ah2 exam 4

7. Application of RICE (rest, ice, compression, and elevation) is indicated for initial management of which type of injury? a. Muscle spasms b. Sprains and strains c. Repetitive strain injury d. Dislocations and subluxations

7. b. Application of cold, compression, and elevation are indicated to prevent edema resulting from sprain and some strain injuries. Muscle spasms are usually treated with heat applications and massage and repetitive strain injuries require cessation of the precipitating activity and physical therapy. Dislocations or subluxations require immediate reduction and immobilization to prevent vascular impairment and bone cell death.

9. The patient had a fracture. At 3 weeks to 6 months there is clinical union, and this is the first stage of healing that is sufficient to prevent movement of the fracture site when the bones are gently stressed. How is this stage of fracture healing documented? a. Ossification b. Remodeling c. Consolidation d. Callus formation

9. a. Ossification is the stage of fracture healing when there is clinical union and enough strength to prevent movement at the fracture site. Remodeling is the normal function of the bone. Consolidation is when the distance between bone fragments eventually closes and radiologic union first occurs. The callus formation stage appears by the end of the second week of injury when minerals and new bone matrix are deposited in the osteoid that is produced in the granulation tissue stage.

The nurse admits a 55-year-old female with multiple sclerosis to a long-term care facility. Which finding is of most immediate concern to the nurse? A. Ataxic gait B. Radicular pain C. Severe fatigue D. Urinary retention

A. Ataxic gait An ataxic gait is a staggering, uncoordinated gait. Fall risk is the highest in individuals with gait instability or visual or cognitive impairments. The other signs and symptoms (e.g., fatigue, urinary retention, radicular pain) may also occur in the patient with multiple sclerosis and need to be managed, but are not the priority.

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. Apply external cooling device. b. Check mental status every 15 minutes. c. Avoid the use of sedative medications. d. Rewarm if temperature is <91° F (32.8° C).

ANS: 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 needed at this stage. Sedative medications are administered during therapeutic hypothermia. DIF: Cognitive Level: Apply (application) REF: 1681 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

10. The x-ray shows that the patient's fracture is at the remodeling stage. What characteristics of the fracture healing process are happening at this stage (select all that apply)? a. Radiologic union b. Absorption of excess cells c. Return to preinjury strength and shape d. Semisolid blood clot at the ends of fragments e. Deposition and absorption of bone in response to stress f. Unorganized network of bone woven around fracture parts

10. a, b, c, e. When the remodeling stage of healing occurs, radiologic union is present. Excess callus is reabsorbed, trabecular bone is laid, and the bone returns to its preinjury structure strength and shape. The osteoblasts and osteoclasts function normally in response to stress. The fracture hematoma stage is when the hematoma at the ends of the fragments becomes a semisolid blood clot. There is an unorganized network of bone composed of cartilage, osteoblasts, calcium, and phosphorus woven around fracture parts in the callus formation stage.

12. A patient with a fractured femur experiences the complication of malunion. The nurse recognizes that what happens with this complication? a. The fracture heals in an unsatisfactory position. b. The fracture fails to heal properly despite treatment. c. Fracture healing progresses more slowly than expected. d. Loss of bone substances occurs as a result of immobilization.

12. a. A malunion occurs when the bone heals in the expected time but in an unsatisfactory position, possibly resulting in deformity or dysfunction. Nonunion occurs when the fracture fails to heal properly despite treatment and delayed union is healing of the fracture at a slower rate than expected. In posttraumatic osteoporosis, the loss of bone substances occurs as a result of immobilization.

13. What is a disadvantage of open reduction and internal fixation of a fracture compared to closed reduction? a. Infection b. Skin irritation c. Nerve impairment d. Complications of immobility

13. a. Open reduction uses a surgical incision to correct bone alignment but infection is the main disadvantage, as well as anesthesia complications or the effect of preexisting medical conditions. Skin irritation and nerve impairment is most likely with skin traction. Prolonged immobility is possible with skeletal traction.

20. What surgical treatment will the nurse prepare the patient for in the presence of compartment syndrome? a. Fasciotomy b. Amputation c. Internal fixation d. Release of tendons

20. a. Soft tissue edema in the area of the injury may cause an increase of pressure within the closed spaces of the tissue compartments formed by the nonelastic fascia, creating compartment syndrome. If symptoms occur, it may be necessary to incise the fascia surgically, a procedure known as a fasciotomy. Amputation is usually necessary only if the limb becomes septic because of untreated compartment syndrome.

A patient complains of pain in the foot of a leg that was recently amputated. What should the nurse recognize about this pain? a. It is caused by swelling at the incision. b. It should be treated with ordered analgesics. c. It will become worse with the use of a prosthesis. d. It can be managed with diversion because it is psychologic.

34. b. Phantom sensation or phantom pain may occur following amputation, especially if pain was present in the affected limb preoperatively. The pain is a real sensation to the patient and will first be treated with analgesics and other pain interventions (i.e., tricyclic antidepressants, antiseizure drugs, transcutaneous electrical nerve stimulation [TENS], mirror therapy, acupuncture). As recovery and ambulation progress, phantom limb sensation usually subsides.

36. Why does a nurse position a patient with an above-the-knee amputation with a delayed prosthetic fitting prone several times a day? a. To prevent flexion contractures b. To assess the posterior skin flap c. To reduce edema in the residual limb d. To relieve pressure on the incision site

36. a. Flexion contractures, especially of the hip, may be debilitating and delay rehabilitation of the patient with a leg amputation. To prevent hip flexion, the patient should avoid sitting in a chair with the hips flexed or having pillows under the surgical extremity for prolonged periods and the patient should lie on the abdomen for 30 minutes three to four times a day to extend the hip.

38. Which joint surgery is used to arthroscopically remove degenerative tissue in joints? a. Osteotomy b. Arthrodesis c. Debridement d. Synovectomy

38. c. Debridement removes degenerative tissue from joints. Osteotomy corrects bone deformity by removal of a wedge or slice of bone. Arthrodesis surgically fuses a joint to relieve pain. Synovectomy removes tissue involved in joint destruction from rheumatoid arthritis (RA).

8. Which nursing intervention will be included in the plan of care after a patient with a right femur fracture has a hip spica cast applied? a. Avoid placing the patient in prone position. b. Ask the patient about abdominal discomfort. c. Discuss remaining on bed rest for several weeks. d. Use the cast support bar to reposition the patient.

ANS: B Assessment of bowel sounds, abdominal pain, and nausea and vomiting will detect the development of cast syndrome. To avoid breakage, the support bar should not be used for repositioning. After the cast dries, the patient can begin ambulating with the assistance of physical therapy personnel and may be turned to the prone position.

37. A patient undergoes a left above-the-knee amputation with an immediate prosthetic fitting. When the patient arrives on the orthopedic unit after surgery, the nurse should a. place the patient in a prone position. b. check the surgical site for hemorrhage. c. remove the prosthesis and wrap the site. d. keep the residual leg elevated on a pillow.

ANS: B The nurse should monitor for hemorrhage after the surgery. The prosthesis will not be removed. To avoid flexion contracture of the hip, the leg will not be elevated on a pillow. The patient is placed in a prone position after amputation to prevent hip flexion, but this would not be done during the immediate postoperative period.

. Which statement by a 62-year-old patient who has had an above-the-knee amputation indicates that the nurse's discharge teaching has been effective? a. "I should elevate my residual limb on a pillow 2 or 3 times a day." b. "I should lay flat on my abdomen for 30 minutes 3 or 4 times a day." c. "I should change the limb sock when it becomes soiled or each week." d. "I should use lotion on the stump to prevent skin drying and cracking."

ANS: B The patient lies in the prone position several times daily to prevent flexion contractures of the hip. The limb sock should be changed daily. Lotion should not be used on the stump. The residual limb should not be elevated because this would encourage flexion contracture.

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. ask about chronic medical conditions. d. attach a cardiac electrocardiogram monitor.

ANS: 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: 1676 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

36. A 42-year-old patient is admitted to the emergency department with a left femur fracture. Which information obtained by the nurse is most important to report to the health care provider? a. Ecchymosis of the left thigh b. Complaints of severe thigh pain c. Slow capillary refill of the left foot d. Outward pointing toes on the left foot

ANS: C Prolonged capillary refill may indicate complications such as arterial damage or compartment syndrome. The other findings are typical with a left femur fracture

23. A high school teacher with ulnar drift caused by rheumatoid arthritis (RA) is scheduled for a left hand arthroplasty. Which patient statement to the nurse indicates a realistic expectation for the surgery? a. "This procedure will correct the deformities in my fingers." b. "I will not have to do as many hand exercises after the surgery." c. "I will be able to use my fingers with more flexibility to grasp things." d. "My fingers will appear more normal in size and shape after this surgery."

ANS: C The goal of hand surgery in RA is to restore function, not to correct for cosmetic deformity or treat the underlying process. Hand exercises will be prescribed after the surgery.

33. A pedestrian who was hit by a car is admitted to the emergency department with possible right lower leg fractures. The initial action by the nurse should be to a. elevate the right leg. b. splint the lower leg. c. check the pedal pulses. d. verify tetanus immunizations.

ANS: C The initial nursing action should be assessment of the neurovascular status of the injured leg. After assessment, the nurse may need to splint and elevate the leg, based on the assessment data. Information about tetanus immunizations should be done if there is an open wound.

35. The second day after admission with a fractured pelvis, a 64-year-old patient suddenly develops confusion. Which action should the nurse take first? a. Take the blood pressure. b. Assess patient orientation. c. Check the oxygen saturation. d. Observe for facial asymmetry.

ANS: C The patient's history and clinical manifestations suggest a fat embolus. The most important assessment is oxygenation. The other actions are also appropriate but will be done after the nurse assesses gas exchange.

34. The day after a 60-year-old patient has an open reduction and internal fixation (ORIF) for an open, displaced tibial fracture, the priority nursing diagnosis is a. activity intolerance related to deconditioning. b. risk for constipation related to prolonged bed rest. c. risk for impaired skin integrity related to immobility. d. risk for infection related to disruption of skin integrity.

ANS: D A patient having an ORIF is at risk for problems such as wound infection and osteomyelitis. After an ORIF, patients typically are mobilized starting the first postoperative day, so problems caused by immobility are not as likely

44. After change-of-shift report, which patient should the nurse assess first? a. Patient with a Colles' fracture who has right wrist swelling and deformity b. Patient with a intracapsular left hip fracture whose leg is externally rotated c. Patient with a repaired mandibular fracture who is complaining of facial pain d. Patient with right femoral shaft fracture whose thigh is swollen and ecchymotic

ANS: D Swelling and bruising after a femoral shaft fracture suggest hemorrhage and risk for compartment syndrome. The nurse should assess the patient rapidly and then notify the health care provider. The other patients have symptoms that are typical for their injuries, but do not require immediate intervention.

41. Which finding in a patient with a Colles' fracture of the left wrist is most important to communicate to the health care provider? a. Swelling is noted around the wrist. b. The patient is reporting severe pain. c. The wrist has a deformed appearance. d. Capillary refill to the fingers is prolonged.

ANS: D Swelling, pain, and deformity are common findings with a Colles' fracture. Prolonged capillary refill indicates decreased circulation and risk for ischemia. This is not an expected finding and should be immediately reported.

7. A 48-year-old patient with a comminuted fracture of the left femur has Buck's traction in place while waiting for surgery. To assess for pressure areas on the patient's back and sacral area and to provide skin care, the nurse should a. loosen the traction and help the patient turn onto the unaffected side. b. place a pillow between the patient's legs and turn gently to each side. c. turn the patient partially to each side with the assistance of another nurse. d. have the patient lift the buttocks by bending and pushing with the right leg.

ANS: D The patient can lift the buttocks off the bed by using the left leg without changing the right-leg alignment. Turning the patient will tend to move the leg out of alignment. Disconnecting the traction will interrupt the weight needed to immobilize and align the fracture.

21. The nurse is caring for a patient who is to be discharged from the hospital 5 days after insertion of a femoral head prosthesis using a posterior approach. Which statement by the patient indicates a need for additional instruction? a. "I should not cross my legs while sitting." b. "I will use a toilet elevator on the toilet seat." c. "I will have someone else put on my shoes and socks." d. "I can sleep in any position that is comfortable for me."

ANS: D The patient needs to sleep in a position that prevents excessive internal rotation or flexion of the hip. The other patient statements indicate that the patient has understood the teaching.

2. A factory line worker has repetitive strain syndrome in the left elbow. The nurse will plan to teach the patient about a. surgical options. b. elbow injections. c. wearing a left wrist splint. d. modifying arm movements.

ANS: D Treatment for repetitive strain syndrome includes changing the ergonomics of the activity. Elbow injections and surgery are not initial options for this type of injury. A wrist splint might be used for hand or wrist pain.

The critical care nurse recognizes that an ideal plan for caregiver involvement includes a. a caregiver at the bedside at all times b. allowing caregivers at the bedside at preset, brief intervals c. an individually devised plan to involves caregivers with care and comfort measures d. restriction of visiting in the ICU because the environment is overwhelming to caregivers

c. an individually devised plan t involves caregivers with care and comfort measures

When mechanical ventilation is used for the patient with ARDS, what is the rationale for applying positive end-expiratory pressure (PEEP)? a. Prevent alveolar collapse and open up collapsed alveoli b. Permit smaller tidal volumes with permissive hypercapnia c. Promote complete emptying of the lungs during exhalation d. Permit extracorporeal oxygenation and carbon dioxide removal outside the body

a. Positive end-expiratory pressure (PEEP) used with mechanical ventilation applies positive pressure to the airway and lungs at the end of exhalation, keeping the lung partially expanded and preventing collapse of the alveoli and helping to open up collapsed alveoli. Permissive hypercapnia is allowed when the patient with ARDS is ventilated with smaller tidal volumes to prevent barotrauma. Extracorporeal membrane oxygenation and extracorporeal CO2 removal involve passing blood across a gas-exchanging membrane outside the body and then returning oxygenated blood to the body.

When examining a patient with cardiogenic shock, which signs of peripheral hypoperfusion does the nurse expect? Select all that apply. 1 Cyanosis 2 Cold skin 3 Weak pulse 4 Bradycardia 5 Hypertension

1, 2, 3 Cyanosis, cold skin, and a weak pulse are the signs of peripheral hypoperfusion in cardiogenic shock. Bradycardia and hypertension are not seen in cardiogenic shock; instead, tachycardia and low blood pressure are noted. Text Reference - p. 1633

What is the correct order of the pathophysiologic steps involved in systemic inflammatory response syndrome (SIRS)? 1. Activation of coagulation cascade 2. Release of mediators 3. Increase in vascular permeability 4. Leakage of mediators and proteins into interstitial space 5. Digestion of foreign debris by white blood cells

2. Release of mediators 3. Increase in vascular permeability 4. Leakage of mediators and proteins into interstitial space 5. Digestion of foreign debris by white blood cells 1. Activation of coagulation cascade Release of mediators occurs in a patient with systemic inflammatory response syndrome (SIRS) when the inflammatory response is activated. This release increases the vascular permeability. As a result, mediators and proteins leak out of the blood vessels into the interstitial space. White blood cells digest the foreign debris and the coagulation cascade is activated. Text Reference - p. 1649

If the patient in shock is to receive 1000 mL of normal saline in two hours, at what rate should the infusion pump be set? Fill in the blank. ___mL/hour

500 For the 1000 mL of normal saline to be infused in two hours, the infusion pump should be set at 500 mL per hour (1000 mL divided by two hours). Test-Taking Tip: When taking the NCLEX exam, an on-screen calculator will be available for you to determine your response, which you will then type in the provided space. Text Reference - p. 1641

The health care provider prescribes these actions for a patient who has possible septic shock with a BP of 70/42 mm Hg and oxygen saturation of 90%. In which order will the nurse implement the actions? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. Obtain blood and urine cultures. b. Give vancomycin (Vancocin) 1 g IV. c. Infuse vasopressin (Pitressin) 0.01 units/min. d. Administer normal saline 1000 mL over 30 minutes. e. Titrate oxygen administration to keep O2 saturation >95%.

ANS: E, D, C, A, B The initial action for this hypotensive and hypoxemic patient should be to improve the oxygen saturation, followed by infusion of IV fluids and vasopressors to improve perfusion. Cultures should be obtained before administration of antibiotics.

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].) a. A 74-year-old with palpitations and chest pain b. A 43-year-old complaining of 7/10 abdominal pain c. A 21-year-old with multiple fractures of the face and jaw d. A 37-year-old with a misaligned left leg with intact pulses

ANS: C, A, B, D The highest priority is to assess the 21-year-old patient for airway obstruction, which is the most life-threatening injury. The 74-year-old patient may have chest pain from cardiac ischemia and should be assessed and have diagnostic testing for this pain. The 43-year-old patient may have abdominal trauma or bleeding and should be seen next to assess circulatory status. The 37-year-old 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: 1676 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Norepinephrine (Levophed) has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient information indicates that the nurse should consult with the health care provider before administration of the norepinephrine? a. The patient's central venous pressure is 3 mm Hg. b. The patient is receiving low dose dopamine (Intropin). c. The patient is in sinus tachycardia at 100 to 110 beats/min. d. The patient has had no urine output since being admitted.

ANS: A Adequate fluid administration is essential before administration of 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: Application REF: 1733-1735 | 1736 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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 is most appropriate? a. "Do you feel safe in your home?" b. "You should not return to your home." c. "Would you like to see a social worker?" d. "I need to report my concerns to the police."

ANS: 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. A social worker may be appropriate once further assessment is completed. DIF: Cognitive Level: Apply (application) REF: 1682 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

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

ANS: A, B, C, 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 the failing liver cannot convert lactate to bicarbonate. DIF: Cognitive Level: Application REF: 1736-1737 OBJ: Special Questions: Alternate Item Format TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which finding is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been effective? a. Hemoglobin is within normal limits. b. Urine output is 60 mL over the last hour. c. Central venous pressure (CVP) is normal. d. Mean arterial pressure (MAP) is 72 mm Hg.

ANS: B Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. 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.

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. Start a normal saline infusion. b. Give epinephrine (Adrenalin). c. Start continuous ECG monitoring. d. Give diphenhydramine (Benadryl).

ANS: B 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.

A patient with cardiogenic shock has the following vital signs: BP 86/50, pulse 126, respirations 30. The PAWP is increased and cardiac output is low. The nurse will anticipate a. infusion of 5% human albumin. b. administration of furosemide (Lasix) IV. c. titration of an epinephrine (Adrenalin) drip. d. administration of hydrocortisone (SoluCortef).

ANS: 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 heart rate and myocardial oxygen demand. Normal saline infusion would increase the PAWP further. Hydrocortisone might be used for septic or anaphylactic shock. DIF: Cognitive Level: Application REF: 1735 | 1736 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

19. A patient is admitted to the emergency department (ED) after falling through the ice while ice skating. Which assessment will the nurse obtain first? a. Heart rate b. Breath sounds c. Body temperature d. Level of consciousness

ANS: B The priority assessment relates to ABCs (airway, breathing, circulation) and how well the patient is oxygenating, so breath sounds should be assessed first. The other data will also be collected rapidly but are not as essential as the breath sounds. DIF: Cognitive Level: Apply (application) REF: 1685 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The emergency department (ED) receives notification that a patient who has just been in an automobile accident is being transported to your facility with anticipated arrival in 1 minute. In preparation for the patient's arrival, the nurse will obtain a. 500 mL of 5% albumin. b. lactated Ringer's solution. c. two 14-gauge IV catheters. d. dopamine (Intropin) infusion.

ANS: C 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. Although colloids may sometimes be used for volume expansion, crystalloids should be used as the initial therapy for fluid resuscitation. Vasopressor infusion is not used as the initial therapy for hypovolemic shock. DIF: Cognitive Level: Application REF: 1731 | 1732 | 1733 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

10. When rewarming a patient who arrived in the emergency department (ED) with a temperature of 87° F (30.6° C), which assessment 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).

ANS: 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: Apply (application) REF: 1686 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Which assessment is most important for the nurse to make in order to evaluate whether treatment of a patient with anaphylactic shock has been effective? a. Pulse rate b. Orientation c. Blood pressure d. Oxygen saturation

ANS: D Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the oxygen saturation is the most critical assessment. Improvements in the other assessments also will be expected with effective treatment of anaphylactic shock. DIF: Cognitive Level: Application REF: 1724-1725 | 1732 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

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 paradoxic chest movements.

ANS: D Most immediate deaths from trauma occur because of problems with ventilation, so the patient with paradoxic 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: Apply (application) REF: 1676 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

A patient with cardiogenic shock is cool and clammy and hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which action will the nurse anticipate taking? a. Increase the rate for the prescribed dopamine (Intropin) infusion. b. Decrease the rate for the prescribed nitroglycerin (Tridil) infusion. c. Decrease the rate for the prescribed 5% dextrose in water (D5W) infusion. d. Increase the rate for the prescribed sodium nitroprusside (Nipride) infusion.

ANS: D Nitroprusside is an arterial vasodilator and will decrease the SVR and afterload, which will improve cardiac output. Changes in the D5W and nitroglycerin infusions will not directly increase SVR. Increasing the dopamine will tend to increase SVR. DIF: Cognitive Level: Application REF: 1733-1734 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

During change-of-shift report, the nurse learns that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 3 days. Which finding is most important for the nurse to report to the health care provider? a. Decreased bowel sounds b. Apical pulse 110 beats/min c. Pale, cool, and dry extremities d. New onset of confusion and agitation

ANS: D 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: Application REF: 1728-1729 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A nurse manager educates the emergency department staff about their roles during a disaster with mass casualties. Which primary responsibility should the nurse manager discuss with the staff? A. Learn the hospital emergency response plan. B. Report acts of violence to security personnel. C. Contact the American Red Cross for assistance. D. Notify local, state, and national authorities.

Answer: A. Learn the hospital emergency response plan. Rationale: All health care providers need to be prepared for a mass casualty incident; the priority responsibility is to know the agency's emergency response plan. Ch. 69

A nurse in the emergency department is working triage. Which patient assessment findings would indicate immediate care is required? Shortened and externally rotated leg Inability to swallow and move the left arm Warm, edematous, reddened and painful calf Yellow sputum and pain with deep inspiration

Inability to swallow and move the left arm Inability to swallow and move the left arm suggests the patient is experiencing a stroke. A CT scan is indicated within 25 minutes of arrival to determine ischemic versus hemorrhagic origin, which will delineate available treatments. The warm, edematous, reddened and painful calf suggests deep vein thrombosis. Although not an immediate threat, there is a risk of pulmonary emboli. A shortened and externally rotated leg suggests a hip fracture. A patient with yellow sputum and pain with deep inspiration suggest a pneumonia that may require hospitalization or could be treated as an outpatient.

Patients with acute respiratory failure will have drug therapy to meet their individual needs. Which drugs will meet the goal of reducing pulmonary congestion (select all that apply)? a. Morphine b. Furosemide (Lasix) c. Nitroglycerin (Tridil) d. Albuterol (Ventolin) e. Ceftriaxone (Rocephin) f. Methylprednisolone (Solu-Medrol)

a, b, c. Morphine and nitroglycerin (e.g., Tridil) will decrease pulmonary congestion caused by heart failure; IV diuretics (e.g., furosemide [Lasix]) are also used. Inhaled albuterol (Ventolin) or metaproterenol (Alupent) will relieve bronchospasms. Ceftriaxone (Rocephin) and azithromycin (Zithromax) are used to treat pulmonary infections. Methylprednisolone (Solu-Medrol), an IV corticosteroid, will reduce airway inflammation. Morphine is also used to decrease anxiety, agitation, and pain.

23. What emergency considerations must be included with facial fractures (select all that apply)? a. Airway patency b. Oral examination c. Cervical spine injury d. Cranial nerve assessment e. Immobilization of the jaw

a, c. Airway patency and cervical spinal cord injury are the emergency considerations with facial fractures. Oral examination and cranial nerve assessment will be done after the patient is stabilized. Immobilization of the jaw is done surgically for a mandibular fracture.

