Acute Care Final

The nurse is caring for a client receiving mechanical ventilation. The nurse understands which are the possible causes for a high-pressure alarm? (Select all that apply.)

- Secretions - Bronchospasm's - Kinked tubing

Which patient should the nurse prioritize as needing emergent treatment, assuming no other injuries are present except the ones outlined below?

· A patient with a blunt chest trauma with some difficulty breathing.

Tidal volume:

TV= TLC-(IRV+ERV+RV)

A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.)

· Acknowledge the frightening nature of the illness. · Delegate a back rub to the unlicensed assistive personnel (UAP). · Give simple explanations of what is happening. · Stay with the client and speak in a quiet, calm voice.

CroFab

anti-venom to bites from certain snakes (e.g., rattlesnakes, cottonmouths/water moccasins, copperheads)

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.)

· Adherence to proper hand hygiene · Administering anti-ulcer medication · Elevating the head of the bed · Providing oral care per protocol

Which are the top priorities when conducting a primary patient survey during the emergency assessment? (Select all that apply.)

· Airway · Cervical spine

The nurse should expect to assess which clinical manifestations in an adolescent with Cushing's syndrome? (Select all)

· Hyperglycemia · Cushingoid features · Susceptibility to infections

The nursing instructor is preparing to speak to a group of nursing students about direct and indirect insults to the lungs that may lead to the development of acute respiratory distress syndrome (ARDS). The nurse educator is aware that which conditions may lead to the development of ARDS? Select all that apply.

· Septic shock · Viral pneumonia · Aspirin overdose · Head injury

What discharge instructions should the nurse include for a client following a transsphenoidal hypophysectomy?

· Sleep with head of bed at 35 degrees. · Notify the primary healthcare provider for an increased urinary output. · Use a humidifier in the room.

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?

· Start an intravenous line and infuse 0.9% saline solution.

Which patient requires immediate intervention by the nurse to decrease the risk for developing a deep vein thrombosis (DVT)?

· The patient who is immobile because of a fractured hip.

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?

· "It will prevent ulcers from the stress of mechanical ventilation."

The nurse provides discharge instruction to a patient who had a transsphenoidal hypophysectomy. Which patient statement indicates a need for additional teaching?

· "My neck will probably be stiff and sore for several days."

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 accurate?

· "PEEP prevents the lung air sacs from collapsing during exhalation."

The emergency department nurse is triaging patients for the urgent or non-urgent track. Which patient should the nurse triage into the non-urgent track

· A middle-aged adult complaining of sinus headache and possible sinus infection.

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.)

· Administer oxygen via mask or nasal cannula. · Infuse 0.9% sodium chloride via a large-bore intravenous cannula. · Obtain baseline serum electrolytes and cardiac enzymes.

A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.)

· Allow visitors at the client's bedside. · Ensure the client can communicate if awake. · Provide back and hand massages when turning. · Turn the client every 2 hours or more.

A client who has suffered a compound fracture is preparing for discharge to home. During the teaching session, the client asks why he needs antibiotics for a broken bone. Which response by the nurse is most appropriate?

· Antibiotic therapy has been prescribed as a precaution because your bone was exposed to the environment at the time of your injury.

A nurse is caring for a client who is receiving mechanical ventilation when the low pressure alarm sounds. Which of the following situations should the nurse recognize as a possible cause of the alarm?

· Artificial airway cuff leak.

While caring for a patient with an endotracheal tube, the nurses recognizes that suctioning is required how often?

· When adventitious breath sounds are auscultated.

Ngn- 75-year-old male with dyspnea and shortness of breath, med history and nurse's notes, 3 findings require immediate follow up.

-Decreased lung sounds -HR 110/min and regular -Subcutaneous emphysema

A nurse is caring for a patient who remains intubated after receiving a procedure performed under general anesthesia. The nurse understands that extubation will occur when which of the following happens?

Client regained control of coughing and swallowing reflexes, Extubation will NOT occur until the client is able to protect the airway, and the airway is patent. Client must also have adequate cough strengths and adequate LOC.

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?

· Assess the cause of the agitation.

A nurse cares for a male client with hypopituitarism who is prescribed testosterone hormone replacement therapy. The client asks, How long will I need to take this medication? How should the nurse respond?

