Critical care final
You're providing an in-service to new nurse graduates about esophageal varices in patients with cirrhosis. You ask the graduates to list activities that should be avoided by a patient with this condition. Which activities listed are correct: Select all that apply
A. EXCESSIVE COUGHING B. SLEEPING ON THE BACK C. DRINKING JUICE D. ALCOHOL CONSUMPTION E. STRAINING DURING A BOWEL MOVEMENT F. VOMITING Esophageal varices are dilated vessels that are connected from the throat to the stomach. They can become enlarged due to portal hypertension in cirrhosis and can rupture (this is a medical emergency). The patient should avoid activities that could rupture these vessels, such as excessive cough, vomiting, drinking alcohol, and constipation (straining increases thoracic pressure.)
While assisting a patient with chronic pancreatitis to the bathroom, you note the patient's stool to be oily/greasy in appearance. In your documentation you note this as:
A. STEATORRHEA Steatorrhea is an oily/greasy appearance of the stool which can occur in chronic pancreatitis. This occurs due to the inability of the pancreas to produce digestive enzymes which help break down fats. Fats are not being broken down; therefore, it is being excreted into the stool.
In providing care to the patient who may have poly cystic kidney dz the nurse recognizes which finding as the first clinical manifestation of this dz process?
A.Hypertension Hypertension is the first symptom the nurse should assess for when a patient is suspected of having polycystic kidney disease; it occurs as a result of damage to the surrounding renal structures caused by the enlargement of the cysts.
A patient with CKD is experiencing manifestations of anemia. Based on this data which txt does the nurse anticipate for this patient?
Administer erythropoietin (epoetin) injections
A patient with acute pancreatitis is reporting excessive thirst, excessive voiding, and blurred vision. As the nurse, it is priority you?
B. CHECK THE PATIENT'S BLOOD GLUCOSE Patients with acute pancreatitis are at risk for hyperglycemia (the signs and symptoms the patient are reporting are classic symptoms of hyperglycemia). Remember the endocrine function of the pancreas (which is to release insulin/glucagon etc. is insufficient) so the nurse must monitor the patient's blood glucose levels even if the patient is not diabetic.
The correlates which disorder to the development of intracranial renal failure?
B. Glomerulonephritis Intrarenal causes of acute kidney injury (AKI) involve direct damage to the renal parenchymal tissues resulting in impaired nephron functioning. Acute glomerulonephritis and acute tubular necrosis cause intrarenal failure.
The nurse is administering peritoneal dialysis to a patient with CKD and notes the presence of a cloudy dialysate return. After notifying the healthcare provider which action by the nurse is the best?
Culture the dialysate return
A patient is admitted to the ER with the following signs and symptoms: very painful mid-epigastric pain felt in the back, elevated glucose, fever, and vomiting. During the head-to-toe assessment, you notice bluish discoloration around the belly button. As the nurse, you know this is called?
D. Cullen's sign This is known as Cullen's Sign. It represents retroperitoneal bleeding from the leakage of digestive enzymes from the inflamed pancreas into the surrounding tissues which is causing bleeding and it is leaking down to umbilicus tissue.
Which is the priority nursing action when providing care to a patient with a nasogastric tube following a pancreaticoduidenectomy (whipple procedure)
D. ENSURING THAT THE TUBE IS NOT MANIPULATED These NGTs should not be repositioned or irrigated or checked for placement. They are placed intraoperatively. Doing so can cause a breakdown of the anastomotic site. If a patient removes his NGT, it is not to be replaced by the nursing staff. A member of the surgical team should be notified.
The physician orders a patient with CHRONIC pancreatitis to take a pancreatic enzyme. What assessment finding demonstrates the pancreatic enzymes are working properly?
D. STOOL APPEARS FORMED AND SOLID Pancreatic enzymes help the body break down carbs, proteins, and fats because the body is not sufficiently producing digestive enzymes anymore. Hence, the stool will not appear as oily or greasy (decrease in steatorrhea) but appear solid and formed.
a patient is admitted to the critical care unit with an anion gap of 24 mEq/L. The laboratory finding is characteristic of which condition?
DKA
polydipsia, polyuria, abdominal pain, nausea, and fruity breath are typical findings in
DKA
In providing care to a patient who underwent a colostomy 2 days ago for the treatment of colon cancer, which finding requires an immediate intervention
Dark red purplish color of the stoma
The nurse monitors for which therapeutic effect in the patient receiving sodium polystyrene sulfonate (Kayexalate) for the txt of CKD?
Decreased serum K+
In administering lactulose to the patient with hepatic encephalopathy, the nurse correlates effectiveness of this medication to which mechanism of action?
Decreases production and absorption of ammonia
The nurse is educating a new RN in the care of a diabetic patient. The nurse is anticipating that the patient will need a continuous infusion of iv insulin. Which statement by the new RN indicates that teaching has been effective?
I should monitor plasma glucose every hour
The nurse monitors for which electrocardiography change as the first indication of hyperkalemia in the patient with acute kidney dz?
Tall T waves Peaked T waves are the initial indication of hyperkalemia on the electrocardiogram (ECG) and occur when serum potassium is greater than 6.0 mEq/L and less than 7.5 mEq/L.
