cc
What is a normal urine output? 80 to 125 mL/min 180 L/day 80 mL/min 1 to 2 L/day
1 to 2 L/day
The primary care provider has opted to treat a patient with a complete spinal cord injury with glucocorticoids. The orders are for 30 mg/kg over 15 minutes followed in 45 minutes with an infusion of 5.4 mg/kg/min for 23 hours. What is the total 24-hour dose for the 70-kg patient? 2478 mg 5000 mg 10,794 mg 12,750 mg
10,794 mg
The nurse calculates the PaO2/FiO2 ratio for the following values: PaO2 is 78 mm Hg; FiO2 is 0.6 (60%). What is the outcome and the relationship to the ARDS diagnosing criteria? 46.8; meets criteria for ARDS 130; meets criteria for ARDS 468; normal lung function Not enough data to compute the ratio
130; meets criteria for ARDS
In trauma patients, enteral nutrition via nasogastric tube feedings into the small bowel is best initiated within what time frame following the injury? 24 hours 48 hours 7 days 72 hours
24 hours
The patient is a new postoperative patient. She weighs 75 kg. The nurse expects the minimal acceptable urine output to be what? Less than 30 mL/hour. 37 mL/hour. 80 mL/hour. 150 mL/hour
37 mL/hour.
The nurse is caring for a patient admitted with a subarachnoid hemorrhage following surgical repair of the aneurysm. Assessment by the nurse notes blood pressure 90/60 mm Hg, heart rate 115 beats/min, respiratory rate 28 breaths/min, oxygen saturation (SpO2) 99% on supplemental oxygen at 3 L/min by cannula, a Glasgow Coma Score of 4, and a central venous pressure (CVP) of 2 mm Hg. After reviewing the orders, which order is of the highest priority? Furosemide 20 mg intravenous push as needed 500 mL albumin intravenous infusion Decadron 10 mg intravenous push Dilantin 50 mg intravenous push
500 mL albumin intravenous infusion
The patient's serum creatinine level is 0.7 mg/dL. The expected BUN level should be 1 to 2 mg/dL. 7 to 14 mg/dL. 10 to 20 mg/dL. 20 to 30 mg/dL.
7 to 14 mg/dL.
What is a normal glomerular filtration rate? Less than 80 mL/min 80 to 125 mL/min 125 to 180 mL/min More than 189 mL/min
80 to 125 mL/min
A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg.; blood pressure is 144/90 mm Hg, and mean arterial pressure (MAP) is 108 mm Hg. What is the cerebral perfusion pressure (CPP)? 54 mm Hg 72 mm Hg 90 mm Hg 126 mm Hg
90 mm Hg
Daily weights are being recorded for a patient with urine output that has been less than intravenous and oral intake. The patient's weight yesterday was 97.5 kg and this morning it is 99 kg. The nurse understands that this corresponds to what? a. A fluid retention of 1.5 liters. b A fluid loss of 1.5 liters. c An equal intake and output due to insensible losses. d A fluid loss of 0.5 liters.
A
The critical care nurse is responsible for monitoring the patient receiving continuous renal replacement therapy (CRRT). In doing so, what should the nurse do? A Assess that the blood tubing is warm to the touch. B Assess the hemofilter every 6 hours for clotting. c cover the dialysis lines to protect them from light. D Use clean technique during vascular access dressing changes.
A
The nurse is caring for a patient who is being evaluated clinically for brain death by a primary care provider. Which assessment findings by the nurse support brain death? A Absence of a corneal reflex B Unequal, reactive pupils c. Withdrawal from painful stimuli d. Core temperature of 100.8° F
A
The nurse is caring for a patient who is being turned prone as part of treatment for acute respiratory distress syndrome. The nurse understands that the priority nursing concern for this patient is which of the following? a. Management and protection of the airway. b Prevention of gastric aspiration C Prevention of skin breakdown and nerve damage D Psychological support to patient and family
A
Which patient should the nurse notify the organ procurement organization (OPO) to evaluate for possible organ donation? a. A 36-year-old patient with a Glasgow Coma Scale score of 3 with no activity on electroencephalogram A 68-year-old male admitted with unstable atrial fibrillation who has suffered a stroke A 40-year-old brain-injured female with a history of ovabairbi.acnomc/taenstcer and a Glasgow Coma Scale score of 7 A 53-year-old diabetic male with a history of unstable angina status post resuscitation
A
Why is pain control a nursing priority in patients with acute pancreatitis? a Pain increases pancreatic secretions. b The pain is caused by decreased distention of the pancreatic capsule c pain decreases the patient's metabolism d. The pain is caused by dilation of the biliary system
A
What is the most common cause of a pulmonary embolus? An amniotic fluid embolus. A deep vein thrombosis from lower extremities. A fat embolus from a long bone fracture. Vegetation that dislodges from an infected central venous catheter.
A deep vein thrombosis from lower extremities.
Complications common to patients receiving hemodialysis for acute kidney injury include which of the following? Hypotension Dysrhythmias Muscle cramps Hemolysis Air embolism
A,B
Noninvasive diagnostic procedures used to determine kidney function include which of the following? (Select all that apply.) Kidney, ureter, bladder (KUB) x-ray Renal ultrasound Magnetic resonance imaging (MRI) Intravenous pyelography (IVP) Renal angiography
A,B,C
The nurse is caring for a patient in acute respiratory failure and understands that the patient should be positioned (Select all that apply.) A high Fowler's. B side lying with head of bed elevated. C sitting in a chair. D supine with the bed flat. E prone with face turned to the left
A,B,C
The nurse is caring for a patient with cystic fibrosis (CF) and understands that treatment consists of which of the following? (Select all that apply.) A Airway clearance therapies B Antibiotic therapy C Nutritional support D Tracheostomy E Cardiac monitoring
A,B,C
What strategies are appropriate for preventing deep vein thrombosis (DVT) and pulmonary embolus (PE) in an at-risk patient? (Select all that apply.) A Graduated compression stockings B Heparin or low-molecular weight heparin C Sequential compression devices D Strict bed rest E Providing education regarding compression ultrasound
A,B,C
Which of the following statements is true about insulin and parenteral nutrition? (Select alL that apply.) a Amount of parenteral insulin is adjusted based on the previous 24-hour laboratory values. b Insulin may be added to a parenteral nutrition solution. c Subcutaneous insulin is used on a sliding scale during parenteral nutrition. d Supplemental insulin is rarely required for patients receiving parenteral nutrition. e Lingering hyperglycemia after parenteral nutrition has been stopped requires continuing insulin.
A,B,C
Which of the following are components of the Institute for Healthcare Improvement's (IHI's) ventilator bundle? (Select all that apply.) a. Interrupt sedation each day to assess readiness to extubate B Maintain head of bed at least 30 degrees elevation. C Provide deep vein thrombosis prophylaxis. D Provide prophylaxis for peptic ulcer disease. E Swab the mouth with foam swabs every 2 hours.
A,B,C,D
Which of the following are physiological effects of positive end-expiratory pressure (PEEP) used in the treatment of acute respiratory distress syndrome (ARDS)? (Select all that apply.) A Increase functional residual capacity B Prevent collapse of unstable alveoli C Improve arterial oxygenation D Open collapsed alveoli E Improve venous oxygenation
A,B,C,D
The nurse caring for a mechanically ventilated patient prepares to include which strategies to prevent ventilator-associated pneumonia should be into the patient's plan of care? A Drain condensate from the ventilator tubing away from the patient. B Elevate the head of the bed 30 to 45 degrees. C Instill normal saline as part of the suctioning procedure. D Perform regular oral care with chlorhexidine. E Administer antibiotic therapy as prescribed
A,B,D
Which statement(s) about total parenteral nutrition is (are) true? (Select all that apply.) a. Assessing fluid volume status and preventing infection are important nursing considerations. b Fingerstick glucose levels are assessed every 6 hours and prn. c Total parenteral nutrition is administered through a feeding tube and pump d Total parenteral nutrition, with added lipids, provides adequate levels of protein, carbohydrates, and fats. e Soy-based lipids should not be given if propofol is prescribed.
A,B,D,E
What are the nursing priorities for the management of acute pancreatitis? (Select all that apply.) a Managing respiratory dysfunction b Assessing and maintaining electrolyte balance c. Withholding analgesics that could mask abdominal discomfort d Stimulating gastric content motility into the duodenum e Utilizing supportive therapies aimed at decreasing gastrin release
A,B,E
When caring for the patient with upper GI bleeding, the nurse assesses for which of the following? (Select all that apply.) A Severity of blood loss B. Hemodynamic stability C. Vital signs every 30 minutes D Signs of hypervolemic shock E Necessity for fluid resuscitation
A,B,E
The family of a critically ill patient has asked to discuss organ donation with the patient's nurse. When preparing to answer the family's questions, the nurse understands which concern(s) most often influence a family's decision to donate? (Select all that apply.) A Donor disfigurement influences on funeral care B Fear of inferior medical care provided to donor C Age and location of all possible organ recipients D Concern that donated organs will not be used E Fear that the potential donor may not be deceased F Concern over financial costs associated with donation
A,B,E,F
The nurse is caring for a mechanically ventilated patient and responds to a high inspiratory pressure alarm. Recognizing possible causes for the alarm, the nurse assesses for which of the following? a Coughing or attempting to talk b Disconnection from the ventilator c Kinks in the ventilator tubing d Need for suctioning e Spontaneous breathing
A,C,D
The patient is admitted with acute kidney injury from a postrenal cause. Acceptable treatments for that diagnosis include what intervention? Bladder catheterization Increasing fluid volume intake Ureteral stenting Placement of nephrostomy tubes Increasing cardiac output
A,C,D
The patient is in the critical care unit and will receive dialysis this morning. The nurse will take which actions: A Evaluate morning laboratory results and report abnormal results. B Administer the patient's antihypertensive medications.abirb.com/test CAssess the dialysis access site and report abnormalities. D Weigh the patient to monitor fluid status. E Give all medications except for antihypertensive medications.
