in a busy emergency department assesses a patient who complains of 6/10 abdominal pain and states, "I had a temperature of 104.6º F (40.3º C) at home." The nurse's first action should be to a. assess the patient's current vital signs. b. obtain a clean-catch urine for urinalysis. c. tell the patient that it may be several hours before being seen by the doctor. d. ask the health care provider to order an analgesic medication for the patient.

A The patient's pain and statement about an elevated temperature indicate that the nurse should obtain vital signs before deciding how rapidly the patient should be seen by the health care provider. A urinalysis may be needed, but vital signs will provide the nurse with the data needed to determine this. The health care provider will not order a medication before assessing the patient. DIF: Cognitive Level: Application REF: 1770-1771 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

18. A patient's cardiac monitor has a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious and pulseless. Which action should the nurse take first? a. Defibrillate at 360 joules. b. Give O2 per bag-valve-mask. c. Give epinephrine (Adrenalin) IV. d. Prepare for endotracheal intubation.

A The patient's rhythm and assessment indicate ventricular fibrillation and cardiac arrest; the initial action should be to defibrillate. If a defibrillator is not immediately available or is unsuccessful in converting the patient to a better rhythm, the other actions may be appropriate. DIF: Cognitive Level: Application REF: 831-833 | Algorithms for Treatment of Dysrhythmias on Evolve OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

15. The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first? a. Remove the patient's rings. b. Apply ice packs to both hands. c. Apply calamine lotion to itching areas. d. Give diphenhydramine (Benadryl) 50 mg PO.

A The patient's rings should be removed first because it might not be possible to remove them if swelling develops. The other orders should also be implemented as rapidly as possible after the nurse has removed the jewelry. DIF: Cognitive Level: Analyze (analysis) REF: 1640 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

19. An unresponsive patient is admitted to the emergency department (ED) after falling through the ice while ice skating. Which assessment will the nurse obtain first? a. Pulse c. Breath sounds b. Heart rhythm d. Body temperature

A The priority assessment in an unresponsive patient relates to CAB (circulation, airway, breathing) so a pulse check should be performed first. While assessing the pulse, the nurse should look for signs of breathing. The other data will also be collected rapidly but are not as essential as determining if there is a pulse. DIF: Cognitive Level: Apply (application) REF: 1630 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

37. A patient who has chest pain is admitted to the emergency department (ED), and all the following diagnostic tests are ordered. Which one will the nurse arrange to be completed first? a. Electrocardiogram (ECG) b. Computed tomography (CT) scan c. Chest x-ray d. Troponin level

A The priority for the patient is to determine whether an acute myocardial infarction (AMI) is occurring so that reperfusion therapy can begin as quickly as possible. ECG changes occur very rapidly after coronary artery occlusion. Troponin levels will increase after about 3 hours. Data from the CT scan and chest x-ray may impact the patient's care but are not helpful in determining whether the patient is experiencing a myocardial infarction (MI). DIF: Cognitive Level: Application REF: 782 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

18. An unresponsive 79-yr-old patient is admitted to the emergency department (ED) during a summer heat wave. The patient's core temperature is 105.4° F (40.8° C), blood pressure (BP) is 88/50 mm Hg, and pulse is 112 beats/min. The nurse will plan to a. apply wet sheets and a fan to the patient. b. provide O2 at 2 L/min with a nasal cannula. c. start lactated Ringer's solution at 1000 mL/hr. d. give acetaminophen (Tylenol) rectal suppository.

A The priority intervention is to cool the patient. Antipyretics are not effective in decreasing temperature in heat stroke and 100% O2 should be given, which requires a high flow rate through a non-rebreather mask. An older patient would be at risk for developing complications such as pulmonary edema if given fluids at 1000 mL/hr. DIF: Cognitive Level: Apply (application) REF: 1637 TOP: Nursing Process: Planning

23. To evaluate the effectiveness of IV methylprednisolone (Solu-Medrol) given to a patient with a T4 spinal cord injury, which information is most important for the nurse to obtain? a. Leg strength and sensation b. Skin temperature and color c. Blood pressure and apical heart rate d. Respiratory effort and O2 saturation

A The purpose of methylprednisolone administration is to help preserve motor function and sensation. Therefore the nurse will assess this patient for lower extremity function. The other data also will be collected by the nurse, but they do not reflect the effectiveness of the methylprednisolone. DIF: Cognitive Level: Application REF: 1554-1555 OBJ: Special Questions: Prioritization TOP: Nursing Process: Evaluation

11. When prone positioning is used in the care of a patient with acute respiratory distress syndrome (ARDS), which information obtained by the nurse indicates that the positioning is effective? a. The patient's PaO2 is 90 mm Hg, and the SaO2 is 92%. b. Endotracheal suctioning results in minimal mucous return. c. Sputum and blood cultures show no growth after 24 hours. d. The skin on the patient's back is intact and without redness.

A The purpose of prone positioning is to improve the patient's oxygenation as indicated by the PaO2 and SaO2. The other information will be collected but does not indicate whether prone positioning has been effective. DIF: Cognitive Level: Application REF: 1762-1763 TOP: Nursing Process: Evaluation

20. Following an earthquake, patients are triaged by emergency medical personnel and transported to the emergency department (ED). Which patient will the nurse need to assess first? a. A patient with a red tag c. A patient with a black tag b. A patient with a blue tag d. A patient with a yellow tag

A The red tag indicates a patient with a life-threatening injury requiring rapid treatment. The other tags indicate patients with less urgent injuries or those who are likely to die. DIF: Cognitive Level: Remember (knowledge) REF: 1646 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

21. Following an earthquake, patients are triaged by emergency medical personnel and are transported to the hospital. Which of these patients will the nurse need to assess first? a. A patient with a red tag b. A patient with a blue tag c. A patient with a yellow tag d. A patient with a green tag

A The red tag indicates a patient with a life-threatening injury requiring rapid treatment. The other tags indicate patients with less urgent injuries or those who are likely to die. DIF: Cognitive Level: Knowledge REF: 1785-1786 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

33. While admitting a 42-yr-old patient with a possible brain injury after a car accident to the emergency department (ED), the nurse obtains the following information. Which finding is most important to report to the health care provider? a. The patient takes warfarin (Coumadin) daily. b. The patient's blood pressure is 162/94 mm Hg. c. The patient is unable to remember the accident. d. The patient complains of a severe dull headache.

A The use of anticoagulants increases the risk for intracranial hemorrhage and should be immediately reported. The other information would not be unusual in a patient with a head injury who had just arrived in the ED. DIF: Cognitive Level: Analyze (analysis) REF: 1328 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

33. When admitting a patient with a possible coup-contracoup injury after a car accident to the emergency department, the nurse obtains the following information. Which finding is most important to report to the health care provider? a. The patient takes warfarin (Coumadin) daily. b. The patient's blood pressure is 162/94 mm Hg. c. The patient is unable to remember the accident. d. The patient complains of a severe dull headache.

A The use of anticoagulants increases the risk for intracranial hemorrhage and should be immediately reported. The other information would not be unusual in a patient with a head injury who had just arrived to the ED. DIF: Cognitive Level: Application REF: 1437-1438 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

11. A client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60 beats/min, pulse pressure increase from 26 to 40 mm Hg, and respiratory irregularities. What action by the nurse takes priority? a. Call the provider or Rapid Response Team. b. Increase the rate of the IV fluid administration. c. Notify respiratory therapy for a breathing treatment. d. Prepare to give IV pain medication.

A These manifestations indicate Cushing's syndrome, a potentially life-threatening increase in intracranial pressure (ICP), which is an emergency. Immediate medical attention is necessary, so the nurse notifies the provider or the Rapid Response Team. Increasing fluids would increase the ICP. The client does not need a breathing treatment or pain medication.. DIF: Applying/Application REF: 952 KEY: Neurologic disorders| Rapid Response Team| critical rescue

17. A client who had a severe traumatic brain injury is being discharged home, where the spouse will be a full-time caregiver. What statement by the spouse would lead the nurse to provide further education on home care? a. "I know I can take care of all these needs by myself." b. "I need to seek counseling because I am very angry." c. "Hopefully things will improve gradually over time." d. "With respite care and support, I think I can do this."

A This caregiver has unrealistic expectations about being able to do everything without help. Acknowledging anger and seeking counseling show a realistic outlook and plans for accomplishing goals. Hoping for improvement over time is also realistic, especially with the inclusion of the word "hopefully." Realizing the importance of respite care and support also is a realistic outlook. DIF: Evaluating/Synthesis REF: 957 KEY: Neurologic disorders| discharge teaching| psychosocial response| coping

3. The nurse gets the hand-off report on four clients. Which client should the nurse assess first? a. Client with a blood pressure change of 128/74 to 110/88 mm Hg b. Client with oxygen saturation unchanged at 94% c. Client with a pulse change of 100 to 88 beats/min d. Client with urine output of 40 mL/hr for the last 2 hours

A This client has a falling systolic blood pressure, rising diastolic blood pressure, and narrowing pulse pressure, all of which may be indications of the progressive stage of shock. The nurse should assess this client first. The client with the unchanged oxygen saturation is stable at this point. Although the client with a change in pulse has a slower rate, it is not an indicator of shock since the pulse is still within the normal range; it may indicate the client's pain or anxiety has been relieved, or he or she is sleeping or relaxing. A urine output of 40 mL/hr is only slightly above the normal range, which is 30 mL/hr. DIF: Analyzing/Analysis REF: 743 KEY: Shock| perfusion| nursing assessment

20. A nurse assesses a client with the National Institutes of Health (NIH) Stroke Scale and determines the client's score to be 36. How should the nurse plan care for this client? a. The client will need near-total care. b. The client will need cuing only. c. The client will need safety precautions. d. The client will be discharged home.

A This client has severe neurologic deficits and will need near-total care. Safety precautions are important but do not give a full picture of the client's dependence. The client will need more than cuing to complete tasks. A home discharge may be possible, but this does not help the nurse plan care for a very dependent client. DIF: Analyzing/Analysis REF: 935 KEY: Neurologic disorders| neurologic assessment

23. A client has a subarachnoid bolt. What action by the nurse is most important? a. Balancing and recalibrating the device b. Documenting intracranial pressure readings c. Handling the fiberoptic cable with care to avoid breakage d. Monitoring the client's phlebostatic axis

A This device needs frequent balancing and recalibration in order to read correctly. Documenting readings is important, but it is more important to ensure the device's accuracy. The fiberoptic transducer-tipped catheter has a cable that must be handled carefully to avoid breaking it, but ensuring the device's accuracy is most important. The phlebostatic axis is not related to neurologic monitoring. DIF: Applying/Application REF: 956 KEY: Neurologic disorders| neurologic assessment| equipment safety

17. A nurse supervises an unlicensed assistive personnel (UAP) applying electrocardiographic monitoring. Which statement should the nurse provide to the UAP related to this procedure? a. "Clean the skin and clip hairs if needed." b. "Add gel to the electrodes prior to applying them." c. "Place the electrodes on the posterior chest." d. "Turn off oxygen prior to monitoring the client."

A To ensure the best signal transmission, the skin should be clean and hairs clipped. Electrodes should be placed on the anterior chest, and no additional gel is needed. Oxygen has no impact on electrocardiographic monitoring.. DIF: Remembering/Knowledge REF: 652 KEY: Assessment/diagnostic examination| interdisciplinary team| unlicensed assistive personnel (UAP)

24. A patient who has had a subarachnoid hemorrhage is being cared for in the intensive care unit. Which information about the patient is most important to communicate to the health care provider? a. The patient's blood pressure is 90/50 mm Hg. b. The patient complains about having a stiff neck. c. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs). d. The patient complains of an ongoing severe headache.

A To prevent cerebral vasospasm and maintain cerebral perfusion, blood pressure needs to be maintained at a level higher than 90 mm Hg systolic after a subarachnoid hemorrhage. A low BP or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP. An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider. DIF: Cognitive Level: Application REF: 1472-1473 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

1. A hospital responds to a local mass casualty event. Which action should the nurse supervisor take to prevent staff post-traumatic stress disorder during a mass casualty event? a. Provide water and healthy snacks for energy throughout the event. b. Schedule 16-hour shifts to allow for greater rest between shifts. c. Encourage counseling upon deactivation of the emergency response plan. d. Assign staff to different roles and units within the medical facility.

A To prevent staff post-traumatic stress disorder during a mass casualty event, the nurses should use available counseling, encourage and support co-workers, monitor each other's stress level and performance, take breaks when needed, talk about feelings with staff and managers, and drink plenty of water and eat healthy snacks for energy. Nurses should also keep in touch with family, friends, and significant others, and not work for more than 12 hours per day. Encouraging counseling upon deactivation of the plan, or after the emergency response is over, does not prevent stress during the casualty event. Assigning staff to unfamiliar roles or units may increase situational stress and is not an approach to prevent post-traumatic stress disorder. DIF: Remembering/Knowledge REF: 145 KEY: Post-traumatic stress disorder

19. A nurse cares for a client who is on a cardiac monitor. The monitor displayed the rhythm shown below: Which action should the nurse take first? a. Assess airway, breathing, and level of consciousness. b. Administer an amiodarone bolus followed by a drip. c. Cardiovert the client with a biphasic defibrillator. d. Begin cardiopulmonary resuscitation (CPR).

A Ventricular tachycardia occurs with repetitive firing of an irritable ventricular ectopic focus, usually at a rate of 140 to 180 beats/min or more. Ventricular tachycardia is a lethal dysrhythmia. The nurse should first assess if the client is alert and breathing. Then the nurse should call a Code Blue and begin CPR. If this client is pulseless, the treatment of choice is defibrillation. Amiodarone is the antidysrhythmic of choice, but it is not the first action. DIF: Applying/Application REF: 670 KEY: Cardiac electrical conduction| medical emergency

9. A nurse wants to become part of a Disaster Medical Assistance Team (DMAT) but is concerned about maintaining licensure in several different states. Which statement best addresses these concerns? a. "Deployed DMAT providers are federal employees, so their licenses are good in all 50 states." b. "The government has a program for quick licensure activation wherever you are deployed." c. "During a time of crisis, licensure issues would not be the government's priority concern." d. "If you are deployed, you will be issued a temporary license in the state in which you are working."

A When deployed, DMAT health care providers are acting as agents of the federal government, and so are considered federal employees. Thus their licenses are valid in all 50 states. Licensure is an issue that the government would be concerned with, but no programs for temporary licensure or rapid activation are available. DIF: Understanding/Comprehension REF: 142 KEY: Emergency nursing

22. When evaluating the outcomes of preoperative teaching with a patient scheduled for a coronary artery bypass graft (CABG) using the internal mammary artery, the nurse determines that additional teaching is needed when the patient says, a. "I will have incisions in my leg where they will remove the vein." b. "They will circulate my blood with a machine during the surgery." c. "I will need to take an aspirin a day after the surgery to keep the graft open." d. "They will use an artery near my heart to bypass the area that is obstructed."

A When the internal mammary artery is used there is no need to have a saphenous vein removed from the leg. The other statements by the patient are accurate and indicate that the teaching has been effective. DIF: Cognitive Level: Application REF: 783-784 TOP: Nursing Process: Evaluation

21. A few days after experiencing a myocardial infarction (MI) and successful percutaneous coronary intervention, the patient states, "It was just a little chest pain. As soon as I get out of here, I'm going for my vacation as planned." Which reply would be most appropriate for the nurse to make? a. "What do you think caused your chest pain?" b. "Where are you planning to go for your vacation?" c. "Sometimes plans need to change after a heart attack." d. "Recovery from a heart attack takes at least a few weeks."

A When the patient is experiencing denial, the nurse should assist the patient in testing reality until the patient has progressed beyond this step of the emotional adjustment to MI. Asking the patient about vacation plans reinforces the patient's plan, which is not appropriate in the immediate post-MI period. Reminding the patient in denial about the MI is likely to make the patient angry and lead to distrust of the nursing staff. DIF: Cognitive Level: Apply (application) REF: 727 TOP: Nursing Process: Implementation

3. After resuscitation, a patient who had a cardiac arrest is nonresponsive to commands and therapeutic hypothermia is prescribed. Which action will the nurse include in the plan of care? a. Rapidly infuse cold normal saline. b. Avoid the use of sedative medications. c. Check neurologic status every 30 minutes. d. Rewarm if temperature is >91° F (32.8° C).

A When therapeutic hypothermia is used postresuscitation, cold normal saline is infused to rapidly lower body temperature to 89.6° F to 93.2° F (32° C to 34° C). Since hypothermia will decrease brain activity, neurologic assessment every 30 minutes is not needed. Sedative medications are administered during therapeutic hypothermia. DIF: Cognitive Level: Application REF: 1773-1774 TOP: Nursing Process: Planning

3. After the return of spontaneous circulation following the resuscitation of a patient who had a cardiac arrest, therapeutic hypothermia is ordered. Which action will the nurse include in the plan of care? a. Initiate cooling per protocol. b. Avoid the use of sedative drugs. c. Check mental status every 15 minutes. d. Rewarm if temperature is below 91° F (32.8° C).

A When therapeutic hypothermia is used postresuscitation, external cooling devices or cold normal saline infusions are used to rapidly lower body temperature to 89.6° F to 93.2° F (32° C to 34° C). Because hypothermia will decrease brain activity, assessing mental status every 15 minutes is not done at this stage. Sedative drugs are given during therapeutic hypothermia. DIF: Cognitive Level: Apply (application) REF: 1634 TOP: Nursing Process: Planning

38. During change-of-shift report, the nurse learns that a patient with a head injury has decorticate posturing to noxious stimulation. Which positioning shown in the accompanying figure will the nurse expect to observe? a. 1 c. 3 b. 2 d. 4

A With decorticate posturing, the patient exhibits internal rotation and adduction of the arms with flexion of the elbows, wrists, and fingers. The other illustrations are of decerebrate, mixed decorticate and decerebrate posturing, and opisthotonic posturing. DIF: Cognitive Level: Understand (comprehension) REF: 1360 TOP: Nursing Process: Assessment

26. After receiving change-of-shift report on the following four patients, which patient should the nurse see first? a. A patient with right-sided weakness who has an infusion of tPA prescribed b. A patient who has atrial fibrillation and a new order for warfarin (Coumadin) c. A patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due d. A patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop) scheduled

A tPA needs to be infused within the first few hours after stroke symptoms start in order to be effective in minimizing brain injury. The other medications also should be given as quickly as possible, but timing of the medications is not as critical. DIF: Cognitive Level: Application REF: 1471 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Implementation

26. After receiving change-of-shift report on the following four patients, which patient should the nurse see first? a. A 60-yr-old patient with right-sided weakness who has an infusion of tPA prescribed b. A 50-yr-old patient who has atrial fibrillation and a new order for warfarin (Coumadin) c. A 30-yr-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine scheduled d. A 40-yr-old patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due

A tPA needs to be infused within the first few hours after stroke symptoms start in order to be effective in minimizing brain injury. The other medications should also be given as quickly as possible, but timing of the medications is not as critical. DIF: Cognitive Level: Analyze (analysis) REF: 1355 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Implementation

10. A nurse is seeing many clients in the neurosurgical clinic. With which clients should the nurse plan to do more teaching? (Select all that apply.) a. Client with an aneurysm coil placed 2 months ago who is taking ibuprofen (Motrin) for sinus headaches b. Client with an aneurysm clip who states that his family is happy there is no chance of recurrence c. Client who had a coil procedure who says that there will be no problem following up for 1 year d. Client who underwent a flow diversion procedure 3 months ago who is taking docusate sodium (Colace) for constipation e. Client who underwent surgical aneurysm ligation 3 months ago who is planning to take a Caribbean cruise

A, B After a coil procedure, up to 20% of clients experience re-bleeding in the first year. The client with this coil should not be taking drugs that interfere with clotting. An aneurysm clip can move up to 5 years after placement, so this client and family need to be watchful for changing neurologic status. The other statements show good understanding. DIF: Evaluating/Synthesis REF: 940 KEY: Neurologic disorders

1. Which interventions will the nurse plan for a comatose patient who is to begin therapeutic hypothermia (select all that apply)? a. Assist with endotracheal intubation. b. Insert an indwelling urinary catheter. c. Begin continuous cardiac monitoring. d. Obtain an order to restrain the patient. e. Prepare to give sympathomimetic drugs.

A, B, C Cooling can produce dysrhythmias, so the patient's heart rhythm should be continuously monitored and dysrhythmias treated if necessary. Bladder catheterization and endotracheal intubation are needed during cooling. Sympathomimetic drugs tend to stimulate the heart and increase the risk for fatal dysrhythmias such as ventricular fibrillation. Patients receiving therapeutic hypothermia are comatose or do not follow commands so restraints are not indicated. DIF: Cognitive Level: Apply (application) REF: 1634 TOP: Nursing Process: Planning

1. A nurse cares for a client with burn injuries during the resuscitation phase. Which actions are priorities during this phase? (Select all that apply.) a. Administer analgesics. b. Prevent wound infections. c. Provide fluid replacement.. d. Decrease core temperature. e. Initiate physical therapy.

A, B, C Nursing priorities during the resuscitation phase include securing the airway, supporting circulation and organ perfusion by fluid replacement, keeping the client comfortable with analgesics, preventing infection through careful wound care, maintaining body temperature, and providing emotional support. Physical therapy is inappropriate during the resuscitation phase but may be initiated after the client has been stabilized. DIF: Applying/Application REF: 473 KEY: Skin lesions/wounds| pharmacologic pain management| infection control

2. Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) in patients admitted to the hospital (select all that apply)? a. Ambulate postoperative patients as soon as possible after surgery. b. Use aseptic technique when manipulating invasive lines or devices. c. Remove indwelling urinary catheters as soon as possible after surgery. d. Administer prescribed antibiotics within 1 hour for patients with possible sepsis. e. Advocate for parenteral nutrition for patients who cannot take in adequate calories.

A, B, C, D Because sepsis is the most frequent etiology for SIRS, measures to avoid infection such as removing indwelling urinary catheters as soon as possible, use of aseptic technique, and early ambulation should be included in the plan of care. Adequate nutrition is important in preventing SIRS. Enteral, rather than parenteral, nutrition is preferred when patients are unable to take oral feedings because enteral nutrition helps maintain the integrity of the intestine, thus decreasing infection risk. Antibiotics should be given within 1 hour after being prescribed to decrease the risk of sepsis progressing to SIRS. DIF: Cognitive Level: Apply (application) REF: 1606 TOP: Nursing Process: Planning

4. The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.) a. Adherence to proper hand hygiene b. Administering anti-ulcer medication c. Elevating the head of the bed d. Providing oral care per protocol e. Suctioning the client on a regular schedule

A, B, C, D The "ventilator bundle" is a group of care measures to prevent ventilator-associated pneumonia.. Actions in the bundle include using proper hand hygiene, giving anti-ulcer medications, elevating the head of the bed, providing frequent oral care per policy, preventing aspiration, and providing pulmonary hygiene measures. Suctioning is done as needed. DIF: Remembering/Knowledge REF: 621 KEY: Mechanical ventilation| respiratory system| core measures| infection control| pneumonia

7. A client has meningitis following brain surgery. What comfort measures may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Applying a cool washcloth to the head b. Assisting the client to a position of comfort c. Keeping voices soft and soothing d. Maintaining low lighting in the room e. Providing antipyretics for fever

A, B, C, D The client with meningitis often has high fever, pain, and some degree of confusion. Cool washcloths to the forehead are comforting and help with pain. Allowing the client to assume a position of comfort also helps manage pain. Keeping voices low and lights dimmed also helps convey caring in a nonthreatening manner. The nurse provides antipyretics for fever. DIF: Applying/Application REF: 962 KEY: neurologic disorders| delegation| comfort measures| communication| unlicensed assistive personnel (UAP)

3. A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.) a. Acknowledge the frightening nature of the illness. b. Delegate a back rub to the unlicensed assistive personnel (UAP). c. Give simple explanations of what is happening. d. Request a prescription for antianxiety medication. e. Stay with the client and speak in a quiet, calm voice.

A, B, C, E Clients with PEs are often anxious. The nurse can acknowledge the client's fears, delegate comfort measures, give simple explanations the client will understand, and stay with the client. Using a calm, quiet voice is also reassuring. Sedatives and antianxiety medications are not used routinely because they can contribute to hypoxia. If the client's anxiety is interfering with diagnostic testing or treatment, they can be used, but there is no evidence that this is the case. DIF: Applying/Application REF: 609 KEY: Pulmonary embolism| thromboembolic events| psychosocial response| anxiety| support

6. The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this? (Select all that apply.) a. Chest wall stiffness b. Decreased muscle strength c. Inability to cooperate d. Less lung elasticity e. Poor vision and hearing

A, B, D Age-related changes that increase the difficulty of weaning older adults from mechanical ventilation include increased stiffness of the chest wall, decreased muscle strength, and less elasticity of lung tissue. Not all older adults have an inability to cooperate or poor sensory acuity. DIF: Remembering/Knowledge REF: 622 KEY: Mechanical ventilation| older adult

2. The nurse is caring for a patient who has an intraaortic balloon pump (IABP) after a massive heart attack. When assessing the patient, the nurse notices blood backing up into the IABP catheter. In which order should the nurse take the following actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Confirm that the IABP console has turned off. b. Assess the patient's vital signs and orientation. c. Obtain supplies for insertion of a new IABP catheter. d. Notify the health care provider of the IABP malfunction.

A, B, D, C Blood in the IABP catheter indicates a possible tear in the balloon. The console should shut off automatically to prevent complications such as air embolism. Next, the nurse will assess the patient and communicate with the health care provider about the patient's assessment and the IABP problem. Finally, supplies for insertion of a new IABP catheter may be needed based on the patient assessment and the decision of the health care provider. DIF: Cognitive Level: Analyze (analysis) REF: 1568 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning

1. A patient with suspected neurogenic shock after a diving accident has arrived in the emergency department. A cervical collar is in place. Which actions should the nurse take (select all that apply)? a. Prepare to administer atropine IV. b. Obtain baseline body temperature. c. Infuse large volumes of lactated Ringer's solution. d. Provide high-flow O2 (100%) by nonrebreather mask. e. Prepare for emergent intubation and mechanical ventilation.

A, B, D, E All of the actions are appropriate except to give large volumes of lactated Ringer's solution. The patient with neurogenic shock usually has a normal blood volume, and it is important not to volume overload the patient. In addition, lactated Ringer's solution is used cautiously in all shock situations because an ischemic liver cannot convert lactate to bicarbonate. DIF: Cognitive Level: Apply (application) REF: 1600 TOP: Nursing Process: Implementation

8. A nurse is working with many stroke clients. Which clients would the nurse consider referring to a mental health provider on discharge? (Select all that apply.) a. Client who exhibits extreme emotional lability b. Client with an initial National Institutes of Health (NIH) Stroke Scale score of 38 c. Client with mild forgetfulness and a slight limp d. Client who has a past hospitalization for a suicide attempt e. Client who is unable to walk or eat 3 weeks post-stroke

A, B, D, E Clients most at risk for post-stroke depression are those with a previous history of depression, severe stroke (NIH Stroke Scale score of 38 is severe), and post-stroke physical or cognitive impairment. The client with mild forgetfulness and a slight limp would be a low priority for this referral. DIF: Applying/Application REF: 935 KEY: Neurologic disorders| stroke| psychosocial response| depression| nursing assessment

3. A nursing student studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in what ways? (Select all that apply.) a. Accompanied by shortness of breath b. Feelings of fear or anxiety c. Lasts less than 15 minutes d. No relief from taking nitroglycerin e. Pain occurs without known cause

A, B, D, E The pain from an MI is often accompanied by shortness of breath and fear or anxiety. It lasts longer than 15 minutes and is not relieved by nitroglycerin. It occurs without a known cause such as exertion. DIF: Remembering/Knowledge REF: 762 KEY: Coronary artery disease| pathophysiology

5. A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.) a. Allow visitors at the client's bedside. b. Ensure the client can communicate if awake. c. Keep the television tuned to a favorite channel. d.. Provide back and hand massages when turning. e. Turn the client every 2 hours or more.

A, B, D, E There are many basic care measures that can be employed for the client who is on a ventilator. Allowing visitation, providing a means of communication, massaging the client's skin, and routinely turning and repositioning the client are some of them. Keeping the TV on will interfere with sleep and rest. DIF: Applying/Application REF: 619 KEY: Comfort measures| mechanical ventilation

2. An emergency department (ED) nurse is preparing to transfer a client to the trauma intensive care unit. Which information should the nurse include in the nurse-to-nurse hand-off report? (Select all that apply.) a. Mechanism of injury b. Diagnostic test results c.. Immunizations d. List of home medications e. Isolation precautions

A, B, E Hand-off communication should be comprehensive so that the receiving nurse can continue care for the client fluidly. Communication should be concise and should include only the most essential information for a safe transition in care. Hand-off communication should include the client's situation (reason for being in the ED), brief medical history, assessment and diagnostic findings, Transmission-Based Precautions needed, interventions provided, and response to those interventions. DIF: Applying/Application REF: 108 KEY: SBAR| hand-off communication

2. A nurse cares for a client with burn injuries who is experiencing anxiety and pain. Which nonpharmacologic comfort measures should the nurse implement? (Select all that apply.) a. Music as a distraction b. Tactile stimulation c. Massage to injury sites d. Cold compresses e. Increasing client control

A, B, E Nonpharmacologic comfort measures for clients with burn injuries include music therapy, tactile stimulation, massaging unburned areas, warm compresses, and increasing client control. DIF: Remembering/Knowledge REF: 480 KEY: Nonpharmacologic pain management

4. An emergency department nurse moves to a new city where heat-related illnesses are common. Which clients does the nurse anticipate being at higher risk for heat-related illnesses? (Select all that apply.) a. Homeless individuals b. Illicit drug users c. White people d. Hockey players e. Older adults

A, B, E Some of the most vulnerable, at-risk populations for heat-related illness include older adults; blacks (more than whites); people who work outside, such as construction and agricultural workers (more men than women); homeless people; illicit drug users (especially cocaine users); outdoor athletes (recreational and professional); and members of the military who are stationed in countries with hot climates (e.g., Iraq, Afghanistan). DIF: Remembering/Knowledge REF: 120 KEY: Heat-related illness| environmental emergencies

2. A nurse teaches a client with a new permanent pacemaker. Which instructions should the nurse include in this client's teaching? (Select all that apply.) a. "Until your incision is healed, do not submerge your pacemaker. Only take showers." b. "Report any pulse rates lower than your pacemaker settings." c. "If you feel weak, apply pressure over your generator." d. "Have your pacemaker turned off before having magnetic resonance imaging (MRI)." e.. "Do not lift your left arm above the level of your shoulder for 8 weeks."

A, B, E The client should not submerge in water until the site has healed; after the incision is healed, the client may take showers or baths without concern for the pacemaker. The client should be instructed to report changes in heart rate or rhythm, such as rates lower than the pacemaker setting or greater than 100 beats/min. The client should be advised of restrictions on physical activity for 8 weeks to allow the pacemaker to settle in place. The client should never apply pressure over the generator and should avoid tight clothing. The client should never have MRI because, whether turned on or off, the pacemaker contains metal. The client should be advised to inform all health care providers that he or she has a pacemaker. DIF: Applying/Application REF: 675 KEY: Cardiac electrical conduction| patient education

2. A nurse teaches a client who has severe allergies to prevent bug bites. Which statements should the nurse include in this client's teaching? (Select all that apply.) a. "Consult an exterminator to control bugs in and around your home." b. "Do not swat at insects or wasps." c. "Wear sandals whenever you go outside." d. "Keep your prescribed epinephrine auto-injector in a bedside drawer." e. "Use screens in your windows and doors to prevent flying insects from entering."

A, B, E To prevent arthropod bites and stings, clients should wear protective clothing, cover garbage cans, use screens in windows and doors, inspect clothing and shoes before putting them on, consult an exterminator, remove nests, avoid swatting at insects, and carry a prescription epinephrine auto-injector at all times if they are known to be allergic to bee or wasp stings. DIF: Applying/Application REF: 126 KEY: Bee and insect sting| environmental emergencies

5. A nurse plans care for a client with burn injuries. Which interventions should the nurse implement to prevent infection in the client? (Select all that apply.) a. Ask all family members and visitors to perform hand hygiene before touching the client. b. Carefully monitor burn wounds when providing each dressing change. c. Clean equipment with alcohol between uses with each client on the unit. d. Allow family members to only bring the client plants from the hospital's gift shop. e. Use aseptic technique and wear gloves when performing wound care.

A, B, E To prevent infection in a client with burn injuries the nurse should ensure everyone performs hand hygiene, monitor wounds for signs of infection, and use aseptic technique, including wearing gloves when performing wound care. The client should have disposable equipment that is not shared with another client, and plants should not be allowed in the client's room. DIF: Applying/Application REF: 483 KEY: Infection control| Standard Precautions| Transmission-Based Precautions

5. The nurse is caring for a client with suspected severe sepsis. What does the nurse prepare to do within 3 hours of the client being identified as being at risk? (Select all that apply.) a. Administer antibiotics. b. Draw serum lactate levels. c. Infuse vasopressors. d. Measure central venous pressure. e. Obtain blood cultures.

A, B, E Within the first 3 hours of suspecting severe sepsis, the nurse should draw (or facilitate) serum lactate levels, obtain blood cultures (or other cultures), and administer antibiotics (after the cultures have been obtained). Infusing vasopressors and measuring central venous pressure are actions that should occur within the first 6 hours. DIF: Remembering/Knowledge REF: 753 KEY: Shock| critical rescue| medical emergencies

1. The student nurse studying shock understands that the common manifestations of this condition are directly related to which problems? (Select all that apply.) a. Anaerobic metabolism b. Hyperglycemia c. Hypotension d. Impaired renal perfusion e. Increased perfusion

A, C The common manifestations of shock, no matter the cause, are directly related to the effects of anaerobic metabolism and hypotension. Hyperglycemia, impaired renal function, and increased perfusion are not manifestations of shock. DIF: Remembering/Knowledge REF: 741 KEY: Shock| pathophysiology

1. A nursing student studying the neurologic system learns which information? (Select all that apply.) a. An aneurysm is a ballooning in a weakened part of an arterial wall. b. An arteriovenous malformation is the usual cause of strokes. c. Intracerebral hemorrhage is bleeding directly into the brain. d. Reduced perfusion from vasospasm often makes stroke worse. e. Subarachnoid hemorrhage is caused by high blood pressure.

A, C, D An aneurysm is a ballooning of the weakened part of an arterial wall. Intracerebral hemorrhage is bleeding directly into the brain. Vasospasm often makes the damage from the initial stroke worse because it causes decreased perfusion. An arteriovenous malformation (AVM) is unusual. Subarachnoid hemorrhage is usually caused by a ruptured aneurysm or AVM. DIF: Remembering/Knowledge REF: 932 KEY: Neurologic disorders

7. A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations should the nurse correlate with neurogenic shock? (Select all that apply.) a. Heart rate of 34 beats/min b. Blood pressure of 185/65 mm Hg c. Urine output less than 30 mL/hr d. Decreased level of consciousness e. Increased oxygen saturation

A, C, D Neurogenic shock with acute spinal cord injury manifests with decreased oxygen saturation, symptomatic bradycardia, decreased level of consciousness, decreased urine output, and hypotension. DIF: Applying/Application REF: 896 KEY: Spinal cord/back injury| shock

6. A nurse cares for older clients who have traumatic brain injury. What should the nurse understand about this population? (Select all that apply.) a. Admission can overwhelm the coping mechanisms for older clients. b. Alcohol is typically involved in most traumatic brain injuries for this age group. c. These clients are more susceptible to systemic and wound infections. d. Other medical conditions can complicate treatment for these clients. e. Very few traumatic brain injuries occur in this age group.

A, C, D Older clients often tolerate stress poorly, which includes being admitted to a hospital that is unfamiliar and noisy. Because of decreased protective mechanisms, they are more susceptible to both local and systemic infections. Other medical conditions can complicate their treatment and recovery. Alcohol is typically not related to traumatic brain injury in this population; such injury is most often from falls and motor vehicle crashes. The 65- to 76-year-old age group has the second highest rate of brain injuries compared to other age groups. DIF: Remembering/Knowledge REF: 951 KEY: Neurologic disorders| older adults| trauma

3. A nurse plans care for a client with burn injuries. Which interventions should the nurse include in this client's plan of care to ensure adequate nutrition? (Select all that apply.) a. Provide at least 5000 kcal/day. b. Start an oral diet on the first day. c. Administer a diet high in protein. d. Collaborate with a registered dietitian. e. Offer frequent high-calorie snacks.

A, C, D, E A client with a burn injury needs a high-calorie diet, including at least 5000 kcal/day and frequent high-calorie snacks. The nurse should collaborate with a registered dietitian to ensure the client receives a high-calorie and high-protein diet required for wound healing. Oral diet therapy should be delayed until GI motility resumes. DIF: Remembering/Knowledge REF: 485 KEY: Nutrition| nutritional requirements

2. The nurse working in the emergency department assesses a client who has symptoms of stroke. For what modifiable risk factors should the nurse assess? (Select all that apply.) a. Alcohol intake b. Diabetes c. High-fat diet d. Obesity e. Smoking

A, C, D, E Alcohol intake, a high-fat diet, obesity, and smoking are all modifiable risk factors for stroke. Diabetes is not modifiable but is a risk factor that can be controlled with medical intervention. DIF: Remembering/Knowledge REF: 933 KEY: Neurologic disorders| stroke| nursing assessment

2. The nurse caring for hospitalized clients includes which actions on their care plans to reduce the possibility of the clients developing shock? (Select all that apply.) a. Assessing and identifying clients at risk b. Monitoring the daily white blood cell count c. Performing proper hand hygiene d. Removing invasive lines as soon as possible e. Using aseptic technique during procedures

A, C, D, E Assessing and identifying clients at risk for shock is probably the most critical action the nurse can take to prevent shock from occurring. Proper hand hygiene, using aseptic technique, and removing IV lines and catheters are also important actions to prevent shock. Monitoring laboratory values does not prevent shock but can indicate a change. DIF: Applying/Application REF: 752 KEY: Shock| nursing assessment| infection control

1. When caring for a patient who experienced a T1 spinal cord transsection 2 days ago, which collaborative and nursing actions will the nurse include in the plan of care (select all that apply)? a. Urinary catheter care b. Nasogastric (NG) tube feeding c. Continuous cardiac monitoring d. Avoidance of cool room temperature e. Administration of H2 receptor blockers

A, C, D, E The patient is at risk for bradycardia and poikilothermia caused by sympathetic nervous system dysfunction and should have continuous cardiac monitoring and maintenance of a relatively warm room temperature. Gastrointestinal (GI) motility is decreased initially and NG suctioning is indicated. To avoid bladder distention, a urinary retention catheter is used during this acute phase. Stress ulcers are a common complication but can be avoided through the use of the H2 receptor blockers such as famotidine. DIF: Cognitive Level: Application REF: 1555 | 1558-1561 OBJ: Special Questions: Alternate Item Format TOP: Nursing Process: Planning

1. When caring for a patient who experienced a T2 spinal cord transection 24 hours ago, which collaborative and nursing actions will the nurse include in the plan of care (select all that apply)? a. Urinary catheter care b. Nasogastric (NG) tube feeding c. Continuous cardiac monitoring d. Administration of H2 receptor blockers e. Maintenance of a warm room temperature

A, C, D, E The patient is at risk for bradycardia and poikilothermia caused by sympathetic nervous system dysfunction and should have continuous cardiac monitoring and maintenance of a relatively warm room temperature. To avoid bladder distention, a urinary retention catheter is used during this acute phase. Stress ulcers are a common complication, but can be avoided through the use of the H2 receptor blockers such as famotidine. Gastrointestinal motility is decreased initially, and NG suctioning is indicated. DIF: Cognitive Level: Apply (application) REF: 1426 TOP: Nursing Process: Planning

1. Emergency medical services (EMS) brings a large number of clients to the emergency department following a mass casualty incident. The nurse identifies the clients with which injuries with yellow tags? (Select all that apply.) a. Partial-thickness burns covering both legs b.. Open fractures of both legs with absent pedal pulses c. Neck injury and numbness of both legs d. Small pieces of shrapnel embedded in both eyes e. Head injury and difficult to arouse f.. Bruising and pain in the right lower abdomen

A, C, D, F Clients with burns, spine injuries, eye injuries, and stable abdominal injuries should be treated within 30 minutes to 2 hours, and therefore should be identified with yellow tags. The client with the open fractures and the client with the head injury would be classified as urgent with red tags. DIF: Analyzing/Analysis REF: 141 KEY: Triage| emergency nursing

1. A nurse assesses a client who recently experienced a traumatic spinal cord injury. Which assessment data should the nurse obtain to assess the client's coping strategies? (Select all that apply.) a. Spiritual beliefs b.. Level of pain c. Family support d. Level of independence e. Annual income f. Previous coping strategies

A, C, D, F Information about the client's preinjury psychosocial status, usual methods of coping with illness, difficult situations, and disappointments should be obtained. Determine the client's level of independence or dependence and his or her comfort level in discussing feelings and emotions with family members or close friends. Clients who are emotionally secure and have a positive self-image, a supportive family, and financial and job security often adapt to their injury. Information about the client's spiritual and religious beliefs or cultural background also assists the nurse in developing the plan of care. The other options do not supply as much information about coping. DIF: Applying/Application REF: 894 KEY: Spinal cord/back injury| coping

3. A nurse is providing health education at a community center. Which instructions should the nurse include in teaching about prevention of lightning injuries during a storm? (Select all that apply.) a. Seek shelter inside a building or vehicle. b. Hide under a tall tree. c. Do not take a bath or shower. d. Turn off the television. e. Remove all body piercings. f. Put down golf clubs or gardening tools.

A, C, D, F When thunder is heard, shelter should be sought in a safe area such as a building or an enclosed vehicle. Electrical equipment such as TVs and stereos should be turned off. Stay away from plumbing, water, and metal objects. Do not stand under an isolated tall tree or a structure such as a flagpole. Body piercings will not increase a person's chances of being struck by lightning. DIF: Remembering/Knowledge REF: 130 KEY: Lightning injuries| environmental emergencies

2. A nurse is caring for a client who had coronary artery bypass grafting yesterday. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assist the client to the chair for meals and to the bathroom. b. Encourage the client to use the spirometer every 4 hours. c. Ensure the client wears TED hose or sequential compression devices. d. Have the client rate pain on a 0-to-10 scale and report to the nurse. e. Take and record a full set of vital signs per hospital protocol.

A, C, E The nurse can delegate assisting the client to get up in the chair or ambulate to the bathroom, applying TEDs or sequential compression devices, and taking/recording vital signs. The spirometer should be used every hour the day after surgery. Assessing pain using a 0-to-10 scale is a nursing assessment, although if the client reports pain, the UAP should inform the nurse so a more detailed assessment is done. DIF: Applying/Application REF: 768 KEY: Coronary artery disease| coronary artery bypass graft| delegation| activity| unlicensed assistive personnel (UAP)

5. A nursing student studying traumatic brain injuries (TBIs) should recognize which facts about these disorders? (Select all that apply.) a. A client with a moderate trauma may need hospitalization. b. A Glasgow Coma Scale score of 10 indicates a mild brain injury. c. Only open head injuries can cause a severe TBI. d. A client with a Glasgow Coma Scale score of 3 has severe TBI. e. The terms "mild TBI" and "concussion" have similar meanings.

A, D, E "Mild TBI" is a term used synonymously with the term "concussion." A moderate TBI has a Glasgow Coma Scale (GCS) score of 9 to 12, and these clients may need to be hospitalized. Both open and closed head injuries can cause a severe TBI, which is characterized by a GCS score of 3 to 8. DIF: Remembering/Knowledge REF: 947 KEY: Neurologic disorders| trauma

4. A nurse has applied to work at a hospital that has National Stroke Center designation. The nurse realizes the hospital adheres to eight Core Measures for ischemic stroke care. What do these Core Measures include? (Select all that apply.) a. Discharging the client on a statin medication b.. Providing the client with comprehensive therapies c. Meeting goals for nutrition within 1 week d. Providing and charting stroke education e. Preventing venous thromboembolism

A, D, E Core Measures established by The Joint Commission include discharging stroke clients on statins, providing and recording stroke education, and taking measures to prevent venous thromboembolism. The client must be assessed for therapies but may go elsewhere for them. Nutrition goals are not part of the Core Measures. DIF: Remembering/Knowledge REF: 945 KEY: Neurologic disorders| stroke| Core Measures

1. A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations should the nurse assess? (Select all that apply.) a. Decrease in cardiac output b. Increase in cardiac output c. Decrease in blood pressure d. Increase in blood pressure e. Decrease in urine output f. Increase in urine output

A, D, E Elevated heart rates in a healthy client initially cause blood pressure and cardiac output to increase. However, in a client who has congestive heart failure or a client with long-term tachycardia, ventricular filling time, cardiac output, and blood pressure eventually decrease. As cardiac output and blood pressure decrease, urine output will fall. DIF: Applying/Application REF: 657 KEY: Cardiac electrical conduction| heart failure

5. An emergency department nurse plans care for a client who is admitted with heat stroke. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Administer oxygen via mask or nasal cannula. b. Administer ibuprofen, an antipyretic medication. c. Apply cooling techniques until core body temperature is less than 101° F. d. Infuse 0.9% sodium chloride via a large-bore intravenous cannula. e. Obtain baseline serum electrolytes and cardiac enzymes.

A, D, E Heat stroke is a medical emergency. Oxygen therapy and intravenous fluids should be provided, and baseline laboratory tests should be performed as quickly as possible. The client should be cooled until core body temperature is reduced to 102° F. Antipyretics should not be administered. DIF: Understanding/Comprehension REF: 123 KEY: Heat-related illness| environmental emergencies

4. A client is in the early stages of shock and is restless. What comfort measures does the nurse delegate to the nursing student? (Select all that apply.) a. Bringing the client warm blankets b. Giving the client hot tea to drink c. Massaging the client's painful legs d. Reorienting the client as needed e. Sitting with the client for reassurance

A, D, E The student can bring the client warm blankets, reorient the client as needed to decrease anxiety, and sit with the client for reassurance. The client should be NPO at this point, so hot tea is prohibited. Massaging the legs is not recommended as this can dislodge any clots present, which may lead to pulmonary embolism. DIF: Applying/Application REF: 744 KEY: Shock| nonpharmacologic comfort interventions| delegation

1. A nurse is teaching a wilderness survival class. Which statements should the nurse include about the prevention of hypothermia and frostbite? (Select all that apply.) a. "Wear synthetic clothing instead of cotton to keep your skin dry." b. "Drink plenty of fluids. Brandy can be used to keep your body warm." c. "Remove your hat when exercising to prevent the loss of heat." d. "Wear sunglasses to protect skin and eyes from harmful rays." e. "Know your physical limits. Come in out of the cold when limits are reached."

A, D, E To prevent hypothermia and frostbite, the nurse should teach clients to wear synthetic clothing (which moves moisture away from the body and dries quickly), layer clothing, and wear a hat, facemask, sunscreen, and sunglasses. The client should also be taught to drink plenty of fluids, but to avoid alcohol when participating in winter activities. Clients should know their physical limits and come in out of the cold when these limits have been reached. DIF: Applying/Application REF: 131 KEY: Cold-related illness| environmental emergencies

4. The complex care provided during an emergency requires interdisciplinary collaboration. Which interdisciplinary team members are paired with the correct responsibilities? (Select all that apply.) a. Psychiatric crisis nurse - Interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis b. Forensic nurse examiner - Performs rapid assessments to ensure clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources c. Triage nurse - Provides basic life support interventions such as oxygen, basic wound care, splinting, spinal immobilization, and monitoring of vital signs d. Emergency medical technician - Obtains client histories, collects evidence, and offers counseling and follow-up care for victims of rape, child abuse, and domestic violence e. Paramedic - Provides prehospital advanced life support, including cardiac monitoring, advanced airway management, and medication administration

A, E The psychiatric crisis nurse evaluates clients with emotional behaviors or mental illness and facilitates follow-up treatment plans. The psychiatric crisis nurse also works with clients and families when experiencing a crisis. Paramedics are advanced life support providers who can perform advanced techniques that may include cardiac monitoring, advanced airway management and intubation, establishing IV access, and administering drugs en route to the emergency department.. The forensic nurse examiner is trained to recognize evidence of abuse and to intervene on the client's behalf. The forensic nurse examiner will obtain client histories, collect evidence, and offer counseling and follow-up care for victims of rape, child abuse, and domestic violence. The triage nurse performs rapid assessments to ensure clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources. The emergency medical technician is usually the first caregiver and provides basic life support and transportation to the emergency department. DIF: Understanding/Comprehension REF: 106 KEY: Interdisciplinary team| emergency nursing

15. After an acute myocardial infarction (AMI), a patient ambulates in the hospital hallway. When the nurse evaluates the patient's response to the activity, which data would indicate that the exercise level should be decreased? a. O2 saturation drops from 99% to 95%. b. Heart rate increases from 66 to 98 beats/min. c. Respiratory rate goes from 14 to 20 breaths/min. d. Blood pressure (BP) changes from 118/60 to 126/68 mm Hg.

B A change in heart rate of more than 20 beats over the resting heart rate indicates that the patient should stop and rest. The increases in BP and respiratory rate, and the slight decrease in O2 saturation, are normal responses to exercise. DIF: Cognitive Level: Apply (application) REF: 732 TOP: Nursing Process: Evaluation

5. A nurse is triaging clients in the emergency department (ED). Which client should the nurse prioritize to receive care first? a. A 22-year-old with a painful and swollen right wrist b. A 45-year-old reporting chest pain and diaphoresis c. A 60-year-old reporting difficulty swallowing and nausea d. An 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101° F

B A client experiencing chest pain and diaphoresis would be classified as emergent and would be triaged immediately to a treatment room in the ED. The other clients are more stable. DIF: Applying/Application REF: 111 KEY: Triage| emergency nursing

12. A nurse is caring for several clients at risk for shock. Which laboratory value requires the nurse to communicate with the health care provider? a. Creatinine: 0.9 mg/dL b. Lactate: 6 mmol/L c. Sodium: 150 mEq/L d. White blood cell count: 11,000/mm3

B A lactate level of 6 mmol/L is high and is indicative of possible shock. A creatinine level of 0.9 mg/dL is normal. A sodium level of 150 mEq/L is high, but that is not related directly to shock. A white blood cell count of 11,000/mm3 is slightly high but is not as critical as the lactate level. DIF: Analyzing/Analysis REF: 750 KEY: Shock| nursing assessment| laboratory values

4. After surgery for an abdominal aortic aneurysm, a patient's central venous pressure (CVP) monitor indicates low pressures. Which action should the nurse take? a. Administer IV diuretic medications. b. Increase the IV fluid infusion per protocol. c. Increase the infusion rate of IV vasodilators. d. Elevate the head of the patient's bed to 45 degrees.

