CCN FINAL
Mechanism for development of diabetes insipidus include?
* ADH deficiency * ADH insensitivity *excessive water intake.
S/S of end stage liver disease
*malnutrition *Impaired coagulation *Ascites *Dysrhythmias (box 18.5, pg. 492)
ABLS Resuscitation 2 mL LR × 70 kg × 45% TBSA =
6,300 mL of LR infused over 24 hours
The nurse is caring for a burn-injured patient who weighs 70 kg, and the burn injury covers 45% of his body surface area. The nurse calculates the fluid needs for the first 24 hours after a burn injury using a standard fluid resuscitation formula. The nurse plans to administer what amount of fluid in the first 24 hours? 4x70x45? or 2x70x45?
6300 mL?????
The charge nurse is reviewing the status of patients in the critical care unit. Regarding which patient should the nurse notify the organ procurement organization to evaluate for possible organ donation?
A 36-year-old patient with a Glasgow Coma Scale score of 3 with no activity on electroencephalogram
The patient is admitted with end-stage liver disease. The nurse evaluates the patient for which of the following? (Select all that apply.)
Malnutrition Ascites Disseminated intravascular coagulation
Child with Spiral bone fracture
call CPS
Which nursing diagnosis is a high-priority for both diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome?
✓ Fluid volume deficiency
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)?
✓ 90 mm Hg *CPP = MAP — ICP
What is the most common cause of a pulmonary embolus?
✓ A deep vein thrombosis from lower extremities.
Mechanisms for development of diabetes insipidus include which of the following? (Select all that apply.) "2"
✓ ADH deficiency ✓ ADH insensitivity
The nurse has just completed administration of a 1000-L bolus of 0.9% normal saline. The nurse assesses the patient to be slightly confused, with a mean arterial blood pressure (MAP) of 50 mm Hg, a heart rate of 110 beats/min, urine output of 10 mL for the past hour, and a central venous pressure (CVP/RAP) of 3 mm Hg. What is the best interpretation of these results by the nurse?
✓ Additional interventions are indicated. *Ex: request more fluids from PCP
A patient with newly diagnosed type 1 diabetes is being transitioned from an infusion of intravenous (IV) regular insulin to an intensive insulin therapy regimen of insulin glargine and insulin aspart. How should the nurse manage this transition in insulin delivery?
✓ Administer the insulin glargine and discontinue the IV infusion in several hours.
The nurse is caring for a patient in spinal shock. Vital signs include blood pressure 100/70 mm Hg, heart rate 70 beats/min, respirations 24 breaths/min, oxygen saturation 95% on room air, and an oral temperature of 96.8° F. Which intervention is most important for the nurse to include in the patient's plan of care?
✓ Application of slow rewarming measures
The nurse is caring for a patient admitted following a motor vehicle crash. Over the past 2 hours, the patient has received 6 units of packed red blood cells and 4 units of fresh frozen plasma by rapid infusion. To prevent complications, what is the priority nursing intervention?
✓ Assess core body temperature.
The nurse is caring for a young adult patient admitted with shock. The nurse understands which assessment findings best assess tissue perfusion in a patient in shock? (Select all that apply.)
✓ Blood pressure✓ Level of consciousness✓ Urine output
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?
✓ CVP of 2 mm Hg
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 what action should be taken next?
✓ Call the health care provider (PCP) immediately.
PreRenal- 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?
✓ Contact the primary health care provider and expect an order for a normal saline bolus.
The patient diagnosed with acute respiratory distress syndrome (ARDS) would exhibit which symptom?
✓ Decreasing PaO2 levels despite increased FiO2 administration
An older adult patient has presented to the emergency department with altered mental status, hypothermia, and clinical signs of heart failure. Myxedema is suspected. Which of the following laboratory findings support this diagnosis?
✓ Elevated thyroid-stimulating hormone
The nurse is caring for a patient admitted to the critical care unit 48 hours ago with a diagnosis of severe sepsis. As part of this patient's care plan, what intervention is most important for the nurse to discuss with the multidisciplinary care team?
✓ Enteral feedings
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?
✓ Heart rate > than 120 beats per minute.*Ex: HR 125
Complications common to patients receiving hemodialysis for acute kidney injury include which of the following? (Select all that apply.) "2"
✓ Hypotension✓ Dysrhythmias
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.) "4"
✓ Increase functional residual capacity ✓ Prevent collapse of unstable alveoli ✓ Improve arterial oxygenation ✓ Open collapsed alveoli
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?
✓ Noninvasive positive-pressure ventilation (NPPV)
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?
✓ Notify the organ procurement organization (OPO)
The nurse has admitted a patient to the ED following a fall from a first-floor hotel balcony. The patient, 22 years old and smelling of alcohol, begins to vomit. Which intervention is most appropriate?
✓ Prepare to suction the oropharynx while maintaining cervical spine immobilization.
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?
✓ Provide rest periods between nursing interventions.
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 patient, what are the priority nursing actions?
✓ Reduce ambient room temperature and administer antipyretics.
The nurse is caring for a client after a supratentorial craniotomy. The nurse places a sign above the client's bed stating that the client should be maintained in which position?