Which changes of aging contribute to the increased risk for respiratory failure in older adults (select all that apply)? a. Alveolar dilation b. Increased delirium c. Changes in vital signs d. Increased infection risk e. Decreased respiratory muscle strength f. Diminished elastic recoil within the airways

a, d, e, f. Changes from aging that increase the older adult's risk for respiratory failure include alveolar dilation, increased risk for infection, decreased respiratory muscle strength, and diminished elastic recoil in the airways. Although delirium can complicate ventilator management, it does not increase the older patient's risk for respiratory failure. The older adult's blood pressure (BP) and heart rate (HR) increase but this does not affect the risk for respiratory failure. The ventilatory capacity is decreased and the larger air spaces decrease the surface area for gas exchange, which increases the risk.

The best patient response to treatment of ARDS occurs when initial management includes what? a. Treatment of the underlying condition b. Administration of prophylactic antibiotics c. Treatment with diuretics and mild fluid restriction d. Endotracheal intubation and mechanical ventilation

a. Because ARDS is precipitated by a physiologic insult, a critical factor in its prevention and early management is treatment of the underlying condition. Prophylactic antibiotics, treatment with diuretics and fluid restriction, and mechanical ventilation are also used as ARDS progresses.

Which assessment finding should cause the nurse to suspect the early onset of hypoxemia? a. Restlessness b. Hypotension c. Central cyanosis d. Cardiac dysrhythmias

a. Because the brain is very sensitive to a decrease in oxygen delivery, restlessness, agitation, disorientation, and confusion are early signs of hypoxemia, for which the nurse should be alert. Mild hypertension is also an early sign, accompanied by tachycardia. Central cyanosis is an unreliable, late sign of hypoxemia. Cardiac dysrhythmias also occur later early RAT is late to BED

In caring for the patient with ARDS, what is the most characteristic sign the nurse would expect the patient to exhibit? a. Refractory hypoxemia b. Bronchial breath sounds c. Progressive hypercapnia d. Increased pulmonary artery wedge pressure (PAWP)

a. Refractory hypoxemia - hypoxemia that does not respond to increasing concentrations of oxygenation by any route - is a hallmark of ARDS and is *always* present. Bronchial breath sounds *may* be associated with the progression of ARDS. PaCO2 levels *may be normal* until the patient is no longer able to compensate in response to the hypoxemia. Pulmonary artery wedge pressure (PAWP) that is normally elevated in cardiogenic pulmonary edema is *normal* in the pulmonary edema of ARDS.

Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires immediate action by the nurse? a. Only continuous IV opioids have been ordered. b. The patient does not respond to verbal stimulation. c. There is no cough or gag when the patient is suctioned. d. The patient's oxygen saturation fluctuates between 90% to 93%.

a. only continuous IV opioids have been ordered

Which physiologic mechanism of hypoxemia occurs with pulmonary fibrosis? a. Anatomic shunt b. Diffusion limitation c. Intrapulmonary shunt d. V/Q mismatch ratio of less than 1

b. Diffusion limitation in pulmonary fibrosis is caused by thickened alveolar-capillary interface, which slows gas transport.

A patient with respiratory failure has a respiratory rate of 6 breaths/minute and an O2 sat of 88%. The patient is increasingly lethargic. Which intervention will the nurse anticipate? a. administration of 100% oxygen by non-rebreather mask b. endotracheal intubation and positive pressure ventilation c. insertion of mini tracheostomy with frequent suctioning d. initiation of CPAP ventilation

b. endotracheal intubation and positive pressure ventilation

The patient is being admitted to the intensive care unit (ICU) with hypercapnic respiratory failure. Which manifestations should the nurse expect to assess in the patient (select all that apply)? a. Cyanosis b. Metabolic acidosis c. Morning headache d. Respiratory acidosis e. Use of tripod position f. Rapid, shallow respirations

c, d, e, f. Morning headache, respiratory acidosis, the use of tripod position, and rapid, shallow respirations would be expected. The other manifestations are characteristic of hypoxemic respiratory failure.

When explaining respiratory failure to the patient's family, what should the nurse use as an accurate description? a. The absence of ventilation b. Any episode in which part of the airway is obstructed c. Inadequate gas exchange to meet the metabolic needs of the body d. An episode of acute hypoxemia caused by a pulmonary dysfunction

c. Respiratory failure results when the transfer of oxygen or carbon dioxide function of the respiratory system is impaired and, although the definition is determined by PaO2 and PaCO2 levels, the major factor in respiratory failure is inadequate gas exchange to meet tissue oxygen (O2 ) needs. Absence of ventilation is respiratory arrest and partial airway obstruction may not necessarily cause respiratory failure. Acute hypoxemia may be caused by factors other than pulmonary dysfunction

The critical care nurse recognizes that an ideal plan for caregiver involvement includes a. a caregiver at the bedside at all times b. allowing caregivers at the bedside at preset, brief intervals c. an individually devised plan to involves caregivers with care and comfort measures d. restriction of visiting in the ICU because the environment is overwhelming to caregivers

c. an individually devised plan to involves caregivers with care and comfort measures

The nurse suspects an ankle sprain when a patient at an urgent care center describes a. being hit by another soccer player during a game b. having ankle pain after sprinting around the track c. dropping a 10-lb weight on his lower leg at the gym d. twisting his ankle while running bases during a baseball game

d. twisting his ankle while running bases during a baseball game

A patient with left knee pain is diagnosed with bursitis. The nurse will explain that bursitis is an inflammation of a. the synovial membrane that lines the joint. b. a small, fluid-filled sac found at some joints. c. the fibrocartilage that acts as a shock absorber in the knee joint. d. any connective tissue that is found supporting the joints of the body.

B. Bursae are fluid-filled sacs that cushion joints and bony prominences. Fibrocartilage is a solid tissue that cushions some joints. Bursae are a specific type of connective tissue. The synovial membrane lines many joints but is not a bursa.

To prevent muscle atrophy, the nurse teaches the patient with a leg immobilized in traction to perform (select all that apply) a.flexion contractions. b.tetanic contractions. c.isotonic contractions. d.isometric contractions. e.extension contractions.

d.isometric contractions Isometric contractions increase the tension within a muscle but do not produce movement. Repeated isometric contractions make muscles grow larger and stronger. Muscular atrophy (i.e., decrease in size) occurs with the absence of contraction that results from immobility.

Which types of shock may cause reduced urinary output in a patient? Select all that apply. 1 Septic shock 2 Hypovolemic shock 3 Obstructive shock 4 Neurogenic shock 5 Anaphylactic shock 6 Cardiogenic shock.

1, 2, 3, 6 Decreased urine output is a clinical manifestation of septic, hypovolemic, obstructive and cardiogenic shock. Neurogenic shock is associated with bladder dysfunction. Anaphylactic shock is associated with urinary incontinence. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation. Text Reference - p. 1635

When examining a patient with septic shock, what symptoms would the nurse expect to find? Select all that apply. 1 Paralytic ileus 2 Gastrointestinal (GI) bleeding 3 Pulsus paradoxus 4 Distended jugular vein 5 Decreased urinary output

1, 2, 5 Patients suffering from septic shock may experience decreased tissue perfusion, which may result in a paralytic ileus, GI bleeding, and decreased urinary output. Pulsus paradoxus and jugular vein distension are found in obstructive shock and are mainly the result of compromised hemodynamics. Text Reference - p. 1637

11. A patient is brought to the emergency department with an injured lower left leg following a fall while rock climbing. The nurse identifies the presence of a fracture based on what cardinal sign of fracture? a. Muscle spasms b. Obvious deformity c. Edema and swelling d. Pain and tenderness

11. b. Deformity is the cardinal sign of fracture but may not be apparent in all fractures. Other supporting signs include edema and swelling, localized pain and tenderness, muscle spasm, ecchymosis, loss of function, crepitation, and an inability to bear weight.

14. A young patient with a fractured femur has a hip spica cast applied. While the cast is drying, what should the nurse do? a. Elevate the legs above the level of the heart for 24 hours. b. Turn the patient to both sides and prone to supine every 2 hours. c. Cover the cast with a light blanket to avoid chilling from evaporation. d. Assess the patient frequently for abdominal pain, nausea, and vomiting.

14. d. Complaints of abdominal pain or pressure, nausea, and vomiting are signs of cast syndrome that occur when hip spica casts or body jacket braces are applied too tightly, causing compression of the superior mesenteric artery against the duodenum. The cast may need to be split or removed and the health care provider should be notified. Elevation is not indicated for a spica cast and the patient with a spica cast should not be placed in the prone position during the initial drying stage because the cast is so large and heavy it may break. A cast should never be covered with a blanket because heat builds up in the cast and may increase edema.

15. A patient is admitted with an open fracture of the tibia following a bicycle accident. During assessment of the patient, what specifically should the nurse question the patient about? a. Any previous injuries to the leg b. The status of tetanus immunization c. The use of antibiotics in the last month d. Whether the injury was exposed to dirt or gravel

15. b. Infection is the greatest risk with an open fracture and all open fractures are considered contaminated. Tetanus prevention is always indicated if the patient has not been immunized or does not have current boosters. Prophylactic antibiotics are often used in management of open fractures but recent antibiotic therapy is not relevant, nor is previous injury to the site.

21. Which type of fracture occurred when there is radial nerve and brachial artery damage and the fracture is reduced with a hanging arm cast? a. Fractured tibia b. Colles' fracture c. Fractured humerus d. Femoral shaft fracture

21. c. The fractured humerus may cause radial nerve and brachial artery damage and it may be reduced nonsurgically with a hanging arm cast. A fractured tibia and femoral shaft are in the leg. The Colles' fracture is in the wrist and manifests with pronounced swelling and obvious deformity of the wrist; it is treated with closed manipulation and immobilization.

What are the primary pathophysiologic changes that occur in the injury or exudative phase of ARDS (select all that apply)? a. Atelectasis b. Shortness of breath c. Interstitial and alveolar edema d. Hyaline membranes line the alveoli e. Influx of neutrophils, monocytes, and lymphocytes

22. a, c, d. The injury or exudative phase is the early phase of ARDS when atelectasis and interstitial and alveoli edema occur and hyaline membranes composed of necrotic cells, protein, and fibrin line the alveoli. Together, these decrease gas exchange capability and lung compliance. Shortness of breath occurs but it is not a physiologic change. The increased inflammation and proliferation of fibroblasts occurs in the reparative or proliferative phase of ARDS, which occurs 1 to 2 weeks after the initial lung injury.

26. The nurse suspects a fat embolism rather than a pulmonary embolism from a venous thrombosis when the patient with a fracture develops what? a. Tachycardia and dyspnea b. A sudden onset of chest pain c. Petechiae around the neck and upper chest d. Electrocardiographic (ECG) changes and decreased PaO2

26. c. Patients with fractures are at risk for both fat embolism and pulmonary embolism from venous thromboembolism but there is a difference in the time of occurrence, with fat embolism occurring shortly after the injury and thrombotic embolism occurring several days after immobilization. They both may cause pulmonary symptoms of chest pain, tachypnea, dyspnea, apprehension, tachycardia, and cyanosis. However, fat embolism may cause petechiae located around the neck, anterior chest wall, axilla, buccal membrane of the mouth, and conjunctiva of the eye, which differentiates it from thrombotic embolism.

27. Which kind of hip fracture is usually repaired with a hip prosthesis? a. Intracapsular b. Extracapsular c. Subtrochanteric d. Intertrochanteric

27. a. A hip prosthesis is usually used for intracapsular fractures. The other options are all extracapsular fractures.

A patient is admitted to the hospital with a suspected diagnosis of obstructive shock. What could be the possible causes of this type of shock? Select all that apply. 1 Hypersensitivity to antibiotics 2 Spinal cord injury 3 Cardiac tamponade 4 Tension pneumothorax 5 Superior vena cava syndrome

3, 4, 5 Obstructive shock develops when a physical obstruction to blood flow occurs resulting in decreased cardiac output. This can be caused by restricted diastolic filling of the right ventricle from compression caused by cardiac tamponade, tension pneumothorax, or superior vena cava syndrome. Hypersensitivity to antibiotics may cause anaphylactic shock. Spinal cord injury may lead to neurogenic shock. Text Reference - p. 1637

35. Priority Decision: An immediate prosthetic fitting during surgery is used for a patient with a traumatic below-theknee amputation. During the immediate postoperative period, what is a priority nursing intervention? a. Monitor the patient's vital signs. b. Assess the incision for hemorrhage. c. Elevate the residual limb on pillows. d. Have the patient flex and extend the knee every hour.

35. a. Because the device covers the residual limb, the surgical site cannot be directly seen and postoperative hemorrhage is not apparent on dressings, requiring vigilant assessment of vital signs for signs of bleeding. Elevation of the residual limb with an immediate prosthetic fitting is not necessary because the device itself prevents edema formation. Exercises to the leg are not performed in the immediate postoperative period to avoid disruption of ligatures and the suture line.

37. A patient who had a below-the-knee amputation is to be fitted with a temporary prosthesis. It is most important for the nurse to teach the patient to do what? a. Inspect the residual limb daily for irritation. b. Apply an elastic shrinker before applying the prosthesis. c. Perform range-of-motion (ROM) exercises to the affected leg four times a day. d. Apply alcohol to the residual limb every morning and evening to toughen the skin.

37. a. Skin breakdown on the residual limb can prevent the use of a prosthesis so the limb should be inspected every day for signs of irritation or pressure areas. No substances except water and mild soap should be used on the residual limb and range-of-motion (ROM) exercises are not necessary when the patient is using a prosthesis. A residual limb shrinker is an elastic stocking that is used to mold the limb in preparation for prosthesis use but a cotton residual limb sock is worn with the prosthesis.

Priority Decision: A patient with severe ulnar deviation of the hands undergoes an arthroplasty with reconstruction and replacement of finger joints. Postoperatively, what is it most important for the nurse to do? a. Position the fingers lower than the elbow. b. Perform neurovascular assessments of the fingers q2-4hr. c. Encourage the patient to gently flex, extend, abduct, and adduct the fingers q4hr. d. Remind the patient that function of the hands is more important than their cosmetic appearance.

43. b. Neurovascular checks of the fingers following surgery of the hands are essential to detect compromised vascular and neurologic function caused by trauma or edema. Postoperatively, the hands are elevated with a bulky dressing in place and when the dressing is removed, a guided splinting program is started. Exercises are performed three to four times a day when the splints are removed and the patient is discharged. Before surgery, it must be made clear to the patient that the goal of the surgery is to restore function related to grasp, pinch, stability, and strength and the hands will not necessarily have good cosmetic appearance.

44. Priority Decision: Following change-of-shift handoff, which patient should the nurse assess first? a. A 58-year-old male experiencing phantom pain and requesting analgesic b. A 72-year-old male being transferred to a skilled nursing unit following repair of a hip fracture c. A 25-year-old female in left leg skeletal traction asking for the weights to be lifted for a few minutes d. A 68-year-old male with a new lower leg cast complaining that the cast is too tight and he cannot feel his toes

44. d. The patient with a tight cast may be at risk for neurovascular compromise (impaired circulation and peripheral nerve damage) and should be assessed first. The other patients should be seen as soon as possible. Providing analgesia for the patient with phantom pain would be the next priority. The patient in skeletal traction needs explanation of the purpose and functioning of the traction. She may need analgesia or muscle relaxants to help tolerate the traction.

The patient works on a computer 8 hours each day. What kind of repetitive strain injury would be expected in this patient? a. Meniscus injury b. Rotator cuff injury c. Radial-ulnar fracture d. Carpal tunnel syndrome

5. d. Carpal tunnel syndrome would be expected related to the continuous wrist movements. Injuries of the menisci, which are fibrocartilage in the knee, are common with athletes. Radial-ulnar fractures are seen with great force such as a car accident or a fall. Rotator cuff injuries occur with sudden adduction forces applied to the cuff while the arm is held in abduction. They are commonly seen with repetitive overhead motions.

6. The athlete comes to the clinic with bursitis. What does the nurse know happens to the tissue to cause pain when bursitis occurs? a. Tearing of a ligament b. Stretching of muscle and fascia sheath c. Inflammation of synovial membrane sac at friction sites d. Incomplete separation of articular surfaces of joint caused by ligament injury

6. c. Bursitis is inflammation of synovial membrane sac at friction sites. Tearing of a ligament is a sprain. Stretching of muscle and fascia sheath is a strain. Incomplete separation of articular surfaces of joints caused by ligament injury is subluxation.

Which types of shock may cause reduced urinary output in a patient? Select all that apply. A. Septic shock B. Hypovolemic shock C. Neurogenic shock D. Anaphylactic shock E. Cardiogenic shock.

A, B, E Decreased urine output is a clinical manifestation of septic, hypovolemic, obstructive and cardiogenic shock. Neurogenic shock is associated with bladder dysfunction. Anaphylactic shock is associated with urinary incontinence. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation. Text Reference - p. 1635

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.

A 78 yo man has confusion and temp of 104 F. He is a diabetic with purulent drainage from his right great toe. His assessment findings are BP 84/80, HR 110, RR 42 and shallow, CO 8L/min, and PAWP 4 mmHg. The pt's symptoms are most likely indicative of A) Sepsis B) Septic shock C) Multiple organ dysfunction syndrome D) Systemic inflammatory response syndrome

B) Septic shock

The nurse is caring for a patient who is experiencing cardiogenic shock as a result of myocardial infarction. Which nursing assessment finding is most concerning? 1 PaO2 60 mm Hg 2 Blood pressure 100/56 mm Hg 3 Urine output 260 mL in eight hours 4 Heart rate 96 beats/minute

1 A PaO2 of 60 is below the normal 80 to 100 mm Hg. The patient experiencing cardiogenic shock will exhibit hypotension and tachycardia, and therefore a blood pressure of 100/56 mm Hg and heart rate of 96 would not apply. A urine output of 260 cc/8 hrs is borderline but not reportable without a continued trending pattern. Text Reference - p. 1633

What therapy is provided to a patient with acute respiratory distress syndrome (ARDS)? 1 Mechanical ventilation 2 Oxygen via a Venturi mask 3 Oxygen via a non-rebreather mask 4 Small volume nebulizer treatments

1 A patient with acute respiratory distress syndrome (ARDS) would be intubated and receive mechanical ventilation. Small volume nebulizer treatments would open airways; however, this intervention will not sufficiently treat ARDS. Oxygen via a Venturi mask or a non-rebreather mask would be insufficient to promote oxygenation and perfusion. Text Reference - p. 1651

What occurs when the inflammatory response is activated in a patient with systemic inflammatory response syndrome (SIRS)? 1 Release of mediators 2 Decrease in metabolism 3 Damage of the mesothelium 4 Decrease in vascular permeability

1 A release of mediators occurs when the inflammatory response is activated. Other changes that occur include an increase in metabolism or hypermetabolism, direct damage to the endothelium, and an increase in vascular permeability. Text Reference - p. 1649

The health care provider prescribes a dose of dobutamine for a patient in cardiogenic shock due to myocardial infarction. What appropriate actions should the nurse perform for safely administering the medication? Select all that apply. 1 Monitor heart rate and blood pressure. 2 Stop infusion if tachydysrhythmias develop. 3 Always administer with sodium bicarbonate. 4 Administer through a central line. 5 Use a glass bottle for infusion.

1, 2, 4 Dobutamine is a sympathomimetic medication. When used in therapy with dobutamine, the patient's heart rate and blood pressure should be continuously monitored, as they may worsen hypotension, requiring the addition of a vasopressor. The infusion should be stopped if tachydysrhythmias develop. The administration through a central line is recommended, because infiltration leads to tissue sloughing. The drug should not be administered with sodium bicarbonate, because it can get deactivated. Because dobutamine is not adsorbed in plastic containers, it is not necessary to administer the drug in glass bottles. Test-Taking Tip: Key words or phrases in the stem of the question such as first, primary, early, or best are important. Similarly, words such as only, always, never, and all in the alternatives are frequently evidence of a wrong response. As in life, no real absolutes exist in nursing; however, every rule has its exceptions, so answer with care. Text Reference - p. 1643

A nurse is examining a patient with anaphylactic shock due to an insect bite. What types of skin manifestations would the nurse expect to find? Select all that apply. 1 Pallor 2 Pruritus 3 Flushing 4 Urticaria 5 Cold, clammy skin

2, 3, 4 Insect bites may cause allergic reactions and anaphylactic shock. The skin manifestations may include pruritus, flushing, and urticaria caused by massive vasodilation, release of vasoactive mediators, and an increase in capillary permeability. Pallor and cold, clammy skin changes are usually seen in cardiogenic, hypovolemic, and obstructive shock caused by decreased circulatory volume and tissue perfusion. Text Reference - p. 1636

While planning the management of oxygen delivery in a patient with shock, what appropriate measures should the nurse undertake? Select all that apply. 1 Encourage the patient to move around to increase lung expansion. 2 Space activities that increase oxygen consumption. 3 Monitor continuously by using a central venous catheter. 4 Space activities that decrease oxygen consumption. 5 Administer supplemental oxygen as prescribed.

2, 3, 5 To optimize oxygen supply and ventilation in a patient suffering from shock, the activities that increase oxygen consumption should be evenly spaced. Mixed venous oxygen saturation should be monitored through a central venous catheter. The patient should not exert energy by excessive moving around because it increases oxygen demand. Text Reference - p. 1641

The nurse assesses a patient with multisystem organ dysfunction syndrome. What assessment finding is most indicative of deterioration? 1 Arterial PO2 of 95% 2 Pulse rate of 108 beats/minute 3 Total urine output of 120 mL over the past eight hours 4 Auscultation of fine bilateral crackles and a moist cough

3 A decrease in urine output to less than 30 mL/hr in an adult is an early indication of hypoperfusion to the kidneys, as well as other vital organs. This may or may not be accompanied by changes in vital signs. An arterial PO2 of 95%, a pulse rate of 108 beats/minute, and auscultation of crackles and a moist cough may also be indications of early deterioration but are not as specific as a low urinary output in identifying deterioration. Text Reference - p. 1649

9. 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 adequate quantities of a. vaccine. b. atropine. c. antibiotics. d. whole blood.

ANS: 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: 1690 TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

3. The occupational health nurse will teach the patient whose job involves many hours of typing about the need to a. obtain a keyboard pad to support the wrist. b. do stretching exercises before starting work. c. wrap the wrists with compression bandages every morning. d. avoid using nonsteroidal antiinflammatory drugs (NSAIDs) for pain.

ANS: A Repetitive strain injuries caused by prolonged times working at a keyboard can be prevented by the use of a pad that will keep the wrists in a straight position. Stretching exercises during the day may be helpful, but these would not be needed before starting. Use of a compression bandage is not needed, although a splint may be used for carpal tunnel syndrome. NSAIDs are appropriate to use to decrease swelling.

30. Which nursing action for a patient who has had right hip replacement surgery can the nurse delegate to experienced unlicensed assistive personnel (UAP)? a. Reposition the patient every 1 to 2 hours. b. Assess for skin irritation on the patient's back. c. Teach the patient quadriceps-setting exercises. d. Determine the patient's pain level and tolerance.

ANS: A Repositioning of orthopedic patients is within the scope of practice of UAP (after they have been trained and evaluated in this skill). The other actions should be done by licensed nursing staff members. (B and D are assessments, C is teaching.)

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.

ANS: 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: Apply (application) REF: 1697 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A patient with septic shock has a BP of 70/46 mm Hg, pulse 136, respirations 32, temperature 104° F, and blood glucose 246 mg/dL. Which of these prescribed interventions will the nurse implement first? a. Give normal saline IV at 500 mL/hr. b. Infuse drotrecogin- (Xigris) 24 mcg/kg. c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL. d. Titrate norepinephrine (Levophed) to keep mean arterial pressure (MAP) at 65 to 70 mm Hg.

ANS: A Because of the low systemic vascular resistance (SVR) 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: Application REF: 1735-1737 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient with septic shock has a urine output of 20 mL/hr for the past 3 hours. The pulse rate is 120 and the central venous pressure and pulmonary artery wedge pressure are low. Which of these orders by the health care provider will the nurse question? a. Give furosemide (Lasix) 40 mg IV. b. Increase normal saline infusion to 150 mL/hr. c. Administer hydrocortisone (SoluCortef) 100 mg IV. d. Prepare to give drotrecogin alpha (Xigris) 24 mcg/kg/hr.