B A low CVP indicates hypovolemia and a need for an increase in the infusion rate. Diuretic administration will contribute to hypovolemia and elevation of the head or increasing vasodilators may decrease cerebral perfusion. DIF: Cognitive Level: Apply (application) REF: 1564 TOP: Nursing Process: Planning

7. A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes the client's heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate? a.. Allow the client to rest quietly. b. Assess the client for bleeding. c. Document the findings in the chart. d. Medicate the client for pain.

B A major complication related to intra-arterial blood pressure monitoring is hemorrhage from the insertion site. Since these vital signs are out of the normal range, are a change, and are consistent with blood loss, the nurse should assess the client for any bleeding associated with the arterial line. The nurse should document the findings after a full assessment. The client may or may not need pain medication and rest; the nurse first needs to rule out any emergent bleeding. DIF: Applying/Application REF: 771 KEY: Coronary artery disease| intra-arterial blood pressure monitoring| equipment safety| vital signs

9. Which action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness? a. Coordinate the transfer of the patient to the operating room. b. Provide discharge instructions about monitoring neurologic status. c. Transport the patient to radiology for magnetic resonance imaging (MRI). d. Arrange to admit the patient to the neurologic unit for 24 hours of observation.

B A patient with a minor head trauma is usually discharged with instructions about neurologic monitoring and the need to return if neurologic status deteriorates. MRI, hospital admission, and surgery are not usually indicated in a patient with a concussion. DIF: Cognitive Level: Apply (application) REF: 1327 TOP: Nursing Process: Planning

9. A patient who has a head injury is diagnosed with a concussion. Which action will the nurse plan to take? a. Coordinate the transfer of the patient to the operating room. b. Provide discharge instructions about monitoring neurologic status. c. Transport the patient to radiology for magnetic resonance imaging (MRI) of the brain. d. Arrange to admit the patient to the neurologic unit for observation for 24 hours.

B A patient with a minor head trauma is usually discharged with instructions about neurologic monitoring and the need to return if neurologic status deteriorates. MRI, hospital admission, or surgery are not indicated in a patient with a concussion. DIF: Cognitive Level: Application REF: 1440 TOP: Nursing Process: Planning

25. Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown origin? a. Explain the association between dysrhythmias and syncope. b. Instruct the patient to call for assistance before getting out of bed. c. Teach the patient about the need to avoid caffeine and other stimulants. d. Tell the patient about the benefits of implantable cardioverter-defibrillators.

B A patient with fainting episodes is at risk for falls. The nurse will plan to minimize the risk by having assistance whenever the patient is up. The other actions may be needed if dysrhythmias are found to be the cause of the patient's syncope but are not appropriate for syncope of unknown origin. DIF: Cognitive Level: Apply (application) REF: 777 TOP: Nursing Process: Planning

20. A nurse assesses a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which assessment finding should alert the nurse to a potential complication? a.. Partial pressure of arterial oxygen (PaO2) of 80 mm Hg b. Urine output of 20 mL/hr c. Productive cough with white pulmonary secretions d. Core temperature of 100.6° F (38° C)

B A significant loss of fluid occurs with burn injuries, and fluids must be replaced to maintain hemodynamics. If fluid replacement is not adequate, the client may become hypotensive and have decreased perfusion of organs, including the brain and kidneys. A low urine output is an indication of poor kidney perfusion. The other manifestations are not complications of burn injuries. DIF: Applying/Application REF: 479 KEY: Intravenous fluids| vascular perfusion

27. Which action by a new registered nurse (RN) who is orienting to the telemetry unit indicates a good understanding of the treatment of heart dysrhythmias? a. Prepares defibrillator settings at 360 joules for a patient whose monitor shows asystole. b. Injects IV adenosine (Adenocard) over 2 seconds to a patient with supraventricular tachycardia c. Turns the synchronizer switch to the "on" position before defibrillating a patient with ventricular fibrillation d. Gives the prescribed dose of diltiazem (Cardizem) to a patient with new-onset type II second degree AV block

B Adenosine must be given over 1 to 2 seconds to be effective. The other actions indicate a need for more teaching about treatment of heart dysrhythmias. The RN should hold the diltiazem until discussing it with the health care provider. The treatment for asystole is immediate CPR. The synchronizer switch should be "off" when defibrillating. DIF: Cognitive Level: Analyze (analysis) REF: 765 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Evaluation

11. Norepinephrine has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient data indicate that the nurse should consult with the health care provider before starting the norepinephrine? a. The patient is receiving low dose dopamine. b. The patient's central venous pressure is 3 mm Hg. c. The patient is in sinus tachycardia at 120 beats/min. d. The patient has had no urine output since being admitted.

B Adequate fluid administration is essential before giving vasopressors to patients with hypovolemic shock. The patient's low central venous pressure indicates a need for more volume replacement. The other patient data are not contraindications to norepinephrine administration. DIF: Cognitive Level: Apply (application) REF: 1598 TOP: Nursing Process: Implementation

14. Which statement by patient who is being discharged from the emergency department (ED) after a concussion indicates a need for intervention by the nurse? a. "I will return if I feel dizzy or nauseated." b. "I am going to drive home and go to bed." c. "I do not even remember being in an accident." d. "I can take acetaminophen (Tylenol) for my headache."

B After a head injury, the patient should avoid driving and operating heavy machinery. Retrograde amnesia is common after a concussion. The patient can take acetaminophen for headache and should return if symptoms of increased intracranial pressure such as dizziness or nausea occur. DIF: Cognitive Level: Apply (application) REF: 1332 TOP: Nursing Process: Assessment

18. A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. The nurse will anticipate teaching the patient about a. tPA. c. warfarin (Coumadin). b. aspirin . d. nimodipine

B After a transient ischemic attack, patients typically are started on medications such as aspirin to inhibit platelet function and decrease stroke risk. tPA is used for acute ischemic stroke. Coumadin is usually used for patients with atrial fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage. DIF: Cognitive Level: Apply (application) REF: 1353 TOP: Nursing Process: Planning

19. A patient with extensive electrical burn injuries is admitted to the emergency department. Which of these prescribed interventions should the nurse implement first? a. Start two large bore IVs. b. Place on cardiac monitor. c. Apply dressings to burned areas. d. Assess for pain at contact points.

B After an electrical burn, the patient is at risk for fatal dysrhythmias and should be placed on a cardiac monitor. The other actions should be accomplished in the following order: Start two IVs, assess for pain, and apply dressings. DIF: Cognitive Level: Application REF: 474 | 478 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

19. A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first? a. Assess pain level. c. Check potassium level. b. Place on heart monitor. d. Assess oral temperature.

B After an electrical burn, the patient is at risk for life-threatening dysrhythmias and should be placed on a heart monitor. Assessing the oral temperature and pain is not as important as assessing for cardiac dysrhythmias. Checking the potassium level is important, but it will take time before the laboratory results are back. The first intervention is to place the patient on a heart monitor and assess for dysrhythmias so that they can be monitored and treated if necessary. DIF: Cognitive Level: Analyze (analysis) REF: 431 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

2. A client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is on an intravenous infusion of heparin. The client's spouse asks why the client needs this medication. What response by the nurse is best? a. "The t-PA didn't dissolve the entire coronary clot." b. "The heparin keeps that artery from getting blocked again." c. "Heparin keeps the blood as thin as possible for a longer time." d. "The heparin prevents a stroke from occurring as the t-PA wears off."

B After the original intracoronary clot has dissolved, large amounts of thrombin are released into the bloodstream, increasing the chance of the vessel reoccluding. The other statements are not accurate. Heparin is not a "blood thinner," although laypeople may refer to it as such. DIF: Understanding/Comprehension REF: 768 KEY: Coronary artery disease| thrombolytic agents| patient education

14. A client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery. The client's sternal wound has not yet healed. What statement by the client most indicates a higher risk of developing sepsis after discharge? a. "All my friends and neighbors are planning a party for me." b. "I hope I can get my water turned back on when I get home." c. "I am going to have my daughter scoop the cat litter box." d. "My grandkids are so excited to have me coming home!"

B All these statements indicate a potential for leading to infection once the client gets back home. A large party might include individuals who are themselves ill and contagious. Having litter boxes in the home can expose the client to microbes that can lead to infection. Small children often have upper respiratory infections and poor hand hygiene that spread germs. However, the most worrisome statement is the lack of running water for handwashing and general hygiene and cleaning purposes. DIF: Analyzing/Analysis REF: 754 KEY: Shock| primary prevention| infection control

24. After change-of-shift report in the progressive care unit, who should the nurse care for first? a. Patient who had an inferior myocardial infarction 2 days ago and has crackles in the lung bases b. Patient with suspected urosepsis who has new orders for urine and blood cultures and antibiotics c. Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rate of 54 beats/minute d. Patient admitted with anaphylaxis 3 hours ago who now has clear lung sounds and a blood pressure of 108/58 mm Hg

B Antibiotics should be given within the first hour for patients who have sepsis or suspected sepsis in order to prevent progression to systemic inflammatory response syndrome and septic shock. The data on the other patients indicate that they are more stable. Crackles heard only at the lung bases do not require immediate intervention in a patient who has had a myocardial infarction. Mild bradycardia does not usually require atropine in patients who have a spinal cord injury. The findings for the patient admitted with anaphylaxis indicate resolution of bronchospasm and hypotension. DIF: Cognitive Level: Analyze (analysis) REF: 1601 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Assessment

9. Which finding is the best indicator that the fluid resuscitation for a 90-kg patient with hypovolemic shock has been effective? a. Hemoglobin is within normal limits. b. Urine output is 65 mL over the past hour. c. Central venous pressure (CVP) is normal. d. Mean arterial pressure (MAP) is 72 mm Hg.

B Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. Urine output should be equal to or more than 0.5 mL/kg/hr. The hemoglobin level, CVP, and MAP are useful in determining the effects of fluid administration, but they are not as useful as data indicating good organ perfusion. DIF: Cognitive Level: Analyze (analysis) REF: 1589 TOP: Nursing Process: Evaluation

3. A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at greatest risk for atrial fibrillation? a. A 45-year-old who takes an aspirin daily b. A 50-year-old who is post coronary artery bypass graft surgery c. A 78-year-old who had a carotid endarterectomy d. An 80-year-old with chronic obstructive pulmonary disease

B Atrial fibrillation occurs commonly in clients with cardiac disease and is a common occurrence after coronary artery bypass graft surgery. The other conditions do not place these clients at higher risk for atrial fibrillation. DIF: Applying/Application REF: 666 KEY: Health screening| cardiac electrical conduction

5. A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on this client's medication administration record to prevent a common complication of this condition? a. Sotalol (Betapace) b. Warfarin (Coumadin) c. Atropine (Sal-Tropine) d. Lidocaine (Xylocaine)

B Atrial fibrillation puts clients at risk for developing emboli. Clients at risk for emboli are treated with anticoagulants, such as heparin, enoxaparin, or warfarin. Sotalol, atropine, and lidocaine are not appropriate for this complication. DIF: Applying/Application REF: 667 KEY: Cardiac electrical conduction| medication

2. The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by autocontamination? a. Use a disposable blood pressure cuff to avoid sharing with other clients. b. Change gloves between wound care on different parts of the client's body. c. Use the closed method of burn wound management for all wound care. d. Advocate for proper and consistent handwashing by all members of the staff.

B Autocontamination is the transfer of microorganisms from one area to another area of the same client's body, causing infection of a previously uninfected area.. Although all techniques listed can help reduce the risk for infection, only changing gloves between performing wound care on different parts of the client's body can prevent autocontamination. DIF: Applying/Application REF: 485 KEY: Infection control| Standard Precautions

2. A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification should the nurse suggest to avoid further slowing of the heart rate? a. "Make certain that your bath water is warm." b. "Avoid straining while having a bowel movement." c. "Limit your intake of caffeinated drinks to one a day." d. "Avoid strenuous exercise such as running."

B Bearing down strenuously during a bowel movement is one type of Valsalva maneuver, which stimulates the vagus nerve and results in slowing of the heart rate. Such a response is not desirable in a person who has bradycardia. The other instructions are not appropriate for this condition. DIF: Applying/Application REF: 663 KEY: Functional ability

33. When admitting a patient with a myocardial infarction (MI) to the intensive care unit, which action should the nurse carry out first? a. Obtain the blood pressure. b. Attach the cardiac monitor. c. Assess the peripheral pulses. d. Auscultate the breath sounds.

B Because dysrhythmias are the most common complication of MI, the first action should be to place the patient on a cardiac monitor. The other actions also are important and should be accomplished as quickly as possible. DIF: Cognitive Level: Application REF: 779-780 | 787-788 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

39. To improve the physical activity level for a mildly obese 71-yr-old patient, which action should the nurse plan to take? a. Stress that weight loss is a major benefit of increased exercise. b. Determine what kind of physical activities the patient usually enjoys. c. Tell the patient that older adults should exercise for no more than 20 minutes at a time. d. Teach the patient to include a short warm-up period at the beginning of physical activity.

B Because patients are more likely to continue physical activities that they already enjoy, the nurse will plan to ask the patient about preferred activities. The goal for older adults is 30 minutes of moderate activity on most days. Older adults should plan for a longer warm-up period. Benefits of exercises, such as improved activity tolerance, should be emphasized rather than aiming for significant weight loss in older mildly obese adults. DIF: Cognitive Level: Apply (application) REF: 708 TOP: Nursing Process: Planning

10. Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock? a. Check temperature every 2 hours. b. Monitor breath sounds frequently. c. Maintain patient in supine position. d. Assess skin for flushing and itching.

B Because pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the nurse should assess the breath sounds frequently. The head of the bed is usually elevated to decrease dyspnea in patients with cardiogenic shock. Elevated temperature and flushing or itching of the skin are not typical of cardiogenic shock. DIF: Cognitive Level: Apply (application) REF: 1591 TOP: Nursing Process: Implementation

21. After endotracheal suctioning, the nurse notes that the intracranial pressure (ICP) for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action should the nurse take first? a. Document the increase in intracranial pressure. b. Ensure that the patient's neck is in neutral position. c. Notify the health care provider about the change in pressure. d. Increase the rate of the prescribed propofol (Diprivan) infusion.

B Because suctioning will cause a transient increase in ICP, the nurse should initially check for other factors that might be contributing to the increase and observe the patient for a few minutes. Documentation is needed, but this is not the first action. There is no need to notify the health care provider about this expected reaction to suctioning. Propofol is used to control patient anxiety or agitation. There is no indication that anxiety has contributed to the increase in ICP. DIF: Cognitive Level: Analyze (analysis) REF: 1325 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

14. A patient with paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. Which action will the nurse include in the plan of care? a. Educate on the use of the Credé method. b. Teach the patient how to self-catheterize. c. Catheterize for residual urine after voiding. d. Assist the patient to the toilet every 2 hours.

B Because the patient's bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty. The Credé method is more appropriate for a bladder that is flaccid, such as occurs with a reflexic neurogenic bladder. Catheterization after voiding will not resolve the patient's incontinence. DIF: Cognitive Level: Application REF: 1561-1562 TOP: Nursing Process: Planning

14. A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic bladder. Which action will the nurse include in the plan of care? a. Teach the patient the Credé method. b. Instruct the patient how to self-catheterize. c. Catheterize for residual urine after voiding. d. Assist the patient to the toilet every 2 hours.

B Because the patient's bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty. The Credé method is more appropriate for a bladder that is flaccid, such as occurs with areflexic neurogenic bladder. Catheterization after voiding will not resolve the patient's incontinence. DIF: Cognitive Level: Apply (application) REF: 1433 TOP: Nursing Process: Planning

14. A patient admitted with acute respiratory failure has ineffective airway clearance related to thick secretions. Which nursing intervention would specifically address this patient problem? a. Encourage use of the incentive spirometer. b. Offer the patient fluids at frequent intervals. c. Teach the patient the importance of ambulation. d. Titrate oxygen level to keep O2 saturation above 93%.

B Because the reason for the poor airway clearance is the thick secretions, the best action will be to encourage the patient to improve oral fluid intake. Patients should be instructed to use the incentive spirometer on a regular basis (e.g., every hour) to facilitate the clearance of the secretions. The other actions may also be helpful in improving the patient's gas exchange, but they do not address the thick secretions that are causing the poor airway clearance. DIF: Cognitive Level: Apply (application) REF: 1617 TOP: Nursing Process: Planning

23. Which finding about a patient who is receiving vasopressin to treat septic shock indicates an immediate need for the nurse to report the finding to the health care provider? a. The patient's urine output is 18 mL/hr. b. The patient is complaining of chest pain. c. The patient's peripheral pulses are weak. d. The patient's heart rate is 110 beats/minute.

B Because vasopressin is a potent vasoconstrictor, it may decrease coronary artery perfusion. The other information is consistent with the patient's diagnosis, and should be reported to the health care provider but does not indicate an immediate need for a change in therapy. DIF: Cognitive Level: Apply (application) REF: 1599 TOP: Nursing Process: Assessment

10. After a hospital's emergency department (ED) has efficiently triaged, treated, and transferred clients from a community disaster to appropriate units, the hospital incident command officer wants to "stand down" from the emergency plan. Which question should the nursing supervisor ask at this time? a.. "Are you sure no more victims are coming into the ED?" b. "Do all areas of the hospital have the supplies and personnel they need?" c. "Have all ED staff had the chance to eat and rest recently?" d. "Does the Chief Medical Officer agree this disaster is under control?"

B Before "standing down," the incident command officer ensures that the needs of the other hospital departments have been taken care of because they may still be stressed and may need continued support to keep functioning. Many more "walking wounded" victims may present to the ED; that number may not be predictable. Giving staff the chance to eat and rest is important, but all areas of the facility need that too. Although the Chief Medical Officer (CMO) may be involved in the incident, the CMO does not determine when the hospital can "stand down." DIF: Applying/Application REF: 145 KEY: Psychosocial response| crisis intervention

13. A provider prescribes diazepam (Valium) to a client who was bitten by a black widow spider. The client asks, "What is this medication for?" How should the nurse respond? a. "This medication is an antivenom for this type of bite." b. "It will relieve your muscle rigidity and spasms." c. "It prevents respiratory difficulty from excessive secretions." d. "This medication will prevent respiratory failure."

B Black widow spider venom produces a syndrome known as latrodectism, which manifests as severe abdominal pain, muscle rigidity and spasm, hypertension, and nausea and vomiting. Diazepam is a muscle relaxant that can relieve pain related to muscle rigidity and spasms. It does not prevent respiratory difficulty or failure. DIF: Applying/Application REF: 127 KEY: Benzodiazepine| spider bite| environmental emergencies

10. Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the patient's caregiver is accurate? a. "PEEP will push more air into the lungs during inhalation." b. "PEEP prevents the lung air sacs from collapsing during exhalation." c. "PEEP will prevent lung damage while the patient is on the ventilator." d. "PEEP allows the breathing machine to deliver 100% O2 to the lungs."

B By preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation. PEEP will not prevent lung damage (e.g., fibrotic changes that occur with ARDS), push more air into the lungs, or change the fraction of inspired oxygen (FIO2) delivered to the patient. DIF: Cognitive Level: Understand (comprehension) REF: 1624 TOP: Nursing Process: Implementation

20. A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first? a. Document the BP and ICP in the patient's record. b. Report the BP and ICP to the health care provider. c. Elevate the head of the patient's bed to 60 degrees. d. Continue to monitor the patient's vital signs and ICP.

B Calculate the cerebral perfusion pressure (CPP): (CPP = Mean arterial pressure [MAP] - ICP). MAP = DBP + 1/3 (Systolic blood pressure [SBP] - Diastolic blood pressure [DBP]). Therefore the MAP is 70, and the CPP is 56 mm Hg, which are below the normal values of 60 to 100 mm Hg and are approaching the level of ischemia and neuronal death. Immediate changes in the patient's therapy such as fluid infusion or vasopressor administration are needed to improve the CPP. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation will also be done, but they are not the first actions that the nurse should take. DIF: Cognitive Level: Analyze (analysis) REF: 1327 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

26. Which of these nursing actions should be done first for a patient who has suffered a burn injury while working on an electrical power line? a. Obtain the blood pressure. b. Stabilize the cervical spine. c. Assess for the contact points. d. Check alertness and orientation.

B Cervical spine injuries are commonly associated with electrical burns. Therefore stabilization of the cervical spine takes precedence after airway management. The other actions also are included in the emergent care after electrical burns, but the most important action is to avoid spinal cord injury. DIF: Cognitive Level: Application REF: 474 | 478 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

3. The nurse is admitting a patient who has chest pain. Which assessment data suggest that the pain is caused by an acute myocardial infarction (AMI)? a. The pain increases with deep breathing. b. The pain has lasted longer than 30 minutes. c. The pain is relieved after the patient takes nitroglycerin. d. The pain is reproducible when the patient raises the arms.

B Chest pain that lasts for 20 minutes or more is characteristic of AMI. Changes in pain that occur with raising the arms or with deep breathing are more typical of musculoskeletal pain or pericarditis. Stable angina is usually relieved when the patient takes nitroglycerin. DIF: Cognitive Level: Apply (application) REF: 720 TOP: Nursing Process: Assessment

3. Which information collected by the nurse who is admitting a patient with chest pain suggests that the pain is caused by an acute myocardial infarction (AMI)? a. The pain increases with deep breathing. b. The pain has persisted longer than 30 minutes. c. The pain worsens when the patient raises the arms. d. The pain is relieved after the patient takes nitroglycerin.

B Chest pain that lasts for 20 minutes or more is characteristic of AMI. Changes in pain that occur with raising the arms or with deep breathing are more typical of pericarditis or musculoskeletal pain. Stable angina is usually relieved when the patient takes nitroglycerin. DIF: Cognitive Level: Application REF: 779 TOP: Nursing Process: Assessment

8. After noting that a patient with a head injury has clear nasal drainage, which action should the nurse take? a. Have the patient blow the nose. b. Check the nasal drainage for glucose. c. Assure the patient that rhinorrhea is normal after a head injury. d. Obtain a specimen of the fluid to send for culture and sensitivity.

B Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. Blowing the nose is avoided to prevent CSF leakage. DIF: Cognitive Level: Application REF: 1438-1439 TOP: Nursing Process: Implementation

8. A 20-yr-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take? a. Have the patient gently blow the nose. b. Check the drainage for glucose content. c. Teach the patient that rhinorrhea is expected after a head injury. d. Obtain a specimen of the fluid to send for culture and sensitivity.

B Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. Blowing the nose is avoided to prevent CSF leakage. DIF: Cognitive Level: Apply (application) REF: 1327 TOP: Nursing Process: Implementation

4. A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition? a. Sinus tachycardia b. Speech alterations c. Fatigue d. Dyspnea with activity

B Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events includes changes in mentation, speech, sensory function, and motor function. Clients with atrial fibrillation often have a rapid ventricular response as a result. Fatigue is a nonspecific complaint. Clients with atrial fibrillation often have dyspnea as a result of the decreased cardiac output caused by the rhythm disturbance. DIF: Applying/Application REF: 666 KEY: Cardiac electrical conduction| vascular perfusion

5. When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral atherosclerosis a. to monitor and record the blood pressure daily. b. to call the health care provider if stools are tarry. c. that clopidogrel will dissolve clots in the cerebral arteries. d. that clopidogrel will reduce cerebral artery plaque formation.

B Clopidogrel inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients should be advised to notify the health care provider about any signs of bleeding. The medication does not lower blood pressure, decrease plaque formation, or dissolve clots. DIF: Cognitive Level: Apply (application) REF: 1353 TOP: Nursing Process: Implementation

1. A patient who has been in the intensive care unit for 4 days has disturbed sensory perception from sleep deprivation. Which action should the nurse include in the plan of care? a. Administer prescribed sedatives or opioids at bedtime to promote sleep. b. Cluster nursing activities so that the patient has uninterrupted rest periods. c. Silence the alarms on the cardiac monitors to allow 30- to 40-minute naps. d. Eliminate assessments between 2200 and 0600 to allow uninterrupted sleep.

B Clustering nursing activities and providing uninterrupted rest periods will minimize sleep-cycle disruption. Sedative and opioid medications tend to decrease the amount of rapid eye movement (REM) sleep and can contribute to sleep disturbance and disturbed sensory perception. Silencing the alarms on the cardiac monitors would be unsafe in a critically ill patient, as would discontinuing all assessments during the night. DIF: Cognitive Level: Apply (application) REF: 1556 TOP: Nursing Process: Planning

9. The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia. An appropriate nursing intervention to help the patient communicate is to a. have the patient practice facial and tongue exercises. b. ask simple questions that the patient can answer with "yes" or "no." c. develop a list of words that the patient can read and practice reciting. d. prevent embarrassing the patient by changing the subject if the patient does not respond.

B Communication will be facilitated and less frustrating to the patient when questions that require a "yes" or "no" response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond. DIF: Cognitive Level: Application REF: 1470 | 1480 TOP: Nursing Process: Implementation

16. Several weeks after a stroke, a patient has urinary incontinence resulting from an impaired awareness of bladder fullness. For an effective bladder training program, which nursing intervention will be best to include in the plan of care? a. Limit fluid intake to 1200 mL daily to reduce urine volume. b. Assist the patient onto the bedside commode every 2 hours. c. Perform intermittent catheterization after each voiding to check for residual urine. d. Use an external "condom" catheter to protect the skin and prevent embarrassment.

B Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder. A 1200 mL fluid restriction may lead to dehydration. Intermittent catheterization and use of a condom catheter are appropriate in the acute phase of stroke but should not be considered solutions for long-term management because of the risks for urinary tract infection (UTI) and skin breakdown. DIF: Cognitive Level: Application REF: 1482-1483 TOP: Nursing Process: Planning

16. Several weeks after a stroke, a 50-yr-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention should be planned to begin an effective bladder training program? a. Limit fluid intake to 1200 mL daily to reduce urine volume. b. Assist the patient onto the bedside commode every 2 hours. c. Perform intermittent catheterization after each voiding to check for residual urine. d. Use an external "condom" catheter to protect the skin and prevent embarrassment.

B Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder. A 1200-mL fluid restriction may lead to dehydration. Intermittent catheterization and use of a condom catheter are appropriate in the acute phase of stroke, but should not be considered solutions for long-term management because of the risks for urinary tract infection and skin breakdown. DIF: Cognitive Level: Apply (application) REF: 1360 TOP: Nursing Process: Planning

20. When caring for a patient who is recovering from a sudden cardiac death (SCD) event and has no evidence of an acute myocardial infarction (AMI), the nurse will anticipate teaching the patient that a. sudden cardiac death events rarely reoccur. b. additional diagnostic testing will be required. c. long-term anticoagulation therapy will be needed. d. limiting physical activity will prevent future SCD events.

B Diagnostic testing (e.g., stress test, Holter monitor, electrophysiologic studies, cardiac catheterization) is used to determine the possible cause of the SCD and treatment options. SCD is likely to recur. Anticoagulation therapy will not have any effect on the incidence of SCD, and SCD can occur even when the patient is resting. DIF: Cognitive Level: Apply (application) REF: 733 TOP: Nursing Process: Planning

18. Premature ventricular contractions (PVCs) occur while the nurse is suctioning a patient's endotracheal tube. Which action by the nurse is best? a. Decrease the suction pressure to 80 mm Hg. b. Stop and ventilate the patient with 100% oxygen. c. Document the dysrhythmia in the patient's chart. d. Give prescribed PRN antidysrhythmic medications.

B Dysrhythmias during suctioning may indicate hypoxemia or sympathetic nervous system stimulation, and the nurse should stop suctioning and ventilate the patient with 100% oxygen. Lowering the suction pressure will decrease the effectiveness of suctioning without improving the hypoxemia. Because the PVCs occurred during suctioning, there is no need for antidysrhythmic medications (which may have adverse effects) unless they recur when the patient is well oxygenated. DIF: Cognitive Level: Application REF: 1703-1704 TOP: Nursing Process: Implementation

25. For a patient who has been admitted the previous day to the coronary care unit with an acute myocardial infarction (AMI), the nurse will anticipate teaching about a. typical emotional responses to AMI. b. when patient cardiac rehabilitation will begin. c. discharge drugs such as aspirin and β-blockers. d. the pathophysiology of coronary artery disease.

B Early after an AMI, the patient will want to know when resumption of usual activities can be expected. At this time, the patient's anxiety level or denial will prevent good understanding of complex information such as coronary artery disease (CAD) pathophysiology. Teaching about discharge medications should be done when the time for discharge is closer. The nurse should support the patient by decreasing anxiety rather than discussing the typical emotional response to myocardial infarction (MI). DIF: Cognitive Level: Application REF: 788-789 TOP: Nursing Process: Planning

19. Which nursing action has the highest priority for a patient who was admitted 16 hours earlier with a C5 spinal cord injury? a. Cardiac monitoring for bradycardia b. Assessment of respiratory rate and effort c. Administration of low-molecular-weight heparin d. Application of pneumatic compression devices to legs

B Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function. The other actions also are appropriate for preventing deterioration or complications but are not as important as assessment of respiratory effort. DIF: Cognitive Level: Analyze (analysis) REF: 1429 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

12. The central venous oxygen saturation (ScvO2) is decreasing in a patient who has severe pancreatitis. To determine the possible cause of the decreased ScvO2, the nurse assesses the patient's a. lipase level. c. urinary output. b. temperature. d. body mass index.

B Elevated temperature increases metabolic demands and O2 use by tissues, resulting in a drop in O2 saturation of central venous blood. Information about the patient's body mass index, urinary output, and lipase will not help in determining the cause of the patient's drop in ScvO2. DIF: Cognitive Level: Apply (application) REF: 1565 TOP: Nursing Process: Assessment

6. A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain adequate nutrition, the nurse should plan to take which action? a. Administer vitamins and minerals intravenously. b. Insert a feeding tube and initiate enteral feedings. c. Infuse total parenteral nutrition via a central catheter. d. Encourage an oral intake of at least 5000 kcal per day.

B Enteral feedings can usually be started during the emergent phase at low rates and increased over 24 to 48 hours to the goal rate. During the emergent phase, the patient will be unable to eat enough calories to meet nutritional needs and may have a paralytic ileus that prevents adequate nutrient absorption. Vitamins and minerals may be administered during the emergent phase, but these will not assist in meeting the patient's caloric needs. Parenteral nutrition increases the infection risk, does not help preserve gastrointestinal function, and is not routinely used in burn patients unless the gastrointestinal tract is not available for use. DIF: Cognitive Level: Apply (application) REF: 446 TOP: Nursing Process: Planning

36. Which action will the public health nurse take to reduce the incidence of epidemic encephalitis in a community? a. Teach about prophylactic antibiotics after exposure to encephalitis. b. Encourage the use of effective insect repellent during mosquito season. c. Remind patients that most cases of viral encephalitis can be cared for at home. d. Arrange to screen school-age children for West Nile virus during the school year.

B Epidemic encephalitis is usually spread by mosquitoes and ticks. Use of insect repellent is effective in reducing risk. Encephalitis frequently requires that the patient be hospitalized in an intensive care unit during the initial stages. Antibiotic prophylaxis is not used to prevent encephalitis because most encephalitis is viral. West Nile virus is most common in adults over age 50 during the summer and early fall. DIF: Cognitive Level: Apply (application) REF: 1342 TOP: Nursing Process: Planning

1. During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient has an unobstructed airway. Which action should the nurse take next? a. Palpate extremities for bilateral pulses. b. Observe the patient's respiratory effort. c. Check the patient's level of consciousness. d. Examine the patient for any external bleeding.

B Even with a patent airway, patients can have other problems that compromise ventilation, so the next action is to assess the patient's breathing. The other actions are also part of the initial survey but assessment of breathing should be done immediately after assessing for airway patency. DIF: Cognitive Level: Apply (application) REF: 1630 TOP: Nursing Process: Assessment

3. While close family members are visiting, a patient has a respiratory arrest, and resuscitation is started. Which action by the nurse is best? a. Tell the family members that watching the resuscitation will be very stressful. b. Ask family members if they wish to remain in the room during the resuscitation. c. Take the family members quickly out of the patient room and remain with them. d. Assign a staff member to wait with family members just outside the patient room.

B Evidence indicates that many family members want the option of remaining in the room during procedures such as cardiopulmonary resuscitation (CPR) and that this decreases anxiety and facilitates grieving. The other options may be appropriate if the family decides not to remain with the patient. DIF: Cognitive Level: Analyze (analysis) REF: 1558 TOP: Nursing Process: Implementation

14. Which statement by a patient who is being discharged from the emergency department (ED) after a head injury indicates a need for intervention by the nurse? a. "I will return if I feel dizzy or nauseated." b. "I am going to drive home and go to bed." c. "I do not even remember being in an accident." d. "I can take acetaminophen (Tylenol) for my headache."

B Following a head injury, the patient should avoid operating heavy machinery. Retrograde amnesia is common after a concussion. The patient can take acetaminophen for headache and should return if symptoms of increased intracranial pressure such as dizziness or nausea occur. DIF: Cognitive Level: Application REF: 1444 TOP: Nursing Process: Assessment

6. The intensive care unit (ICU) nurse educator determines that teaching a new staff nurse about arterial pressure monitoring has been effective when the nurse a. balances and calibrates the monitoring equipment every 2 hours. b. positions the zero-reference stopcock line level with the phlebostatic axis. c. ensures that the patient is supine with the head of the bed flat for all readings. d. rechecks the location of the phlebostatic axis with changes in the patient's position.

B For accurate measurement of pressures, the zero-reference level should be at the phlebostatic axis. There is no need to rebalance and recalibrate monitoring equipment every 2 hours. Accurate hemodynamic readings are possible with the patient's head raised to 45 degrees or in the prone position. The anatomic position of the phlebostatic axis does not change when patients are repositioned. DIF: Cognitive Level: Apply (application) REF: 1560 TOP: Nursing Process: Evaluation

4. A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate? a. Decrease the heparin rate. b. Increase the heparin rate. c. No change to the heparin rate. d. Stop heparin; start warfarin (Coumadin).

B For clients on heparin, a PTT of 1.5 to 2.5 times the normal value is needed to demonstrate the heparin is working. A normal PTT is 25 to 35 seconds, so this client's PTT value is too low. The heparin rate needs to be increased. Warfarin is not indicated in this situation. DIF: Applying/Application REF: 606 KEY: Pulmonary embolism| thromboembolic events| anticoagulants| laboratory values

6. A patient who has experienced blunt abdominal trauma during a motor vehicle collision is complaining of increasing abdominal pain. The nurse will plan to teach the patient about the purpose of a. peritoneal lavage. b. abdominal ultrasonography. c. nasogastric (NG) tube placement. d. magnetic resonance imaging (MRI).

B For patients who are at risk for intraabdominal bleeding, focused abdominal ultrasonography is the preferred method to assess for intraperitoneal bleeding. An MRI would not be used. Peritoneal lavage is an alternative, but it is more invasive. An NG tube would not be helpful in the diagnosis of intraabdominal bleeding. DIF: Cognitive Level: Apply (application) REF: 1633 TOP: Nursing Process: Planning

12. A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. Which action should the nurse take prior to the initiation of cardioversion? a. Administer intravenous adenosine. b. Turn off oxygen therapy. c. Ensure a tongue blade is available. d. Position the client on the left side.

B For safety during cardioversion, the nurse should turn off any oxygen therapy to prevent fire. The other interventions are not appropriate for a cardioversion. The client should be placed in a supine position. DIF: Remembering/Knowledge REF: 668 KEY: Assessment/diagnostic examination| safety

9. A nurse plans care for a client admitted with a snakebite to the right leg. With whom should the nurse collaborate? a. The facility's neurologist b. The poison control center c. The physical therapy department d. A herpetologist (snake specialist)

B For the client with a snakebite, the nurse should contact the regional poison control center immediately for specific advice on antivenom administration and client management. DIF: Remembering/Knowledge REF: 124 KEY: Snakebite| poison control| environmental emergencies

5. A client is being prepared for a mechanical embolectomy. What action by the nurse takes priority? a. Assess for contraindications to fibrinolytics. b. Ensure that informed consent is on the chart. c. Perform a full neurologic assessment. d. Review the client's medication lists.

B For this invasive procedure, the client needs to give informed consent. The nurse ensures that this is on the chart prior to the procedure beginning. Fibrinolytics are not used. A neurologic assessment and medication review are important, but the consent is the priority. DIF: Applying/Application REF: 938 KEY: Neurologic disorders| stroke| informed consent

7. A patient with acute respiratory distress syndrome (ARDS) and acute renal failure has the following medications prescribed. Which medication should the nurse discuss with the health care provider before administration? a. ranitidine (Zantac) 50 mg IV b. gentamicin (Garamycin) 60 mg IV c. sucralfate (Carafate) 1 g per nasogastric tube d. methylprednisolone (Solu-Medrol) 40 mg IV

B Gentamicin, which is one of the aminoglycoside antibiotics, is potentially nephrotoxic, and the nurse should clarify the drug and dosage with the health care provider before administration. The other medications are appropriate for the patient with ARDS. DIF: Cognitive Level: Application REF: 1761-1762 TOP: Nursing Process: Implementation

13. A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by the nurse takes priority? a. Assessing that the ventilator settings are correct b. Ensuring there is a bag-valve-mask in the room c. Obtaining personal protective equipment d. Planning to suction the client upon arrival to the room

B Having a bag-valve-mask device is critical in case the client needs manual breathing. The respiratory therapist is usually primarily responsible for setting up the ventilator, although the nurse should know and check the settings. Personal protective equipment is important, but ensuring client safety takes priority. The client may or may not need suctioning on arrival.. DIF: Applying/Application REF: 615 KEY: Mechanical ventilation| patient safety| critical rescue

20. When caring for a patient who has survived a sudden cardiac death (SCD) event and has no evidence of an acute myocardial infarction (AMI), the nurse will anticipate teaching the patient a. that sudden cardiac death events rarely reoccur. b. about the purpose of outpatient Holter monitoring. c. how to self-administer low-molecular-weight heparin. d. to limit activities after discharge to prevent future events.

B Holter monitoring is used to determine whether the patient is experiencing dysrhythmias such as ventricular tachycardia during normal daily activities. SCD is likely to recur. Heparin will not have any effect on the incidence of SCD, and SCD can occur even when the patient is resting. DIF: Cognitive Level: Application REF: 793-794 TOP: Nursing Process: Planning

14. A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first? a. Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours b. Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg c. Client who is 1 day post percutaneous coronary intervention, going home this morning d. Client who is 2 days post coronary artery bypass graft, became dizzy this a.m. while walking

B Hypertension after coronary artery bypass graft surgery can be dangerous because it puts too much pressure on the suture lines and can cause bleeding. The charge nurse should see this client first. The client who became dizzy earlier should be seen next. The client on the nitroglycerin drip is stable. The client going home can wait until the other clients are cared for. DIF: Analyzing/Analysis REF: 777 KEY: Coronary artery disease| coronary artery bypass graft| collaboration

32. After receiving change-of-shift report on four patients, which patient should the nurse assess first? a. Patient with rheumatic fever who has sharp chest pain with a deep breath b. Patient with acute aortic regurgitation whose blood pressure is 86/54 mm Hg c. Patient with infective endocarditis who has a murmur and splinter hemorrhages d. Patient with dilated cardiomyopathy who has bilateral crackles at the lung bases

B Hypotension in patients with acute aortic regurgitation may indicate cardiogenic shock. The nurse should immediately assess this patient for other findings such as dyspnea, chest pain or tachycardia. The findings in the other patients are typical of their diagnoses and do not indicate a need for urgent assessment and intervention. DIF: Cognitive Level: Analyze (analysis) REF: 792 OBJ: Special Questions: Multiple Patients | Special Questions: Prioritization TOP: Nursing Process: Assessment

22. After assessing a client who is receiving an amiodarone intravenous infusion for unstable ventricular tachycardia, the nurse documents the findings and compares these with the previous assessment findings: Vital Signs Nursing Assessment Time: 0800 Temperature: 98° F Heart rate: 68 beats/min Blood pressure: 135/60 mm Hg Respiratory rate: 14 breaths/min Oxygen saturation: 96% Oxygen therapy: 2 L nasal cannula Time: 1000 Temperature: 98.2° F Heart rate: 50 beats/min Blood pressure: 132/57 mm Hg Respiratory rate: 16 breaths/min Oxygen saturation: 95% Oxygen therapy: 2 L nasal cannula Time: 0800 Client alert and oriented. Cardiac rhythm: normal sinus rhythm. Skin: warm, dry, and appropriate for race. Respirations equal and unlabored. Client denies shortness of breath and chest pain. Time: 1000 Client alert and oriented. Cardiac rhythm: sinus bradycardia. Skin: warm, dry, and appropriate for race. Respirations equal and unlabored. Client denies shortness of breath and chest pain. Client voids 420 mL of clear yellow urine. Based on the assessments, which action should the nurse take? a. Stop the infusion and flush the IV. b. Slow the amiodarone infusion rate. c. Administer IV normal saline. d. Ask the client to cough and deep breathe.

B IV administration of amiodarone may cause bradycardia and atrioventricular (AV) block. The correct action for the nurse to take at this time is to slow the infusion, because the client is asymptomatic and no evidence reveals AV block that might require pacing. Abruptly ceasing the medication could allow fatal dysrhythmias to occur. The administration of IV fluids and encouragement of coughing and deep breathing exercises are not indicated, and will not increase the client's heart rate. DIF: Applying/Application REF: 660 KEY: Cardiac electrical conduction| medication

6. A client has hemodynamic monitoring after a myocardial infarction. What safety precaution does the nurse implement for this client? a. Document pulmonary artery wedge pressure (PAWP) readings and assess their trends. b. Ensure the balloon does not remain wedged. c. Keep the client on strict NPO status. d.. Maintain the client in a semi-Fowler's position.

B If the balloon remains inflated, it can cause pulmonary infarction or rupture. The nurse should ensure the balloon remains deflated between PAWP readings. Documenting PAWP readings and assessing trends is an important nursing action related to hemodynamic monitoring, but is not specifically related to safety. The client does not have to be NPO while undergoing hemodynamic monitoring. Positioning may or may not affect readings. DIF: Applying/Application REF: 770 KEY: Coronary artery disease| hemodynamic monitoring| equipment safety

19. The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The drainage slows significantly. What action by the nurse is most important? a. Increase the setting on the suction. b. Notify the provider immediately. c. Re-position the chest tube. d. Take the tubing apart to assess for clots.

B If the drainage in the chest tube decreases significantly and dramatically, the tube may be blocked by a clot. This could lead to cardiac tamponade. The nurse should notify the provider immediately. The nurse should not independently increase the suction, re-position the chest tube, or take the tubing apart. DIF: Applying/Application REF: 778 KEY: Coronary artery bypass graft| critical rescue| chest tubes| cardiovascular system

16. Gastric lavage and administration of activated charcoal are ordered for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which prescribed action should the nurse plan to do first? a. Insert a large-bore orogastric tube. b. Assist with intubation of the patient. c. Prepare a 60-mL syringe with saline. d. Give first dose of activated charcoal.

B In an unresponsive patient, intubation is done before gastric lavage and activated charcoal administration to prevent aspiration. The other actions will be implemented after intubation. DIF: Cognitive Level: Analyze (analysis) REF: 1630 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning

15. A nurse is caring for four clients who might be brain dead. Which client would best meet the criteria to allow assessment of brain death? a. Client with a core temperature of 95° F (35° C) for 2 days b. Client in a coma for 2 weeks from a motor vehicle crash c. Client who is found unresponsive in a remote area of a field by a hunter d. Client with a systolic blood pressure of 92 mm Hg since admission

B In order to determine brain death, clients must meet four criteria: 1) coma from a known cause, 2) normal or near-normal core temperature, 3) normal systolic blood pressure, and 4) at least one neurologic examination. The client who was in the car crash meets two of these criteria. The clients with the lower temperature and lower blood pressure have only one of these criteria. There is no data to support assessment of brain death in the client found by the hunter. DIF: Remembering/Knowledge REF: 954 KEY: Neurologic disorders| brain death| neurologic assessment

26. After evacuation of an epidural hematoma, a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter. Which information obtained by the nurse requires urgent communication with the health care provider? a. Pulse of 102 beats/min b. Temperature of 101.6° F c. Intracranial pressure of 15 mm Hg d. Mean arterial pressure of 90 mm Hg

B Infection is a serious consideration with ICP monitoring, especially with intraventricular catheters. The temperature indicates the need for antibiotics or removal of the monitor. The ICP, arterial pressure, and apical pulse only require ongoing monitoring at this time. DIF: Cognitive Level: Analyze (analysis) REF: 1320 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

21. Which of these nursing actions included in the care of a mechanically ventilated patient with acute respiratory distress syndrome (ARDS) can the RN delegate to an experienced LPN/LVN working in the intensive care unit? a. Assess breath sounds b. Insert a retention catheter c. Place patient in the prone position d. Monitor pulmonary artery pressures

B Insertion of retention catheters is included in LPN/LVN education and scope of practice and can be safely delegated to an LPN/LVN who is experienced in caring for critically ill patients. Placing a patient who is on a ventilator in the prone position requires multiple staff and should be supervised by an RN. Assessment of breath sounds and obtaining pulmonary artery pressures require advanced assessment skills and should be done by the RN caring for a critically ill patient. DIF: Cognitive Level: Application REF: 1761-1763 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

16. A patient has ST segment changes that indicate an acute inferior wall myocardial infarction. Which lead will be best for monitoring the patient? a. I b. II c. V6 d. MCL1

B Lead II reflects the inferior area of the heart that is experiencing the ST segment changes and will best reflect any electrocardiographic (ECG) changes that indicate further damage to the myocardium. The other leads do not reflect the inferior part of the myocardial wall and will not provide data about further ischemic changes. DIF: Cognitive Level: Analysis REF: 837-839 TOP: Nursing Process: Implementation

16. A patient has ST segment changes that suggest an acute inferior wall myocardial infarction. Which lead would be best for monitoring the patient? a. I c. V2 b. II d. V6

B Leads II, III, and AVF reflect the inferior area of the heart and the ST segment changes. Lead II will best capture any electrocardiographic changes that indicate further damage to the myocardium. The other leads do not reflect the inferior part of the myocardial wall and will not provide data about further ischemic changes in that area. DIF: Cognitive Level: Analyze (analysis) REF: 758 TOP: Nursing Process: Implementation

6. A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center? a. Level I - Located within remote areas and provides advanced life support within resource capabilities b. Level II - Located within community hospitals and provides care to most injured clients c. Level III - Located in rural communities and provides only basic care to clients d. Level IV - Located in large teaching hospitals and provides a full continuum of trauma care for all clients

B Level I trauma centers are usually located in large teaching hospital systems and provide a full continuum of trauma care for all clients. Both Level II and Level III facilities are usually located in community hospitals. These trauma centers provide care for most clients and transport to Level I centers when client needs exceed resource capabilities. Level IV trauma centers are usually located in rural and remote areas. These centers provide basic care, stabilization, and advanced life support while transfer arrangements to higher-level trauma centers are made. DIF: Remembering/Knowledge REF: 115 KEY: Trauma center| emergency nursing

2. Which nursing intervention is likely to be most effective when assisting the patient with coronary artery disease to make appropriate dietary changes? a. Inform the patient about a diet containing no saturated fat and minimal salt. b. Help the patient modify favorite high-fat recipes by using monounsaturated oils. c. Emphasize the increased risk for heart problems unless the patient makes the dietary changes. d. Give the patient a list of low-sodium, low-cholesterol foods that should be included in the diet.

B Lifestyle changes are more likely to be successful when consideration is given to the patient's values and preferences. The highest percentage of calories from fat should come from monounsaturated or polyunsaturated fats. Although low-sodium and low-cholesterol foods are appropriate, providing the patient with a list alone is not likely to be successful in making dietary changes. Completely removing saturated fat from the diet is not a realistic expectation. Up to 7% of calories in the therapeutic lifestyle changes diet can come from saturated fat. Telling the patient about the increased risk without assisting further with strategies for dietary change is unlikely to be successful. DIF: Cognitive Level: Analyze (analysis) REF: 705 TOP: Nursing Process: Implementation

3. A client presents to the emergency department after prolonged exposure to the cold. The client is difficult to arouse and speech is incoherent. Which action should the nurse take first? a. Reposition the client into a prone position. b. Administer warmed intravenous fluids to the client. c. Wrap the client's extremities in warm blankets. d. Initiate extracorporeal rewarming via hemodialysis.

B Moderate hypothermia manifests with muscle weakness, increased loss of coordination, acute confusion, apathy, incoherence, stupor, and impaired clotting. Moderate hypothermia should be treated by core rewarming methods, which include administration of warm IV fluids, heated oxygen, and heated peritoneal, pleural, gastric, or bladder lavage, and by positioning the client in a supine position to prevent orthostatic changes. The client's trunk should be warmed prior to the extremities to prevent peripheral vasodilation. Extracorporeal warming with cardiopulmonary bypass or hemodialysis is a treatment for severe hypothermia. DIF: Applying/Application REF: 131 KEY: Cold-related illness| environmental emergencies

14. The nurse is caring for a patient who has an intraaortic balloon pump in place. Which action should be included in the plan of care? a. Avoid the use of anticoagulant medications. b. Measure the patient's urinary output every hour. c. Provide passive range of motion for all extremities. d. Position the patient supine with head flat at all times.