A,C,D
The most common reasons for initiating dialysis in acute kidney injury include which of the following? Acidosis Hypokalemia V olume overload Hyperkalemia Uremia
A,C,D,E
Presence of which substances would indicate a problem with renal function. a. Protein. b Sodium c Creatinine d Red blood cells e Uric acid
A,D,E
The nurse is assisting with endotracheal intubation of the patient and recognizes that the procedure will be done in what order? (Put a comma and space between each answer choice.) A Assess balloon on endotracheal tube for symmetry and leaks. b. Assess lung fields for bilateral expansion. c. Inflate balloon of endotracheal tube. d. Insert endotracheal tube with laryngoscope and blade e. Suction oropharynx.
A,E,D,C,B
When assessing bowel sounds, what action should the nurse take? A Using the "bell" part of the stethoscope. B Listening at least 15 minutes. C Expecting bowel sounds to be regular in rhythm. D Listening for 5 minutes before noting "absent bowel sounds"
D
In addition to residual stomach volume, what other evidence suggests feeding intolerance? Abdominal distention Absence of tympany on percussion Active bowel sounds Elevated blood glucose by fingerstick
Abdominal distention
The nurse is caring for a patient who has a peptic ulcer. To treat the ulcer and prevent more ulcers from forming, the nurse should be prepared to administer what medication? H2-histamine receptor blockers Gastrin V agal stimulation Vitamin B12
H2-histamine receptor blockers
The patient diagnosed with acute kidney injury and has been getting dialysis 3 days per week reports general malaise and is tachypneic. An arterial blood gas is ordered and shows that the patient's pH is 7.19, with a PCO2 of 30 mm Hg and a bicarbonate level of 13 mEq/L. The nurse prepares to take what action? Administer morphine to slow the respiratory rate. Prepare for intubation and mechanical ventilation. Administer intravenous sodium bicarbonate. Cancel tomorrow's dialysis session.
Administer intravenous sodium bicarbonate.
The nurse is caring for a patient admitted to the emergency department in status epilepticus. Vital signs assessed by the nurse include blood pressure 160/100 mm Hg, heart rate 145 beats/min, respiratory rate 36 breaths/min, oxygen saturation (SpO2) 96% on 100% supplemental oxygen by non-rebreather mask. After establishing an intravenous (IV) line, which order should the nurse implement first? Obtain stat serum electrolytes. Administer lorazepam. Obtain stat portable chest x-ray. Administer phenytoin.
Administer lorazepam.
The nurse is to administer 100 mg phenytoin intravenous (IV). Vital signs assessed by the nurse include blood pressure 90/60 mm Hg, heart rate 52 beats/min, respiratory rate 18 breaths/min, and oxygen saturation (SpO2) 99% on supplemental oxygen at 3 L/min by cannula. To prevent complications, what is the best action by the nurse? Administer over 2 minutes. Administer over 5 minutes. Mix medication with 0.9% normal saline. Administer via central line.
Administer over 5 minutes.
The etiology of noncardiogenic pulmonary edema in acute respiratory distress syndrome (ARDS) is related to form of damage? Alveolar-capillary membrane Left ventricle Mainstem bronchus Trachea
Alveolar-capillary membrane
The nurse is caring for a patient admitted to the ED following a fall from a 10-foot ladder. Upon admission, the nurse assesses the patient to be awake, alert, and moving all four extremities. The nurse also notes bruising behind the left ear and straw-colored drainage from the left nare. What is the most appropriate nursing action? Insert bilateral ear plugs. Monitor airway patency. Maintain neutral head position. Apply a small nasal drip pad.
Apply a small nasal drip pad.
The nurse is caring for a patient receiving peritoneal dialysis. the patient suddenly reports experiencing abdominal pain and chills. The patient's temperature is elevated. The nurse should take what action? Assess peritoneal dialysate return. Check the patient's blood sugar. Evaluate the patient's neurological status. Inform the provider of probable visceral perforation
Assess peritoneal dialysate return.
What term is used to describe an increase in blood urea nitrogen (BUN) and serum creatinine? Oliguria Azotemia Acute kidney injury Prerenal disease
Azotemia
A 53-year-old, 80-kg patient is admitted to the cardiac surgical intensive care unit after cardiac surgery. The nurse notifies the physician, who orders an ABG analysis, electrolyte levels, and a portable chest x-ray study. How does the nurse interpret the following blood gas levels? pH 7.28 PaCO2 46 mm Hg Bicarbonate 22 mEq/L PaO2 58 mm Hg O2 saturation 88% A Hypoxemia and compensated respiratory alkalosis B Hypoxemia and uncompensated respiratory acidosis C Normal arterial blood gas levels D Normal oxygen level and partially compensated metabolic acidosis
B
The nurse caring for an elderly patient who was admitted with renal insufficiency realizes that with advance age often comes declining renal function. What is an expected laboratory finding for this patient? A. An increased glomerular filtration rate (GFR) B A normal serum creatinine level C Lower serum levels of prescribed medications D Hypokalemia
B
The nurse is to assist in performing bedside endoscopy on a patient. To prevent respiratory complications, the nurse places the patient in what position a Supine in Trendelenburg position. b A left lateral reverse Trendelenburg position. c. Flat with the feet elevated. d. A semi-fowler's position.
B
The patient has elevated blood urea nitrogen (BUN) and serum creatinine levels with a normal BUN/creatinine ratio. What do these levels most likely indicate? a Increased nitrogen intake b Acute kidney injury, such as acute tubular necrosis (ATN) c Hypovolemia d Fluid resuscitation
B
The patient is admitted for GI bleeding of unknown cause. Before ordering endoscopy, the health care provider (PCP) orders octreotide to be given intravenously. What is the purpose of this medication? a. To increase portal pressure and improve liver function b To decrease splanchnic blood flow and portal pressure c To vasodilate the splanchnic arteriolar bed d To increase blood flow in the liver's collateral circulation
B
The primary care provider orders fosphenytoin, 1.5 g intravenous (IV) loading dose for a 75-kg patient in status epilepticus. What is the most important action by the nurse? a the primary care provider to discuss the order. b Administer drug at a slow infusion rate c. Mix medication with 0.9% normal saline. d. Administer via central line.
B
The transplant clinic coordinator is evaluating relatives of a patient with end-stage renal disease, whose blood type is A positive, for suitability as a living donor for kidney transplantation. Which family member best qualifies for evaluation? A A 65-year-old brother with a history of hypertension; blood type A positive B A 35-year-old female with a history of food allergies; blood type O negative C A 14-year-old son, otherwise healthy with no history; blood type B negative D A 70-year-old mother, with a history of sinus infections; blood type A positive
B
A family member approaches the nurse caring for their gravely ill son and states, "We want to donate our son's organs." What is the best action by the nurse? A Arrange a multidisciplinary meeting with physicians. B Consult the hospital's ethics committee for a ruling. C Notify the organ procurement organization (OPO). D Obtain family consent to withdraw life support.
C
The nurse is caring for a critically ill patient with respiratory failure who is being treated with mechanical ventilation. As part of the patient's care to prevent stress ulcers, the nurse would provide what intervention? (Select all that apply.) a. Vagal stimulation b Proton pump inhibitors c Anticholinergic drugs d Antacids e Cholinergic drugs
B,C,D
Vascular sounds such as bruits, heard in the abdomen during physical assessment, may indicate which of the following? a Obstructed portal circulation b Dilated vessels c. Tortuous vessels d Constricted vessels e Presence of an abscess
B,C,D
Which statement is true regarding oral care for the prevention of ventilator-associated pneumonia (VAP)? (Select all that apply.) a. Tooth brushing is performed every 2 hours for the greatest effect. b. Implementing a comprehensive oral care program is an intervention for preventing VAP c. Oral care protocols should include oral suctioning and brushing teeth. d Protocols that include chlorhexidine gluconate have been effective in preventing VAP e Avoid brushing teeth for two hours after chlorhexidine use.
B,C,D
The patient is admitted with end-stage liver disease. The nurse evaluates the patient for which of the following? (Select all that apply.) a Hypoglycemia b Malnutrition c Ascites d Hypercoagulation e Disseminated intravascular coagulation
B,C,E
Which intervention(s) is (are) critical during intravenous lipid administration? (Select all that apply.) A Assessing glucose levels B Changing the tubing every 24 hours C Holding lipids when administering antibiotics through the same line D Monitoring triglyceride levels E Maintaining elevation of the head of the bed
B,D
The correct order of actions for a patient starting enteral nutrition with a feeding tube is: (Put a comma and space between each answer choice.) a. Initiate tube feeding b. Insert feeding tube c. Flush tube to verify patency d. Obtain chest radiograph e. Assess residuals
B,D,C,A,E
A patient is being mechanically ventilated in the synchronized intermittent mandatory ventilation mode at a rate of 4 breaths/min. Spontaneous reabsiprbi.rcaotmio/tensst are 12 breaths/min. After receiving a dose of morphine sulfate, respirations decrease to 4 breaths/min. Which acid-base disturbance will likely occur? A Metabolic acidosis B Metabolic alkalosis C Respiratory acidosis D Respiratory alkalosis
C
A patient's status deteriorates and mechanical ventilation is now required. The pulmonologist wants the patient to receive 10 breaths/min from the ventilator but wants to encourage the patient to breathe spontaneously in between the mechanical breaths at his own tidal volume. This mode of ventilation is referred to by what term? A Assist/control ventilation b Controlled ventilation c Intermittent mandatory ventilation d Positive end-expiratory pressure
C
Conditions that produce acute kidney injury by directly acting on functioning kidney tissue are classified as intrarenal. What is the most common intrarenal condition that produces such a kidney injury? a Prolonged ischemia. b Exposure to nephrotoxic substances. c. Acute tubular necrosis (ATN). d. Hypotension for several hours.
