Critical Care Final Review
Which of the following labs are of most importance to monitor for a patient with an MI? SATA? a. Troponin I/ T b. Myoglobin c. AST/ALT d. CBC
A & B
Management of patient with upper GI bleeding is effective the lab results reveal which of the following: A) Decreasing blood urea nitrogen (BUN) B) Hematocrit (Hct) of 35% C) Urinary output of 20 mL/hr D) Urine-specific gravity of 1.030
A) Decreasing blood urea nitrogen (BUN)
Which diagnostic test is used first to evaluate a client with upper GI bleeding? A) Hemoglobin (Hgb) levels and hematocrit (Hct) B) Endoscopy C) Arteriography D) Upper GI series
A) Hemoglobin (Hgb) levels and hematocrit (Hct)
A patient has been admitted to the hospital with GI bleeding. Which is a priority nursing action for this patient? A) Obtain complete vital signs B) Administer prescribed medication for pain C) Administer prescribed antacids every 2 hours D) Administer prescribed medication for nausea and vomiting
A) Obtain complete vital signs
The client is admitted with full-thickness burns may be developing DIC. Which signs/symptoms would support the diagnosis of DIC? A) Oozing blood from the IV catheter site B) Sudden onset of chest pain and frothy sputum C) Foul smelling, concentrated urine D) A reddened, inflamed central line catheter site
A) Oozing blood from the IV catheter site
Which of the following patients with diabetes mellitus are at an increased risk for diabetic ketoacidosis? A. An 84-year-old male with visual impairments. B. A 25-year-old female who has been vomiting for the past 2 days due to a GI illness and has decreased her insulin dosage. C. A 54-year-old female recently diagnosed with a urinary tract infection. D. A 60-year-old male who recently traveled to another state to visit his grandchildren. E. None of these options are correct.
A, B, C
The nurse providing an overview of burns to a community group is teaching the causes for thermal burns. The causes include: (select all that apply) a. Contact with steam b. Exposure to hot liquids c. Being splashed with drain water d. Stepping on hot charcoal e. Friction injuries
A, B, D, E
A nurse is assessing for the presence of Brudzinski's sign in a client who has suspected meningitis. Which of the following actions should the nurse take when performing this technique? Select all that apply. a. Place client in supine position b. Flex client's hip and knee c. Place hands behind client's neck d. Bend client's head toward chest e. Straighten the client's flexed leg at the knee
A, C, D
A nurse is caring for a group of clients. Which of the following clients are at risk for a PE? (SATA) a. A client who has a BMI of 30 b. A female client who is postmenopausal c. A client who has a fractured femur d. A client who is a marathon runner e. A client who has chronic a-fib
A, C, E
The nurse plans care for a client with a major burn injury keeping in mind that the goals for initial burn wound management would include: Select all that apply. a. Decrease the risk of developing compartment syndrome. b. Promote physical/psychological comfort. c. Prevent infection. d. Reduce the degree of scarring. e. Decrease fluid and electrolyte loss.
A, C, E
A nurse is planning care for a client who has meningitis and is at risk for increased intracranial pressure (ICP). Which of the following actions should the nurse plan to take? a. Implement seizure precautions b. Perform neuro checks 4x a day c. Administer morphine for the report of neck and generalized pain d. Turn off room lights and television e. Monitor for impaired extraocular movements f. Encourage the client the cough frequently
A, D, E
The nurse is preparing to administer medications to a patient with AKI. Which of the following medications would the nurse clarify with the MD before administering to this patient? Select all that apply. a. Vancomycin 500 mg IV Q6 b. Lactated Ringers 1000 mL IV @ 125 mL/hr c. Furosemide 40 mg IV Q6 d. Ibuprofen 400 mg PO Q4 e. Lisinopril 10 mg PO daily
A, D, E
Which of the following signs and symptoms would most likely be found in a client with aortic regurgitation? Select all that apply: A. Weakness B. Confusion C. Exertional dyspnea D. Chest pain E. Fatigue
A, D, E
Which lab result would the nurse expect in the client diagnosed with DIC? A) A decreased prothrombin time (PT) B) A low fibrinogen level C) An increased platelet count D) An increased white blood cell count
B) A low fibrinogen level
What should the nurse emphasize when teaching patients at risk for upper GI bleeding to prevent bleeding episodes? A) All stools and vomitus must be tested for the presence of blood. B) The use of over-the-counter (OTC) medications of any kind should be avoided. C) Antacids should be taken with all prescribed medications to prevent gastric irritation. D) Misoprostol (Cytotec) should be used to protect the gastric mucosa in individuals with peptic ulcers.