ANS: A Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock. The other orders are appropriate. DIF: Cognitive Level: Application REF: 1724-1726 | 1731 | 1733 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

12. A 20-year-old 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 (Mucomyst). b. Discuss the use of chelation therapy. c. Start oxygen using a non-rebreather mask. d. Have the patient drink large amounts of water.

ANS: 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: 1689 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

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 b. Heart rate 112 beats/minute c. Decreased bowel sounds d. Pale, cool, and dry extremities

ANS: 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

A patient is treated in the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to a. administer oxygen. b. attach a cardiac monitor. c. obtain the blood pressure. d. check the level of consciousness.

ANS: A The initial actions of the nurse are focused on the ABCs—airway, breathing, circulation—and administration of oxygen should be done first. The other actions should be accomplished as rapidly as possible after oxygen administration. DIF: Cognitive Level: Application REF: 1729-1731 | 1732 | 1733 | 1736-1737 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient with shock of unknown etiology whose hemodynamic monitoring indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure has the following collaborative interventions prescribed. Which intervention will the nurse question? a. Infuse normal saline at 250 mL/hr. b. Keep head of bed elevated to 30 degrees. c. Give nitroprusside (Nipride) unless systolic BP <90 mm Hg. d. Administer dobutamine (Dobutrex) to keep systolic BP >90 mm Hg.

ANS: A The patient's elevated pulmonary artery wedge pressure indicates volume excess. A normal saline infusion at 250 mL/hr will exacerbate this. The other actions are appropriate for the patient. DIF: Cognitive Level: Application REF: 1719 | 1721-1722 | 1735 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

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 1 to 2 hours before being seen by the doctor.

ANS: 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: Apply (application) REF: 1675-1676 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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 any itching areas. d. Give diphenhydramine (Benadryl) 50 mg PO.

ANS: 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: Apply (application) REF: 1687 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

When preparing to cool a patient who is to begin therapeutic hypothermia, which intervention will the nurse plan to do (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.

ANS: 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: 1681 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

6. The nurse will instruct the patient with a fractured left radius that the cast will need to remain in place a. for several months. b. for at least 3 weeks. c. until swelling of the wrist has resolved. d. until x-rays show complete bony union.

ANS: B Bone healing starts immediately after the injury, but since ossification does not begin until 3 weeks postinjury, the cast will need to be worn for at least 3 weeks. Complete union may take up to a year. Resolution of swelling does not indicate bone healing.

14. Which action will the nurse take in order to evaluate the effectiveness of Buck's traction for a 62-year-old patient who has an intracapsular fracture of the right femur? a. Check peripheral pulses. b. Ask about hip pain level. c. Assess for hip contractures. d. Monitor for hip dislocation.

ANS: B Buck's traction keeps the leg immobilized and reduces painful muscle spasm. Hip contractures and dislocation are unlikely to occur in this situation. The peripheral pulses will be assessed, but this does not help in evaluating the effectiveness of Buck's traction.

29. A young man arrives in the emergency department with ankle swelling and severe pain after twisting his ankle playing basketball. Which of these prescribed collaborative interventions will the nurse implement first? a. Take the patient to have x-rays. b. Wrap the ankle and apply an ice pack. c. Administer naproxen (Naprosyn) 500 mg PO. d. Give acetaminophen with codeine (Tylenol #3).

ANS: B Immediate care after a sprain or strain injury includes the application of cold and compression to the injury to minimize swelling. The other actions should be taken after the ankle is wrapped with a compression bandage and ice is applied.

26. A patient is being discharged 4 days after hip replacement surgery using the posterior approach. Which patient action requires immediate intervention by the nurse? a. The patient uses crutches with a swing-to gait. b. The patient leans over to pull shoes and socks on. c. The patient sits straight up on the edge of the bed. d. The patient bends over the sink while brushing teeth.

ANS: B Leaning over would flex the hip at greater than 90 degrees and predispose the patient to hip dislocation. The other patient actions are appropriate and do not require any immediate action by the nurse to protect the patient.

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

ANS: B Antibiotics should be administered within the first hour for patients who have sepsis or suspected sepsis in order to prevent progression to systemic inflammatory response syndrome (SIRS) 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.

Which of these findings is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been successful? a. Hemoglobin is within normal limits. b. Urine output is 60 mL over the last hour. c. Pulmonary artery wedge pressure (PAWP) is normal. d. Mean arterial pressure (MAP) is 65 mm Hg.

ANS: B Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. The hemoglobin level, PAWP, 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: Application REF: 1733-1735 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

Which information about a patient who is receiving vasopressin (Pitressin) to treat septic shock is most important for the nurse to communicate to the heath care provider? a. The patient's heart rate is 108 beats/min. b. The patient is complaining of chest pain. c. The patient's peripheral pulses are weak. d. The patient's urine output is 15 mL/hr.

ANS: 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 a need for a change in therapy. DIF: Cognitive Level: Application REF: 1735-1736 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The following therapies are prescribed by the health care provider for a patient who has respiratory distress and syncope after a bee sting. Which will the nurse administer first? a. normal saline infusion b. epinephrine (Adrenalin) c. dexamethasone (Decadron) d. diphenhydramine (Benadryl)

ANS: B 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 also are appropriate but would not be the first ones administered. DIF: Cognitive Level: Application REF: 1736-1737 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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).

ANS: 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 diagnosis of intraabdominal bleeding. DIF: Cognitive Level: Apply (application) REF: 1678 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

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 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.

ANS: 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: Apply (application) REF: 1689 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

When 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. BP 92/56 mm Hg b. Skin cool and clammy c. Apical pulse 118 beats/min d. Arterial oxygen saturation 91%

ANS: B Since 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 also will be reported, but does not indicate deterioration of the patient's status. DIF: Cognitive Level: Application REF: 1723 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity *sepsis starts off seca*

When the nurse is assessing a patient who is receiving a nitroprusside (Nipride) infusion to treat cardiogenic shock, which finding indicates that the medication is effective? a. No heart murmur is audible. b. Skin is warm, pink, and dry. c. Troponin level is decreased. d. Blood pressure is 90/40 mm Hg.

ANS: B Warm, pink, and dry skin indicates that perfusion to tissues is improved. Since nitroprusside is a vasodilator, the blood pressure may be low even if the medication is effective. Absence of a heart murmur and a decrease in troponin level are not indicators of improvement in shock. DIF: Cognitive Level: Application REF: 1721 | 1723 | 1733-1735 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

40. Which action will the urgent care nurse take when caring for a patient who has a possible knee meniscus injury? a. Encourage bed rest for 24 to 48 hours. b. Avoid palpation or movement of the knee. c. Apply a knee immobilizer to the affected leg. d. Administer intravenous narcotics for pain relief.

ANS: C A knee immobilizer may be used for several days after a meniscus injury to stabilize the knee and minimize pain. Patients are encouraged to ambulate with crutches. The knee is assessed by flexing, internally rotating, and extending the knee (McMurray's test). The pain associated with a meniscus injury will not typically require IV opioid administration; nonsteroidal antiinflammatory drugs (NSAIDs) are usually recommended for pain relief.

28. A patient arrived at the emergency department after tripping over a rug and falling at home. Which finding is most important for the nurse to communicate to the health care provider? a. There is bruising at the shoulder area. b. The patient reports arm and shoulder pain. c. The right arm appears shorter than the left. d. There is decreased shoulder range of motion.

ANS: C A shorter limb after a fall indicates a possible dislocation, which is an orthopedic emergency. Bruising, pain, and decreased range of motion also should be reported, but these do not indicate that emergent treatment is needed to preserve function.

10. Which statement by the patient indicates a good understanding of the nurse's teaching about a new short-arm plaster cast? a. "I can get the cast wet as long as I dry it right away with a hair dryer." b. "I should avoid moving my fingers and elbow until the cast is removed." c. "I will apply an ice pack to the cast over the fracture site off and on for 24 hours." d. "I can use a cotton-tipped applicator to rub lotion on any dry areas under the cast."

ANS: C Ice application for the first 24 hours after a fracture will help reduce swelling and can be placed over the cast. Plaster casts should not get wet. The patient should be encouraged to move the joints above and below the cast. Patients should not insert objects inside the cast.

24. When giving home care instructions to a patient who has comminuted forearm fractures and a long-arm cast on the left arm, which information should the nurse include? a. Keep the left shoulder elevated on a pillow or cushion. b. Keep the hand immobile to prevent soft tissue swelling. c. Call the health care provider for increased swelling or numbness of the hand. d. Avoid nonsteroidal antiinflammatory drugs (NSAIDs) for 24 hours after the injury.

ANS: C Increased swelling or numbness may indicate increased pressure at the injury, and the health care provider should be notified immediately to avoid damage to nerves and other tissues. The patient should be encouraged to move the joints above and below the cast to avoid stiffness. There is no need to elevate the shoulder, although the forearm should be elevated to reduce swelling. NSAIDs are appropriate to treat pain after a fracture.

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 about 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.

ANS: 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: Apply (application) REF: 1679 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

22. A 28-year-old 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.

ANS: 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: 1688 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

8. A 22-year-old patient who experienced a near 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. b. Palpate peripheral pulses. c. Auscultate breath sounds. d. Check pupil reaction to light.

ANS: C Because pulmonary edema is a common complication after near 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: Apply (application) REF: 1686 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which finding by the nurse will help confirm a diagnosis of neurogenic shock? a. Cool, clammy skin b. Inspiratory crackles c. Apical heart rate 48 beats/min d. Temperature 101.2° F (38.4° C)

ANS: C Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock. DIF: Cognitive Level: Comprehension REF: 1721-1722 | 1723 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

When the charge nurse is evaluating the skills of a new RN, which action by the new RN indicates a need for more education in the care of patients with shock? 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. Decreasing the room temperature to 68° F for a patient with neurogenic shock d. Increasing the nitroprusside (Nipride) infusion rate for a patient with a high SVR

ANS: C Patients with *neurogenic* shock may have *poikilothermia*. The room temperature should be kept warm to avoid hypothermia. The other actions by the new RN are appropriate. DIF: Cognitive Level: Application REF: 1721-1722 | 1724 OBJ: Special Questions: Delegation TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment

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

ANS: C Since 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. Elevated temperature and flushing or itching of the skin are not typical of cardiogenic shock. DIF: Cognitive Level: Application REF: 1721 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

After receiving 1000 mL 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 the administration of a. nitroglycerine (Tridil). b. drotrecogin alpha (Xigris). c. norepinephrine (Levophed). d. sodium nitroprusside (Nipride).

ANS: C When fluid resuscitation is unsuccessful, vasopressor drugs are administered to increase the systemic vascular resistance (SVR) and improve tissue perfusion. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Drotrecogin alpha may decrease inappropriate inflammation and help prevent systemic inflammatory response syndrome, but it will not directly improve blood pressure. Nitroprusside is an arterial vasodilator and would further decrease SVR. DIF: Cognitive Level: Application REF: 1731 | 1733-1735 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

2. The emergency department (ED) nurse is initiating 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. Check neurologic status every 2 hours. c. Place cooling blankets above and below patient. d. Give acetaminophen (Tylenol) 650 mg per nasogastric tube. e. Insert rectal temperature probe and attach to cooling blanket control panel.

ANS: 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: 15-16 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

22. Which action will the nurse include in the plan of care for a patient who has had a total right knee arthroplasty? a. Avoid extension of the right knee beyond 120 degrees. b. Use a compression bandage to keep the right knee flexed. c. Teach about the need to avoid weight bearing for 4 weeks. d. Start progressive knee exercises to obtain 90-degree flexion.

ANS: D After knee arthroplasty, active or passive flexion exercises are used to obtain a 90-degree flexion of the knee. The goal for extension of the knee will be 180 degrees. A compression bandage is used to hold the knee in an extended position after surgery. Full weight bearing is expected before discharge.

5. A 19-year-old 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).

ANS: 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: 1681 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance

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. b. Palpate for abdominal pain. c. Ask the patient about nausea. d. Check stools for occult blood.

ANS: D Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill patients. The other assessments also will be done, but these will not help in determining the effectiveness of the pantoprazole administration.

2. During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal pulse is absent and the 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.

ANS: 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: Apply (application) REF: 1676 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient who has been involved in a motor vehicle crash is admitted to the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which of these prescribed interventions should the nurse implement first? a. Place the patient on continuous cardiac monitor. b. Draw blood to type and crossmatch for transfusions. c. Insert two 14-gauge IV catheters in antecubital space. d. Administer oxygen at 100% per non-rebreather mask

ANS: D The first priority in the initial management of shock is maintenance of the airway and ventilation. Cardiac monitoring, insertion of IV catheters, and obtaining blood for transfusions also should be rapidly accomplished, but only after actions to maximize oxygen delivery have been implemented. DIF: Cognitive Level: Application REF: 1732 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

17. A 54-year-old patient arrives in the emergency department (ED) after 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.

ANS: 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/all visible powder should be brushed off. The other actions can be done after the decontamination is completed. DIF: Cognitive Level: Apply (application) REF: 1690 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A 42-year-old man who is scheduled for an arthrocentesis arrives at the outpatient surgery unit and states, "I do not want this procedure done today." Which response by the nurse is most appropriate? A. "When would you like to reschedule the procedure?" B. "Tell me what your concerns are about this procedure." C. "The procedure is safe, so why should you be worried?" D. "The procedure is not painful because an anesthetic is used."

B. "Tell me what your concerns are about this procedure." The nurse should use therapeutic communication to determine the patient's concern about the procedure. The nurse should not provide false reassurance. It is not appropriate for the nurse to assume the patient is concerned about pain or to assume the patient is asking to reschedule the procedure.

A 42-year-old male patient complains of shoulder pain when the nurse moves his arm behind the back. Which question should the nurse ask? a. "Are you able to feed yourself without difficulty?" b. "Do you have difficulty when you are putting on a shirt?" c. "Are you able to sleep through the night without waking?" d. "Do you ever have trouble lowering yourself to the toilet?"

B. The patient's pain will make it more difficult to accomplish tasks like putting on a shirt or jacket. This pain should not affect the patient's ability to feed himself or use the toilet because these tasks do not involve moving the arm behind the patient. The arm will not usually be positioned behind the patient during sleeping.

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.

A chemical explosion occurs at a nearby industrial site. The first responders report that victims are being decontaminated at the scene and approximately 125 workers will need medical evaluation and care. The nurse receiving this report should know that this will first require activation of A. a code blue alert. B. a disaster medical assistance team. C. the local police and fire departments. D. the hospital's emergency response plan.

D. the hospital's emergency response plan.

The patient progressed from acute lung injury to acute respiratory distress syndrome (ARDS). He is on the ventilator and receiving propofol (Diprivan) for sedation and fentanyl (Sublimaze) to decrease anxiety, agitation, and pain in order to decrease his work of breathing, O2 consumption, carbon dioxide production, and risk of injury. What intervention is recommended in caring for this patient? a. A sedation holiday b. Monitoring for hypermetabolism c. Keeping his legs still to avoid dislodging the airway d. Repositioning him every 4 hours to decrease agitation

a. A sedation holiday is needed to assess the patient's condition and readiness to extubate. A hypermetabolic state occurs with critical illness. With malnourished patients, enteral or parenteral nutrition is started within 24 hours; with well-nourished patients it is started within 3 days. With these medications, the patient will be assessed for cardiopulmonary depression. Venous thromboembolism prophylaxis will be used but there is no reason to keep the legs still. Repositioning the patient every 2 hours may help to decrease discomfort and agitation

Although ARDS may result from direct lung injury or indirect lung injury as a result of systemic inflammatory response syndrome (SIRS), the nurse is aware that ARDS is most likely to occur in the patient with a host insult resulting from a. sepsis. b. oxygen toxicity. c. prolonged hypotension. d. cardiopulmonary bypass.

a. Although ARDS may occur in the patient who has virtually any severe illness and may be both a cause and a result of systemic inflammatory response syndrome (SIRS), the most common precipitating insults of ARDS are sepsis, gastric aspiration, and severe massive trauma.

Priority Decision: After endotracheal intubation and mechanical ventilation have been started, a patient in respiratory failure becomes very agitated and is breathing asynchronously with the ventilator. What is it most important for the nurse to do first? a. Evaluate the patient's pain level, ABGs, and electrolyte values b. Sedate the patient to unconsciousness to eliminate patient awareness c. Administer the PRN vecuronium (Norcuron) to promote synchronous ventilations d. Slow the rate of ventilations provided by the ventilator to allow for spontaneous breathing by the patient

a. It is most important to assess the patient for the cause of the restlessness and agitation (e.g., pain, hypoxemia, electrolyte imbalances) and treat the underlying cause before sedating the patient. Although sedation, analgesia, and neuromuscular blockade are often used to control agitation and pain, these treatments may contribute to prolonged ventilator support and hospital days. *nursing process - start by assessing*

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) 80%, tidal volume 450, rate 16/minute, 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. Respiratory rate 22 breaths/minute c. Crackles audible at lung bases d. Heart rate 106 beats/minute

a. O2 Sat of 99%

A patient has a PaO2 of 50 mm Hg and a PaCO2 of 42 mm Hg because of an intrapulmonary shunt. Which therapy is the patient most likely to respond best to? a. Positive pressure ventilation b. Oxygen administration at a FIO2 of 100% c. Administration of O2 per nasal cannula at 1 to 3 L/min d. Clearance of airway secretions with coughing and suctioning

a. Patients with a shunt are usually more hypoxemic than patients with a V/Q mismatch because the alveoli are filled with fluid, which prevents gas exchange. Hypoxemia resulting from an intrapulmonary shunt is usually not responsive to high O2 concentrations and the patient will usually require positive pressure ventilation. Hypoxemia associated with a V/Q mismatch usually responds favorably to O2 administration at 1 to 3 L/min by nasal cannula. Removal of secretions with coughing and suctioning is generally not effective in reversing an acute hypoxemia resulting from a shunt.

A patient with a massive hemothorax and pneumothorax has absent breath sounds in the right lung. To promote improved V/Q matching, how should the nurse position the patient? a. On the left side b. On the right side c. In a reclining chair bed d. Supine with the head of the bed elevated

a. When there is impaired function of one lung, the patient should be positioned with the unaffected lung in the dependent position to promote perfusion to the functioning tissue. If the diseased lung is positioned dependently, more V/Q mismatch would occur. The head of the bed may be elevated or a reclining chair may be used, with the patient positioned on the unaffected side, to maximize thoracic expansion if the patient has increased work of breathing. *good lung down*

A patient in hypercapnic respiratory failure has a nursing diagnosis of ineffective airway clearance related to increasing exhaustion. What is an appropriate nursing intervention for this patient? a. Inserting an oral airway b. Performing augmented coughing c. Teaching the patient huff coughing d. Teaching the patient slow pursed lip breathing

b. Augmented coughing is done by applying pressure on the abdominal muscles at the beginning of expiration. This type of coughing helps to increase abdominal pressure and expiratory flow to assist the cough to remove secretions in the patient who is exhausted. An oral airway is used only if there is a possibility that the tongue will obstruct the airway. Huff coughing prevents the glottis from closing during the cough and works well for patients with chronic obstructive pulmonary disease (COPD) to clear central airways. Slow pursed lip breathing allows more time for expiration and prevents small bronchioles from collapsing.

A patient with acute respiratory distress syndrome (ARDS) and acute kidney injury has the following medications ordered. Which medication should the nurse discuss with the health care provider before giving? a. Pantoprazole (Protonix) 40 mg IV b. Gentamicin (Garamycin) 60 mg IV c. Sucralfate (Carafate) 1 g per nasogastric tube d. Methylprednisolone (Solu-Medrol) 60 mg IV

b. Gentamicin 60 mg IV

Which patient with the following manifestations is most likely to develop hypercapnic respiratory failure? a. Rapid, deep respirations in response to pneumonia b. Slow, shallow respirations as a result of sedative overdose c. Large airway resistance as a result of severe bronchospasm d. Poorly ventilated areas of the lung caused by pulmonary edema

b. Hypercapnic respiratory failure is associated with alveolar hypoventilation with increases in alveolar and arterial carbon dioxide (CO2) and often is caused by problems outside the lungs. A patient with slow, shallow respirations is not exchanging enough gas volume to eliminate CO2. Deep, rapid respirations reflect hyperventilation and often accompany lung problems that cause hypoxemic respiratory failure. Pulmonary edema and large airway resistance cause obstruction of oxygenation and result in a V/Q mismatch or shunt typical of hypoxemic respiratory failure.

A patient has a core temperature of 90F. The most appropriate rewarming technique would be a. passive rewarming with warm blankets b. active internal rewarming using IV fluids c. passive rewarming using air-filled warming blankets d. active external rewarming by submersing in a warm bath

b. active internal rewarming using IV fluids

To evaluate the effectiveness of ordered interventions for a patient with ventilatory failure, which diagnostic test will be most useful to the nurse? a. chest x ray b. oxygen saturation c. ABG analysis d. CVP monitoring

c. ABG analysis

The nurse suspects the early stage of ARDS in any seriously ill patient who manifests what? a. Develops respiratory acidosis b. Has diffuse crackles and rhonchi c. Exhibits dyspnea and restlessness d. Has a decreased PaO2 and an increased PaCO2

c. Early signs of ARDS are insidious and difficult to detect but the nurse should be alert for any early signs of hypoxemia, such as dyspnea, restlessness, tachypnea, cough, and decreased mentation, in patients at risk for ARDS. Abnormal findings on physical examination or diagnostic studies, such as adventitious lung sounds, signs of respiratory distress, respiratory alkalosis, or decreasing PaO2, are usually indications that ARDS has progressed beyond the initial stages.

The patient with a history of heart failure and acute respiratory failure has thick secretions that she is having difficulty coughing up. Which intervention would best help to mobilize her secretions? a. Administer more IV fluid b. Perform postural drainage c. Provide O2 by aerosol mask d. Suction airways nasopharyngeally

c. For the patient with a history of heart failure, current acute respiratory failure, and thick secretions, the best intervention is to liquefy the secretions with either aerosol mask or using normal saline administered by a nebulizer. Excess IV fluid may cause cardiovascular distress and the patient probably would not tolerate postural drainage with her history. Suctioning thick secretions without thinning them is difficult and increases the patient's difficulty in maintaining oxygenation. With copious secretions, this could be done after thinning the secretions.

When the V/Q lung scan result returns with a mismatch ratio that is greater than 1, which condition should be suspected? a. Pain b. Atelectasis c. Pulmonary embolus d. Ventricular septal defect

c. There will be more ventilation than perfusion (V/Q ratio greater than 1) with a pulmonary embolus. Pain and atelectasis will cause a V/Q ratio less than 1. A ventricular septal defect causes an anatomic shunt as the blood bypasses the lungs.

A 72-year-old man tells the nurse that he cannot perform most of the physical activities he could do 5 years ago because of overall joint aches and pains. What can the nurse do to assist the patient to prevent further deconditioning and decrease the risk for developing musculoskeletal problems? a. Limit weight-bearing exercise to prevent stress on fragile bones and possible hip fractures. b. Advise the patient to avoid the use of canes and walkers because they increase dependence on ambulation aids. c. Advise the patient to increase his activity by more frequently climbing stairs in buildings and other environments with steps. d. Discuss use of over-the-counter (OTC) medications to decrease inflammation and pain so that exercise can be maintained.

d. Almost all older adults have some degree of decreased muscle strength, joint stiffness, and pain with motion. The use of mild antiinflammatory agents decreases inflammation and pain and can help the patient to maintain activity and prevent further deconditioning but other prescribed drugs and potential abdominal problems must be considered by the patient. Musculoskeletal problems in the older adult can be prevented with appropriate strategies, especially exercise. Stair walking can create enough stress on fragile bones to cause a hip fracture and use of ramps may help to prevent falls. Walkers and canes should be used as necessary to decrease stress on joints so that activity can be maintained.