C
Continuous venovenous hemodialysis is used for what purpose? a Remove fluids and solutes through the process of convection. b Remove plasma water in cases of volume overload. c Remove plasma water and solutes by adding dialysate d Combine ultrafiltration, convection and dialysis
C
Intrapulmonary shunting refers to what outcome? a. Alveoli that are not perfused. b blood that is shunted from the left side of the heart to the right and causes heart failure. c. Blood that is shunted from the right side of the heart to the left without oxygenation. d. Shunting of blood supply to only one lung.
C
The liver plays what major role in homeostasis? a Synthesizing factor I but not factor II. b Synthesizing clotting factors without the need for vitamin K. c Removing active clotting factors from the circulation. d. Synthesizing factor II but not factor I.
C
The nurse assessing a patient with a new arteriovenous fistula, does not hear a bruit or feel a thrill. Pulses distal to the fistula are not palpable. The nurse should take what action? a Reassess the patient in an hour. b Raise the arm above the level of the patient's heart. c. Notify the primary health care provider immediately. d. Apply warm packs to the fistula site and reassess.
C
The nurse is assessing a patient who is admitted with abdominal pain. To detect abdominal masses, the nurse should engage in what action? A Observe for skin pigmentation and discolorations. B Looks for pulsations originating from the vena cava. C Has the patient take a deep breath. D Watches for signs of pain and distention.
C
The nurse is caring for a patient in the critical care unit who, after being declared brain dead, rate 12 breaths/min via assist/control ventilation. The oxygen saturation (SpO2) is 99% and core temperature 93.8° F. Which primary care provider order should the nurse implement first? A Apply forced air warming device to keep temperature > 96.8° F B Obtain basic metabolic panel every 4 hours until surgery C Begin phenylephrine (Neo-Synephrine) for systolic BP < 90 mm Hg D Draw arterial blood gas every 4 hours until surgery
C
The nurse is caring for a patient who has a temporary percutaneous dialysis catheter in place. In caring for this patient, the nurse should take what action? a. Apply a sterile gauze dressing to maintain sterility. b Replace the transparent dressing every 10 days to prevent manipulation. c Assess the catheter site for redness and/or swelling. d Use the catheter for drawing blood samples to reduce pabaitribe.cnotmd/teistcomfort.
C
The nurse is caring for a patient with active GI bleeding. Estimated blood loss is 1,000 mL. Which of the following assessments would the nurse expect to find with this amount of blood loss? a All vital signs would expect to be normal with this amount of blood loss. b Oral temperature of 103° F. c Heart rate > than 120 beats per minute. d Systolic blood pressure of 120 mm Hg.
C
The patient getting hemodialysis for the second time reports a headache and nausea and, a little later, of becoming confused. The nurse realizes these are symptoms of what possible complication? a Dialyzer membrane incompatibility b A shift in potassium levels c Dialysis disequilibrium syndrome d Hypothermia
C
The patient has a hemoglobin of 8.5 g/dL and hematocrit of 27%. The nurse administers 2 units of packed red blood cells to the patient and repeats the lab work a few hours later. The new hemoglobin and hematocrit would be expected to be what？ A Hemoglobin 7.5 g/dL and hematocrit 25% B Hemoglobin 9.5 g/dL and hematocrit 29% C Hemoglobin 10.5 g/dL and hematocrit 32% D Hemoglobin 12.5 g/dL and hematocrit 36%
C
The patient has just returned from having an arteriovenous fistula placed. The patient asks, "When will they be able to use this and take this other catheter out?" The nurse should provide what response? A "It can be used immediately so the catheter can come out anytime." B "It will take 2 to 4 weeks to heal before it can be used." c. "The fistula will be usable in about 4 to 6 weeks." d. "The fistula was made using graft material so it depends on the manufacturer.
C
When assessing the patient's bowel sounds, the nurse engages in what action? A Listening to the abdomen after palpation is done. B Placing the patient in a relaxed prone position. C Listens to bowel sounds before palpation. D Placing a pillow over the patient's knees.
C
While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the patient's left naris. What is the best nursing action? a Have the patient blow the nose until clear. b Insert bilateral cotton nasal packing. c. Place a nasal drip pad under the nose. d. Suction the left nares until the drainage clears.
C
While neuromuscular blocking agents are used in the management of some ventilated patients what is their primary mode of action? a. Analgesiab. Anticonvulsant c. Paralysisd. Sedation
C
The nurse is caring for a mechanically ventilated patient and is charting outside the patient's room when the ventilator alarm sounds. What is the priority order for the nurse to complete these actions? (Put a comma and space between each answer choice.) a. Check quickly for possible causes of the alarm that can be fixed. b. After troubleshooting, connect back to mechanical ventilator and reassess patient. c. Go to patient's bedside. d. Manually ventilate the patient while getting respiratory therapist
C,A,D,B
The nurse is preparing to monitor intracranial pressure (ICP) with a fluid-filled monitoring system. The nurse understands which principles and/or components to be essential when implementing ICP monitoring? (Select all that apply.) a. Use of a heparin flush solution b Manually flushing the device "prn" c Recording ICP as a "mean" value d Use of a pressurized flush system e Zero referencing the transducer system
C,E
The primary care provider orders the following mechanical ventilation settings for a patient who weighs 75 kg and whose spontaneous respiratory rate is 22 breaths/min. What arterial blood gas abnormality may occur if the patient continues to be tachypneic at these ventilator settings? Settings:Tidal volume: 600 mL (8 mL per kg) FiO2: 0.5 Respiratory rate: 14 breaths/min Mode assist/control Positive end-expiratory pressure: 10 cm H2O Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
D
Trends in nutritional management of the patient with pancreatitis are changing regarding what aspect of care? a. Patients with pancreatitis must eat nothing in order to prevent release of secretin b Nasogastric suction is essential in treating patients with pancreatitis. c A nasogastric tube is no longer required to treat patients with ileus. d Immediate oral feeding in patients with mild pancreatitis may help recovery
D
A patient is being mechanically ventilated in the synchronized intermittent mandatory ventilation mode at a rate of 4 breaths/min. Spontaneous respirations are 12 breaths/min. ThE patient receives a dose of morphine sulfate, and now respirations decrease to 4 breaths/min. What adjustments may need to be made to the patient's ventilator settings? A Add positive end-expiratory pressure (PEEP). B Add pressure support. C Change to assist/control ventilation at a rate of 4 breaths/mis D crease the synchronized intermittent mandatory ventilation respiratory rate.
D
A patient is receiving enteral tube feedings and has developed drug-nutrient interactions. The nurse recognizes which drug as having the potential for causing drug-nutrient reactions? a. Aspirinb. B Enoxaparin c. Ibuprofen d. Phenytoin
D
After coronary artery bypass graft surgery a patient is transported to the surgical intensive care unit at noon and placed on mechanical ventilation. How should the nurse interpret the patient's initial arterial blood gas levels?pH 7.31 PaCO2 48 mm Hg Bicarbonate 22 mEq/L PaO2 115 mm Hg O2 saturation 99% a Normal arterial blood gas levels with a high oxygen level b Partly compensated respiratory acidosis, normal oxygen c Uncompensated metabolic acidosis with high oxygen levels d Uncompensated respiratory acidosis; hyperoxygenated
D
In assessing the patient reporting abdominal pain, it is important for the nurse to understand that fact? A Pain receptors in the abdomen are more likely to be localized. B Pain of a peptic ulcer is easily distinguished from that of heart attack. C Visceral pain often leads to tachycardia and hypertension. D Increasing intensity of pain is always significant.
D
The nurse admits a patient to the emergency department with new onset of slurred speech and right-sided weakness. What is the priority nursing action to assure effective care? a Assess for the presence of a headache. bAssess the patient's general orientation. c. Determine the patient's drug allergies. d. Determine the time of symptom onset.
D
The nurse caring for a patient with acute pancreatitis implements what intervention in order to provide adequate pain control? a Suggests that the patient receive epidural analgesia. b Provides oral pain medication on an "as needed" (PRN) basis. c Removes any nasogastric tubes. d Administers pain medication on a routine schedule
D
The nurse is caring for a mechanically ventilated patient with a sustained ICP of 18 mm Hg. The nurse needs to perform an hourly neurological assessment, suction the endotracheal tube, perform oral hygiene care, and reposition the patient to the left side. What is the best action by the nurse? a Hyperoxygenate during endotracheal suctioning. b Elevate the patient's head of the bed 30 degrees. c Apply bilateral heel protectors after repositioning. d Provide rest periods between nursing interventions.
D
The nurse is caring for a mechanically ventilated patient. The primary care providers are considering performing a tracheostomy because the patient is having difficulty weaning from mechanical ventilation. Related to tracheostomy, the nurse understands which of the following? a Patient outcomes are better if the tracheostomy is done within a week of intubation. b Percutaneous tracheostomy can be done safely at the bedside by the respiratory therapist. c. Procedures performed in the operating room are associated with fewer complications. d. The greatest risk after a percutaneous tracheostomy is accidental decannulation.