B Monitoring urine output will help determine whether the patient's cardiac output has improved and also help monitor for balloon displacement blocking the renal arteries. The head of the bed can be elevated up to 30 degrees. Heparin is used to prevent thrombus formation. Limited movement is allowed for the extremity with the balloon insertion site to prevent displacement of the balloon. DIF: Cognitive Level: Apply (application) REF: 1569 TOP: Nursing Process: Planning

3. A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock? a. Inspiratory crackles c. Cool, clammy extremities b. Heart rate 45 beats/min d. Temperature 101.2°F (38.4°C)

B Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock. DIF: Cognitive Level: Understand (comprehension) REF: 1590 TOP: Nursing Process: Assessment

11. The nurse is admitting a patient who has a neck fracture at the C6 level to the intensive care unit. Which assessment findings indicate neurogenic shock? a. Involuntary and spastic movement b. Hypotension and warm extremities c. Hyperactive reflexes below the injury d. Lack of sensation or movement below the injury

B Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of spinal cord injury. Lack of movement and sensation indicate spinal cord injury but not neurogenic shock. DIF: Cognitive Level: Understand (comprehension) REF: 1423 TOP: Nursing Process: Assessment

8. A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. Which action should the nurse take prior to providing advanced cardiac life support? a. Contact the on-call orthopedic surgeon. b. Don personal protective equipment. c. Notify the Rapid Response Team. d. Obtain a complete history from the paramedic.

B Nurses must recognize and plan for a high risk of contamination with blood and body fluids when engaging in trauma resuscitation. Standard Precautions should be taken in all resuscitation situations and at other times when exposure to blood and body fluids is likely. Proper attire consists of an impervious cover gown, gloves, eye protection, a facemask, a surgical cap, and shoe covers. DIF: Applying/Application REF: 116 KEY: Infection control| Standard Precautions| emergency nursing| staff safety

5. A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic testing reveals the client has an alteration in the gene CYP2C19. What action by the nurse is best? a. Instruct the client to eliminate all vitamin K from the diet. b. Prepare preoperative teaching for an inferior vena cava (IVC) filter. c. Refer the client to a chronic illness support group. d.. Teach the client to use a soft-bristled toothbrush.

B Often clients are discharged from the hospital on warfarin (Coumadin) after a PE. However, clients with a variation in the CYP2C19 gene do not metabolize warfarin well and have higher blood levels and more side effects. This client is a poor candidate for warfarin therapy, and the prescriber will most likely order an IVC filter device to be implanted. The nurse should prepare to do preoperative teaching on this procedure. It would be impossible to eliminate all vitamin K from the diet. A chronic illness support group may be needed, but this is not the best intervention as it is not as specific to the client as the IVC filter. A soft-bristled toothbrush is a safety measure for clients on anticoagulation therapy. DIF: Applying/Application REF: 608 KEY: Pulmonary embolism| thromboembolic events| patient education| genetic alterations

15. A client with coronary artery disease (CAD) asks the nurse about taking fish oil supplements. What response by the nurse is best? a. "Fish oil is contraindicated with most drugs for CAD." b. "The best source is fish, but pills have benefits too." c. "There is no evidence to support fish oil use with CAD." d. "You can reverse CAD totally with diet and supplements."

B Omega-3 fatty acids have shown benefit in reducing lipid levels, in reducing the incidence of sudden cardiac death, and for stabilizing atherosclerotic plaque. The best source is fish three times a week or some fish oil supplements. The other options are not accurate. DIF: Understanding/Comprehension REF: 761 KEY: Coronary artery disease| lipid-reducing agents| supplements| patient education

10. The nurse suspects that the patient with stable angina is experiencing a side effect of the prescribed drug metoprolol (Lopressor) if the a. patient is restless and agitated. b. blood pressure is 90/54 mm Hg. c. patient complains about feeling anxious. d. heart monitor shows normal sinus rhythm.

B Patients taking β-adrenergic blockers should be monitored for hypotension and bradycardia. Because this class of medication inhibits the sympathetic nervous system, restlessness, agitation, hypertension, and anxiety will not be side effects. Normal sinus rhythm is a normal and expected heart rhythm. DIF: Cognitive Level: Apply (application) REF: 715 TOP: Nursing Process: Evaluation

7. After the nurse teaches the patient about the use of carvedilol (Coreg) in preventing anginal episodes, which statement by a patient indicates that the teaching has been effective? a. "Carvedilol will help my heart muscle work harder." b. "It is important not to suddenly stop taking the carvedilol." c. "I can expect to feel short of breath when taking carvedilol." d. "Carvedilol will increase the blood flow to my heart muscle."

B Patients who have been taking β-adrenergic blockers can develop intense and frequent angina if the medication is suddenly discontinued. Carvedilol (Coreg) decreases myocardial contractility. Shortness of breath that occurs when taking β-adrenergic blockers for angina may be due to bronchospasm and should be reported to the health care provider. Carvedilol works by decreasing myocardial O2 demand, not by increasing blood flow to the coronary arteries. DIF: Cognitive Level: Apply (application) REF: 715 TOP: Nursing Process: Evaluation

5. The health care provider prescribes clopidogrel (Plavix) for a patient with cerebral atherosclerosis. When teaching about the new medication, the nurse will tell the patient a. to monitor and record the blood pressure daily. b. to call the health care provider if stools are tarry. c. that Plavix will dissolve clots in the cerebral arteries. d. that Plavix will reduce cerebral artery plaque formation.

B Plavix inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients should be advised to notify the health care provider about any signs of bleeding. The medication does not lower blood pressure, decrease plaque formation, or dissolve clots. DIF: Cognitive Level: Application REF: 1468-1469 TOP: Nursing Process: Implementation

7. A nurse works at a community center for older adults. What self-management measure can the nurse teach the clients to prevent shock? a.. Do not get dehydrated in warm weather. b. Drink fluids on a regular schedule. c. Seek attention for any lacerations. d. Take medications as prescribed.

B Preventing dehydration in older adults is important because the age-related decrease in the thirst mechanism makes them prone to dehydration. Having older adults drink fluids on a regular schedule will help keep them hydrated without the influence of thirst (or lack of thirst). Telling clients not to get dehydrated is important, but not the best answer because it doesn't give them the tools to prevent it from occurring. Older adults should seek attention for lacerations, but this is not as important an issue as staying hydrated. Taking medications as prescribed may or may not be related to hydration. DIF: Applying/Application REF: 744 KEY: Older adult| fluid and electrolyte imbalance| patient education| primary prevention

9. Amlodipine (Norvasc) is ordered for a patient with newly diagnosed Prinzmetal's (variant) angina. When teaching the patient, the nurse will include the information that amlodipine will a. reduce the "fight or flight" response. b. decrease spasm of the coronary arteries. c. increase the force of myocardial contraction. d. help prevent clotting in the coronary arteries.

B Prinzmetal's angina is caused by coronary artery spasm. Calcium channel blockers (e.g., amlodipine, nifedipine [Procardia]) are a first-line therapy for this type of angina. Platelet inhibitors, such as aspirin, help prevent coronary artery thrombosis, and β-blockers decrease sympathetic stimulation of the heart. Medications or activities that increase myocardial contractility will increase the incidence of angina by increasing oxygen demand. DIF: Cognitive Level: Application REF: 776 TOP: Nursing Process: Implementation

43. After reviewing a patient's history, vital signs, physical assessment, and laboratory data, which information shown in the accompanying figure is most important for the nurse to communicate to the health care provider? a. Hyperglycemia c. Q waves on ECG b. Bilateral crackles d. Elevated troponin

B Pulmonary congestion suggests that the patient may be developing heart failure, a complication of myocardial infarction (MI). Hyperglycemia is common after MI because of the inflammatory process that occurs with tissue necrosis. Troponin levels will be elevated for several days after MI. Q waves often develop with ST-segment-elevation MI. DIF: Cognitive Level: Analyze (analysis) REF: 720 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

28. The nurse is caring for a patient who has an arterial catheter in the left radial artery for arterial pressure-based cardiac output (APCO) monitoring. Which information obtained by the nurse requires a report to the health care provider? a. The patient has a positive Allen test result. b. There is redness at the catheter insertion site. c. The mean arterial pressure (MAP) is 86 mm Hg. d. The dicrotic notch is visible in the arterial waveform.

B Redness at the catheter insertion site indicates possible infection. The Allen test is performed before arterial line insertion, and a positive test result indicates normal ulnar artery perfusion. A MAP of 86 mm Hg is normal, and the dicrotic notch is normally present on the arterial waveform. DIF: Cognitive Level: Apply (application) REF: 1562 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

11. The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patient's nose. Which admission order should the nurse question? a. Keep the head of bed elevated. b. Insert nasogastric tube to low suction. c. Turn patient side to side every 2 hours. d. Apply cold packs intermittently to face.

B Rhinorrhea may indicate a dural tear with cerebrospinal fluid leakage. Insertion of a nasogastric tube will increase the risk for infections such as meningitis. Turning the patient, elevating the head, and applying cold packs are appropriate orders. DIF: Cognitive Level: Apply (application) REF: 1332 TOP: Nursing Process: Implementation

10. A patient has a stroke affecting the right hemisphere of the brain. Based on knowledge of the effects of right brain damage, the nurse establishes a nursing diagnosis of a. impaired physical mobility related to right hemiplegia. b. risk for injury related to denial of deficits and impulsiveness. c. impaired verbal communication related to speech-language deficits. d. ineffective coping related to depression and distress about disability.

B Right-sided brain damage typically causes denial of any deficits and poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability. DIF: Cognitive Level: Application REF: 1482-1484 TOP: Nursing Process: Diagnosis

2. Which hemodynamic parameter best reflects the effectiveness of drugs that the nurse gives to reduce a patient's left ventricular afterload? a. Mean arterial pressure (MAP) b. Systemic vascular resistance (SVR) c. Pulmonary vascular resistance (PVR) d. Pulmonary artery wedge pressure (PAWP)

B SVR reflects the resistance to ventricular ejection, or afterload. The other parameters may be monitored but do not reflect afterload as directly. DIF: Cognitive Level: Apply (application) REF: 1560 TOP: Nursing Process: Evaluation

23. A patient who has had an acute myocardial infarction (AMI) asks the nurse about when sexual intercourse can be resumed. Which response by the nurse is best? a. "Most patients are able to enjoy intercourse without any complications." b. "Sexual activity uses about as much energy as climbing two flights of stairs." c. "The doctor will discuss sexual intercourse when your heart is strong enough." d. "Holding and cuddling are good ways to maintain intimacy after a heart attack."

B Sexual activity places about as much physical stress on the cardiovascular system as climbing two flights of stairs. The other responses do not directly address the patient's question, or may not be accurate for this patient. DIF: Cognitive Level: Application REF: 792 TOP: Nursing Process: Implementation

23. A patient who is recovering from an acute myocardial infarction (AMI) asks the nurse when sexual intercourse can be resumed. Which response by the nurse is best? a. "Most patients are able to enjoy intercourse without any complications." b. "Sexual activity uses about as much energy as climbing two flights of stairs." c. "The doctor will provide sexual guidelines when your heart is strong enough." d. "Holding and cuddling are good ways to maintain intimacy after a heart attack."

B Sexual activity places about as much physical stress on the cardiovascular system as most moderate-energy activities such as climbing two flights of stairs. The other responses do not directly address the patient's question or may not be accurate for this patient. DIF: Cognitive Level: Apply (application) REF: 732 TOP: Nursing Process: Implementation

1. Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Which response by the nurse is best for this situation? a. "This type of monitoring system is complex and it is managed by skilled staff." b. "The monitoring system helps show whether blood flow to the brain is adequate." c. "The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure." d. "This monitoring system has multiple benefits including facilitation of cerebrospinal fluid drainage."

B Short and simple explanations should be given initially to patients and family members. The other explanations are either too complicated to be easily understood or may increase the family members' anxiety. DIF: Cognitive Level: Analyze (analysis) REF: 1326 TOP: Nursing Process: Implementation

1. When family members ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring for a patient, which response by the nurse is best? a. "This type of monitoring system is complex and highly skilled staff are needed." b. "The monitoring system helps show whether blood flow to the brain is adequate." c. "The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure." d. "This monitoring system has multiple benefits including facilitation of cerebrospinal fluid drainage."

B Short and simple explanations should be given to patients and family members. The other explanations are either too complicated to be easily understood or may increase the family member's anxiety. DIF: Cognitive Level: Application REF: 1438 TOP: Nursing Process: Implementation

2. A nurse is caring for a client after surgery. The client's respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since they were last assessed 4 hours ago. What action by the nurse is best? a. Ask if the client needs pain medication. b. Assess the client's tissue perfusion further. c. Document the findings in the client's chart. d. Increase the rate of the client's IV infusion.

B Signs of the earliest stage of shock are subtle and may manifest in slight increases in heart rate, respiratory rate, or blood pressure. Even though these readings are not out of the normal range, the nurse should conduct a thorough assessment of the client, focusing on indicators of perfusion. The client may need pain medication, but this is not the priority at this time. Documentation should be done thoroughly but is not the priority either. The nurse should not increase the rate of the IV infusion without an order. DIF: Applying/Application REF: 743 KEY: Shock| perfusion| nursing assessment

21. After suctioning, the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 16 mm Hg. Which action should the nurse take first? a. Document the increase in intracranial pressure. b. Assure that the patient's neck is not in a flexed position. c. Notify the health care provider about the change in pressure. d. Increase the rate of the prescribed propofol (Diprovan) infusion.

B Since suctioning will cause a transient increase in intracranial pressure, the nurse should initially check for other factors that might be contributing to the increase and observe the patient for a few minutes. Documentation is needed, but this is not the first action. There is no need to notify the health care provider about this expected reaction to suctioning. Propofol is used to control patient anxiety or agitation; there is no indication that anxiety has contributed to the increase in intracranial pressure. DIF: Cognitive Level: Application REF: 1426 | 1435-1437 | 1436-1437 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

14. A patient has a nursing diagnosis of ineffective airway clearance related to thick, secretions. Which action will be best for the nurse to include in the plan of care? a. Encourage use of the incentive spirometer. b. Offer the patient fluids at frequent intervals. c. Teach the patient the importance of coughing. d. Increase oxygen level to keep O2 saturation >95%.

B Since the reason for the poor airway clearance is the thick secretions, the best action will be to encourage the patient to improve oral fluid intake. The use of the incentive spirometer should be more frequent in order to facilitate the clearance of the secretions. The other actions also may be helpful in improving the patient's gas exchange, but they do not address the thick secretions that are causing the poor airway clearance. DIF: Cognitive Level: Application REF: 1755 TOP: Nursing Process: Planning

23. A patient who is on the telemetry unit develops atrial flutter, rate 150, with associated dyspnea and diaphoresis. Which of these actions that are included in the hospital dysrhythmia protocol should the nurse take first? a. Obtain a 12-lead electrocardiogram (ECG). b. Give O2 at 3 to 4 L/min. c. Take the patient's blood pressure and respiratory rate. d. Notify the health care provider of the change in rhythm.

B Since this patient has dyspnea in association with the new rhythm, the nurse's initial actions should be to address the patient's airway, breathing, and circulation (ABC) by oxygen administration. The other actions also are important and should be implemented rapidly. DIF: Cognitive Level: Application REF: 824 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

27. The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? a. The pulse rate is 102 beats/min. b. The patient has difficulty speaking. c. The blood pressure is 144/86 mm Hg. d. There are fine crackles at the lung bases.

B Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during the procedure. Slightly elevated pulse rate and blood pressure are not unusual because of anxiety associated with the procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility during the procedure. The nurse should have the patient take some deep breaths. DIF: Cognitive Level: Analyze (analysis) REF: 1351 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

27. The nurse is caring for a patient with carotid artery narrowing who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? a. The pulse rate is 104 beats/min. b. The patient has difficulty talking. c. The blood pressure is 142/88 mm Hg. d. There are fine crackles at the lung bases.

B Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during the procedure. Slightly elevated pulse rate and blood pressure are not unusual because of anxiety associated with the procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility during the procedure; the nurse should have the patient take some deep breaths. DIF: Cognitive Level: Application REF: 1469-1471 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

10. When planning the response to the potential use of smallpox as an agent of terrorism, the emergency department (ED) nurse-manager will plan to obtain sufficient quantities of a. blood. b. vaccine. c. atropine. d. antibiotics.

B Smallpox infection can be prevented or ameliorated by the administration of vaccine given rapidly after exposure. The other interventions would be helpful for other agents of terrorism but not for smallpox. DIF: Cognitive Level: Comprehension REF: 1783-1784 TOP: Nursing Process: Planning

7. A student nurse is preparing morning medications for a client who had a stroke. The student plans to hold the docusate sodium (Colace) because the client had a large stool earlier. What action by the supervising nurse is best? a. Have the student ask the client if it is desired or not. b. Inform the student that the docusate should be given. c. Tell the student to document the rationale. d. Tell the student to give it unless the client refuses.

B Stool softeners should be given to clients with neurologic disorders in order to prevent an elevation in intracranial pressure that accompanies the Valsalva maneuver when constipated. The supervising nurse should instruct the student to administer the docusate. The other options are not appropriate. The medication could be held for diarrhea. DIF: Applying/Application REF: 942 KEY: Neurologic disorders| stool softeners| constipation| intracranial pressure

2. To determine the effectiveness of medications that a patient has received to reduce left ventricular afterload, which hemodynamic parameter will the nurse monitor? a. Central venous pressure (CVP) b. Systemic vascular resistance (SVR) c. Pulmonary vascular resistance (PVR) d. Pulmonary artery wedge pressure (PAWP)

B Systemic vascular resistance reflects the resistance to ventricular ejection, or afterload. The other parameters will be monitored, but do not reflect afterload as directly. DIF: Cognitive Level: Application REF: 1687-1689 TOP: Nursing Process: Evaluation

4. A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. During the primary survey of the patient, the nurse should a. obtain a complete set of vital signs. b. obtain a Glasgow Coma Scale score. c. attach an electrocardiogram monitor. d. ask about chronic medical conditions.

B The Glasgow Coma Scale is included when assessing for disability during the primary survey. The other information is part of the secondary survey. DIF: Cognitive Level: Apply (application) REF: 1632 TOP: Nursing Process: Assessment

16. A client has presented to the emergency department with an acute myocardial infarction (MI). What action by the nurse is best to meet The Joint Commission's Core Measures outcomes? a. Obtain an electrocardiogram (ECG) now and in the morning. b. Give the client an aspirin. c. Notify the Rapid Response Team. d. Prepare to administer thrombolytics.

B The Joint Commission's Core Measures set for acute MI require that aspirin is administered when a client with MI presents to the emergency department or when an MI occurs in the hospital. A rapid ECG is vital, but getting another one in the morning is not part of the Core Measures set. The Rapid Response Team is not needed if an emergency department provider is available. Thrombolytics may or may not be needed. DIF: Remembering/Knowledge REF: 766 KEY: Coronary artery disease| Core Measures| The Joint Commission

17. The public health nurse is planning a program to decrease the incidence of meningitis in teenagers and young adults. Which action is most likely to be effective? a. Emphasize the importance of hand washing. b. Immunize adolescents and college freshman. c. Support serving healthy nutritional options in the college cafeteria. d. Encourage adolescents and young adults to avoid crowds in the winter.

B The Neisseria meningitides vaccination is recommended for children ages 11 and 12 years, unvaccinated teens entering high school, and college freshmen. Hand washing may help decrease the spread of bacteria, and good nutrition may increase resistance to infection. but those are not as effective as immunization. Because adolescents and young adults are in school or the workplace, avoiding crowds is not realistic. DIF: Cognitive Level: Analyze (analysis) REF: 1340 TOP: Nursing Process: Implementation

7. A patient with cardiogenic shock has the following vital signs: BP 102/50, pulse 128, respirations 28. The pulmonary artery wedge pressure (PAWP) is increased, and cardiac output is low. The nurse will anticipate an order for which medication? a. 5% albumin infusion c. epinephrine (Adrenalin) drip b. furosemide (Lasix) IV d. hydrocortisone (Solu-Cortef)

B The PAWP indicates that the patient's preload is elevated, and furosemide is indicated to reduce the preload and improve cardiac output. Epinephrine would further increase the heart rate and myocardial oxygen demand. 5% albumin would also increase the PAWP. Hydrocortisone might be considered for septic or anaphylactic shock. DIF: Cognitive Level: Apply (application) REF: 1600 TOP: Nursing Process: Planning

10. A client's mean arterial pressure is 60 mm Hg and intracranial pressure is 20 mm Hg. Based on the client's cerebral perfusion pressure, what should the nurse anticipate for this client? a. Impending brain herniation b. Poor prognosis and cognitive function c. Probable complete recovery d. Unable to tell from this information

B The cerebral perfusion pressure (CPP) is the intracranial pressure subtracted from the mean arterial pressure: in this case, 60 - 20 = 40. For optimal outcomes, CPP should be at least 70 mm Hg. This client has very low CPP, which will probably lead to a poorer prognosis with significant cognitive dysfunction should the client survive. This data does not indicate impending brain herniation or complete recovery. DIF: Analyzing/Analysis REF: 949 KEY: Neurologic disorders| nursing assessment| neurologic assessment

1. On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 104.1° F (40.1° C), pulse 132 beats/min, respirations 26 breaths/min, blood pressure 106/66 mm Hg. Which action should the nurse take? a. Encourage the client to drink cool water or sports drinks. b. Start an intravenous line and infuse 0.9% saline solution. c. Administer acetaminophen (Tylenol) 650 mg orally. d. Encourage rest and re-assess in 15 minutes.

B The client demonstrates signs of heat stroke. This is a medical emergency and priority care includes oxygen therapy, IV infusion with 0.9% saline solution, insertion of a urinary catheter, and aggressive interventions to cool the client, including external cooling and internal cooling methods. Oral hydration would not be appropriate for a client who has symptoms of heat stroke because oral fluids would not provide necessary rapid rehydration, and the confused client would be at risk for aspiration. Acetaminophen would not decrease this client's temperature or improve the client's symptoms. The client needs immediate medical treatment; therefore, rest and re-assessing in 15 minutes is inappropriate. DIF: Applying/Application REF: 121 KEY: Heat-related illness| environmental emergencies

21. The nurse is caring for a client on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm below: After calling for assistance and a defibrillator, which action should the nurse take next? a. Perform a pericardial thump. b. Initiate cardiopulmonary resuscitation (CPR). c. Start an 18-gauge intravenous line. d. Ask the client's family about code status..

B The client's rhythm is ventricular fibrillation. This is a lethal rhythm that is best treated with immediate defibrillation. While the nurse is waiting for the defibrillator to arrive, the nurse should start CPR. A pericardial thump is not a treatment for ventricular fibrillation. If the client does not already have an IV, other members of the team can insert one after defibrillation. The client's code status should already be known by the nurse prior to this event. DIF: Applying/Application REF: 671 KEY: Cardiac electrical conduction| medical emergency

34. When the nursing supervisor is evaluating the performance of a new RN, which action indicates that the new RN is safe in providing care to a patient who is receiving mechanical ventilation with 10 cm of peak end-expiratory pressure (PEEP)? a. The RN plans to suction the patient every 2 hours. b. The RN uses a closed-suction technique to suction the patient. c. The RN tapes connection between the ventilator tubing and the ET. d. The RN changes the ventilator circuit tubing routinely every 24 hours.

B The closed-suction technique is suggested when patients require high levels of PEEP to prevent the loss of PEEP that occurs when disconnecting the patient from the ventilator. Suctioning should not be scheduled routinely, but it should be done only when patient assessment data indicate the need for suctioning. Taping connections between the ET and the ventilator tubing would restrict the ability of the tubing to swivel in response to patient repositioning. Ventilator tubing changes increase the risk for ventilator-associated pneumonia (VAP) and are not indicated routinely. DIF: Cognitive Level: Application REF: 1703-1704 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation

33. The nurse educator is evaluating the performance of a new registered nurse (RN) who is providing care to a patient who is receiving mechanical ventilation with 15 cm H2O of peak end-expiratory pressure (PEEP). Which action indicates that the new RN is safe? a. The RN plans to suction the patient every 1 to 2 hours. b. The RN uses a closed-suction technique to suction the patient. c. The RN tapes the connection between the ventilator tubing and the ET. d. The RN changes the ventilator circuit tubing routinely every 48 hours.

B The closed-suction technique is used when patients require high levels of PEEP (>10 cm H2O) to prevent the loss of PEEP that occurs when disconnecting the patient from the ventilator. Suctioning should not be scheduled routinely, but it should be done only when patient assessment data indicate the need for suctioning. Taping connections between the ET and ventilator tubing would restrict the ability of the tubing to swivel in response to patient repositioning. Ventilator tubing changes increase the risk for ventilator-associated pneumonia and are not indicated routinely. DIF: Cognitive Level: Apply (application) REF: 1571 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation

9. A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take first? a. Monitor the pulses every hour. b. Notify the health care provider. c. Elevate both legs above heart level with pillows. d. Encourage the patient to flex and extend the toes.

B The decrease in pulse and numbness in a patient with circumferential burns indicates decreased circulation to the legs and the need for an escharotomy. Monitoring the pulses is not an adequate response to the decrease in circulation. Elevating the legs or increasing toe movement will not improve the patient's circulation. DIF: Cognitive Level: Apply (application) REF: 433 TOP: Nursing Process: Implementation

13. When titrating IV nitroglycerin for a patient with a myocardial infarction (MI), which action will the nurse take to evaluate the effectiveness of the drug? a. Monitor heart rate. c. Check blood pressure. b. Ask about chest pain. d. Observe for dysrhythmias.

B The goal of IV nitroglycerin administration in MI is relief of chest pain by improving the balance between myocardial oxygen supply and demand. The nurse will also monitor heart rate and blood pressure and observe for dysrhythmias, but these parameters will not indicate whether the medication is effective. DIF: Cognitive Level: Apply (application) REF: 725 TOP: Nursing Process: Evaluation

40. Which patient at the cardiovascular clinic requires the most immediate action by the nurse? a. Patient with type 2 diabetes whose current blood glucose level is 145 mg/dL b. Patient with stable angina whose chest pain has recently increased in frequency c. Patient with familial hypercholesterolemia and a total cholesterol of 465 mg/dL d. Patient with chronic hypertension whose blood pressure today is 172/98 mm Hg

B The history of more frequent chest pain suggests that the patient may have unstable angina, which is part of the acute coronary syndrome spectrum. This will require rapid implementation of actions such as cardiac catheterization and possible percutaneous coronary intervention. The data about the other patients suggest that their conditions are stable. DIF: Cognitive Level: Analyze (analysis) REF: 719 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Planning

28. A 70-yr-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? a. Take the patient's blood pressure. b. Check the respiratory rate and effort. c. Assess the Glasgow Coma Scale score. d. Send the patient for a computed tomography (CT) scan.

B The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, and circulation) are completed. DIF: Cognitive Level: Analyze (analysis) REF: 1354 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

33. A patient who is receiving mechanical ventilation is anxious and is "fighting" the ventilator. Which action should the nurse take first? a. Ventilate the patient with a manual resuscitation bag. b. Verbally coach the patient to breathe with the ventilator. c. Sedate the patient with the ordered PRN lorazepam (Ativan). d. Increase the rate for the ordered propofol (Diprivan) infusion.

B The initial response by the nurse should be to try to decrease the patient's anxiety by coaching the patient about how to coordinate respirations with the ventilator. The other actions also may be helpful if the verbal coaching is ineffective in reducing the patient's anxiety. DIF: Cognitive Level: Application REF: 1704-1705 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

15. While waiting for cardiac transplantation, a patient with severe heart failure has a ventricular assist device (VAD) implanted. When developing the plan of care, the nursing actions should include a. administration of immunosuppressive medications. b. monitoring the surgical incision for signs of infection. c. teaching the patient the reason for continuous bed rest. d. preparing the patient to have the VAD in place permanently.

B The insertion site for the VAD provides a source for transmission of infection to the circulatory system and requires frequent monitoring. Patient's with VADs are able to have some mobility and may not be on bed rest. The VAD is a bridge to transplantation, not a permanent device. Immunosuppression is not necessary for nonbiologic devices like the VAD. DIF: Cognitive Level: Application REF: 1700-1701 TOP: Nursing Process: Planning

8. Which action should the nurse take when the low pressure alarm sounds for a patient who has an arterial line in the right radial artery? a. Check the right hand for pallor. b. Assess for cardiac dysrhythmias. c. Flush the arterial line with saline. d. Rezero the monitoring equipment.

B The low pressure alarm indicates a drop in the patient's blood pressure, which may be caused by cardiac dysrhythmias. There is no indication to rezero the equipment. Pallor of the right hand would be caused by occlusion of the radial artery by the arterial catheter, not by low pressure. There is no indication of a need for flushing the line. DIF: Cognitive Level: Application REF: 1689-1691 TOP: Nursing Process: Implementation

6. Following a head injury, an unconscious 32-year-old patient is admitted to the emergency department (ED). The patient's spouse and children stay at the patient's side and constantly ask about the treatment being given. What action is best for the nurse to take? a. Ask the family to stay in the waiting room until the initial assessment is completed. b. Allow the family to stay with the patient and briefly explain all procedures to them. c. Call the family's pastor or spiritual advisor to support them while initial care is given. d. Refer the family members to the hospital counseling service to deal with their anxiety.

B The need for information about the diagnosis and care is very high in family members of acutely ill patients, and the nurse should allow the family to observe care and explain the procedures. A pastor or counseling service can offer some support, but research supports information as being more effective. Asking the family to stay in the waiting room will increase their anxiety. DIF: Cognitive Level: Application REF: 1438 TOP: Nursing Process: Implementation

11. When assessing an older patient admitted to the emergency department (ED) with a broken arm and facial bruises, the nurse observes several additional bruises in various stages of healing. Which statement or question by the nurse should be first? a. "You should not go home." b. "Do you feel safe at home?" c. "Would you like to see a social worker?" d. "I need to report my concerns to the police."

B The nurse's initial response should be to further assess the patient's situation. Telling the patient not to return home may be an option once further assessment is done. A social worker or police report may be appropriate once further assessment is completed. DIF: Cognitive Level: Analyze (analysis) REF: 1644 TOP: Nursing Process: Implementation

19. Three days after experiencing a myocardial infarction (MI), a patient who is scheduled for discharge asks for assistance with hygiene activities, saying, "I am too nervous about my heart to be alone while I get washed up." Based on this information, which nursing diagnosis is appropriate? a. Activity intolerance related to weakness b. Anxiety related to change in health status c. Denial related to lack of acceptance of the MI d. Altered body image related to cardiac disease

B The patient data indicate anxiety about the impact of the MI is a concern. The other nursing diagnoses may be appropriate for some patients after an MI, but the data for this patient do not support denial, activity intolerance, or altered body image. DIF: Cognitive Level: Apply (application) REF: 725 TOP: Nursing Process: Diagnosis

5. A patient with a head injury opens the eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to remove a painful stimulus. The nurse records the patient's Glasgow Coma Scale score as a. 9. b. 11. c. 13. d. 15.

B The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor response. DIF: Cognitive Level: Application REF: 1434 TOP: Nursing Process: Assessment

5. A patient with a head injury opens his eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. The nurse records the patient's Glasgow Coma Scale score as a. 9. c. 13. b. 11. d. 15.

B The patient has scores of 3 for eye opening, 3 for best verbal response, and 5 for best motor response. DIF: Cognitive Level: Apply (application) REF: 1323 TOP: Nursing Process: Assessment

16. A 20-yr-old patient who sustained a T2 spinal cord injury 10 days ago tells the nurse, "I want to be transferred to a hospital where the nurses know what they are doing." Which action by the nurse is appropriate? a. Respond that abusive language will not be tolerated. b. Request that the patient provide input for the plan of care. c. Perform care without responding to the patient's comments. d. Reassure the patient about the competence of the nursing staff.

B The patient is demonstrating behaviors consistent with the anger phase of the grief process, and the nurse should allow expression of anger and seek the patient's input into care. Expression of anger is appropriate at this stage, and should be accepted by the nurse. Reassurance about the competency of the staff will not be helpful in responding to the patient's concerns. Ignoring the patient's comments will increase the patient's anger and sense of helplessness. DIF: Cognitive Level: Apply (application) REF: 1435 TOP: Nursing Process: Implementation

20. A patient develops sinus bradycardia at a rate of 32 beats/minute, has a BP of 80/36 mm Hg, and is complaining of feeling faint. Which action should the nurse take? a. Continue to monitor the rhythm and BP. b. Apply the transcutaneous pacemaker (TCP). c. Have the patient perform the Valsalva maneuver. d. Give the scheduled dose of diltiazem (Cardizem).

B The patient is experiencing symptomatic bradycardia, and treatment with TCP is appropriate. Continued monitoring of the rhythm and BP is an inadequate response. Calcium channel blockers will further decrease the heart rate, and the diltiazem should be held. The Valsalva maneuver will further decrease the rate. DIF: Cognitive Level: Application REF: 823-825 | 835-836 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

5. When the nurse is caring for an obese patient with left lower lobe pneumonia, gas exchange will be best when the patient is positioned a. on the left side. b. on the right side. c. in the tripod position. d. in the high-Fowler's position.

B The patient should be positioned with the "good" lung in the dependent position to improve the match between ventilation and perfusion. The obese patient's abdomen will limit respiratory excursion when sitting in the high-Fowler's or tripod positions. DIF: Cognitive Level: Application REF: 1754-1755 TOP: Nursing Process: Implementation

33. After receiving information about four patients during change-of-shift report, which patient should the nurse assess first? a. Patient with acute pericarditis who has a pericardial friction rub b. Patient who has just returned to the unit after balloon valvuloplasty c. Patient who has hypertrophic cardiomyopathy and a heart rate of 116 d. Patient with a mitral valve replacement who has an anticoagulant scheduled

B The patient who has just arrived after balloon valvuloplasty will need assessment for complications such as bleeding and hypotension. The information about the other patients is consistent with their diagnoses and does not indicate any complications or need for urgent assessment or intervention. DIF: Cognitive Level: Analyze (analysis) REF: 793 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Planning

15. When the nurse is developing a rehabilitation plan for a 30-yr-old patient with a C6 spinal cord injury, an appropriate goal is that the patient will be able to a. drive a car with powered hand controls. b. push a manual wheelchair on a flat surface. c. turn and reposition independently when in bed. d. transfer independently to and from a wheelchair.

B The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn independently in bed. DIF: Cognitive Level: Apply (application) REF: 1423 TOP: Nursing Process: Planning

13. A patient with a T1 spinal cord injury is admitted to the intensive care unit. The nurse will teach the patient and family that a. use of the shoulders will be preserved. b. full function of the patient's arms will be retained. c. total loss of respiratory function may occur temporarily. d. elevations in heart rate are common with this type of injury.

B The patient with a T1 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with cervical spine injury. Loss of respiratory function occurs with cervical spine injuries. Bradycardia is associated with injuries above the T6 level. DIF: Cognitive Level: Comprehension REF: 1549-1550 TOP: Nursing Process: Implementation

13. The nurse will explain to the patient who has a T2 spinal cord transection injury that a. use of the shoulders will be limited. b. function of both arms should be retained. c. total loss of respiratory function may occur. d. tachycardia is common with this type of injury.

B The patient with a T2 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with cervical spine injury. Loss of respiratory function occurs with cervical spine injuries. Bradycardia is associated with injuries above the T6 level. DIF: Cognitive Level: Understand (comprehension) REF: 1420 TOP: Nursing Process: Implementation

21. Four hours after mechanical ventilation is initiated for a patient with chronic obstructive pulmonary disease (COPD), the patient's arterial blood gas (ABG) results include a pH of 7.50, PaO2 of 80 mm Hg, PaCO2 of 29 mm Hg, and HCO3- of 23 mEq/L (23 mmol/L). The nurse will anticipate the need to a. increase the FIO2. b. decrease the respiratory rate. c. increase the tidal volume (VT). d. leave the ventilator at the current settings.

B The patient's PaCO2 and pH indicate respiratory alkalosis caused by too high a respiratory rate. The PaO2 is appropriate for a patient with COPD, increasing the tidal volume would further lower the PaCO2, and the PaCO2 and pH indicate a need to make the ventilator changes. DIF: Cognitive Level: Analysis REF: 1710-1711 TOP: Nursing Process: Planning

4. The oxygen saturation (SpO2) for a patient with left lower lobe pneumonia is 90%. The patient has wheezes, a weak cough effort, and complains of fatigue. Which action should the nurse take next? a. Position the patient on the left side. b. Assist the patient with staged coughing. c. Place a humidifier in the patient's room. d. Schedule a 4-hour rest period for the patient.

B The patient's assessment indicates that assisted coughing is needed to help remove secretions, which will improve oxygenation. A 4-hour rest period at this time may allow the O2 saturation to drop further. Humidification will not be helpful unless the secretions can be mobilized. Positioning on the left side may cause a further decrease in oxygen saturation because perfusion will be directed more toward the more poorly ventilated lung. DIF: Cognitive Level: Apply (application) REF: 1616 TOP: Nursing Process: Implementation

24. A patient whose heart monitor shows sinus tachycardia, rate 132, is apneic, and has no palpable pulses. What action should the nurse take next? a. Perform synchronized cardioversion. b. Start cardiopulmonary resuscitation (CPR). c. Give atropine per agency dysrhythmia protocol. d. Provide supplemental O2 via non-rebreather mask.

B The patient's clinical manifestations indicate pulseless electrical activity, and the nurse should immediately start CPR. The other actions would not be of benefit to this patient. DIF: Cognitive Level: Apply (application) REF: 763 TOP: Nursing Process: Implementation

2. A nurse is caring for a patient whose hemodynamic monitoring indicates a blood pressure of 92/54 mm Hg, a pulse of 64 beats/min, and an elevated pulmonary artery wedge pressure (PAWP). Which intervention ordered by the health care provider should the nurse question? a. Elevate head of bed to 30 degrees. b. Infuse normal saline at 250 mL/hr. c. Hold nitroprusside if systolic BP is less than 90 mm Hg. d. Titrate dobutamine to keep systolic BP is greater than 90 mm Hg.

B The patient's elevated PAWP indicates volume excess in relation to cardiac pumping ability, consistent with cardiogenic shock. A saline infusion at 250 mL/hr will exacerbate the volume excess. The other actions will help to improve cardiac output, which should lower the PAWP and may raise the BP. DIF: Cognitive Level: Apply (application) REF: 1600 TOP: Nursing Process: Planning

3. A patient is admitted to the burn unit with burns to the upper body and head after a garage fire. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take? a. Encourage the patient to cough and auscultate the lungs again. b. Notify the health care provider and prepare for endotracheal intubation. c. Document the results and continue to monitor the patient's respiratory rate. d. Reposition the patient in high-Fowler's position and reassess breath sounds.

B The patient's history and clinical manifestations suggest airway edema and the health care provider should immediately be notified so that intubation can rapidly be done. Placing the patient in a more upright position or having the patient cough will not address the problem of airway edema. Continuing to monitor is inappropriate because immediate action should occur. DIF: Cognitive Level: Application REF: 481-482 TOP: Nursing Process: Implementation

3. A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take? a. Encourage the patient to cough and auscultate the lungs again. b. Notify the health care provider and prepare for endotracheal intubation. c. Document the results and continue to monitor the patient's respiratory rate. d. Reposition the patient in high-Fowler's position and reassess breath sounds.

B The patient's history and clinical manifestations suggest airway edema, and the health care provider should be notified immediately so that intubation can be done rapidly. Placing the patient in a more upright position or having the patient cough will not address the problem of airway edema. Continuing to monitor is inappropriate because immediate action should occur. DIF: Cognitive Level: Apply (application) REF: 434 TOP: Nursing Process: Implementation

26. An 81-yr-old patient who has been in the intensive care unit (ICU) for a week is now stable and transfer to the progressive care unit is planned. On rounds, the nurse notices that the patient has new onset confusion. The nurse will plan to a. give PRN lorazepam (Ativan) and cancel the transfer. b. inform the receiving nurse and then transfer the patient. c. notify the health care provider and postpone the transfer. d. obtain an order for restraints as needed and transfer the patient.

B The patient's history and symptoms most likely indicate delirium associated with the sleep deprivation and sensory overload in the ICU environment. Informing the receiving nurse and transferring the patient is appropriate. Postponing the transfer is likely to prolong the delirium. Benzodiazepines and restraints contribute to delirium and agitation. DIF: Cognitive Level: Apply (application) REF: 1557 TOP: Nursing Process: Planning

2. On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 56%, Hb 17.2 mg/dL (172 g/L), serum K+ 4.8 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse anticipate taking? a. Continue to monitor the laboratory results. b. Increase the rate of the ordered IV solution. c. Type and crossmatch for a blood transfusion. d. Document the findings in the patient's record.

B The patient's lab data show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Documentation and continuing to monitor are inadequate responses to the data. Since the hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase. DIF: Cognitive Level: Application REF: 479-483 TOP: Nursing Process: Planning

3. A patient with respiratory failure has a respiratory rate of 8 and an SpO2 of 89%. The patient is increasingly lethargic. The nurse will anticipate assisting with a. administration of 100% oxygen by non-rebreather mask. b. endotracheal intubation and positive pressure ventilation. c. insertion of a mini-tracheostomy with frequent suctioning. d. initiation of bilevel positive pressure ventilation (BiPAP).

B The patient's lethargy, low respiratory rate, and SpO2 indicate the need for mechanical ventilation with ventilator-controlled respiratory rate. Administration of high flow oxygen will not be helpful because the patient's respiratory rate is so low. Insertion of a mini-tracheostomy will facilitate removal of secretions, but it will not improve the patient's respiratory rate or oxygenation. BiPAP requires that the patient initiate an adequate respiratory rate to allow adequate gas exchange. DIF: Cognitive Level: Application REF: 1754-1756 TOP: Nursing Process: Planning

3. A patient with respiratory failure has a respiratory rate of 6 breaths/min and an oxygen saturation (SpO2) of 88%. The patient is increasingly lethargic. Which intervention will the nurse anticipate? a. Administration of 100% O2 by non-rebreather mask b. Endotracheal intubation and positive pressure ventilation c. Insertion of a mini-tracheostomy with frequent suctioning d. Initiation of continuous positive pressure ventilation (CPAP)

B The patient's lethargy, low respiratory rate, and SpO2 indicate the need for mechanical ventilation with ventilator-controlled respiratory rate. Giving high-flow O2 will not be helpful because the patient's respiratory rate is so low. Insertion of a mini-tracheostomy will facilitate removal of secretions, but it will not improve the patient's respiratory rate or oxygenation. CPAP requires that the patient initiate an adequate respiratory rate to allow adequate gas exchange. DIF: Cognitive Level: Apply (application) REF: 1616 TOP: Nursing Process: Planning

23. A patient with possible cerebral edema has a serum sodium level of 115 mEq/L (115 mmol/L) and a decreasing level of consciousness (LOC) and complains of a headache. Which of these prescribed interventions should the nurse implement first? a. Draw blood for arterial blood gases (ABGs). b. Administer 5% hypertonic saline intravenously. c. Administer acetaminophen (Tylenol) 650 mg orally. d. Send patient for computed tomography (CT) of the head.

B The patient's low sodium indicates that hyponatremia may be causing the cerebral edema, and the nurse's first action should be to correct the low sodium level. Acetaminophen (Tylenol) will have minimal effect on the headache because it is caused by cerebral edema and increased intra-cranial pressure (ICP). Drawing ABGs and obtaining a CT scan may add some useful information, but the low sodium level may lead to seizures unless it is addressed quickly. DIF: Cognitive Level: Application REF: 1452-1455 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

26. The nurse reviews the electronic health record for a patient scheduled for a total hip replacement. Which assessment data shown in the accompanying figure increase the patient's risk for respiratory complications after surgery? a. Older age and anemia c. Recent arthroscopic procedure b. Albumin level and weight loss d. Confusion and disorientation to time

B The patient's recent weight loss and low protein stores indicate possible muscle weakness, which make it more difficult for an older patient to recover from the effects of general anesthesia and immobility associated with the hip surgery. The other information will also be noted by the nurse but does not place the patient at higher risk for respiratory failure. DIF: Cognitive Level: Analyze (analysis) REF: 1615 TOP: Nursing Process: Assessment

18. A patient's heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious, apneic, and pulseless. Which action should the nurse take first? a. Give epinephrine (Adrenalin) IV. b. Perform immediate defibrillation. c. Prepare for endotracheal intubation. d. Ventilate with a bag-valve-mask device.

B The patient's rhythm and assessment indicate ventricular fibrillation and cardiac arrest; the initial action should be to defibrillate. If a defibrillator is not immediately available or is unsuccessful in converting the patient to a better rhythm, begin chest compressions. The other actions may also be appropriate but not first. DIF: Cognitive Level: Analyze (analysis) REF: 771 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

13. The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine output has dramatically increased. Which action by the nurse would best support maintaining kidney function? a. Monitor white blood cells (WBCs). b. Continue to measure the urine output. c. Assess that blisters and edema have subsided. d. Encourage the patient to eat an adequate number of calories.

B The patient's urine output indicates that the patient is entering the acute phase of the burn injury and moving on from the emergent stage. At the end of the emergent phase, capillary permeability normalizes, and the patient begins to diurese large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may be longer in some patients. Blisters and edema begin to resolve, but this process requires more time. WBCs may increase or decrease, based on the patient's immune status and any infectious processes. The WBC count does not indicate kidney function. Although adequate nutrition is important for healing, it does not ensure adequate kidney functioning. DIF: Cognitive Level: Understand (comprehension) REF: 442 TOP: Nursing Process: Application

10. A nurse receives new prescriptions for a client with severe burn injuries who is receiving fluid resuscitation per the Parkland formula. The client's urine output continues to range from 0.2 to 0.25 mL/kg/hr. Which prescription should the nurse question? a. Increase intravenous fluids by 100 mL/hr. b. Administer furosemide (Lasix) 40 mg IV push. c. Continue to monitor urine output hourly. d. Draw blood for serum electrolytes STAT.

B The plan of care for a client with a burn includes fluid and electrolyte resuscitation. Furosemide would be inappropriate to administer. Postburn fluid needs are calculated initially by using a standardized formula such as the Parkland formula. However, needs vary among clients, and the final fluid volume needed is adjusted to maintain hourly urine output at 0.5 mL/kg/hr. Based on this client's inadequate urine output, fluids need to be increased, urine output needs to be monitored hourly, and electrolytes should be evaluated to ensure appropriate fluids are being infused. DIF: Applying/Application REF: 478 KEY: Intravenous fluids| medication

17. A nurse is caring for four clients. Which client should the nurse assess first? a. Client with an acute myocardial infarction, pulse 102 beats/min b. Client who is 1 hour post angioplasty, has tongue swelling and anxiety c. Client who is post coronary artery bypass, chest tube drained 100 mL/hr d. Client who is post coronary artery bypass, potassium 4.2 mEq/L

B The post-angioplasty client with tongue swelling and anxiety is exhibiting manifestations of an allergic reaction that could progress to anaphylaxis. The nurse should assess this client first. The client with a heart rate of 102 beats/min may have increased oxygen demands but is just over the normal limit for heart rate. The two post coronary artery bypass clients are stable. DIF: Analyzing/Analysis REF: 774 KEY: Coronary artery disease| critical rescue| medical emergencies| hypersensitivities| allergic reaction

20. When a patient is admitted to the emergency department after a submersion injury, which assessment will the nurse obtain first? a. Apical pulse b. Lung sounds c. Body temperature d. Level of consciousness

B The priority assessment data are how well the patient is oxygenating, so lung sounds should be assessed first. The other data also will be collected rapidly but are not as essential as the lung sounds. DIF: Cognitive Level: Application REF: 1770 | 1779 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

8. A nurse is caring for a patient who has burns of the ears, head, neck, and right arm and hand. The nurse should place the patient in which position? a. Place the right arm and hand flexed in a position of comfort. b. Elevate the right arm and hand on pillows and extend the fingers. c. Assist the patient to a supine position with a small pillow under the head. d. Position the patient in a side-lying position with rolled towel under the neck.

B The right hand and arm should be elevated to reduce swelling and the fingers extended to avoid flexion contractures (even though this position may not be comfortable for the patient). The patient with burns of the ears should not use a pillow for the head because this will put pressure on the ears, and the pillow may stick to the ears. Patients with neck burns should not use a pillow or rolled towel because the head should be maintained in an extended position in order to avoid contractures. DIF: Cognitive Level: Apply (application) REF: 441 TOP: Nursing Process: Implementation

8. Which action will be included in the plan of care for a patient who has burns of the ears, head, neck, and right arm and hand? a. Place the right arm and hand flexed in a position of comfort. b. Elevate the right arm and hand on pillows and extend the fingers. c. Assist the patient to a supine position with a small pillow under the head. d. Position the patient in a side-lying position with rolled towel under the neck.

B The right hand and arm should be elevated to reduce swelling and the fingers extended to avoid flexion contractures (even though this position may not be comfortable for the patient). The patient with burns of the ears should not use a pillow since this will put pressure on the ears and may stick to the ears. Patients with neck burns should not use a pillow, since the head should be maintained in an extended position in order to avoid contractures. DIF: Cognitive Level: Application REF: 485 TOP: Nursing Process: Implementation

9. A nurse is caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP). Which assessment finding by the nurse indicates that the PEEP may need to be reduced? a. The patient's PaO2 is 50 mm Hg and the SaO2 is 88%. b. The patient has subcutaneous emphysema on the upper thorax. c. The patient has bronchial breath sounds in both the lung fields. d. The patient has a first-degree atrioventricular heart block with a rate of 58 beats/min.

B The subcutaneous emphysema indicates barotrauma caused by positive pressure ventilation and PEEP. Bradycardia, hypoxemia, and bronchial breath sounds are all concerns and will need to be addressed, but they are not specific indications that PEEP should be reduced. DIF: Cognitive Level: Apply (application) REF: 1623 TOP: Nursing Process: Assessment

16. A nurse cares for a client with burn injuries from a house fire. The client is not consistently oriented and reports a headache. Which action should the nurse take? a. Increase the client's oxygen and obtain blood gases. b. Draw blood for a carboxyhemoglobin level. c. Increase the client's intravenous fluid rate. d. Perform a thorough Mini-Mental State Examination.