What is the primary reason that hemodynamic monitoring is instituted in severe respiratory failure? a. To detect V/Q mismatches b. To continuously measure the arterial BP c. To evaluate oxygenation and ventilation status d. To evaluate cardiac status and blood flow to tissues

d. Hemodynamic monitoring with a pulmonary artery catheter is instituted in severe respiratory failure to determine the amount of blood flow to tissues and the response of the lungs and heart to hypoxemia. Continuous BP monitoring may be performed but BP is a reflection of cardiac activity, which can be determined by the pulmonary artery catheter findings. Arterial blood gases (ABGs) are important to evaluate oxygenation and ventilation status and V/Q mismatches.

The nurse assesses that a patient in respiratory distress is developing respiratory fatigue and the risk of respiratory arrest when the patient displays which behavior? a. Cannot breathe unless he is sitting upright b. Uses the abdominal muscles during expiration c. Has an increased inspiratory-expiratory (I/E) ratio d. Has a change in respiratory rate from rapid to slow

d. The increase in respiratory rate required to blow off accumulated CO2 predisposes to respiratory muscle fatigue. The slowing of a rapid rate in a patient in acute distress indicates tiring and the possibility of respiratory arrest unless ventilatory assistance is provided. A decreased inspiratory-expiratory (I/E) ratio, orthopnea, and accessory muscle use are common findings in respiratory distress but do not necessarily signal respiratory fatigue or arrest.

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. a patient with septicemia who has intercostal and suprasternal retractions

A pt is scheduled for total ankle replacement. The nurse should tell the pt that after surgery he should avoid a. lifting heavy objects b. sleeping on the back c. abduction exercises of the affected ankle d. bearing weight on the affected leg for 6 weeks

d. bearing weight on the affected leg for 6 weeks

This morning a 21-yr-old male patient had a long leg cast applied, and he asks to crutch walk before dinner. Which statement explains why the nurse will decline the patient's request? "No one is available to assist and accompany the patient." "The cast is not dry yet, and it may be damaged while using crutches." "Rest, ice, compression, and elevation are in process to decrease pain." "Excess edema and complications are prevented when the leg is elevated for 24 hours."

"Excess edema and complications are prevented when the leg is elevated for 24 hours." For the first 24 hours after a lower extremity cast is applied, the leg should be elevated on pillows above heart level to avoid excessive edema and compartment syndrome. A plaster cast will also be drying during this 24-hour period. RICE is used for soft tissue injuries, not with long leg casts.

A 21-yr-old soccer player has injured the anterior crucial ligament (ACL) and is having reconstructive surgery. Which patient statement indicates more teaching is required? "I probably won't be able to play soccer for 6 to 8 months." "They will have me do range of motion with my knee soon after surgery." "I can't wait to get this done now so I can play soccer for the next tournament." "I will need to wear an immobilizer and progressively bear weight on my knee."

"I can't wait to get this done now so I can play soccer for the next tournament." The patient does not understand the severity of ACL reconstructive surgery if planning to resume playing soccer soon; safe return will not occur for 6 to 8 months. Initial range of motion, immobilization, and progressive weight bearing will be overseen by a physical therapist.

A nurse performs discharge teaching for a 58-yr-old woman after a left hip arthroplasty using the posterior approach. Which statement by the patient indicates teaching is successful? "Leg-raising exercises are necessary for several months." "I should not try to drive a motor vehicle for 2 to 3 weeks." "I will not have any restrictions now on hip and leg movements." "Blood tests will be done weekly while taking enoxaparin (Lovenox)."

"Leg-raising exercises are necessary for several months." Exercises designed to restore strength and muscle tone will be done for months after surgery. The exercises include leg raises in supine and prone positions. Driving a car is not allowed for 4 to 6 weeks. In the posterior approach hip arthroplasties, extremes of internal rotation and 90-degree flexion of the hip must be avoided for 4 to 6 weeks postoperatively. The knees must be kept apart. The patient should never cross the legs or twist to reach behind. To prevent thromboembolism, enoxaparin is administered subcutaneously and can be given at home. Enoxaparin does not require monitoring of the patient's coagulation status.

How is systemic inflammatory response syndrome (SIRS) different from multiple organ dysfunction syndrome (MODS)? 1 Shock leads to SIRS, and SIRS causes MODS. 2 MODS is reversible, and SIRS has irreversible changes. 3 SIRS is caused by shock, and MODS is caused by perfusion deficits. 4 Homeostasis fails before SIRS, and homeostasis is maintained in MODS.

1 Any type of shock triggers the systemic inflammatory response. Generalized inflammation in organs remote from the initial shock is systemic inflammatory response syndrome (SIRS). Multiple organ dysfunction syndrome (MODS) results from SIRS. Both SIRS and MODS are reversible in the early stages. SIRS is caused by some kind of injury to the body such as sepsis, ischemia, infarction, and injury; SIRS can lead to MODS if not treated. In SIRS, a type of shock triggers a systemic inflammatory response, after which the body's homeostasis fails. In MODS, homeostasis fails and medical intervention is needed. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Text Reference - p. 1649

The intensive care unit nurse is caring for a patient who is ventilated mechanically. To prevent sepsis in this patient, which nursing intervention does the nurse include in the plan of care? 1 Provide oral care every two to four hours. 2 Turn patient from side to side every eight hours. 3 Position patient in a supine position every two hours. 4 Use clean gloves when suctioning the endotracheal tube.

1 Providing oral care every two to four hours is correct, because research has found that the oral flora of critically ill patients are predominately gram-negative organisms that can potentially cause ventilator-associated pneumonia. Oral care will help reduce the organisms. Turning the patient from side to side every eight hours is incorrect, because patients need to be turned at least every two hours to prevent accumulation of mucus, which could lead to pneumonia. Positioning the patient in a supine position is incorrect, because patients should have the head of the bed elevated during mechanical ventilation. The nurse should use sterile gloves when conducting endotracheal suctioning of the patient. Test-Taking Tip: Never leave a question unanswered. Even if answering is no more than an educated guess on your part, go ahead and mark an answer. You might be right, but if you leave it blank, you will certainly be wrong and lose precious points. Text Reference - p. 1648

The nurse reviews the medical record of a patient with pneumonia and notes that the patient has hypotension, hypothermia, leukocytosis, and hypoxemia. What should the nurse infer from these findings? 1 The patient has septic shock. 2 The patient has neurogenic shock. 3 The patient has cardiogenic shock. 4 The patient has hypovolemic shock.

1 Septic shock is most commonly found in the patient having gram-negative bacterial infections, such as pneumonia. Because it is characterized by hypertension, hypothermia, leukocytosis, and hypoxemia in patients with infections, the nurse concludes that the patient has septic shock. Neurogenic shock is most commonly seen in the patient who has an injury. Cardiogenic shock is caused by cardiovascular disorders, such as a myocardial infarction and cardiomyopathy. Hypovolemic shock is caused by hemorrhage or trauma. Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response. Text Reference - p. 1637

A patient is showing signs of anaphylactic shock from an insect sting. Which primary health care provider's prescription does the nurse implement first? 1 Epinephrine 1:1000, 0.5 mg subcutaneous (SQ) 2 Normal saline intravenous (IV) to run at 150 mL/hr 3 Diphenhydramine 50 mg IV 4 Oxygen via nasal cannula at 3 L

1 The patient in anaphylaxis experiences bronchial spasm and constriction. The administration of epinephrine is necessary to reverse this process and facilitate an open airway. Although administering normal saline, diphenhydramine, and oxygen are appropriate, they must be done after an airway has been established. Text Reference - p. 1646

A nurse caring for a patient with multiple organ dysfunction syndrome understands that the patient may be at increased risk of bleeding. What nursing interventions should the nurse perform to manage this patient? Select all that apply. 1 Observe bleeding sites. 2 Decrease fluid intake. 3 Provide enteral feedings. 4 Administer platelets and clotting factors. 5 Minimize traumatic interventions.

1, 4, 5 The patient with multiple organ dysfunction syndrome is at a risk of bleeding due to increased bleeding time, thrombocytopenia, and dysfunctional clotting process. The nursing interventions should be aimed at preventing potential bleeding and replacing factors being lost. The patient should be observed for frank or occult bleeding from potential sites. The factors like platelets and clotting factors should be replaced if deficient. Traumatic interventions such as intramuscular injections or multiple venipunctures should be avoided. Decreasing the fluid intake and providing enteral feedings will not help in minimizing hematologic complications. Text Reference - p. 1650

Priority Decision: A patient has fallen in the bathroom of the hospital room and reports pain in the upper right arm and elbow. Before splinting the injury, the nurse knows that the priority management of a possible fracture should include which action? a. Elevation of the arm b. Application of ice to the site c. Notification of the health care provider d. Neurovascular checks below the site of the injur

16. d. Pulses, sensation, and motor function distal to the injury should be checked before and after splinting to assess for nerve or vascular damage and documented to avoid doubts about whether a problem discovered later was missed during the original examination or was caused by the treatment. Elevation of the limb and application of ice should be instituted after the extremity is splinted.

17. To assess for neurologic status in a patient with a fractured humerus, what should the nurse ask the patient to do? a. Evert, invert, dorsiflex, and plantar flex the foot. b. Abduct, adduct, and oppose the fingers and pronate and supinate the hand. c. Assess the location, quality, and intensity of pain below the site of the injury. d. Assess the color, temperature, capillary refill, peripheral pulses, and presence of edema in the extremity.

17. b. Neurologic assessment includes evaluation of motor and sensory function and, in the upper extremity, includes abduction and adduction of the fingers, opposition of the fingers, and supination and pronation of the hands. It also includes sensory perception in the fingers. Evaluation of the feet would occur in lower extremity injuries. Assessment of color, temperature, capillary refill, peripheral pulses, and edema evaluates vascular status.

18. A patient is discharged from the outpatient clinic following application of a synthetic fiberglass long arm cast for a fractured ulna. Before discharge, the nurse instructs the patient to do what? a. Never get the cast wet. b. Move the shoulder and fingers frequently. c. Place tape petals around the edges of the cast when it is dry. d. Use a sling to support the arm at waist level for the first 48 hours.

18. b. A patient with any type of cast should exercise the joints above and below the cast frequently and moving the fingers frequently will improve circulation and help to prevent edema. Unlike plaster casts, thermoplastic resin or fiberglass casts are relatively waterproof and, if they become wet, can be dried with a hair dryer on low setting. Tape petals are used on plaster casts to protect the edges from breaking and crumbling but are not necessary for synthetic casts. After the cast is applied, the extremity should be elevated at about the level of the heart to promote venous return and ice may be used to prevent edema.

19. A patient with a fractured tibia accompanied by extensive soft tissue damage initially has a splint applied and held in place with an elastic bandage. What early sign should alert the nurse that the patient is developing compartment syndrome? a. Paralysis of the toes b. Absence of peripheral pulses c. Distal pain unrelieved by opioid analgesics d. Skin over the injury site is blanched when the bandage is removed

19. c. Pain that is distal to the injury and is unrelieved by opioid analgesics is the earliest sign of compartment syndrome. Paralysis and absence of peripheral pulses will eventually occur if it is not treated but these are late signs that often appear after permanent damage has occurred. The overlying skin may appear normal because the surface vessels are not occluded.

22. The woman with osteoporosis slipped on the ice and now her wrist hurts. If there is a fracture, what type of fracture is expected? a. Dislocation b. Open fracture c. Colles' fracture d. Incomplete fracture

22. c. A Colles' fracture most often occurs in patients over 50 years of age with osteoporosis and frequently when the patient attempts to break a fall with an outstretched arm and hand. Dislocation is the complete separation of articular surfaces of the joint caused by a ligament injury. Open fracture is when there is communication with the external environment. A fracture is incomplete if only part of the bone shaft is fractured and the bone is still in one piece.

24. In a patient with a stable vertebral fracture, what should the nurse teach the patient to do? a. Remain on bed rest until the pain is gone. b. Logroll to keep the spine straight when turning. c. How to use bone cement to correct the problem. d. Take as much analgesic as needed to relieve the pain.

24. b. The spine should be kept straight by turning the shoulders and hips together (logrolling). This keeps the spine in good alignment until union has been accomplished. Bed rest may be required for a short time but not until the pain is gone. Analgesics should be taken only as ordered. If they do not relieve the pain, the health care provider should be notified. Bone cement is used by the surgeon to stabilize vertebral compression fractures.

When is a fat embolism most likely to occur? a. 24 to 48 hours following a fractured tibia b. 36 to 72 hours following a skull fracture c. 4 to 5 days following a fractured femur d. 5 to 6 days following a pelvic fracture

25. a. Initial manifestations of fat embolism usually occur 24 to 48 hours after injury and are associated with fractures of long bones and multiple fractures related to pelvic injuries, including fractures of the femur, tibia, ribs, and pelvis.

28. An older adult woman is admitted to the emergency department after falling at home. The nurse cautions her not to put weight on the leg after finding what in the patient assessment? a. Inability to move the toes and ankle b. Edema of the thigh extending to the knee c. Internal rotation of the leg with groin pain d. Shortening and external rotation of the leg

28. d. The classic signs of a hip fracture are shortening of the leg and external rotation accompanied by severe pain at the fracture site and additional injury could be caused by weight bearing on the extremity. The patient may not be able to move the hip or the knee but movement in the ankle and toes is not affected.

29. A patient with an extracapsular hip fracture is admitted to the orthopedic unit and placed in Buck's traction. The nurse explains to the patient that the purpose of the traction is to do what? a. Pull bone fragments back into alignment b. Immobilize the leg until healing is complete c. Reduce pain and muscle spasms before surgery d. Prevent damage to the blood vessels at the fracture site

29. c. Although surgical repair is the preferred method of managing intracapsular and extracapsular hip fractures, initially patients frequently may be treated with skin traction, such as Buck's traction or Russell's traction, to immobilize the limb temporarily and to relieve the painful muscle spasms before surgery is performed. Prolonged traction would be required to reduce the fracture or immobilize it for healing, creating a very high risk for complications of immobility.

A patient is brought to the emergency department (ED) after multiple bee stings. On assessment, the nurse finds that the patient has edema on the lips and tongue as well as chest pain, dizziness, wheezing, and stridor. What type of shock should the nurse document this as? 1 Septic shock 2 Neurogenic shock 3 Anaphylactic shock 4 Obstructive shock

3 Anaphylactic shock is an acute, life-threatening hypersensitivity reaction to a sensitizing substance that, in this case, is insect venom. The reaction quickly causes massive vasodilation, release of vasoactive mediators, and an increase in capillary permeability. As capillary permeability increases, fluid leaks from the vascular space into the interstitial space. The consequences of these pathophysiologic processes include edema on the lips and tongue, chest pain, wheezing, and stridor. Sepsis is a systemic inflammatory response to a documented or suspected infection. Neurogenic shock is a hemodynamic phenomenon that can occur within 30 minutes of a spinal cord injury at the fifth thoracic (T5) vertebra or above. Text Reference - p. 1636

The nurse is administering oxygen therapy to a patient in septic shock. What are the possible factors that directly affect oxygen delivery in the patient and should be monitored? Select all that apply. 1 Urine output 2 White blood cells 3 Cardiac output 4 Available hemoglobin 5 Arterial oxygen saturation

3, 4, 5 Oxygen delivery depends on cardiac output, available hemoglobin, and arterial oxygen saturation (SaO2). The amount of blood that the heart pumps to the body may decide the amount of oxygen delivered to the tissues. Hemoglobin, the protein content in red blood cells, is responsible for carrying oxygen molecules. Low hemoglobin means a low oxygen supply to the tissues. Arterial oxygen saturation indicates the total oxygen carried by the blood in the arteries and implies the level of tissue oxygenation. The urine output and white blood cells are also important parameters to be monitored in a patient who suffers from a shock. However, these do not impact the oxygen delivery directly. Text Reference - p. 1641

31. What should the nurse include in discharge instructions for the patient following a hip prosthesis with a posterior approach? a. Restrict walking for 2 to 3 months. b. Take a bath rather than a shower to prevent falling. c. Keep the leg internally rotated while sitting and standing. d. Have a family member put on the patient's shoes and socks.

31. d. Patients with hip prostheses with a posterior approach must avoid extreme flexion, adduction, or internal rotation for at least 6 weeks to prevent dislocation of the prosthesis. Gradual weight bearing on the limb is allowed and ambulation should be encouraged. The leg should be not be externally rotated.

3. The patient asks, "What does the doctor mean when he says that I have an avulsion fracture in my leg? I thought I had a sprain!" What is the best response by the nurse? a. "It is a fracture with more than two fragments." b. "It means that a ligament pulled a bone fragment loose." c. "The line of the fracture is twisted along the shaft of the bone." d. "The line of the fracture is at right angles to the longitudinal axis of the bone."

3. b. An avulsion fracture occurs when a ligament pulls a bone fragment loose, with pain similar to a sprain. A fracture with two or more fragments is a comminuted fracture. It is a spiral fracture when it is twisted around a bone shaft. It is a transverse fracture when the line of fracture is at right angles to the longitudinal axis.

30. A patient with a fractured right hip has an anterior open reduction and internal fixation of the fracture. What should the nurse plan to do postoperatively? a. Get the patient up to the chair on the first postoperative day. b. Position the patient only on the back and the unoperative side. c. Keep the leg abductor pillow on the patient even when bathing. d. Ambulate the patient with partial weight bearing by discharge.

30. a. Because the fracture site is internally fixed with pins or plates, the fracture site is stable and the patient is moved from the bed to the chair on the first postoperative day. Ambulation begins on the first or second postoperative day without weight bearing on the affected leg. Weight bearing on the affected extremity is usually restricted for 6 to 12 weeks until adequate healing is evident on x-ray. The patient may be positioned on the operative side following internal fixation and abductor pillows are used for patients who have total hip replacements.

What is the clinical manifestation of systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS) on the respiratory system? 1 Pulmonary edema 2 Pulmonary fibrosis 3 Pulmonary embolism 4 Pulmonary hypertension

4 Systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS) affect the respiratory system and lead to pulmonary hypertension. Pulmonary edema is caused by fluid accumulation in the air spaces. Pulmonary fibrosis is a respiratory disorder caused by scars in the lung tissues or inhalation of airborne toxins. A pulmonary embolism is caused by blood clots or blockage in the pulmonary arteries. Text Reference - p. 1651

A massive gastrointestinal bleed has resulted in hypovolemic shock in an older patient. What is a priority nursing diagnosis? 1 Acute pain 2 Impaired tissue integrity 3 Decreased cardiac output 4 Ineffective tissue perfusion

4 The many deleterious effects of shock are all related to inadequate perfusion and oxygenation of every body system. Ineffective tissue perfusion supersedes acute pain, impaired tissue integrity, and decreased cardiac output, because circulation is a priority. Acute pain may occur, but is not a priority at this time. Tissue integrity is not impaired. Text Reference - p. 1633

4. The patient with osteoporosis had a spontaneous hip fracture. How should the nurse document this before the x-ray results return? a. Open fracture b. Oblique fracture c. Pathologic fracture d. Greenstick fracture

4. c. A pathologic fracture is a spontaneous fracture at the site of bone disease, such as osteoporosis. An open fracture is when there is communication with the external environment. The oblique fracture has a slanted fracture line. A greenstick fracture is splintered on one side and the other side is bent.

40. A 65-year-old patient has undergone a right total hip arthroplasty with a cemented prosthesis for treatment of severe osteoarthritis of the hip. What is included in the activity the nurse anticipates for the patient on the patient's first or second postoperative day? a. Transfer from the bed to the chair twice a day only b. Turning from the back to the unaffected side q2hr only c. Crutch walking with non-weight bearing on the operative leg d. Ambulation and weight bearing on the right leg with a walker

40. d. Physical therapy is initiated on the first postoperative day with ambulation and weight bearing using a walker for a patient with a cemented prosthesis and non-weight bearing on the operative side for an uncemented prosthesis. In addition, the patient sits in the chair at least twice a day and is turned to both sides and back with the operative leg supported.

41. When positioning the patient after a total hip arthroplasty with a posterior approach, it is important that the nurse maintain the affected extremity in what position? a. Adduction and flexion b. Abduction and extension c. Abduction and internal rotation d. Adduction and external rotation

41. b. Following a total hip arthroplasty with a posterior approach, during hospitalization an abduction pillow is placed between the legs to maintain abduction and the leg is extended. Extremes of internal rotation, adduction, and 90-degree flexion of the hip must be avoided for 4 to 6 weeks postoperatively to prevent dislocation of the prosthesis.

42. Following a knee arthroplasty, a patient has a continuous passive motion machine for the affected joint. The nurse explains to the patient that this device is used for what purpose? a. To relieve edema and pain at the incision site b. To promote early joint mobility and increase knee flexion c. To prevent venous stasis and the formation of a deep venous thrombosis d. To improve arterial circulation to the affected extremity to promote healing

42. b. Continuous passive motion machines are frequently used following knee surgery to promote earlier joint mobility. Because joint dislocation is not a problem with knee replacements, early exercise with straight leg raises and gentle ROM is also encouraged postoperatively.

The nurse is assisting in the care of several patients in the critical care unit. Which patient is most at risk for developing multiple organ dysfunction syndrome (MODS)? A 22-yr-old patient with systemic lupus erythematosus admitted with a pelvic fracture A 48-yr-old patient with lung cancer admitted for syndrome of inappropriate antidiuretic hormone and hyponatremia A 65-yr-old patient with coronary artery disease, dyslipidemia, and primary hypertension admitted for unstable angina A 82-yr-old patient with type 2 diabetes mellitus and chronic kidney disease admitted for peritonitis related to a peritoneal dialysis catheter infection

A 82-yr-old patient with type 2 diabetes mellitus and chronic kidney disease admitted for peritonitis related to a peritoneal dialysis catheter infection A patient with peritonitis is at high risk for developing sepsis. In addition, a patient with diabetes is at high risk for infections and impaired healing. Sepsis and septic shock are the most common causes of MODS. Individuals at greatest risk for developing MODS are older adults and persons with significant tissue injury or preexisting disease. MODS can be initiated by any severe injury or disease process that activates a massive systemic inflammatory response.

Appropriate treatment modalities for the mgmt. of cardiogenic shock include (select all) A) dobutamine to increase myocardial contractility B) vasopressors to increase systemic vascular resistance C) circulatory assist devices such as an intraaortic balloon pump D) corticosteroids to stabilize the cell wall in the infarcted myocardium E) Trendelenburg positioning to facilitate venous return and increase preload

A) dobutamine to increase myocardial contractility C) circulatory assist devices such as an intraaortic balloon pump

15. A patient with a right lower leg fracture will be discharged home with an external fixation device in place. Which information will the nurse teach? a. "You will need to check and clean the pin insertion sites daily." b. "The external fixator can be removed for your bath or shower." c. "You will need to remain on bed rest until bone healing is complete." d. "Prophylactic antibiotics are used until the external fixator is removed."

ANS: A Pin insertion sites should be cleaned daily to decrease the risk for infection at the site. An external fixator allows the patient to be out of bed and avoid the risks of prolonged immobility. The device is surgically placed and is not removed until the bone is stable. Prophylactic antibiotics are not routinely given when an external fixator is used.

12. A 32-year-old patient who has had an open reduction and internal fixation (ORIF) of left lower leg fractures continues to complain of severe pain in the leg 15 minutes after receiving the prescribed IV morphine. Pulses are faintly palpable and the foot is cool. Which action should the nurse take next? a. Notify the health care provider. b. Assess the incision for redness. c. Reposition the left leg on pillows. d. Check the patient's blood pressure.

ANS: A The patient's clinical manifestations suggest compartment syndrome and delay in diagnosis and treatment may lead to severe functional impairment. The data do not suggest problems with blood pressure or infection. Elevation of the leg will decrease arterial flow and further reduce perfusion.

20. Following an earthquake, patients are triaged by emergency medical personnel and are transported to the emergency department (ED). Which patient 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 black tag d. A patient with a yellow tag

ANS: 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: 1692 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

18. An unresponsive 79-year-old 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) 88/50, and pulse 112. The nurse initially will plan to a. apply wet sheets and a fan to the patient. b. provide O2 at 6 L/min with a nasal cannula. c. start lactated Ringer's solution at 1000 mL/hr. d. give acetaminophen (Tylenol) rectal suppository.