D
The nurse is caring for a patient who has a Sengstaken-Blakemore tube in place. In caring for this patient, the nurse must take what action regarding the tube? a Maintain as little traction as possible b Apply external traction using side rail of the bed. c Deflate the gastric esophageal balloons simultaneously. d Deflate the esophageal balloon before the gastric balloon.
D
The patient being admitted to the hospital takes an over-the-counter supplement of Vitamin D and is concerned because the primary care provider (PCP) did not order that vitamin D to be given in the hospital. What explanation should the nurse? a The body does not store vitamins so the doctor will have to be called. b The kidneys will produce enough vitamin D and that supplements are not needed. c. Over-the-counter supplements are never given in the hospital. d. Vitamins D is stored in the liver with a 10-month supply to prevent deficiency.
D
The patient is admitted with acute pancreatitis. The nurse should be prepared to take what action? a Assess pain level because pancreatic pain is unique in character. b Examine laboratory values for low amylase levels. c Expect lipase levels to decrease within 24 hours. d Evaluate C-reactive protein as a gauge of severity.
D
What is an advantage of peritoneal dialysis? A Peritoneal dialysis is time intensive. B It has a decreased risk of peritonitis. C Any biochemical disturbances are corrected rapidly. D The danger of hemorrhage is minimal.
D
Which of the following patients is at the highest risk for hyperosmolar hyperglycemic syndrome? a An 18-year-old college student with type 1 diabetes who exercises excessively b A 45-year-old woman with type 1 diabetes who forgets to take her insulin in the morning c A 75-year-old man with type 2 diabetes and coronary artery disease who has recently started on insulin injections. d An 83-year-old, long-term care resident with type 2 diabetes and advanced Alzheimer's disease who recently developed influenza
D
A patient with a history of emphysema, diabetes, and hyperlipidemia is in the critical care unit on a ventilator. The nutrition assessment notes that the patient has a protein and vitamin deficiency and is underweight. Which formula for nutritional assessment is most appropriate? Renal specific formula Higher protein formula High medium-chain triglyceride formula Lactose-free formula
Higher protein formula
A patient's ventilator settings are adjusted to treat hypoxemia. The fraction of inspired oxygen is increased from.60 to.70, and the positive end-expiratory pressure is increased from 10 to 15 cm H2O. Shortly after these adjustments, the nurse notes that the patient's blood pressure drops from 120/76 mm Hg to 90/60 mm Hg. What is the most likely cause of this decrease in blood pressure? a Decrease in cardiac output b Hypovolemia c Increase in venous return d Oxygen toxicity
Decrease in cardiac output
What is the most common cause of acute kidney injury (AKI) in critically ill patients? Sepsis Fluid overload Medications Hemodynamic instability
Sepsis
A patient is being fed through a nasogastric tube placed in the stomach. The nurse would carry out which intervention to minimize aspiration risk? Add blue dye to the formula. Assess the residual every hour. Elevate the head of the bed 30 degrees. Provide feedings via continuous infusion.
Elevate the head of the bed 30 degrees
What are the risks of total parenteral nutrition? (Select all that apply.) Diarrhea Elevated blood sugar Infection at the catheter site Volume overload Aspiration
Elevated blood sugar Infection at the catheter site Volume overload
The nurse is caring for a mechanically ventilated patient following bilateral lung transplantation. When planning the care of this patient, what is the priority nursing intervention? Thirty-degree elevation of head of bed Endotracheal suctioning as needed Frequent side to side repositioning Sequential compression stockings
Endotracheal suctioning as needed
The patient has been admitted to the hospital with nausea and vomiting that started 5 days earlier with a blood pressure of 80/44 mm Hg and heart rate of 122 beats/min. The patient reports having not voided in 8 hours but there is no distention of the bladder. The nurse anticipates what "stat" order? A blood transfusion Fluid replacement with 0.45% saline Infusion of an inotropic agent An antiemetic
Fluid replacement with 0.45% saline
While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mm Hg and a CPP of 85 mm Hg. What is the best interpretation by the nurse? Both pressures are high. Both pressures are low. ICP is high; CPP is normal. ICP is high; CPP is low.
ICP is high; CPP is normal.
How does malnutrition contributes to infection risk? Hampering normal gastrointestinal motility Impairing immune function Increasing blood glucose Increasing drug interactions
Impairing immune function
The nurse is caring for a patient admitted with bacterial meningitis. Vital signsassessed by the nurse include blood pressure 110/70 mm Hg, heart rate 110 beats/min, respiratory rate 30 beats/min, oxygen saturation 95% on supplemental oxygen at 3 L/min, and a temperature 103.5° F. What is the priority nursing action? Elevate the head of the bed 30 degrees. Keep lights dim at all times. Implement seizure precautions. Maintain bed rest at all times.
Implement seizure precautions.
A patient with acute pancreatitis is started on parenteral nutrition. The student nurse listed possible interventions for this patient. Which intervention needs correction before finalizing the plan of care? Change the intravenous tubing every 24 hours. Infuse antibiotics through the intravenous line. Monitor the blood glucose every 6 hours. Monitor the fluid and electrolyte balance.
Infuse antibiotics through the intravenous line
What is a strategy for preventing thromboembolism in patients at risk who cannot take anticoagulants? Administration of two aspirin tablets every 4 hours. Infusion of thrombolytics. Insertion of a vena cava filter. Subcutaneous heparin administration every 12 hours.
Insertion of a vena cava filter.
The patient receiving hemodialysis 3 days a week is 74 inches tall and weighs 100 kg. In planning the care for this patient, the nurse provides what nutritional recommendation? Intaking 2500 to 3500 kcal diet per day Limiting protein intake to less than 50 grams per day Encouraging potassium intake of 10 mEq per day Limiting fluid intake of less than 500 mL per day
Intaking 2500 to 3500 kcal diet per day
With sudden cessation of renal function, all body systems are affected by the inability to maintain fluid and electrolyte balance and eliminate metabolic waste. In critically ill patients, what statement regarding renal dysfunction is true? a It is a very rare problem. b It affects nearly two thirds of patients c. It has a low mortality once renal replacement therapy has been initiated. d. It has little effect on morbidity, mortality, or quality of life.
It affects nearly two thirds of patients
The patient reporting severe flank pain when urinating. has a urinalysis that shows sediment and crystals along with a few bacteria. This information suggestions what about the nature of the condition? It is prerenal. It is postrenal. It is intrarenal It is not renal related.
It is postrenal.
The patient's potassium level is 7.0 mEq/L. Besides dialysis, which of the following actually reduces plasma potassium levels and total body potassium content safely in a patient with renal dysfunction? Kayexalate Kayexalate with sorbitol Regular insulin Calcium gluconate
Kayexalate
What risk is the rationale for the recommendation of endotracheal rather than nasotracheal intubation? a Basilar skull fracture b Cervical hyperextension c Impaired ability to "mouth" words d Sinusitis and infection
Sinusitis and infection
The nurse admits a patient to the emergency department (ED) with a suspected cervical spine injury. What is the priority nursing action? Keep the neck in the hyperextended position. Maintain proper head and neck alignment. Prepare for immediate endotracheal intubation. Remove cervical collar upon arrival to the ED.
Maintain proper head and neck alignment.
The nurse receives a patient from the emergency department following a closed head injury. After insertion of an ventriculostomy, the nurse assesses the following vital signs: blood pressure 100/60 mm Hg, heart rate 52 beats/min, respiratory rate 24 breaths/min, oxygen saturation (SpO2) 97% on supplemental oxygen at 45% via Venturi mask, Glasgow Coma Scale score of 4, and intracranial pressure (ICP) of 18 mm Hg. Which order should the nurse institute first? Mannitol 1 g intravenous Portable chest x-ray Seizure precautions Ancef 1 g intravenous
Mannitol 1 g intravenous
The nurse is concerned that a patient is at increased risk of developing a pulmonary embolus and develops a plan of care for prevention to include which intervention? Antiseptic oral care Bed rest with head of bed elevated Coughing and deep breathing Mobility
Mobility
The nurse is caring for a patient 3 days following a complete cervical spine injury at the C3 level. The patient is in spinal shock. Following emergent intubation and mechanical ventilation, what is the priority nursing action? Maintain body temperature. Monitor blood pressure. Pad all bony prominences. Use proper hand washing.
Monitor blood pressure.
The patient is to start total parenteral nutrition (TPN). The nurse knows to prepare which site for catheter insertion? Basilic vein Femoral artery Radial artery Subclavian vein
Subclavian vein
The nurse assesses a patient with a skull fracture and notes a Glasgow Coma Scale score of 3. Additional vital signs assessed by the nurse include blood pressure 100/70 mm Hg, heart rate 55 beats/min, respiratory rate 10 breaths/min, oxygen saturation (SpO2) 94% on oxygen at 3 L per nasal cannula. What is the priority nursing action? Monitor the patient's airway patency. Elevate the head of the patient's bed. Increase supplemental oxygen delivery. Support bony prominences with padding.
Monitor the patient's airway patency.
A patient presents to the emergency department in acute respiratory failure secondary to community-acquired pneumonia. The patient has a history of chronic obstructive pulmonary disease. The nurse anticipates which treatment to facilitate ventilation? a. Emergency tracheostomy and mechanical ventilation b Mechanical ventilation via an endotracheal tube c Noninvasive positive-pressure ventilation (NPPV) d Oxygen at 100% via bag-valve-mask device
Noninvasive positive-pressure ventilation (NPPV)
What event triggers acute kidney injury from post renal etiology? Obstruction of the flow of urine. Conditions that interfere with renal perfusion. Hypovolemia or decreased cardiac output. Conditions that act directly on functioning kidney tissue.
