All You Need Is Chocolate In Both Hands Block 4 Final Review

A patient arrives to the ER due to experiencing burns while in an enclosed warehouse. Which assessment findings below demonstrate the patient may have experienced an inhalation injury? A. Carbonaceous sputum B. Hair singeing on the head and nose C. Lhermitte's Sign D. Bright red lips E. Hoarse voice F. Tachycardia

Carbonaceous sputum Hair singeing on the head and nose Bright red lips Hoarse voice Tachycardia

A nurse is caring for a client with a central venous pressure (CVP) of 4 mm Hg. Which nursing intervention is appropriate? A. Call the health care provider and obtain an order for a fluid bolus. B. Re-zero the equipment and take another reading. C. Call the physician and obtain an order for a diuretic. D. Continue to monitor the client as ordered.

Continue to monitor the client as ordered.

Treatment with norepinephrine in a client diagnosed with hypotension has been unsuccessful. What second-line vasopressors would the nurse suspect the health care provider might prescribe? Select all that apply. A. Epinephrine B. Vasopressin C. Nitroglycerin D. Dobutamine E. Phenylephrine

Epinephrine Vasopressin Phenylephrine

Ten minutes following administration of an antibiotic, the nurse assesses a client to have edematous lips, hoarseness, and expiratory stridor. Vital signs assessed by the nurse include blood pressure 70/40 mm Hg, heart rate 130 beats/min, and respirations 36 breaths/min. What is the priority intervention? A. Diphenhydramine 50 mg intravenously B. Epinephrine 3 to 5 ml of a 1:10,000 solution intravenously C. Methylprednisolone 125 mg intravenously D. Prednisone 10 mg PO

Epinephrine 3 to 5 ml of a 1:10,000 solution intravenously

A client with severe sepsis has a BP of 80/46 mm Hg, pulse 136, respirations 32, temperature 104° F, CVP 1, and blood glucose 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first? A. Give normal saline bolus of 1000 ml B. Give acetaminophen 650 mg rectally C. Start insulin gtt to maintain blood glucose below 180 mg/dL D. Start norepinephrine gtt to keep MAP greater than 65 mmHg

Give normal saline bolus of 1000 ml

A patient is receiving mechanical ventilation with PEEP. The patient had developed a tension pneumothorax. Select ALL the signs and symptoms that can present with this condition: A. Hypotension B. Jugular Venous Distention C. Bradycardia D. Tracheal deviation E. Hyperemia

Hypotension Jugular Venous Distention Tracheal deviation

The nurse is admitting a client with a fracture at C6 level to the intensive care unit. Which assessment finding(s) indicate(s) neurogenic shock? A. Hypertension, tachycardia, and cool extremities B. Involuntary, spastic movements of the arms and legs C. Hypotension, bradycardia, and warm, pink extremities D. Lack of sensation or movement below the level of injury

Hypotension, bradycardia, and warm, pink extremities

A nurse observes for early manifestations of acute respiratory distress syndrome in a client being treated for smoke inhalation. Which signs and symptoms indicate the possible onset of ARDS in this client? Cough with blood tinged sputum and respiratory alkalosisDecrease in both white and red blood cell countsLow SaO2 unresponsive to increased oxygen administrationHypertension and elevated PaO2 A. Cough with blood tinged sputum and respiratory alkalosis B. Decrease in both white and red blood cell counts C. Low SaO2 unresponsive to increased oxygen administration D. Hypertension and elevated PaO2

Low SaO2 unresponsive to increased oxygen administration Rationale: ARDS is manifested and similar to an extreme state of respiratory distress that would include diaphoresis, tachypnea, and use of accessory muscles. Because of damage and alterations in lung tissue, the client would not be able to increase his or her oxygenation despite an increase in the flow or amount of oxygen. Blood pressure and acid-base imbalances vary depending on the stage of ARDS. Test-taking Tip: Look at key words to help determine the best answer choices. First, eliminate the two options that do not suggest impaired oxygenation.

A patient is complaining of chest pain. On the bedside cardiac monitor you observe pronounce T-wave inversion. You obtain the patient's vital signs and find the following: Blood pressure 190/98, HR 110, oxygen saturation 96% on room air, and respiratory rate 20. Select-all-that-apply in regards to the MOST IMPORTANT nursing interventions you will provide based on the patient's current status: A. Obtain a 12-lead EKG B. Place the patient in supine position C. Assess urinary output D. Administer Nitroglycerin sublingual as ordered per protocol E. Collect cardiac enzymes as ordered per protocol F. Encourage patient to cough and deep breath G. Administer Morphine IV as ordered per protocol H. Place patient on oxygen via nasal cannula I. No interventions are needed at this time

Obtain a 12-lead EKG Administer Nitroglycerin sublingual as ordered per protocol Collect cardiac enzymes as ordered per protocol Administer Morphine IV as ordered per protocol Place patient on oxygen via nasal cannula

Which finding for a client with a head injury should the nurse report immediately to the health care provider? A. Intracranial pressure is 19 mm Hg when patient is turned. B. Pale yellow urine output is 1200 mL over the last 2 hours. C. Ventriculostomy drained 40 mL of clear cerebrospinal fluid in the last 6 hours. D. Blood pressure of 132/60 and an ICP 16.