B These manifestations are consistent with moderated carbon monoxide poisoning. This client is at risk for carbon monoxide poisoning because he or she was in a fire in an enclosed space. The other options will not provide information related to carbon monoxide poisoning. DIF: Applying/Application REF: 474 KEY: Medical emergency

1. A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority? a. Assess the client's lung sounds. b. Notify the Rapid Response Team. c. Provide reassurance to the client. d. Take a full set of vital signs.

B This client has manifestations of a pulmonary embolism, and the most critical action is to notify the Rapid Response Team for speedy diagnosis and treatment. The other actions are appropriate also but are not the priority. DIF: Remembering/Knowledge REF: 605 KEY: Critical rescue| Rapid Response Team| thromboembolic event| pulmonary embolism

19. After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes and restlessness. The client has IV fluids running at 75 mL/hr. What action by the nurse is best? a. Assess the client's magnesium level. b. Assess the client's sodium level. c. Increase the rate of the IV infusion. d. Provide oral care every hour.

B This client has manifestations of hypernatremia, which is a possible complication after craniotomy. The nurse should assess the client's serum sodium level. Magnesium level is not related. The nurse does not independently increase the rate of the IV infusion. Providing oral care is also a good option but does not take priority over assessing laboratory results. DIF: Applying/Application REF: 961 KEY: Neurologic disorders| fluid and electrolyte imbalances| nursing assessment

23. A nurse is caring for a client on the medical stepdown unit. The following data are related to this client: Subjective Information Laboratory Analysis Physical Assessment Shortness of breath for 20 minutes Feels frightened "Can't catch my breath" pH: 7.12 PaCO2: 28 mm Hg PaO2: 58 mm Hg SaO2: 88% Pulse: 120 beats/min Respiratory rate: 34 breaths/min Blood pressure 158/92 mm Hg Lungs have crackles What action by the nurse is most appropriate? a. Call respiratory therapy for a breathing treatment. b. Facilitate a STAT pulmonary angiography. c. Prepare for immediate endotracheal intubation. d. Prepare to administer intravenous anticoagulants.

B This client has manifestations of pulmonary embolism (PE); however, many conditions can cause the client's presentation.. The gold standard for diagnosing a PE is pulmonary angiography. The nurse should facilitate this test as soon as possible. The client does not have wheezing, so a respiratory treatment is not needed. The client is not unstable enough to need intubation and mechanical ventilation. IV anticoagulants are not given without a diagnosis of PE. DIF: Analyzing/Analysis REF: 605 KEY: Pulmonary embolism| thromboembolic event| laboratory values| respiratory system| clotting

1. A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt like his legs were very heavy. Currently the client's neurologic examination is normal. About what drug should the nurse plan to teach the client? a. Alteplase (Activase) b. Clopidogrel (Plavix) c. Heparin sodium d. Mannitol (Osmitrol)

B This client's manifestations are consistent with a transient ischemic attack, and the client would be prescribed aspirin or clopidogrel on discharge. Alteplase is used for ischemic stroke. Heparin and mannitol are not used for this condition. DIF: Remembering/Knowledge REF: 930 KEY: Neurologic disorders| antiplatelet medications| patient education

21. After receiving change-of-shift report, which of these patients should the nurse assess first? a. A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500 mL/hour b. A patient with smoke inhalation who has wheezes and altered mental status c. A patient with full-thickness leg burns who has a dressing change scheduled d. A patient with abdominal burns who is complaining of level 8 (0 to 10 scale) pain

B This patient has evidence of lower airway injury and hypoxemia and should be assessed immediately to determine need for oxygen or intubation. The other patients also should be assessed as rapidly as possible, but they do not have evidence of life-threatening complications. DIF: Cognitive Level: Application REF: 481 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Assessment

21. Which patient should the nurse assess first? a. A patient with burns who is complaining of level 8 (0 to 10 scale) pain b. A patient with smoke inhalation who has wheezes and altered mental status c. A patient with full-thickness leg burns who is scheduled for a dressing change d. A patient with partial thickness burns who is receiving IV fluids at 500 mL/hr

B This patient has evidence of lower airway injury and hypoxemia, and should be assessed immediately to determine the need for O2 or intubation (or both). The other patients should also be assessed as rapidly as possible, but they do not have evidence of life-threatening complications. DIF: Cognitive Level: Analyze (analysis) REF: 437 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Assessment

4. A nurse is caring for a client after surgery who is restless and apprehensive. The unlicensed assistive personnel (UAP) reports the vital signs and the nurse sees they are only slightly different from previous readings. What action does the nurse delegate next to the UAP? a.. Assess the client for pain or discomfort. b. Measure urine output from the catheter. c. Reposition the client to the unaffected side. d. Stay with the client and reassure him or her.

B Urine output changes are a sensitive early indicator of shock. The nurse should delegate emptying the urinary catheter and measuring output to the UAP as a baseline for hourly urine output measurements. The UAP cannot assess for pain. Repositioning may or may not be effective for decreasing restlessness, but does not take priority over physical assessments. Reassurance is a therapeutic nursing action, but the nurse needs to do more in this situation. DIF: Applying/Application REF: 743 KEY: Shock| nursing assessment| renal system| delegation| unlicensed assistive personnel (UAP)

7. While the patient's full-thickness burn wounds to the face are exposed, what nursing action prevents cross contamination? a. Use sterile gloves when removing dressings. b. Wear gown, cap, mask, and gloves during care. c. Keep the room temperature at 70° F (20° C) at all times. d. Give IV antibiotics to prevent bacterial colonization of wounds.

B Use of gowns, caps, masks, and gloves during all patient care will decrease the possibility of wound contamination for a patient whose burns are not covered. When removing contaminated dressings and washing the dirty wound, use nonsterile, disposable gloves. The room temperature should be kept at approximately 85° F for patients with open burn wounds to prevent shivering. Systemic antibiotics are not well absorbed into deep burns because of the lack of circulation. DIF: Cognitive Level: Apply (application) REF: 440 TOP: Nursing Process: Implementation

5. The nurse notes that a patient's cardiac monitor shows that every other beat is earlier than expected, has no P wave, and has a QRS complex with a wide and bizarre shape. How will the nurse document the rhythm? a. Ventricular couplets b. Ventricular bigeminy c. Ventricular R-on-T phenomenon d. Ventricular multifocal contractions

B Ventricular bigeminy describes a rhythm in which every other QRS complex is wide and bizarre looking. Pairs of wide QRS complexes are described as couplets. There is no indication that the premature ventricular contractions (PVCs) are multifocal or that the R-on-T phenomenon is occurring. DIF: Cognitive Level: Application REF: 830 TOP: Nursing Process: Assessment

16. A client is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the client needs more education regarding this medication? a. Hamburger and French fries b. Large chef's salad and muffin c. No selection; spouse brings pizza d. Tuna salad sandwich and chips

B Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors. Foods high in vitamin K thus interfere with its action and need to be eaten in moderate, consistent amounts. The chef's salad most likely has too many leafy green vegetables, which contain high amounts of vitamin K. The other selections, while not particularly healthy, will not interfere with the medication's mechanism of action. DIF: Evaluating/Synthesis REF: 607 KEY: Patient education| anticoagulants| nursing process evaluation

22. When evaluating the effectiveness of preoperative teaching with a patient scheduled for coronary artery bypass graft (CABG) surgery using the internal mammary artery, the nurse determines that additional teaching is needed when the patient says which of the following? a. "They will circulate my blood with a machine during surgery." b. "I will have incisions in my leg where they will remove the vein." c. "They will use an artery near my heart to go around the area that is blocked." d. "I will need to take an aspirin every day after the surgery to keep the graft open."

B When the internal mammary artery is used there is no need to have a saphenous vein removed from the leg. The other statements by the patient are accurate and indicate that the teaching has been effective. DIF: Cognitive Level: Apply (application) REF: 724 TOP: Nursing Process: Evaluation

21. A few days after experiencing a myocardial infarction (MI), the patient states, "I just had a little chest pain. As soon as I get out of here, I'm going for my vacation as planned." Which response should the nurse make? a. "Where are you planning to go for your vacation?" b. "What do you think caused your chest pain episode?" c. "Sometimes plans need to change after a heart attack." d. "Recovery from a heart attack takes at least a few weeks."

B When the patient is experiencing denial, the nurse should assist the patient in testing reality until the patient has progressed beyond this step of the emotional adjustment to MI. Asking the patient about vacation plans reinforces the patient's plan, which is not appropriate in the immediate post-MI period. Reminding the patient in denial about the MI is likely to make the patient angry and lead to distrust of the nursing staff. DIF: Cognitive Level: Application REF: 788-789 TOP: Nursing Process: Implementation

1. When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes dry, pale, and hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth? a. First-degree skin destruction b. Full-thickness skin destruction c. Deep partial-thickness skin destruction d. Superficial partial-thickness skin destruction

B With full-thickness skin destruction, the appearance is pale and dry or leathery, and the area is painless because of the associated nerve destruction. Erythema, swelling, and blisters point to a deep partial-thickness burn. With superficial partial-thickness burns, the area is red, but no blisters are present. First-degree burns exhibit erythema, blanching, and pain. DIF: Cognitive Level: Understand (comprehension) REF: 432 TOP: Nursing Process: Assessment

1. A nurse is caring for clients in a busy emergency department. Which actions should the nurse take to ensure client and staff safety? (Select all that apply.) a. Leave the stretcher in the lowest position with rails down so that the client can access the bathroom.. b. Use two identifiers before each intervention and before mediation administration. c. Attempt de-escalation strategies for clients who demonstrate aggressive behaviors. d. Search the belongings of clients with altered mental status to gain essential medical information. e. Isolate clients who have immune suppression disorders to prevent hospital-acquired infections.

B, C, D To ensure client and staff safety, nurses should use two identifiers per The Joint Commission's National Patient Safety Goals; follow the hospital's security plan, including de-escalation strategies for people who demonstrate aggressive or violent tendencies; and search belongings to identify essential medical information. Nurses should also use standard fall prevention interventions, including leaving stretchers in the lowest position with rails up, and isolating clients who present with signs and symptoms of contagious infectious disorders. DIF: Applying/Application REF: 108 KEY: Safety| patient safety| staff safety

1. Which actions should the nurse start to reduce the risk for ventilator-associated pneumonia (VAP) (select all that apply)? a. Obtain arterial blood gases daily. b. Provide a "sedation holiday" daily. c. Give prescribed pantoprazole (Protonix). d. Elevate the head of the bed to at least 30°. e. Provide oral care with chlorhexidine (0.12%) solution daily.

B, C, D, E All of these interventions are part of the ventilator bundle that is recommended to prevent VAP. Arterial blood gases may be done daily but are not always necessary and do not help prevent VAP. DIF: Cognitive Level: Apply (application) REF: 1623 TOP: Nursing Process: Implementation

3. An emergency room nurse is caring for a trauma client. Which interventions should the nurse perform during the primary survey? (Select all that apply.) a. Foley catheterization b. Needle decompression c. Initiating IV fluids d. Splinting open fractures e. Endotracheal intubation f. Removing wet clothing g. Laceration repair

B, C, E, F The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. The primary survey is based on the standard mnemonic ABC, with an added D and E: Airway and cervical spine control; Breathing; Circulation; Disability; and Exposure. After the completion of primary diagnostic and laboratory studies, and the insertion of gastric and urinary tubes, the secondary survey (a complete head-to-toe assessment) can be carried out. DIF: Applying/Application REF: 115 KEY: Primary survey| emergency nursing

4. A hospital prepares for a mass casualty event. Which functions are correctly paired with the personnel role? (Select all that apply.) a. Paramedic - Decides the number, acuity, and resource needs of clients b. Hospital incident commander - Assumes overall leadership for implementing the emergency plan c. Public information officer - Provides advanced life support during transportation to the hospital d. Triage officer - Rapidly evaluates each client to determine priorities for treatment e. Medical command physician - Serves as a liaison between the health care facility and the media

B, D The hospital incident commander assumes overall leadership for implementing the emergency plan. The triage officer rapidly evaluates each client to determine priorities for treatment.. The paramedic provides advanced life support during transportation to the hospital. The public information officer serves as a liaison between the health care facility and the media. The medical command physician decides the number, acuity, and resource needs of clients. DIF: Remembering/Knowledge REF: 143 KEY: Emergency nursing| interdisciplinary team

11. A nurse is dismissing a client from the emergency department who has a mild traumatic brain injury. What information obtained from the client represents a possible barrier to self-management? (Select all that apply.) a. Does not want to purchase a thermometer b. Is allergic to acetaminophen (Tylenol) c. Laughing, says "Strenuous? What's that?" d. Lives alone and is new in town with no friends e. Plans to have a beer and go to bed once home

B, D, E Clients should take acetaminophen for headache. An allergy to this drug may mean the client takes aspirin or ibuprofen (Motrin), which should be avoided. The client needs neurologic checks every 1 to 2 hours, and this client does not seem to have anyone available who can do that. Alcohol needs to be avoided for at least 24 hours. A thermometer is not needed. The client laughing at strenuous activity probably does not engage in any kind of strenuous activity, but the nurse should confirm this. DIF: Evaluating/Synthesis REF: 957 KEY: Neurologic disorders| patient education

1. A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.) a. Client who had a reaction to contrast dye yesterday b. Client with a new spinal cord injury on a rotating bed c. Middle-aged man with an exacerbation of asthma d. Older client who is 1-day post hip replacement surgery e. Young obese client with a fractured femur

B, D, E Conditions that place clients at higher risk of developing PE include prolonged immobility, central venous catheters, surgery, obesity, advancing age, conditions that increase blood clotting, history of thromboembolism, smoking, pregnancy, estrogen therapy, heart failure, stroke, cancer (particularly lung or prostate), and trauma. A contrast dye reaction and asthma pose no risk for PE. DIF: Remembering/Knowledge REF: 604 KEY: Pulmonary embolism| nursing assessment| clotting| thromboembolic event

13. An intraaortic balloon pump (IABP) is being used for a patient who is in cardiogenic shock. An assessment finding indicating to the nurse that the goals of treatment with the IABP are being met is a a. heart rate of 110 beats/min. b. urine output of 20 mL/hr. c. cardiac output (CO) of 5 L/min. d. stroke volume (SV) of 40 mL/beat.

C A CO of 5 L/min is normal and indicates that the IABP has been successful in treating the shock. The low SV signifies continued cardiogenic shock. The tachycardia and low urine output also suggest continued cardiogenic shock. DIF: Cognitive Level: Application REF: 1688 | 1697-1701 TOP: Nursing Process: Evaluation

13. An intraaortic balloon pump (IABP) is being used for a patient who is in cardiogenic shock. Which assessment data indicate to the nurse that the goals of treatment with the IABP are being met? a. Urine output of 25 mL/hr b. Heart rate of 110 beats/minute c. Cardiac output (CO) of 5 L/min d. Stroke volume (SV) of 40 mL/beat

C A CO of 5 L/min is normal and indicates that the IABP has been successful in treating the shock. The low SV signifies continued cardiogenic shock. The tachycardia and low urine output also suggest continued cardiogenic shock. DIF: Cognitive Level: Apply (application) REF: 1569 TOP: Nursing Process: Evaluation

15. Following an acute myocardial infarction (AMI), a patient ambulates in the hospital hallway. When the nurse is evaluating the patient's response, which of these assessment data would indicate that the exercise level should be decreased? a. BP changes from 118/60 to 126/68 mm Hg. b. Oxygen saturation drops from 100% to 98%. c. Heart rate increases from 66 to 90 beats/minute. d. Respiratory rate goes from 14 to 22 breaths/minute.

C A change in heart rate of more than 20 beats or more indicates that the patient should stop and rest. The increases in BP and respiratory rate, and the slight decrease in oxygen saturation, are normal responses to exercise. DIF: Cognitive Level: Application REF: 792 TOP: Nursing Process: Evaluation

1. A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be disoriented to person, place, and time. What action by the nurse is best? a. Assess the client's pupillary responses. b. Request a neurologic consultation. c. Stop the infusion and call the provider. d. Take and document a full set of vital signs.

C A change in neurologic status in a client receiving t-PA could indicate intracranial hemorrhage. The nurse should stop the infusion and notify the provider immediately. A full assessment, including pupillary responses and vital signs, occurs next. The nurse may or may not need to call a neurologist. DIF: Applying/Application REF: 768 KEY: Coronary artery disease| neurologic system| critical rescue| Rapid Response Team| thrombolytic agents

13. A nurse is triaging clients in the emergency department. Which client should the nurse classify as "nonurgent?" a. A 44-year-old with chest pain and diaphoresis b. A 50-year-old with chest trauma and absent breath sounds c. A 62-year-old with a simple fracture of the left arm d. A 79-year-old with a temperature of 104° F

C A client in a nonurgent category can tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with a simple arm fracture and palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and would be considered nonurgent. The client with chest pain and diaphoresis and the client with chest trauma are emergent owing to the potential for clinical deterioration and would be seen immediately.. The client with a high fever may be stable now but also has a risk of deterioration. DIF: Applying/Application REF: 111 KEY: Triage| emergency nursing

9. A nurse is triaging clients in the emergency department. Which client should be considered "urgent"? a. A 20-year-old female with a chest stab wound and tachycardia b. A 45-year-old homeless man with a skin rash and sore throat c. A 75-year-old female with a cough and a temperature of 102° F d. A 50-year-old male with new-onset confusion and slurred speech

C A client with a cough and a temperature of 102° F is urgent. This client is at risk for deterioration and needs to be seen quickly, but is not in an immediately life-threatening situation. The client with a chest stab wound and tachycardia and the client with new-onset confusion and slurred speech should be triaged as emergent. The client with a skin rash and a sore throat is not at risk for deterioration and would be triaged as nonurgent. DIF: Applying/Application REF: 112 KEY: Triage| emergency nursing

4. While triaging clients in a crowded emergency department, a nurse assesses a client who presents with symptoms of tuberculosis. Which action should the nurse take first? a. Apply oxygen via nasal cannula. b. Administer intravenous 0.9% saline solution. c. Transfer the client to a negative-pressure room. d. Obtain a sputum culture and sensitivity.

C A client with signs and symptoms of tuberculosis or other airborne pathogens should be placed in a negative-pressure room to prevent contamination of staff, clients, and family members in the crowded emergency department. DIF: Applying/Application REF: 108 KEY: Infection control| Transmission-Based Precautions| emergency nursing| staff safety

17. A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department complaining of shortness of breath and dyspnea. Which assessment finding by the nurse is most important to report to the health care provider? a. The patient has bibasilar lung crackles. b. The patient is sitting in the tripod position. c. The patient's respiratory rate has decreased from 30 to 10 breaths/min. d. The patient's pulse oximetry indicates an O2 saturation of 91%.

C A decrease in respiratory rate in a patient with respiratory distress suggests the onset of fatigue and a high risk for respiratory arrest. Therefore immediate action such as positive pressure ventilation is needed. Patients who are experiencing respiratory distress frequently sit in the tripod position because it decreases the work of breathing. Crackles in the lung bases may be the baseline for a patient with COPD. An oxygen saturation of 91% is common in patients with COPD and will provide adequate gas exchange and tissue oxygenation. DIF: Cognitive Level: Application REF: 1751-1752 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

7. A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment should the nurse complete next? a. Pulmonary auscultation b. Pulse strength and amplitude c.. Level of consciousness d. Mobility and gait stability

C A heart rate of 40 beats/min or less with widened QRS complexes could have hemodynamic consequences. The client is at risk for inadequate cerebral perfusion. The nurse should assess for level of consciousness, light-headedness, confusion, syncope, and seizure activity. Although the other assessments should be completed, the client's level of consciousness is the priority. DIF: Applying/Application REF: 670 KEY: Cardiac electrical conduction| vascular perfusion

3. A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the client's oxygen saturation has not significantly improved. What response by the nurse is best? a. "Breathing so rapidly interferes with oxygenation." b. "Maybe the client has respiratory distress syndrome." c. "The blood clot interferes with perfusion in the lungs." d. "The client needs immediate intubation and mechanical ventilation."

C A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless the clot is dissolved, this process will continue unabated. Hyperventilation can interfere with oxygenation by shallow breathing, but there is no evidence that the client is hyperventilating, and this is also not the most precise physiologic answer. Respiratory distress syndrome can occur, but this is not as likely. The client may need to be mechanically ventilated, but without concrete data on FiO2 and SaO2, the nurse cannot make that judgment. DIF: Applying/Application REF: 603 KEY: Pulmonary embolism| thromboembolic event| respiratory system| oxygen saturation

14. A patient with burns covering 40% total body surface area (TBSA) is in the acute phase of burn treatment. Which snack would be best for the nurse to offer to this patient? a. Bananas c. Vanilla milkshake b. Orange gelatin d. Whole grain bagel

C A patient with a burn injury needs high-protein and high-calorie food intake, and the milkshake is the highest in these nutrients. The other choices are not as nutrient dense as the milkshake. Gelatin is likely high in sugar. The bagel is a good carbohydrate choice but low in protein. Bananas are a good source of potassium but are not high in protein and calories. DIF: Cognitive Level: Analyze (analysis) REF: 446 TOP: Nursing Process: Planning

24. The provider requests the nurse start an infusion of an inotropic agent on a client. How does the nurse explain the action of these drugs to the client and spouse? a. "It constricts vessels, improving blood flow." b. "It dilates vessels, which lessens the work of the heart." c. "It increases the force of the heart's contractions." d. "It slows the heart rate down for better filling."

C A positive inotrope is a medication that increases the strength of the heart's contractions. The other options are not correct. DIF: Remembering/Knowledge REF: 772 KEY: Coronary artery disease| inotropic agents| patient education

2. Aspirin is ordered for a patient who is admitted with a possible stroke. Which information obtained during the admission assessment indicates that the nurse should consult with the health care provider before giving the aspirin? a. The patient has dysphasia. b. The patient has atrial fibrillation. c. The patient states, "My symptoms started with a terrible headache." d. The patient has a history of brief episodes of right-sided hemiplegia.

C A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin use, so the nurse can administer the aspirin. DIF: Cognitive Level: Application REF: 1466 TOP: Nursing Process: Assessment

2. A patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin? a. The patient has dysphasia. b. The patient has atrial fibrillation. c. The patient reports that symptoms began with a severe headache. d. The patient has a history of brief episodes of right-sided hemiplegia.

C A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack are not contraindications to aspirin use. DIF: Cognitive Level: Apply (application) REF: 1348 TOP: Nursing Process: Assessment

1. To evaluate the effectiveness of prescribed therapies for a patient with ventilatory failure, which diagnostic test will be most useful to the nurse? a. Chest x-rays b. Pulse oximetry c. Arterial blood gas (ABG) analysis d. Pulmonary artery pressure monitoring

C ABG analysis is most useful in this setting because ventilatory failure causes problems with CO2 retention, and ABGs provide information about the PaCO2 and pH. The other tests also may be done to help in assessing oxygenation or determining the cause of the patient's ventilatory failure. DIF: Cognitive Level: Application REF: 1752-1754 TOP: Nursing Process: Assessment

21. The nurse is taking a health history from a 24-year-old patient with hypertrophic cardiomyopathy (HC). Which information obtained by the nurse is most relevant? a. The patient reports using cocaine once at age 16. b. The patient has a history of a recent upper respiratory infection. c. The patient's 29-year-old brother has had a sudden cardiac arrest. d. The patient has a family history of coronary artery disease (CAD).

C About half of all cases of HC have a genetic basis, and it is the most common cause of sudden cardiac death in otherwise healthy young people; the information about the patient's brother will be helpful in planning care (such as an automatic implantable cardioverter-defibrillator [AICD]) for the patient and in counseling other family members. The patient should be counseled against use of stimulant drugs, but the one-time use indicates that the patient is not at current risk for cocaine use. Viral infections and CAD are risk factors for dilated cardiomyopathy, but not for HC. DIF: Cognitive Level: Application REF: 861-862 TOP: Nursing Process: Assessment

19. A nurse uses the rule of nines to assess a client with burn injuries to the entire back region and left arm. How should the nurse document the percentage of the client's body that sustained burns? a. 9% b. 18% c. 27% d. 36%

C According to the rule of nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the client received burns to the back (18%) and one arm (9%), totaling 27% of the body. DIF: Applying/Application REF: 476 KEY: Skin lesions/wounds

25. Which of these nursing actions included in the care of a patient who has been experiencing stroke symptoms for 60 minutes can the nurse delegate to an LPN/LVN? a. Assess the patient's gag and cough reflexes. b. Determine when the stroke symptoms began. c. Administer the prescribed clopidogrel (Plavix). d. Infuse the prescribed IV metoprolol (Lopressor).

C Administration of oral medications is included in LPN education and scope of practice. The other actions require more education and scope of practice and should be done by the RN. DIF: Cognitive Level: Application REF: 1473 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

10. A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action by the nurse takes priority? a. Administer an aspirin. b.. Call for an electrocardiogram (ECG). c. Maintain airway patency. d. Notify the provider.

C Airway always is the priority. The other actions are important in this situation as well, but the nurse should stay with the client and ensure the airway remains patent (especially if vomiting occurs) while another person calls the provider (or Rapid Response Team) and facilitates getting an ECG done. Aspirin will probably be administered, depending on the provider's prescription and the client's current medications. DIF: Applying/Application REF: 769 KEY: Coronary artery disease| critical rescue| medical emergencies

1. An emergency room nurse assesses a client who has been raped. With which health care team member should the nurse collaborate when planning this client's care? a. Emergency medicine physician b. Case manager c. Forensic nurse examiner d. Psychiatric crisis nurse

C All other members of the health care team listed may be used in the management of this client's care. However, the forensic nurse examiner is educated to obtain client histories and collect evidence dealing with the assault, and can offer the counseling and follow-up needed when dealing with the victim of an assault. DIF: Understanding/Comprehension REF: 106 KEY: Interdisciplinary team| emergency nursing

15. A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current. What is the priority nursing assessment? a. Oral temperature c. Extremity movement b. Peripheral pulses d. Pupil reaction to light

C All patients with electrical burns should be considered at risk for cervical spine injury, and assessment of extremity movement will provide baseline data. The other assessment data are also necessary but not as essential as determining the cervical spine status. DIF: Cognitive Level: Analyze (analysis) REF: 431 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

32. A patient admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI) is restless and anxious. The blood pressure is 86/40 and heart rate is 110. Based on this information, which nursing diagnosis is a priority for the patient? a. Acute pain related to myocardial ischemia b. Anxiety related to perceived threat of death c. Decreased cardiac output related to cardiogenic shock d. Activity intolerance related to decreased cardiac output

C All the nursing diagnoses may be appropriate for this patient, but the hypotension indicates that the priority diagnosis is decreased cardiac output, which will decrease perfusion to all vital organs (e.g., brain, kidney, heart). DIF: Cognitive Level: Application REF: 786 OBJ: Special Questions: Prioritization TOP: Nursing Process: Diagnosis

21. Family members are in the patient's room when the patient has a cardiac arrest and the staff start resuscitation measures. Which action should the nurse take next? a. Keep the family in the room and assign a staff member to explain the care given and answer questions. b. Ask the family to wait outside the patient's room with a designated staff member to provide emotional support. c. Ask the family members whether they would prefer to remain in the patient's room or wait outside the room. d. Tell the family members that patients are comforted by having family members present during resuscitation efforts.

C Although many family members and patients report benefits from family presence during resuscitation efforts, the nurse's initial action should be to determine the preference of these family members. The other actions may be appropriate, but this will depend on what is learned when assessing family preferences. DIF: Cognitive Level: Analyze (analysis) REF: 1632 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

22. A patient's family members are in the patient room when the patient has a cardiac arrest and emergency personnel start resuscitation measures. Which action is best for the nurse to take initially? a. Have the family wait outside the patient room with a designated staff member to provide emotional support. b. Keep the family in the room and assign a member of the team to explain the care given and answer questions. c. Ask the family members about whether they would prefer to remain in the patient room or wait outside the room. d. Advise the family members that patients are comforted by having family members present during resuscitation efforts.

C Although many family members and patients report benefits from family presence during resuscitation efforts, the nurse's initial action should be to determine the preference of these family members. The other actions may be appropriate, but this will depend on what is learned when assessing family preferences. DIF: Cognitive Level: Application REF: 1771-1772 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

6. Which of these statements made by a patient with coronary artery disease after the nurse has completed teaching about the therapeutic lifestyle changes (TLC) diet indicates that further teaching is needed? a. "I will switch from whole milk to 1% or nonfat milk." b. "I like fresh salmon and I will plan to eat it more often." c. "I will miss being able to eat peanut butter sandwiches." d. "I can have a cup of coffee with breakfast if I want one."

C Although only 30% of the daily calories should come from fats, most of the fat in the TLC diet should come from monosaturated fats such as are found in nuts, olive oil, and canola oil. The patient can include peanut butter sandwiches as part of the TLC diet. The other patient comments indicate a good understanding of the TLC diet. DIF: Cognitive Level: Application REF: 768 TOP: Nursing Process: Evaluation

30. A patient with a T4 spinal cord injury asks the nurse if he will be able to be sexually active. Which initial response by the nurse is best? a. Reflex erections frequently occur, but orgasm may not be possible. b. Sildenafil (Viagra) is used by many patients with spinal cord injury. c. Multiple options are available to maintain sexuality after spinal cord injury. d. Penile injection, prostheses, or vacuum suction devices are possible options.

C Although sexuality will be changed by the patient's spinal cord injury, there are options for expression of sexuality and for fertility. The other information also is correct, but the choices will depend on the degrees of injury and the patient's individual feelings about sexuality. DIF: Cognitive Level: Analyze (analysis) REF: 1435 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

27. A 26-year-old patient with a T3 spinal cord injury asks the nurse about whether he will be able to be sexually active. Which initial response by the nurse is best? a. Reflex erections frequently occur, but orgasm may not be possible. b. Sildenafil (Viagra) is used by many patients with spinal cord injury. c. Multiple options are available to maintain sexuality after spinal cord injury. d. Penile injection, prostheses, or vacuum suction devices are possible options.

C Although sexuality will be changed by the patient's spinal cord injury, there are options for expression of sexuality and for fertility. The other information also is correct, but the choices will depend on the degrees of injury and the patient's individual feelings about sexuality. DIF: Cognitive Level: Application REF: 1563-1564 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

22. Which patient is most appropriate for the burn unit charge nurse to assign to a registered nurse (RN) who has floated from the hospital medical unit? a. A patient who has twice-daily burn debridements to partial-thickness facial burns b. A patient who has just returned from having a cultured epithelial autograft to the chest c. A patient who has a weight loss of 15% from admission and will have enteral feedings started d. A patient who has blebs under an autograft on the thigh and has an order for bleb aspiration

C An RN from a medical unit would be familiar with malnutrition and with administration and evaluation of response to enteral feedings. The other patients require burn assessment and care that is more appropriate for staff who regularly care for burned patients. DIF: Cognitive Level: Analyze (analysis) REF: 442 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

34. A patient admitted with bacterial meningitis and a temperature of 102° F (38.8° C) has orders for all of these collaborative interventions. Which action should the nurse take first? a. Administer ceftizoxime (Cefizox) 1 g IV. b. Use a cooling blanket to lower temperature. c. Swap the nasopharyngeal mucosa for cultures. d. Give acetaminophen (Tylenol) 650 mg PO.

C Antibiotic therapy should be instituted rapidly in bacterial meningitis, but cultures must be done before antibiotics are started. As soon as the cultures are done, the antibiotic should be started. Hypothermia therapy and acetaminophen administration are appropriate but can be started after the other actions are implemented. DIF: Cognitive Level: Application REF: 1440-1441 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

1. Which diagnostic test will provide the nurse with the most specific information to evaluate the effectiveness of interventions for a patient with ventilatory failure? a. Chest x-ray b. O2 saturation c. Arterial blood gas analysis d. Central venous pressure monitoring

C Arterial blood gas (ABG) analysis is most useful in this setting because ventilatory failure causes problems with CO2 retention, and ABGs provide information about the PaCO2 and pH. The other tests may also be done to help in assessing oxygenation or determining the cause of the patient's ventilatory failure. DIF: Cognitive Level: Apply (application) REF: 1614 TOP: Nursing Process: Assessment

17. A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering the medications, the patient says, "I don't need the aspirin today. I don't have any aches or pains." Which action should the nurse take? a. Document that the aspirin was refused by the patient. b. Tell the patient that the aspirin is used to prevent aches. c. Explain that the aspirin is ordered to decrease stroke risk. d. Call the health care provider to clarify the medication order.

C Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the patient's refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider. The aspirin is not ordered to prevent aches and pains. DIF: Cognitive Level: Application REF: 1468-1469 TOP: Nursing Process: Implementation

17. A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, "I don't need the aspirin today. I don't have a fever." Which action should the nurse take? a. Document that the aspirin was refused by the patient. b. Tell the patient that the aspirin is used to prevent a fever. c. Explain that the aspirin is ordered to decrease stroke risk. d. Call the health care provider to clarify the medication order.

C Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the patient's refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider. The aspirin is not ordered to prevent aches and pains. DIF: Cognitive Level: Apply (application) REF: 1353 TOP: Nursing Process: Implementation

13. The nurse caring for a patient admitted with burns over 30% of the body surface will recognize that the patient has moved from the emergent to the acute phase of the burn injury when a. white blood cell levels decrease. b. blisters and edema have subsided. c. the patient has large quantities of pale urine. d. the patient has been hospitalized for 48 hours.

C At the end of the emergent phase, capillary permeability normalizes and the patient begins to diurese large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may be longer in some patients. Blisters and edema begin to resolve, but this process requires more time. White blood cells may increase or decrease, based on the patient's immune status and any infectious processes. DIF: Cognitive Level: Comprehension REF: 479-480 TOP: Nursing Process: Application

7. A patient admitted with possible stroke has been aphasic for 3 hours, and his current blood pressure (BP) is 174/94 mm Hg. Which order by the health care provider should the nurse question? a. Keep head of bed elevated at least 30 degrees. b. Infuse normal saline intravenously at 75 mL/hr. c. Start a labetalol drip to keep BP less than 140/90 mm Hg. d. Administer tissue plasminogen activator (tPA) intravenously per protocol.

C Because elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if mean arterial pressure (MAP) is greater than130 mm Hg or systolic pressure is greater than 220 mm Hg. Fluid intake should be 1500 to 2000 mL/day to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient meets the other criteria for tPA use. DIF: Cognitive Level: Apply (application) REF: 1354 TOP: Nursing Process: Implementation

22. A patient who has deep human bite wounds on the left hand is being treated in the urgent care center. Which action will the nurse plan to take? a. Prepare to administer rabies immune globulin (BayRab). b. Assist the health care provider with suturing of the bite wounds. c. Teach the patient the reason for the use of prophylactic antibiotics. d. Keep the wounds dry until the health care provider can assess them.

C Because human bites of the hand frequently become infected, prophylactic antibiotics are usually prescribed to prevent infection. To minimize infection, deep bite wounds on the extremities are left open. Rabies immune globulin might be used after an animal bite. Initial treatment of bite wounds includes copious irrigation to help clean out contaminants and microorganisms. DIF: Cognitive Level: Apply (application) REF: 1642 TOP: Nursing Process: Planning

8. A 22-yr-old patient who experienced a drowning accident in a local pool, but now is awake and breathing spontaneously, is admitted for observation. Which assessment will be most important for the nurse to take during the observation period? a. Auscultate heart sounds. c. Auscultate breath sounds. b. Palpate peripheral pulses. d. Check mental orientation.

C Because pulmonary edema is a common complication after drowning, the nurse should assess the breath sounds frequently. The other information also will be obtained by the nurse, but it is not as pertinent to the patient's admission diagnosis. DIF: Cognitive Level: Analyze (analysis) REF: 1640 TOP: Nursing Process: Implementation

22. A patient who had a C7 spinal cord injury 1 week ago has a weak cough effort and crackles. The initial intervention by the nurse should be to a. suction the patient's nasopharynx. b. notify the patient's health care provider. c. push upward on the epigastric area as the patient coughs. d. encourage incentive spirometry every 2 hours during the day.

C Because the cough effort is poor, the initial action should be to use assisted coughing techniques to improve the patient's ability to mobilize secretions. The use of the spirometer may improve respiratory status, but the patient's ability to take deep breaths is limited by the loss of intercostal muscle function. Suctioning may be needed if the patient is unable to expel secretions by coughing but should not be the nurse's first action. The health care provider should be notified if airway clearance interventions are not effective or additional collaborative interventions are needed. DIF: Cognitive Level: Analyze (analysis) REF: 1429 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

12. The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired self-feeding ability for a patient with right-sided hemiplegia. Which intervention should be included in the plan of care? a. Provide a wide variety of food choices. b. Provide oral care before and after meals. c. Assist the patient to eat with the left hand. d. Teach the patient the "chin-tuck" technique.

C Because the nursing diagnosis indicates that the patient's imbalanced nutrition is related to the right-sided hemiplegia, the appropriate interventions will focus on teaching the patient to use the left hand for self-feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition. DIF: Cognitive Level: Application REF: 1482-1483 TOP: Nursing Process: Planning

20. The nurse notes thick, white respiratory secretions for a patient who is receiving mechanical ventilation. Which intervention will be most effective in resolving this problem? a. Suction the patient every hour. b. Reposition the patient every 2 hours. c. Add additional water to the patient's enteral feedings. d. Instill 5 mL of sterile saline into the endotracheal tube (ET) before suctioning.

C Because the patient's secretions are thick, better hydration is indicated. Suctioning every hour without any specific evidence for the need will increase the incidence of mucosal trauma and would not address the etiology of the ineffective airway clearance. Instillation of saline does not liquefy secretions and may decrease the SpO2. Repositioning the patient is appropriate but will not decrease the thickness of secretions. DIF: Cognitive Level: Application REF: 1703-1704 TOP: Nursing Process: Implementation

20. The nurse notes thick, white secretions in the endotracheal tube (ET) of a patient who is receiving mechanical ventilation. Which intervention will most directly treat this finding? a. Reposition the patient every 1 to 2 hours. b. Increase suctioning frequency to every hour. c. Add additional water to the patient's enteral feedings. d. Instill 5 mL of sterile saline into the ET before suctioning.

C Because the patient's secretions are thick, better hydration is indicated. Suctioning every hour without any specific evidence for the need will increase the incidence of mucosal trauma and would not address the etiology of the ineffective airway clearance. Instillation of saline does not liquefy secretions and may decrease the SpO2. Repositioning the patient is appropriate but will not decrease the thickness of secretions. DIF: Cognitive Level: Apply (application) REF: 1572 TOP: Nursing Process: Implementation

23. A patient who is on the telemetry unit develops atrial flutter, rate 150, with associated dyspnea and chest pain. Which action that is included in the hospital dysrhythmia protocol should the nurse do first? a. Obtain a 12-lead electrocardiogram (ECG). b. Notify the health care provider of the change in rhythm. c. Give supplemental O2 at 2 to 3 L/min via nasal cannula. d. Assess the patient's vital signs including O2 saturation.

C Because this patient has dyspnea and chest pain in association with the new rhythm, the nurse's initial actions should be to address the patient's airway, breathing, and circulation (ABC) by starting with O2 administration. The other actions are also important and should be implemented rapidly. DIF: Cognitive Level: Analyze (analysis) REF: 765 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

11. An emergency department (ED) case manager is consulted for a client who is homeless. Which intervention should the case manager provide? a.. Communicate client needs and restrictions to support staff. b. Prescribe low-cost antibiotics to treat community-acquired infection. c.. Provide referrals to subsidized community-based health clinics. d.. Offer counseling for substance abuse and mental health disorders.

C Case management interventions include facilitating referrals to primary care providers who are accepting new clients or to subsidized community-based health clinics for clients or families in need of routine services. The ED nurse is accountable for communicating pertinent staff considerations, client needs, and restrictions to support staff (e.g., physical limitations, isolation precautions) to ensure that ongoing client and staff safety issues are addressed. The ED physician prescribes medications and treatments. The psychiatric nurse team evaluates clients with emotional behaviors or mental illness and facilitates the follow-up treatment plan, including possible admission to an appropriate psychiatric facility. DIF: Understanding/Comprehension REF: 114 KEY: Interdisciplinary team| emergency nursing

26. Which nursing action is a priority for a patient who has suffered a burn injury while working on an electrical power line? a. Inspect the contact burns. c. Stabilize the cervical spine. b. Check the blood pressure. d. Assess alertness and orientation.

C Cervical spine injuries are commonly associated with electrical burns. Therefore stabilization of the cervical spine takes precedence after airway management. The other actions are also included in the emergent care after electrical burns, but the most important action is to avoid spinal cord injury. DIF: Cognitive Level: Analyze (analysis) REF: 431 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

6. A nurse administers prescribed adenosine (Adenocard) to a client. Which response should the nurse assess for as the expected therapeutic response? a. Decreased intraocular pressure b. Increased heart rate c. Short period of asystole d. Hypertensive crisis

C Clients usually respond to adenosine with a short period of asystole, bradycardia, hypotension, dyspnea, and chest pain. Adenosine has no conclusive impact on intraocular pressure. DIF: Applying/Application REF: 662 KEY: Cardiac electrical conduction| medication

11. A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions should the nurse implement to address this client's concerns? a. Administer oxygen therapy at 2 liters per nasal cannula. b. Provide the client with a sleeping pill to stimulate rest. c. Schedule periods of exercise and rest during the day. d. Ask unlicensed assistive personnel to help bathe the client.

C Clients who have atrial fibrillation are at risk for decreased cardiac output and fatigue when completing activities of daily living. The nurse should schedule periods of exercise and rest during the day to decrease fatigue. The other interventions will not assist the client with self-care activities. DIF: Applying/Application REF: 658 KEY: Cardiac electrical conduction

34. Which information about a patient who has been receiving thrombolytic therapy for an acute myocardial infarction is most important for the nurse to communicate to the health care provider? a. An increase in troponin levels from baseline b. A large bruise at the patient's IV insertion site c. No change in the patient's reported level of chest pain d. A decrease in ST-segment elevation on the electrocardiogram

C Continued chest pain suggests that the thrombolytic therapy is not effective and that other interventions such as percutaneous coronary intervention may be needed. Bruising is a possible side effect of thrombolytic therapy, but it is not an indication that therapy should be discontinued. The decrease of the ST-segment elevation indicates that thrombolysis is occurring and perfusion is returning to the injured myocardium. An increase in troponin levels is expected with reperfusion and is related to the washout of cardiac biomarkers into the circulation as the blocked vessel is opened. DIF: Cognitive Level: Analyze (analysis) REF: 723 OBJ: Special Questions: Prioritization TOP: Nursing Process: Evaluation

12. A provider prescribes Crotalidae Polyvalent Immune Fab (CroFab) for a client who is admitted after being bitten by a pit viper snake. Which assessment should the nurse complete prior to administering this medication? a. Assess temperature and for signs of fever. b. Check the client's creatinine kinase level. c. Ask about allergies to pineapple or papaya. d. Inspect the skin for signs of urticaria (hives).

C CroFab is an antivenom for pit viper snakebites. Clients should be assessed for hypersensitivity to bromelain (a pineapple derivative), papaya, and sheep protein prior to administration. During and after administration, the nurse should assess for urticaria, fever, and joint pain, which are signs of serum sickness. DIF: Understanding/Comprehension REF: 125 KEY: Antivenom| snakebite| environmental emergencies

11. When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care? a. Apply an eye patch to the right eye. b. Approach the patient from the right side. c. Place needed objects on the patient's left side. d. Teach the patient that the left visual deficit will resolve.

C During the acute period, the nurse should place objects on the patient's unaffected side. Because there is a visual defect in the right half of each eye, an eye patch is not appropriate. The patient should be approached from the left side. The visual deficit may not resolve, although the patient can learn to compensate for the defect. DIF: Cognitive Level: Apply (application) REF: 1362 TOP: Nursing Process: Planning

11. When caring for a patient with left-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care during the acute period of the stroke? a. Apply an eye patch to the left eye. b. Approach the patient from the left side. c. Place objects needed for activities of daily living on the patient's right side. d. Reassure the patient that the visual deficit will resolve as the stroke progresses.

C During the acute period, the nurse should place objects on the patient's unaffected side. Since there is a visual defect in the left half of each eye, an eye patch is not appropriate. The patient should be approached from the right side. The visual deficit may not resolve, although the patient can learn to compensate for the defect. DIF: Cognitive Level: Application REF: 1470-1471 TOP: Nursing Process: Planning

7. A patient with hypotension and temperature elevation after doing yard work on a hot day is treated in the ED. After the nurse has completed discharge teaching, which statement by the patient indicates that the teaching has been effective? a. "I will take salt tablets when I work outdoors in the summer." b. "I should take acetaminophen (Tylenol) if I start to feel too warm." c. "I should have sports drinks when exercising outside in hot weather." d. "I will get into a cool environment if I notice that I am feeling confused."

C Electrolyte solutions such as sports drinks help replace fluid and electrolytes lost when exercising in hot weather. Salt tablets are not recommended because of the risks of gastric irritation and hypernatremia. Antipyretic medications are not effective in lowering body temperature elevations caused by excessive exposure to heat. A patient who is confused is likely to have more severe hyperthermia and will be unable to remember to take appropriate action. DIF: Cognitive Level: Application REF: 1775-1776 TOP: Nursing Process: Evaluation

12. The mixed venous oxygen saturation (SvO2) is decreasing in a patient who has severe pancreatitis. To determine the possible cause of the decreased SvO2, the nurse assesses the patient's a. weight. b. amylase. c. temperature. d. urinary output.

C Elevated temperature increases metabolic demands and oxygen use by tissues, resulting in a drop in oxygen saturation of mixed venous blood. Information about the patient's weight, urinary output, and amylase will not help in determining the cause of the patient's drop in SvO2. DIF: Cognitive Level: Application REF: 1695-1696 TOP: Nursing Process: Assessment

13. To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care for a patient who requires intubation and mechanical ventilation? a. Avoid use of positive end-expiratory pressure (PEEP). b. Suction every 2 hours. c. Elevate head of bed to 30 to 45 degrees. d. Give enteral feedings at no more than 10 mL/hr.

C Elevation of the head decreases the risk for aspiration. PEEP is frequently needed to improve oxygenation in patients receiving mechanical ventilation. Suctioning should be done only when the patient assessment indicates that it is necessary. Enteral feedings should provide adequate calories for the patient's high energy needs. DIF: Cognitive Level: Application REF: 1760-1761 TOP: Nursing Process: Planning

29. A patient with increased intracranial pressure after a head injury has a ventriculostomy in place. Which action can the nurse delegate to unlicensed assistive personnel (UAP) who regularly work in the intensive care unit? a. Document intracranial pressure every hour. b. Turn and reposition the patient every 2 hours. c. Check capillary blood glucose level every 6 hours. d. Monitor cerebrospinal fluid color and volume hourly.

C Experienced UAP can obtain capillary blood glucose levels when they have been trained and evaluated in the skill. Monitoring and documentation of cerebrospinal fluid (CSF) color and intracranial pressure (ICP) require registered nurse (RN)-level education and scope of practice. Although repositioning patients is frequently delegated to UAP, repositioning a patient with a ventriculostomy is complex and should be supervised by the RN. DIF: Cognitive Level: Apply (application) REF: 1319 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

2. A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active and has no known risk factors for PE. What action by the nurse is most appropriate? a. Encourage the client to walk 5 minutes each hour. b. Refer the client to smoking cessation classes. c. Teach the client about factor V Leiden testing. d.. Tell the client that sometimes no cause for disease is found.

C Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events, including PE. A client with no known risk factors for this disorder should be referred for testing. Encouraging the client to walk is healthy, but is not related to the development of a PE in this case, nor is smoking. Although there are cases of disease where no cause is ever found, this assumption is premature. DIF: Applying/Application REF: 605 KEY: Pulmonary embolism| thrombotic events| patient education| genetic testing

13. A client has an intra-arterial blood pressure monitoring line. The nurse notes bright red blood on the client's sheets. What action should the nurse perform first? a.. Assess the insertion site. b. Change the client's sheets. c.. Put on a pair of gloves. d. Assess blood pressure.

C For the nurse's safety, he or she should put on a pair of gloves to prevent blood exposure. The other actions are appropriate as well, but first the nurse must don a pair of gloves. DIF: Applying/Application REF: 771 KEY: Standard Precautions| infection control| intra-arterial blood pressure monitoring| staff safety

10. Esomeprazole (Nexium) is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the drug? a. Bowel sounds c. Stool occult blood b. Stool frequency d. Abdominal distention

C H2 blockers and proton pump inhibitors are given to prevent Curling's ulcer in the patient who has sustained burn injuries. Proton pump inhibitors usually do not affect bowel sounds, stool frequency, or appetite. DIF: Cognitive Level: Apply (application) REF: 443 TOP: Nursing Process: Evaluation

4. A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be administered in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, the nurse will decrease the fluid infusion rate to a. 350 mL/hour. b. 523 mL/hour. c. 938 mL/hour. d. 1250 mL/hour.

C Half of the fluid replacement using the Parkland formula is administered in the first 8 hours and the other half over the next 16 hours. In this case, the patient should receive half of the initial rate, or 938 mL/hr. DIF: Cognitive Level: Application REF: 483 TOP: Nursing Process: Implementation

4. A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be administered in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids? a. 219 mL/hr c. 938 mL/hr b. 625 mL/hr d. 1875 mL/hr

C Half of the fluid replacement using the Parkland formula is administered in the first 8 hours and the other half over the next 16 hours. In this case, the patient should receive half of the initial rate, or 938 mL/hr. DIF: Cognitive Level: Apply (application) REF: 439 TOP: Nursing Process: Implementation

12. Heparin is ordered for a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI). What is the purpose of the heparin? a. Heparin enhances platelet aggregation at the plaque site. b. Heparin decreases the size of the coronary artery plaque. c. Heparin prevents the development of new clots in the coronary arteries. d. Heparin dissolves clots that are blocking blood flow in the coronary arteries.