Obstruction of the flow of urine.
A patient has been admitted to the critical care unit after a stroke. After "failing" a swallow study, the patient is placed on enteral feedings. Following placement of a nasogastric tube for tube feeding, what is the next critical step? Administer medications. Cap off and wait 24 hours before starting feedings. Obtain a chest radiograph. Start the tube feeding.
Obtain a chest radiograph.
Which acid-base disturbances commonly occurs with the hyperventilation and impaired gas exchange seen in severe exacerbation of asthma? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Respiratory acidosis
In assessing a patient, the nurse understands that what symptomology is an early sign of hypoxemia? Clubbing of nail beds Cyanosis Hypotension Restlessness
Restlessness
What statement is true about calorie-dense feedings? (Select all that apply.) They are most useful in heart failure and liver disease. They are most useful in malabsorption syndromes. They contain 2 kcal/mL and 70 g protein/L. They include increased fiber. They are especially good for patients with lung disease
They are most useful in heart failure and liver disease. They contain 2 kcal/mL and 70 g protein/L.
A patient is being ventilated and has been started on enteral feedings with a nasogastric small-bore feeding tube. What is the primary reason the nurse must frequently assess tube placement? To assess for paralytic ileus To maintain the patency of the feeding tube To monitor for skin breakdown on the nose To prevent aspiration of the feedings
To prevent aspiration of the feedings
A patient who is receiving continuous enteral feedings has just vomited 250 mL of milky green fluid. What is the most likely cause of the vomiting? A bowel obstruction Developed an ileus Gastrointestinal bleeding Tube feeding intolerance
Tube feeding intolerance
18. The patient is admitted with upper GI bleeding following an episode of forceful retching associated with excessive alcohol intake. The nurse suspects a Mallory-Weiss tear and is aware of what related fact? A A Mallory-Weiss tear is a longitudinal tear in the gastroesophageal mucosa. B Treatment includes prescribing chewable aspirin. C The bleeding is self-limiting with little actual blood loss. D The bleeding is not usually associated with alcohol intake or retching.
a
A patient diagnosed with severe pancreatitis is orally intubated and on mechanical ventilation. The patient's calcium level this morning was 5.5 mg/dL. The nurse notifies the provider and should have taken what action? a Places the patient on seizure precautions. b Prepare for the provider to come and remove the endotracheal tube. c Withhold any further calcium treatments. d Place an oral airway at the bedside.
a
After gastric bypass surgery, the patient is getting vitamin B12 via injection. The patient asks why the vitamin can't be given by mouth. What explanation should the nurse provide? a The patient may not have enough intrinsic factor for normal absorption. b The patient would have to drink water, and the small intestine can't handle water. c The vitamin is absorbed in the upper part of the small bowel and would travel too fast. d. All vitamins are absorbed in the terminal ileum and it would take too long for B 12
a
Continuous venovenous hemofiltration is used for what purpose? a Remove fluids and solutes through the process of convection. b Remove plasma water in cases of volume overload. c Remove plasma water and solutes by adding dialysate. d. Combine ultrafiltration, convection and dialysis.
a
During rounds, the primary care provider (PCP) alerts the team that proning is being considered for a patient with acute respiratory distress syndrome. The nurse should have what understanding about the benefit of proning? a It is an optional treatment if the PaO2/FiO2 ratio is less 100. b It presents less of a risk for skin breakdown because the patient is face down. c It is possible with minimal help from co-workers. d It is used to provide continuous lateral rotational turning
a
How does the liver detoxify the blood? a Converting fat-soluble compounds to water-soluble compounds. b Converting water-soluble compounds to fat-soluble compounds. c Excreting fat-soluble compounds in feces. d Metabolizing inactive toxic substances to active forms.
a
Renin plays a role in blood pressure regulation by what process? a. Activation of the renin-angiotensin-aldosterone cascade. b Suppression of angiotensin production. c Decreasing of sodium reabsorption. d Inhibition of aldosterone release.
a
Slow continuous ultrafiltration is also known as isolated ultrafiltration and is used for what purpose? a Remove plasma water in cases of volume overload. b Remove fluids and solutes through the process of convection c Remove plasma water and solutes by adding dialysate. d Combine ultrafiltration, convection and dialysis.
a
The nurse admits a patient to the critical care unit following a motorcycle crash. Assessment findings by the nurse include blood pressure 100/50 mm Hg, heart rate 58 beats/min, respiratory rate 30 breaths/min, and temperature of 100.5° F. The patient is lethargic, responds to voice but falls asleep readily when not stimulated. which nursing action is most important to include in this patient's plan of care? a Frequent neurological assessments b Side to side position changes c Range of motion to extremities d Frequent oropharyngeal suctioning
a
The nurse caring for a patient who has undergone major abdominal surgery notices that the patient's urine output has been less than 20 mL/hour for the past 2 hours. At 0200 in the morning the patient's blood pressure is 100/60 mm Hg, and the pulse is 110 beats per minute. Previously, the pulse was 90 beats per minute with a blood pressure of 120/80 mm Hg. The nurse should take what action? a. Contact the primary health care provider and expect an order for a normal saline bolus. b Wait until 0900 when the provider makes rounds to report the assessment findings. c Continue to evaluate urine output for 2 more hours. d Ignore the urine output, as this is most likely postrenal in origin.
a
The nurse has just received a patient from the emergency department with an admitting diagnosis of bacterial meningitis. To prevent the spread of nosocomial infections to other patients, what is the best action by the nurse? a. Implement droplet precautions upon admission. b Wash hands thoroughly before leaving the room. c Scrub the hub of all central line ports prior to use. d Dispose of all bloody dressings in biohazard bags.
a
The nurse is caring for a patient who is being treated for peptic ulcer disease. Suddenly, the patient yells, "my abdomen is killing me".When the nurse notes that the patient's abdomen is rigid should action should be taken next? a Call the health care provider (PCP) immediately. b Give the patient pain medication. c Remove the NG tube. d Give the patient an antacid.
a
The nurse is caring for a patient who is mechanically ventilated. The nurse understands that what statement should be considered when determining appropriate nursing interventions? a Communication with intubated patients is often difficult. b Controlled ventilation is the preferred mode for most patients. c Patients with chronic obstructive pulmonary disease wean easily from mechanical ventilation. d Wrist restraints are applied to all patients to avoid self-extubation.
a
The nurse is caring for a patient who is passing bright red blood rectally. The nurse should expect to insert a nasogastric tube for what purpose? A Rule out massive upper GI bleeding. b Detect the presence of melena in the stomach. c Visually determine the presence of occult bleeding. d Obtain samples for guaiac to confirm current bleeding.
a
The nurse is caring for a patient who is receiving several cardiac medications designed to stimulate the sympathetic nervous system, as well as vitamin b 12 andH2 blocker. The nurse should do take which of the following actions? a. Assess for signs of peptic ulcer. b Be watchful for increased saliva production. c valuate for a decrease in potassium level. d Give the patient medications to prevent anemia.
a
The nurse responds to a high heart rate alarm for a patient in the neurological intensive care unit. The nurse arrives to find the patient sitting in a chair experiencing a tonic-clonic seizure. What is the best nursing action? a Assist the patient to the floor and provide soft head support. b Insert a nasogastric tube and connect to continuous wall suction. c Open the patient's mouth and insert a padded tongue blade. d Restrain the patient's extremities until the seizure subsides.
a
The patient admitted with pancreatitis presents with severe ascites. In caring for this patient, the nurse should take what action? a Monitor the patient's blood pressure and evaluate for dehydration b Restrict intravenous and oral fluid intake because of fluid shifts. c Avoid the use of colloid IV solutions in managing the patient's fluid status. d Only use crystalloid fluids to prevent IV lines from clotting.
a
The patient diagnosed with acute respiratory distress syndrome (ARDS) would exhibit which symptom? a Decreasing PaO2 levels despite increased FiO2 administration b Elevated alveolar surfactant levels c Increased lung compliance with increased FiO2 administration d Respiratory acidosis associated with hyperventilation
a
The patient has a Glasgow Coma Scale (GCS) score of 3 and discussions have been held with the family about withdrawing life support. Which statement by the nurse best describes requirements that must be met to sustain Centers for Medicare and Medicaid Services (CMS) Conditions of Participation? a "I need to notify the organ procurement organization OPO of my patient's impending death." b "I will contact the physician to obtain informed consent for organ donation." c "The charge nurse will notify organ procurement organization OPO once the patient has been pronounced brain dead." d "I need the physician to evaluate my patient's suitability for organ donation."
a
The patient is admitted reporting generalized fatigue and has a low hemoglobin and hematocrit (anemia). The patient denies vomiting and states that last bowel movement was earlier that day was normal in color and consistency. However, because GI blood loss can be a cause of anemia, the nurse should expect to take what action? a Obtain a stool sample for guaiac testing. b Chart that the patient reports the presence of melena in stool. c Inspect the patient's next stool for the presence of coffee-ground contents d Obtain guaiac positive stools only if bleeding appears current.