· When your beard thickens and your voice deepens, the dose is decreased, but treatment will continue forever.

Which of the following are clinical manifestations of Cushing Syndrome? (Select all)

· weight gain · moon face · purple/red striae · Hypokalemia

The nurse suctions a mechanically ventilated patient using in-line sectioning. Which information should the nurse document in the medical record after procedure is completed?

· The amount of secretions, color of secretions, consistency of secretions, patient's response to procedure.

Ngn- client with pneumonia and dyspnea, rapid breathing, high blood pressure, o2 increased. What condition is client most likely experiencing?

ARDS

An 80-year-old woman was admitted to the hospital after a motor vehicle crash. Her injuries include a left fractured hip, left compound fractured wrist, and multiple contusion and lacerations. The nurse notes that preoperativeBuck's traction has been applied to the client's left leg with two weights of 5 Lbs. each. Her left lower arm has an external fixator to manage the open wound while the fracture heals. For each nursing action below use an X to specify whether the action would be "Indicated" (appropriate or necessary), "Contraindicated" (could be harmful) or "Non-essential (makes no difference, or not necessary).

-Indicated: assess pin sites, check the cast, assist the client when ambulating, check all traction -Contraindicated: remove traction for 2 hours -Non-essential: take temp every hour

A patient with severe hypokalemia is prescribed parenteral administration of potassium. How does the nurse administer potassium to the patient?

1 mEq of potassium to 10 mL intravenous solution

Labs of hypothyroidism:

Decrease in serum TSH, increased T3, T4, free T4, and an increase in radioactive iodine uptake

For a patient with symptomatic sinus bradycardia, appropriate nursing interventions include establishing IV access to administer which medication?

· Atropine

A 28-year-old female client was admitted to the emergency department (ED) with recent burns on both arms. Her husband explained that when she was cooking dinner, she accidentally started a grease fire while he was downstairs in the basement watching football. She put on oven mitts to cover both hands and tried to smother the fire with a towel and a small fire extinguisher, which was quickly successful. The nurse notes that the client has superficial partial-thickness burns on most of the anterior surfaces of both arms, but her hands are not affected. She also has a few superficial burns on about half of the posterior aspects of both arms. Select the nursing actions below that are indicated (appropriate or necessary) for the client's care at this time.

-Indicated: initiate an IV, remove eschar, manage pain, administer tetanus -Non-essential: 12-lead EKG, O2 therapy, help client take a shower

The nurse is assessing a patient diagnosed with Graves disease. What physical characteristics of Graves disease would the nurse expect to find

· Bulging eyes.

A nurse is assigned to care for four clients. The client with which of the following drainage tubes is at an increased risk for hypokalemia?

· NG tube to suction

The nurse is caring for a patient who is receiving oxygen therapy for pneumonia. How should the nurse best assess whether the patient is hypoxemic?

· Assess the patient's oxygen saturation level.

The nurse is caring for a client who has just been admitted to the nursing unit after receiving flame burns to the face and chest. The nurse notes a hoarse cough, and the client is expectorating sputum with black flecks. The client suddenly becomes restless and his color is becoming dusky. Based on this data, which interpretation should the nurse make?

· The burn has probably caused laryngeal edema, which has occluded the airway.

A nurse explains the homeostatic mechanisms involved in fluid homeostasis to a student nurse. Which of the following statements accurately describe this process? (Select all that apply.)

· The kidneys selectively retain electrolytes and water and excrete wastes and excesses according to the body's needs. · The cardiovascular system is responsible for pumping and carrying nutrients and water throughout the body. · The lungs regulate oxygen and carbon dioxide levels of the blood, which is especially crucial in maintaining acid-base balance. · The parathyroid glands secrete parathyroid hormone, which regulates the level of calcium and phosphorus.

A nurse cares for a client with a hypofunctioning anterior pituitary gland. Which hormones should the nurse expect to be affected by this condition? (Select all that apply.)

· Thyroid-stimulating hormone · Follicle-stimulating hormone · Growth hormone

A patient is experiencing dysfunction of the hypothalamus. Which hormones will be affected by this dysfunction? (Select all that apply.)

· Thyrotropin-releasing hormone (TRH) · Corticotropin-releasing hormone (CRH) · Gonadotropin-releasing hormone (Gn-RH) · Growth hormone-releasing hormone (GHRH)

The occupational health nurse is assessing an employee who has just had respiratory exposure to a toxin. What should the nurse assess? (Select all that apply.)