B) The use of over-the-counter (OTC) medications of any kind should be avoided.
A patient presents with upper gastrointestinal (GI) bleeding. During the patient's assessment, the nurse notes coffee ground vomitus. How should the nurse classify the finding? A) Melena B) Hematemesis C) Occult bleeding D) Mallory-Weiss tear
B)Hematemesis
A nurse is planning care for a client who has bacterial meningitis. Which of the following actions should the nurse include in the plan of care? Select all that apply. a. Monitor for bradycardia b. Provide an emesis basin at the bedside c. Administer antipyretic medication d. Perform a skin assessment e. Keep the head of the bed flat
B, C, D
A female patient presents to the emergency room with acute confusion. The patient has a suspected case of sepsis from a urinary tract infection. What is the most common culprit of urosepsis? A. Human immunodeficiency virus B. Escherichia coli C. Staphylococcus aureus D. Streptococcus pneumoniae
B. Escherichia coli
Which of the following is NOT a sign or symptom of Diabetic Ketoacidosis? a. Positive Ketones in the urine b. Oliguria c. Polydipsia d. Abdominal Pain
B. Oliguria
A nurse completing discharge teaching with a client who had a surgical placement of a mechanical heart valve. Which of the following statements by the client indicates understanding of the teaching? A."I will be glad to get back to my exercise routine right away" B."I will have my prothrombin time checked on a regular basis" C."I will talk to my dentist about no longer needing antibiotics before dental exams" D."I will continue to limit my intake of foods containing potassium"
B."I will have my prothrombin time checked on a regular basis"
The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply a. Discourage reminiscing b. Make the decisions for the family c. Encourage expression of feelings, concerns, and fears d. Explain everything that is happening to all family members e. Touch and hold the client's or family member's hand if appropriate f. Be honest and let the client and family know they will not be abandoned by the nurse
C, E, F
Which newly admitted client does the nurse consider to be at highest risk for development of sepsis? A. 76-year-old man with hypertension and early dementia B. 90-year-old community-dwelling man with atrial fibrillation C. 67-year-old woman 2 days postoperative from bowel surgery D. 52-year-old woman with moderate asthma and severe degenerative joint disease of the right knee
C. 67-year-old woman 2 days postoperative from bowel surgery
The client who has had a myocardial infarction is admitted to the telemetry unit. Which referral would be most appropriate for the client? A. Social worker B. Physical therapy C. Cardiac rehabilitation D. Occupational therapy
C. Cardiac rehabilitation
A patient with heart failure is taking Losartan and Spironolactone. The patient is havingEKG changes that presents with tall peaked T-waves and flat p-waves. Which of the following lab results confirms these findings? A. Na+ 135 B. BNP 560 C. K+ 8.0 D. K+ 1.5
C. K+ 8.0
A nurse completing discharge teaching regarding diet with a client who had a surgical placement of a mechanical heart valve. Which of the following statements by the client indicates understanding of the teaching? A."I will be sure to eat high-fat dairy products." B."I will be glad to get back to my normal eating habits right away of lots of red and processed meats." C."I will be sure to limit my intake of foods containing saturated fats and sugar." D."Foods that are high in sodium are encouraged."
C."I will be sure to limit my intake of foods containing saturated fats and sugar."
An intensive care nurse is aware of the need to identify patients who may be at risk of developing disseminated intravascular coagulation (DIC). Which of the following ICU patients most likely faces the highest risk of DIC? A) A patient with extensive burns B) A patient who has a diagnosis of acute respiratory distress syndrome C) A patient who suffered multiple trauma in a workplace accident D) A patient who is being treated for septic shock
D) A patient who is being treated for septic shock
A patient is being treated for DIC and the nurse has prioritized the nursing diagnosis of Risk for Deficient Fluid Volume Related to Bleeding. How can the nurse best determine if goals of care relating to this diagnosis are being met? A) Assess for edema. B) Assess skin integrity frequently. C) Assess the patients level of consciousness frequently. D) Closely monitor intake and output.