a
The patient is being treated for an H. pylori infection with proton pump inhibitor,metronidazole, and tetracycline but is not responding. The nurse expects that what action to be appropriate? a Bismuth will be added to the current triple therapy. b A 6-day course of levofloxacin may be used. The tetracycline will be discontinued. d. The proton pump inhibitor will be changed to a higher dose
a
The patient is getting neomycin for treatment of hepatic encephalopathy. While the patient is receiving this medication, it is especially important that the nurse that what action? a Evaluate renal function studies daily. b Give the medication every 12 hours. c. Evaluate liver studies for signs of neomycin-induced damage. d. Obtain stool guaiac tests to ensure that pathogens are being destroyed.
a
The patient is in need of immediate hemodialysis, but has no vascular access. The nurse prepares the patient for what intervention? a Insertion of a percutaneous catheter at the bedside. b Insertion a percutaneous tunneled catheter at the bedside. c Creation of an arteriovenous fistula. abirb.com/test d Creation of an arteriovenous graft.
a
When it is noted that a patient's endotracheal tube is not secured tightened, he respiratory care practitioner assists the nurse in taping the tube. After the tube is retaped, the nurse auscultates the patient's lungs and notes that the breath sounds over the left lung fields are absent. The nurse suspects is the cause of this finding? a The endotracheal tube is in the right mainstem bronchus. b The patient has a left pneumothorax. c The patient has aspirated secretions during the d The stethoscope earpiece is clogged with wax.
a
Which of the following devices is best suited to deliver 65% oxygen to a patient who is spontaneously breathing? a Face mask with non-rebreathing reservoir b Low-flow nasal cannula c Simple face mask d Venturi mask
a
Which patient being cared for in the emergency department should the charge nurse evaluate first? a A patient with a complete spinal injury at the C5 dermatome level b A patient with a Glasgow Coma Scale score of 15 on 3-L nasal cannula c. An alert patient with a subdural bleed who is complaining of a headache d. An ischemic stroke patient with a blood pressure of 190/100 mm Hg
a
Which statement is true regarding venous thromboembolism (VTE) and pulmonary embolus (PE)? a PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk factors for VTE. b Bradycardia and hyperventilation are classic symptoms of PE. c Dyspnea, chest pain, and hemoptysis occur in nearly all patients with PE. dMost critically ill patients are at low risk for VTE and PE and do not require prophylaxis.
a
In an unconscious patient, eye movements are tested by the oculocephalic response. Which statements regarding the testing of this reflex are true? (Select all that apply.) a. Doll's eyes absent indicate a disruption in normal brainstem processing. b Doll's eyes present indicate brainstem activity. c Eye movement in the opposite direction as the head when turned indicates an intact reflex. d Eye movement in the same direction as the head when turned indicates an intact reflex. e Increased intracranial pressure (ICP) is a contraindication to the assessment of this reflex .f. Presence of cervical injuries is a contraindication to the assessment of this reflex.
a,b,c,e,f
The nurse is caring for a patient admitted with new onset of slurred speech, facial droop, and left-sided weakness 8 hours ago. Diagnostic computed tomography scan rules out the presence of an intracranial bleed. Which actions are most important to include in the patient's plan of care? (Select all that apply.) a Make frequent neurological assessments. b Maintain CO2 level at 50 mm Hg. c Maintain MAP less than 130 mm Hg. d Prepare for thrombolytic administration. e Restrain affected limb to prevent injury.
a,c
What are the diagnostic criteria for acute respiratory distress syndrome (ARDS)? (Select all that apply.) a Bilateral infiltrates on chest x-ray study b Decreased cardiac output abirb.com/test c PaO2/FiO2 ratio of less than 200 d Pulmonary artery occlusion pressure (PAOP) of more than 18 mm Hg e Acute onset within 7 days of clinical insult
a,c
Infection by Helicobacter pylori bacteria is a major cause of what type of ulcer? a. Duodenal b. Cushing's c. Curling's d. Stress
a. Duodenal
A 53-year-old, 80-kg patient is admitted to the cardiac surgical intensive care unit after cardiac surgery.Pulmonary artery pressures are elevated. The nurse suctions the patient and obtains pink, frothy secretions. Loud crackles are audible throughout lung fields. The nurse notifies the physician, who orders an ABG analysis, electrolyte levels, and a portable chest x-ray study. In comambirubn.ciocma/teinstg with the physician, which statement indicates the nurse understands what is likely occurring with the patient? a "May we have an order for cardiac enzymes? This patient is exhibiting signs of a myocardial infarction." b "My assessment indicates potential fluid overload." c "The patient is having frequent PVCs that are compromising the cardiac output." d The patient is having a hypertensive crisis; what medications would you like to order?"
b
A 65-year-old patient admitted to the progressive care unit with a diagnosis of community-acquired pneumonia, has a history of chronic obstructive pulmonary disease and diabetes. A set of arterial blood gases obtained on admissiaobnirbw.coitmh/oteust supplemental oxygen shows pH 7.35; PaCO2 55 mm Hg; bicarbonate 30 mEq/L; PaO2 65 mm Hg. These blood gases reflect what condition? a Hypoxemia and compensated metabolic alkalosis. b Hypoxemia and compensated respiratory acidosis. c Normal oxygenation and partly compensated metabolic alkalosis. d Normal oxygenation and uncompensated respiratory acidosis.
b
A PaCO2 of 48 mm Hg is associated with what outcome? a Hyperventilation b Hypoventilation c Increased absorption of O2 d. Increased excretion of HCO3
b
A patient at high risk for pulmonary embolism is receiving enoxaparin. The nurse should provide the patient with what explanation? a "I'm going to contact the pharmacist to see if you can take this medication by mouth." b "This injection is being given to prevent blood clots from forming." c. "This medication will dissolve any blood clots you might get." d. "I will contact your primary care provide to discuss why you are getting this medication."
b
A patient diagnosed with type 1 diabetes is receiving a continuous subcutaneous insulin infusion via an insulin pump contacts the clinic to report mechanical failure of the infusion pump. The nurse instructs the patient to begin monitoring for signs of what possible complication? Adrenal insufficiency Diabetic ketoacidosis Hyperosmolar, hyperglycemic state Hypoglycemia
b
A patient is having complications from abdominal surgery and remains NPO. Because enteral tube feedings are not possible, the decision is to initiate parenteral feedings. What are the major complications for this therapy? a. Aspiration pneumonia and sepsis b Fluid and electrolyte imbalances and sepsis c Fluid overload and pulmonary edema d Hypoglycemia and renal insufficiency
b
A patient is having difficulty weaning from mechanical ventilation. The nurse assesses the patient and notes what potential cause of this difficult weaning? a Cardiac output of 6 L/min b Hemoglobin of 8 g/dL c Negative sputum culture and sensitivity d White blood cell count of 8000
b
How is peritoneal dialysis different from hemodialysis? a. It is more frequently used for acute kidney injury. b It uses the patient's own semipermeable membrane (peritoneal membrane). c It is not useful in cases of drug overdose or electrolyte imbalance. d It is not indicated in cases of water intoxication.
b
Lactulose is considered the first-line treatment for hepatic encephalopathy and works by what process? Causing ammonia to enter the bloodstream via the colon. Trapping ammonia in the bowel for excretion. Causing constipation and inhibiting the excretion of ammonia. Creating an alkaline environment in the bowel.
b
The nurse assesses a patient who is admitted for an overdose of sedatives. The nurse expects to find which acid-base alteration? a Hyperventilation and respiratory acidosis b Hypoventilation and respiratory acidosis c Hypoventilation and respiratory alkalosis d Respiratory acidosis and normal oxygen levels
b
The nurse assessing a patient diagnosed with acute respiratory distress syndrome expects what assessment finding? a Cardiac output of 10 L/min and low systemic vascular resistance. b PAOP of 10 mm Hg and PaO2 of 55. c. PAOP of 20 mm Hg and cardiac output of 3 L/min.d. d PAOP of 5 mm Hg and high systemic vascular resistance.
b
The nurse caring for a patient diagnosed with acute respiratory failure identifies "Risk for Ineffective Airway Clearance" as a nursing diagnosis. What nursing intervention is relevant to this diagnosis? a Elevate head of bed to 30 degrees. b Obtain order for venous thromboembolism prophylaxis. c Provide adequate sedation. d patient every 2 hours.
b
The nurse is caring for a patient diagnosed with liver disease. When assessing the patient's laboratory values, the nurse should take what action? a Disregard the level of conjugated bilirubin. b Review the indirect serum bilirubin. c Call the provider immediately if the direct bilirubin is elevated. d. Be aware that unconjugated bilirubin is harmless.
b
The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine injury who is reporting a severe headache. The nurse assesses a blood pressure of 180/90 mm Hg, heart rate 60 beats/min, respirations 24 breaths/min, and 50 mL of urine via indwelling urinary catheter for the past 4 hours. What is the best action by the nurse? a Administer acetaminophen as ordered for the headache. b Assess for a kinked urinary catheter and assess for bowel impaction. c Encourage the patient to take slow, deep breaths. d Notify the physician of the patient's blood pressure.
b
The nurse is caring for a patient with a heart rate of 140 beats/min. The primary care provider (PCP) orders parasympathetic medications to slow down the heart rate. With this type of medication, the nurse should implement what intervention? a Evaluate the patient for symptoms of constipation. b Observe for diarrhea. c Assess mucus membranes for signs of dryness. d. Expect decreased bowel sounds.
b
The nurse is caring for a patient with severe ascites secondary to chronic liver failure. The patient lying supine in bed reports difficulty breathing. The nurse's first action should be to take what action? a Measure abdominal girth to determine the amount of fluid accumulation. b Position the patient in a semi-Fowler's position. c Prepare the patient for emergent paracentesis. abirb.com/test d Administer diuretics.