ANS: A 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: Apply (application) REF: 1683 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

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. Use aseptic technique when caring for invasive lines or devices. b. Ambulate postoperative patients as soon as possible after surgery. c. Remove indwelling urinary catheters as soon as possible after surgery. d. Advocate for parenteral nutrition for patients who cannot take oral feedings. e. Administer prescribed antibiotics within 1 hour for patients with possible sepsis.

ANS: A, B, C, E 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 administered within 1 hour after being prescribed to decrease the risk of sepsis progressing to SIRS.

42. Which information obtained by the nurse about a 29-year-old patient with a lumbar vertebral compression fracture is most important to report to the health care provider? a. Patient refuses to be turned due to back pain. b. Patient has been incontinent of urine and stool. c. Patient reports lumbar area tenderness to palpation. d. Patient frequently uses oral corticosteroids to treat asthma.

ANS: B Changes in bowel or bladder function indicate possible spinal cord compression and should be reported immediately because surgical intervention may be needed. The other findings are also pertinent but are consistent with the patient's diagnosis and do not require immediate intervention

9. A patient has a long-arm plaster cast applied for immobilization of a fractured left radius. Until the cast has completely dried, the nurse should a. keep the left arm in dependent position. b. avoid handling the cast using fingertips. c. place gauze around the cast edge to pad any roughness. d. cover the cast with a small blanket to absorb the dampness.

ANS: B Until a plaster cast has dried, using the palms rather than the fingertips to handle the cast helps prevent creating protrusions inside the cast that could place pressure on the skin. The left arm should be elevated to prevent swelling. The edges of the cast may be petaled once the cast is dry, but padding the edges before that may cause the cast to be misshapen. The cast should not be covered until it is dry because heat builds up during drying.

13. A patient with a complex pelvic fracture from a motor vehicle crash is on bed rest. Which nursing assessment finding is important to report to the health care provider? a. The patient states that the pelvis feels unstable. b. Abdomen is distended and bowel sounds are absent. c. There are ecchymoses across the abdomen and hips. d. The patient complains of pelvic pain with palpation.

ANS: B The abdominal distention and absent bowel sounds may be due to complications of pelvic fractures such as paralytic ileus or hemorrhage or trauma to the bladder, urethra, or colon. Pelvic instability, abdominal pain with palpation, and abdominal bruising would be expected with this type of injury.

17. When doing discharge teaching for a 19-year-old patient who has had a repair of a fractured mandible, the nurse will include information about a. administration of nasogastric tube feedings. b. how and when to cut the immobilizing wires. c. the importance of high-fiber foods in the diet. d. the use of sterile technique for dressing changes.

ANS: B The jaw will be wired for stabilization, and the patient should know what emergency situations require that the wires be cut to protect the airway. There are no dressing changes for this procedure. The diet is liquid, and patients are not able to chew high-fiber foods. Initially, the patient may receive nasogastric tube feedings, but by discharge, the patient will swallow liquid through a straw.

16. A patient who has had an open reduction and internal fixation (ORIF) of a hip fracture tells the nurse that he is ready to get out of bed for the first time. Which action should the nurse take? a. Use a mechanical lift to transfer the patient from the bed to the chair. b. Check the postoperative orders for the patient's weight-bearing status. c. Avoid administration of pain medications before getting the patient up. d. Delegate the transfer of the patient to nursing assistive personnel (NAP).

ANS: B The nurse should be familiar with the weight-bearing orders for the patient before attempting the transfer. Mechanical lifts are not typically needed after this surgery. Pain medications should be given because the movement is likely to be painful for the patient. The registered nurse (RN) should supervise the patient during the initial transfer to evaluate how well the patient is able to accomplish this skill.

38. Before assisting a patient with ambulation 2 days after a total hip replacement, which action is most important for the nurse to take? a. Observe the status of the incisional drain device. b. Administer the ordered oral opioid pain medication. c. Instruct the patient about the benefits of ambulation. d. Change the hip dressing and document the wound appearance.

ANS: B The patient should be adequately medicated for pain before any attempt to ambulate. Instructions about the benefits of ambulation may increase the patient's willingness to ambulate, but decreasing pain with ambulation is more important. The presence of an incisional drain or timing of dressing change will not affect ambulation.

27. After being hospitalized for 3 days with a right femur fracture, a 32-year-old patient suddenly develops shortness of breath and tachypnea. The patient tells the nurse, "I feel like I am going to die!" Which action should the nurse take first? a. Stay with the patient and offer reassurance. b. Administer the prescribed PRN oxygen at 4 L/min. c. Check the patient's legs for swelling or tenderness. d. Notify the health care provider about the symptoms.

ANS: B The patient's clinical manifestations and history are consistent with a pulmonary embolus, and the nurse's first action should be to ensure adequate oxygenation. The nurse should offer reassurance to the patient, but meeting the physiologic need for oxygen is a higher priority. The health care provider should be notified after the oxygen is started and pulse oximetry and assessment for fat embolus or venous thromboembolism (VTE) are obtained.

45. When caring for a patient who is using Buck's traction after a hip fracture, which action can the nurse delegate to unlicensed assistive personnel (UAP)? a. Monitor the skin under the traction boot for redness. b. Ensure that the weight for the traction is off the floor. c. Check for intact sensation and movement in the affected leg. d. Offer reassurance that hip and leg pain are normal after hip fracture.

ANS: B UAP can be responsible for maintaining the integrity of the traction once it has been established. Assessment of skin integrity and circulation should be done by the registered nurse (RN). UAP should notify the RN if the patient experiences hip and leg pain because pain and effectiveness of pain relief measures should be assessed by the RN.

1. When teaching seniors at a community recreation center, which information will the nurse include about ways to prevent fractures? a. Tack down scatter rugs in the home. b. Most falls happen outside the home. c. Buy shoes that provide good support and are comfortable to wear. d. Range-of-motion exercises should be taught by a physical therapist.

ANS: C Comfortable shoes with good support will help decrease the risk for falls. Scatter rugs should be eliminated, not just tacked down. Activities of daily living provide range of motion exercise; these do not need to be taught by a physical therapist. Falls inside the home are responsible for many injuries.

4. Which discharge instruction will the emergency department nurse include for a patient with a sprained ankle? a. Keep the ankle loosely wrapped with gauze. b. Apply a heating pad to reduce muscle spasms. c. Use pillows to elevate the ankle above the heart. d. Gently move the ankle through the range of motion.

ANS: C Elevation of the leg will reduce the amount of swelling and pain. Compression bandages are used to decrease swelling. For the first 24 to 48 hours, cold packs are used to reduce swelling. The ankle should be rested and kept immobile to prevent further swelling or injury.

43. When a patient arrives in the emergency department with a facial fracture, which action will the nurse take first? a. Assess for nasal bleeding and pain. b. Apply ice to the face to reduce swelling. c. Use a cervical collar to stabilize the spine. d. Check the patient's alertness and orientation.

ANS: C Patients who have facial fractures are at risk for cervical spine injury and should be treated as if they have a cervical spine injury until this is ruled out. The other actions are also necessary, but the most important action is to prevent cervical spine injury.

25. A patient who slipped and fell in the shower at home has a proximal humerus fracture immobilized with a left-sided long-arm cast and a sling. Which nursing intervention will be included in the plan of care? a. Use surgical net dressing to hang the arm from an IV pole. b. Immobilize the fingers of the left hand with gauze dressings. c. Assess the left axilla and change absorbent dressings as needed. d. Assist the patient in passive range of motion (ROM) for the right arm.

ANS: C The axilla can become excoriated when a sling is used to support the arm, and the nurse should check the axilla and apply absorbent dressings to prevent this. A patient with a sling would not have traction applied by hanging. The patient will be encouraged to move the fingers on the injured arm to maintain function and to help decrease swelling. The patient will do active ROM on the uninjured side.

1. A patient who arrives at the emergency department experiencing severe left knee pain is diagnosed with a patellar dislocation. The initial patient teaching by the nurse will focus on the need for a. a knee immobilizer. b. gentle knee flexion. c. monitored anesthesia care. d. physical activity restrictions.

ANS: C The first goal of collaborative management is realignment of the knee to its original anatomic position, which will require anesthesia or monitored anesthesia care (MAC), formerly called conscious sedation. Immobilization, gentle range-of-motion (ROM) exercises, and discussion about activity restrictions will be implemented after the knee is realigned.

32. Following a motorcycle accident, a 58-year-old patient arrives in the emergency department with massive left lower leg swelling. Which action will the nurse take first? a. Elevate the leg on 2 pillows. b. Apply a compression bandage. c. Check leg pulses and sensation. d. Place ice packs on the lower leg.

ANS: C The initial action by the nurse will be to assess the circulation to the leg and to observe for any evidence of injury such as fractures or dislocations. After the initial assessment, the other actions may be appropriate, based on what is observed during the assessment.

18. After the health care provider has recommended amputation for a patient who has nonhealing ischemic foot ulcers, the patient tells the nurse that he would rather die than have an amputation. Which response by the nurse is best? a. "You are upset, but you may lose the foot anyway." b. "Many people are able to function with a foot prosthesis." c. "Tell me what you know about your options for treatment." d. "If you do not want an amputation, you do not have to have it."

ANS: C The initial nursing action should be to assess the patient's knowledge level and feelings about the options available. Discussion about the patient's option to not have the procedure, the seriousness of the condition, or rehabilitation after the procedure may be appropriate after the nurse knows more about the patient's current level of knowledge and emotional state.

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 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 drink sports drinks when working outside in hot weather." d. "I will move to a cool environment if I notice that I am feeling confused."

ANS: 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: Apply (application) REF: 1682 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

Which type of shock causes an absence of bowel sounds? 1 Cardiogenic shock 2 Neurogenic shock 3 Hypovolemic shock 4 Anaphylactic shock

Absence of bowel sounds is associated with hypovolemic shock. Decreased bowel sounds are seen with cardiogenic shock. Bowel dysfunction is associated with neurogenic shock. Abdominal pain, nausea and vomiting are seen with anaphylactic shock. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options. Text Reference - p. 1635

An 18-yr-old man who fell through the ice on a pond near his farm was admitted to the emergency department with somnolence. Vital signs are blood pressure of 82 mm Hg systolic with Doppler, respirations of 9 breaths/min, and core temperature of 90°F (32.2°C). The nurse should anticipate which intervention? Active core rewarming Immersion in a hot bath Rehydration and massage Passive external rewarming

Active core rewarming Active internal or core rewarming is used for moderate to severe hypothermia and involves the application of heat directly to the core. Immersion in a hot bath, rehydration, and massage are not appropriate interventions in the treatment of severe hypothermia. Passive rewarming is used in mild hypothermia.

When entering the grocery store, a patient trips on the curb and sprains the right ankle. Which initial care is appropriate (select all that apply.)? Select all that apply. Apply ice directly to the skin. Apply heat to the ankle every 2 hours. Administer antiinflammatory medication. Compress ankle using an elastic bandage. Rest and elevate the ankle above the heart. Perform passive and active range of motion.

Administer antiinflammatory medication. Compress ankle using an elastic bandage. Rest and elevate the ankle above the heart. Appropriate care for a sprain is represented with the acronym RICE (rest, ice, compression, and elevation). Antiinflammatory medication should be used to decrease swelling if not contraindicated for the patient. After the injury, the ankle should be immobilized and rested. Prolonged immobilization is not required unless there is significant injury. Ice is indicated, but will cause tissue damage if applied directly to the skin. Apply ice to sprains as soon as possible and leave in place for 20 to 30 minutes at a time. Moist heat may be applied 24 to 48 hours after the injury.

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

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

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

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

A mass casualty incident was identified on a nearby freeway. Which patient would likely be designated "red" during triage at the site? An individual who is distraught at the violence of the incident An individual who has experienced an open arm fracture from falling debris An individual who is not expected to survive a crushing head and neck wound An individual whose femoral artery has been severed and is bleeding profusely

An individual whose femoral artery has been severed and is bleeding profusely Red indicates a life-threatening injury requiring immediate intervention, such as severe bleeding. Emotional trauma would not warrant a "red" designation, and a fracture would likely be deemed "yellow," urgent but not life threatening. Those not expected to survive are categorized "blue." "Black" identifies the dead.

The nurse provides information to a patient who was exposed to anthrax by inhalation. The nurse determines the teaching has been successful if the patient makes which statement? A. "Anthrax can be spread by person-to-person contact." B. "It is not necessary to receive the anthrax vaccine." C. "An antibiotic will be prescribed for 2 months." D. "Antibiotics are only indicated for an active infection."

Answer: C. "An antibiotic will be prescribed for 2 months." Rationale: Postexposure prophylaxis includes a 60-day course of antibiotics. Ciprofloxacin (Cipro) is the treatment of choice. Anthrax is not spread by person-to-person contact; anthrax is spread by direct contact with the bacteria and its spores. The patient may receive the anthrax vaccine (three doses); if vaccinated, the course of antibiotic therapy is reduced to 30 days. Antibiotics are indicated after exposure to inhaled anthrax. Ch. 69

Which patient should the nurse prepare to transfer to a regional burn center? A. A 53-year-old patient with a chemical burn to the anterior chest and neck B. A 25-year-old pregnant patient with a carboxyhemoglobin level of 1.5% C. A 42-year-old patient who is scheduled for skin grafting of a burn wound D. A 39-year-old patient with a partial-thickness burn to the right upper arm

Answer: A. A 53-year-old patient with a chemical burn to the anterior chest and neck Rationale: The American Burn Association (ABA) has established referral criteria to determine which burn injuries should be treated in burn centers where specialized facilities and personnel are available to handle this type of trauma (see Table 25-3). Patients with chemical burns should be referred to a burn center. A normal serum carboxyhemoglobin level for nonsmokers is 0% to 1.5% and for smokers is 4% to 9%. Skin grafting for burn wound management is not a criteria for a referral to a burn center. Partial-thickness burns greater than 10% total body surface area (TBSA) should be referred to a burn center; a burn to the right upper arm is 4% TBSA. Ch. 25

The nurse is caring for a 71 kg patient during the first 12 hours after a thermal burn injury. Which outcomes if observed by the nurse would indicate adequate fluid resuscitation (select all that apply)? A. Heart rate is 94 beats/minute. B. Mean arterial pressure is 54 mm Hg. C. Urine output is 46 mL/hour. D. Urine specific gravity is 1.040. E. Systolic blood pressure 88 mm Hg

Answer: A. Heart rate is 94 beats/minute. C. Urine output is 46 mL/hour. Rationale: Assessment of the adequacy of fluid resuscitation is best made using either urine output or cardiac factors. Urine output should be 0.5 to 1 mL/kg/hr (or 75 to 100 mL/hr for an electrical burn patient with evidence of hemoglobinuria/myoglobinuria). Cardiac factors include a mean arterial pressure (MAP) greater than 65 mm Hg, systolic blood pressure (BP) greater than 90 mm Hg, heart rate less than 120 beats/minute. Normal range for urine specific gravity is 1.003 to 1.030. Ch. 25

The nurse is caring for a patient who sustained a deep partial thickness burn to the anterior chest area. Which statement would be appropriate for the nurse to include when documenting the appearance of this type of burn? A. Skin is hard with a dry, waxy white appearance with visible venous patterns. B. Skin blanches with pressure and is red with delayed blister formation. C. Skin is red and shiny with the presence of clear fluid-filled blisters. D. Skin is charred and leathery with visible muscles, tendons, and bones

Answer: C. Skin is red and shiny with the presence of clear fluid-filled blisters. Rationale: Deep partial thickness burns have fluid-filled vesicles that are red and shiny; may appear wet (if vesicles have ruptured); and mild to moderate edema may be present. Deep partial thickness burns result in severe pain related to nerve injury. Superficial partial thickness burns are red and blanch with pressure; pain and mild edema are present. Superficial partial thickness burns may have vesicles that appear 24 hours after the burn injury. Full-thickness burns are dry, waxy white, leathery, or hard; thrombosed vessels may be visible. Full-thickness burns result in an insensitivity to pain because of nerve destruction, and there may be involvement of muscles, tendons, and bones. Ch. 25

A patient arrives in the emergency department after ingesting 8 g of acetaminophen (Tylenol). Which question is most important for the nurse to ask? A. Have you tried to commit suicide before? B. Do you feel like you have a fever? C. What time did you take the Tylenol? D. Are you experiencing any abdominal pain?

Answer: C. What time did you take the Tylenol? Rationale: Acetaminophen will bind to activated charcoal and pass through the gastrointestinal tract without being absorbed. Activated charcoal is most effective if administered within 1 hour of ingestion of acetaminophen and other select poisons. Ch. 69

The patient has frostbite on the distal toes of both feet. The patient is scheduled for amputation of damaged tissue. Which assessment finding or diagnostic study is most objective in determining tissue viability? Arteriogram showing blood vessels Peripheral pulse palpation bilaterally Patches of black, indurated, cold tissue Bilateral pale, cool skin below the ankles

Arteriogram showing blood vessels Arteriography determines viable tissue for salvage based on blood flow observed in real time and is considered the gold standard for evaluating arterial perfusion. Only arteriography determines where tissue perfusion stops and amputation needs to occur. Bilateral peripheral pulse assessment and areas of black, indurated, cold, and pale skin indicate ischemia.

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

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

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

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

Which assessment parameter will the nurse address during the secondary survey of a patient in triage? Blood pressure and heart rate Patency of the patient's airway Neurologic status and level of consciousness Presence or absence of breath sound and quality of breathing

Blood pressure and heart rate Vital signs are considered to be a part of the secondary survey in the triage process. Airway, breathing, circulation, and a brief neurologic assessment are components of the primary survey that is done to identify life-threatening conditions.

The nurse is caring for a 55-yr-old man who has a catheter in the right radial artery for invasive arterial blood pressure monitoring after abdominal aortic aneurysm surgery. Which observation by the nurse would require an emergency intervention? Arterial pressure bag is inflated to 250 mm Hg. Calculated mean arterial pressure is 74 mm Hg. Patient's head of bed elevation is at 30 degrees. Capillary refill time in the right hand is 5 seconds.

Capillary refill time in the right hand is 5 seconds. Neurovascular status distal to the arterial insertion site is monitored hourly. If arterial flow is compromised, the limb will be cool and pale, with capillary refill time longer than 3 seconds. Symptoms of neurologic impairment include paresthesia, pain, or paralysis. Neurovascular impairment can result in loss of a limb and is an emergency. The pressure bag should be inflated to 300 mm Hg. Normal range for mean arterial pressure is 70 to 105 mm Hg. The backrest elevation may be up to 45 degrees unless the patient has orthostatic changes.

The postanesthesia care unit (PACU) has several patients with endotracheal tubes. Which patient should receive the least amount of endotracheal suctioning? Transplantation of a kidney Replacement of aortic valve Cerebral aneurysm resection Formation of an ileal conduit

Cerebral aneurysm resection The nurse should avoid suctioning the patient after a craniotomy until it is necessary because suctioning will increase this patient's intracranial pressure. The patients with a kidney transplantation, aortic valve replacement, or formation of an ileal conduit will not be negatively affected by suctioning, although it should only be done when needed, not routinely.

The most accurate assessment parameters for the nurse to use to determine adequate tissue perfusion in the pt. with MODS are A) BP, HR, RR B) breath sounds, BP, temp C) pulse pressure, LOC, and pupillary response D) LOC, urine output, and skin color and temp

D) LOC, urine output, and skin color and temp

A pt. has a spinal cord injury at T4. VS include a falling BP with bradycardia. The nurse recognizes that the pt. is experiencing A) a relative hypervolemia B) an absolute hypovolemia C) Neurogenic shock from low blood flow D) Neurogenic shock from massive vasodilation

D) Neurogenic shock from massive vasodilation

The nurse completes an admission history for a 73-yr-old man with osteoarthritis scheduled for total knee arthroplasty. Which response is expected when asking the patient the reason for admission? Recent knee trauma Debilitating joint pain Repeated knee infections Onset of frozen knee joint

Debilitating joint pain The most common reason for knee arthroplasty is debilitating joint pain despite exercise, weight management, and drug therapy. Recent knee trauma, repeated knee infections, and onset of frozen knee joint are not primary indicators for a knee arthroplasty.

When caring for a critically ill patient who is being mechanically ventilated, the nurse will monitor for which clinical manifestation of multiple organ dysfunction syndrome (MODS)? Increased serum albumin Decreased respiratory compliance Increased gastrointestinal (GI) motility Decreased blood urea nitrogen (BUN)/creatinine ratio

Decreased respiratory compliance Clinical manifestations of MODS include symptoms of respiratory distress, signs and symptoms of decreased renal perfusion, decreased serum albumin and prealbumin, decreased GI motility, acute neurologic changes, myocardial dysfunction, disseminated intravascular coagulation (DIC), and changes in glucose metabolism.

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

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

A 68-yr-old male patient diagnosed with sepsis is orally intubated on mechanical ventilation. Which nursing action is most important? Use the open-suctioning technique. Administer morphine for discomfort. Limit noise and cluster care activities. Elevate the head of the bed 30 degrees.

Elevate the head of the bed 30 degrees. The two major complications of endotracheal intubation are unplanned extubation and aspiration. To prevent aspiration, all intubated patients and patients receiving enteral feedings must have the head of the bed elevated a minimum of 30 to 45 degrees unless medically contraindicated. Closed-suction technique is preferred over the open-suction technique because oxygenation and ventilation are maintained during suctioning, and exposure to secretions is reduced. The nurse should provide comfort measures such as morphine to relieve anxiety and pain associated with intubation. To promote rest and sleep, the nurse should limit noise and cluster activities.

A 19-yr-old male patient has a plaster cast applied to the right arm for a Colles' fracture after a skateboarding accident. Which nursing action is most appropriate? Elevate the right arm on two pillows for 24 hours. Apply heating pad to reduce muscle spasms and pain. Limit movement of the thumb and fingers on the right hand. Place arm in a sling to prevent movement of the right shoulder.

Elevate the right arm on two pillows for 24 hours. The casted extremity should be elevated at or above heart level for 24 hours to reduce swelling or inflammation. The cast should be supported on pillows during the drying period to prevent denting and flattening of the cast. Ice (not heat) should be applied for the first 24 to 36 hours to reduce swelling or inflammation. Active movement of the thumb and fingers should be encouraged to reduce edema and increase venous return. A sling may be used to support and protect the extremity after the cast is completely dry, but the patient should perform active movements of the shoulder to prevent stiffness or contracture.

The nurse formulates a nursing diagnosis of Impaired physical mobility related to decreased muscle strength for an older adult patient recovering from left total knee arthroplasty. What nursing intervention is appropriate? Promote vitamin C and calcium intake in the diet. Provide passive range of motion to all of the joints q4hr. Keep the left leg in extension and abduction to prevent contractures. Encourage isometric quadriceps-setting exercises at least four times a day.

Encourage isometric quadriceps-setting exercises at least four times a day. Emphasis is placed on postoperative exercise of the affected leg, with isometric quadriceps setting beginning on the first day after surgery. Vitamin C and calcium do not improve muscle strength, but they will facilitate healing. The patient should be able to perform active range of motion to all joints. Keeping the leg in one position (extension and abduction) may contribute to contractures.

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

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

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

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

The nurse would recognize which clinical manifestation as suggestive of sepsis? Sudden diuresis unrelated to drug therapy Hyperglycemia in the absence of diabetes Respiratory rate of seven breaths per minute Bradycardia with sudden increase in blood pressure

Hyperglycemia in the absence of diabetes Hyperglycemia in patients with no history of diabetes is a diagnostic criterion for sepsis. Oliguria, not diuresis, typically accompanies sepsis along with tachypnea and tachycardia.

The patient is brought to the emergency department after a car accident and is diagnosed with a femur fracture. What nursing intervention should the nurse implement at this time to decrease risk of a fat embolus? Administer enoxaparin (Lovenox). Provide range-of-motion exercises. Apply sequential compression boots. Immobilize the fracture preoperatively.

Immobilize the fracture preoperatively. The nurse immobilizes the long bone to reduce movement of the fractured bone ends and decrease the risk of a fat embolus development before surgical reduction. Enoxaparin is used to prevent blood clots not fat emboli. Range of motion and compression boots will not prevent a fat embolus in this patient.