C Heparin helps prevent the conversion of fibrinogen to fibrin and decreases coronary artery thrombosis. It does not change coronary artery plaque, dissolve already formed clots, or enhance platelet aggregation. DIF: Cognitive Level: Understand (comprehension) REF: 722 TOP: Nursing Process: Implementation

3. The nurse teaches burn prevention to a community group. Which statement by a member of the group should cause the nurse the greatest concern? a. "I get my chimney swept every other year." b. "My hot water heater is set at 120 degrees." c. "Sometimes I wake up at night and smoke." d. "I use a space heater when it gets below zero."

C House fires are a common occurrence and often lead to serious injury or death. The nurse should be most concerned about a person who wakes up at night and smokes. The nurse needs to question this person about whether he or she gets out of bed to do so, or if this person stays in bed, which could lead to falling back asleep with a lighted cigarette. Although it is recommended to have chimneys swept every year, skipping a year does not pose as much danger as smoking in bed, particularly if the person does not burn wood frequently. Water heaters should be set below 140° F. Space heaters should be used with caution, and the nurse may want to ensure that the person does not allow it to get near clothing or bedding. DIF: Applying/Application REF: 472 KEY: Safety| smoking cessation

24. The nurse is reviewing laboratory results on a patient who had a large burn 48 hours ago. Which result requires priority action by the nurse? a. Hematocrit of 53% c. Serum potassium of 6.1 mEq/L b. Serum sodium of 147 mEq/L d. Blood urea nitrogen of 37 mg/dL

C Hyperkalemia can lead to life-threatening dysrhythmias and indicates that the patient requires cardiac monitoring and immediate treatment to lower the potassium level. The other laboratory values are also abnormal and require changes in treatment, but they are not as immediately life threatening as the elevated potassium level. DIF: Cognitive Level: Analyze (analysis) REF: 443 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

20. Which stroke risk factor for a 48-yr-old male patient in the clinic is most important for the nurse to address? a. The patient is 25 lb above the ideal weight. b. The patient drinks a glass of red wine with dinner daily. c. The patient's usual blood pressure (BP) is 170/94 mm Hg. d. The patient works at a desk and relaxes by watching television.

C Hypertension is the single most important modifiable risk factor. People who drink more than 1 (for women) or 2 (for men) alcoholic beverages a day may increase their risk for hypertension. Physical inactivity and obesity contribute to stroke risk but not as much as hypertension. DIF: Cognitive Level: Analyze (analysis) REF: 1347 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

3. A patient has a junctional escape rhythm on the monitor. The nurse will expect the patient to have a heart rate of _____ beats/min. a. 15 to 20 c. 40 to 60 b. 20 to 40 d. 60 to 100

C If the sinoatrial (SA) node fails to discharge, the atrioventricular (AV) node will automatically discharge at the normal rate of 40 to 60 beats/minute. The slower rates are typical of the bundle of His and Purkinje system and may be seen with failure of both the SA and AV node to discharge. The normal SA node rate is 60 to 100 beats/min. DIF: Cognitive Level: Understand (comprehension) REF: 760 TOP: Nursing Process: Assessment

3. A patient has a junctional escape rhythm on the monitor. The nurse will expect the patient to have a heart rate of how many beats/minute? a. 15 to 20 b. 20 to 40 c. 40 to 60 d. 60 to 100

C If the sinoatrial (SA) node fails to discharge, the atrioventricular (AV) node will automatically discharge at the normal rate of 40 to 60. The slower rates are typical of the bundle of His and the Purkinje system and may be seen with failure of both the SA and AV node to discharge. The normal SA node rate is 60 to 100 beats/minute. DIF: Cognitive Level: Comprehension REF: 822 | 823 TOP: Nursing Process: Assessment

8. A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that a priority goal for this problem has been met? a. Chooses preferred items from the menu b. Eats 75% to 100% of all meals and snacks c. Has clear lung sounds on auscultation d. Gains 2 pounds after 1 week

C Impaired swallowing can lead to aspiration, so the priority goal for this problem is no aspiration.. Clear lung sounds is the best indicator that aspiration has not occurred. Choosing menu items is not related to this problem. Eating meals does not indicate the client is not still aspirating. A weight gain indicates improved nutrition but still does not show a lack of aspiration. DIF: Evaluating/Synthesis REF: 942 KEY: Neurologic disorders| stroke| aspiration

7. A nurse cares for clients during a community-wide disaster drill. Once of the clients asks, "Why are the individuals with black tags not receiving any care?" How should the nurse respond? a. "To do the greatest good for the greatest number of people, it is necessary to sacrifice some." b. "Not everyone will survive a disaster, so it is best to identify those people early and move on." c. "In a disaster, extensive resources are not used for one person at the expense of many others." d. "With black tags, volunteers can identify those who are dying and can give them comfort care."

C In a disaster, military-style triage is used; this approach identifies the dead or expectant dead with black tags. This practice helps to maintain the goal of triage, which is doing the most good for the most people. Precious resources are not used for those with overwhelming critical injury or illness, so that they can be allocated to others who have a reasonable expectation of survival. Clients are not "sacrificed." Telling students to move on after identifying the expectant dead belittles their feelings and does not provide an adequate explanation. Clients are not black-tagged to allow volunteers to give comfort care. DIF: Understanding/Comprehension REF: 141 KEY: Triage| emergency nursing

21. A 19-yr-old student comes to the student health center at the end of the semester complaining that, "My heart is skipping beats." An electrocardiogram (ECG) shows occasional unifocal premature ventricular contractions (PVCs). What action should the nurse take next? a. Insert an IV catheter for emergency use. b. Start supplemental O2 at 2 to 3 L/min via nasal cannula. c. Ask the patient about current stress level and caffeine use. d. Have the patient taken to the nearest emergency department (ED).

C In a patient with a normal heart, occasional PVCs are a benign finding. The timing of the PVCs suggests stress or caffeine as possible etiologic factors. The patient is hemodynamically stable, so there is no indication that the patient needs supplemental O2, an IV, or to be seen in the ED. DIF: Cognitive Level: Apply (application) REF: 768 TOP: Nursing Process: Implementation

9. A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first? a. Assess the level of consciousness and pupillary reactions. b. Ascertain the time food or liquid was last consumed. c. Auscultate breath sounds over the trachea and bronchi. d. Measure abdominal girth and auscultate bowel sounds.

C Inhalation injuries are present in 7% of clients admitted to burn centers. Drooling and difficulty swallowing can mean that the client is about to lose his or her airway because of this injury. Absence of breath sounds over the trachea and bronchi indicates impending airway obstruction and demands immediate intubation. Knowing the level of consciousness is important in assessing oxygenation to the brain. Ascertaining the time of last food intake is important in case intubation is necessary (the nurse will be more alert for signs of aspiration). However, assessing for air exchange is the most important intervention at this time. Measuring abdominal girth is not relevant in this situation. DIF: Applying/Application REF: 474 KEY: Medical emergency| respiratory distress/failure

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

C Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is generalized, it does not indicate localization of pain or flexion withdrawal. DIF: Cognitive Level: Comprehension REF: 1429-1430 TOP: Nursing Process: Assessment

3. When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, the nurse reports the response as a. flexion withdrawal. c. decorticate posturing. b. localization of pain. d. decerebrate posturing.

C Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is generalized, it does not indicate localization of pain or flexion withdrawal. DIF: Cognitive Level: Understand (comprehension) REF: 1318 TOP: Nursing Process: Assessment

27. The family members of a patient who has been admitted to the intensive care unit (ICU) with multiple traumatic injuries have just arrived in the ICU waiting room. Which action should the nurse take first? a. Explain ICU visitation policies and encourage family visits. b. Escort the family from the waiting room to the patient's bedside. c. Describe the patient's injuries and the care that is being provided. d. Invite the family to participate in an interprofessional care conference.

C Lack of information is a major source of anxiety for family members and should be addressed first. Family members should be prepared for the patient's appearance and the ICU environment before visiting the patient for the first time. ICU visiting should be individualized to each patient and family rather than being dictated by rigid visitation policies. Inviting the family to participate in a multidisciplinary conference is appropriate but should not be the initial action by the nurse. DIF: Cognitive Level: Analyze (analysis) REF: 1558 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

28. The family members of a patient who has just been admitted to the intensive care unit (ICU) with multiple traumatic injuries have just arrived in the ICU waiting room. Which action should the nurse take first? a. Immediately take the family members to the patient's room. b. Discuss ICU visitation policies and encourage family visits. c. Describe the patient's injuries and the care that is being provided. d. Invite the family to participate in a multidisciplinary care conference.

C Lack of information is a major source of anxiety for family members and should be addressed first. Family members should be prepared for the patient's appearance and the ICU environment before visiting the patient for the first time. ICU visiting should be individualized to each patient and family rather than being dictated by rigid visitation policies. Inviting the family to participate in a multidisciplinary conference is appropriate but should not be the initial action by the nurse. DIF: Cognitive Level: Application REF: 1686-1687 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

2. To assist the patient with coronary artery disease (CAD) in making appropriate dietary changes, which of these nursing interventions will be most effective? a. Instruct the patient that a diet containing no saturated fat and minimal sodium will be necessary. b. Emphasize the increased risk for cardiac problems unless the patient makes the dietary changes. c. Assist the patient to modify favorite high-fat recipes by using monosaturated oils when possible. d. Provide the patient with a list of low-sodium, low-cholesterol foods that should be included in the diet.

C Lifestyle changes are more likely to be successful when consideration is given to the patient's values and preferences. The highest percentage of calories from fat should come from monosaturated fats. Although low-sodium and low-cholesterol foods are appropriate, providing the patient with a list alone is not likely to be successful in making dietary changes. Removing saturated fat from the diet completely is not a realistic expectation; up to 7% of calories in the therapeutic lifestyle changes (TLC) diet can come from saturated fat. Telling the patient about the increased risk without assisting further with strategies for dietary change is unlikely to be successful. DIF: Cognitive Level: Application REF: 767-768 TOP: Nursing Process: Implementation

4. A nurse cares for a client who has facial burns. The client asks, "Will I ever look the same?" How should the nurse respond? a.. "With reconstructive surgery, you can look the same." b. "We can remove the scars with the use of a pressure dressing." c. "You will not look exactly the same but cosmetic surgery will help." d. "You shouldn't start worrying about your appearance right now."

C Many clients have unrealistic expectations of reconstructive surgery and envision an appearance identical or equal in quality to the preburn state. The nurse should provide accurate information that includes something to hope for. Pressure dressings prevent further scarring; they cannot remove scars. The client and the family should be taught the expected cosmetic outcomes. DIF: Applying/Application REF: 488 KEY: Psychosocial response| patient education

18. While caring for a patient who has just been admitted with meningococcal meningitis, the RN observes all of the following. Which one requires action by the RN? a. The bedrails at the head and foot of the bed are both elevated. b. The patient receives a regular diet from the dietary department. c. The nursing assistant goes into the patient's room without a mask. d. The lights in the patient's room are turned off and the blinds are shut.

C Meningococcal meningitis is spread by respiratory secretions, so it is important to maintain respiratory isolation as well as standard precautions. Because the patient may be confused and weak, bedrails should be elevated at both the food and head of the bed. Low light levels in the room decrease pain caused by photophobia. Nutrition is an important aspect of care in a patient with meningitis. DIF: Cognitive Level: Application REF: 1453-1455 TOP: Nursing Process: Assessment

14. When caring for a patient who has an intraaortic balloon pump in place, which action will be included in the plan of care? a. Avoid the use of anticoagulant medications. b. Keep the head of the bed elevated 45 degrees. c. Measure the patient's urinary output every hour. d. Provide passive range of motion for all extremities.

C Monitoring urine output will help determine whether the patient's cardiac output has improved and also help monitor for balloon displacement. The head of the bed should be no higher than 30 degrees. Heparin is used to prevent thrombus formation. Limited movement is allowed for the extremity with the balloon insertion site to prevent displacement of the balloon. DIF: Cognitive Level: Application REF: 1697-1699 TOP: Nursing Process: Planning

15. The emergency department (ED) triage nurse is assessing four victims of an automobile accident. Which patient has the highest priority for treatment? a. A patient with absent pedal pulses b. A patient with an open femur fracture c. A patient with a sucking chest wound d. A patient with bleeding of facial lacerations

C Most immediate deaths from trauma occur because of problems with ventilation, so the patient with a sucking chest wound should be treated first. Face and head fractures can obstruct the airway, but the patient with facial injuries has lacerations only. The other two patients also need rapid intervention but do not have airway or breathing problems. DIF: Cognitive Level: Application REF: 1768 | 1769-1771 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Assessment

10. A student nurse is caring for a client who will be receiving sodium nitroprusside (Nipride) via IV infusion. What action by the student causes the registered nurse to intervene? a. Assessing the IV site before giving the drug b. Obtaining a programmable ("smart") IV pump c. Removing the IV bag from the brown plastic cover d. Taking and recording a baseline set of vital signs

C Nitroprusside degrades in the presence of light, so it must be protected by leaving it in the original brown plastic bag when infusing. The other actions are correct, although a "smart" pump is not necessarily required if the facility does not have them available. The drug must be administered via an IV pump, although the programmable pump is preferred for safety. DIF: Applying/Application REF: 748 KEY: Vasoconstrictors| shock| supervision| communication

4. An older patient with cardiogenic shock is cool and clammy. Hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention should the nurse anticipate? a. Increase the rate for the dopamine infusion. b. Decrease the rate for the nitroglycerin infusion. c. Increase the rate for the sodium nitroprusside infusion. d. Decrease the rate for the 5% dextrose in normal saline (D5/.9 NS) infusion.

C Nitroprusside is an arterial vasodilator and will decrease the SVR and afterload, which will improve cardiac output. Changes in the D5/.9 NS and nitroglycerin infusions will not directly decrease SVR. Increasing the dopamine will tend to increase SVR. DIF: Cognitive Level: Apply (application) REF: 1599 TOP: Nursing Process: Planning

23. After assessing an older adult client with a burn wound, the nurse documents the findings as follows: Vital Signs Laboratory Results Wound Assessment Heart rate: 110 beats/min Blood pressure: 112/68 mm Hg Respiratory rate: 20 breaths/min Oxygen saturation: 94% Pain: 3/10 Red blood cell count: 5,000,000/mm3 White blood cell count: 10,000/mm3 Platelet count: 200,000/mm3 Left chest burn wound, 3 cm × 2.5 cm × 0.5 cm, wound bed pale, surrounding tissues with edema present Based on the documented data, which action should the nurse take next? a. Assess the client's skin for signs of adequate perfusion. b. Calculate intake and output ratio for the last 24 hours. c. Prepare to obtain blood and wound cultures. d. Place the client in an isolation room.

C Older clients have a decreased immune response, so they may not exhibit signs that their immune system is actively fighting an infection, such as fever or an increased white blood cell count. They also are at higher risk for sepsis arising from a localized wound infection. The burn wound shows signs of local infection, so the nurse should assess for this and for systemic infection before the client manifests sepsis. Placing the client in an isolation room, calculating intake and output, and assessing the client's skin should all be implemented but these actions do not take priority over determining whether the client has an infection. DIF: Analyzing/Analysis REF: 474 KEY: Infection control| Standard Precautions

7. A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED). The nurse determines that discharge teaching has been effective when the patient makes which statement? a. "I'll take salt tablets when I work outdoors in the summer." b. "I should take acetaminophen (Tylenol) if I start to feel too warm." c. "I need to drink extra fluids when working outside in hot weather." d. "I'll move to a cool environment if I notice that I'm feeling confused"

C Oral fluids and electrolyte replacement solutions such as sports drinks help replace fluid and electrolytes lost when exercising in hot weather. Salt tablets are not recommended because of the risks of gastric irritation and hypernatremia. Antipyretic drugs are not effective in lowering body temperature elevations caused by excessive exposure to heat. A patient who is confused is likely to have more severe hyperthermia and will be unable to remember to take appropriate action. DIF: Cognitive Level: Apply (application) REF: 1637 TOP: Nursing Process: Evaluation

5. When caring for a patient with pulmonary hypertension, which parameter will the nurse monitor to evaluate whether treatment has been effective? a. Mean arterial pressure (MAP) b. Central venous pressure (CVP) c. Pulmonary vascular resistance (PVR) d. Pulmonary artery wedge pressure (PAWP)

C PVR is a major contributor to pulmonary hypertension, and a decrease would indicate that pulmonary hypertension was improving. The other parameters also may be monitored, but do not directly assess for pulmonary hypertension. DIF: Cognitive Level: Application REF: 1687-1689 TOP: Nursing Process: Evaluation

5. When caring for a patient with pulmonary hypertension, which parameter will the nurse use to directly evaluate the effectiveness of the treatment? a. Central venous pressure (CVP) b. Systemic vascular resistance (SVR) c. Pulmonary vascular resistance (PVR) d. Pulmonary artery wedge pressure (PAWP)

C PVR is a major contributor to pulmonary hypertension, and a decrease would indicate that pulmonary hypertension was improving. The other parameters may also be monitored but do not directly assess for pulmonary hypertension. DIF: Cognitive Level: Apply (application) REF: 1560 TOP: Nursing Process: Evaluation

11. A nurse is caring for a client with paraplegia who is scheduled to participate in a rehabilitation program. The client states, "I do not understand the need for rehabilitation; the paralysis will not go away and it will not get better." How should the nurse respond? a. "If you don't want to participate in the rehabilitation program, I'll let the provider know." b. "Rehabilitation programs have helped many clients with your injury. You should give it a chance." c. "The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability." d. "When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first."

C Participation in rehabilitation programs has many purposes, including prevention of disability, maintenance of functional ability, and restoration of function. The other responses do not meet this client's needs. DIF: Applying/Application REF: 900 KEY: Spinal cord/back injury

16. When the nurse educator is evaluating the skills of a new registered nurse (RN) caring for patients experiencing shock, which action by the new RN indicates a need for more education? a. Placing the pulse oximeter on the ear for a patient with septic shock b. Keeping the head of the bed flat for a patient with hypovolemic shock c. Maintaining a cool room temperature for a patient with neurogenic shock d. Increasing the nitroprusside infusion rate for a patient with a very high SVR

C Patients with neurogenic shock have poikilothermia. The room temperature should be kept warm to avoid hypothermia. The other actions by the new RN are appropriate. DIF: Cognitive Level: Apply (application) REF: 1590 OBJ: Special Questions: Delegation TOP: Nursing Process: Evaluation

22. A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred? a. Blood pressure that is 20 mm Hg below baseline b. Oxygen saturation of 94% on room air c. Poor peripheral pulses and cool skin d. Urine output of 1.2 mL/kg/hr for 4 hours

C Poor peripheral pulses and cool skin may be signs of impending cardiogenic shock and should be reported immediately. A blood pressure drop of 20 mm Hg is not worrisome. An oxygen saturation of 94% is just slightly below normal. A urine output of 1.2 mL/kg/hr for 4 hours is normal. DIF: Remembering/Knowledge REF: 772 KEY: Coronary artery disease| critical rescue| nursing assessment

9. Diltiazem (Cardizem) is ordered for a patient with newly diagnosed Prinzmetal's (variant) angina. When teaching the patient, the nurse will include the information that diltiazem will a. reduce heart palpitations. b. prevent coronary artery plaque. c. decrease coronary artery spasms. d. increase contractile force of the heart.

C Prinzmetal's angina is caused by coronary artery spasm. Calcium channel blockers (e.g., diltiazem, amlodipine [Norvasc]) are a first-line therapy for this type of angina. Lipid-lowering drugs help reduce atherosclerosis (i.e., plaque formation), and β-adrenergic blockers decrease sympathetic stimulation of the heart (i.e., palpitations). Medications or activities that increase myocardial contractility will increase the incidence of angina by increasing O2 demand. DIF: Cognitive Level: Apply (application) REF: 713 TOP: Nursing Process: Implementation

6. To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform? a. Auscultate bowel sounds. c. Check stools for occult blood. b. Ask the patient about nausea. d. Palpate for abdominal tenderness.

C Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill patients. The other assessments will also be done, but these will not help in determining the effectiveness of the pantoprazole administration. DIF: Cognitive Level: Apply (application) REF: 1606 TOP: Nursing Process: Evaluation

10. Which information will the nurse include when teaching a patient who is scheduled for a radiofrequency catheter ablation for treatment of atrial flutter? a. The procedure prevents or minimizes the risk for sudden cardiac death. b. The procedure uses cold therapy to stop the formation of the flutter waves. c. The procedure uses electrical energy to destroy areas of the conduction system. d. The procedure stimulates the growth of new conduction pathways between the atria.

C Radiofrequency catheter ablation therapy uses electrical energy to "burn" or ablate areas of the conduction system as definitive treatment of atrial flutter (i.e., restore normal sinus rhythm) and tachydysrhythmias. All other statements regarding the procedure are incorrect. DIF: Cognitive Level: Apply (application) REF: 765 TOP: Nursing Process: Implementation

22. A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first? a. Complete blood count (CBC) b. Chest radiograph (chest x-ray) c. Computed tomography (CT) scan d. 12-Lead electrocardiogram (ECG)

C Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the less brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan. DIF: Cognitive Level: Analyze (analysis) REF: 1354 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

29. When caring for a patient who has an arterial catheter in the radial artery to monitor blood pressure, which information obtained by the nurse is most important to report to the health care provider? a. The patient has a positive Allen test. b. The mean arterial pressure (MAP) is 86 mm Hg. c. There is redness at the catheter insertion site. d. The dicrotic notch is visible in the waveform.

C Redness at the catheter insertion site indicates possible infection. The Allen test is performed before arterial line insertion, and a positive test indicates normal ulnar artery perfusion. A MAP of 86 is normal and the dicrotic notch is normally present on the arterial waveform. DIF: Cognitive Level: Application REF: 1690-1691 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

9. A patient who experienced a near drowning accident in a local lake, but now is awake and breathing spontaneously, is admitted for observation. Which action will be most important for the nurse to take during the observation period? a. Listen to heart sounds. b. Palpate peripheral pulses. c. Auscultate breath sounds. d. Check pupil reaction to light.

C Since pulmonary edema is a common complication after near drowning, the nurse should assess the breath sounds frequently. The other information also will be collected by the nurse, but it is not as pertinent to the patient's admission diagnosis. DIF: Cognitive Level: Application REF: 1778-1880 TOP: Nursing Process: Implementation

22. When caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak cough effort and loose-sounding secretions, the initial intervention by the nurse should be to a. suction the patient's oral and pharyngeal airway. b. administer oxygen at 7 to 9 L/min with a face mask. c. place the hands on the epigastric area and push upward when the patient coughs. d. encourage the patient to use an incentive spirometer every 2 hours during the day.

C Since the cough effort is poor, the initial action should be to use assisted coughing techniques to improve the ability to mobilize secretions. Administration of oxygen will improve oxygenation, but the data do not indicate hypoxemia. The use of the spirometer may improve respiratory status, but the patient's ability to take deep breaths is limited by the loss of intercostal muscle function. Suctioning may be needed if the patient is unable to expel secretions by coughing but should not be the nurse's first action. DIF: Cognitive Level: Application REF: 1559 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

27. The charge nurse observes an inexperienced staff nurse caring for a patient who has had a craniotomy for resection of a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene? a. The staff nurse assesses neurologic status every hour. b. The staff nurse elevates the head of the bed to 30 degrees. c. The staff nurse suctions the patient routinely every 2 hours. d. The staff nurse administers an analgesic before turning the patient.

C Suctioning increases intracranial pressure and should only be done when the patient's respiratory condition indicates it is needed. The other actions by the staff nurse are appropriate. DIF: Cognitive Level: Apply (application) REF: 1325 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation

23. When the nurse is weaning a patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation, which patient assessment indicates that the weaning protocol should be discontinued? a. The patient heart rate is 98 beats/min. b. The patient's oxygen saturation is 93%. c. The patient respiratory rate is 32 breaths/min. d. The patient's spontaneous tidal volume is 500 mL.

C Tachypnea is a sign that the patient's work of breathing is too high to allow weaning to proceed. The patient's heart rate is within normal limits, although the nurse should continue to monitor it. An oxygen saturation of 93% is acceptable for a patient with COPD. A spontaneous tidal volume of 500 mL is within the acceptable range. DIF: Cognitive Level: Application REF: 1713 TOP: Nursing Process: Evaluation

23. A nurse is weaning a 68-kg patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation. Which patient assessment finding indicates that the weaning protocol should be stopped? a. The patient's heart rate is 97 beats/min. b. The patient's oxygen saturation is 93%. c. The patient respiratory rate is 32 breaths/min. d. The patient's spontaneous tidal volume is 450 mL.

C Tachypnea is a sign that the patient's work of breathing is too high to allow weaning to proceed. The patient's heart rate is within normal limits, but the nurse should continue to monitor it. An O2 saturation of 93% is acceptable for a patient with COPD. A spontaneous tidal volume of 450 mL is within the acceptable range. DIF: Cognitive Level: Apply (application) REF: 1582 TOP: Nursing Process: Evaluation

17. A nurse teaches a client being treated for a full-thickness burn. Which statement should the nurse include in this client's discharge teaching? a. "You should change the batteries in your smoke detector once a year." b. "Join a program that assists burn clients to reintegration into the community." c. "I will demonstrate how to change your wound dressing for you and your family." d. "Let me tell you about the many options available to you for reconstructive surgery."

C Teaching clients and family members to perform care tasks such as dressing changes is critical for the progressive goal toward independence for the client. All of the other options are important in the rehabilitation stage. However, dressing changes have priority. DIF: Applying/Application REF: 489 KEY: Skin lesions/wounds

14. After teaching a client how to prevent altitude-related illnesses, a nurse assesses the client's understanding. Which statement indicates the client needs additional teaching? a. "If my climbing partner can't think straight, we should descend to a lower altitude." b. "I will ask my provider about medications to help prevent acute mountain sickness." c. "My partner and I will plan to sleep at a higher elevation to acclimate more quickly." d. "I will drink plenty of fluids to stay hydrated while on the mountain."

C Teaching to prevent altitude-related illness should include descending when symptoms start, staying hydrated, and taking acetazolamide (Diamox), which is commonly used to prevent and treat acute mountain sickness. The client should be taught to sleep at a lower elevation. DIF: Applying/Application REF: 134 KEY: Altitude-related illness| environmental emergencies

23. A patient admitted with dermal ulcers who has a history of a T3 spinal cord injury tells the nurse, "I have a pounding headache and I feel sick to my stomach." Which action should the nurse take first? a. Check for a fecal impaction. c. Assess the blood pressure (BP). b. Give the prescribed antiemetic. d. Notify the health care provider.

C The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine if autonomic hyperreflexia is occurring. Notification of the patient's health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated if autonomic hyperreflexia is ruled out as the cause of the nausea. After checking the BP, the nurse may assess for a fecal impaction using lidocaine jelly to prevent further increased BP. DIF: Cognitive Level: Analyze (analysis) REF: 1431 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

24. A patient with a history of a T2 spinal cord injury tells the nurse, "I feel awful today. My head is throbbing, and I feel sick to my stomach." Which action should the nurse take first? a. Assess for a fecal impaction. b. Give the prescribed antiemetic. c. Check the blood pressure (BP). d. Notify the health care provider.

C The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine whether autonomic dysreflexia is occurring. Notification of the patient's health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated after autonomic dysreflexia is ruled out as the cause of the nausea. The nurse may assess for a fecal impaction, but this should be done after checking the BP and lidocaine jelly should be used to prevent further increases in the BP. DIF: Cognitive Level: Application REF: 1556-1557 | 1560-1561 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

4. A patient who is unconscious after a fall from a ladder is transported to the emergency department by family members. During the primary survey of the patient, the nurse should a. assess the patient's vital signs. b. attach a cardiac electrocardiogram (ECG) monitor. c. obtain a Glasgow Coma Scale score. d. ask about chronic medical conditions.

C The Glasgow Coma Scale is included when assessing for disability during the primary survey. The other information is part of the secondary survey. DIF: Cognitive Level: Application REF: 1769-1771 TOP: Nursing Process: Assessment

23. A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory abilities. To meet The Joint Commission's Core Measures set, by what time should the client have a percutaneous coronary intervention performed? a. 1530 (3:30 PM) b. 1600 (4:00 PM) c. 1630 (4:30 PM) d. 1700 (5:00 PM)

C The Joint Commission's Core Measures set for MI includes percutaneous coronary intervention within 90 minutes of diagnosis of myocardial infarction. Therefore, the client should have a percutaneous coronary intervention performed no later than 1630 (4:30 PM). DIF: Remembering/Knowledge REF: 774 KEY: Coronary artery disease| Core Measures| The Joint Commission

17. The community health nurse is developing a program to decrease the incidence of meningitis in adolescents and young adults. Which nursing action is most important? a. Vaccinate 11- and 12-year-old children against Haemophilus influenzae. b. Emphasize the importance of hand washing to prevent spread of infection. c. Immunize adolescents and college freshman against Neisseria meningitides. d. Encourage adolescents and young adults to avoid crowded areas in the winter.

C The Neisseria meningitides vaccination is recommended for children ages 11 and 12, unvaccinated teens entering high school, and college freshmen. Hand washing may help decrease the spread of bacteria, but it is not as effective as immunization. Vaccination with Haemophilus influenzae is for infants and toddlers. Because adolescents and young adults are in school or the workplace, avoiding crowds is not realistic. DIF: Cognitive Level: Application REF: 1453-1455 TOP: Nursing Process: Implementation

19. The nurse is caring for a 22-year-old patient who came to the emergency department with acute respiratory distress. Which information about the patient requires the most rapid action by the nurse? a. Respiratory rate is 32 breaths/min. b. Pattern of breathing is shallow. c. The patient's PaO2 is 45 mm Hg. d. The patient's PaCO2 is 34 mm Hg.

C The PaO2 indicates severe hypoxemia and respiratory failure. Rapid action is needed to prevent further deterioration of the patient. Although the shallow breathing, rapid respiratory rate, and low PaCO2 also need to be addressed, the most urgent problem is the patient's poor oxygenation. DIF: Cognitive Level: Application REF: 1746-1747 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

30. Which information about a 30-yr-old patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse? a. Intracranial pressure of 15 mm Hg b. Cerebrospinal fluid (CSF) drainage of 25 mL/hr c. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg d. Cardiac monitor shows sinus tachycardia at 120 beats/minute

C The PbtO2 should be 20 to 40 mm Hg. Lower levels indicate brain ischemia. An intracranial pressure (ICP) of 15 mm Hg is at the upper limit of normal. CSF is produced at a rate of 20 to 30 mL/hr. The reason for the sinus tachycardia should be investigated, but the elevated heart rate is not as concerning as the decrease in PbtO2. DIF: Cognitive Level: Analyze (analysis) REF: 1316 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

17. A 38-yr-old patient who has had a spinal cord injury returned home following a stay in a rehabilitation facility. The home care nurse notes the spouse is performing many of the activities that the patient had been managing unassisted during rehabilitation. The appropriate nursing action at this phase of rehabilitation is to a. remind the patient about the importance of independence in daily activities. b. tell the spouse to stop helping because the patient is able to perform activities independently. c. develop a plan to increase the patient's independence in consultation with the patient and the spouse. d. recognize that it is important for the spouse to be involved in the patient's care and encourage participation.

C The best action by the nurse will be to involve all parties in developing an optimal plan of care. Because family members who will be assisting with the patient's ongoing care need to believe their input is important, telling the spouse that the patient can perform activities independently is not the best choice. Reminding the patient about the importance of independence may not change the behaviors of the spouse. Supporting the activities of the spouse will lead to ongoing dependency by the patient. DIF: Cognitive Level: Apply (application) REF: 1432 TOP: Nursing Process: Implementation

17. After a 25-year-old patient has returned home following rehabilitation for a spinal cord injury, the home care nurse notes that the spouse is performing many of the activities that the patient had been managing during rehabilitation. The most appropriate action by the nurse at this time is to a. tell the spouse that the patient can perform activities independently. b. remind the patient about the importance of independence in daily activities. c. develop a plan to increase the patient's independence in consultation with the patient and the spouse. d. recognize that it is important for the spouse to be involved in the patient's care and support the spouse's participation.

C The best action by the nurse will be to involve all the parties in developing an optimal plan of care. Because family members who will be assisting with the patient's ongoing care need to feel that their input is important, telling the spouse that the patient can perform activities independently is not the best choice. Reminding the patient about the importance of independence may not change the behaviors of the spouse. Supporting the activities of the spouse will lead to ongoing dependency by the patient. DIF: Cognitive Level: Application REF: 1565 TOP: Nursing Process: Implementation

24. A patient with hyperlipidemia has a new order for colesevelam (Welchol). Which nursing action is appropriate when scheduling this medication? a. Administer the medication at the patient's usual bedtime. b. Have the patient take the colesevelam 1 hour before breakfast. c. Give the patient's other medications 2 hours after colesevelam. d. Have the patient take the dose at the same time as the prescribed aspirin.

C The bile acid sequestrants interfere with the absorption of many other drugs and giving other medications at the same time should be avoided. Taking an aspirin concurrently with the colesevelam may increase the incidence of gastrointestinal side effects such as heartburn. For maximum effect, colesevelam should be administered with meals. DIF: Cognitive Level: Apply (application) REF: 711 TOP: Nursing Process: Implementation

7. A patient who was admitted with a myocardial infarction experiences a 45-second episode of ventricular tachycardia, then converts to sinus rhythm with a heart rate of 98 beats/min. Which action should the nurse take next? a. Immediately notify the health care provider. b. Document the rhythm and continue to monitor the patient. c. Prepare to give IV amiodarone per agency dysrhythmia protocol. d. Perform synchronized cardioversion per agency dysrhythmia protocol.

C The burst of sustained ventricular tachycardia indicates that the patient has significant ventricular irritability, and antidysrhythmic medication administration is needed to prevent further episodes. The nurse should notify the health care provider after the medication is started. Cardioversion is not indicated given that the patient has returned to a sinus rhythm. Documentation and continued monitoring are not adequate responses to this situation. DIF: Cognitive Level: Analyze (analysis) REF: 766 TOP: Nursing Process: Implementation

7. A patient who was admitted with a myocardial infarction experiences a 50-second episode of ventricular tachycardia, then converts to sinus rhythm with a heart rate of 98 beats/minute. Which action should the nurse take next? a. Notify the health care provider. b. Perform synchronized cardioversion. c. Administer the PRN IV lidocaine (Xylocaine). d. Document the rhythm and monitor the patient.

C The burst of sustained ventricular tachycardia indicates that the patient has significant ventricular irritability, and antidysrhythmic medication administration is needed to prevent further episodes. The nurse should notify the health care provider after the medications are administered. Defibrillation is not indicated given that the patient is currently in a sinus rhythm. Documentation and continued monitoring are not adequate responses to this situation. DIF: Cognitive Level: Application REF: 831 | Algorithms for Treatment of Dysrhythmias on Evolve TOP: Nursing Process: Implementation

31. The nurse is caring for a patient who has a head injury and fractured right arm after being assaulted. Which assessment information requires rapid action by the nurse? a. The apical pulse is slightly irregular. b. The patient complains of a headache. c. The patient is more difficult to arouse. d. The blood pressure (BP) increases to 140/62 mm Hg.

C The change in level of consciousness (LOC) is an indicator of increased intracranial pressure (ICP) and suggests that action by the nurse is needed to prevent complications. The change in BP should be monitored but is not an indicator of a need for immediate nursing action. Headache and a slightly irregular apical pulse are not unusual in a patient after a head injury. DIF: Cognitive Level: Apply (application) REF: 1317 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

16. During the administration of the fibrinolytic agent to a patient with an acute myocardial infarction (AMI), the nurse should stop the drug infusion if the patient experiences a. bleeding from the gums. b. surface bleeding from the IV site. c. a decrease in level of consciousness. d. a nonsustained episode of ventricular tachycardia.

C The change in level of consciousness indicates that the patient may be experiencing intracranial bleeding, a possible complication of fibrinolytic therapy. Bleeding of the gums and prolonged bleeding from IV sites are expected side effects of the therapy. The nurse should address these by avoiding any further injuries, but they are not an indication to stop infusion of the fibrinolytic medication. A nonsustained episode of ventricular tachycardia is a common reperfusion dysrhythmia and may indicate that the therapy is effective. DIF: Cognitive Level: Application REF: 783-784 TOP: Nursing Process: Evaluation

16. During the administration of the thrombolytic agent to a patient with an acute myocardial infarction, the nurse should stop the drug infusion if the patient experiences a. bleeding from the gums. b. increase in blood pressure. c. a decrease in level of consciousness. d. a nonsustained episode of ventricular tachycardia.

C The change in level of consciousness indicates that the patient may be experiencing intracranial bleeding, a possible complication of thrombolytic therapy. Some bleeding of the gums is an expected side effect of the therapy but not an indication to stop infusion of the thrombolytic medication. A decrease in blood pressure could indicate internal bleeding. A nonsustained episode of ventricular tachycardia is a common reperfusion dysrhythmia and may indicate that the therapy is effective. DIF: Cognitive Level: Apply (application) REF: 723 TOP: Nursing Process: Evaluation

28. Which assessment finding by the nurse who is caring for a patient who has had coronary artery bypass grafting using a right radial artery graft is most important to communicate to the physician? a. Complaints of incisional chest pain b. Crackles audible at both lung bases c. Pallor and weakness of the right hand d. Redness on either side of the chest incision

C The changes in the right hand indicate compromised blood flow, which requires immediate evaluation and actions such as prescribed calcium channel blockers or surgery. The other changes are expected and/or require nursing interventions. DIF: Cognitive Level: Application REF: 788 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

22. A nurse reviews the following data in the chart of a client with burn injuries: Admission Notes Wound Assessment 36-year-old female with bilateral leg burns NKDA Health history of asthma and seasonal allergies Bilateral leg burns present with a white and leather-like appearance. No blisters or bleeding present. Client rates pain 2/10 on a scale of 0-10. Based on the data provided, how should the nurse categorize this client's injuries? a. Partial-thickness deep b. Partial-thickness superficial c. Full thickness d. Superficial

C The characteristics of the client's wounds meet the criteria for a full-thickness injury: color that is black, brown, yellow, white, or red; no blisters; minimal pain; and firm and inelastic outer layer. Partial-thickness superficial burns appear pink to red and are painful. Partial-thickness deep burns are deep red to white and painful. Superficial burns are pink to red and are also painful. DIF: Analyzing/Analysis REF: 467 KEY: Skin lesions/wounds

10. A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)? a. Assess the client for sedation needs. b. Get family permission for restraints. c. Provide frequent oral care per protocol. d. Use nonverbal pain assessment tools.

C The client on mechanical ventilation needs frequent oral care, which can be delegated to the UAP. The other actions fall within the scope of practice of the nurse. DIF: Applying/Application REF: 619 KEY: Mechanical ventilation| oral care| delegation| unlicensed assistive personnel (UAP)

26. A nurse is caring for four clients in the neurologic/neurosurgical intensive care unit. Which client should the nurse assess first? a. Client who has been diagnosed with meningitis with a fever of 101° F (38.3° C) b. Client who had a transient ischemic attack and is waiting for teaching on clopidogrel (Plavix) c. Client receiving tissue plasminogen activator (t-PA) who has a change in respiratory pattern and rate d. Client who is waiting for subarachnoid bolt insertion with the consent form already signed

C The client receiving t-PA has a change in neurologic status while receiving this fibrinolytic therapy. The nurse assesses this client first as he or she may have an intracerebral bleed. The client with meningitis has expected manifestations. The client waiting for discharge teaching is a lower priority. The client waiting for surgery can be assessed quickly after the nurse sees the client who is receiving t-PA, or the nurse could delegate checking on this client to another nurse. DIF: Analyzing/Analysis REF: 938 KEY: Neurologic disorders| critical rescue| nursing assessment

3. An emergency room nurse is triaging victims of a multi-casualty event. Which client should receive care first? a. A 30-year-old distraught mother holding her crying child b. A 65-year-old conscious male with a head laceration c. A 26-year-old male who has pale, cool, clammy skin d. A 48-year-old with a simple fracture of the lower leg

C The client with pale, cool, clammy skin is in shock and needs immediate medical attention. The mother does not have injuries and so would be the lowest priority. The other two people need medical attention soon, but not at the expense of a person in shock. DIF: Applying/Application REF: 117 KEY: Triage| emergency nursing

21. A patient who has neurogenic shock is receiving a phenylephrine infusion through a right forearm IV. Which assessment finding obtained by the nurse indicates a need for immediate action? a. The patient's heart rate is 58 beats/min. b. The patient's extremities are warm and dry. c. The patient's IV infusion site is cool and pale. d. The patient's urine output is 28 mL over the past hour.

C The coldness and pallor at the infusion site suggest extravasation of the phenylephrine. The nurse should discontinue the IV and, if possible, infuse the drug into a central line. An apical pulse of 58 beats/min is typical for neurogenic shock but does not indicate an immediate need for nursing intervention. A 28-mL urinary output over 1 hour would require the nurse to monitor the output over the next hour, but an immediate change in therapy is not indicated. Warm, dry skin is consistent with early neurogenic shock, but it does not indicate a need for a change in therapy or immediate action. DIF: Cognitive Level: Analyze (analysis) REF: 1599 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

35. The nurse obtains the following data when assessing a patient who experienced an ST-segment-elevation myocardial infarction (STEMI) 2 days previously. Which information is most important to report to the health care provider? a. The troponin level is elevated. b. The patient denies having a heart attack. c. Bilateral crackles in the mid-lower lobes. d. Occasional premature atrial contractions (PACs).

C The crackles indicate that the patient may be developing heart failure, a possible complication of myocardial infarction (MI). The health care provider may need to order medications such as diuretics or angiotensin-converting enzyme inhibitors for the patient. Elevation in troponin level at this time is expected. PACs are not life-threatening dysrhythmias. Denial is a common response in the immediate period after the MI. DIF: Cognitive Level: Analyze (analysis) REF: 720 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

36. After change-of-shift report on a ventilator weaning unit, which patient should the nurse assess first? a. Patient who failed a spontaneous breathing trial and has been placed in a rest mode on the ventilator b. Patient who is intubated and has continuous partial pressure end-tidal CO2 (PETCO2) monitoring c. Patient who was successfully weaned and extubated 4 hours ago and has no urine output for the last 6 hours d. Patient with a central venous O2 saturation (ScvO2) of 69% while on bilevel positive airway pressure (BiPAP)

C The decreased urine output may indicate acute kidney injury or that the patient's cardiac output and perfusion of vital organs have decreased. Any of these causes would require rapid action. The data about the other patients indicate that their conditions are stable and do not require immediate assessment or changes in their care. Continuous PETCO2 monitoring is frequently used when patients are intubated. The rest mode should be used to allow patient recovery after a failed SBT, and an ScvO2 of 69% is within normal limits. DIF: Cognitive Level: Analyze (analysis) REF: 1582 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Planning

5. After the nurse has finished teaching a patient about use of sublingual nitroglycerin (Nitrostat), which patient statement indicates that the teaching has been effective? a. "I can expect indigestion as a side effect of nitroglycerin." b. "I can only take the nitroglycerin if I start to have chest pain." c. "I will call an ambulance if I still have pain 5 minutes after taking the nitroglycerin." d. "I will help slow down the progress of the plaque formation by taking nitroglycerin."

C The emergency medical services (EMS) system should be activated when chest pain or other symptoms are not completely relieved 5 minutes after taking one nitroglycerin. Nitroglycerin can be taken to prevent chest pain or other symptoms from developing (e.g., before intercourse). Gastric upset is not an expected side effect of nitroglycerin. Nitroglycerin does not impact the underlying pathophysiology of coronary artery atherosclerosis. DIF: Cognitive Level: Application REF: 775-776 TOP: Nursing Process: Evaluation

1. When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is red, swollen, and covered with large blisters. The patient states that they are very painful. The nurse will document the injury as a. full-thickness skin destruction. b. deep full-thickness skin destruction. c. deep partial-thickness skin destruction. d. superficial partial-thickness skin destruction.

C The erythema, swelling, and blisters point to a deep partial-thickness burn. With full-thickness skin destruction, the appearance is pale and dry or leathery and the area is painless because of the associated nerve destruction. With superficial partial-thickness burns, the area is red, but no blisters are present. DIF: Cognitive Level: Comprehension REF: 475 TOP: Nursing Process: Assessment

32. When the charge nurse is evaluating the care that a new RN staff member provides to a patient receiving mechanical ventilation, which action by the new RN indicates the need for more education? a. The RN turns the FIO2 up to 100% before suctioning. b. The RN secures a bite block in place using adhesive tape. c. The RN positions the patient with the head of bed at 10 degrees. d. The RN asks for assistance to turn the patient to the prone position.

C The head of the patient's bed should be positioned at 30 to 45 degrees to prevent ventilator-acquired pneumonia. The other actions by the new RN are appropriate. DIF: Cognitive Level: Application REF: 1711 OBJ: Special Questions: Delegation TOP: Nursing Process: Evaluation

25. A patient experiences dizziness and shortness of breath for several days. During cardiac monitoring in the emergency department (ED), the nurse obtains the following electrocardiographic (ECG) tracing. The nurse interprets this cardiac rhythm as a. sinus rhythm with premature ventricular contractions (PVCs). b. junctional escape rhythm. c. third-degree atrioventricular (AV) block. d. sinus rhythm with premature atrial contractions (PACs).

C The inconsistency between the atrial and ventricular rates and the variable P-R interval indicate that the rhythm is third-degree AV block. Sinus rhythm with PACs or PVCs will have a normal rate and consistent P-R intervals with occasional PACs or PVCs. A junctional escape rhythm will not have P waves. DIF: Cognitive Level: Application REF: 829-830 OBJ: Special Questions: Alternate Item Format TOP: Nursing Process: Assessment

19. Which assessment finding obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning? a. The patient was last suctioned 6 hours ago. b. The patient's oxygen saturation drops to 93%. c. The patient's respiratory rate is 32 breaths/min. d. The patient has occasional audible expiratory wheezes.

C The increase in respiratory rate indicates that the patient may have decreased airway clearance and requires suctioning. Suctioning is done when patient assessment data indicate that it is needed and not on a scheduled basis. Occasional expiratory wheezes do not indicate poor airway clearance, and suctioning the patient may induce bronchospasm and increase wheezing. An O2 saturation of 93% is acceptable and does not suggest that immediate suctioning is needed. DIF: Cognitive Level: Apply (application) REF: 1571 TOP: Nursing Process: Assessment

26. While assessing a patient with a central venous catheter, the nurse notes the catheter insertion site is red and tender and the patient's temperature is 101.8° F. The nurse will plan to a. administer analgesics and antibiotics. b. check the site frequently for any swelling. c. discontinue the catheter and culture the tip. d. change the flush system and monitor the site.

C The information indicates that the patient has a local and systemic infection caused by the catheter and the catheter should be discontinued. Changing the flush system, administration of analgesics, and continued monitoring will not help prevent or treat the infection. Administration of antibiotics is appropriate, but the line should still be discontinued to avoid further complications such as endocarditis. DIF: Cognitive Level: Application REF: 1696 TOP: Nursing Process: Planning

15. A patient who has right-sided weakness after a stroke is attempting to use the left hand for feeding and other activities. The patient's wife insists on feeding and dressing him, telling the nurse, "I just don't like to see him struggle." Which nursing diagnosis is most appropriate for the patient? a. Situational low self-esteem related to increasing dependence on others b. Interrupted family processes related to effects of illness of a family member c. Disabled family coping related to inadequate understanding by patient's spouse d. Impaired nutrition: less than body requirements related to hemiplegia and aphasia

C The information supports the diagnosis of disabled family coping because the wife does not understand the rehabilitation program. There are no data supporting low self-esteem, and the patient is attempting independence. The data do not support an interruption in family processes because this may be a typical pattern for the couple. There is no indication that the patient has impaired nutrition. DIF: Cognitive Level: Application REF: 1480-1482 | 1483-1484 TOP: Nursing Process: Diagnosis

15. A male patient who has right-sided weakness after a stroke is making progress in learning to use the left hand for feeding and other activities. The nurse observes that when the patient's wife is visiting, she feeds and dresses him. Which nursing diagnosis is most appropriate for the patient? a. Interrupted family processes related to effects of illness of a family member b. Situational low self-esteem related to increasing dependence on spouse for care c. Disabled family coping related to inadequate understanding by patient's spouse d. Impaired nutrition: less than body requirements related to hemiplegia and aphasia

C The information supports the diagnosis of disabled family coping because the wife does not understand the rehabilitation program. There are no data supporting low self-esteem, and the patient is attempting independence. The data do not support an interruption in family processes because this may be a typical pattern for the couple. There is no indication that the patient has impaired nutrition. DIF: Cognitive Level: Apply (application) REF: 1362 TOP: Nursing Process: Diagnosis

25. After reviewing the information shown in the accompanying figure for a patient with pneumonia and sepsis, which information is most important to report to the health care provider? Physical Assessment Laboratory Data Vital Signs ∙ Petechiae noted on chest and legs ∙ Crackles heard bilaterally in lung bases ∙ No redness or swelling at central line IV site ∙ Blood urea nitrogen (BUN) 34 mg/Dl ∙ Hematocrit 30% ∙ Platelets 50,000/µL ∙ Temperature 100°F (37.8°C) ∙ Pulse 102/min ∙ Respirations 26/min ∙ BP 110/60 mm Hg ∙ O2 saturation 93% on 2L O2 via nasal cannula a. Temperature and IV site appearance b. Oxygen saturation and breath sounds c. Platelet count and presence of petechiae d. Blood pressure, pulse rate, respiratory rate.

C The low platelet count and presence of petechiae suggest that the patient may have disseminated intravascular coagulation and that multiple organ dysfunction syndrome is developing. The other information will also be discussed with the health care provider but does not indicate that the patient's condition is deteriorating or that a change in therapy is needed immediately. DIF: Cognitive Level: Analyze (analysis) REF: 1606 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

6. An unconscious patient is admitted to the emergency department (ED) with a head injury. The patient's spouse and teenage children stay at the patient's side and ask many questions about the treatment being given. What action is best for the nurse to take? a. Call the family's pastor or spiritual advisor to take them to the chapel. b. Ask the family to stay in the waiting room until the assessment is completed. c. Allow the family to stay with the patient and briefly explain all procedures to them. d. Refer the family members to the hospital counseling service to deal with their anxiety.