✓ Semi-Fowler's
The need for fluid resuscitation can be assessed best in the trauma patient by monitoring and trending which of the following tests?
✓ Serum lactate levels
Which of the following laboratory values would be found in a patient with syndrome of inappropriate secretion of antidiuretic hormone?
✓ Serum sodium 115 mEq/L
A client who is unresponsive and pulseless and who has a possible neck injury is brought into the emergency department after a motor vehicle crash. What should the nurse do to open the client's airway?
✓ Stabilize the skull and push up the jaw
A patient 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; pulmonary artery diastolic pressure is 2 mm Hg; cardiac output is 4 L/min; urine output is 250 mL/hr; chest drainage is 200 mL/hr. What is the best interpretation by the nurse?
✓ The patient is at risk for developing hypovolemic shock.
How does continuous renal replacement therapy (CRRT) differ from conventional intermittent hemodialysis?
✓ The process removes solutes and water slowly.
The nurse is starting to administer a unit of packed red blood cells (PRBCs) to a patient admitted in hypovolemic shock secondary to hemorrhage. Vital signs include blood pressure 60/40 mm Hg, heart rate 150 beats/min, respirations 42 breaths/min, and temperature 100.6° F. What is the best action by the nurse?
✓ Titrate rate of blood administration to patient response.
Lactulose is considered the first-line treatment for hepatic encephalopathy and works by what process?
✓ Trapping ammonia in the bowel for excretion.
In hyperosmolar hyperglycemic syndrome, the laboratory results are similar to those of diabetic ketoacidosis, with three major exceptions. What differences would you expect to see in patients with hyperosmolar hyperglycemic syndrome?
Higher serum glucose, higher osmolality, and no ketosis
In the management of diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome, when is an intravenous (IV) solution that contains dextrose started?
When the blood glucose reaches 250 mg/dL ***200 mg/dl? Add dextrose to maintenance IV solutions once serum glucose level reaches 250 mg/dL in DKA or 300 mg/dL in HHS.
The nurse is caring for a patient admitted with severe sepsis. Vital signs assessed by the nurse include blood pressure 80/50 mm Hg, heart rate 120 beats/min, respirations 28 breaths/min, oral temperature of 102° F, and a right atrial pressure (RAP) of 1 mm Hg. Assuming physician orders, which intervention should the nurse carry out first?
✓ Isotonic fluid challenge
The nurse has just completed an infusion of a 1000 mL bolus of 0.9% normal saline in a patient with severe sepsis. One hour later, which laboratory result requires immediate nursing action?
✓ Lactate 6 mmol/L
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?
✓ Management and protection of the airway
The nurse suspects that a client who had a myocardial infarction is developing cardiogenic shock. The nurse should assess for which peripheral vascular symptom of this complication?
✓ Cool, clammy skin with weak or thready pedal pulses
What diagnostic procedure is required to make a definitive diagnosis of pulmonary embolism?
pulmonary angiogram
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.
During the treatment and management of the trauma patient, maintaining tissue perfusion, oxygenation, and nutritional support are strategies to prevent what potential complication?
✓ Multi-system organ dysfunction (MODS)
The nurse is caring for a patient who sustained rib fractures after hitting the steering wheel of a car. The patient is spontaneously breathing and receiving oxygen via face mask; the oxygen saturation is 95%. During the nurse's assessment, the oxygen saturation drops to 80%. The patient's blood pressure has dropped from 128/76 mm Hg to 84/60 mm Hg. The nurse assesses that breath sounds are absent throughout the left lung fields. The nurse notifies the physician and anticipates what prescribed intervention?
✓ Needle thoracostomy and chest tube insertion.
Which of the following patients is at the greatest risk of developing acute kidney injury?
✓ One discharged 2 weeks earlier after aminoglycoside therapy of 2 weeks.
The nurse is caring for a patient in acute respiratory failure and understands that the patient should be positioned (Select all that apply.) "3"
✓ high Fowler's.✓ side lying with head of bed elevated.✓ sitting in a chair.
Using Rule of 9s, calculate the patients TBSA% with burns to the groin, chest, abdomen, and anterior portion of the leg.
1+9+9+9 = 28%
The nurse is managing the pain of a patient with burns. The provider has prescribed opiates to be given intramuscularly. The nurse contacts the provider to change the prescription to intravenous administration because
tissue edema may interfere with drug absorption of injectable routes.
A patient with a 60% burn in the acute phase of treatment develops a tense abdomen, decreasing urine output, hypercapnia, and hypoxemia. Based on this assessment, the nurse anticipates interventions to evaluate and treat the patient for
intra-abdominal hypertension.
The nurse is managing a donor patient six hours before the scheduled harvesting of the patient's organs. Which assessment finding requires immediate action by the nurse?
pH 7.30; PaCO2 38 mm Hg; HCO3 16 mEq/L
A definitive diagnosis of pulmonary embolism can be made by
pulmonary angiogram.
The nurse is caring for a patient with an electrical injury. The nurse understands that patients with electrical injury are at a high risk for acute kidney injury secondary to
release of myoglobin from injured tissues.