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

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

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

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

The patient has developed cardiogenic shock after a left anterior descending myocardial infection. Which circulatory-assist device should the nurse expect to use for this patient? Cardiopulmonary bypass Impedance cardiography (ICG) Intraaortic balloon pump (IABP) Central venous pressure (CVP) measurement

Intraaortic balloon pump (IABP) The most commonly used mechanical circulatory assist device is the IABP, and it is used to decrease ventricular workload, increase myocardial perfusion, and augment circulation. Cardiopulmonary bypass provides circulation during open heart surgery. It is not used as an assist device after surgery. ICG is a noninvasive method to obtain cardiac output and assess thoracic fluid status. CVP measurement is an invasive measurement of right ventricular preload and reflects fluid volume problems.

A nurse teaches the emergency department staff about their roles during a mass casualty incident. Which primary responsibility is expected of all licensed and unlicensed health care staff? Notify local, state, and national authorities. Assist security personnel to patrol the area. Learn the hospital emergency response plan. Contact the American Red Cross for assistance.

Learn the hospital emergency response plan. All health care providers must be prepared for a mass casualty incident. The priority responsibility is to know the agency's emergency response plan.

The nurse is caring for a patient with osteoarthritis scheduled for total left knee arthroplasty. Preoperatively, the nurse assesses for which contraindication to surgery? Pain Left knee stiffness Left knee infection Left knee instability

Left knee infection The patient must be free of infection before total knee arthroplasty. An infection in the joint could lead to even greater pain and joint instability, requiring more extensive surgery. The nurse must assess the patient for signs of infection, such as redness, swelling, fever, and elevated white blood cell count. Pain, knee stiffness, or instability are typical of osteoarthritis.

A 42-yr-old man underwent amputation below the knee on the left leg after a recent heavy farm machinery accident. Which intervention should the nurse include in the plan of care? Sit in a chair for 1 to 2 hours three times each day. Dangle the residual limb for 20 to 30 minutes every 6 hours. Lie prone with hip extended for 30 minutes four times per day. Elevate the residual limb on a pillow for 4 to 5 days after surgery.

Lie prone with hip extended for 30 minutes four times per day. To prevent hip flexion contractures, the patient should lie on the abdomen for 30 minutes three or four times each day and position the hip in extension while prone. The patient should avoid sitting in a chair for more than 1 hour with hips flexed or having pillows under the surgical extremity. The patient should avoid dangling the residual limb over the bedside to minimize edema.

A male patient is brought into the emergency department with multiple stab wounds to the legs, one stab wound to the left abdomen, and gang tattoos on both arms. He refused to identify his attacker and then loses consciousness. Police identify him as the assailant in the fatal stabbing of another man. What is the nurse's priority? Guard locked access doors. Maintain patient safety from revenge. Maintain personal and work place safety. Attain open patient airway and breathing.

Maintain personal and work place safety. The nurse's priority is to maintain personal and work place safety. Violence can erupt in the emergency department when treating gang members if the rival gang seeks revenge, or the patient's gang members seek to protect the patient with their presence. Staff members can be victims of that violence, so they should maintain a safe work environment by seeking law enforcement and security assistance in maintaining safety for the staff and the patient. ABCs are the usual priority, but this situation does not show any problem with the patient's airway or breathing.

The nurse is completing discharge teaching with an 80-yr-old male patient who is recovering from a right total hip arthroplasty by posterior approach. Which patient action indicates further instruction is needed? Uses an elevated toilet seat Sits with feet flat on the floor Maintains hip in adduction and internal rotation Verifies need to notify future caregivers about the prosthesis

Maintains hip in adduction and internal rotation The patient should not force hip into adduction or internal rotation because these movements could dislocate the hip prosthesis. Sitting with feet flat on the floor (avoiding crossing the legs), using an elevated toilet seat, and notifying future caregivers about the prosthesis indicate understanding of discharge teaching.

The nurse is caring for a patient placed in Buck's traction before open reduction and internal fixation of a left hip fracture. Which care can be delegated to the LPN/LVN? Assess skin integrity around the traction boot. Determine correct body alignment to enhance traction. Remove weights from traction when turning the patient. Monitor pain intensity and administer prescribed analgesics.

Monitor pain intensity and administer prescribed analgesics. The LPN/LVN can monitor pain intensity and administer analgesics. Assessment of skin integrity and determining correct alignment to enhance traction are within the RN scope of practice. Removing weights from the traction should not be delegated or done. Removal of weights can cause muscle spasms and bone misalignment, and should not be delegated or done.

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

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

The nurse is caring for a patient intubated and on a mechanical ventilator for several days. Which weaning parameter would tell the nurse if the patient has enough muscle strength to breathe without assistance? Tidal volume Minute ventilation Forced vital capacity Negative inspiratory force

Negative inspiratory force The negative inspiratory force measures inspiratory muscle strength. Tidal volume and minute ventilation assess the patient's respiratory endurance. Forced vital capacity is not used as a measure to determine weaning from a ventilator.

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

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

Which guideline for the assessment of intimate partner violence (IPV) should the emergency nurse follow? Patients should be routinely screened for family and IPV. Patients whom the nurse deems high risk should be assessed for IPV. All female patients and patients under 18 should be assessed for IPV. Patients should be assessed for IPV provided corroborating evidence exists.

Patients should be routinely screened for family and IPV. In the emergency department, the nurse needs to screen for family and IPV. Routine screening for this risk factor is required. Such assessment should not be limited to female, high-risk, or young patients, and evidence need not be present to screen for the problem.

Which interventions should the nurse perform before using an open-suctioning technique for a patient with an endotracheal (ET) tube (select all that apply.)? Select all that apply. Put on clean gloves. Administer a bronchodilator. Perform a cardiopulmonary assessment. Hyperoxygenate the patient for 30 seconds. Perform hand hygiene before performing the procedure. Insert a few drops of normal saline into the ET to break up secretions.

Perform a cardiopulmonary assessment. Hyperoxygenate the patient for 30 seconds. Suctioning is preceded by a thorough assessment and hyperoxygenation for 30 seconds. Sterile, not clean, gloves are necessary, and it is not necessary to administer a bronchodilator. Instillation of normal saline into the ET tube is not an accepted standard practice. (Yeaaaaah, I will argue to the death that hand hygiene is definitely also necessary...)

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

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

When planning care for a patient on a mechanical ventilator, the nurse understands that the application of positive end-expiratory pressure (PEEP) to the ventilator settings has which therapeutic effect? Increased inflation of the lungs Prevention of barotrauma to the lung tissue Prevention of alveolar collapse during expiration Increased fraction of inspired oxygen concentration (FIO2) administration

Prevention of alveolar collapse during expiration PEEP is positive pressure that is applied to the airway during exhalation. This positive pressure prevents the alveoli from collapsing, improving oxygenation and enabling a reduced FIO2 requirement. PEEP does not cause increased inflation of the lungs or prevent barotrauma. Actually auto-PEEP resulting from inadequate exhalation time may contribute to barotrauma.

The nurse is caring for a 76-yr-old man who has undergone left total knee arthroplasty to relieve the pain of severe osteoarthritis. What care would be expected postoperatively? Progressive leg exercises to obtain 90-degree flexion Early ambulation with full weight bearing on the left leg Bed rest for 3 days with the left leg immobilized in extension Immobilization of the left knee in 30-degree flexion to prevent dislocation

Progressive leg exercises to obtain 90-degree flexion The patient is encouraged to engage in progressive leg exercises until 90-degree flexion is possible; continuous passive motion also may be used based on surgeon preference. Early ambulation is implemented, sometimes the day of surgery, but orders are likely to indicate weight bearing as tolerated rather than full weight bearing. Immobilization and bed rest are not indicated. The patient's knee is unlikely to dislocate.

A 64-yr-old woman is admitted to the emergency department vomiting bright red blood. The patient's vital signs are blood pressure of 78/58 mm Hg, pulse of 124 beats/min, respirations of 28 breaths/min, and temperature of 97.2°F (36.2°C). Which physician order should the nurse complete first? Obtain a 12-lead ECG and arterial blood gases. Rapidly administer 1000 mL normal saline solution IV. Administer norepinephrine (Levophed) by continuous IV infusion. Carefully insert a nasogastric tube and an indwelling bladder catheter.

Rapidly administer 1000 mL normal saline solution IV. Isotonic crystalloids, such as normal saline solution, should be used in the initial resuscitation of hypovolemic shock. Vasopressor drugs (e.g., norepinephrine) may be considered if the patient does not respond to fluid resuscitation and blood products. Other orders (e.g., insertion of nasogastric tube and indwelling bladder catheter and obtaining the diagnostic studies) can be initiated after fluid resuscitation is initiated.

Three days after experiencing a series of tick bites, a patient presents to the emergency department. Which manifestation would indicate the patient is experiencing tick paralysis? Respiratory distress Aggression and frequent falls Decreased level of consciousness Fever and necrosis at the bite sites

Respiratory distress A classic manifestation of tick paralysis is flaccid ascending paralysis, which develops over 1 to 2 days. Without tick removal, the patient dies as respiratory muscles become paralyzed. Aggression, decreased level of consciousness, fever, and necrosis at the bite sites are not characteristic of the problem.

Students are having an end of the semester party, which includes drinking alcohol, having snacks, and swimming. A student was found floating in the pool. Which action by first responders is most important? Immobilizing the cervical spine Evacuating water from the lungs Securing the airway and providing ventilation Establishing IV access and infusing warmed fluids

Securing the airway and providing ventilation Aggressive resuscitation efforts (e.g., airway and ventilation management), especially in the prehospital phase, improve survival of drowning victims. Initial evaluation involves assessment of airway, cervical spine, breathing, and circulation. Treatment of submersion injuries focuses on correcting hypoxia and fluid imbalances, supporting basic physiologic functions, and rewarming when hypothermia is present. Most drowning victims do not aspirate any liquid due to laryngospasm.

The nurse in collaboration with respiratory therapy is determining a patient's readiness to wean from the ventilator. Which finding indicates the patient is not a candidate for weaning (select all that apply.)? Select all that apply. Minute volume of 8 L/min Patient follow commands Serum hemoglobin of 6 g/dL Respirations of 28 breaths/min Mean arterial pressure (MAP) of 45 mm Hg Negative inspiratory force (NIF) of -15 cm H2O

Serum hemoglobin of 6 g/dL Mean arterial pressure (MAP) of 45 mm Hg Negative inspiratory force (NIF) of -15 cm H2O Findings that support readiness for weaning are minute volume of 8 L/min, patient is alert and follow commands, and respirations of 28 breaths/min. Findings that indicate the patient is not ready for weaning include serum hemoglobin of 6 g/dL, mean arterial pressure (MAP) of 45 mm Hg, and negative inspiratory force (NIF) of -15 cm H2O. Extubating a patient with severe anemia, poor perfusion, and weakened breathing effort will likely result in poor outcomes such as worsening of condition and reintubation.

A 64-yr-old male patient admitted to the critical care unit for gastrointestinal hemorrhage complains of feeling tense and nervous. He appears restless with increased blood pressure and pulse. If the physical assessment shows no other changes, it is most important for the critical care nurse to take which action? Administer prescribed IV dose of lorazepam (Ativan). Stay with the patient and encourage expression of concerns. Ask a family member to remain at the bedside with the patient. Teach the patient how to use guided imagery to reduce anxiety.

Stay with the patient and encourage expression of concerns. Anxiety is a common problem for critically ill patients. The nurse should first stay with the patient and encourage the patient to express concerns and needs. After expression of feelings, the nurse should determine the appropriate intervention if needed (e.g., lorazepam, guided imagery, family presence). In addition, staying with the patient will allow the nurse to continue to assess for physiologic changes associated with recurrent gastrointestinal bleeding.

Which hematologic problem significantly increases the risks associated with pulmonary artery (PA) catheter insertion? Leukocytosis Hypovolemia Hemolytic anemia Thrombocytopenia

Thrombocytopenia PA catheter insertion carries a significant risk of bleeding, which is exacerbated when the patient has low levels of platelets. Leukocytosis, hypovolemia, and anemia are less likely to directly increase the risks associated with PA insertion.

An injured soldier underwent left leg amputation 2 weeks ago, but now reports shooting pain and heaviness in the left leg. What action by the nurse is supported by research findings? Use mirror therapy. Give opioid analgesics. Rebandage the residual limb. Show the patient the leg is gone.

Use mirror therapy. Mirror therapy has been shown to reduce phantom limb pain in some patients. Opioid analgesics, rebandaging the residual limb, and showing the patient that the leg is gone may not decrease phantom limb pain.

The nurse reviews the electronic medical 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. Albumin level and recent weight loss b. Mild confusion and recent weight loss c. Age and recent arthroscopic procedure. d. Anemia and recent arthroscopic procedure

a. albumin level and recent weight loss

An older man arrives in triage disoriented and dyspneic. His skin is hot and dry. His wife states that he was fine earlier today. The nurse's next priority would be to a. assess his vital signs. b. obtain a brief medical history from his wife. c. start supplemental O2 and have the ED physician see him. d. determine the kind of insurance he has before treating him.

a. assess his vital signs.

A pt c pelvic Fx should be monitored for a. changes in UO b. petechiae on the abd c. a palpable lump in the buttock d. sudden increase in BP

a. changes in UO (could indicate damage to urinary structures)

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

a. dyspnea and tachypnea

A 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. Suction the endotracheal tube every 2 to 4 hours. c. Limit the use of positive end-expiratory pressure. d. Give enteral feedings at no more than 10 mL/hr.

a. elevate head of bed to 30 to 45 degrees

A pt with a humeral Fx is returning for a 4 week check. The nurse explains that initial evidence of healing on x-ray is indicated by a. formation of callus b. complete bony union c. hematoma at Fx site d. presence of granulation tissue

a. formation of callus

What are effective interventions to decrease absorption or increase elimination of an ingested poison (SATA)? a. hemodialysis b. milk dilution c. eye irrigation d. gastric lavage e. activated charcoal

a. hemodialysis d. gastric lavage e. activated charcoal

The nurse instructs the pt s/p AKA that the residual limb should not be routinely elevated because this position promotes a. hip flexion contracture b. clot formation at incision site c. skin irritation and breakdown d. increased risk of wound dehiscence

a. hip flexion contracture

The purpose of adding PEEP to positive pressure ventilation is to a. increase functional residual capacity and improve oxygenation b. increased FIO2 in an attempt to wean the patient and avoid O2 toxicity c. determine if the patient is in synchrony with the ventilator or needs to be paralyzed d. determine if the patient is able to be weaned and avoid the risk of pneumomediastinum

a. increase functional residual capacity and improve oxygenation

While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient's oxygen saturation from 94% to 88%. Which action should the nurse take next? a. increase oxygen flow rate b. suction the patient's oropharynx c. instruct the patient to cough and deep breathe d. help patient sit in a more upright position

a. increase oxygen flow rate

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 b. On the right side c. In the tripod position d. In the high-Fowler's position

a. on the left side ("good" lung dependent for more perfusion of working cells)

When admitting a patient with possible respiratory failure with a high PaCO2, which assessment information should be immediately reported to the health care provider? a. The patient is 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. the patient is somnolent

The nurse is caring for a 33-year-old 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/minute.

a. the patient's PAO2 is 45 mm Hg

A patient with tendonitis asks what the tendon does. The nurse's response is based on the knowledge that tendons a.connect bone to muscle. b.provide strength to muscle. c.lubricate joints with synovial fluid. d.relieve friction between moving parts.

a.connect bone to muscle Tendons are composed of dense, fibrous connective tissue that contains bundles of closely packed collagen fibers arranged in the same plane for additional strength. They connect the muscle sheath to adjacent bone.

1. Which actions should the nurse initiate 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. Elevate the head of the bed to at least 30°. d. Give prescribed pantoprazole (Protonix). e. Provide oral care with chlorhexidine (0.12%) solution daily.

b, c, d, e

The nurse suspects that a patient with PEEP is experiencing negative effects of this ventilatory maneuver when which of the following is assessed? a. Increasing PaO2 b. Decreasing blood pressure c. Decreasing heart rate (HR) d. Increasing central venous pressure (CVP)

b. PEEP increases intrathoracic and intrapulmonic pressures, compresses the pulmonary capillary bed, and reduces blood return to both the right and left sides of the heart. Increased PaO2 is an expected effect of PEEP. Preload (CVP) and cardiac output (CO) are decreased, often with a dramatic decrease in BP.

A patient with ARDS has a nursing diagnosis of risk for infection. To detect the presence of infections commonly associated with ARDS, what should the nurse monitor? a. Gastric aspirate for pH and blood b. Quality, quantity, and consistency of sputum c. Subcutaneous emphysema of the face, neck, and chest d. Mucous membranes of the oral cavity for open lesions

b. Ventilator-associated pneumonia (VAP) is one of the most common complications of ARDS. Early detection requires frequent monitoring of sputum smears and cultures and assessment of the quality, quantity, and consistency of sputum. Prevention of VAP is done with strict infection control measures, ventilator bundle protocol, and subglottal secretion drainage. Blood in gastric aspirate may indicate a stress ulcer and subcutaneous emphysema of the face, neck, and chest occurs with barotrauma during mechanical ventilation. Oral infections may result from prophylactic antibiotics and impaired host defenses but are not common.

The oxygen saturation (SpO2) for a patient with left lower lobe pneumonia is 90%. The patient has rhonchi, a weak cough effort, and complains of fatigue. Which action is a priority for the nurse to take? 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 2-hour rest period for the patient.

b. assist the patient with staged coughing

A patient admitted with acute respiratory failure has a nursing diagnosis of ineffective airway clearance related to thick secretions. Which action is a priority 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 ambulation. d. Titrate oxygen level to keep O2 saturation >93%.

b. offer the patient fluids at frequent intervals

In patients with ARDS who survive the acute phase of lung injury, what manifestations are seen when they progress to the fibrotic phase? a. Chronic pulmonary edema and atelectasis b. Resolution of edema and healing of lung tissue c. Continued hypoxemia because of diffusion limitation d. Increased lung compliance caused by the breakdown of fibrotic tissue

c. In the fibrotic phase of ARDS, diffuse scarring and fibrosis of the lungs occur, resulting in decreased surface area for gas exchange and continued hypoxemia caused by diffusion limitation. Although edema is resolved, lung compliance is decreased because of interstitial fibrosis. Long-term mechanical ventilation is required. The patient has a poor prognosis for survival.

When teaching the patient about what was happening when experiencing an *intrapulmonary* shunt, which explanation is accurate? a. This occurs when an obstruction impairs the flow of blood to the ventilated areas of the lung. b. This occurs when blood passes through an anatomic channel in the heart and bypasses the lungs. c. This occurs when blood flows through the capillaries in the lungs without participating in gas exchange. d. Gas exchange across the alveolar capillary interface is compromised by thickened or damaged alveolar membranes.

c. Intrapulmonary shunt occurs when blood flows through the capillaries in the lungs without participating in gas exchange (e.g., acute respiratory distress syndrome [ARDS], pneumonia). Obstruction impairs the flow of blood to the ventilated areas of the lung in a V/Q mismatch ratio greater than 1 (e.g., pulmonary embolus). Blood passes through an anatomic channel in the heart and bypasses the lungs with anatomic shunt (e.g., ventricular septal defect). Gas exchange across the alveolar capillary interface is compromised by thickened or damaged alveolar membranes in diffusion limitation (e.g., pulmonary fibrosis, ARDS).

Which intervention is most likely to prevent or limit barotrauma in the pt c ARDS who is mechanically ventilated a. Decreasing PEEP b. Increasing tidal volume c. Use of permissive hypercapnia d. Use of PPV

c. Use of permissive hypercapnia - Decreasing TV can help prevent barotrauma by dec peak airway pressures but this can mean allowing higher CO2 levels. Hypercapnia isn't awesome but it won't kill you like hypoxemia will.

2. The nurse teaches individuals that one of the best ways to prevent musculoskeletal injuries during physical exercise is by doing what? a. Increase muscle strength with daily isometric exercise. b. Avoid exercising on concrete or hard pavement surfaces. c. Perform stretching and warm-up exercises before exercise. d. Wrap susceptible joints with elastic bandages or adhesive tape before exercise.

c. Warm-up exercises "prelengthen" potentially strained tissues by avoiding the quick stretch often encountered in sports and also increase the temperature of muscle, resulting in increased speed of cell metabolism, increased speed of nerve impulses, and improved oxygenation of muscle fibers. Stretching is also thought to improve kinesthetic awareness, lessening the chance of uncoordinated movement. Muscle strength is not a key factor in soft tissue injuries and taping or wrapping joints may actually predispose a person to injury by weakening the joint, unless a previous injury is being treated.

The nurse suspects a neurovascular problem based on assessment of a. exaggerated strength with movement b. increased redness and heat below the injury c. decreased sensation distal to the Fx site d. purulent drainage at the site of an open Fx

c. decreased sensation distal to the Fx site

An older woman arrives in the ED complaining of severe pain in her right shoulder. The nurse notes that her clothes are soiled with urine and feces. She tells the nurse that she lives with her son and that she "fell." She is tearful and asks you if she can be admitted. What possibility should the nurse consider? a. dementia b. possible cancer c. family violence d. orthostatic hypotension

c. family violence

Maintenance of fluid balance in the pt c ARDS involves a. hydration using colloids b. administration of surfactant c. fluid restriction and diuretics PRN d. keeping the Hgb at/above 9

c. fluid restriction and diuretics PRN

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. insertion of a pulmonary artery catheter. d. positioning the patient for a chest x-ray.

c. insertion of a pulmonary artery catheter

The nursing management of a patient with an artificial airway includes a. maintaining ET tube cuff pressure at 30 cm H2O b. routine suctioning of the tube at least every 2 hours c. observing for cardiac dysrhythmias during suctioning d. preventing tube dislodgement by limiting mouth care to lubrication of the lips

c. observing for cardiac dysrhythmias during suctioning

Which arterial blood gas (ABG) results would most likely indicate acute respiratory failure in a patient with chronic lung disease? a. PaO2 52 mm Hg, PaCO2 56 mm Hg, pH 7.4 b. PaO2 46 mm Hg, PaCO2 52 mm Hg, pH 7.36 c. PaO2 48 mm Hg, PaCO2 54 mm Hg, pH 7.38 d. PaO2 50 mm Hg, PaCO2 54 mm Hg, pH 7.28

d. In a patient with normal lung function, respiratory failure is commonly defined as a PaO2 ≤60 mm Hg or a PaCO2>45 mm Hg or both. However, because the patient with chronic pulmonary disease normally maintains low PaO2 and high PaCO2, acute respiratory failure in these patients can be defined as an acute decrease in PaO2 or an increase in PaCO2 from the patient's baseline parameters, accompanied by an acidic pH. The pH of 7.28 reflects an acidemia and a loss of compensation in the patient with chronic lung disease. *look for ones that are acidotic, to start with*

In caring for a patient in acute respiratory failure, the nurse recognizes that noninvasive positive pressure ventilation (NIPPV) may be indicated for which patient? a. Is comatose and has high oxygen requirements b. Has copious secretions that require frequent suctioning c. Responds to hourly bronchodilator nebulization treatments d. Is alert and cooperative but has increasing respiratory exhaustion

d. Noninvasive positive pressure ventilation (NIPPV) involves the application of a face mask and delivery of a volume of air under inspiratory pressure. Because the device is worn externally, the patient must be able to cooperate in its use and frequent access to the airway for suctioning or inhaled medications must not be necessary. It is not indicated when high levels of oxygen are needed or respirations are absent.

Prone positioning is considered for a patient with ARDS who has not responded to other measures to increase PaO2. The nurse knows that this strategy will a. increase the mobilization of pulmonary secretions. b. decrease the workload of the diaphragm and intercostal muscles. c. promote opening of atelectatic alveoli in the upper portion of the lung. d. promote perfusion of nonatelectatic alveoli in the anterior portion of the lung.

d. When a patient with ARDS is supine, alveoli in the posterior areas of the lung are dependent and fluid-filled and the heart and mediastinal contents place more pressure on the lungs, predisposing to atelectasis. If the patient is turned prone, air-filled nonatelectatic alveoli in the anterior portion of the lung receive more blood and perfusion may be better matched to ventilation, causing less V/Q mismatch. Lateral rotation therapy is used to stimulate postural drainage and help mobilize pulmonary secretions.