The nurse is preparing to discharge a patient with CKD. In teaching the patient about calcium acetate tablets, which explanation by the nurse is best?
The calcium acetate will lower your serum phosphate levels
The nurse is providing care to a patient diagnosed with cirrhosis and monitors for which clinical manifesting of stage 1 hepatic encephalopathy?
Tremors
The nurse is caring for a patient admitted with a dxn of AKI. The patient asks the nurse, are my kidneys failing? Will i need a transplant? Which response by the nurse is the most appropriate?
Your condition be reversed with prompt treatment and usually will not destroy the kidney?
the nurse monitors for which finding in the patient with hyperthyroidism
a.weight loss
The nurse correlates an increase in the secretion of cortisol to an increase in the release of which of the following hormones?
adrenocorticotropic hormone
which intervention would the nurse perform when caring for a client in the emergency department reporting chest pain?
all of the above
a client receiving a blood transfusion reports itching and difficulty breathing. upon assessment the nurse notes an increased heart rate and low blood pressure. Which type of shock would the nurse suspect the client is experiencing?
anaphylactic shock
which assessment finding will the nurse expect when caring for a client with right ventricular failure?
bilateral lower leg edema
which assessment finding indicates that disseminated intravascular coagulation is occurring in a post partum client who has experienced an abruptio placentae?
bleeding at the venipuncture
diabetes insipidus (DI)
condition caused by insufficient antidiuretic hormone secreted by posterior lobe of pituitary gland; symptoms include polyuria and polydipsia
which finding about a clients angina is most important for the nurse to communicate to the health care provider?
continues after rest and nitroglycerin
which finding will the nurse expect when caring for a client who is in hypovolemic shock?
cool skin temperature
The nurse incorporates the nursing diagnosis fluid volume deficit related to a lack of secretion of vasopressin in the plan of care for the patient with which disorder?
diabetes insipidus
which clinical manifestation would the nurse include when teaching a client with heart failure about signs and symptoms that indicate a need to contact the primary health care provider?
extreme fatigue coughing at night difficulty breathing
HHS s/s
extreme hyperglycemia; hyperosmolarity w/ dehydration; NO ketoacidosis; CNS dysfunction-decreased LOC
Myxedema coma
extreme hypothyroidism(abrupt med cessation), rare with a high mortality rate = decreased cardiac output leads to decreased tissue perfusion which leads to brain and organ depletion leading to multi-organ failure
which action describes a therapeutic effect of atenolol?
heart rate decreases
In HHS laboratory results are similar to those in DKA but with three major exceptions. Which lab findings should the nurse anticipate in a patient with HHS?
higher serum glucose, higher osmolality, and no ketosis
which patient statement indicates a need for further clarification regarding medications after a bilateral adrenalectomy?
if I have nausea or vomiting I will skip the medication until it is resolved.
In caring for a patient with elevated secretion of triiodothyronine and thyroxine the nurse assesses for which findings?
increased heart
Kussmaul respirations the rapid deep breathing seen in DKA is the body's effort to compensate for metabolic acidosis caused by
ketones bodies
The nurse assesses a client who is experiencing profound(late) hypovolemic shock. When monitoring the clients abc's, which response would the nurse expect?
metabolic acidosis
Which complication will the nurse anticipate when caring for a client in late hypovolemic shock?
metabolic acidosis
A patient undergoes surgical resection of a thyroid tumor. immediately following surgery which intervention has the highest priority?
monitoring the respiratory status for a sign of obstruction
which finding would the nurse expect when assessing a client diagnosed with hypovolemic shock?
oliguria
The nurse notes that which disorder places the patient at greatest risk for hypertensive crisis?
pheochromocytoma
Which likely cause would a nurse suspect is responsible for a drop in blood pressure after a client sustains multiple internal injuries in a motor vehicle accident and the blood pressure suddenly drops from 134/90 to 80/60 mm Hg?
reduction in circulating blood volume
which outcome would the nurse use to determine effectiveness of sublingual nitroglycerin?
relief of anginal pain
A patient with type 1 diabetes is admitted with altered mental status. The following abg readings are obtained: ph 6.38; PaCo2 20mm; PaO2 98 mm HCO3 24. The nurse interprets the carbon dioxide reading is a result of
respiratory compensation for ketoacidosis
which action will the nurse take before delivering the prescribed shock when assisting with cardioversion?
shout "clear" to all persons at the bedside
which explanation would the nurse give about the purpose of the procedure when a client with angina is schedules to have a cardiac catherization?
to visualize the disease process in the coronary arteries
which laboratory test is important for the nurse to monitor when a client is admitted with acute coronary syndrome?
troponin
which statement by the women indicates that the teaching has been effective after the nurse teaches a group of women about coronary artery disease and myocardial infarction ?
unusual fatigue is a common symptom of CAD
In evaluating the therapeutic effects of vasopressin the nurse monitors for which finding?
urine output of 30 to 50 mL/hr
which additional assessment finding will the nurse expect when the blood pressure for a client with possible ruptured spleen after a motor vehicle accident is 100/60 mm Hg?
weakened peripheral pulses