C The need for information about the diagnosis and care is very high in family members of acutely ill patients. The nurse should allow the family to observe care and explain the procedures unless they interfere with emergent care needs. A pastor or counseling service can offer some support, but research supports information as being more effective. Asking the family to stay in the waiting room will increase their anxiety. DIF: Cognitive Level: Analyze (analysis) REF: 1332 TOP: Nursing Process: Implementation

30. The nurse notes that a patient's endotracheal tube (ET), which was at the 22-cm mark, is now at the 25-cm mark, and the patient is anxious and restless. Which action should the nurse take next? a. Check the O2 saturation. b. Offer reassurance to the patient. c. Listen to the patient's breath sounds. d. Notify the patient's health care provider.

C The nurse should first determine whether the ET tube has been displaced into the right mainstem bronchus by listening for unilateral breath sounds. If so, assistance will be needed to reposition the tube immediately. The other actions are also appropriate, but detection and correction of tube malposition are the most critical actions. DIF: Cognitive Level: Analyze (analysis) REF: 1573 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

42. After reviewing information shown in the accompanying figure from the medical records of a 43-yr-old patient, which risk factor modification for coronary artery disease should the nurse include in patient teaching? a. Importance of daily physical activity b. Effect of weight loss on blood pressure c. Dietary changes to improve lipid levels d. Cardiac risk associated with previous tobacco use

C The patient has an elevated low-density lipoprotein cholesterol and low high-density lipoprotein cholesterol, which will increase the risk of coronary artery disease. Although the blood pressure is in the prehypertensive range, the patient's waist circumference and body mass index indicate an appropriate body weight. The risk for coronary artery disease a year after quitting smoking is the same as a nonsmoker. The patient's occupation indicates that daily activity is at the levels suggested by national guidelines. DIF: Cognitive Level: Analyze (analysis) REF: 703 TOP: Nursing Process: Planning

19. A patient's heart monitor shows sinus rhythm, rate 64. The PR interval is 0.18 seconds at 1:00 AM, 0.22 seconds at 2:30 PM, and 0.28 seconds at 4:00 PM. Which action should the nurse take next? a. Place the transcutaneous pacemaker pads on the patient. b. Give atropine sulfate 1 mg IV per agency dysrhythmia protocol. c. Call the health care provider before giving scheduled metoprolol (Lopressor). d. Document the patient's rhythm and assess the patient's response to the rhythm.

C The patient has progressive first-degree atrioventricular (AV) block, and the β-blocker should be held until discussing the drug with the health care provider. Documentation and assessment are appropriate but not fully adequate responses. The patient with first-degree AV block usually is asymptomatic and a pacemaker is not indicated. Atropine is sometimes used for symptomatic bradycardia, but there is no indication that this patient is symptomatic. DIF: Cognitive Level: Analyze (analysis) REF: 767 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

29. A patient who is complaining of a "racing" heart and feeling "anxious" comes to the emergency department. The nurse places the patient on a heart monitor and obtains the following electrocardiographic (ECG) tracing. Which action should the nurse take next? a. Prepare to perform electrical cardioversion. b. Have the patient perform the Valsalva maneuver. c. Obtain the patient's vital signs including O2 saturation. d. Prepare to give a β-blocker medication to slow the heart rate.

C The patient has sinus tachycardia, which may have multiple etiologies such as pain, dehydration, anxiety, and myocardial ischemia. Further assessment is needed before determining the treatment. Vagal stimulation or β-blockade may be used after further assessment of the patient. Electrical cardioversion is used for some tachydysrhythmias but would not be used for sinus tachycardia. DIF: Cognitive Level: Analyze (analysis) REF: 763 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

26. A patient who is complaining of a "racing" heart and nervousness comes to the emergency department. The nurse places the patient on a cardiac monitor and obtains the following electrocardiographic (ECG) tracing. Which action should the nurse take next? a. Get ready to perform electrical cardioversion. b. Have the patient perform the Valsalva maneuver. c. Obtain the patient's blood pressure and oxygen saturation. d. Prepare to give β-blocker medication to slow the heart rate.

C The patient has sinus tachycardia, which may have multiple etiologies such as pain, dehydration, anxiety, and myocardial ischemia; further assessment is needed before determining the treatment. Vagal stimulation or β-blockade may be used after further assessment of the patient. Electrical cardioversion is used for some tachydysrhythmias, but would not be used for sinus tachycardia. DIF: Cognitive Level: Analysis REF: 824-825 OBJ: Special Questions: Alternate Item Format, Prioritization TOP: Nursing Process: Implementation

11. A patient has received instruction on the management of a new permanent pacemaker before discharge from the hospital. The nurse recognizes that teaching has been effective when the patient tells the nurse, a. "It will be 6 weeks before I can take a bath or return to my usual activities." b. "I will notify the airlines when I make a reservation that I have a pacemaker." c. "I won't lift the arm on the pacemaker side up very high until I see the doctor." d. "I must avoid cooking with a microwave oven or being near a microwave in use."

C The patient is instructed to avoid lifting the arm on the pacemaker side above the shoulder to avoid displacing the pacemaker leads. The patient should notify airport security about the presence of a pacemaker before going through the metal detector, but there is no need to notify the airlines when making a reservation. Microwave oven use does not affect the pacemaker. The insertion procedure involves minor surgery that will have a short recovery period. DIF: Cognitive Level: Application REF: 837 TOP: Nursing Process: Evaluation

30. Which electrocardiographic (ECG) change is most important for the nurse to report to the health care provider when caring for a patient with chest pain? a. Inverted P wave c. ST-segment elevation b. Sinus tachycardia d. First-degree atrioventricular block

C The patient is likely to be experiencing an ST-segment-elevation myocardial infarction. Immediate therapy with percutaneous coronary intervention or thrombolytic medication is indicated to minimize myocardial damage. The other ECG changes may also suggest a need for therapy but not as rapidly. DIF: Cognitive Level: Analyze (analysis) REF: 714 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

12. Which intervention by a new nurse who is caring for a patient who has just had an implantable cardioverter-defibrillator (ICD) inserted indicates a need for more teaching about the care of patients with ICDs? a. The nurse administers amiodarone (Cordarone) to the patient. b. The nurse helps the patient fill out the application for obtaining a Medic Alert device. c. The nurse encourages the patient to do active range of motion exercises for all extremities. d. The nurse teaches the patient that sexual activity can be resumed when the incision is healed.

C The patient should avoid moving the arm on the ICD insertion site until healing has occurred to prevent displacement of the ICD leads. The other actions by the new nurse are appropriate for this patient. DIF: Cognitive Level: Apply (application) REF: 772 TOP: Nursing Process: Evaluation

14. A patient will attempt oral feedings for the first time after having a stroke. The nurse should assess the gag reflex and then a. order a varied pureed diet. c. assist the patient into a chair. b. assess the patient's appetite. d. offer the patient a sip of juice.

C The patient should be as upright as possible before attempting feeding to make swallowing easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient. Pureed diets are not recommended because the texture is too smooth. The patient may have a poor appetite, but the oral feeding should be attempted. DIF: Cognitive Level: Apply (application) REF: 1360 TOP: Nursing Process: Implementation

18. In preparation for discharge, the nurse teaches a patient with chronic stable angina how to use the prescribed short-acting and long-acting nitrates. Which patient statement indicates that the teaching has been effective? a. "I will check my pulse rate before I take any nitroglycerin tablets." b. "I will put the nitroglycerin patch on as soon as I get any chest pain." c. "I will stop what I am doing and sit down before I put the nitroglycerin under my tongue." d. "I will be sure to remove the nitroglycerin patch before taking any sublingual nitroglycerin."

C The patient should sit down before taking the nitroglycerin to decrease cardiac workload and prevent orthostatic hypotension. Transdermal nitrates are used prophylactically rather than to treat acute pain and can be used concurrently with sublingual nitroglycerin. Although the nurse should check blood pressure before giving nitroglycerin, patients do not need to check the pulse rate before taking nitrates. DIF: Cognitive Level: Apply (application) REF: 716 TOP: Nursing Process: Evaluation

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

C The patient with Brown-Séquard syndrome has loss of motor function on the ipsilateral side and will require the nurse to move the left leg. Pain sensation will be lost in the patient's right leg. Arm weakness will not be a problem for a patient with a T7 injury. The patient will retain position sense for the right leg. DIF: Cognitive Level: Apply (application) REF: 1422 TOP: Nursing Process: Implementation

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

C The patient with Brown-Séquard syndrome has loss of motor function on the ipsilateral side and will require the nurse to move the right leg. Pain sensation will be lost on the patient's left leg. Left arm weakness will not be a problem for a patient with a T7 injury. The patient will retain position sense for the left leg. DIF: Cognitive Level: Application REF: 1550-1551 TOP: Nursing Process: Implementation

7. A patient who is unconscious has ineffective cerebral tissue perfusion and cerebral tissue swelling. Which nursing intervention will be included in the plan of care? a. Encourage coughing and deep breathing. b. Position the patient with knees and hips flexed. c. Keep the head of the bed elevated to 30 degrees. d. Cluster nursing interventions to provide rest periods.

C The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to help reduce ICP. Extreme flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions increases ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic pressure and ICP. DIF: Cognitive Level: Apply (application) REF: 1319 TOP: Nursing Process: Implementation

4. The pulse oximetry for a patient with right lower lobe pneumonia indicates an oxygen saturation of 90%. The patient has rhonchi, a weak cough effort, and complains of fatigue. Which action is best for the nurse to take? a. Position the patient on the right side. b. Place a humidifier in the patient's room. c. Assist the patient with staged coughing. d. Schedule a 2-hour rest period for the patient.

C The patient's assessment indicates that assisted coughing is needed to help remove secretions, which will improve oxygenation. A 2-hour rest period at this time may allow the oxygen saturation to drop further. Humidification will not be helpful unless the secretions can be mobilized. Positioning on the right side may cause a further decrease in oxygen saturation because perfusion will be directed more toward the more poorly ventilated lung. DIF: Cognitive Level: Application REF: 1754-1755 TOP: Nursing Process: Implementation

20. A patient has a systemic BP of 108/51 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first? a. Elevate the head of the patient's bed to 60 degrees. b. Document the BP and ICP in the patient's record. c. Report the BP and ICP to the health care provider. d. Continue to monitor the patient's vital signs and ICP.

C The patient's cerebral perfusion pressure is 56 mm Hg, below the normal of 60 to 100 mm Hg and approaching the level of ischemia and neuronal death. Immediate changes in the patient's therapy such as fluid infusion or vasopressor administration are needed to improve the cerebral perfusion pressure. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation also will be done, but they are not the first actions that the nurse should take. DIF: Cognitive Level: Analysis REF: 1426 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

31. When caring for a patient with acute coronary syndrome who has returned to the coronary care unit after having angioplasty with stent placement, the nurse obtains the following assessment data. Which data indicate the need for immediate action by the nurse? a. Heart rate 102 beats/min c. Report of severe chest pain b. Pedal pulses 1+ bilaterally d. Blood pressure 103/54 mm Hg

C The patient's chest pain indicates that restenosis of the coronary artery may be occurring and requires immediate actions, such as administration of oxygen and nitroglycerin, by the nurse. The other information indicates a need for ongoing assessments by the nurse. DIF: Cognitive Level: Analyze (analysis) REF: 705 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

23. The nurse notes a bright red skin color for a patient who was found unconscious from smoke inhalation in a burning house. Which action should the nurse take first? a. Insert two large-bore IV lines. b. Check the patient's orientation. c. Place the patient on 100% oxygen using a non-rebreather mask. d. Assess for singed nasal hair and dark oral mucous membranes.

C The patient's history and skin color suggest carbon monoxide poisoning, which should be treated by rapidly starting oxygen at 100%. The other actions can be taken after the actions to correct gas exchange. DIF: Cognitive Level: Application REF: 474 | 481 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

12. The nurse obtains the vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature 101.2° F, blood pressure 90/56 mm Hg, pulse 92, respirations 34. Which action should the nurse take next? a. Administer the scheduled IV antibiotic. b. Give the PRN acetaminophen (Tylenol) 650 mg. c. Obtain oxygen saturation using pulse oximetry. d. Notify the health care provider of the patient's vital signs.

C The patient's increased respiratory rate in combination with the admission diagnosis of gram-negative sepsis indicates that acute respiratory distress syndrome (ARDS) may be developing. The nurse should check for hypoxemia, a hallmark of ARDS. The health care provider should be notified after further assessment of the patient. Administration of the scheduled antibiotic and administration of Tylenol also will be done, but they are not the highest priority for a patient who may be developing ARDS. DIF: Cognitive Level: Application REF: 1758 | 1760 TOP: Nursing Process: Implementation

12. The nurse assesses vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature of 101.2° F, blood pressure of 90/56 mm Hg, pulse of 92 beats/min, and respirations of 34 breaths/min. Which action should the nurse take next? a. Give the scheduled IV antibiotic. b. Give the PRN acetaminophen (Tylenol). c. Obtain oxygen saturation using pulse oximetry. d. Notify the health care provider of the patient's vital signs.

C The patient's increased respiratory rate in combination with the admission diagnosis of gram-negative sepsis indicates that acute respiratory distress syndrome (ARDS) may be developing. The nurse should check for hypoxemia, a hallmark of ARDS. The health care provider should be notified after further assessment of the patient. Giving the scheduled antibiotic and the PRN acetaminophen will also be done, but they are not the highest priority for a patient who may be developing ARDS. DIF: Cognitive Level: Analyze (analysis) REF: 1620 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

2. On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which of the following prescribed actions should be the nurse's priority? a. Monitoring urine output every 4 hours. b. Continuing to monitor the laboratory results. c. Increasing the rate of the ordered IV solution. d. Typing and crossmatching for a blood transfusion.

C The patient's laboratory results show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Because the hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase once the patient's fluid balance has been restored. On admission to a burn unit, the urine output would be monitored more often than every 4 hours (likely every1 hour). DIF: Cognitive Level: Analyze (analysis) REF: 434 TOP: Nursing Process: Planning

20. The nurse is caring for an older patient who was hospitalized 2 days earlier with community-acquired pneumonia. Which assessment information is most important to communicate to the health care provider? a. Persistent cough of blood-tinged sputum. b. Scattered crackles in the posterior lung bases. c. Oxygen saturation 90% on 100% O2 by nonrebreather mask. d. Temperature 101.5° F (38.6° C) after 2 days of IV antibiotics.

C The patient's low SpO2 despite receiving a high fraction of inspired oxygen (FIO2) indicates the possibility of acute respiratory distress syndrome (ARDS). The patient's blood-tinged sputum and scattered crackles are not unusual in a patient with pneumonia, although they do require continued monitoring. The continued temperature elevation indicates a possible need to change antibiotics, but this is not as urgent a concern as the progression toward hypoxemia despite an increase in O2 flow rate. DIF: Cognitive Level: Analyze (analysis) REF: 1622 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

17. Three days after a myocardial infarction (MI), the patient develops chest pain that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take next? a. Palpate the radial pulses bilaterally. b. Assess the feet for peripheral edema. c. Auscultate for a pericardial friction rub. d. Check the cardiac monitor for dysrhythmias.

C The patient's symptoms are consistent with the development of pericarditis, a possible complication of MI. The other assessments listed are not consistent with the description of the patient's symptoms. DIF: Cognitive Level: Application REF: 780 TOP: Nursing Process: Implementation

17. A patient recovering from a myocardial infarction (MI) develops chest pain on day 3 that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take as focused follow-up on this symptom? a. Assess the feet for pedal edema. b. Palpate the radial pulses bilaterally. c. Auscultate for a pericardial friction rub. d. Check the heart monitor for dysrhythmias.

C The patient's symptoms are consistent with the development of pericarditis, a possible complication of MI. The other assessments listed are not consistent with the description of the patient's symptoms. DIF: Cognitive Level: Apply (application) REF: 721 TOP: Nursing Process: Implementation

1. After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about a. cerebral aneurysm clipping. c. oral low-dose aspirin therapy. b. heparin intravenous infusion. d. tissue plasminogen activator (tPA).

C The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent a stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA. DIF: Cognitive Level: Apply (application) REF: 1353 TOP: Nursing Process: Planning

1. The nurse expects that management of the patient who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects will include a. prophylactic clipping of cerebral aneurysms. b. heparin via continuous intravenous infusion. c. oral administration of low dose aspirin therapy. d. therapy with tissue plasminogen activator (tPA).

C The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA. DIF: Cognitive Level: Application REF: 1468-1469 TOP: Nursing Process: Planning

30. A client has a traumatic brain injury and a positive halo sign. The client is in the intensive care unit, sedated and on a ventilator, and is in critical but stable condition. What collaborative problem takes priority at this time? a. Inability to communicate b. Nutritional deficit c. Risk for acquiring an infection d. Risk for skin breakdown

C The positive halo sign indicates a leak of cerebrospinal fluid. This places the client at high risk of acquiring an infection. Communication and nutrition are not priorities compared with preventing a brain infection.. The client has a definite risk for a skin breakdown, but it is not the immediate danger a brain infection would be. DIF: Applying/Application REF: 952 KEY: Neurologic disorders| infection control| asepsis

15. A client has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority? a. Apply oxygen at 100%. b. Assess the respiratory rate. c. Ensure a patent airway. d. Start two large-bore IV lines.

C The priority for any chest trauma client is airway, breathing, circulation. The nurse first ensures the client has a patent airway. Assessing respiratory rate and applying oxygen are next, followed by inserting IVs. DIF: Remembering/Knowledge REF: 622 KEY: Emergency nursing| primary survey| medical emergencies| trauma| respiratory assessment

37. A patient who has chest pain is admitted to the emergency department (ED), and all of the following are ordered. Which one should the nurse arrange to be completed first? a. Chest x-ray c. Electrocardiogram (ECG) b. Troponin level d. Insertion of a peripheral IV

C The priority for the patient is to determine whether an acute myocardial infarction (AMI) is occurring so that the appropriate therapy can begin as quickly as possible. ECG changes occur very rapidly after coronary artery occlusion, and an ECG should be obtained as soon as possible. Troponin levels will increase after about 3 hours. Data from the chest x-ray may impact the patient's care but are not helpful in determining whether the patient is experiencing a myocardial infarction. Peripheral access will be needed but not before the ECG. DIF: Cognitive Level: Analyze (analysis) REF: 719 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

19. An unresponsive 78-year-old is admitted to the emergency department (ED) during a summer heat wave. The patient's core temperature is 106.2° F (41.2° C), blood pressure (BP) 86/52, and pulse 102. The nurse initially will plan to a. administer an aspirin rectal suppository. b. start O2 at 6 L/min with a nasal cannula. c. apply wet sheets and a fan to the patient. d. infuse lactated Ringer's solution at 1000 mL/hr.

C The priority intervention is to cool the patient. Antipyretics are not effective in decreasing temperature in heat stroke, and 100% oxygen should be given, which requires a high flow rate through a non-rebreather mask. An older patient would be at risk for developing complications such as pulmonary edema if given fluids at 1000 mL/hr. DIF: Cognitive Level: Application REF: 1775-1776 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning

11. A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which laboratory result should the nurse report to the health care provider immediately? a. Arterial pH: 7.32 b. Hematocrit: 52% c. Serum potassium: 6.5 mEq/L d. Serum sodium: 131 mEq/L

C The serum potassium level is changed to the degree that serious life-threatening responses could result. With such a rapid rise in potassium level, the client is at high risk for experiencing severe cardiac dysrhythmias and death. All the other findings are abnormal but do not show the same degree of severity; they would be expected in the emergent phase after a burn injury. DIF: Applying/Application REF: 477 KEY: Electrolyte imbalance

29. The home health nurse is caring for an 81-yr-old who had a stroke 2 months ago. Based on information shown in the accompanying figure from the history, physical assessment, and physical and occupational therapy, which problem is the highest priority? History Physical Assessment Physical/Occupational Therapy ∙ Well controlled type 2 diabetes for 10 years ∙ Married 45 years; spouse has heart failure and chronic obstructive pulmonary disease ∙ Oriented to time, place, person ∙ Speech clear ∙Minimal left leg weakness ∙ Uses cane with walking ∙ Spouse does household cleaning and cooking and assists patient with bathing and dressing a. Risk for hypoglycemia c. Risk for caregiver role strain b. Impaired transfer ability d. Ineffective health maintenance

C The spouse's household and patient care responsibilities, in combination with chronic illnesses, indicate a high risk for caregiver role strain. The nurse should further assess the situation and take appropriate actions. The data about the control of the patient's diabetes indicates that ineffective health maintenance and risk for unstable blood glucose are not priority concerns at this time. Because the patient is able to ambulate with a cane, the nursing diagnosis of impaired transfer ability is not supported. DIF: Cognitive Level: Analyze (analysis) REF: 1362 OBJ: Special Questions: Prioritization TOP: Nursing Process: Diagnosis

12. An emergency department charge nurse notes an increase in sick calls and bickering among the staff after a week with multiple trauma incidents. Which action should the nurse take? a. Organize a pizza party for each shift. b. Remind the staff of the facility's sick-leave policy. c. Arrange for critical incident stress debriefing. d. Talk individually with staff members.

C The staff may be suffering from critical incident stress and needs to have a debriefing by the critical incident stress management team to prevent the consequences of long-term, unabated stress. Speaking with staff members individually does not provide the same level of support as a group debriefing. Organizing a party and revisiting the sick-leave policy may be helpful, but are not as important and beneficial as a debriefing. DIF: Applying/Application REF: 145 KEY: Psychosocial response| crisis intervention

12. A young adult patient who is in the rehabilitation phase after having deep partial-thickness face and neck burns has a nursing diagnosis of disturbed body image. Which statement by the patient best indicates that the problem is resolving? a. "I'm glad the scars are only temporary." b. "I will avoid using a pillow, so my neck will be OK." c. "Do you think dark beige makeup will cover this scar?" d. "I don't think my boyfriend will want to look at me now."

C The willingness to use strategies to enhance appearance is an indication that the disturbed body image is resolving. Expressing feelings about the scars indicates a willingness to discuss appearance but not resolution of the problem. Because deep partial-thickness burns leave permanent scars, a statement that the scars are temporary indicates denial rather than resolution of the problem. Avoiding using a pillow will help prevent contractures, but it does not address the problem of disturbed body image. DIF: Cognitive Level: Apply (application) REF: 447 TOP: Nursing Process: Evaluation

12. A 21-year-old patient who is in the rehabilitation phase after having deep partial-thickness face and neck burns has a nursing diagnosis of disturbed body image. Which action by the patient indicates that the problem is resolving? a. Stating that the scarring will only be temporary. b. Avoiding using a pillow to prevent neck contractures. c. Asking about how to use make-up to cover up the scars. d. Expressing sadness and anger about the scar appearance.

C The willingness to use strategies to enhance appearance is an indication that the disturbed body image is resolving. Expressing feelings about the scars indicates a willingness to discuss appearance, but not resolution of the problem. Because deep partial-thickness burns leave permanent scars, a statement that the scars are temporary indicates denial rather than resolution of the problem. Avoiding using a pillow will help prevent contractures, but it does not address the problem of disturbed body image. DIF: Cognitive Level: Application REF: 492 TOP: Nursing Process: Evaluation

6. A nurse is caring for a client whose wife died in a recent mass casualty accident. The client says, "I can't believe that my wife is gone and I am left to raise my children all by myself." How should the nurse respond? a. "Please accept my sympathies for your loss." b. "I can call the hospital chaplain if you wish." c. "You sound anxious about being a single parent." d. "At least your children still have you in their lives."

C Therapeutic communication includes active listening and honesty. This statement demonstrates that the nurse recognizes the client's distress and has provided an opening for discussion. Extending sympathy and offering to call the chaplain do not give the client the opportunity to discuss feelings. Stating that the children still have one parent discounts the client's feelings and situation. DIF: Applying/Application REF: 146 KEY: Psychosocial response| crisis intervention

6. A nurse caring for a client notes the following assessments: white blood cell count 3800/mm3, blood glucose level 198 mg/dL, and temperature 96.2° F (35.6° C). What action by the nurse takes priority? a. Document the findings in the client's chart. b. Give the client warmed blankets for comfort. c. Notify the health care provider immediately. d. Prepare to administer insulin per sliding scale.

C This client has several indicators of sepsis with systemic inflammatory response. The nurse should notify the health care provider immediately. Documentation needs to be thorough but does not take priority. The client may appreciate warm blankets, but comfort measures do not take priority. The client may or may not need insulin. DIF: Applying/Application REF: 750 KEY: Shock| nursing assessment| critical rescue| communication

20. A nurse performs an admission assessment on a 75-year-old client with multiple chronic diseases. The client's blood pressure is 135/75 mm Hg and oxygen saturation is 94% on 2 liters per nasal cannula. The nurse assesses the client's rhythm on the cardiac monitor and observes the reading shown below: Which action should the nurse take first? a. Begin external temporary pacing. b. Assess peripheral pulse strength. c.. Ask the client what medications he or she takes. d. Administer 1 mg of atropine..

C This client is stable and therefore does not require any intervention except to determine the cause of the bradycardia. Bradycardia is often caused by medications. Clients who have multiple chronic diseases are often on multiple medications that can interact with each other. The nurse should assess the client's current medications first. DIF: Applying/Application REF: 658 KEY: Cardiac electrical conduction| medications| adverse effects

6. A client had an embolectomy for an arteriovenous malformation (AVM). The client is now reporting a severe headache and has vomited. What action by the nurse takes priority? a. Administer pain medication. b. Assess the client's vital signs. c. Notify the Rapid Response Team. d. Raise the head of the bed.

C This client may be experiencing a rebleed from the AVM. The most important action is to call the Rapid Response Team as this is an emergency. The nurse can assess vital signs while someone else notifies the Team, but getting immediate medical attention is the priority. Administering pain medication may not be warranted if the client must return to surgery. The optimal position for the client with an AVM has not been determined, but calling the Rapid Response Team takes priority over positioning. DIF: Applying/Application REF: 941 KEY: Neurologic disorders| critical rescue| Rapid Response Team| communication

27. The nurse assesses a client's Glasgow Coma Scale (GCS) score and determines it to be 12 (a 4 in each category). What care should the nurse anticipate for this client? a. Can ambulate independently b. May have trouble swallowing c. Needs frequent re-orientation d. Will need near-total care

C This client will most likely be confused and need frequent re-orientation. The client may not be able to ambulate at all but should do so independently, not because of mental status. Swallowing is not assessed with the GCS. The client will not need near-total care. DIF: Analyzing/Analysis REF: 934 KEY: Neurologic disorders| neurologic assessment

2. The nurse needs to quickly estimate the heart rate for a patient with a regular heart rhythm. Which method will be best to use? a. Count the number of large squares in the R-R interval and divide by 300. b. Print a 1-minute electrocardiogram (ECG) strip and count the number of QRS complexes. c. Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10. d. Calculate the number of small squares between one QRS complex and the next and divide into 1500.

C This is the quickest way to determine the ventricular rate for a patient with a regular rhythm. All the other methods are accurate, but take longer. DIF: Cognitive Level: Analyze (analysis) REF: 759 TOP: Nursing Process: Assessment

2. The nurse needs to estimate quickly the heart rate for a patient with a regular heart rhythm. Which method will be best to use? a. Print a 1-minute electrocardiogram (ECG) strip and count the number of QRS complexes. b. Count the number of large squares in the R-R interval and divide by 300. c. Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10. d. Calculate the number of small squares between one QRS complex and the next and divide into 1500.

C This is the quickest way to determine the ventricular rate for a patient with a regular rhythm. All the other methods are accurate, but take longer. DIF: Cognitive Level: Application REF: 819-821 TOP: Nursing Process: Assessment

38. The nurse has just received change-of-shift report about the following four patients. Which patient should the nurse assess first? a. 38-year-old who has pericarditis and is complaining of sharp, stabbing chest pain b. 45-year-old who had a myocardial infarction (MI) 4 days ago and is anxious about the planned discharge c. 51-year-old with unstable angina who has just returned to the unit after having a percutaneous coronary intervention (PCI) d. 60-year-old with variant angina who is to receive a scheduled dose of nifedipine (Procardia)

C This patient is at risk for bleeding from the arterial access site for the PCI, so the nurse should assess the patient's blood pressure, pulse, and the access site immediately. The other patients also should be assessed as quickly as possible, but assessment of this patient has the highest priority. DIF: Cognitive Level: Analysis REF: 781-782 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Assessment

14. A patient with ST-segment elevation in three contiguous electrocardiographic leads is admitted to the emergency department and diagnosed as having an ST-segment-elevation myocardial infarction. Which question should the nurse ask to determine whether the patient is a candidate for thrombolytic therapy? a. "Do you have any allergies?" b. "Do you take aspirin on a daily basis?" c. "What time did your chest pain begin?" d. "Can you rate your chest pain using a 0 to 10 scale?"

C Thrombolytic therapy should be started within 6 hours of the onset of the myocardial infarction, so the time at which the chest pain started is a major determinant of the appropriateness of this treatment. The other information is not a factor in the decision about thrombolytic therapy. DIF: Cognitive Level: Apply (application) REF: 723 TOP: Nursing Process: Assessment

12. An emergency department nurse is caring for a client who is homeless. Which action should the nurse take to gain the client's trust? a. Speak in a quiet and monotone voice. b. Avoid eye contact with the client. c. Listen to the client's concerns and needs. d. Ask security to store the client's belongings.

C To demonstrate behaviors that promote trust with homeless clients, the emergency room nurse should make eye contact (if culturally appropriate), speak calmly, avoid any prejudicial or stereotypical remarks, show genuine care and concern by listening, and follow through on promises. The nurse should also respect the client's belongings and personal space. DIF: Understanding/Comprehension REF: 114 KEY: Interdisciplinary team| emergency nursing| case management

8. A patient who has had severe chest pain for several hours is admitted with a diagnosis of possible acute myocardial infarction (AMI). Which of these ordered laboratory tests should the nurse monitor to help determine whether the patient has had an AMI? a. Homocysteine b. C-reactive protein c. Cardiac-specific troponin I and troponin T d. High-density lipoprotein (HDL) cholesterol

C Troponin levels increase about 4 to 6 hours after the onset of myocardial infarction (MI). The other laboratory data are useful in determining the patient's risk for developing coronary artery disease (CAD) but are not helpful in determining whether an acute MI is in progress. DIF: Cognitive Level: Comprehension REF: 780-781 TOP: Nursing Process: Assessment

8. A nurse prepares to administer intravenous cimetidine (Tagamet) to a client who has a new burn injury. The client asks, "Why am I taking this medication?" How should the nurse respond? a. "Tagamet stimulates intestinal movement so you can eat more." b. "It improves fluid retention, which helps prevent hypovolemic shock." c. "It helps prevent stomach ulcers, which are common after burns." d. "Tagamet protects the kidney from damage caused by dehydration."

C Ulcerative gastrointestinal disease (Curling's ulcer) may develop within 24 hours after a severe burn as a result of increased hydrochloric acid production and a decreased mucosal barrier. This process occurs because of the sympathetic nervous system stress response. Cimetidine is a histamine2 blocker and inhibits the production and release of hydrochloric acid. Cimetidine does not affect intestinal movement and does not prevent hypovolemic shock or kidney damage. DIF: Applying/Application REF: 470 KEY: Medication| patient education| peptic ulcer disease prophylaxis

24. The nurse is caring for a patient receiving a continuous norepinephrine (Levophed) IV infusion. Which patient assessment information indicates that the infusion rate may be too high? a. Heart rate is 58 beats/min. b. Mean arterial pressure is 55 mm Hg. c. Systemic vascular resistance (SVR) is elevated. d. Pulmonary artery wedge pressure (PAWP) is low.

C Vasoconstrictors such as norepinephrine (Levophed) will increase SVR, and this will increase the work of the heart and decrease peripheral perfusion. Bradycardia, hypotension, and low PAWP are not associated with norepinephrine infusion. DIF: Cognitive Level: Application REF: 1693-1695 TOP: Nursing Process: Evaluation

24. The nurse is caring for a patient receiving a continuous norepinephrine IV infusion. Which patient assessment finding indicates that the infusion rate may need to be adjusted? a. Heart rate is slow at 58 beats/min. b. Mean arterial pressure (MAP) is 56 mm Hg. c. Systemic vascular resistance (SVR) is elevated. d. Pulmonary artery wedge pressure (PAWP) is low.

C Vasoconstrictors such as norepinephrine will increase SVR, and this will increase the work of the heart and decrease peripheral perfusion. The infusion rate may need to be decreased. Bradycardia, hypotension (MAP of 56 mm Hg), and low PAWP are not associated with norepinephrine infusion. DIF: Cognitive Level: Apply (application) REF: 1560 TOP: Nursing Process: Evaluation

4. The nurse receives a verbal report that a patient has an occlusion of the left posterior cerebral artery. The nurse will anticipate that the patient may have a. dysphasia. b. confusion. c. visual deficits. d. poor judgment.

C Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle cerebral artery involvement. Cognitive deficits and changes in judgment are more typical of anterior cerebral artery occlusion. DIF: Cognitive Level: Application REF: 1466 TOP: Nursing Process: Assessment

12. A nurse is assessing a patient who is receiving a nitroprusside infusion to treat cardiogenic shock. Which finding indicates that the drug is effective? a. No new heart murmurs c. Warm, pink, and dry skin b. Decreased troponin level d. Blood pressure of 92/40 mm Hg

C Warm, pink, and dry skin indicates that perfusion to tissues is improved. Because nitroprusside is a vasodilator, the blood pressure may be low even if the drug is effective. Absence of a heart murmur and a decrease in troponin level are not indicators of improvement in shock. DIF: Cognitive Level: Apply (application) REF: 1599 TOP: Nursing Process: Evaluation

9. An intubated client's oxygen saturation has dropped to 88%. What action by the nurse takes priority? a. Determine if the tube is kinked. b. Ensure all connections are patent. c. Listen to the client's lung sounds. d. Suction the endotracheal tube.

C When an intubated client shows signs of hypoxia, check for DOPE: displaced tube (most common cause), obstruction (often by secretions), pneumothorax, and equipment problems. The nurse listens for equal, bilateral breath sounds first to determine if the endotracheal tube is still correctly placed. If this assessment is normal, the nurse would follow the mnemonic and assess the patency of the tube and connections and perform suction. DIF: Applying/Application REF: 616 KEY: Mechanical ventilation| respiratory assessment| equipment safety| critical rescue

1. The following four patients arrive in the emergency department (ED) after a motor vehicle collision. In which order should the nurse assess them? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. A 74-yr-old patient with palpitations and chest pain b. A 43-yr-old patient complaining of 7/10 abdominal pain c. A 21-yr-old patient with multiple fractures of the face and jaw d. A 37-yr-old patient with a misaligned lower left leg with intact pulses

C, A, B, D The highest priority is to assess the 21-yr-old patient for airway obstruction, which is the most life-threatening injury. The 74-yr-old patient may have chest pain from cardiac ischemia and should be assessed and have diagnostic testing for this pain. The 43-yr-old patient may have abdominal trauma or bleeding and should be seen next to assess circulatory status. The 37-yr-old patient appears to have a possible fracture of the left leg and should be seen soon, but this patient has the least life-threatening injury. DIF: Cognitive Level: Analyze (analysis) REF: 1629 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Assessment

1. These four patients arrive in the emergency department after a motor vehicle crash. In which order should they be assessed? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. A 72-year-old with palpitations and chest pain b. A 45-year-old complaining of 6/10 abdominal pain c. A 22-year-old with multiple fractures of the face and jaw d. A 30-year-old with a misaligned right leg with intact pulses

C, A, B, D The highest priority is to assess the 22-year-old patient for airway obstruction, which is the most life-threatening injury. The 72-year-old patient may have chest pain from cardiac ischemia and should be assessed and have diagnostic testing for this pain. The 45-year-old patient may have abdominal trauma or bleeding and should be seen next to assess circulatory status. The 30-year-old appears to have a possible fracture of the right leg and should be seen soon, but this patient has the least life-threatening injury. DIF: Cognitive Level: Analysis REF: 1768 OBJ: Special Questions: Alternate Item Format, Multiple Patients TOP: Nursing Process: Assessment

2. The emergency department (ED) nurse is starting therapeutic hypothermia in a patient who has been resuscitated after a cardiac arrest. Which actions in the hypothermia protocol can be delegated to an experienced licensed practical/vocational nurse (LPN/LVN) (select all that apply)? a. Continuously monitor heart rhythm. b. Assess neurologic status every 2 hours. c. Give acetaminophen (Tylenol) 650 mg. d. Place cooling blankets above and below patient. e. Attach rectal temperature probe to cooling blanket control panel.

C, D, E Experienced LPN/LVNs have the education and scope of practice to implement hypothermia measures (e.g., cooling blanket, temperature probe) and administer medications under the supervision of a registered nurse (RN). Assessment of neurologic status and monitoring the heart rhythm require RN-level education and scope of practice and should be done by the RN. DIF: Cognitive Level: Apply (application) REF: 1634 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

2. When working with women who are taking hormonal birth control, what health promotion measures should the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.) a. Avoid drinking alcohol. b. Eat more omega-3 fatty acids. c. Exercise on a regular basis. d. Maintain a healthy weight. e. Stop smoking cigarettes.

C, D, E Health promotion measures for clients to prevent thromboembolic events such as PE include maintaining a healthy weight, exercising on a regular basis, and not smoking.. Avoiding alcohol and eating more foods containing omega-3 fatty acids are heart-healthy actions but do not relate to the prevention of PE. DIF: Understanding/Comprehension REF: 604 KEY: Pulmonary embolism| patient education| clotting| thromboembolic event| lifestyle choices

3. After teaching a male client with a spinal cord injury at the T4 level, the nurse assesses the client's understanding. Which client statements indicate a correct understanding of the teaching related to sexual effects of this injury? (Select all that apply.) a. "I will explore other ways besides intercourse to please my partner." b. "I will not be able to have an erection because of my injury." c. "Ejaculation may not be as predictable as before." d. "I may urinate with ejaculation but this will not cause infection." e. "I should be able to have an erection with stimulation."

C, D, E Men with injuries above T6 often are able to have erections by stimulating reflex activity. For example, stroking the penis will cause an erection. Ejaculation is less predictable and may be mixed with urine. However, urine is sterile, so the client's partner will not get an infection. DIF: Applying/Application REF: 901 KEY: Spinal cord/back injury| patient education

6. A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the client's hips and sacrum. Which actions should the nurse take? (Select all that apply.) a. Apply a barrier cream to protect the skin from excoriation. b. Perform range-of-motion (ROM) exercises for the hip joint. c. Re-position the client off of the reddened areas. d. Get the client out of bed and into a chair once a day. e. Obtain a low-air-loss mattress to minimize pressure.

C, E Appropriate interventions to relieve pressure on these areas include frequent re-positioning and a low-air-loss mattress. Reddened areas should not be rubbed because this action could cause more extensive damage to the already fragile capillary system. Barrier cream will not protect the skin from pressure wounds. ROM exercises are used to prevent contractures. Sitting the client in a chair once a day will decrease the client's risk of respiratory complications but will not decrease pressure on the client's hips and sacrum. DIF: Applying/Application REF: 898 KEY: Spinal cord/back injury| skin lesions/wounds

11. When rewarming a patient who arrived in the emergency department (ED) with a temperature of 87° F, which assessment indicates that the nurse should discontinue the rewarming? a. The patient stops shivering. b. The BP decreases to 85/40 mm Hg. c. The patient develops atrial fibrillation. d. The core temperature is 94° F (34.4° C).

D A core temperature of 89.6° F to 93.2° F (32° C to 34° C) indicates that sufficient rewarming has occurred. Dysrhythmias, hypotension, and shivering may occur during rewarming and should be treated but are not an indication to stop rewarming the patient. DIF: Cognitive Level: Application REF: 1778-1779 TOP: Nursing Process: Assessment

10. When rewarming a patient who arrived in the emergency department (ED) with a temperature of 87° F (30.6° C), which finding indicates that the nurse should discontinue active rewarming? a. The patient begins to shiver. b. The BP decreases to 86/42 mm Hg. c. The patient develops atrial fibrillation. d. The core temperature is 94° F (34.4° C).

D A core temperature of at least 89.6° F to 93.2° F (32° C to 34° C) indicates that sufficient rewarming has occurred. Dysrhythmias, hypotension, and shivering may occur during rewarming, and should be treated but are not an indication to stop rewarming the patient. DIF: Cognitive Level: Apply (application) REF: 1634 TOP: Nursing Process: Evaluation

17. A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department complaining of shortness of breath and dyspnea on minimal exertion. Which assessment finding by the nurse is most important to report to the health care provider? a. The patient has bibasilar lung crackles. b. The patient is sitting in the tripod position. c. The patient's pulse oximetry indicates a 91% O2 saturation. d. The patient's respirations have dropped to 10 breaths/minute.

D A drop in respiratory rate in a patient with respiratory distress suggests the onset of fatigue and a high risk for respiratory arrest. Therefore immediate action such as positive-pressure ventilation is needed. Patients who are experiencing respiratory distress frequently sit in the tripod position because it decreases the work of breathing. Crackles in the lung bases may be the baseline for a patient with COPD. An O2 saturation of 91% is common in patients with COPD and will provide adequate gas exchange and tissue oxygenation. DIF: Cognitive Level: Analyze (analysis) REF: 1610 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

14. The nurse is caring for four clients with traumatic brain injuries. Which client should the nurse assess first? a. Client with cerebral perfusion pressure of 72 mm Hg b. Client who has a Glasgow Coma Scale score of 12 c. Client with a PaCO2 of 36 mm Hg who is on a ventilator d. Client who has a temperature of 102° F (38.9° C)

D A fever is a poor prognostic indicator in clients with brain injuries. The nurse should see this client first. A Glasgow Coma Scale score of 12, a PaCO2 of 36, and cerebral perfusion pressure of 72 mm Hg are all desired outcomes. DIF: Applying/Application REF: 953 KEY: Neurologic disorders| neurologic assessment

8. The emergency department (ED) nurse receives report that a seriously injured patient involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 5 minutes. In preparation for the patient's arrival, the nurse will obtain a. a dopamine infusion. c. lactated Ringer's solution. b. a hypothermia blanket. d. two 16-gauge IV catheters.

D A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large-bore IV lines to administer normal saline. Lactated Ringer's solution should be used cautiously and will not be ordered until the patient has been assessed for possible liver abnormalities. Vasopressor infusion is not used as the initial therapy for hypovolemic shock. Patients in shock need to be kept warm not cool. DIF: Cognitive Level: Apply (application) REF: 1600 TOP: Nursing Process: Planning

21. The nurse is obtaining a health history from a 24-yr-old patient with hypertrophic cardiomyopathy (CMP). Which information obtained by the nurse is most important? a. The patient has a history of a recent upper respiratory infection. b. The patient has a family history of coronary artery disease (CAD). c. The patient reports using cocaine a "couple of times" as a teenager. d. The patient's 29-yr-old brother died from a sudden cardiac arrest.

D About half of all cases of hypertrophic CMP have a genetic basis, and it is the most common cause of sudden cardiac death in otherwise healthy young people. The information about the patient's brother will be helpful in planning care (e.g., an automatic implantable cardioverter-defibrillator [AICD]) for the patient and in counseling other family members. The patient should be counseled against the use of stimulant drugs, but the limited past history indicates that the patient is not currently at risk for cocaine use. Viral infections and CAD are risk factors for dilated cardiomyopathy but not for hypertrophic CMP. DIF: Cognitive Level: Analyze (analysis) REF: 796 TOP: Nursing Process: Assessment

38. After receiving change-of-shift report about the following four patients on the cardiac care unit, which patient should the nurse assess first? a. A 39-yr-old patient with pericarditis who is complaining of sharp, stabbing chest pain b. A 56-yr-old patient with variant angina who is scheduled to receive nifedipine (Procardia) c. A 65-yr-old patient who had a myocardial infarction (MI) 4 days ago and is anxious about today's planned discharge d. A 59-yr-old patient with unstable angina who has just returned after a percutaneous coronary intervention (PCI)

D After PCI, the patient is at risk for hemorrhage from the arterial access site. The nurse should assess the patient's blood pressure, pulses, and the access site immediately. The other patients should also be assessed as quickly as possible, but assessment of this patient has the highest priority. DIF: Cognitive Level: Analyze (analysis) REF: 718 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Assessment

17. A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital. Which action should the nurse take first? a. Stay at the bedside and reassure the patient. b. Administer the ordered morphine sulfate IV. c. Assess orientation and level of consciousness. d. Use pulse oximetry to check oxygen saturation.

D Agitation in a patient who may have suffered inhalation injury might indicate hypoxia, and this should be assessed by the nurse first. Administration of morphine may be indicated if the nurse determines that the agitation is caused by pain. Assessing level of consciousness and orientation is also appropriate but not as essential as determining whether the patient is hypoxemic. Reassurance is not helpful to reduce agitation in a hypoxemic patient. DIF: Cognitive Level: Analyze (analysis) REF: 437 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

32. A patient admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI) is restless and anxious. The blood pressure is 86/40 mm Hg, and heart rate is 132 beats/min. Based on this information, which nursing diagnosis is a priority for the patient? a. Acute pain related to myocardial infarction b. Anxiety related to perceived threat of death c. Stress overload related to acute change in health d. Decreased cardiac output related to cardiogenic shock

D All the nursing diagnoses may be appropriate for this patient, but the hypotension and tachycardia indicate decreased cardiac output and shock from the damaged myocardium. This will result in decreased perfusion to all vital organs (e.g., brain, kidney, heart) and is a priority. DIF: Cognitive Level: Analyze (analysis) REF: 714 OBJ: Special Questions: Prioritization TOP: Nursing Process: Diagnosis

6. Which statement made by a patient with coronary artery disease after the nurse has completed teaching about the therapeutic lifestyle changes (TLC) diet indicates that further teaching is needed? a. "I will switch from whole milk to 1% milk." b. "I like salmon and I will plan to eat it more often." c. "I can have a glass of wine with dinner if I want one." d. "I will miss being able to eat peanut butter sandwiches."

D Although only 30% of the daily calories should come from fats, most of the fat in the TLC diet should come from monounsaturated fats such as are found in nuts, olive oil, and canola oil. The patient can include peanut butter sandwiches as part of the TLC diet. The other patient comments indicate a good understanding of the TLC diet. DIF: Cognitive Level: Apply (application) REF: 709 TOP: Nursing Process: Evaluation

22. Which of these patients is most appropriate for the burn unit charge nurse to assign to an RN staff nurse who has floated from the hospital medical unit? a. A 63-year-old patient who has blebs under an autograft on the thigh and has an order for bleb aspiration b. A 45-year-old patient who has just come back to the unit after having a cultured epithelial autograft to the chest c. A 60-year-old patient who has twice-daily burn debridements and dressing changes to partial-thickness facial burns d. A 34-year-old patient who has a weight loss of 15% from admission and requires enteral feedings and parenteral nutrition (PN)

D An RN from a medical unit would be familiar with malnutrition and with administration and evaluation of response to enteral feedings and PN. The other patients require burn assessment and care that is more appropriate for staff who regularly care for burned patients. DIF: Cognitive Level: Analysis REF: 488-490 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

27. Which action will the nurse include in the plan of care for a patient in the rehabilitation phase after a burn injury to the right arm and chest? a. Keep the right arm in a position of comfort. b. Avoid the use of sustained-release narcotics. c. Teach about the purpose of tetanus immunization. d. Apply water-based cream to burned areas frequently.

D Application of water-based emollients will moisturize new skin and decrease flakiness and itching. To avoid contractures, the joints of the right arm should be positioned in an extended position, which is not the position of comfort. Patients may need to continue the use of opioids during rehabilitation. Tetanus immunization would have been given during the emergent phase of the burn injury. DIF: Cognitive Level: Apply (application) REF: 447 TOP: Nursing Process: Planning

18. When assessing a patient with chronic obstructive pulmonary disease (COPD), the nurse finds a new onset of agitation and confusion. Which action should the nurse take first? a. Observe for facial symmetry. b. Notify the health care provider. c. Attempt to calm and reorient the patient. d. Assess oxygenation using pulse oximetry.

D Because agitation and confusion are frequently the initial indicators of hypoxemia, the nurse's initial action should be to assess O2 saturation. The other actions are also appropriate, but assessment of oxygenation takes priority over other assessments and notification of the health care provider. DIF: Cognitive Level: Analyze (analysis) REF: 1611 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

7. When assessing a patient with a possible stroke, the nurse finds that the patient's aphasia started 3.5 hours previously and the blood pressure is 170/92 mm Hg. Which of these orders by the health care provider should the nurse question? a. Infuse normal saline at 75 mL/hr. b. Keep head of bed elevated at least 30 degrees. c. Administer tissue plasminogen activator (tPA) per protocol. d. Titrate labetolol (Normodyne) drip to keep BP less than 140/90 mm Hg.

D Because elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if mean arterial pressure (MAP) is >130 mm Hg or systolic pressure is >220 mm Hg. Fluid intake should be 1500 to 2000 mL daily to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees, unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient meets the other criteria for tPA use. DIF: Cognitive Level: Application REF: 1469-1471 TOP: Nursing Process: Implementation

13. Which assessment information is most important for the nurse to obtain when evaluating whether treatment of a patient with anaphylactic shock has been effective? a. Heart rate c. Blood pressure b. Orientation d. Oxygen saturation

D Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the O2 saturation is the most critical assessment. Improvements in the other assessments will also be expected with effective treatment of anaphylactic shock. DIF: Cognitive Level: Analyze (analysis) REF: 1600 TOP: Nursing Process: Evaluation

11. Nadolol (Corgard) is prescribed for a patient with chronic stable angina and left ventricular dysfunction. To determine whether the drug is effective, the nurse will monitor for a. decreased blood pressure and heart rate. b. fewer complaints of having cold hands and feet. c. improvement in the strength of the distal pulses. d. participation in daily activities without chest pain.