A pt c comminuted Fx of the tibia is to have an ORIF. The nurse explains that ORIF is indicated when a. pt is unable to tolerate prolonged immobilization b. pt cannot tolerate the surgery for a closed reduction c. a temporary cast would be too unstable to provide normal mobility d. adequate alignment cannot be obtained by other, nonsurgical methods

d. adequate alignment cannot be obtained by other, nonsurgical methods

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. Notify the health care provider. b. Check pupils for reaction to light. c. Attempt to calm and reorient the patient. d. Assess oxygenation using pulse oximetry.

d. assess oxygenation using pulse oximetry

The nurse is caring for a 78-year-old 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. Scattered crackles bilaterally in the posterior lung bases. b. Persistent cough that is productive of blood-tinged sputum. c. Temperature of 101.5° F (38.6° C) after 2 days of IV antibiotic therapy. d. Decreased oxygen saturation to 90% with 100% O2 by non-rebreather mask.

d. decreased O2 Sat to 90% with 100% O2 by non-rebreather mask

The O2 delivery system chosen for the pt in acute respiratory failure should a. always be a low-flow device, such as NC or face mask b. administer CPAP centilation to prevent CO2 narcosis c. correct the PaO2 to a normal level as quickly as possible using mechanical ventilation d. maintain the PaO2 at greater than or equal to 60 mmHg at the lowest O2 concentration possible

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

A pt c stable, closed humeral Fx has a temporary splint c bulky padding applied c elastic bandage. The nurse notifies the surgeon of possible early compartment syndrome with the pt experiences a. increasing edema of the limb b. muscle spasms of the lower arm c. bounding pulse at the Fx site d. pain when passively extending fingers

d. pain when passively extending fingers

The primary health care provider prescribes antibiotics and vasopressors for a patient. Which type of shock does the nurse expect to be treating? 1 Septic shock 2 Cardiogenic shock 3 Neurogenic shock 4 Anaphylactic shock

1 Septic shock occurs in response to infection. Therefore, antibiotics are prescribed for a patient with septic shock. Cardiogenic shock occurs when systolic or diastolic function of the heart is impaired. Sympathomimetic drugs are used for the treatment of cardiogenic shock. Injury to the spinal cord at the fifth thoracic vertebra or above causes neurogenic shock. Vasconstricting medications are prescribed to prevent vasodilation for a patient in septic shock. Anaphylactic shock is a life-threatening allergic reaction to a sensitizing substance. Antihistamines, bronchodilators, and corticosteroids are used in the treatment of anaphylactic shock. Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly, because there usually is no pattern to the answers. Text Reference - p. 1645

A patient presents to the emergency department (ED) in a state of shock. On assessment, the nurse finds that the patient is cyanotic and has crackles on auscultation of the lungs. As which type of shock will the nurse classify this? 1 Neurogenic shock 2 Cardiogenic shock 3 Hypovolemic shock 4 Anaphylactic shock

2 A patient with cardiogenic shock shows peripheral hypoperfusion presenting as cyanosis and has crackles on auscultation of the lungs due to pulmonary congestion. In neurogenic shock, the patient demonstrates symptoms related to the injury such as hypotension and bradycardia. The patient in hypovolemic shock may experience tachycardia as a late sign. In anaphylactic shock, the patient may experience wheezing and stridor. Text Reference - p. 1633

What is a manifestation of the irreversible (refractory) stage of shock? 1 Delirium 2 Areflexia 3 Restlessness 4 Alterations in the level of consciousness

2 Areflexia or loss of reflexes is a manifestation of the irreversible stage of shock. The progressive state of shock is associated with delirium. Restlessness and altered levels of consciousness indicate that the patient is in the compensatory stage of shock. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options. Text Reference - p. 1639

A patient in shock is receiving 0.9 % NaCl (normal saline solution-NSS). Which nursing intervention is appropriate for this patient? 1 Monitor the patient's vital signs 2 Monitor for the signs of circulatory overload 3 Monitor for signs of hypernatremia in the patient 4 Monitor for allergic reactions and acute renal failure

2 Circulatory overload occurs due to fluid overload. Continuous infusion of 0.9% NaCl increases the fluid volume in the body and may cause circulatory overload. The patient's vital signs must be checked during transfusion of blood or blood products because they could cause an infection or an allergic reaction. Hypernatremia occurs when the patient is on 1.8%, 3%, and 5% NaCl infusions. Infusion of dextran-40 has a tendency to precipitate allergic reactions and acute renal failure. Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly, because there usually is no pattern to the answers. Text Reference - p. 1642

When caring for a critically ill patient who is being mechanically ventilated, the nurse will astutely monitor for which clinical manifestation of multiple organ dysfunction syndrome (MODS)? 1 Increased serum albumin 2 Decreased respiratory compliance 3 Increased gastrointestinal (GI) motility 4 Decreased blood urea nitrogen (BUN)/creatinine ratio

2 Clinical manifestations of MODS include symptoms of respiratory distress, signs and symptoms of decreased renal perfusion, decreased serum albumin and prealbumin, decreased GI motility, acute neurologic changes, myocardial dysfunction, disseminated intravascular coagulation (DIC), and changes in glucose metabolism. Serum albumin is not increased, GI motility decreases in MODS, and the BUN/Creatinine ratio likely will increase. Text Reference - p. 1649

Which drug helps manage renal manifestations in a patient with systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)? 1 Sucralfate 2 Furosemide 3 Omeprazole 4 Acetaminophen

2 Furosemide is a loop diuretic that helps to manage renal manifestations in a patient with systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS). Sucrafate is administered for prophylaxis against stress ulcers, which are gastrointestinal manifestations of SIRS and MODS. Omeprazole is a proton pump inhibitor that has the same action. Acetaminophen is an antipyretic drug given as an acute intervention to manage fevers in patients who are in shock. Text Reference - p. 1651

Which type of shock is associated with hyperglycemia, presence of pulmonary infiltrates in chest x-ray and increased levels of blood urea nitrogen (BUN)? 1 Septic 2 Cardiogenic 3 Obstructive 4 Hypovolemic

2 Increased blood levels of glucose, nitrogen, cardiac markers and presence of pulmonary infiltrates are seen in cardiogenic shock. Increased blood levels of lactate, glucose, and positive blood cultures are signs of septic shock. Manifestations of obstructive shock are specific to the area or organ of obstruction. Electrolyte imbalances and decreased hemoglobin and hematocrit are seen in hypovolemic shock. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Text Reference - p. 1635

Which type of shock is associated with bradycardia? 1 Septic shock 2 Neurogenic shock 3 Hypovolemic shock 4 Anaphylactic shock

2 Neurogenic shock is associated with bradycardia. Myocardial dysfunction and changes in body temperature are signs of septic shock. Reduction in preload, capillary refill and stroke volume are clinical manifestations of hypovolemic shock. Chest pain is seen in anaphylactic shock. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation. Text Reference - p. 1635

Which type of shock can be treated by minimizing spinal cord trauma with stabilization? 1 Septic shock 2 Neurogenic shock 3 Anaphylactic shock 4 Hypovolemic shock

2 Neurogenic shock is caused by severe injury to the spinal cord and results in loss of sympathetic stimulation of blood vessels. Apart from administering vasoconstrictor agents, minimizing the spinal cord trauma with stabilization is a supporting therapy for neurogenic shock. Septic shock occurs in response to a systemic infection. Obtaining the cultures before starting antibiotics is appropriate care for septic shock. A life-threatening allergic reaction to a sensitizing substance causes anaphylactic shock. Avoiding exposure to allergens is supportive therapy for anaphylactic shock. Excessive loss of intravascular fluid causes hypovolemic shock. Besides restoring fluid volume, correcting the cause of fluid loss is supportive therapy. Test-Taking Tip: If the question asks for an immediate action or response, all of the answers may be correct, so base your selection on identified priorities for action. Text Reference - p. 1645

Which cardiovascular change is commonly found in patients with systemic inflammatory response syndrome (SIRS)? 1 Decrease in heart rate 2 Decrease in capillary refill 3 Decrease in central venous pressure 4 Decrease in pulmonary artery wedge pressure

2 Patients with systemic inflammatory response syndrome (SIRS) have decreased capillary refill. Other cardiovascular changes include increases rather than decreases in heart rate, central venous pressure, and pulmonary artery wedge pressure. Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response. Text Reference - p. 1649

Which system of the body is often the first to show signs of dysfunction in systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)? 1 Neurologic system 2 Respiratory system 3 Cardiovascular system 4 Gastrointestinal system

2 Systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS) occur due to a systemic inflammatory response. Inflammatory mediators have a direct effect on the pulmonary vasculature. Thus, the respiratory system is often the first system to show signs of dysfunction. Signs of nervous system dysfunction, such as mental changes, can be early signs of SIRS and MODS. However, the nervous system is not the first system to show signs of SIRS and MODS. When the respiratory system is affected, ventilation-perfusion mismatch becomes worse. Tissue oxygen demands increase, leading to cardiovascular changes. Hence, cardiovascular changes occur after changes in the respiratory system. In the early stages of SIRS and MODS, there is shunting away of blood from the gastrointestinal tract, making it vulnerable to ischemic injury. However, such changes show signs of dysfunction later than does the respiratory system. Text Reference - p. 1649

A patient admitted to the hospital after a motor vehicle accident (MVA) is in hypovolemic shock. On examination, the nurse finds that the patient is becoming anxious, and the urine output is decreasing. What appropriate action should the nurse perform? 1 Prepare for administering blood products. 2 Begin crystalloid fluid replacement. 3 Start fluids only if deterioration occurs. 4 Wait for the patient to compensate naturally.

2 When the volume of blood loss is less than 30 percent, crystalloid fluid replacements are performed to reverse tissue dysfunction. Blood products are administered when the blood volume loss is more than 30 percent. The nurse should not wait for deterioration to occur to start the fluid replacement therapy. This is because the body can typically compensate naturally for a blood volume loss up to 15 percent. Test-Taking Tip: Be alert for grammatical inconsistencies. If the response is intended to complete the stem (an incomplete sentence) but makes no grammatical sense to you, it might be a distractor rather than the correct response. Question writers typically try to eliminate these inconsistencies. Text Reference - p. 1633

When managing a patient with shock, which appropriate actions should the nurse take as part of nutritional therapy? Select all that apply. 1 Plan enteral feeding to meet at least 50 percent of calorie requirements. 2 Start enteral nutrition within the first 24 hours. 3 Wait until the patient recovers to start with enteral nutrition. 4 Start a slow continuous drip of small amounts of enteral feedings. 5 Start parenteral nutrition if enteral feedings are contraindicated.

2, 4, 5 Enteral nutrition should ideally begin within the first 24 hours. It is important because it enhances the perfusion of the (gastrointestinal) GI tract and helps to maintain the integrity of the gastrointestinal mucosa. Enteral feeding should be started with a slow continuous drip of small amounts of enteral feedings. If enteral feedings are contraindicated, parenteral feedings can be started. Enteral feeding should be planned to meet at least 80 percent of the total calorie requirements, but if it is not feasible, parenteral feeding should be started. Nutritional therapy should start as early as possible. The nurse should not wait for the patient to recover before starting nutritional therapy. Text Reference - p. 1644

When examining a patient in the progressive stage of shock, which factors related to the gastrointestinal (GI) system should the nurse consider? Select all that apply. 1 Increased motility and peristalsis 2 Increased likelihood of GI ulcers 3 Increased ability to absorb nutrients 4 Increased risk of GI bleeding 5 Increased risk of bacterial migration from the GI tract to the bloodstream.

2, 4, 5 In the progressive stage of shock, the GI system gets affected by prolonged decreased tissue perfusion. As the blood supply to the GI tract is decreased, the normally protective mucosal barrier becomes ischemic. This ischemia predisposes the patient to ulcers and GI bleeding. It also increases the risk of bacterial migration from the GI tract to the blood. The decreased perfusion to the GI tract also results in a decreased ability to absorb nutrients, decreased motility, and slowed peristalsis. Text Reference - p. 1639

The nurse recalls that cardiogenic shock is differentiated from other forms of shock because the patient with cardiogenic shock typically experiences: 1 Hypotension 2 Dysrhythmias 3 Volume excess 4 Volume depletion

3 In cardiogenic shock the heart fails as a pump. This usually results in fluid retention and poor perfusion of organs, including the kidneys, which adds to the fluid volume excess. As cardiogenic shock progresses, hypotension will develop, but it is not the cause of cardiogenic shock. Dysrhythmias may or may not be present with cardiogenic shock. Volume depletion is not generally seen with cardiogenic shock. It is, however, seen more with hypovolemic or distributive forms of shock. Text Reference - p. 1633

Why is there a loss of lean body mass in patients with systemic inflammatory response syndrome (SIRS) and multiorgan dysfunction syndrome (MODS)? 1 Hypoglycemia occurs. 2 Glucose is converted to glycogen. 3 Fatty acids are mobilized for fuel. 4 Glucose is converted to amino acids.

3 Both SIRS and MODS trigger a hypermetabolism response leading to mobilization of fatty acids for fuel. Such a catabolic state leads to loss of lean body mass. Because catecholamines and glucocorticoids are released, hyperglycemia occurs, not hypoglycemia. Hyperglycemia also occurs, because glycogen stores are converted into glucose. Once glycogen is depleted, amino acids are converted into glucose and there is a reduction in protein stores. Text Reference - p. 1649

What causes dysrhythmias in patients with systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)? 1 Metabolic acidosis resulting in increase in lactate levels 2 Increased capillary permeability in the cardiovascular system 3 Hypokalemia due to activities of aldosterone and catecholamines 4 Aldosterone-mediated sodium and water reabsorption in kidneys

3 In systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS), there are hormonal and metabolic changes and fluid shifts, including the release of aldosterone and catecholamines. Aldosterone increases urinary potassium loss and catecholamines cause potassium to move into the cell, resulting in hypokalemia, which causes dysrhythmias. Dysrhythmias are not associated with an increased lactate level caused by metabolic acidosis. Increased capillary permeability causes tachycardia rather than dysrhythmias. The increase in sodium reabsorption raises the serum osmolality and stimulates the release of the antidiuretic hormone (ADH). Increased sodium is not related to the development of dysrhythmias. Text Reference - p. 1649

Which medical emergency is caused by the failure of two or more organ systems? 1 Crush syndrome 2 Toxic shock syndrome 3 Multiple organ dysfunction syndrome (MODS) 4 Systemic inflammatory response syndrome (SIRS)

3 Multiple organ dysfunction syndrome is caused by the failure of two or more organ systems in an acutely ill patient. A crushing injury to the skeletal muscle causes crush syndrome, which is characterized by shock and renal failure. Bacterial toxins cause toxic shock syndrome, which is characterized by high fever, hypotension and malaise. Systemic inflammatory response syndrome (SIRS) is a systemic inflammatory response caused by infection, ischemia, infarction and injury. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options. Text Reference - p. 1649

The nurse is caring for a patient who developed cardiogenic shock. Which medical diagnosis does the nurse suspect? 1 Urosepsis 2 Hemorrhage 3 Myocardial infarction 4 Tension pneumothorax

3 Myocardial infarction may produce necrotic areas of cardiac tissue that lead to impaired contractility and decreased cardiac output. This may lead to a cardiogenic shock state. Hemorrhage may lead to a hypovolemic shock state, tension pneumothorax may lead to an obstructive shock state, and urosepsis may lead to a septic shock state. Text Reference - p. 1633

A patient experiences a myocardial infarction (MI). The nurse closely monitors the patient for complications and recognizes that hypotension is a warning sign of: 1 A secondary MI 2 Pulmonary edema 3 Cardiogenic shock 4 Fatal dysrhythmias

3 One of the initial cardinal signs of cardiogenic shock after a myocardial infarction (MI) is a slow, steady drop in blood pressure. Hypotension after an MI may be an indirect sign of a secondary MI or a fatal dysrhythmia. Depending on the origin of pulmonary edema, patients may experience hypotension or hypertension. Text Reference - p. 1633

A patient's localized infection has progressed to the point where septic shock now is suspected. What medication is an appropriate treatment modality for this patient? 1 Insulin infusion 2 Intravenous (IV) administration of epinephrine 3 Aggressive IV crystalloid fluid resuscitation 4 Administration of nitrates and β-adrenergic blockers

3 Patients in septic shock require large amounts of crystalloid fluid replacement. Epinephrine is indicated in anaphylactic shock, and insulin infusion is not normally necessary in the treatment of septic shock (but can be). Nitrates and β-adrenergic blockers are used most often in the treatment of patients in cardiogenic shock. Text Reference - p. 1636

A patient in neurogenic shock is receiving phenylephrine. Which nursing actions are appropriate when caring for this patient? 1 Monitoring for signs of dyspnea and pulmonary edema 2 Monitoring for signs of hypokalemia and hyperglycemia 3 Monitoring for signs of reflex bradycardia and restlessness 4 Monitoring for signs of hypothyroidism and Addison's disease

3 Phenylephrine is α-adrenergic agonist and may cause bradycardia and restlessness due to central nervous system stimulation. β-adrenergic agonists such as epinephrine cause dyspnea and pulmonary edema. Phenylephrine does not increase the elimination of potassium levels or blood glucose levels. Therefore, the patient does not have risk of hypokalemia and hyperglycemia. Phenylephrine does not impair thyroid and adrenal gland functioning. Therefore, the nurse will not monitor for the signs of hypothyroidism and Addison's disease. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Text Reference - p. 1643

32. When preparing a patient for discharge following fixation of a mandibular fracture, the nurse determines that teaching has been successful when the patient says what? a. "I can keep my mouth moist by sucking on hard candy." b. "I should cut the wires with scissors if I begin to vomit." c. "I may use a bulk-forming laxative if my liquid diet causes constipation." d. "I should use a moist swab to clean my mouth every time I eat something."

32. c. The low-bulk, high-carbohydrate liquid diet and intake of air through a straw required during mandibular fixation often lead to constipation and flatus, which may be relieved with bulk-forming laxatives, prune juice, or ambulation. Wires or rubber bands should be cut only in the case of cardiac or respiratory arrest and patients should be taught to clear their mouth of vomitus or secretions. The mouth should be thoroughly cleaned with water, saline, or alkaline mouthwashes or using a Water Pik as necessary to remove food debris. Hard candy should not be held in the mouth.

33. Priority Decision: Twenty-four hours after a below-the-knee amputation, a patient uses the call system to tell the nurse that his dressing (a compression bandage) has fallen off. What is the first action that the nurse should take? a. Apply ice to the site. b. Cover the incision with dry gauze. c. Reapply the compression dressing. d. Elevate the extremity on a couple of pillows.

33. c. The compression dressing or bandage supports the soft tissues, reduces edema, hastens healing, minimizes pain, and promotes residual limb shrinkage. If the dressing is left off, edema will form quickly and may delay rehabilitation. Elevation and ice will not be as effective at preventing the edema that will form. Dressing the incision with dry gauze will not provide the benefits of a compression dressing.

39. When the nursing student asks the RN what an arthroplasty is, what is the best description the RN can give the student? a. Surgical fusion of a joint to relieve pain b. Correction of bone deformity by removal of a wedge or slice of bone c. Reconstruction or replacement of a joint to relieve pain and correct deformity d. Used in rheumatoid arthritis to remove the tissue involved in joint destruction

39. c. An arthroplasty is reconstruction or replacement of a joint to relieve pain and correct deformity, especially with osteoarthritis, RA, avascular necrosis, congenital deformities, or dislocations. Arthrodesis is the surgical fusion of a joint to relieve pain. An osteotomy removes a wedge of bone to correct a bone deformity. Synovectomy is used in RA to remove the tissue involved in joint destruction.

Which laboratory finding in a patient with multiple organ dysfunction syndrome (MODS) suggests prerenal manifestations of renal dysfunction? 1 Urine Na+ is 22 mEq/L. 2 Urine specific gravity is 1.010. 3 Urine osmolality is decreased. 4 Urine specific gravity is increased.

4 An increase in urine specific gravity suggests prerenal manifestations in patients with MODS. This occurs due to renal hypoperfusion. A urine Na+ level above 20 mEq/L is a sign of intrarenal manifestations in MODS. It occurs due to acute tubular necrosis. Other intrarenal manifestations of MODS are urine specific gravity of around 1.010 and a decrease of the urine osmolality.

What causes gut bacteria to move into circulation in patients with systemic inflammatory response syndrome (SIRS)? 1 Toxic effects of medicines 2 Effect of inflammatory mediators 3 Decreased gastrointestinal motility 4 Decreased perfusion of gut mucosa

4 Decreased perfusion in the gastrointestinal (GI) tract leads to a breakdown of the normally protective mucosal barrier, which causes the bacterial movement from the GI tract into circulation. In order to control these bacteria, antibiotics are administered. Antibiotics are nephrotoxic medicines that can cause acute kidney injury. The breakdown of the mucosal barrier is the direct effect of hypoperfusion rather than the inflammatory mediators. In critical illnesses, GI motility is often decreased causing abdominal distension and paralytic ileus. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation. Text Reference - p. 1649

A patient is diagnosed with multiple organ dysfunction syndrome. While aggressive treatment is continued, the nurse suspects infection. What is the most appropriate action that the nurse should perform? 1 Discontinue the aggressive treatment. 2 Reduce oxygen delivery to the patient. 3 Wait for laboratory reports to confirm the suspicion. 4 Obtain a prescription for broad-spectrum antibiotic therapy.

4 If an infection is suspected, broad-spectrum antibiotics should be started immediately to limit the infection. Aggressive treatment for infection control should be carried out in parallel. These patients are usually hypoxemic. Therefore, oxygen should be administered strictly as prescribed. Cultures can be sent, and based on the reports, specific antibiotics can be added. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Example: If you are being asked to identify a diet that is specific to a certain condition, your knowledge about that condition would help you choose the correct response (e.g., cholecystectomy = low-fat, high-protein, low-calorie diet). Text Reference - p. 1650

What type of medication does the nurse anticipate being prescribed by the health care provider to manage confusion, disorientation, and delirium in a patient with systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)? 1 Vasopressors 2 Loop diuretics 3 Proton pump inhibitors 4 Calcium channel blockers

4 Impaired perfusion of the brain may cause confusion, disorientation, and delirium in the patient. The health care provider is likely to prescribe calcium channel blockers to a patient exhibiting confusion, disorientation, and delirium to reduce cerebral vasospasm and improve perfusion of the brain. Vasopressors may be prescribed to combat cardiovascular dysfunction. Loop diuretics are prescribed if there is renal dysfunction. Proton pump inhibitors are prescribed to manage gastrointestinal symptoms. Text Reference - p. 1651

Following coronary artery bypass graft surgery a patient has postoperative bleeding that requires returning to surgery to repair the leak. During surgery, the patient has a myocardial infarction (MI). After restoring the patient's body temperature to normal, which patient assessment is the most important for planning nursing care? 1 Cardiac index (CI) 5 L/min/m2 2 Central venous pressure (CVP) 8 mm Hg 3 Mean arterial pressure (MAP) 86 mm Hg 4 Pulmonary artery pressure (PAP) 28/14 mm Hg

4 Pulmonary hypertension as indicated by an elevated PAP indicates impaired forward flow of blood because of left ventricular dysfunction or hypoxemia. Both can be caused by the MI. The CI, CVP, and MAP readings are normal. Text Reference - p. 1639

What is the goal in the care of a systemic inflammatory response syndrome (SIRS) patient whose bilirubin level is 3 mg/dL? 1 Patient will be free of stress ulcers. 2 Patient will not feel abdominal distension. 3 Patient will maintain intraabdominal pressures. 4 Patient will maintain adequate tissue perfusion.