Pale yellow urine output is 1200 mL over the last 2 hours.

A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect? A. Myocardial infarction (MI) B. Pneumothorax C. Pulmonary embolism D. Heart failure

Pneumothorax Pneumothorax (air in the pleural space) is a potential complication of all central venous access devices. Signs and symptoms include chest pain, dyspnea, shoulder or neck pain, irritability, palpitations, light-headedness, hypotension, cyanosis, and unequal breath sounds. A chest X-ray reveals the collapse of the affected lung that results from pneumothorax. Triple-lumen catheter insertion through the subclavian vein isn't associated with pulmonary embolism, MI, or heart failure.

When caring for a client with acute coronary syndrome who has returned to the unit after having angioplasty with stent placement, the nurse obtains the following assessment data. Which data indicate the need for immediate action by the nurse? A. Heart rate of 112 beats/min B. Pedal pulses 1+ bilaterally C. Report of chest pain D. Blood pressure 99/54 mm Hg

Report of chest pain

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

Report the BP and the ICP to the health care provider Rationale: Calculate the cerebral perfusion pressure (CCP): (CCP = mean arterial blood pressure [MAP] - ICP). MAP = DBP +1/3 (systolic blood presure [SBP] - diastolic blood pressure [DBP]). Therefore the (MAP) is 70 and the CCP is 56 mmHg, which is below the normal of 60 to 100 mmHg and approaching the level of ischemia and neuronal death. Immediate changes in he patient's therapy such as fluid infusion or vasopressor administration are needed to improve the cerebral perfusion pressure. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation will also be done, but they are not the first actions that the nurse should take.

A client is admitted to the critical care unit following coronary artery bypass surgery. Two hours postoperatively, the nurse assesses the following information: pulse is 120 beats/min; blood pressure is 70/50 mm Hg; cardiac output is 3 L/min; urine output is 250 mL/hr; chest drainage is 400 mL/hr. What is the best interpretation by the nurse? A. The assessed values are within normal limits B. The client is at risk for developing cardiogenic shock C. The client is at risk for developing fluid volume overload D. The client is at risk for developing hypovolemic shock

The client is at risk for developing hypovolemic shock

An adult client in the ICU has a central venous catheter in place. Over the past 24 hours, the client has developed signs and symptoms that are suggestive of a central line associated bloodstream infection (CLABSI). What aspect of the client's care may have increased susceptibility to CLABSI? A. The client has received antibiotics and IV fluids through the same line. B. The client was treated for vancomycin-resistant enterococcus (VRE) during a previous admission. C. The client's central line was placed in the femoral vein. D. The client had blood cultures drawn from the central line.

The client's central line was placed in the femoral vein.

A client has an advanced directive on file at the hospital that identifies a close friend as the legal healthcare agent. A nurse needs to obtain informed consent for the client for surgery. Due to sedation, the client is unable to sign the form or give verbal consent. Who should provide consent for the client? A. The client's oldest adult child B. Since the client is unable to give consent, the surgery cannot be performed C. The client's durable power of attorney for healthcare D. The client's spouse

The client's durable power of attorney for healthcare

The ICU nurse caring for a client in shock is administering vasoactive medications as per orders. The nurse should administer this medication in what way? A. Through a central venous line B. By a gravity infusion set C. By IV push for rapid onset of action D. Mixed with parenteral feedings to balance osmosis

Through a central venous line

A client is being mechanically ventilated in the ICU. The ventilator alarms begin to sound. The nurse should complete which action first? A. Manually ventilate the client. B. Troubleshoot to identify the malfunction. C. Notify the respiratory therapist. D. Reposition the endotracheal tube.

Troubleshoot to identify the malfunction. Rationale: The nurse should first immediately attempt to identify and correct the problem and, if the problem cannot be identified and/or corrected, the patient must be manually ventilated with an Ambu bag. The respiratory therapist may be notified, but this is not the first action by the nurse. The nurse should not reposition the ET tube as a first response to an alarm.