D Because the drug is ordered to improve the patient's angina, effectiveness is indicated if the patient is able to accomplish daily activities without chest pain. Blood pressure and heart rate may decrease, but these data do not indicate that the goal of decreased angina has been met. The noncardioselective β-adrenergic blockers can cause peripheral vasoconstriction, so the nurse would not expect an improvement in distal pulse quality or skin temperature. DIF: Cognitive Level: Apply (application) REF: 715 TOP: Nursing Process: Evaluation

11. Nadolol (Corgard) is prescribed for a patient with angina. To determine whether the drug is effective, the nurse will monitor for a. decreased blood pressure and apical pulse rate. b. fewer complaints of having cold hands and feet. c. improvement in the quality of the peripheral pulses. d. the ability to do daily activities without chest discomfort.

D Because the medication is ordered to improve the patient's angina, effectiveness is indicated if the patient is able to accomplish daily activities without chest pain. Blood pressure (BP) and apical pulse rate may decrease, but these data do not indicate that the goal of decreased angina has been met. The noncardioselective β-blockers can cause peripheral vasoconstriction, so the nurse would not expect an improvement in peripheral pulse quality or skin temperature. DIF: Cognitive Level: Application REF: 776 TOP: Nursing Process: Evaluation

15. When analyzing the rhythm of a patient's electrocardiogram (ECG), the nurse will need to investigate further upon finding a(n) a. isoelectric ST segment. c. QT interval of 0.38 second. b. PR interval of 0.18 second. d. QRS interval of 0.14 second.

D Because the normal QRS interval is less than 0.12 seconds, the patient's QRS interval of 0.14 seconds indicates that the conduction through the ventricular conduction system is prolonged. The PR interval and QT interval are within normal range and ST segment should be isoelectric (flat). DIF: Cognitive Level: Apply (application) REF: 761 TOP: Nursing Process: Assessment

10. Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the family members of a patient with ARDS is correct? a. "PEEP will prevent fibrosis of the lung from occurring." b. "PEEP will push more air into the lungs during inhalation." c. "PEEP allows the ventilator to deliver 100% oxygen to the lungs." d. "PEEP prevents the lung air sacs from collapsing during exhalation."

D By preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation. PEEP will not prevent the fibrotic changes that occur with ARDS, push more air into the lungs, or change the fraction of inspired oxygen (FIO2) delivered to the patient. DIF: Cognitive Level: Comprehension REF: 1761-1762 TOP: Nursing Process: Implementation

4. Which information given by a patient admitted with chronic stable angina will help the nurse confirm this diagnosis? a. The patient rates the pain at a level 3 to 5 (0 to 10 scale). b. The patient states that the pain "wakes me up at night." c. The patient says that the frequency of the pain has increased over the last few weeks. d. The patient states that the pain is resolved after taking one sublingual nitroglycerin tablet.

D Chronic stable angina is typically relieved by rest or nitroglycerin administration. The level of pain is not a consistent indicator of the type of angina. Pain occurring at rest or with increased frequency is typical of unstable angina. DIF: Cognitive Level: Comprehension REF: 771-776 TOP: Nursing Process: Assessment

4. Which information from a patient helps the nurse confirm the previous diagnosis of chronic stable angina? a. "The pain wakes me up at night." b. "The pain is level 3 to 5 (0 to 10 scale)." c. "The pain has gotten worse over the last week." d. "The pain goes away after a nitroglycerin tablet."

D Chronic stable angina is typically relieved by rest or nitroglycerin administration. The level of pain is not a consistent indicator of the type of angina. Pain occurring at rest or with increased frequency is typical of unstable angina. DIF: Cognitive Level: Understand (comprehension) REF: 712 TOP: Nursing Process: Assessment

2. A client who is hospitalized with burns after losing the family home in a fire becomes angry and screams at a nurse when dinner is served late. How should the nurse respond? a. "Do you need something for pain right now?" b. "Please stop yelling. I brought dinner as soon as I could." c. "I suggest that you get control of yourself." d. "You seem upset. I have time to talk if you'd like."

D Clients should be allowed to ventilate their feelings of anger and despair after a catastrophic event. The nurse establishes rapport through active listening and honest communication and by recognizing cues that the client wishes to talk. Asking whether the client is in pain as the first response closes the door to open communication and limits the client's options. Simply telling the client to stop yelling and to gain control does nothing to promote therapeutic communication. DIF: Applying/Application REF: 146 KEY: Psychosocial response| crisis intervention

3. A nurse is field-triaging clients after an industrial accident. Which client condition should the nurse triage with a red tag? a. Dislocated right hip and an open fracture of the right lower leg b. Large contusion to the forehead and a bloody nose c. Closed fracture of the right clavicle and arm numbness d.. Multiple fractured ribs and shortness of breath

D Clients who have an immediate threat to life are given the highest priority, are placed in the emergent or class I category, and are given a red triage tag. The client with multiple rib fractures and shortness of breath most likely has developed a pneumothorax, which may be fatal if not treated immediately. The client with the hip and leg problem and the client with the clavicle fracture would be classified as class II; these major but stable injuries can wait 30 minutes to 2 hours for definitive care. The client with facial wounds would be considered the "walking wounded" and classified as nonurgent. DIF: Analyzing/Analysis REF: 141 KEY: Triage| emergency nursing

18. A nurse assesses bilateral wheezes in a client with burn injuries inside the mouth. Four hours later the wheezing is no longer heard.. Which action should the nurse take? a. Document the findings and reassess in 1 hour. b. Loosen any constrictive dressings on the chest. c. Raise the head of the bed to a semi-Fowler's position. d.. Gather appropriate equipment and prepare for an emergency airway.

D Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose effective movement of air. When this occurs, wheezing is no longer heard, and neither are breath sounds. These clients can lose their airways very quickly, so prompt action is needed. The client requires establishment of an emergency airway. Swelling usually precludes intubation. The other options do not address this emergency situation. DIF: Applying/Application REF: 474 KEY: Respiratory distress/failure| medical emergency

1. A patient has a nursing diagnosis of disturbed sensory perception related to sleep deprivation. Which action will the nurse include in the plan of care? a. Discontinue assessments during the night to allow uninterrupted sleep. b. Administer prescribed sedatives or opioids at bedtime to promote sleep. c. Silence the alarms on the cardiac monitors to allow 30- to 40-minute naps. d. Cluster nursing activities so that the patient has uninterrupted rest periods.

D Clustering nursing activities and providing uninterrupted rest periods will minimize sleep-cycle disruption. Sedative and opioid medications tend to decrease the amount of rapid eye movement (REM) sleep and can contribute to sleep disturbance and disturbed sensory perception. Silencing the alarms on the cardiac monitors would be unsafe in a critically ill patient, as would discontinuing assessments during the night. DIF: Cognitive Level: Application REF: 1686 TOP: Nursing Process: Planning

9. When preparing to assist with the insertion of a pulmonary artery catheter, the nurse will plan to a. check cardiac enzymes before insertion. b. auscultate heart sounds during insertion. c. place the patient on NPO status before the procedure. d. attach cardiac monitoring leads before the procedure.

D Dysrhythmias can occur as the catheter is floated through the right atrium and ventricle, and it is important for the nurse to monitor for these during insertion. Pulmonary artery catheter insertion does not require anesthesia, and the patient will not need to be NPO. Changes in cardiac enzymes or heart sounds are not expected during pulmonary artery catheter insertion. DIF: Cognitive Level: Application REF: 1691-1693 TOP: Nursing Process: Planning

9. Which nursing action is needed when preparing to assist with the insertion of a pulmonary artery catheter? a. Determine if the cardiac troponin level is elevated. b. Auscultate heart sounds before and during insertion. c. Place the patient on NPO status before the procedure. d. Attach cardiac monitoring leads before the procedure.

D Dysrhythmias can occur as the catheter is floated through the right atrium and ventricle, and it is important for the nurse to monitor for these during insertion. Pulmonary artery catheter insertion does not require anesthesia, and the patient will not need to be NPO. Changes in cardiac troponin or heart and breath sounds are not expected during pulmonary artery catheter insertion. DIF: Cognitive Level: Apply (application) REF: 1564 TOP: Nursing Process: Planning

18. The nurse notes premature ventricular contractions (PVCs) while suctioning a patient's endotracheal tube. Which next action by the nurse is indicated? a. Plan to suction the patient more frequently. b. Decrease the suction pressure to 80 mm Hg. c. Give antidysrhythmic medications per protocol. d. Stop and ventilate the patient with 100% oxygen.

D Dysrhythmias during suctioning may indicate hypoxemia or sympathetic nervous system stimulation. The nurse should stop suctioning and ventilate the patient with 100% O2. There is no indication that more frequent suctioning is needed. Lowering the suction pressure will decrease the effectiveness of suctioning without improving the hypoxemia. Because the PVCs occurred during suctioning, there is no need for antidysrhythmic medications (which may have adverse effects) unless they recur when the suctioning is stopped and patient is well oxygenated. DIF: Cognitive Level: Apply (application) REF: 1571 TOP: Nursing Process: Implementation

16. To verify the correct placement of an endotracheal tube (ET) after insertion, the best initial action by the nurse is to a. auscultate for the presence of bilateral breath sounds. b. obtain a portable chest radiograph to check tube placement. c. observe the chest for symmetrical movement with ventilation. d. use an end-tidal CO2 monitor to check for placement in the trachea.

D End-tidal CO2 monitors are currently recommended for rapid verification of ET placement. Auscultation for bilateral breath sounds and checking chest expansion also are used, but they are not as accurate as end-tidal CO2 monitoring. A chest x-ray confirms the placement but is done after the tube is secured. DIF: Cognitive Level: Application REF: 1701-1702 TOP: Nursing Process: Evaluation

29. The care plan for a patient who has increased intracranial pressure and a ventriculostomy includes the following nursing actions. Which action can the nurse delegate to nursing assistive personnel (NAP) who regularly work in the intensive care unit? a. Monitor cerebrospinal fluid color hourly. b. Document intracranial pressure every hour. c. Turn and reposition the patient every 2 hours. d. Check capillary blood glucose level every 6 hours.

D Experienced NAP can obtain capillary blood glucose levels when they have been trained and evaluated in the skill. Monitoring and documentation of cerebrospinal fluid (CSF) color and intracranial pressure (ICP) require RN-level education and scope of practice. Although repositioning patients is frequently delegated to NAP, repositioning a patient with a ventriculostomy is complex and should be done by the RN. DIF: Cognitive Level: Application REF: 1442 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

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

D Fecal impaction is a common stimulus for autonomic dysreflexia. The other actions may be included in the plan of care but will not reduce the risk for autonomic dysreflexia. DIF: Cognitive Level: Application REF: 1560-1561 TOP: Nursing Process: Planning

11. A nurse assesses a client admitted with a brown recluse spider bite. Which priority assessment should the nurse perform to identify complications of this bite? a. Ask the client about pruritus at the bite site. b. Inspect the bite site for a bluish purple vesicle. c. Assess the extremity for redness and swelling. d. Monitor the client's temperature every 4 hours.

D Fever and chills indicate systemic toxicity, which can lead to hemolytic reactions, kidney failure, pulmonary edema, cardiovascular collapse, and death. Assessing for a fever should be the nurse's priority. All other symptoms are normal for a brown recluse bite and should be assessed, but they do not provide information about complications from the bite, and therefore are not the priority. DIF: Applying/Application REF: 126 KEY: Spider bite| environmental emergencies

5. A 19-yr-old patient is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of the left hand. When asked about tetanus immunization, the patient denies having any previous vaccinations. The nurse will anticipate giving a. tetanus immunoglobulin (TIG) only. b. TIG and tetanus-diphtheria toxoid (Td). c. tetanus-diphtheria toxoid and pertussis vaccine (Tdap) only. d. TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap).

D For an adult with no previous tetanus immunizations, TIG and Tdap are recommended. The other immunizations are not sufficient for this patient. DIF: Cognitive Level: Apply (application) REF: 1634 TOP: Nursing Process: Planning

5. An 18-year-old is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of the right hand. When asked about tetanus immunization, the patient denies having any previous vaccinations. The nurse will anticipate administration of a. tetanus-diphtheria toxoid (Td) only. b. tetanus immunoglobulin (TIG) only. c. TIG and tetanus-diphtheria toxoid (Td). d. TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap).

D For an adult with no previous tetanus immunizations, TIG and Tdap are recommended. The other immunizations are not sufficient for this patient. DIF: Cognitive Level: Application REF: 1773-1774 TOP: Nursing Process: Planning

10. Ranitidine (Zantac) is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which information will the nurse collect to evaluate the effectiveness of the medication? a. Bowel sounds b. Stool frequency c. Abdominal distention d. Stools for occult blood

D H2 blockers are given to prevent Curling's ulcer in the patient who has suffered burn injuries. H2 blockers do not impact on bowel sounds, stool frequency, or appetite. DIF: Cognitive Level: Application REF: 487-488 TOP: Nursing Process: Evaluation

12. A patient with a non-ST-segment-elevation myocardial infarction (NSTEMI) is receiving heparin. What is the purpose of the heparin? a. Platelet aggregation is enhanced by IV heparin infusion. b. Heparin will dissolve the clot that is blocking blood flow to the heart. c. Coronary artery plaque size and adherence are decreased with heparin. d. Heparin will prevent the development of new clots in the coronary arteries.

D Heparin helps prevent the conversion of fibrinogen to fibrin and decreases coronary artery thrombosis. It does not change coronary artery plaque, dissolve already formed clots, or enhance platelet aggregation. DIF: Cognitive Level: Comprehension REF: 775 TOP: Nursing Process: Implementation

24. Which of these laboratory results requires the most rapid action by the nurse who is caring for a patient who suffered a large burn 48 hours ago? a. Hct 52% b. BUN 36 mg/dL c. Serum sodium 146 mEq/L d. Serum potassium 6.2 mEq/L

D Hyperkalemia can lead to fatal bradycardia and indicates that the patient requires cardiac monitoring and immediate treatment to lower the potassium level. The other laboratory values also are abnormal and require changes in treatment, but they are not as immediately life threatening as the elevated potassium level. DIF: Cognitive Level: Application REF: 487 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

20. The nurse obtains all of the following information about a 65-year-old patient in the clinic. When developing a plan to decrease stroke risk, which risk factor is most important for the nurse to address? a. The patient has a daily glass of wine to relax. b. The patient is 25 pounds above the ideal weight. c. The patient works at a desk and relaxes by watching television. d. The patient's blood pressure (BP) is usually about 180/90 mm Hg.

D Hypertension is the single most important modifiable risk factor and this patient's hypertension is at the stage 2 level. People who drink more than 1 (for women) or 2 (for men) alcoholic beverages a day may increase risk for hypertension. Physical inactivity and obesity contribute to stroke risk but not so much as hypertension. DIF: Cognitive Level: Application REF: 1463-1466 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

17. Which laboratory result for a patient with multifocal premature ventricular contractions (PVCs) is most important for the nurse to communicate to the health care provider? a. Blood glucose of 243 mg/dL c. Serum sodium of 134 mEq/L b. Serum chloride of 92 mEq/L d. Serum potassium of 2.9 mEq/L

D Hypokalemia increases the risk for ventricular dysrhythmias such as PVCs, ventricular tachycardia, and ventricular fibrillation. The health care provider will need to prescribe a potassium infusion to correct this abnormality. Although the other laboratory values are also abnormal, they are not likely to be the etiology of the patient's PVCs and do not require immediate correction. DIF: Cognitive Level: Analyze (analysis) REF: 768 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

21. A 21-year-old student arrives at the student health center at the end of the quarter complaining that, "My heart is skipping beats." An electrocardiogram (ECG) shows occasional premature ventricular contractions (PVCs). What action should the nurse take first? a. Have the patient transported to the hospital emergency department (ED). b. Administer O2 at 2 to 3 L/min using nasal prongs. c. Ask the patient about any history of coronary artery disease. d. Question the patient about current stress level and coffee use.

D In a patient with a normal heart, occasional PVCs are a benign finding. The timing of the PVCs suggests stress or caffeine as possible etiologic factors. It is unlikely that the patient has coronary artery disease, and this should not be the first question the nurse asks. The patient is hemodynamically stable, so there is no indication that the patient needs to be seen in the ED or that oxygen needs to be administered. DIF: Cognitive Level: Application REF: 830 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

17. Gastric lavage and administration of activated charcoal are prescribed for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 diazepam (Valium) tablets. Which action will the nurse plan to take first? a. Administer activated charcoal. b. Insert a large-bore orogastric tube. c. Prepare a 60-mL syringe with saline. d. Assist with intubation of the patient.

D In an unresponsive patient, intubation is done before gastric lavage and activated charcoal administration to prevent aspiration. The other actions will be implemented after intubation. DIF: Cognitive Level: Application REF: 1781-1782 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning

35. A patient with a subarachnoid hemorrhage is intubated and placed on a mechanical ventilator. When monitoring the patient, the nurse will need to notify the health care provider if the patient develops a. oxygen saturation of 94%. b. respirations of 18 breaths/min. c. green nasogastric tube drainage. d. increased jugular vein distention (JVD).

D Increases in JVD in a patient with a subarachnoid hemorrhage may indicate an increase in intra-cranial pressure (ICP) and that the PEEP setting is too high for this patient. A respiratory rate of 18, O2 saturation of 94%, and green nasogastric tube drainage are normal. DIF: Cognitive Level: Application REF: 1711-1712 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

34. The nurse is caring for a patient with a subarachnoid hemorrhage who is intubated and placed on a mechanical ventilator with 10 cm H2O of peak end-expiratory pressure (PEEP). When monitoring the patient, the nurse will need to notify the health care provider immediately if the patient develops a. O2 saturation of 93%. b. green nasogastric tube drainage. c. respirations of 20 breaths/minute. d. increased jugular venous distention.

D Increases in jugular venous distention in a patient with a subarachnoid hemorrhage may indicate an increase in intracranial pressure (ICP) and that the PEEP setting is too high for this patient. A respiratory rate of 20, O2 saturation of 93%, and green nasogastric tube drainage are within normal limits. DIF: Cognitive Level: Apply (application) REF: 1579 TOP: Nursing Process: Assessment

1. The registered nurse assigns a client who has an open burn wound to a licensed practical nurse (LPN). Which instruction should the nurse provide to the LPN when assigning this client? a. "Administer the prescribed tetanus toxoid vaccine." b. "Assess the client's wounds for signs of infection." c. "Encourage the client to breathe deeply every hour." d. "Wash your hands on entering the client's room."

D Infection can occur when microorganisms from another person or from the environment are transferred to the client. Although all of the interventions listed can help reduce the risk for infection, handwashing is the most effective technique for preventing infection transmission. DIF: Applying/Application REF: 466 KEY: Infection control| Standard Precautions| collaboration

21. Which nursing interventions included in the care of a mechanically ventilated patient with acute respiratory failure can the registered nurse (RN) delegate to an experienced licensed practical/vocational nurse (LPN/LVN) working in the intensive care unit? a. Assess breath sounds every hour. b. Monitor central venous pressures. c. Place patient in the prone position. d. Insert an indwelling urinary catheter.

D Insertion of indwelling urinary catheters is included in LPN/LVN education and scope of practice and can be safely delegated to an LPN/LVN who is experienced in caring for critically ill patients. Placing a patient who is on a ventilator in the prone position requires multiple staff, and should be supervised by an RN. Assessment of breath sounds and obtaining central venous pressures require advanced assessment skills and should be done by the RN caring for a critically ill patient. DIF: Cognitive Level: Apply (application) REF: 1615 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

13. A nurse cares for a client who has burn injuries. The client's wife asks, "When will his high risk for infection decrease?" How should the nurse respond? a. "When the antibiotic therapy is complete." b. "As soon as his albumin levels return to normal." c. "Once we complete the fluid resuscitation process." d. "When all of his burn wounds have closed."

D Intact skin is a major barrier to infection and other disruptions in homeostasis. No matter how much time has passed since the burn injury, the client remains at high risk for infection as long as any area of skin is open. Although the other options are important goals in the client's recovery process, they are not as important as skin closure to decrease the client's risk for infection. DIF: Understanding/Comprehension REF: 466 KEY: Skin lesions/wounds| infection control

36. Which of these nursing interventions included in the plan of care for a patient who had an acute myocardial infarction (AMI) 3 days ago is most appropriate for the RN to delegate to an experienced LPN/LVN? a. Evaluating the patient's response to ambulation in the hallway b. Completing the documentation for a home health nurse referral c. Educating the patient about the pathophysiology of heart disease d. Reinforcing teaching about the purpose of prescribed medications

D LPN/LVN education and scope of practice include reinforcing education that has previously been done by the RN. Evaluating the patient response to exercise after an AMI requires more education and should be done by the RN. Teaching and discharge planning/documentation are higher level skills that require RN education and scope of practice. DIF: Cognitive Level: Application REF: 789-793 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

36. A patient had a non-ST-segment-elevation myocardial infarction (NSTEMI) 3 days ago. Which nursing intervention included in the plan of care is appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Evaluation of the patient's response to walking in the hallway b. Completion of the referral form for a home health nurse follow-up c. Education of the patient about the pathophysiology of heart disease d. Reinforcement of teaching about the purpose of prescribed medications

D LPN/LVN education and scope of practice include reinforcing education that has previously been done by the RN. Evaluating the patient's response to exercise after a NSTEMI requires more education and should be done by the RN. Teaching and discharge planning and referral are skills that require RN education and scope of practice. DIF: Cognitive Level: Apply (application) REF: 729 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

4. Which parameter is best for the nurse to monitor to determine whether the prescribed IV mannitol (Osmitrol) has been effective for an unconscious patient? a. Hematocrit b. Blood pressure c. Oxygen saturation d. Intracranial pressure

D Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure. It may initially reduce hematocrit and increase blood pressure, but these are not the best parameters for evaluation of the effectiveness of the drug. Oxygen saturation will not directly improve as a result of mannitol administration. DIF: Cognitive Level: Application REF: 1432-1433 TOP: Nursing Process: Evaluation

18. A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action? a. The patient receives a regular diet tray. b. The bedrails on both sides of the bed are elevated. c. Staff have turned off the lights in the patient's room. d. Staff have entered the patient's room without a mask.

D Meningococcal meningitis is spread by respiratory secretions, so it is important to maintain respiratory isolation as well as standard precautions. Because the patient may be confused and weak, bedrails should be elevated at both the foot and head of the bed. Low light levels in the room decrease pain caused by photophobia. Nutrition is an important aspect of care in a patient with meningitis. DIF: Cognitive Level: Apply (application) REF: 1341 TOP: Nursing Process: Assessment

14. The emergency department (ED) triage nurse is assessing four victims involved in a motor vehicle collision. Which patient has the highest priority for treatment? a. A patient with no pedal pulses b. A patient with an open femur fracture c. A patient with bleeding facial lacerations d. A patient with paradoxical chest movement

D Most immediate deaths from trauma occur because of problems with ventilation, so the patient with paradoxical chest movements should be treated first. Face and head fractures can obstruct the airway, but the patient with facial injuries only has lacerations. The other two patients also need rapid intervention but do not have airway or breathing problems. DIF: Cognitive Level: Analyze (analysis) REF: 1629 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Assessment

1. A nurse assesses a client's electrocardiograph tracing and observes that not all QRS complexes are preceded by a P wave. How should the nurse interpret this observation? a. The client has hyperkalemia causing irregular QRS complexes. b. Ventricular tachycardia is overriding the normal atrial rhythm. c. The client's chest leads are not making sufficient contact with the skin. d. Ventricular and atrial depolarizations are initiated from different sites.

D Normal rhythm shows one P wave preceding each QRS complex, indicating that all depolarization is initiated at the sinoatrial node. QRS complexes without a P wave indicate a different source of initiation of depolarization. This finding on an electrocardiograph tracing is not an indication of hyperkalemia, ventricular tachycardia, or disconnection of leads. DIF: Understanding/Comprehension REF: 649 KEY: Cardiac electrical conduction

5. A client undergoing hemodynamic monitoring after a myocardial infarction has a right atrial pressure of 0.5 mm Hg. What action by the nurse is most appropriate? a. Level the transducer at the phlebostatic axis. b. Lay the client in the supine position. c. Prepare to administer diuretics. d. Prepare to administer a fluid bolus..

D Normal right atrial pressures are from 1 to 8 mm Hg. Lower pressures usually indicate hypovolemia, so the nurse should prepare to administer a fluid bolus. The transducer should remain leveled at the phlebostatic axis. Positioning may or may not influence readings. Diuretics would be contraindicated. DIF: Applying/Application REF: 770 KEY: Coronary artery disease| hemodynamic monitoring| fluid and electrolyte imbalance

11. Which prescribed drug is best for the nurse to give before scheduled wound debridement on a patient with partial-thickness burns? a. ketorolac c. gabapentin (Neurontin) b. lorazepam (Ativan) d. hydromorphone (Dilaudid)

D Opioid pain medications are the best choice for pain control. The other drugs are used as adjuvants to enhance the effects of opioids. DIF: Cognitive Level: Analyze (analysis) REF: 445 TOP: Nursing Process: Implementation

11. Which of these medications that are prescribed as needed for a patient who has partial thickness burns will be best for the nurse to use before wound debridement? a. ketorolac (Toradol) b. lorazepam (Ativan) c. gabapentin (Neurontin) d. hydromorphone (Dilaudid)

D Opioid pain medications are the best choice for pain control. The other medications are used as adjuvants to enhance the effect of opioids. DIF: Cognitive Level: Application REF: 485 TOP: Nursing Process: Implementation

7. When monitoring the effectiveness of treatment for a patient with a large anterior wall myocardial infarction, the most pertinent measurement for the nurse to obtain is a. central venous pressure (CVP). b. systemic vascular resistance (SVR). c. pulmonary vascular resistance (PVR). d. pulmonary artery wedge pressure (PAWP).

D PAWP reflects left ventricular end diastolic pressure (or left ventricular preload) and is a sensitive indicator of cardiac function. Because the patient is high risk for left ventricular failure, the PAWP must be monitored. An increase will indicate left ventricular failure. The other values would also provide useful information, but the most definitive measurement of changes in cardiac function is the PAWP. DIF: Cognitive Level: Apply (application) REF: 1563 TOP: Nursing Process: Evaluation

7. When monitoring for the effectiveness of treatment for a patient with left ventricular failure, the most important information for the nurse to obtain is a. mean arterial pressure (MAP). b. systemic vascular resistance (SVR). c. pulmonary vascular resistance (PVR). d. pulmonary artery wedge pressure (PAWP).

D PAWP reflects left ventricular end diastolic pressure (or left ventricular preload). Because the patient in left ventricular failure will have a high PAWP, a decrease in this value will be the best indicator of patient improvement. The other values would also provide useful information, but the most definitive measurement of improvement is a drop in PAWP. DIF: Cognitive Level: Application REF: 1687-1689 | 1691-1692 TOP: Nursing Process: Evaluation

10. The nurse will suspect that the patient with stable angina is experiencing a side effect of the prescribed metoprolol (Lopressor) if a. the patient is restless and agitated. b. the blood pressure is 190/110 mm Hg. c. the patient complains about feeling anxious. d. the cardiac monitor shows a heart rate of 45.

D Patients taking β-blockers should be monitored for bradycardia. Because this category of medication inhibits the sympathetic nervous system, restlessness, agitation, hypertension, and anxiety will not be side effects. DIF: Cognitive Level: Application REF: 776 TOP: Nursing Process: Evaluation

25. Which assessment finding in a patient who was admitted the previous day with a basilar skull fracture is most important to report to the health care provider? a. Bruising under both eyes b. Complaint of severe headache c. Large ecchymosis behind one ear d. Temperature of 101.5° F (38.6° C)

D Patients who have basilar skull fractures are at risk for meningitis, so the elevated temperature should be reported to the health care provider. The other findings are typical of a patient with a basilar skull fracture. DIF: Cognitive Level: Application REF: 1440 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

25. The nurse is caring for a patient who was admitted the previous day with a basilar skull fracture after a motor vehicle crash. Which assessment finding indicates a possible complication that should be reported to the health care provider? a. Complaint of severe headache b. Large contusion behind left ear c. Bilateral periorbital ecchymosis d. Temperature of 101.4° F (38.6° C)

D Patients who have basilar skull fractures are at risk for meningitis, so the elevated temperature should be reported to the health care provider. The other findings are typical of a patient with a basilar skull fracture. DIF: Cognitive Level: Apply (application) REF: 1339 TOP: Nursing Process: Assessment

19. A patient with a left-brain stroke suddenly bursts into tears when family members visit. The nurse should a. use a calm voice to ask the patient to stop the crying behavior. b. explain to the family that depression is normal following a stroke. c. have the family members leave the patient alone for a few minutes. d. teach the family that emotional outbursts are common after strokes.

D Patients who have left-sided brain stroke are prone to emotional outbursts that are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient's outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the patient's control, and asking the patient to stop will lead to embarrassment. DIF: Cognitive Level: Apply (application) REF: 1364 TOP: Nursing Process: Implementation

19. A patient with a left-sided brain stroke suddenly bursts into tears when family members visit. The nurse should a. use a calm voice to ask the patient to stop the crying behavior. b. explain to the family that depression is normal following a stroke. c. have the family members leave the patient alone for a few minutes. d. teach the family that emotional outbursts are common after strokes.

D Patients who have left-sided brain stroke are prone to emotional outbursts, which are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient's outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the patient's control and asking the patient to stop will lead to embarrassment. DIF: Cognitive Level: Application REF: 1483-1484 TOP: Nursing Process: Implementation

30. Which statement by a patient with restrictive cardiomyopathy indicates that the nurse's discharge teaching about self-management has been effective? a. "I will avoid taking aspirin or other antiinflammatory drugs." b. "I can restart my exercise program that includes hiking and biking." c. "I will need to limit my intake of salt and fluids even in hot weather." d. "I will take antibiotics before my teeth are cleaned at the dental office."

D Patients with restrictive cardiomyopathy are at risk for infective endocarditis and should use prophylactic antibiotics for any procedure that may cause bacteremia. The other statements indicate a need for more teaching by the nurse. Dehydration and vigorous exercise impair ventricular filling in patients with restrictive cardiomyopathy. There is no need to avoid salt (unless ordered), aspirin, or nonsteroidal antiinflammatory drugs.

8. A client is in the preoperative holding area prior to an emergency coronary artery bypass graft (CABG). The client is yelling at family members and tells the doctor to "just get this over with" when asked to sign the consent form. What action by the nurse is best? a. Ask the family members to wait in the waiting area. b. Inform the client that this behavior is unacceptable. c. Stay out of the room to decrease the client's stress levels. d. Tell the client that anxiety is common and that you can help.

D Preoperative fear and anxiety are common prior to cardiac surgery, especially in emergent situations. The client is exhibiting anxiety, and the nurse should reassure the client that fear is common and offer to help. The other actions will not reduce the client's anxiety. DIF: Applying/Application REF: 776 KEY: Coronary artery disease| preoperative nursing| psychosocial response| anxiety| coping| therapeutic communication

23. A patient with a stroke has progressive development of neurologic deficits with increasing weakness and decreased level of consciousness (LOC). Which nursing diagnosis has the highest priority for the patient? a. Impaired physical mobility related to weakness b. Disturbed sensory perception related to brain injury c. Risk for impaired skin integrity related to immobility d. Risk for aspiration related to inability to protect airway

D Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses also are appropriate, but interventions to prevent aspiration are the priority at this time. DIF: Cognitive Level: Application REF: 1477-1479 OBJ: Special Questions: Prioritization TOP: Nursing Process: Diagnosis

23. Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness. Which patient problem do they determine has the highest priority for the patient? a. Impaired physical mobility related to weakness b. Disturbed sensory perception related to brain injury c. Risk for impaired skin integrity related to immobility d. Risk for aspiration related to inability to protect airway

D Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses are also appropriate, but interventions to prevent aspiration are the priority at this time. DIF: Cognitive Level: Analyze (analysis) REF: 1354 OBJ: Special Questions: Prioritization TOP: Nursing Process: Analysis

8. A patient develops increasing dyspnea and hypoxemia 2 days after heart surgery. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by heart failure, the nurse will plan to assist with a. obtaining a ventilation-perfusion scan. b. drawing blood for arterial blood gases. c. positioning the patient for a chest x-ray. d. insertion of a pulmonary artery catheter.

D Pulmonary artery wedge pressures are normal in the patient with ARDS because the fluid in the alveoli is caused by increased permeability of the alveolar-capillary membrane rather than by the backup of fluid from the lungs (as occurs in cardiogenic pulmonary edema). The other tests will not help in differentiating cardiogenic from noncardiogenic pulmonary edema. DIF: Cognitive Level: Apply (application) REF: 1625 TOP: Nursing Process: Implementation

12. A nurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. Which action should the nurse take next? a. Administer furosemide (Lasix). b. Perform chest physiotherapy. c. Document and reassess in an hour. d. Place the client in an upright position.

D Pulmonary edema can result from fluid resuscitation given for burn treatment. This can occur even in a young healthy person. Placing the client in an upright position can relieve lung congestion immediately before other measures can be carried out. Although Lasix may be used to treat pulmonary edema in clients who are fluid overloaded, a client with a burn injury will lose a significant amount of fluid through the broken skin; therefore, Lasix would not be appropriate. Chest physiotherapy will not get rid of fluid. DIF: Applying/Application REF: 475 KEY: Respiratory distress/failure

15. After having a craniectomy and left anterior fossae incision, a 64-yr-old patient has impaired physical mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is to a. cluster nursing activities to allow longer rest periods. b. turn and reposition the patient side to side every 2 hours. c. position the bed flat and log roll to reposition the patient. d. perform range-of-motion (ROM) exercises every 4 hours.

D ROM exercises will help prevent the complications of immobility. Patients with anterior craniotomies are positioned with the head elevated. The patient with a craniectomy should not be turned to the operative side. When the patient is weak, clustering nursing activities may lead to more fatigue and weakness. DIF: Cognitive Level: Apply (application) REF: 1338 TOP: Nursing Process: Implementation

15. After having a craniectomy and left anterior fossae incision, a patient has a nursing diagnosis of impaired physical mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is to a. position the bed flat and log roll the patient. b. cluster nursing activities to allow longer rest periods. c. turn and reposition the patient side to side every 2 hours. d. perform range-of-motion (ROM) exercises every 4 hours.

D ROM exercises will help to prevent the complications of immobility. Patients with anterior craniotomies are positioned with the head elevated. The patient with a craniectomy should not be turned to the operative side. When the patient is weak, clustering nursing activities may lead to more fatigue and weakness. DIF: Cognitive Level: Application REF: 1450-1451 TOP: Nursing Process: Implementation

22. A patient with right-sided weakness that started 90 minutes earlier is admitted to the emergency department and all these diagnostic tests are ordered. Which test should be done first? a. Electrocardiogram (ECG) b. Complete blood count (CBC) c. Chest radiograph (Chest x-ray) d. Noncontrast computed tomography (CT) scan

D Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the smaller the area of brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan. DIF: Cognitive Level: Application REF: 1469 | 1471 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

22. A student nurse asks for an explanation of "refractory hypoxemia." What answer by the nurse instructor is best? a. "It is chronic hypoxemia that accompanies restrictive airway disease." b. "It is hypoxemia from lung damage due to mechanical ventilation." c. "It is hypoxemia that continues even after the client is weaned from oxygen." d. "It is hypoxemia that persists even with 100% oxygen administration."

D Refractory hypoxemia is hypoxemia that persists even with the administration of 100% oxygen. It is a cardinal sign of acute respiratory distress syndrome. It does not accompany restrictive airway disease and is not caused by the use of mechanical ventilation or by being weaned from oxygen. DIF: Understanding/Comprehension REF: 612 KEY: Respiratory disorders| respiratory system| pathophysiology

3. A patient with a stroke experiences right-sided arm and leg paralysis and facial drooping on the right side. When admitting the patient, which clinical manifestation will the nurse expect to find? a. Impulsive behavior b. Right-sided neglect c. Hyperactive left-sided reflexes d. Difficulty in understanding commands

D Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and use of language. The left-side reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a right-side stroke. DIF: Cognitive Level: Application REF: 1466-1468 TOP: Nursing Process: Assessment

19. When assessing a 53-yr-old patient with bacterial meningitis, the nurse obtains the following data. Which finding requires the most immediate intervention? a. The patient exhibits nuchal rigidity. b. The patient has a positive Kernig's sign. c. The patient's temperature is 101° F (38.3° C). d. The patient's blood pressure is 88/42 mm Hg.

D Shock is a serious complication of meningitis, and the patient's low blood pressure indicates the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernig's sign are expected with bacterial meningitis. The nurse should intervene to lower the temperature, but this is not as life threatening as the hypotension. DIF: Cognitive Level: Analyze (analysis) REF: 1339 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

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

D Shock is a serious complication of meningitis, and the patient's low blood pressure indicates the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernig's sign are expected with bacterial meningitis. The nurse should intervene to lower the temperature, but this is not as life threatening as the hypotension. DIF: Cognitive Level: Application REF: 1452-1453 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

18. When assessing a patient with chronic lung disease, the nurse finds a sudden onset of agitation and confusion. Which action should the nurse take first? a. Check pupil reaction to light. b. Notify the health care provider. c. Attempt to calm and reassure the patient. d. Assess oxygenation using pulse oximetry.

D Since agitation and confusion are frequently the initial indicators of hypoxemia, the nurse's initial action should be to assess oxygen saturation. The other actions also are appropriate, but assessment of oxygenation takes priority over other assessments and notification of the health care provider. DIF: Cognitive Level: Application REF: 1750-1751 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

18. A nurse assesses a client's electrocardiogram (ECG) and observes the reading shown below: How should the nurse document this client's ECG strip? a. Ventricular tachycardia b. Ventricular fibrillation c. Sinus rhythm with premature atrial contractions (PACs) d. Sinus rhythm with premature ventricular contractions (PVCs)

D Sinus rhythm with PVCs has an underlying regular sinus rhythm with ventricular depolarization that sometimes precede atrial depolarization. Ventricular tachycardia and ventricular fibrillation rhythms would not have sinus beats present. Premature atrial contractions are atrial contractions initiated from another region of the atria before the sinus node initiates atrial depolarization. DIF: Applying/Application REF: 669 KEY: Cardiac electrical conduction| documentation

14. A client is on mechanical ventilation and the client's spouse wonders why ranitidine (Zantac) is needed since the client "only has lung problems." What response by the nurse is best? a. "It will increase the motility of the gastrointestinal tract." b. "It will keep the gastrointestinal tract functioning normally." c. "It will prepare the gastrointestinal tract for enteral feedings." d. "It will prevent ulcers from the stress of mechanical ventilation."

D Stress ulcers occur in many clients who are receiving mechanical ventilation, and often prophylactic medications are used to prevent them. Frequently used medications include antacids, histamine blockers, and proton pump inhibitors. Zantac is a histamine blocking agent. DIF: Understanding/Comprehension REF: 621 KEY: Mechanical ventilation| histamine blocker| communication

4. An emergency department (ED) charge nurse prepares to receive clients from a mass casualty within the community. What is the role of this nurse during the event? a. Ask ED staff to discharge clients from the medical-surgical units in order to make room for critically injured victims. b. Call additional medical-surgical and critical care nursing staff to come to the hospital to assist when victims are brought in. c. Inform the incident commander at the mass casualty scene about how many victims may be handled by the ED. d.. Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims..

D The ED charge nurse should direct additional nursing staff to help care for current ED clients while the ED staff prepares to receive mass casualty victims; however, they should not be assigned to the most critically ill or injured clients. The house supervisor and unit directors would collaborate to discharge stable clients. The hospital incident commander is responsible for mobilizing resources and would have the responsibility for calling in staff.. The medical command physician would be the person best able to communicate with on-scene personnel regarding the ability to take more clients. DIF: Applying/Application REF: 144 KEY: Emergency nursing

1. To determine whether there is a delay in impulse conduction through the ventricles, the nurse will measure the duration of the patient's a. P wave. c. PR interval. b. Q wave. d. QRS complex.

D The QRS complex represents ventricular depolarization. The P wave represents the depolarization of the atria. The PR interval represents depolarization of the atria, atrioventricular node, bundle of His, bundle branches, and the Purkinje fibers. The Q wave is the first negative deflection following the P wave and should be narrow and short. DIF: Cognitive Level: Understand (comprehension) REF: 759 TOP: Nursing Process: Assessment

4. The nurse obtains a monitor strip on a patient who has had a myocardial infarction and makes the following analysis: P wave not apparent, ventricular rate 162, R-R interval regular, P-R interval not measurable, and QRS complex wide and distorted, QRS duration 0.18 second. The nurse interprets the patient's cardiac rhythm as a. atrial fibrillation. b. sinus tachycardia. c. ventricular fibrillation. d. ventricular tachycardia.

D The absence of P waves, wide QRS, rate >150, and the regularity of the rhythm indicate ventricular tachycardia. Atrial fibrillation is grossly irregular, has a narrow QRS configuration, and has fibrillatory atrial activity. Sinus tachycardia has P waves. Ventricular fibrillation is irregular and does not have a consistent QRS duration. DIF: Cognitive Level: Application REF: 830-831 TOP: Nursing Process: Assessment

4. The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, PR interval not measurable, ventricular rate of 162, R-R interval regular, and QRS complex wide and distorted, and QRS duration of 0.18 second. The nurse interprets the patient's cardiac rhythm as a. atrial flutter. c. ventricular fibrillation. b. sinus tachycardia. d. ventricular tachycardia.

D The absence of P waves, wide QRS, rate greater than 150 beats/min, and the regularity of the rhythm indicate ventricular tachycardia. Atrial flutter is usually regular, has a narrow QRS configuration, and has flutter waves present representing atrial activity. Sinus tachycardia has P waves. Ventricular fibrillation is irregular and does not have a consistent QRS duration. DIF: Cognitive Level: Apply (application) REF: 764 TOP: Nursing Process: Assessment

2. During the primary survey of a patient with multiple traumatic injuries, the nurse observes that the patient's right pedal pulses are absent and the leg is swollen. Which of these actions will the nurse take next? a. Assess further for a cause of the decreased circulation. b. Send blood to the lab for a complete blood count (CBC). c. Finish the airway, breathing, circulation, disability survey. d. Initiate isotonic fluid infusion through two large-bore IV lines.

D The assessment data indicate that the patient may have arterial trauma and hemorrhage. When a possibly life-threatening injury is found during the primary survey, the nurse should immediately start interventions before proceeding with the survey. Although a CBC is indicated, administration of IV fluids should be started first. Completion of the primary survey and further assessment should be completed after the IV fluids are initiated. DIF: Cognitive Level: Application REF: 1769-1771 TOP: Nursing Process: Implementation

2. During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal and posterior tibial pulses are absent and the entire leg is swollen. Which action will the nurse take next? a. Send blood to the lab for a complete blood count. b. Assess further for a cause of the decreased circulation. c. Finish the airway, breathing, circulation, disability survey. d. Start normal saline fluid infusion with a large-bore IV line.

D The assessment data indicate that the patient may have arterial trauma and hemorrhage. When a possibly life-threatening injury is found during the primary survey, the nurse should immediately start interventions before proceeding with the survey. Although a complete blood count is indicated, administration of IV fluids should be started first. Completion of the primary survey and further assessment should be completed after the IV fluids are initiated. DIF: Cognitive Level: Analyze (analysis) REF: 1630 TOP: Nursing Process: Implementation

24. A patient with hyperlipidemia has a new order for colesevelam (Welchol). Which nursing action is appropriate when giving the medication? a. Administer the medication at the patient's bedtime. b. Have the patient take this medication with an aspirin. c. Encourage the patient to take the colesevelam with a sip of water. d. Give the patient's other medications 2 hours after the colesevelam.

D The bile acid sequestrants interfere with the absorption of other drugs, and giving other medications at the same time should be avoided. Taking an aspirin concurrently with the colesevelam may increase the incidence of gastrointestinal side effects such as heartburn. An increased fluid intake is encouraged for patients taking the bile acid sequestrants to reduce the risk for constipation. For maximum effect, colesevelam should be administered with meals. DIF: Cognitive Level: Application REF: 770-771 TOP: Nursing Process: Implementation

2. While at a public park, a nurse encounters a person immediately after a bee sting. The person's lips are swollen, and wheezes are audible.. Which action should the nurse take first? a. Elevate the site and notify the person's next of kin. b. Remove the stinger with tweezers and encourage rest. c. Administer diphenhydramine (Benadryl) and apply ice. d. Administer an EpiPen from the first aid kit and call 911.

D The client's swollen lips indicate that anaphylaxis may be developing, and this is a medical emergency. 911 should be called immediately, and the client transported to the emergency department as quickly as possible. If an EpiPen is available, it should be administered at the first sign of an anaphylactic reaction. The other answers do not provide adequate interventions to treat airway obstruction due to anaphylaxis. DIF: Applying/Application REF: 129 KEY: Bee and insect sting| anaphylaxis| environmental emergencies

35. The nurse obtains the following data when caring for a patient who experienced an acute myocardial infarction (AMI) 2 days previously. Which information is most important to report to the health care provider? a. The patient denies ever having a heart attack. b. The cardiac-specific troponin level is elevated. c. The patient has occasional premature atrial contractions (PACs). d. Crackles are auscultated bilaterally in the mid-lower lobes.

D The crackles indicate that the patient may be developing heart failure, a possible complication of myocardial infarction (MI). The health care provider may need to order medications such as diuretics or angiotensin-converting enzyme (ACE) inhibitors for the patient. Elevation in cardiac troponin level at this time is expected. PACs are not life-threatening dysrhythmias. Denial is a common response in the immediate period after the MI. DIF: Cognitive Level: Application REF: 779-780 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

24. After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first? a. A patient whose cranial x-ray shows a linear skull fracture b. A patient who has an initial Glasgow Coma Scale score of 13 c. A patient who lost consciousness for a few seconds after a fall d. A patient whose right pupil is 10 mm and unresponsive to light

D The dilated and nonresponsive pupil may indicate an intracerebral hemorrhage and increased intracranial pressure. The other patients are not at immediate risk for complications such as herniation. DIF: Cognitive Level: Analysis REF: 1432-1433 | 1437-1438 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

24. After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first? a. A 20-yr-old patient whose cranial x-ray shows a linear skull fracture b. A 50-yr-old patient who has an initial Glasgow Coma Scale score of 13 c. A 30-yr-old patient who lost consciousness for a few seconds after a fall d. A 40-yr-old patient whose right pupil is 10 mm and unresponsive to light

D The dilated and nonresponsive pupil may indicate an intracerebral hemorrhage and increased intracranial pressure. The other patients are not at immediate risk for complications such as herniation. DIF: Cognitive Level: Analyze (analysis) REF: 1328 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Assessment

5. After the nurse has finished teaching a patient about the use of sublingual nitroglycerin (Nitrostat), which patient statement indicates that the teaching has been effective? a. "I can expect nausea as a side effect of nitroglycerin." b. "I should only take nitroglycerin when I have chest pain." c. "Nitroglycerin helps prevent a clot from forming and blocking blood flow to my heart." d. "I will call an ambulance if I still have pain after taking three nitroglycerin 5 minutes apart."

D The emergency response system (ERS) should be activated when chest pain or other symptoms are not completely relieved after three sublingual nitroglycerin tablets taken 5 minutes apart. Nitroglycerin can be taken to prevent chest pain or other symptoms from developing (e.g., before intercourse). Gastric upset (e.g., nausea) is not an expected side effect of nitroglycerin. Nitroglycerin does not impact the underlying pathophysiology of coronary artery atherosclerosis. DIF: Cognitive Level: Apply (application) REF: 716 TOP: Nursing Process: Evaluation

37. After change-of-shift report, which patient should the progressive care nurse assess first? a. Patient who was extubated this morning and has a temperature of 101.4°F (38.6°C) b. Patient with bilevel positive airway pressure (BiPAP) for obstructive sleep apnea and a respiratory rate of 16 c. Patient with arterial pressure monitoring who is 2 hours post-percutaneous coronary intervention and needs to void d. Patient who is receiving IV heparin for a venous thromboembolism and has a partial thromboplastin time (PTT) of 101 sec

D The findings for this patient indicate high risk for bleeding from an elevated (nontherapeutic) PTT. The nurse needs to adjust the rate of the infusion (dose) per the health care provider's parameters. The patient with BiPAP for sleep apnea has a normal respiratory rate. The patient recovering from the percutaneous coronary intervention will need to be assisted with voiding and this task could be delegated to unlicensed assistive personnel. The patient with a fever may be developing ventilator-associated pneumonia, but addressing the bleeding risk is a higher priority. DIF: Cognitive Level: Analyze (analysis) REF: 1556 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Planning

8. An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. Which action should the nurse take first? a. Assess level of consciousness. b. Obtain vital signs. c.. Administer oxygen therapy. d. Evaluate respiratory status.

D The first priority for a client with a spinal cord injury is assessment of respiratory status and airway patency. Clients with cervical spine injuries are particularly prone to respiratory compromise and may even require intubation. The other assessments should be performed after airway and breathing are assessed. DIF: Applying/Application REF: 894 KEY: Spinal cord/back injury

22. The nurse has received change-of-shift report about the following patients on the progressive care unit. Which patient should the nurse see first? a. A patient with atrial fibrillation, rate 88 and irregular, who has a dose of warfarin (Coumadin) due b. A patient with second-degree atrioventricular (AV) block, type 1, rate 60, who is dizzy when ambulating c. A patient who is in a sinus rhythm, rate 98 and regular, recovering from an elective cardioversion 2 hours ago d. A patient whose implantable cardioverter-defibrillator (ICD) fired twice today and has a dose of amiodarone (Cordarone) due

D The frequent firing of the ICD indicates that the patient's ventricles are very irritable and the priority is to assess the patient and give the amiodarone. The other patients can be seen after the amiodarone is given. DIF: Cognitive Level: Analyze (analysis) REF: 773 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Implementation

22. The nurse has received change-of-shift report about the following patients on the telemetry unit. Which patient should the nurse see first? a. A patient with atrial fibrillation, rate 88, who has a new order for warfarin (Coumadin) b. A patient with type 1 second-degree atrioventricular (AV) block, rate 60, who is dizzy when ambulating c. A patient who is in a sinus rhythm, rate 98, after having electrical cardioversion 2 hours ago d. A patient whose implantable cardioverter-defibrillator (ICD) fired three times today who has a dose of amiodarone (Cordarone) due

D The frequent firing of the ICD indicates that the patient's ventricles are very irritable, and the priority is to assess the patient and administer the amiodarone. The other patients may be seen after the amiodarone is administered. DIF: Cognitive Level: Analysis REF: 833-835 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

31. The nurse educator is evaluating the care that a new registered nurse (RN) provides to a patient receiving mechanical ventilation. Which action by the new RN indicates the need for more education? a. The RN increases the FIO2 to 100% before suctioning. b. The RN secures a bite block in place using adhesive tape. c. The RN asks for assistance to resecure the endotracheal tube. d. The RN positions the patient with the head of bed at 10 degrees.