4 The nurse will plan to maintain adequate tissue perfusion for a systemic inflammatory response syndrome (SIRS) patient with bilirubin level of 3 mg/dL. An elevation of the bilirubin indicates impaired liver function. Stress ulcer prophylaxis is routine and would have been initiated before SIRS occurred. Abdominal distention and increased intraabdominal pressures are associated with impaired liver function. Monitoring these conditions is essential but is of a lower priority than maintaining tissue perfusion. Text Reference - p. 1651

What laboratory finding correlates with a medical diagnosis of cardiogenic shock? 1 Decreased liver enzymes 2 Increased white blood cells 3 Decreased red blood cells, hemoglobin, and hematocrit 4 Increased blood urea nitrogen (BUN) and serum creatinine levels

4 The renal hypoperfusion that accompanies cardiogenic shock results in increased BUN and creatinine levels. Impaired perfusion of the liver results in increased liver enzymes, whereas white blood cell levels typically do not increase in cardiogenic shock. Red blood cell indices are typically normal because of relative hypovolemia. Test-Taking Tip: Bring to your test prep with a positive attitude about yourself, your nursing knowledge, and your test-taking abilities. A positive attitude is achieved through self-confidence gained by effective study. This means (a) answering questions (assessment), (b) organizing study time (planning), (c) reading and further study (implementation), and (d) answering questions (evaluation). Text Reference - p. 1633

Which sign of neurologic dysfunction is commonly seen in both systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)? 1 Increased heart rate 2 Increased liver enzymes 3 Difficulty breathing 4 Confusion, agitation, and lethargy

4 The sign of neurologic dysfunction commonly seen in systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS) is change in mental status, which may cause the patient to become confused, agitated, and lethargic. The patient's heart rate increases due to changes in the cardiovascular system. The patient's liver enzymes increase due to dysfunction in the hepatic system and finally the dysfunction results in hepatic encephalopathy. The patient's dyspnea is caused by changes in the respiratory system by inflammatory mediators. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Text Reference - p. 1649

The nurse reviews the plan of care for a patient with multisystem organ dysfunction syndrome. What is the most desirable outcome for the patient? 1 The patient will be free of signs and symptoms of sepsis 2 The patient will maintain a balanced fluid intake and output 3 The patient will experience enhanced overall well-being and mental rest 4 The patient will demonstrate improved perfusion and oxygenation of organs

4 The underlying pathophysiology of multisystem organ dysfunction syndrome (MODS) is a lack of perfusion to organs, resulting in tissue and/or organ hypoxia. Interventions to improve perfusion with fluids or medications improve patient outcomes. The outcomes listed in the other answer options are appropriate and desirable for the patient with MODS, but they are secondary to improved perfusion and oxygenation. Text Reference - p. 1647

Which factor indicates that tracheostomy placement would be preferable to endotracheal intubation? The patient is unable to clear secretions. The patient is at high risk for aspiration. A long-term airway is probably necessary. An upper airway obstruction is impairing the patient's ventilation.

A long-term airway is probably necessary. A tracheostomy is indicated when the need for an artificial airway is expected to be long term. Aspiration risk, an inability to clear secretions, and upper airway obstruction are indications for an artificial airway, but these are not specific indications for tracheostomy.

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

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

The patient with neurogenic shock is receiving a phenylephrine (Neo-Synephrine) infusion through a left forearm IV. Which assessment information obtained by the nurse indicates a need for immediate action? a. The patient's IV infusion site is cool and pale. b. The patient has warm, dry skin on the extremities. c. The patient has an apical pulse rate of 58 beats/min. d. The patient's urine output has been 28 mL over the last hour.

ANS: A The coldness and pallor at the infusion site suggest extravasation of the phenylephrine. The nurse should discontinue the IV and, if possible, infuse the medication into a central line. An apical pulse of 58 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: Application REF: 1733-1734 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Which information obtained by the nurse when caring for a patient who has cardiogenic shock indicates 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 has crackles throughout both lung fields. d. The patient's extremities are cool and pulses are weak.

ANS: 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 consistent with the patient's diagnosis of cardiogenic shock. DIF: Cognitive Level: Application REF: 1740-1741 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

11. A patient who is to have no weight bearing on the left leg is learning to walk using crutches. Which observation by the nurse indicates that the patient can safely ambulate independently? a. The patient moves the right crutch with the right leg and then the left crutch with the left leg. b. The patient advances the left leg and both crutches together and then advances the right leg. c. The patient uses the bedside chair to assist in balance as needed when ambulating in the room. d. The patient keeps the padded area of the crutch firmly in the axillary area when ambulating.

ANS: B Patients are usually taught to move the crutches and the injured leg forward at the same time and then to move the unaffected leg. Patients are discouraged from using furniture to assist with ambulation. The patient is taught to place weight on the hands, not in the axilla, to avoid nerve damage. If the 2- or 4-point gaits are to be used, the crutch and leg on opposite sides move forward, not the crutch and same-side leg. *OMGGGGG these questions kill me. OK, NWB one LE: crutches, then good LE.*

19. The day after a having a right below-the-knee amputation, a patient complains of pain in the right foot. Which action is best for the nurse to take? a. Explain the reasons for the phantom limb pain. b. Administer prescribed analgesics to relieve the pain. c. Loosen the compression bandage to decrease incisional pressure. d. Inform the patient that this phantom pain will diminish over time.

ANS: B Phantom limb sensation is treated like any other type of postoperative pain would be treated. Explanations of the reason for the pain may be given, but the nurse should still medicate the patient. The compression bandage is left in place except during physical therapy or bathing. Although the pain may decrease over time, it still requires treatment now.

5. A 22-year-old tennis player has an arthroscopic repair of a rotator cuff injury performed in same-day surgery. When the nurse plans postoperative teaching for the patient, which information will be included? a. "You will not be able to serve a tennis ball again." b. "You will work with a physical therapist tomorrow." c. "The doctor will use the drop-arm test to determine the success of surgery." d. "Leave the shoulder immobilizer on for the first 4 days to minimize pain."

ANS: B Physical therapy after a rotator cuff repair begins on the first postoperative day to prevent "frozen shoulder." A shoulder immobilizer is used immediately after the surgery, but leaving the arm immobilized for several days would lead to loss of range of motion (ROM). The drop-arm test is used to test for rotator cuff injury, but not after surgery. The patient may be able to return to pitching after rehabilitation.

39. When assessing for Tinel's sign in a patient with possible right-sided carpal tunnel syndrome, the nurse will ask the patient about a. weakness in the right little finger. b. tingling in the right thumb and fingers. c. burning in the right elbow and forearm. d. tremor when gripping with the right hand.

ANS: B Testing for Tinel's sign will cause tingling in the thumb and first three fingers of the affected hand in patients who have carpal tunnel syndrome. The median nerve does not innervate the right little finger or elbow and forearm. Tremor is not associated with carpal tunnel syndrome.

1. During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient is breathing and 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.

ANS: 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: 1676 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The patient has been part of a community emergency response team (CERT) for a tropical storm in Dallas with temperatures near 100°F (37.7°C) for the past 2 weeks. When assessing the patient, the nurse finds hypotension, body temperature of 104°F (40°C), dry and ashen skin, and neurologic symptoms. What treatments should the nurse anticipate (select all that apply.)? Select all that apply. Administer 100% O2. Immerse in an ice bath. Administer cool IV fluids. Cover the patient to prevent chilling. Administer acetaminophen (Tylenol). Administer chlorpromazine for shivering.

Administer 100% O2. Administer cool IV fluids. Administer chlorpromazine for shivering. The patient is experiencing heatstroke. Treatment focuses first on stabilizing the patient's ABC and rapidly reducing the core temperature. Administration of 100% O2 compensates for the patient's hypermetabolic state. Cooling the body with IV fluids is effective. Immersion in an ice bath will cause shivers that increase core temperature, so a cool water bath should be used for conductive cooling. Removing the clothing, covering the patient with wet sheets, and placing the patient in front of a fan will cause evaporative cooling. If shivering ensues, treatment with chlorpromazine is indicated. Shivering increases core temperature due to the heat generated by muscle activity. Excessive covers will not be used. Acetaminophen will not be effective because the increase in temperature is not related to infection.

A 50-yr-old woman with a suspected brain tumor is scheduled for a CT scan with contrast media. The nurse notifies the physician that the patient reported an allergy to shellfish. Which response by the physician should the nurse question? Infuse IV diphenhydramine before the procedure. Administer lorazepam (Ativan) before the procedure. Complete the CT scan without the use of contrast media. Premedicate with hydrocortisone sodium succinate (Solu-Cortef).

Administer lorazepam (Ativan) before the procedure. An individual with an allergy to shellfish is at an increased risk to develop anaphylactic shock if contrast media is injected for a CT scan. To prevent anaphylactic shock, the nurse should always confirm the patient's allergies before diagnostic procedures (e.g., CT scan with contrast media). Appropriate interventions may include cancelling the procedure, completing the procedure without contrast media, or premedication with diphenhydramine or hydrocortisone. IV fluids may be given to promote renal clearance of the contrast media and prevent renal toxicity and acute kidney injury. The use of an antianxiety agent such as lorazepam would not be effective in preventing an allergic reaction to the contrast media.

A 47-yr-old man who was lost in the mountains for 2 days is admitted to the emergency department with cold exposure and a core body temperature of 86.6ºF (30.3ºC). Which nursing action is most important? Administer warmed IV fluids. Position patient under a radiant heat lamp. Place an air-filled warming blanket on the patient. Immerse the extremities in a water bath (102° to 108°F [38.9° to 42.2°C]).

Administer warmed IV fluids. A patient with a core body temperature of 86.6ºF (30.3ºC) has moderate hypothermia. Active core rewarming is used for moderate to severe hypothermia and includes administration of warmed IV fluids (109.4ºF [43ºC]). Patients with moderate to severe hypothermia should have the core warmed before the extremities to prevent after drop (or further drop in core temperature). This occurs when cold peripheral blood returns to the central circulation. Use passive or active external rewarming for mild hypothermia. Active external rewarming involves fluid-filled warming blankets or radiant heat lamps. Immersion of extremities in a water bath is indicated for frostbite.

An 18-yr-old young woman has been admitted to the emergency department after ingesting an entire bottle of chewable multivitamins in a suicide attempt. The nurse should anticipate which intervention? Induced vomiting Whole-bowel irrigation Administration of activated charcoal Administration of fresh frozen plasma

Administration of activated charcoal Among the most common treatments for poisoning is the administration of activated charcoal. Induced vomiting is not typically indicated, and there is no need for plasma administration. Whole-bowel irrigation may be used as an adjunct therapy later in treatment, but the use of activated charcoal is central to the treatment of poisonings.

The nurse is planning to change the dressing covering a deep partial-thickness burn of the right lower leg. Which prescribed medication should the nurse administer 30 minutes before the scheduled dressing change? A. zolpidem (Ambien) B. morphine sulfate C. sertraline (Zoloft) D. enoxaparin (Lovenox)

Answer: B. morphine sulfate Rationale: Deep partial-thickness burns result in severe pain related to nerve injury. The nurse should plan to administer analgesics before the dressing change to promote patient comfort. Morphine sulfate is a common opioid used for pain control. Sedative/hypnotics and antidepressant agents can also be given with analgesics to control the anxiety, insomnia, and/or depression that patients may experience. Zolpidem promotes sleep; sertraline is an antidepressant; and enoxaparin is an anticoagulant. Ch. 25

The nurse is providing emergent care for a patient with a possible inhalation injury sustained in a house fire. The patient is anxious and disoriented, and the skin is a cherry red color. Which action should the nurse take first? A. Assist the patient to a high Fowler's position. B. Teach the patient deep breathing exercises. C. Allow the patient to verbalize feelings. D. Administer 100% humidified oxygen.

Answer: D. Administer 100% humidified oxygen. Rationale: Carbon monoxide (CO) poisoning may occur in house fires; CO displaces oxygen on the hemoglobin molecule resulting in hypoxia. High levels of CO in the blood result in a skin color that is described as cherry red. Hypoxia may cause anxious behaviors and altered mental status. Emergency treatment for inhalation injury and CO poisoning includes the immediate administration of 100% humidified oxygen. The other interventions are appropriate for inhalation injury but are not as emergent as oxygen administration. Ch. 25

A patient is admitted to the emergency department with cold exposure and a core body temperature of 86.6o F (30.3o C). Which action is most appropriate for the nurse to take? A. Immerse the extremities in a water bath (102° to 108° F) [38.9° to 42.2° C]) B. Place an air-filled warming blanket on the patient. C. Position patient under a radiant heat lamp. D. Administer warmed intravenous (IV) fluids.

Answer: D. Administer warmed intravenous (IV) fluids. Rationale: A patient with a core body temperature of 86.6o F (30.3o C) has moderate hypothermia. Active core rewarming is used for moderate to severe hypothermia and includes administration of warmed IV fluids (109.4° F [43° C]). Patients with moderate to severe hypothermia should have the core warmed before the extremities to prevent after drop (or further drop in core temperature). This occurs when cold peripheral blood returns to the central circulation. Use passive or active external rewarming for mild hypothermia. Active external rewarming involves fluid-filled warming blankets or radiant heat lamps. Immersion of extremities in a water bath is indicated for frostbite. Ch. 69

A nurse is performing triage in the emergency department. Which patient should the nurse see first? A. 18-year-old patient with type 1 diabetes mellitus who has a 4-cm laceration on right leg. B. 32-year-old patient with drug overdose who is unresponsive with poor respiratory effort. C. 56-year-old patient with substernal chest pain who is diaphoretic with shortness of breath. D. 78-year-old patient with right hip fracture who is confused; blood pressure is 98/62 mm Hg.

Answer: B. 32-year-old patient with drug overdose who is unresponsive with poor respiratory effort. Rationale: Patient with drug overdose is unstable and needs to be seen immediately. Patient with chest pain (possible myocardial infarction) should be seen second. Patient with hip fracture should be seen third. Patient with laceration is the most stable and should be seen last. Ch. 69

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

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

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

B, D, A, C, E, F edema; surfactant; atelectasis; refractory low O2; IR; dec gas exch In the injury or exudative phase of ARDS (1-7 days after acute lung injury), there is interstitial edema and surfactant dysfunction that lead to atelectasis. Widespread atelectasis decreases lung compliance, hyaline membranes form, and refractory hypoxemia occurs. In the reparative or proliferative phase (1-2 weeks after acute lung injury), there is an increased inflammatory response which worsens hypoxia. In the fibrotic phase (2-3 weeks after acute lung injury), the lung tissue is remodeled by collagen and fibrous tissue, which decreases the available surface area for gas exchange.

The patient had tibia and fibula fractures repaired using open reduction internal fixation. A fiberglass cast is in place. She wants to know when she can resume exercise classes. To answer this question, the nurse must understand the stages of union occur in what order? (Answer with a letter followed by a comma and a space (e.g. A, B, C, D).) a. Ossification b. Granulation c. Remodeling d. Consolidation e. Callus formation f. Fracture hematoma

F, B, E, A, D, C A fracture hematoma occurs in the first 72 hours after the fracture injury. Granulation produces the basis for new bone substance 3 to 14 days after injury. Callus formation (composed of cartilage, osteoblasts, calcium, and phosphorus) appears by the end of the second week after injury. Ossification of the callus will prevent movement at the fracture when the bones are gently stressed and occurs from 3 weeks to 6 months after the fracture and continues until the fracture is healed. Consolidation occurs when the distance between bone fragments diminishes and there is radiologic evidence of union. Remodeling is the reabsorption of excess bone tissue in the final stage of bone healing; it occurs in response to gradually increased stress on the bone or weight bearing.

A 70-yr-old patient in the intensive care unit (ICU) has become agitated and inattentive since his heart surgery. The nurse knows that ICU delirium frequently occurs in individuals with preexisting dementia, history of alcohol abuse, and severe disease. What interventions should the nurse provide to improve the patient's cognition (select all that apply.)? Select all that apply. Improve oxygenation. Initiate early mobilization. Provide a small amount of beer. Have the family stay with the patient. Enable the patient to sleep on a schedule with dim lights. Encourage conversation in the patient's room to help reorient.

Improve oxygenation. Initiate early mobilization. Have the family stay with the patient. Enable the patient to sleep on a schedule with dim lights. ICU delirium is common in ICU patients. Improving oxygenation, enabling the patient to sleep, early mobilization, and decreasing sensory overload along with orientation is all helpful in improving the patient's cognition. The beer may or may not be allowed for this patient, and the nurse should not assume that it will help. Having a family member stay with the patient to reorient the patient is helpful, but the family group may increase sensory overload with conversations not involving the patient.

The home care nurse visits a 74-yr-old man diagnosed with Parkinson's disease who fell while walking this morning. What observation is of most concern to the nurse? 2 × 6 cm right calf abrasion with sanguineous drainage Left leg externally rotated and shorter than the right leg Stooped posture with a shuffling gait and slow movements Mild pain and minimal swelling of the right ankle and foot

Left leg externally rotated and shorter than the right leg Clinical manifestations of hip fracture include external rotation, muscle spasm, shortening of the affected extremity, and severe pain and tenderness in the region of the fracture site. Expected clinical manifestations of Parkinson's disease include a stooped posture, shuffling gait, and slow movements. An abrasion is a soft tissue injury. Mild pain and minimal swelling may occur with a sprain or strain.

In reviewing the chart, which patient assessment is likely to have the greatest impact on this patient's risk of death from the accident? - Male - Found floating face down after surfing accident - CPR done by rescuers - Sinus tachycardia with frequent premature ventricular contractions (PVCs) - Mechanical ventilation - Left pupil size 10 cm, not reactive to light - Pulmonary artery wedge pressure (PAWP) 16 mm Hg - PaO2 108 mm Hg, FIO2 50%, PEEP 5 cm - Cool extremities, weak peripheral pulses

Left pupil 10 cm, not reactive to light Unilateral pupil dilation without response to light can be a clinical indicator of tentorial herniation of the brain and can occur in a surfing accident as the surfboard and patient are forcefully tossed around in the waves. If the excessive intracranial pressure is allowed to continue, the patient is at a high risk for brainstem death. This finding merits emergency interventions to prevent death. The PAWP, sinus tachycardia with frequent PVCs, and cool extremities with weak peripheral pulses do not indicate imminent death.

A 28-yr-old woman with a fracture of the proximal left tibia in a long leg cast and complains of severe pain and a prickling sensation in the left foot. The toes on the left foot are pale and cool. Which nursing action is a priority? Notify the health care provider immediately. Elevate the left leg above the level of the heart. Administer prescribed morphine sulfate intravenously. Apply ice packs to the left proximal tibia over the cast.

Notify the health care provider immediately. Notify the health care provider immediately of this change in patient's condition, which suggest development of compartment syndrome. Pain unrelieved by drugs and out of proportion to the level of injury is one of the first indications of impending compartment syndrome. Changes in sensation (tingling) also suggest compartment syndrome. Because elevation of the extremity may lower venous pressure and slow arterial perfusion, the extremity should not be elevated above heart level. Similarly, the application of cold compresses may result in vasoconstriction and exacerbate compartment syndrome. Administration of morphine may be warranted, but it is not the first priority.

The nurse is caring for a 72-yr-old man in cardiogenic shock after an acute myocardial infarction. Which clinical manifestations would be most concerning? Restlessness, heart rate of 124 beats/min, and hypoactive bowel sounds Mean arterial pressure of 54 mm Hg; increased jaundice; and cold, clammy skin PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and puncture site bleeding Agitation, respiratory rate of 32 breaths/min, and serum creatinine of 2.6 mg/dL

PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and puncture site bleeding Severe hypoxemia, lactic acidosis, and bleeding are clinical manifestations of the irreversible state of shock. Recovery from this stage is not likely because of multiple organ system failure. Restlessness, tachycardia, and hypoactive bowel sounds are clinical manifestations that occur during the compensatory stage of shock. Decreased mean arterial pressure, jaundice, cold and clammy skin, agitation, tachypnea, and increased serum creatinine are clinical manifestations of the progressive stage of shock.

The nurse is caring for a 65-yr-old man with acute respiratory distress syndrome (ARDS) who is on pressure support ventilation (PSV), fraction of inspired oxygen (FIO2) at 80%, and positive end-expiratory pressure (PEEP) at 15 cm H2O. The patient weighs 72 kg. What finding would indicate that treatment is effective? PaO2 of 60 mm Hg Tidal volume of 700 mL Cardiac output of 2.7 L/min Inspiration to expiration ratio of 1:2

PaO2 of 60 mm Hg Severe hypoxemia (PaO2 less than 40 mm Hg) occurs with ARDS, and PEEP is increased to improve oxygenation and prevent oxygen toxicity by reducing FIO2. A PaO2 level of 60 mm Hg indicates that treatment is effective and oxygenation status has improved. Decreased cardiac output is a complication of PEEP. Normal cardiac output is 4 to 8 L/minute. Normal tidal volume is 6 to 10 mL/kg. PSV delivers a preset pressure but the tidal volume varies with each breath. I:E ratio is usually set at 1:2 to 1:1.5 and does not indicate patient improvement.

11. A patient with acute respiratory distress syndrome (ARDS) is placed in the prone position. When prone positioning is used, 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 patient's PaO2 is 89 mm Hg and the SaO2 is 91%

What are the appropriate nursing interventions for the patient with delirium in the ICU? SATA. a. use clocks and calendars to maintain orientation b. encourage round-the-clock presence of caregivers at the bedside c. silence all alarms, reduce overhead paging, and avoid conversations around the patient d. sedate the patient with appropriate drugs to protect the patient from harmful behaviors e. identify physiologic factors that may be contributing to the patient's confusion and irritability

a. use clocks and calendars to maintain orientation d. sedate the patient with appropriate drugs to protect the patient from harmful behaviors e. identify physiologic factors that may be contributing to the patient's confusion and irritability

Which descriptions are characteristic of hypoxemic respiratory failure (select all that apply)? a. Referred to as ventilatory failure b. Primary problem is inadequate O2 transfer c. Risk of inadequate O2 saturation of hemoglobin exists d. Body is unable to compensate for acidemia of increased PaCO2 e. Most often caused by ventilation-perfusion (V/Q) mismatch and shunt f. Exists when PaO2 is 60 mm Hg or less, even when O2 is administered at 60%

b, c, e, f. Hypoxemic respiratory failure is often caused by ventilation-perfusion (V/Q) mismatch and shunt. It is called oxygenation failure because the primary problem is inadequate oxygen transfer. There is a risk of inadequate oxygen saturation of hemoglobin and it exists when PaO2 is 60 mm Hg or less, even when oxygen is administered at 60%. Ventilatory failure is hypercapnic respiratory failure. Hypercapnic respiratory failure results from an imbalance between ventilatory supply and ventilatory demand and the body is unable to compensate for the acidemia of increased PaCO2

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? 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% oxygen to the lungs."

b. peep prevents the lung air sacs from collapsing during exhalation

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. Blood urea nitrogen (BUN) level 32 mg/dL b. Red-brown drainage from orogastric tube c. Scattered coarse crackles heard throughout lungs d. Arterial blood gases: pH 7.31, PaCO2 50, PaO2 68

b. red-brown drainage from orogastric tube

A pt c OA is scheduled for a THA. The nurse explains the purpose of this procedure is to (SATA) a. fuse the joint b. replace the joint c. prevent further damage d. improve or maintain ROM e. decrease the amount of destruction in the joint

b. replace the joint d. improve or maintain ROM

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.

b. the patient has subcutaneous emphysema on the upper thorax

The nurse documents 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. 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. obtain O2Sat using pulse oximetry

The nurse monitors the patient with positive pressure mechanical ventilation for a. paralytic ileus because pressure on the abdominal contents affects bowel motility b. diuresis and sodium depletion because of increased release of atrial natriuretic peptide c. signs of cardiovascular insufficiency because pressure in the chest impedes venous return d. respiratory acidosis in a patient with COPD because of alveolar hyperventilation and increased PaO2 levels

c. signs of cardiovascular insufficiency because pressure in the chest impedes venous return

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 respirations have decreased from 30 to 10 breaths/minute. d. The patient's pulse oximetry indicates an O2 saturation of 91%.

c. the patient's respirations have decreased from 30 to 10 breaths/minute

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. use pulse oximetry to check the O2 Sat

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. insert an indwelling urinary catheter

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

d. lower the PEEP