D) Closely monitor intake and output.
The nurse would promote hemodynamic stability in a patient with upper GI bleeding by: A) Encouraging oral fluid intake B) Monitoring central venous pressure C) Monitoring laboratory test results and vital signs D) Giving blood, electrolytes, and fluid replacement
D) Giving blood, electrolytes, and fluid replacement
A patient diagnosed with diabetes mellitus is being discharged home and you are teaching them about preventing DKA. What statement by the patient demonstrates they understood your teaching about this condition? (Page, 2016). A. "I should not be alarmed if ketones are present in my urine because this is expected during illness." B. "It is normal for my blood sugar to be 250-350 mg/dL while I'm sick." C. "I will hold off taking my insulin while I'm sick." D. "It is important I check my blood glucose every 3-4 hours when I'm sick and consume liquids."
D. "It is important I check my blood glucose every 3-4 hours when I'm sick and consume liquids."
These drugs are used as first-line treatment of heart failure. They work by allowing more blood to flow to the heart which decreases the workload of the heart. However, some patients can develop a nagging cough with these types of drugs. This description describes? A. Beta-blockers B. Vasodilators C. Angiotensin II receptor blockers D. Angiotensin-converting-enzyme inhibitors
D. Angiotensin-converting-enzyme inhibitors
What type of insulin do you expect the doctor to order for treatment of DKA? A. IV Novolog B. IV Levemir C. IV NPH D. IV Regular Insulin
D. IV Regular Insulin
A nurse is assessing a patient expected to have diabetic ketoacidosis. She would expect to see all of the following findings except: A. Kussmaul respirations B. GI effects (nausea, vomiting, & abdominal pain) C. Fruity odor of breath D. Weight gain E. Polydipsia
D. Weight gain
The nurse should set which goals when planning care for the family of a dying ICU patient? (Select all that apply) a. Encourage family members to talk about their feelings and concerns. b. Establish trust between the family and the members of the health care team. c. Identify and respect the family's cultural and religious beliefs or practices. d. Establish respect for family choices and support their decisions. e. Establish a sympathetic approach in response to family members' feelings.
a, b, c, d
A patient with septic shock has a BP of 70/46 mm Hg, pulse 136, respirations 32, temperature 104° F, and blood glucose 246 mg/dL. Which of these prescribed interventions will the nurse implement first? a. Bolus of 30ml/kg of crystalloid solution b. Infuse drotrecogin- (Xigris) 24 mcg/kg. c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL. d. Titrate norepinephrine (Levophed) to keep mean arterial pressure (MAP) at 65 to 70 mm Hg.
a. Bolus of 30ml/kg of crystalloid solution
A patient is admitted to the ED with chest pain that is consistent with MI based on elevated troponin levels. Heart sounds are normal. The nurse should alert the primary health care provider because the vital sign changes & pt assessment are most consistent with which complication? a. Cardiogenic Shock b. Cardiac Tamponade c. Pulmonary Embolism d. Dissecting Thoracic Aortic Aneurysm
a. Cardiogenic Shock
When caring for a patient in acute septic shock, what should the nurse anticipate? a. Infusing large amounts of IV fluids b. Administering osmotic and/or loop diuretics c. Administering IV diphenhydramine (Benadryl) d. Assisting with insertion of a ventricular assist device (VAD)
a. Infusing large amounts of IV fluids
A client who is admitted after a thermal burn injury has the following vital signs: blood pressure 70/40, heart rate 140 bpm, respiratory rate 25/min. He is pale in color and it is difficult to find pedal pulses. Which action will the nurse take first? a. Begin intravenous fluids b. Check the pulses with a Doppler device c. Obtain a Complete Blood Count (CBC) d. Obtain an Electrocardiogram (ECG)
a. begin intravenous fluids
The client is diagnosed with meningococcal meningitis. Which preventive measure would the nurse expect the health-care provider to order for the significant others living in the client's home? a. Haemophilus influenzae vaccine. b. Antimicrobial chemoprophylaxis. c. 10-day dose pack of corticosteroids. d. A gamma globulin injection.
b. Antimicrobial chemoprophylaxis.