D The head of the patient's bed should be positioned at 30 to 45 degrees to prevent ventilator-associated pneumonia. The other actions by the new RN are appropriate. DIF: Cognitive Level: Apply (application) REF: 1579 OBJ: Special Questions: Supervision TOP: Nursing Process: Evaluation

17. A patient arrives in the emergency department (ED) after topical exposure to powdered lime at work. Which action should the nurse take first? a. Obtain the patient's vital signs. b. Obtain a baseline complete blood count. c. Decontaminate the patient by showering with water. d. Brush off any visible powder on the skin and clothing.

D The initial action should be to protect staff members and decrease the patient's exposure to the toxin by decontamination. Patients exposed to powdered lime should not be showered; instead, any and all visible powder should be brushed off. The other actions can be done after the decontamination is completed. DIF: Cognitive Level: Analyze (analysis) REF: 1643 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

15. While waiting for heart transplantation, a patient with severe cardiomyopathy has a ventricular assist device (VAD) implanted. When planning care for this patient, the nurse should anticipate a. preparing the patient for a permanent VAD. b. administering immunosuppressive medications. c. teaching the patient the reason for complete bed rest. d. monitoring the surgical incision for signs of infection.

D The insertion site for the VAD provides a source for transmission of infection to the circulatory system and requires frequent monitoring. Patients with VADs are able to have some mobility and may not be on bed rest. The VAD is a bridge to transplantation, not a permanent device. Immunosuppression is not necessary for nonbiologic devices such as the VAD. DIF: Cognitive Level: Apply (application) REF: 1569 TOP: Nursing Process: Planning

17. To inflate the cuff of an endotracheal tube (ET) when the patient is on mechanical ventilation, the nurse a. inflates the cuff until the pilot balloon is firm. b. inflates the cuff with a minimum of 10 mL of air. c. injects air into the cuff until a manometer shows 15 mm Hg pressure. d. injects air into the cuff until a slight leak is heard only at peak inflation.

D The minimal occluding volume technique involves injecting air into the cuff until an air leak is present only at peak inflation. The volume to inflate the cuff varies with the ET and the patient's size. Cuff pressure should be maintained at 20 to 25 mm Hg. An accurate assessment of cuff pressure cannot be obtained by palpating the pilot balloon. DIF: Cognitive Level: Comprehension REF: 1701-1702 TOP: Nursing Process: Implementation

17. To maintain proper cuff pressure of an endotracheal tube (ET) when the patient is on mechanical ventilation, the nurse should a. inflate the cuff with a minimum of 10 mL of air. b. inflate the cuff until the pilot balloon is firm on palpation. c. inject air into the cuff until a manometer shows 15 mm Hg pressure. d. inject air into the cuff until a slight leak is heard only at peak inflation.

D The minimal occluding volume technique involves injecting air into the cuff until an air leak is present only at peak inflation. The volume to inflate the cuff varies with the ET and the patient's size. Cuff pressure should be maintained at 20 to 25 mm Hg. An accurate assessment of cuff pressure cannot be obtained by palpating the pilot balloon. DIF: Cognitive Level: Understand (comprehension) REF: 1571 TOP: Nursing Process: Implementation

30. When the ventilator alarm sounds, the nurse finds the patient lying in bed holding the endotracheal tube (ET). Which action should the nurse take first? a. Offer reassurance to the patient. b. Activate the hospital's rapid response team. c. Call the health care provider to reinsert the tube. d. Manually ventilate the patient with 100% oxygen.

D The nurse should ensure maximal patient oxygenation by manually ventilating with a bag-valve-mask system. Offering reassurance to the patient, notifying the health care provider about the need to reinsert the tube, and activating the rapid response team also are appropriate after the nurse has stabilized the patient's oxygenation. DIF: Cognitive Level: Application REF: 1704-1706 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

29. The nurse responds to a ventilator alarm and finds the patient lying in bed gasping and holding the endotracheal tube (ET) in her hand. Which action should the nurse take next? a. Activate the rapid response team. b. Provide reassurance to the patient. c. Call the health care provider to reinsert the tube. d. Manually ventilate the patient with 100% oxygen.

D The nurse should ensure maximal patient oxygenation by manually ventilating with a bag-valve-mask system. Offering reassurance to the patient, notifying the health care provider about the need to reinsert the tube, and activating the rapid response team are also appropriate after the nurse has stabilized the patient's oxygenation. DIF: Cognitive Level: Analyze (analysis) REF: 1573 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

19. A patient's cardiac monitor shows sinus rhythm, rate 60 to 70. The P-R interval is 0.18 seconds at 1:00 AM, 0.20 seconds at 2:30 PM, and 0.23 seconds at 4:00 PM. Which action should the nurse take at this time? a. Prepare for possible temporary pacemaker insertion. b. Administer atropine sulfate 1 mg IV per agency protocol. c. Document the patient's rhythm and assess the patient's response to the rhythm. d. Call the health care provider before giving the prescribed metoprolol (Lopressor).

D The patient has progressive first-degree atrioventricular (AV) block, and the β-blocker should be held until discussing the medication with the health care provider. Documentation and assessment are appropriate but not fully adequate responses. The patient with first-degree AV block usually is asymptomatic, and a pacemaker is not indicated. Atropine is sometimes used for symptomatic bradycardia, but there is no indication that this patient is symptomatic. DIF: Cognitive Level: Application REF: 828-829 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

20. A patient develops sinus bradycardia at a rate of 32 beats/min, has a blood pressure (BP) of 80/42 mm Hg, and is complaining of feeling faint. Which action should the nurse take next? a. Recheck the heart rhythm and BP in 5 minutes. b. Have the patient perform the Valsalva maneuver. c. Give the scheduled dose of diltiazem (Cardizem). d. Apply the transcutaneous pacemaker (TCP) pads.

D The patient is experiencing symptomatic bradycardia and treatment with TCP is appropriate. Continued monitoring of the rhythm and BP is an inadequate response. Calcium channel blockers will further decrease the heart rate and the diltiazem should be held. The Valsalva maneuver will further decrease the rate. DIF: Cognitive Level: Apply (application) REF: 775 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

11. The nurse knows that discharge teaching about the management of a new permanent pacemaker has been most effective when the patient states a. "It will be several weeks before I can return to my usual activities." b. "I will avoid cooking with a microwave oven or being near one in use." c. "I will notify the airlines when I make a reservation that I have a pacemaker." d. "I won't lift the arm on the pacemaker side until I see the health care provider."

D The patient is instructed to avoid lifting the arm on the pacemaker side above the shoulder to avoid displacing the pacemaker leads. The patient should notify airport security about the presence of a pacemaker before going through the metal detector, but there is no need to notify the airlines when making a reservation. Microwave oven use does not affect the pacemaker. The insertion procedure involves minor surgery that will have a short recovery period. DIF: Cognitive Level: Apply (application) REF: 775 TOP: Nursing Process: Evaluation

30. Which electrocardiographic (ECG) change is most important for the nurse to communicate to the health care provider when caring for a patient with chest pain? a. Frequent premature atrial contractions (PACs) b. Inverted P wave c. Sinus tachycardia d. ST segment elevation

D The patient is likely to be experiencing an ST-segment-elevation myocardial infarction (STEMI) and immediate therapy with percutaneous coronary intervention (PCI) or fibrinolytic medications is indicated to minimize the amount of myocardial damage. The other ECG changes also may suggest a need for therapy, but not as rapidly. DIF: Cognitive Level: Application REF: 780-781 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

20. A patient admitted with acute dyspnea is newly diagnosed with dilated cardiomyopathy. Which information will the nurse plan to teach the patient about managing this disorder? a. A heart transplant should be scheduled as soon as possible. b. Elevating the legs above the heart will help relieve dyspnea. c. Careful compliance with diet and medications will prevent heart failure. d. Notify the health care provider about symptoms such as shortness of breath.

D The patient should be instructed to notify the health care provider about any worsening of heart failure symptoms. Because dilated cardiomyopathy does not respond well to therapy, even patients with good compliance with therapy may have recurrent episodes of heart failure. Elevation of the legs above the heart will worsen symptoms (although this approach is appropriate for a patient with hypertrophic cardiomyopathy). The patient with terminal or end-stage cardiomyopathy may consider heart transplantation. DIF: Cognitive Level: Apply (application) REF: 800 TOP: Nursing Process: Planning

20. A patient admitted with acute dyspnea is diagnosed with dilated cardiomyopathy. Which information will the nurse include when teaching the patient about management of this disorder? a. Elevating the legs above the heart will help relieve angina. b. No more than two alcoholic drinks daily are recommended. c. Careful compliance with diet and medications will prevent heart failure. d. Notify the doctor about any symptoms of heart failure such as shortness of breath.

D The patient should be instructed to notify the health care provider about any worsening of heart failure symptoms. Because dilated cardiomyopathy does not respond well to therapy, even patients with good compliance with therapy may have recurrent episodes of heart failure. The patient is instructed to avoid alcoholic beverages. Elevation of the legs above the heart will worsen symptoms (although this approach is appropriate for a patient with hypertrophic cardiomyopathy). DIF: Cognitive Level: Application REF: 863 TOP: Nursing Process: Planning

18. After the nurse teaches a patient with chronic stable angina about how to use the prescribed short-acting and long-acting nitrates, which statement by the patient indicates that the teaching has been effective? a. "I will put on the nitroglycerin patch as soon as I develop any chest pain." b. "I will check the pulse rate in my wrist just before I take any nitroglycerin." c. "I will be sure to remove the nitroglycerin patch before using any sublingual nitroglycerin." d. "I will stop what I am doing and sit down before I put the nitroglycerin under my tongue."

D The patient should sit down before taking the nitroglycerin to decrease cardiac workload and prevent orthostatic hypotension. Transdermal nitrates are used prophylactically rather than to treat acute pain and can be used concurrently with sublingual nitroglycerin. Although the nurse should check blood pressure before giving nitroglycerin, patients do not need to check the pulse rate before taking nitrates. DIF: Cognitive Level: Application REF: 775-776 TOP: Nursing Process: Evaluation

15. When the nurse is developing a rehabilitation plan for a patient with a C6 spinal cord injury, an appropriate patient goal is that the patient will be able to a. transfer independently to a wheelchair. b. drive a car with powered hand controls. c. turn and reposition independently when in bed. d. push a manual wheelchair on flat, smooth surfaces.

D The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn independently in bed. DIF: Cognitive Level: Application REF: 1552 TOP: Nursing Process: Planning

31. When caring for a patient with acute coronary syndrome who has returned to the coronary care unit after having balloon angioplasty, the nurse obtains the following assessment data. Which data indicate the need for immediate intervention by the nurse? a. Pedal pulses 1+ b. Heart rate 100 beats/min c. Blood pressure 104/56 mm Hg d. Chest pain level 8 on a 10-point scale

D The patient's chest pain indicates that restenosis of the coronary artery may be occurring and requires immediate actions, such as administration of oxygen and nitroglycerin, by the nurse. The other information indicates a need for ongoing assessments by the nurse. DIF: Cognitive Level: Application REF: 781-782 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

8. A patient with a history of several transient ischemic attacks (TIAs) arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. The nurse anticipates the need to prepare the patient for a. surgical endarterectomy. b. transluminal angioplasty. c. intravenous heparin administration. d. tissue plasminogen activator (tPA) infusion.

D The patient's history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is having an acute ischemic stroke. DIF: Cognitive Level: Application REF: 1471-1472 TOP: Nursing Process: Planning

8. A patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for a. surgical endarterectomy. b. transluminal angioplasty. c. intravenous heparin drip administration. d. tissue plasminogen activator (tPA) infusion.

D The patient's history and clinical manifestations suggest an acute ischemic stroke, and a patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is having an acute ischemic stroke. DIF: Cognitive Level: Apply (application) REF: 1355 TOP: Nursing Process: Planning

23. A patient who was found unconscious in a burning house is brought to the emergency department by ambulance. The nurse notes that the patient's skin color is bright red. Which action should the nurse take first? a. Insert two large-bore IV lines. b. Check the patient's orientation. c. Assess for singed nasal hair and dark oral mucous membranes. d. Place the patient on 100% O2using a nonrebreather mask.

D The patient's history and skin color suggest carbon monoxide poisoning, which should be treated by rapidly starting O2 at 100%. The other actions can be taken after the action to correct gas exchange. DIF: Cognitive Level: Analyze (analysis) REF: 433 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

20. The nurse is caring for a patient who was hospitalized 2 days earlier with aspiration pneumonia. Which assessment information is most important to communicate to the health care provider? a. Cough that is productive of blood-tinged sputum b. Scattered crackles throughout the posterior lung bases c. Temperature of 101.5° F (38.6° C) after 2 days of IV antibiotic therapy d. Oxygen saturation (SpO2) has dropped to 90% with administration of 100% O2 by non-rebreather mask.

D The patient's low SpO2 despite receiving a high fraction of inspired oxygen (FIO2) indicates the possibility of acute respiratory distress syndrome (ARDS). The patient's blood-tinged sputum and scattered crackles are not unusual in a patient with pneumonia, although they do require continued monitoring. The continued temperature elevation indicates a possible need to change antibiotics, but this is not as urgent a concern as the progression toward hypoxemia despite an increase in O2 flow rate. DIF: Cognitive Level: Application REF: 1760 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

10. Which information will the nurse include when teaching a patient who is scheduled to have a permanent pacemaker inserted for treatment of chronic atrial fibrillation with slow ventricular response? a. The pacemaker prevents or minimizes ventricular irritability. b. The pacemaker paces the atria at rates up to 500 impulses/minute. c. The pacemaker discharges if ventricular fibrillation and cardiac arrest occur. d. The pacemaker stimulates a heart beat if the patient's heart rate drops too low.

D The permanent pacemaker will discharge when the ventricular rate drops below the set rate. The pacemaker will not decrease ventricular irritability or discharge if the patient develops ventricular fibrillation. Since the patient has a slow ventricular rate, overdrive pacing will not be used. DIF: Cognitive Level: Application REF: 834-835 TOP: Nursing Process: Implementation

10. A patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse plan to take? a. Administer IV furosemide (Lasix). b. Initiate high-dose barbiturate therapy. c. Type and crossmatch for blood transfusion. d. Prepare the patient for immediate craniotomy.

D The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation. If intracranial pressure (ICP) is elevated after surgery, furosemide or high-dose barbiturate therapy may be needed, but these will not be of benefit unless the hematoma is removed. Minimal blood loss occurs with head injuries, and transfusion is usually not necessary. DIF: Cognitive Level: Application REF: 1440-1441 TOP: Nursing Process: Planning

10. While assisting with the placement of a pulmonary artery (PA) catheter, the nurse notes that the catheter is correctly placed when the balloon is inflated and the monitor shows a a. typical PA pressure waveform. b. tracing of the systemic arterial pressure. c. tracing of the systemic vascular resistance. d. typical PA wedge pressure (PAWP) tracing.

D The purpose of a PA line is to measure PAWP, so the catheter is floated through the pulmonary artery until the dilated balloon wedges in a distal branch of the pulmonary artery, and the PAWP readings are available. After insertion, the balloon is deflated and the PA waveform will be observed. Systemic arterial pressures are obtained using an arterial line, and the systemic vascular resistance is a calculated value, not a waveform. DIF: Cognitive Level: Understand (comprehension) REF: 1564 TOP: Nursing Process: Assessment

25. A nurse is assessing a client who had a myocardial infarction. Upon auscultating heart sounds, the nurse hears the following sound. What action by the nurse is most appropriate? (Click the media button to hear the audio clip.) a. Assess for further chest pain. b. Call the Rapid Response Team. c. Have the client sit upright. d. Listen to the client's lung sounds.

D The sound the nurse hears is an S3 heart sound, an abnormal sound that may indicate heart failure. The nurse should next assess the client's lung sounds. Assessing for chest pain is not directly related. There is no indication that the Rapid Response Team is needed. Having the client sit up will not change the heart sound. DIF: Applying/Application REF: 762 KEY: Coronary artery disease| respiratory assessment| respiratory system| nursing assessment

11. A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what should the nurse ensure as a priority? a. The client is able to initiate spontaneous breaths. b. The inspired oxygen has adequate humidification. c. The upper peak airway pressure limit alarm is off. d. The upper peak airway pressure limit alarm is on.

D The upper peak airway pressure limit alarm will sound when the airway pressure reaches a preset maximum. This is critical to prevent damage to the lungs. Alarms should never be turned off. Initiating spontaneous breathing is important for some modes of ventilation but not others. Adequate humidification is important but does not take priority over preventing injury. DIF: Applying/Application REF: 619 KEY: Mechanical ventilation| respiratory system| equipment safety

20. Six hours after a thermal burn covering 50% of a patient's total body surface area (TBSA), the nurse obtains these data when assessing a patient. What is the priority information to communicate to the health care provider? a. Blood pressure is 94/46 per arterial line. b. Serous exudate is leaking from the burns. c. Cardiac monitor shows a pulse rate of 104. d. Urine output is 20 mL per hour for the past 2 hours.

D The urine output should be at least 0.5 to 1.0 mL/kg/hr during the emergent phase, when the patient is at great risk for hypovolemic shock. The nurse should notify the health care provider because a higher IV fluid rate is needed. BP during the emergent phase should be greater than 90 systolic, and the pulse rate should be less than 120. Serous exudate from the burns is expected during the emergent phase. DIF: Cognitive Level: Application REF: 478-483 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

21. A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a. The patient's speech is difficult to understand. b. The patient's blood pressure (BP) is 144/90 mm Hg. c. The patient takes a diuretic because of a history of hypertension. d. The patient has atrial fibrillation and takes warfarin (Coumadin).

D The use of warfarin probably contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient's care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated. DIF: Cognitive Level: Analyze (analysis) REF: 1349 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

21. A patient with sudden-onset right-sided weakness has a CT scan and is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a. The patient's speech is difficult to understand. b. The patient's blood pressure is 144/90 mm Hg. c. The patient takes a diuretic because of a history of hypertension. d. The patient has atrial fibrillation and takes warfarin (Coumadin).

D The use of warfarin will have contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient's care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated. DIF: Cognitive Level: Application REF: 1465-1466 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

21. A client is brought to the emergency department after sustaining injuries in a severe car crash. The client's chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. What action by the nurse is the priority? a.. Administer oxygen and reassess. b.. Auscultate the client's lung sounds. c. Facilitate a portable chest x-ray. d. Prepare to assist with intubation.

D This client has manifestations of flail chest and, with the other signs, needs to be intubated and mechanically ventilated immediately. The nurse does not have time to administer oxygen and wait to reassess, or to listen to lung sounds. A chest x-ray will be taken after the client is intubated. DIF: Applying/Application REF: 614 KEY: Trauma| respiratory system| respiratory disorders| mechanical ventilation

18. A client in the intensive care unit is scheduled for a lumbar puncture (LP) today. On assessment, the nurse finds the client breathing irregularly with one pupil fixed and dilated. What action by the nurse is best? a. Ensure that informed consent is on the chart. b. Document these findings in the client's record. c. Give the prescribed preprocedure sedation. d. Notify the provider of the findings immediately.

D This client is exhibiting signs of increased intracranial pressure. The nurse should notify the provider immediately because performing the LP now could lead to herniation. Informed consent is needed for an LP, but this is not the priority. Documentation should be thorough, but again this is not the priority. The preprocedure sedation (or other preprocedure medications) should not be given as the LP will most likely be canceled. DIF: Applying/Application REF: 952 KEY: Neurologic disorders| neurologic assessment| communication

3. A nurse receives a report on a client who had a left-sided stroke and has homonymous hemianopsia. What action by the nurse is most appropriate for this client? a. Assess for bladder retention and/or incontinence. b. Listen to the client's lungs after eating or drinking. c. Prop the client's right side up when sitting in a chair. d. Rotate the client's meal tray when the client stops eating.

D This condition is blindness on the same side of both eyes. The client must turn his or her head to see the entire visual field. The client may not see all the food on the tray, so the nurse rotates it so uneaten food is now within the visual field. This condition is not related to bladder function, difficulty swallowing, or lack of trunk control. DIF: Applying/Application REF: 936 KEY: Neurologic disorders| stroke| visual disorders

16. After receiving change-of-shift report on a medical unit, which patient should the nurse assess first? a. A patient with cystic fibrosis who has thick, green-colored sputum b. A patient with pneumonia who has crackles bilaterally in the lung bases c. A patient with emphysema who has an oxygen saturation of 90% to 92% d. A patient with septicemia who has intercostal and suprasternal retractions

D This patient's history of septicemia and labored breathing suggest the onset of ARDS, which will require rapid interventions such as administration of O2 and use of positive-pressure ventilation. The other patients should also be assessed, but their assessment data are typical of their disease processes and do not suggest deterioration in their status. DIF: Cognitive Level: Analyze (analysis) REF: 1622 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Assessment

16. After receiving change-of-shift report, which patient will the nurse assess first? a. A patient with cystic fibrosis who has thick, green-colored sputum b. A patient with pneumonia who has coarse crackles in both lung bases c. A patient with emphysema who has an oxygen saturation of 91% to 92% d. A patient with septicemia who has intercostal and suprasternal retractions

D This patient's history of septicemia and labored breathing suggest the onset of ARDS, which will require rapid interventions such as administration of oxygen and use of positive pressure ventilation. The other patients also should be assessed as quickly as possible, but their assessment data are typical of their disease processes and do not suggest deterioration in their status. DIF: Cognitive Level: Analysis REF: 1758-1760 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Assessment

9. A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should the nurse perform prior to defibrillating this client? a. Make sure the defibrillator is set to the synchronous mode. b. Administer 1 mg of intravenous epinephrine. c. Test the equipment by delivering a smaller shock at 100 joules. d. Ensure that everyone is clear of contact with the client and the bed.

D To avoid injury, the rescuer commands that all personnel clear contact with the client or the bed and ensures their compliance before delivery of the shock. A precordial thump can be delivered when no defibrillator is available. Defibrillation is done in asynchronous mode. Equipment should not be tested before a client is defibrillated because this is an emergency procedure; equipment should be checked on a routine basis. Epinephrine should be administered after defibrillation. DIF: Applying/Application REF: 668 KEY: Cardiac electrical conduction| safety

8. A patient who has had chest pain for several hours is admitted with a diagnosis of rule out acute myocardial infarction (AMI). Which laboratory test should the nurse monitor to best determine whether the patient has had an AMI? a. Myoglobin c. C-reactive protein b. Homocysteine d. Cardiac-specific troponin

D Troponin levels increase about 4 to 6 hours after the onset of myocardial infarction (MI) and are highly specific indicators for MI. Myoglobin is released within 2 hours of MI, but it lacks specificity and its use is limited. The other laboratory data are useful in determining the patient's risk for developing coronary artery disease but are not helpful in determining whether an acute MI is in progress. DIF: Cognitive Level: Understand (comprehension) REF: 722 TOP: Nursing Process: Assessment

34. Which action could the nurse delegate to unlicensed assistive personnel (UAP) trained as electrocardiogram (ECG) technicians working on the cardiac unit? a. Select the best lead for monitoring a patient with an admission diagnosis of Dressler syndrome. b. Obtain a list of herbal medications used at home while admitting a new patient with pericarditis. c. Teach about the need to monitor the weight daily for a patient who has hypertrophic cardiomyopathy. d. Watch the heart monitor for changes in rhythm while a patient who had a valve replacement ambulates.

D Under the supervision of registered nurses (RNs), UAPs check the patient's cardiac monitor and obtain information about changes in heart rate and rhythm with exercise. Teaching and obtaining information about home medications (prescribed or complementary) and selecting the best leads for monitoring patients require more critical thinking and should be done by the RN. DIF: Cognitive Level: Apply (application) REF: 782 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

13. Which action should the nurse take when preparing for cardioversion of a patient with supraventricular tachycardia who is alert and has a blood pressure of 110/66 mm Hg? a. Turn the synchronizer switch to the "off" position. b. Perform cardiopulmonary resuscitation (CPR) until the paddles are in correct position. c. Set the defibrillator/cardioverter energy to 300 joules. d. Administer a sedative before cardioversion is implemented.

D When a patient has a nonemergency cardioversion, sedation is used just before the procedure. The synchronizer switch is turned on for cardioversion. The initial level of joules for cardioversion is low (e.g., 50). CPR is not indicated for this patient. DIF: Cognitive Level: Application REF: 833-834 TOP: Nursing Process: Implementation

10. An emergency department nurse is caring for a client who has died from a suspected homicide. Which action should the nurse take? a. Remove all tubes and wires in preparation for the medical examiner. b. Limit the number of visitors to minimize the family's trauma. c. Consult the bereavement committee to follow up with the grieving family. d. Communicate the client's death to the family in a simple and concrete manner.

D When dealing with clients and families in crisis, communicate in a simple and concrete manner to minimize confusion. Tubes must remain in place for the medical examiner. Family should be allowed to view the body. Offering to call for additional family support during the crisis is suggested. The bereavement committee should be consulted, but this is not the priority at this time. DIF: Applying/Application REF: 114 KEY: Death| emergency nursing

5. During the emergent phase of burn care, which nursing action will be most useful in determining whether the patient is receiving adequate fluid infusion? a. Check skin turgor. b. Monitor daily weight. c. Assess mucous membranes. d. Measure hourly urine output.

D When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hour. The patient's weight is not useful in this situation because of the effects of third spacing and evaporative fluid loss. Mucous membrane assessment and skin turgor also may be used, but they are not as adequate in determining that fluid infusions are maintaining adequate perfusion. DIF: Cognitive Level: Application REF: 483 TOP: Nursing Process: Evaluation

5. During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion? a. Check skin turgor. c. Assess mucous membranes. b. Monitor daily weight. d. Measure hourly urine output.

D When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hr. The patient's weight is not useful in this situation because of the effects of third spacing and evaporative fluid loss. Mucous membrane assessment and skin turgor also may be used, but they are not as adequate in determining that fluid infusions are maintaining adequate perfusion. DIF: Cognitive Level: Analyze (analysis) REF: 434 TOP: Nursing Process: Evaluation

25. When caring for the patient with a pulmonary artery pressure catheter, the nurse notes that the PA waveform indicates that the catheter is in the wedged position. Which action should the nurse take? a. Inflate the PA balloon. b. Change the flush system. c. Zero balance the transducer. d. Notify the health care provider.

D When the catheter is in the wedge position, blood flow past the catheter is obstructed, placing the patient at risk for pulmonary infarction. A health care provider or specially trained nurse should be called to reposition the catheter. The other actions will not correct the wedging of the PA catheter. DIF: Cognitive Level: Application REF: 1696 TOP: Nursing Process: Implementation

16. After an employee spills industrial acids on the arms and legs at work, what is the priority action that the occupational health nurse at the facility should take? a. Apply an alkaline solution to the affected area. b. Place cool compresses on the area of exposure. c. Cover the affected area with dry, sterile dressings. d. Flush the burned area with large amounts of water.

D With chemical burns, the initial action is to remove the chemical from contact with the skin as quickly as possible. Covering the affected area or placing cool compresses on the area will leave the chemical in contact with the skin. Application of an alkaline solution is not recommended. DIF: Cognitive Level: Application REF: 477 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

1. In which order will the nurse perform the following actions when caring for a patient with possible C5 spinal cord trauma who is admitted to the emergency department? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Infuse normal saline at 150 mL/hr. b. Monitor cardiac rhythm and blood pressure. c. Administer O2 using a nonrebreather mask. d. Immobilize the patient's head, neck, and spine. e. Transfer the patient to radiology for spinal computed tomography (CT).

D, C, B, A, E The first action should be to prevent further injury by stabilizing the patient's spinal cord if the patient does not have penetrating trauma. Maintenance of oxygenation by administration of 100% O2 is the second priority. Because neurogenic shock is a possible complication, monitoring of heart rhythm and BP are indicated followed by infusing normal saline for volume replacement. A CT scan to determine the extent and level of injury is needed once initial assessment and stabilization are accomplished. DIF: Cognitive Level: Analyze (analysis) REF: 1425 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

1. In which order will the nurse take these actions when doing a dressing change for a partial-thickness burn wound on a patient's chest? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Apply sterile gauze dressing. b. Document wound appearance. c. Apply silver sulfadiazine cream. d. Give IV fentanyl (Sublimaze). e. Clean wound with saline-soaked gauze.

D, E, C, A, B Because partial-thickness burns are very painful, the nurse's first action should be to give pain medications. The wound will then be cleaned, antibacterial cream applied, and covered with a new sterile dressing. The last action should be to document the appearance of the wound. DIF: Cognitive Level: Analyze (analysis) REF: 445 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

3. In which order will the nurse take these actions when doing a dressing change for a partial-thickness burn wound on a patient's back? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. Apply sterile gauze dressing. b. Document wound appearance. c. Apply silver sulfadiazine cream. d. Administer IV fentanyl (Sublimaze). e. Clean wound with saline-soaked gauze.

D, E, C, A, B Since partial-thickness burns are very painful, the nurse's first action should be to administer pain medications. The wound will then be cleaned, antibacterial cream applied, and covered with a new sterile dressing. The last action should be to document the appearance of the wound. DIF: Cognitive Level: Application REF: 488 | 490 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

1. When assisting with oral intubation of a patient who is having respiratory distress, in which order will the nurse take these actions? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Obtain a portable chest-x-ray. b. Position the patient in the supine position. c. Inflate the cuff of the endotracheal tube after insertion. d. Attach an end-tidal CO2 detector to the endotracheal tube. e. Oxygenate the patient with a bag-valve-mask device for several minutes.

E, B, C, D, A The patient is pre-oxygenated with a bag-valve-mask system for 3 to 5 minutes before intubation and then placed in a supine position. After the intubation, the cuff on the endotracheal tube is inflated to occlude and protect the airway. Tube placement is assessed first with an end-tidal CO2 sensor and then with chest x-ray examination. DIF: Cognitive Level: Analyze (analysis) REF: 1570 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

1. In which order will the nurse perform the following actions when caring for a patient with possible C6 spinal cord trauma who is admitted to the emergency department? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. Infuse normal saline at 150 mL/hr. b. Monitor cardiac rhythm and blood pressure. c. Administer O2 using a non-rebreather mask. d. Transfer the patient to radiology for spinal computed tomography (CT). e. Immobilize the patient's head, neck, and spine.

E, C, B, A, D The first action should be to prevent further injury by stabilizing the patient's spinal cord. Maintenance of oxygenation by administration of 100% O2 is the second priority. Because neurogenic shock is a possible complication, monitoring of heart rhythm and BP are indicated, followed by infusing normal saline for volume replacement. A CT scan to determine the extent and level of injury is needed once initial assessment and stabilization are accomplished. DIF: Cognitive Level: Application REF: 1553 | 1555 | 1558-1559 OBJ: Special Questions: Alternate Item Format, Prioritization TOP: Nursing Process: Implementation

1. The health care provider orders the following interventions for a 67-kg patient who has septic shock with a blood pressure of 70/42 mm Hg and O2 saturation of 90% on room air. In which order will the nurse implement the actions? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Give vancomycin 1 g IV. b. Obtain blood and urine cultures c. Start norepinephrine 0.5 mcg/min. d. Infuse normal saline 2000 mL over 30 minutes. e. Titrate oxygen administration to keep O2 saturation above 95%.

E, D, C, B, A The initial action for this hypotensive and hypoxemic patient should be to improve the O2 saturation, followed by infusion of IV fluids and vasopressors to improve perfusion. Cultures should be obtained before giving antibiotics. DIF: Cognitive Level: Analyze (analysis) REF: 1600 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

2. A client had an embolic stroke and is having an echocardiogram. When the client asks why the provider ordered "a test on my heart," how should the nurse respond? a. "Most of these types of blood clots come from the heart." b. "Some of the blood clots may have gone to your heart too." c. "We need to see if your heart is strong enough for therapy." d. "Your heart may have been damaged in the stroke too."

A An embolic stroke is caused when blood clots travel from one area of the body to the brain. The most common source of the clots is the heart. The other statements are inaccurate. DIF: Understanding/Comprehension REF: 931 KEY: Neurologic disorders| stroke| patient education

5. An emergency department nurse assesses a client admitted after a lightning strike. Which assessment should the nurse complete first? a. Electrocardiogram (ECG) b. Wound inspection c. Creatinine kinase d. Computed tomography of head

A Clients who survive an immediate lightning strike can have serious myocardial injury, which can be manifested by ECG and myocardial perfusion abnormalities. The nurse should prioritize the ECG. Other assessments should be completed but are not the priority. DIF: Applying/Application REF: 130 KEY: Lightning injuries| environmental emergencies

12. A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the nurse collect to determine whether the patient is developing postconcussion syndrome? a. Short-term memory c. Glasgow Coma Scale b. Muscle coordination d. Pupil reaction to light

A Decreased short-term memory is one indication of postconcussion syndrome. The other data may be assessed but are not indications of postconcussion syndrome. DIF: Cognitive Level: Apply (application) REF: 1327 TOP: Nursing Process: Assessment

13. A patient arrives in the emergency department (ED) a few hours after taking "20 to 30" acetaminophen (Tylenol) tablets. Which action will the nurse plan to take? a. Give N-acetylcysteine (Mucomyst). b. Discuss the use of chelation therapy. c. Have the patient drink large amounts of water. d. Administer oxygen using a non-rebreather mask.

A N-acetylcysteine is the recommended treatment to prevent liver damage after acetaminophen overdose. The other actions might be used for other types of poisoning, but they will not be appropriate for a patient with acetaminophen poisoning. DIF: Cognitive Level: Comprehension REF: 1781-1782 TOP: Nursing Process: Planning

2. A patient with a head injury has admission vital signs of blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse? a. Blood pressure 156/60, pulse 55, respirations 12 b. Blood pressure 130/72, pulse 90, respirations 32 c. Blood pressure 148/78, pulse 112, respirations 28 d. Blood pressure 110/70, pulse 120, respirations 30

A Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad and indicate that the intracranial pressure (ICP) has increased, and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process. DIF: Cognitive Level: Application REF: 1429-1430 TOP: Nursing Process: Assessment

13. When admitting a patient who has a tumor of the right frontal lobe, the nurse would expect to find a. judgment changes. b. expressive aphasia. c. right-sided weakness. d. difficulty swallowing.

A The frontal lobes control intellectual activities such as judgment. Speech is controlled in the parietal lobe. Weakness and hemiplegia occur on the contralateral side from the tumor. Swallowing is controlled by the brainstem. DIF: Cognitive Level: Application REF: 1447 | 1448 TOP: Nursing Process: Assessment

28. A patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? a. Check the respiratory rate. b. Monitor the blood pressure. c. Send the patient for a CT scan. d. Obtain the Glasgow Coma Scale score.

A The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, circulation) are completed. DIF: Cognitive Level: Application REF: 1469-1471 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

16. The following actions are part of the routine emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first? a. Remove the patient's rings. b. Place ice packs on both hands. c. Apply calamine lotion to any itching areas. d. Give diphenhydramine (Benadryl) 100 mg PO.

A The patient's rings should be removed first because it might not be possible to remove them if swelling develops. The other orders also should be implemented as rapidly as possible after the nurse has removed the jewelry. DIF: Cognitive Level: Application REF: 1779-1781 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

1. When preparing to defibrillate a patient, in which order will the nurse perform the following steps? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Turn the defibrillator on. b. Deliver the electrical charge. c. Select the appropriate energy level. d. Place the hands-free, multifunction defibrillator pads on the patient's chest. e. Check the location of other staff and call out "all clear."

A, C, D, E, B This order will result in rapid defibrillation without endangering hospital staff. DIF: Cognitive Level: Analyze (analysis) REF: 771 TOP: Nursing Process: Implementation

22. A client has an intraventricular catheter. What action by the nurse takes priority? a. Document intracranial pressure readings. b. Perform hand hygiene before client care. c. Measure intracranial pressure per hospital policy. d. Teach the client and family about the device.

B All of the actions are appropriate for this client. However, performing hand hygiene takes priority because it prevents infection, which is a possibly devastating complication. DIF: Applying/Application REF: 961 KEY: Neurologic disorders| Standard Precautions| infection control

1. When developing a teaching plan for a 61-yr-old patient with multiple risk factors for coronary artery disease (CAD), the nurse should focus primarily on the a. family history of coronary artery disease. b. elevated low-density lipoprotein (LDL) level. c. increased risk associated with the patient's gender. d. increased risk of cardiovascular disease as people age.

B Because family history, gender, and age are nonmodifiable risk factors, the nurse should focus on the patient's LDL level. Decreases in LDL will help reduce the patient's risk for developing CAD. DIF: Cognitive Level: Apply (application) REF: 703 TOP: Nursing Process: Planning

10. After teaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching? a. "I should wear a snug-fitting shirt over the ICD." b.. "I will avoid sources of strong electromagnetic fields." c. "I should participate in a strenuous exercise program." d. "Now I can discontinue my antidysrhythmic medication."

B The client being discharged with an ICD is instructed to avoid strong sources of electromagnetic fields. Clients should avoid tight clothing, which could cause irritation over the ICD generator. The client should be encouraged to exercise but should not engage in strenuous activities that cause the heart rate to meet or exceed the ICD cutoff point because the ICD can discharge inappropriately. The client should continue all prescribed medications. DIF: Applying/Application REF: 674 KEY: Cardiac electrical conduction

20. A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention ordered by the health care provider should the nurse implement first? a. Insert two large-bore IV catheters. b. Provide O2 at 100% per non-rebreather mask. c. Draw blood to type and crossmatch for transfusions. d. Initiate continuous electrocardiogram (ECG) monitoring.

B The first priority in the initial management of shock is maintenance of the airway and ventilation. ECG monitoring, insertion of IV catheters, and obtaining blood for transfusions should also be rapidly accomplished but only after actions to maximize O2 delivery have been implemented. DIF: Cognitive Level: Analyze (analysis) REF: 1597 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

25. During change-of-shift report on a medical unit, the nurse learns that a patient with aspiration pneumonia who was admitted with respiratory distress has become increasingly agitated. Which action should the nurse take first? a. Give the prescribed PRN sedative drug. b. Offer reassurance and reorient the patient. c. Use pulse oximetry to check the oxygen saturation. d. Notify the health care provider about the patient's status.

C Agitation may be an early indicator of hypoxemia. The other actions may also be appropriate, depending on the findings about O2 saturation. DIF: Cognitive Level: Analyze (analysis) REF: 1610 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

5. A nurse assesses a client who has a burn injury.. Which statement indicates the client has a positive perspective of his or her appearance? a. "I will allow my spouse to change my dressings." b. "I want to have surgical reconstruction." c. "I will bathe and dress before breakfast." d. "I have secured the pressure dressings as ordered."

C Indicators that the client with a burn injury has a positive perception of his or her appearance include a willingness to touch the affected body part. Self-care activities such as morning care foster feelings of self-worth, which are closely linked to body image. Allowing others to change the dressing and discussing future reconstruction would not indicate a positive perception of appearance. Wearing the dressing will assist in decreasing complications but will not enhance self-perception. DIF: Applying/Application REF: 488 KEY: Psychosocial response| coping

8. A nurse assesses a client recently bitten by a coral snake. Which assessment should the nurse complete first? a. Unilateral peripheral swelling b. Clotting times c. Cardiopulmonary status d. Electrocardiogram rhythm

C Manifestations of coral snake envenomation are the result of its neurotoxic properties. The physiologic effect is to block neurotransmission, which produces ascending paralysis, reduced perception of pain, and, ultimately, respiratory paralysis. The nurse should monitor for respiratory rate and depth. Severe swelling and clotting problems do not occur with coral snakes but do occur with pit viper snakes. Electrocardiogram rhythm is not affected by neurotoxins. DIF: Applying/Application REF: 124 KEY: Snakebite| environmental emergencies

4. The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication's effectiveness? a. Blood pressure c. Intracranial pressure b. Oxygen saturation d. Hemoglobin and hematocrit

C Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure. It may initially reduce hematocrit and increase blood pressure, but these are not the best parameters for evaluation of the effectiveness of the drug. O2 saturation will not directly improve as a result of mannitol administration. DIF: Cognitive Level: Apply (application) REF: 1322 TOP: Nursing Process: Evaluation

18. A patient is admitted to the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to a. obtain the blood pressure. b. check the level of orientation. c. administer supplemental oxygen. d. obtain a 12-lead electrocardiogram.

C The initial actions of the nurse are focused on the ABCs—airway, breathing, and circulation—and administration of O2 should be done first. The other actions should be accomplished as rapidly as possible after providing O2. DIF: Cognitive Level: Analyze (analysis) REF: 1597 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

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

C The low pressure alarm indicates a drop in the patient's blood pressure, which may be caused by cardiac dysrhythmias. There is no indication to re-zero the equipment. Pallor of the left hand would be caused by occlusion of the radial artery by the arterial catheter, not by low pressure. There is no indication of a need for flushing the line. DIF: Cognitive Level: Apply (application) REF: 1564 TOP: Nursing Process: Implementation

14. A patient who has had a stroke has a new order to attempt oral feedings. The nurse should assess the gag reflex and then a. order a varied pureed diet. b. assess the patient's appetite. c. assist the patient into a chair. d. offer the patient a sip of juice.

C The patient should be as upright as possible before attempting feeding to make swallowing easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient. Pureed diets are not recommended because the texture is too smooth. The patient may have a poor appetite, but the oral feeding should be attempted regardless. DIF: Cognitive Level: Application REF: 1470 TOP: Nursing Process: Implementation

41. A patient with diabetes mellitus and chronic stable angina has a new order for captopril . The nurse should teach the patient that the primary purpose of captopril is to a. decrease the heart rate. c. prevent changes in heart muscle. b. control blood glucose levels. d. reduce the frequency of chest pain.

C The purpose for angiotensin-converting enzyme (ACE) inhibitors in patients with chronic stable angina who are at high risk for a cardiac event is to decrease ventricular remodeling. ACE inhibitors do not directly impact angina frequency, blood glucose, or heart rate. DIF: Cognitive Level: Apply (application) REF: 715 TOP: Nursing Process: Planning

5. After receiving 2 L of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate an order for a. furosemide . c. norepinephrine . b. nitroglycerin . d. sodium nitroprusside .

C When fluid resuscitation is unsuccessful, vasopressor drugs are given to increase the systemic vascular resistance (SVR) and blood pressure and improve tissue perfusion. Furosemide would cause diuresis and further decrease the BP. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Nitroprusside is an arterial vasodilator and would further decrease SVR. DIF: Cognitive Level: Apply (application) REF: 1599 TOP: Nursing Process: Planning

1. A 58-year-old patient who began experiencing right-sided arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. Obtain CT scan without contrast. b. Infuse tissue plasminogen activator (tPA). c. Administer oxygen to keep O2 saturation >95%. d. Use National Institute of Health Stroke Scale to assess patient.

C, D, A, B The initial actions should be those that help with airway, breathing, and circulation. Baseline neurologic assessments should be done next. A CT scan will be needed to rule out hemorrhagic stroke before tPA can be administered. DIF: Cognitive Level: Application REF: 1470 OBJ: Special Questions: Alternate Item Format, Prioritization TOP: Nursing Process: Implementation

39. Which is the correct point on the accompanying figure where the nurse will assess for ecchymosis when admitting a patient with a basilar skull fracture? a. A b. B c. C d. D

D Battle's sign (postauricular ecchymosis) and periorbital ecchymoses are associated with basilar skull fracture. DIF: Cognitive Level: Understand (comprehension) REF: 1369 TOP: Nursing Process: Assessment

1. When developing a health teaching plan for a 60-year-old man with the following risk factors for coronary artery disease (CAD), the nurse should focus on the a. family history of coronary artery disease. b. increased risk associated with the patient's gender. c. high incidence of cardiovascular disease in older people. d. elevation of the patient's serum low density lipoprotein (LDL) level.

D Because family history, gender, and age are nonmodifiable risk factors, the nurse should focus on the patient's LDL level. Decreases in LDL will help reduce the patient's risk for developing CAD. DIF: Cognitive Level: Application REF: 767 TOP: Nursing Process: Planning

15. When analyzing the waveforms of a patient's electrocardiogram (ECG), the nurse will need to investigate further upon finding a a. T wave of 0.16 second. b. P-R interval of 0.18 second. c. Q-T interval of 0.34 second. d. QRS interval of 0.14 second.

D Because the normal QRS interval is 0.04 to 0.10 seconds, the patient's QRS interval of 0.14 seconds indicates that the conduction through the ventricular conduction system is prolonged. The P-R interval, Q-T interval, and T wave interval are within the normal range. DIF: Cognitive Level: Application REF: 822 TOP: Nursing Process: Assessment

6. A patient has a normal cardiac rhythm and a heart rate of 72 beats/minute, except that the PR interval is 0.24 seconds. The appropriate intervention by the nurse is to a. notify the patient's health care provider immediately. b. administer atropine per agency bradycardia protocol. c. prepare the patient for temporary pacemaker insertion. d. document the finding and continue to monitor the patient.

D First-degree atrioventricular (AV) block is asymptomatic and requires ongoing monitoring because it may progress to more serious forms of heart block. The rate is normal, so there is no indication that atropine is needed. Immediate notification of the health care provider about an asymptomatic rhythm is not necessary. DIF: Cognitive Level: Application REF: 828-829 TOP: Nursing Process: Implementation

3. A patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find? a. Impulsive behavior b. Right-sided neglect c. Hyperactive left-sided tendon reflexes d. Difficulty comprehending instructions

D Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and use of language. The left-side reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a right-side stroke. DIF: Cognitive Level: Apply (application) REF: 1350 TOP: Nursing Process: Assessment

21. Four hours after mechanical ventilation is initiated, a patient's arterial blood gas (ABG) results include a pH of 7.51, PaO2 of 82 mm Hg, PaCO2 of 26 mm Hg, and HCO3- of 23 mEq/L (23 mmol/L). The nurse will anticipate the need to a. increase the FIO2. c. increase the respiratory rate. b. increase the tidal volume. d. decrease the respiratory rate.

D The patient's PaCO2 and pH indicate respiratory alkalosis caused by too high a respiratory rate. The PaO2 is appropriate for a patient with COPD and increasing the respiratory rate and tidal volume would further lower the PaCO2. DIF: Cognitive Level: Analyze (analysis) REF: 1571 TOP: Nursing Process: Planning

4. A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain? a. Loss of bladder control b. Other medical conditions c. Progression of symptoms d. Time of symptom onset

D The time limit for initiating fibrinolytic therapy for a stroke is 3 to 4.5 hours, so the exact time of symptom onset is the most important information for this client. The other information is not as critical. DIF: Applying/Application REF: 938 KEY: Stroke| neurologic disorders| nursing assessment| fibrinolytic therapy

12. The nurse is preparing to change a client's sternal dressing. What action by the nurse is most important? a. Assess vital signs. b. Don a mask and gown. c. Gather needed supplies. d. Perform hand hygiene.

D To prevent a sternal wound infection, the nurse washes hands or performs hand hygiene as a priority. Vital signs do not necessarily need to be assessed beforehand. A mask and gown are not needed. The nurse should gather needed supplies, but this is not the priority. DIF: Applying/Application REF: 776 KEY: Coronary artery disease| infection control| hand hygiene

2. A client in the emergency department is having a stroke. The client weighs 225 pounds. After the initial bolus of t-Pa, at what rate should the nurse set the IV pump? (Record your answer using a decimal rounded to the nearest tenth.) ____ mL/hr

1.4 mL/hr The client weighs 102 kg. The dose of t-PA is 0.9 mg/kg with a maximum of 90 mg, so the client's dose is 90 mg. 10% of the dose is given as a bolus IV over the first minute (9 mg). That leaves 81 mg to run in over 59 minutes., which rounds to 1.4 mL/hr. DIF: Applying/Application REF: 939 KEY: Neurologic disorders| drug calculation| thrombolytic agents

1. A patient with neurogenic shock after a spinal cord injury is to receive lactated Ringer's solution 400 mL over 20 minutes. When setting the IV pump to deliver the IV fluid, the nurse will set the rate at how many milliliters per hour?

1200 To administer 400 mL in 20 minutes, the nurse will need to set the pump to run at 1200 mL/hour. DIF: Cognitive Level: Understand (comprehension) REF: 1420 TOP: Nursing Process: Implementation

1. A client with severe sepsis has a serum lactate level of 6.2 mmol/L. The client weighs 250 pounds. To infuse the amount of fluid this client requires in 24 hours, at what rate does the nurse set the IV pump? (Record your answer using a whole number.) ____ mL/hr

142 mL/hr The client weighs 250 pounds = 113.63636 kg. The fluid requirement for this client is 30 mL/kg = 3409 mL. To infuse this amount over 24 hours, set the pump at 142 mL/hr (3409/24 = 142). DIF: Analyzing/Analysis REF: 747 KEY: IV fluids| fluid and electrolyte imbalance| critical rescue| sepsis| shock

1. An emergency room nurse cares for a client admitted with a 50% burn injury at 10:00 this morning. The client weighs 90 kg. Using the Parkland formula, calculate the rate at which the nurse should infuse intravenous fluid resuscitation when started at noon. (Record your answer using a whole number.) _____ mL/hr

1500 mL/hr The Parkland formula is 4 mL/kg/% total body surface area burn. This client needs 18,000 mL of fluid during the first 24 hours postburn. Half of the calculated fluid replacement needs to be administered during the first 8 hours after injury, and half during the next 16 hours. This client was burned at 10:00 AM, and fluid was not started until noon. Therefore, 9000 mL must be infused over the next 6 hours at a rate of 1500 mL/hr to meet the criteria of receiving half the calculated dose during the first 8 postburn hours. DIF: Applying/Application REF: 478 KEY: Medication calculation