b
The nurse is caring for a postoperative patient with chronic obstructive pulmonary disease (COPD). Which assessment would be a cue to the patient developing postoperative pneumonia? a. Bradycardia b Change in sputum characteristics c Hypoventilation and respiratory acidosis d Pursed-lip breathing
b
The nurse is discharging a patient home following treatment for community-acquired pneumonia. As part of the discharge teaching, the nurse should provide instruction? a "If you get the pneumococcal vaccine, you'll never get pneumonia again." b "It is important for you to get an annual influenza shot to reduce your risk of pneumonia." c. "Stay away from cold, drafty places because that increases your risk of pneumonia when you get home." d. "Since you have been treated for pneumonia, you now have immunity from getting it in the future."
b
The nurse is managing a donor patient six hours prior to the scheduled harvesting of the patient's organs. Which assessment finding requires immediate action by the nurse? a Morning serum blood glucose of 128 mg/dL b pH 7.30; PaCO2 38 mm Hg; HCO3 16 mEq/L c pulmonary artery temperature of 97.8F d Central venous pressure of 8 mm Hg
b
The nurse, caring for a patient following a subarachnoid hemorrhage, begins a nicardipine infusion. Baseline blood pressure assessed by the nurse is 170/100 mm Hg. Five minutes after beginning the infusion at 5 mg/hr, the nurse assesses the patient's blood pressure to be 160/90 mm Hg. What is the best action by the nurse? Stop the infusion for 5 minutes. Increase the dose by 2.5 mg/hr. Notify the physician of the BP. Begin weaning the infusion.
b
The patient admitted with acute pancreatitis is demonstrating severe abdominal pain, vomiting, and ascites. Using the Ranson classification criteria, the nurse determines that this patient has what morality rate? a. 99%b. 15% c. 40% d. 1%
b
The patient has a temporary percutaneous catheter in place for treatment of acute kidney injury. The catheter has been in place for 5 days. What action should the nurse take? a Prepare to assist with a routine dialysis catheter change to replace the existing catheter. b Evaluate the patient for signs and symptoms of infection. c teach the patient that the catheter is designed for long-term use. d Use one of the three lumens for fluid administration.
b
The patient is admitted with constipation. In anticipation of treatment, the nurse prepares to implement what action? a Give medications that will suppress the autonomic nervous system. b Provide therapies that will innervate the autonomic nervous system. c Teach the patient that the submucosa is the innermost part of the gut wall. d. Give medications intravenously since the submucosa has no blood vessels.
b
The patient is admitted with the diagnosis of GI bleeding. The patient's heart rate is 140 beats per minute with a blood pressure of 84/44 mm Hg. What do these values possibly indicate? a a need for hourly vital signs. b Approximately 25% loss of total blood volume. c. Resolution of hypovolemic shock d. Increased blood flow to the skin, lungs, and liver.
b
The patient is diagnosed with hepatitis. In caring for this patient, the nurse should be prepared to take what action? a Administer antiinflammatory medications. b Provide rest, nutrition, and antiemetics as needed. c Provide antianxiety medications freely to decrease agitation. d Instruct the patient to take over-the-counter antiinflammatory medications at home.
b
What does oxygen saturation (SaO2) represent? a. Alveolar oxygen tension. b. Oxygen that is chemically combined with hemoglobin. c. Oxygen that is physically dissolved in plasma. d. Total oxygen consumption.
b
What is an early signs of the effect of hypoxemia on the nervous system? a. Cyanosisb. b Restlessness c. Tachycardia d. Tachypnea
b
What is the treatment for an acute exacerbation of asthma? a Corticosteroids and theophylline by mouth b Inhaled bronchodilators and intravenous corticosteroids c. Prone positioning or continuous lateral rotation d. Sedation and inhaled bronchodilators
b
When fluid is present in the alveoli what is the result? a Alveoli collapse and atelectasis occurs. b diffusion of oxygen and carbon dioxide is impaired. c Hypoventilation occurs. d The patient is in heart failure.
b
Which assessment would cue the nurse to the potential of acute respiratory distress syndrome (ARDS) in a patient admitted with respiratory distress? a Increased oxygen saturation via pulse oximetry b Increased peak inspiratory pressure on the ventilator c Normal chest radiograph with enlarged cardiac structures d. PaO2/FiO2 ratio > 300
b
nurse notices that patient's oral cavity is only slightly moist and contains a scant amount of thick saliva even though the patient's fluid intake has been sufficient. What is the likely cause of the condition of the patient's mouth? a Thoughts of food b Sympathetic nerve stimulation c Overstimulation of the sublingual glands d Parasympathetic nerve stimulation
b
The nurse is assisting with endotracheal intubation and understands correct placement of the endotracheal tube in the trachea would be identified by which of the following? (Select all that apply.) a Auscultation of air over the epigastrium b Equal bilateral breath sounds upon auscultation c Position above the carina verified by chest x-ray d Positive detection of carbon dioxide (CO2) through CO2 detector devices e Fogging of the endotracheal tube
b,c,d
What factors may predispose a patient to respiratory acidosis? a. Anxiety and fear b Central nervous system depression c Diabetic ketoacidosis d Nasogastric suctioning e Overdose of sedatives
b,e
The nurse is caring for a mechanically ventilated patient with a brain injury. Arterial blood gas values indicate a PaCO2 of 60 mm Hg. The nurse understands this value to have which effect on cerebral blood flow? a. Altered cerebral spinal fluid production and reabsorption b Decreased cerebral blood volume due to vessel constriction c Increased cerebral blood volume due to vessel dilation d No effect on cerebral blood flow (PaCO2 of 60 mm Hg is normal)
c
A mode of pressure-targeted ventilation that provides positive pressure to decrease the workload of spontaneous breathing through what action by the endotracheal tube? a Continuous positive airway pressure b Positive end-expiratory pressure c Pressure support ventilation d T-piece adapter
c
A patient's feeding tube has been successfully placed in the small intestine with continuous flow tube feeding. The nurse knows that this approach was chosen because of what physiological process? a. Intermittent feedings cause increased nausea and vomiting. b The increased filling of the stomach increases absorption. c The intestinal mucosa normally receives nutrients from the stomach in peristaltic waves. d. This will prevent malabsorption syndrome.
c
In evaluating a patient's nutrition, the nurse would monitor which blood test as the most sensitive indicator of protein synthesis and catabolism? a. Albumin b BUN c. Prealbumin d. Triglycerides
c
The nurse caring for a patient with an endotracheal tube understands that endotracheal suctioning is needed to facilitate removal of secretions. What additional information is the nurse aware of concerning this intervention? a It decreases intracranial pressure. b It depresses the cough reflex. c It is done as indicated by patient assessment. d it is more effective if preceded by saline instillation to loosen secretions.
c
The nurse discharging a patient diagnosed with asthma instructs the patient to prevent exacerbation by taking what action? a. Obtaining an appointment for follow-up pulmonary function studies 1 week after discharge. b Limiting activity until patient is able to climb two flights of stairs. c Taking all asthma medications as prescribed. d Taking medications on a "prn" basis according to symptoms
c
The nurse is assessing the exhaled tidal volume (EVT) in a mechanically ventilated patient. What is the rationale for this assessment? a Assess for tension pneumothorax. b Assess the level of positive end-expiratory pressure. C Compare the tidal volume delivered with the tidal volume prescribed. D Determine the patient's work of breathing.
c
The nurse is assessing the patient admitted diagnosed with pancreatitis. In doing so, the nurse takes what action? a Palpates the pancreas for size and shape. b Emphasizes to the patient that pancreatic inflammation does not spread. c Assesses symptoms that could indicate involvement of the stomach d Explains to the patient that back pain is not a sign of pancreatitis.
c
The nurse is caring for a mechanically ventilated patient admitted with injury. Which arterial blood gas value assessed by the nurse indicates optimal gas exchange for a patient with this type of injury? a pH 7.38; PaCO2 55 mm Hg; HCO3 22 mEq/L; PaO2 85 mm Hg b pH 7.38; PaCO2 40 mm Hg; HCO3 24 mEq/L; PaO2 70 mm Hg c. pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg d. pH 7.38; PaCO2 28 mm Hg; HCO3 26 mEq/L; PaO2 65 mm Hg
c
The nurse is caring for a patient 5 days following clipping of an anterior communicating artery aneurysm for a subarachnoid hemorrhage. The nurse assesses the patient to be more lethargic than the previous hour with a blood pressure 95/50 mm Hg, heart rate 110 beats/min, respiratory rate 20 breaths/min, oxygen saturation (SpO2) 95% on 3 L/min oxygen via nasal cannula, and a temperature of 101.5° F. Which order should the nurse institute first? a Blood cultures (2 specimens) for temperature > 101° F b Acetaminophen 650 mg per rectum c 500 mL albumin infusion intravenously d Decadron 20 mg intravenous push every 4 hours
c
The nurse is caring for a patient with a Minnesota tube in place when the patient suddenly shows signs of severe pain and respiratory distress. What action should the nurse take? a Cut the gastric balloon lumen and watch for improved symptoms b Cut the esophageal lumen and watch for improvement. c Cut all three lumina and remove the tube. d Call the provider with an update of the patient's condition.
c
The nurse is preparing to administer a routine dose of phenytoin. The primary care provider orders phenytoin 500 mg intravenous every 6 hours. What is the best action by the nurse? a Administer over 2 minutes. b Administer with 0.9% normal saline intravenous. c Contact the primary care provider to discuss the order. d Assess cardiac rhythm.