A nurse is assessing a client who reports severe headache and a stiff neck. The nurse's assessment reveals positive Kernig's and Brudzinski's signs. Which of the following actions should the nurse perform first? a. Administer antibiotics b. Implement droplet precautions c. Initiate IV access d. Decrease bright lights
b. Implement droplet precautions
A patient is on IV heparin to treat a PE. The patient's most recent PTT was 25 seconds. What order should the nurse anticipate? a. Decrease the heparin rate b. Increase the heparin rate c. No change to the heparin rate d. Stop heparin: start warfarin (Coumadin)
b. Increase the heparin rate
During which stage of shock does increased vascular permeability occur? a. Compensatory b. Progressive c. Initial d. None of the above
b. Progressive
The hospice nurse visits a client who is dying of breast cancer. During the visit, the client says, "If I can just live long enough to celebrate my daughter's 'sweet 16' birthday party, I'll be ready to die." Which phase of coping is this client experiencing? a. Anger b. Denial c. Bargaining d. Depression
c. Bargaining
A client has experienced a PE. The nurse should assess for which symptom, which is commonly most reported? a. Hot , flushed feeling b. Sudden chills and fever c. Chest pain that occurs suddenly d. Dyspnea when deep breaths are taken
c. Chest pain that occurs suddenly
Ten hours after the client with 50% burns is admitted, her blood glucose level is 140 mg/dL. What is the nurse's best action? a. Repeat the glucose measurement b. Obtain a family history of diabetes c. Document the finding d. Stop IV fluids containing dextrose
c. Document the finding
During admission of a patient diagnosed with metastatic breast cancer, you assess for which of the following as a key indicator of clinical depression related to terminal illness? a. Frustration with pain b. Anorexia and nausea c. Feelings of hopelessness d. Inability to carry out activities of daily living
c. Feelings of hopelessness
The nurse recognizes which clinical manifestation as suggestive of sepsis? a. Diuresis unrelated to medication therapy b. Respiratory rate of eight breaths per minute c. Hyperglycemia in the absence of diabetes d. Bradycardia in addition to an increase in blood pressure
c. Hyperglycemia in the absence of diabetes
A patient with PE may develop hypotension for which of the following reasons? a. Pressure on the heart and reduced CO b. Reduced BF to the lungs c. Increased pulmonary vascular resistance and reduced blood delivery to the L side of the heart d. Reduced blood return to the R side of the heart leading to lower BP
c. Increased pulmonary vascular resistance and reduced blood delivery to the L side of the heart
A nurse is reviewing the lab values of a 65 year old woman admitted to the ED with AKI due to dehydration. Which of the following lab values requires immediate intervention? a. Na+: 148 mEq/L b. BUN: 32 mg/dL c. K+: 6.1 mmol/L d. Cr: 2.10 mg/dL
c. K+: 6.1 mmol/L
A 23-year-old male client who has had a full-thickness burn is being discharged from the hospital. Which information is most important for the nurse to provide prior to discharge? a. How to maintain home smoke detectors b. Joining a community reintegration program c. Learning to perform dressing changes d. Options available for scar removal
c. Learning to perform dressing changes
A patient with AKI has a urinary output of 350 mL/day. In addition, morning labs showed an elevated BUN, creatinine, and potassium level. Which type of diet ordered by the physician is the most appropriate for the patient? a. Low-sodium, high-protein, and low-potassium b. High-protein, low-potassium, and low-sodium c. Low-protein, low-potassium, and low-sodium d. High-protein and high-potassium
c. Low-protein, low-potassium, and low-sodium
A client is diagnosed with a ST segment elevation myocardial infarction (STEMI) and is receiving a tissue plasminogen activator, alteplase. Which action is a priority nursing intervention? a. Monitor for kidney failure b. Monitor psychosocial status c. Monitor for signs of bleeding d. Have Heparin sodium available
c. Monitor for signs of bleeding
A patient with AKI has the following lab values: creatinine 2.3 mg/dL, BUN 35 mg/dL, K+ 5.8 mmol/L. The patient's urine output in the past hour was 25 mL. Based on these findings, the nurse is aware that the patient is in what phase of AKI? a. Initiation b. Recovery c. Oliguric d. Diuresis
c. Oliguric