· Time frame of exposure. · Type of respiratory protection used. · Breath sounds. · Intensity of exposure.

Labs of DIC

Elevated PT (prothrombin time), elevated PTT, decreased platelet count, decreased fibrinogen, elevated fibrin degradation product (FDP), elevated D-dimer.

A nurse is assessing a client with Cushing syndrome. Which signs should the nurse expect the client to exhibit? Select all that apply.

Hirsutism, Round face, Buffalo hump.

A nurse is reviewing ECG tracings for the assigned patients. The nurse notes that one patient has first-degree heart block. What part of the ECG tracing is abnormal to make this conclusion and when is it considered abnormal?

· A PR interval consistently longer than 0.20 seconds on the ECG tracings. If the PR interval is consistently longer than 0.20 seconds (or 5 small squares on an ECG paper), this is considered prolonged and indicative of a first-degree heart block.

What are appropriate nursing interventions for a client who is hospitalized after a stroke?

· Assess for neurologic dysfunction · Position the client properly to prevent complications such as pressure ulcers, contractures, and deep vein thrombosis · Assist with rehabilitation and therapy · Administer medications as prescribed. · Monitor for signs of dysphagia · Prevent complications by prophylactic anticoagulation, infection control measures, and fall prevention strategies

The nurse is admitting a patient with a penetrating abdominal injury from a knife wound. What are the priority actions by the nurse for this patient? (Select all that apply.)

· Assessing for manifestations of hemorrhage · Covering any protruding viscera with sterile dressings soaked in · Looking for any associated chest injuries

A patient's plan of care specifies postural drainage. What action should the nurse perform when providing this noninvasive therapy?

· Assist the patient into a position that will allow gravity to move secretions.

The nurse is reviewing the medical history of a patient with adrenal insufficiency. What should the nurse identify as possible causes for the disorder in this patient? (Select all that apply.)

· Cancer · Trauma · Infection · Autoimmune disorder

A client remains intubated after surgery. The RN understands that extubation will occur when which of the following happens?

· Client regains control of coughing and swallowing reflexes.

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.)

· Client with a new spinal cord injury on a rotating bed. · Older client who is 1-day post hip replacement surgery. · Young obese client with a fractured femur.

A nurse is caring for a client in urosepsis, which of the following actions would be appropriate for the patient

· Close monitoring, administering antibiotic therapy, and preventing complications like septic shock, coma, and death.

A patient is being mechanically ventilated. A high-pressure ventilation alarm sounds. The nurse should assess for what cause of this type of alarm?

· Condensation/water in tubing.

Which assessment findings would indicate to the nurse that a patient has suffered from a heat stroke?

· Confusion and bizarre behavior · Hypotension · Bradycardia · Tachycardia · Tachypnea

A nurse is assessing a client who has urosepsis. Which of the following findings should the nurse expect?

· Decreased urinary output.

The nurse is conducting a secondary survey as part of the emergency assessment. Which is the priority nursing action during the health history portion of the assessment?

· Determining drug allergies

A 40 year old female client has a family history of "thyroid problems" and is being seen by the primary healthcare provider for unintentional weight loss, irritability, and chest discomfort. Her probable diagnosis is hyperthyroidism, which the primary HCP plans to confirm by laboratory testing. What additional physical assessment findings would the nurse expect to be present in this client?

· Diaphoresis, insomnia, heat intolerance.

Which assessment data would cause the nurse to document the patient is experiencing early respiratory distress? (Select all that apply.)

· Dyspnea · Restlessness · Tachycardia

Which of the following are the 5 characteristics of ARDS?

· Dyspnea. · Refractory hypoxemia. · Dense pulmonary infiltrates on CXR. · Decreased pulmonary compliance. · Non-cardiac pulmonary edema.

A client has newly diagnosed acromegaly. What should a nurse expect to find in an assessment

· Enlarged facial bones, coarse skin, and large hands and feet.