c
The patient admitted with acute pancreatitis is later diagnosed as having a pseudocyst. What outcome will this event have on the patient's care? a. Surgery for pseudocysts must be done immediately. b A cholecystectomy is usually done when pseudocysts are found. c Pseudocysts may resolve spontaneously, so surgery may be delayed. d Pseudocysts require pancreatic resection, removing the entire pancreas.
c
The patient is admitted with severe abdominal pain due to pancreatitis. The patient asks the nurse, "What causes this? Why does it hurt so much?" The nurse should provide what answer? a"Pancreatitis is extremely rare and no one knows why it causes pain." b "Pancreatitis is caused by diabetes; you should be checked." c. "Injury to certain cells in the pancreas causes it to digest (eat) itself, causing pain." d. "The pain is localized to the pancreas. Fortunately, it will not affect anything else.
c
The patient is being admitted with active GI bleeding. Blood work includes serial hemoglobin and hematocrit levels. The nurse understands that to mean what? A The hematocrit is a direct reflection of quick blood loss. b As extravascular fluid enters the vascular space the hematocrit increases c The hematocrit value does not change substantially during the first few hours. d The administration of intravenous fluids has no effect on hematocrit levels.
c
The patient is on intake and output (I&O) as well as daily weights. The nurse notes that output is considerably less than intake over the last shift, and daily weight is 1 kg more than yesterday. The nurse should take what action? a Draw a trough level after the next dose of antibiotic. b Obtain an order to place the patient on fluid restriction. c. Assess the patient's lungs. d. Insert an indwelling catheter.
c
What diagnostic procedure is required to make a definitive diagnosis of pulmonary embolism? a. Arterial blood gas (ABG) analysis. b Chest x-ray examination. c High resolution multidetector CT angiogram. d Ventilation-perfusion scanning.
c
What important nutritional consideration should be addressed in the elderly population? A Decreased protein requirements. B Increasing caloric requirements with age. C Potential for drug-nutrient interaction related to polypharmacy. D Presence of other diseases that decrease caloric needs.
c
What is the basic underlying pathophysiology of acute respiratory distress syndrome? A decrease in the number of white blood cells available. b Damage to the right mainstem bronchus. c Damage to the type II pneumocytes, which produce surfactant. d Decreased capillary permeability.
c
Which of the following patients is at the greatest risk of developing acute kidney injury? a One who had a diagnostic test using a radiocontrast media 6 days. b One with a history of controlled hypertension with a blood pressure of 138/88 mm Hg. c One discharged 2 weeks earlier after aminoglycoside therapy of 2 weeks. d. One with a history of fluid overload as a result of heart failure.
c
The nurse is caring for a patient with acute respiratory distress syndrome who is hypoxemic despite mechanical ventilation. The primary care provider (PCP) orders a nontraditional ventilator mode as part of treatment. Despite sedation and analgesia, the patient remains restless and appears to be in discomfort. The nurse informs the PCP of this assessment and anticipates what order? a. Continuous lateral rotation therapy b Guided imagery c Neuromuscular blockade d Prone positioning
c Neuromuscular blockade
A 53-year-old, 80-kg patient is admitted to the cardiac surgical intensive care unit after cardiac surgery with the following arterial blood gas (ABG) levels. What is the nurse's interpretation of these values? pH 7.4 PaCO2 40 mm Hg Bicarbonate 24 mEq/L PaO2 95 mm Hg O2 saturation 97% Respirations 20 breaths per minute a Compensated metabolic acidosis b Metabolic alkalosis c Normal ABG values d Respiratory acidosis
c Normal ABG values
The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at the scene briefly but is now conscious upon arrival at the emergency department (ED) with a GCS score of 15. One hour later, the nurse assesses a GCS score of 3. What is the priority nursing action? a Stimulate the patient hourly. b Continue to monitor the patient. c Elevate the head of the bed. d Notify the primary care provider immediately.
d
When assessing the patient for hypoxemia, the nurse recognizes what as an early sign of the effect of hypoxemia on the cardiovascular system? a Heart block b Restlessness c. Tachycardia d. Tachypnea
c. Tachycardia
21. Positive end-expiratory pressure (PEEP) is a mode of ventilatory assistance that produces which of the following conditions. a Each time the patient initiates a breath, the ventilator delivers a full preset tidal volume. b For each spontaneous breath taken by the patient, the tidal volume is determined by the patient's ability to generate negative pressure. c The patient must have a respiratory drive, or no breaths will be delivered. d There is pressure remaining in the lungs at the end of expiration that is measured in cm H2O.
d
A patient presents to the emergency department demonstrating agitation and reporting numbness and tingling in the fingers. Arterial blood gas levels reveal the following: pH 7.51, PaCO2 25, HCO3 25. How should the nurse interprets these blood gas values? a Compensated metabolic alkalosis b Normal values c Uncompensated respiratory acidosis d Uncompensated respiratory alkalosis
d
After receiving the hand-off report from the day shift charge nurse, which patient should the evening charge nurse assess first? a A patient with meningitis complaining of photophobia b A mechanically ventilated patient with a GCS of 6 c A patient with bacterial meningitis on droplet precautions d A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104° F
d
How does continuous renal replacement therapy (CRRT) differ from conventional intermittent hemodialysis? a A hemofilter is used to facilitate ultrafiltration. b It provides faster removal of solute and water. c It does not allow diffusion to occur. d The process removes solutes and water slowly.
d
The amount of effort needed to maintain a given level of ventilation is referred to using what term? Compliance Resistance Tidal volume Work of breathing
d
The critical care nurse is caring for a patient with the diagnosis of sepsis. The patient is on a ventilator and is receiving a proton pump inhibitors (PPI) to reduce the risk for a stress ulcer. In this scenario, a stress ulcer is likely secondary to what? a. Infection with Helicobacter pylori bacteria. b Decreased acetylcholine production. c A decreased number of parietal cells. d Ischemia associated with sepsis.
d
The nurse caring for a mechanically ventilated patient notes the high pressure alarm sounding but cannot quickly identify the cause of the alarm. The nurse notes the patient's oxygen saturation is decreasing and heart rate and respiratory rate are increasing. What is the nurse's priority action? a Ask the respiratory therapist to get a new ventilator b Call the rapid response team to assess the patient c Continue to find the cause of the alarm and fix it d. Manually ventilate the patient while calling for a respiratory therapist
d
The nurse is caring for a patient who has had a portocaval shunt placed surgically. The nurse is aware that this procedure is intended to facilitate what outcome? a Improvement of survival rates in patients with varices. b A decrease in the risk of encephalopathy. c. A decrease the incidence of ascites. d. A decrease in the risk of rebleeding
d
The nurse is caring for a patient who has sustained blunt trauma to the left flank area, and is evaluating the patient's urinalysis results. What related assessment finding should concern the nurse? a Creatinine levels in the urine are similar to blood levels of creatinine. b Sodium and chloride are found in the urine. c Urine uric acid levels have the same values as serum levels. d Red blood cells and albumin are found in the urine.
d
The nurse is caring for a patient whose ventilator settings include 15 cm H2O of positive end-expiratory pressure (PEEP). The nurse understands that although beneficial, PEEP may result in what possible problem? a Fluid overload secondary to decreased venous return. b High cardiac index secondary to more efficient ventricular function. c Hypoxemia secondary to prolonged positive pressure at expiration. d Low cardiac output secondary to increased intrathoracic pressure
d
The nurse is caring for a patient with an intracranial pressure ICP of 18 mm Hg and a GCS score of 3. Following the administration of mannitol, which assessment finding by the nurse requires further action? a ICP of 10 mm Hg b CPP of 70 mm Hg c GCS score of 5 d. CVP of 2mmHg
d
The patient in progressive care unit following arteriovenous fistula implantation in the left upper arm, is due to have blood drawn with the next set of vital signs and assessment. When the nurse assesses the patient, the nurse should take what action? A Draw blood from the left arm. B Take blood pressures from the left arm. C Start a new intravenous line in the left lower arm. D Auscultate the left arm for a bruit and palpate for a thrill.
d
The patient is ordered to have large volume gastric lavage. The nurse will most likely need to prepare for what action? a The insertion of a small-bore nasogastric tube. b Administering 2 to 4 liters of room temperature normal saline. c Removing the nasogastric tube before lavage is started. d insertion of a large-bore nasogastric tube.
d
What objective data is used to determine whether nutrition goals are not being met? a Hyperglycemia, normovolemia, and increased protein level b Overhydration, hypoglycemia, and weight gain c Weight gain, inconsistent glucose, and normovolemia d Weight loss, elevated glucose, and dehydration
d
What risk is the rationale for the recommendation of endotracheal rather than nasotracheal intubation? a Basilar skull fracture b Cervical hyperextension c Impaired ability to "mouth" words d Sinusitis and infection
d
Which treatment can be used to dissolve a thrombus that is lodged in the pulmonary artery? a. Aspirin b. Embolectomy c. Heparind. e Thrombolytics
d
While caring for a patient with a closed head injury, the nurse assesses the patient to be alert with a blood pressure 130/90 mm Hg, heart rate 60 beats/min, respirations 18 breaths/min, and a temperature of 102° F. To reduce the risk of increased intracranial pressure (ICP) in this abirb.com/test patient, what are the priority nursing actions? a. Ensure adequate periods of rest between nursing interventions. b Insert an oral airway and monitor respiratory rate and depth. c Maintain neutral head alignment and avoid extreme hip flexion d Reduce ambient room temperature and administer antipyretics.
d
The removal of plasma water and some low-molecular weight particles by using a pressure or osmotic gradient is identified by what term? a. Dialysisb. b Diffusionc. c Clearance d. Ultrafiltration
d. Ultrafiltration