A nurse is planning care for a patient who has prerenal acute kidney injury following abdominal aortic aneurysm repair. Urinary output is 63 ml in the past 2 hr, and blood pressure is 93/59 mm Hg. The nurse should anticipate which of the following interventions? a. Prepare the patient for a CT scan with contrast dye b. Plan to administer nitroprusside c. Prepare to administer a fluid challenge d. Plan to position the patient in Trendelenburg
c. Prepare to administer a fluid challenge
A client in shock has been started on dopamine. What assessment finding requires the nurse to communicate with the provider immediately? a. Blood pressure of 98/68 mm Hg b. Pedal pulses 1+/4+ bilaterally c. Report of chest heaviness d. Urine Output of 32 mL/hr
c. Report of chest heaviness
A client has a PE and is started on O2. The student nurse asks why the client's O2 sat has not significantly improved. What response by the nurse is best? a. Breathing so rapidly interferes with oxygenation b. Maybe the client has respiratory distress syndrome c. The blood clot interferes with perfusion in the lungs d. The client needs immediate intubation and mechanical ventilation
c. The blood clot interferes with perfusion in the lungs
A nurse is reviewing the use of the meningococcal vaccine (MCV4) for the prevention of meningitis with a newly licensed nurse. Which of the following should the nurse include in the review? a. The vaccine is indicated to reduce the risk of respiratory infection b. The vaccine is administered in a series of four doses c. The vaccine is recommended for young adults before starting college d. The vaccine is initially given at 2 months of age
c. The vaccine is recommended for young adults before starting college
A nurse is presenting a community education program on recommended lifestyle changes to prevent angina and MI. Which of the following changes should the nurse recommend be made first? a.Diet modification b. Relaxation exercises c. Smoking cessation d. Taking omega-3 capsules
c. smoking cessation
The nurse is assisting in the care of several patients in the critical care unit. Which patient is at greatest risk for developing multiple organ dysfunction syndrome (MODS)? a. 22-year-old patient with systemic lupus erythematosus who is admitted with a pelvic fracture after a motor vehicle accident b. 48-year-old patient with lung cancer who is admitted for syndrome of inappropriate antidiuretic hormone and hyponatremia c. 65-year-old patient with coronary artery disease, dyslipidemia, and primary hypertension who is admitted for unstable angina d. 82-year-old patient with type 2 diabetes mellitus and chronic kidney disease who is admitted for peritonitis related to a peritoneal dialysis catheter infection
d. 82-year-old patient with type 2 diabetes mellitus and chronic kidney disease who is admitted for peritonitis related to a peritoneal dialysis catheter infection
Which client would be most at risk for developing disseminated intravascular coagulation (DIC)? a. A 35 year old pregnant client with placenta previa? b. A 42 year old client with a pulmonary embolism c. A 60 year old client receiving hemodialysis 3 days a week d. A 78 year old client with septicemia
d. A 78 year old client with septicemia
A family member asks the nurse to explain the purpose of hospice care. Which of the following is the best response? Hospice care: a. Is appropriate when the patient desires to intentionally end his life b. Focuses on minimizing the disease process as rapidly as possible c. Focuses on symptom management for patients not responding to treatment d. Is holistic care for patients dying or debilitated and not expected to improve
d. Is holistic care for patients dying or debilitated and not expected to improve
Which intervention should the nurse implement to reduce oxygen consumption in a patient diagnosed with MODS? a. Reduce visitors to immediate family for 2 hours each day. b. Group all nursing interventions at the beginning of the shift. c. Keep the patient flat in bed. d. Promote an atmosphere of calm and quiet within the nursing unit.
d. Promote an atmosphere of calm and quiet within the nursing unit.
You are visiting with the husband of a patient who is having difficulty making the transition to palliative care for his dying wife. What is the most desirable outcome for the couple? a. They express hope for a cure. b. They comply with treatment options. c. They set additional goals for the future. d. They acknowledge the symptoms and prognosis
d. They acknowledge the symptoms and prognosis