An 83-year-old female client was transferred to the medical ICU from a skilled nursing facility. Previously at the facility, the patient reported weakness and shortness of breath. The unlicensed assistive personnel (UAP) reported that the patient had several black tarry stools and increasing pallor. The patient's primary health care provider ordered a hemoglobin check, results were 5.0 g/dL. On arrival to the hospital, a recheck of the patient's hemoglobin level was 4.8 g/dL. The patient was diagnosed with a GI bleed and hypovolemic shock. nurse infuses 4 units of packed red blood cells and 2 units of platelets and performs a head-to-toe assessment Selected patient assessment findings are presented in the table below.

· Heart rate, blood pressure, oxygen saturation, lung sounds, and temperature.

The nurse is preparing a teaching tool that focuses on the endocrine system. How should the nurse explain the negative feedback system?

· Hormone secretion increases when target organs send signals.

What mechanisms does nurse anticipate for patient to maintain homeostasis to a patient with increasing serum calcium levels?

· If the serum calcium level rises, the thyroid gland releases calcitonin into the blood, which signals osteoclasts to slow down the removal of calcium from bone, thereby lowering the levels of blood calcium.

A nurse cares for a client with a deficiency of aldosterone. Which assessment finding should the nurse correlate with this deficiency?

· Increased urine output.

A nurse is caring for a patient who has symptomatic bradycardia. What are some appropriate nursing interventions

· Initial stabilization, respiratory and circulation support, continuous telemetry monitoring, management of any symptoms and underlying causes, and the prevention of complications.

An 83-year-old female client was transferred to the medical ICU from a skilled nursing facility. Previously at the facility, the patient reported weakness and shortness of breath. The unlicensed assistive personnel (UAP) reported that the patient had several black tarry stools and increasing pallor. The patient's primary health care provider ordered a hemoglobin check, results were 5.0 g/dL. On arrival to the hospital, a recheck of the patient's hemoglobin level was 4.8 g/dL. The patient was diagnosed with a GI bleed and hypovolemic shock. Which of the following findings require follow up?

· Labs: elevated PT/INR, lactate, BUN, and creatinine. · Assessment: elevated heart rate, low blood pressure, oxygen saturation, lung sounds, and temperature.

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?

· Level of consciousness.

An intubated client's oxygen saturation has dropped to 88%. What action by the nurse takes priority?

· Listen to the client's lung sounds.

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?

· Manually ventilate the patient with 100% oxygen.

A 24-year-old man with a history of heroin use is found lying on the floor. It is unknown how long he has been unconscious. He has a low pulse, shallow respirations, and is cool to the touch. A respondin officer used narcan and EMS put in an endotracheal tube. The man is admitted to the critical care unit. Increased ICP could be a potential complication, what nursing actions would be appropriate?

· Monitor vitals. · Perform frequent neurological assessments. · Keep the clients head elevated at 30 degrees. · Maintain a patent airway and oxygenation. · Monitor fluid balance. · Promote rest and a quiet environment. · Administer medications as prescribed. · Report any changes to health care provider immediately.

The nurse is reviewing orders written for a patient with syndrome of inappropriate antidiuretic hormone (SIADH). Which order should the nurse clarify?

· No added salt diet

What would be an appropriate action for nurse to take if anticipating possibility of thyroid storm?

· Nursing interventions: i. Monitor HR, BP, RR (respiratory failure- may need mechanical ventilation), EKG, and temperature. ii. Keep environment quiet and patient cool (cooling blankets and sedatives as prescribed). iii. No foods containing iodine (seafood, seaweed, dairy, eggs).

Ngn- patient who has pneumothorax, med history, nurses note, vitals, whether the following prescriptions are anticipated, nonessential, or contraindicated.

· Obtain ABGs (Arterial Blood Gases): Anticipated · Prepare for insertion of a chest tube: Anticipated · Obtain intravenous access: Anticipated · Computed tomography (CT) of the chest: Anticipated · Pulmonary Function Tests (PFTs): Nonessential · Thoracentesis: Contraindicated

While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters?

· Platelet count, prothrombin time, and partial thromboplastin time.

The nurse is caring for a patient with third-degree heart block. the patient has a low heart rate and blood pressure, what actions should nurse perform first?

· Prepare the patient for temporary pacing.

The nurse cares for a patient diagnosed with Cushing disease. The nurse expects to observe which finding?

· Protruding abdomen and increased facial fat

A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)?

· Provide frequent oral care per protocol.

The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy?

· Return of distal pulses