A patient who had a myocardial infarction is experiencing severe chest pain and alerts the nurse. The nurse begins the assessment but suddenly the patient becomes unresponsive, no pulse, with the monitor showing a rapid, disorganized ventricular rhythm. What does the nurse interpret this rhythm to be? A. Ventricular Tachycardia B. Atrial Fibrillation C. Ventricular fibrillation D. Third Degree Heart Block

Ventricular fibrillation

When a brain-injured client responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, the nurse reports the response as A. flexion withdrawal B. localization of pain C. decorticate posturing D. decerebrate posturing

decorticate posturing Rationale: Internal rotation, adduction, and flexion of the arms in an unconscious patient is documentedas decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because theflexion is generalized, it does not indicate localization of pain or flexion withdrawal.

A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant? A. elevated blood pressure B. increased urine output C. decreased level of consciousness (LOC) D. decreased heart rate

increased urine output

A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder? A. pH 7.46, PaO2 80 mmHg B. pH 7.36, PaC02 32 mmHg C. pH 7.35, PaCO2 48 mmHg D. pH 7.28, PaO2 50 mmHg

pH 7.28, PaO2 50 mmHg Rationale: ARF is defined as a decrease in arterial oxygen tension (PaO2) to less than 60 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to >50 mm Hg (hypercapnia), with an arterial pH less than 7.35.

Neuromuscular blocking agents are used in the management of some ventilated or neurologically injured clients. Their primary mode of action is: A. analgesia. B. anticonvulsant. C. paralysis. D. sedation.

paralysis.

A 30 year old female patient has deep partial thickness burns on the front and back of the right and left leg, front of right arm, and anterior trunk. The patient weighs 63 kg. Use the Parkland Burn Formula: What is the flow rate during the FIRST 8 hours (mL/hr) based on the total you calculated? A. 921 mL/hr B. 938 mL/hr C. 158 mL/hr D. 789 mL/hr

921 mL/hr

Which patient is most at risk for developing cardiogenic shock? A. A 52-year-old male who is experiencing a severe allergic reaction from shellfish. B. A 25-year-old female who has experienced an upper thoracic spinal cord injury. C. A 72-year-old male who is post-op from a liver transplant. D. A 49-year-old female who is experiencing an acute myocardial infarction.

A 49-year-old female who is experiencing an acute myocardial infarction.

Which client should the nurse prioritize as needing emergent treatment, assuming no other injuries are present except the ones outlined below? A. A client with a sore neck who was immobilized in the field on a backboard with a cervical collar B. A client with a blunt chest trauma with some difficulty breathing C. A client with a possible fractured tibia with adequate pedal pulses D. A client with an acute onset of confusion

A client with a blunt chest trauma with some difficulty breathing

Which client being cared for in the emergency department should the charge nurse evaluate first? A. A client with a complete spinal injury at the C5 dermatome level" B. A client with a Glasgow Coma Scale score of 14 on 3-L nasal cannula C. An alert client with a subdural bleed who is complaining of a headache D. An ischemic stroke client with a blood pressure of 190/100 mm Hg

A client with a complete spinal injury at the C5 dermatome level"

A client had a non-ST-segment-elevation myocardial infarction (NSTEMI) 3 days ago. Which nursing intervention included in the plan of care is appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? A. Evaluation of the patient's response to walking in the hallway B. Completion of the referral form for a home health nurse follow-up C. Education of the patient about the pathophysiology of heart disease D. Administer PO lipid-reducing agent

Administer PO lipid-reducing agent

A terminally ill client on comfort care is reporting pain. The physician has prescribed a large dose of intravenous opioids by continuous infusion. When the nurse assesses the client's respiratory status, the rate has decreased from 16 to 10 breaths per minute. What action should the nurse take? A. Stimulate the client in order to increase respiratory rate. B. Report the decreased respiratory rate to the physician. C. Allow the client to rest comfortably. D. Decrease the rate of IV infusion.

Allow the client to rest comfortably.

A patient has experienced full-thickness burns to the face and neck. As the nurse it is priority to: A. Prevent hypothermia B. Assess the blood pressure C. Assess the airway D. Prevent infection

Assess the airway

A nurse assesses a 76 year old client who has multiple chronic diseases. The client's monitor shows a heart rate is 47 beats/min. The client is awake with stable vital signs and denies discomfort. Which action should the nurse take first? A. Call a code blue B. Initiate external pacing C. Administer 1 mg of atropine D. Assess the client's medications

Assess the client's medications

Which patient below with an increased ICP is experiencing Cushing's Triad?A patient with the following: A. BP 150/112, HR 110, RR 8 B. BP 90/60, HR 80, RR 22 C. BP 200/60, HR 50, RR 8 D. BP 80/40, HR 45, RR 12

BP 200/60, HR 50, RR 8