Critical Care Hesi practice questions:

The nurse is caring for a client who is admitted to the critical care unit with a closed head injury sustained in a motor vehicle collision. Which finding in the client's vital sign flowsheet indicates an increase in intracranial pressure? A.) Heart rate 45 beats per minute and blood pressure 180/80 mm Hg. B.) Heart rate 70 beats per minute and blood pressure 140/100 mm Hg. C.) Heart rate 90 beats per minute and blood pressure 120/80 mm Hg. D.) Heart rate 110 beats per minute and blood pressure 80/40 mm Hg

A.) Heart rate 45 beats per minute and blood pressure 180/80 mm Hg. A hallmark sign of increased intracranial pressure includes a trending of heart rate and blood pressures changes to bradycardia and systolic hypertension with a widening pulse pressure, which is known as Cushing's triad. The client is manifesting Cushing's triad with a heart rate of 45 beats/minute and a systolic blood pressure of 180 with a widened pulse pressure of 100.

A client with chronic kidney disease (CKD) presents with severe anemia. The nurse administers a dose of epoetin alfa (Procrit) during the hemodialysis procedure. Which finding indicates the medication is effective? A.) Increase in hemoglobin and hematocrit. B.) Decrease in oxygen saturation level. C.) Decrease in BUN and creatinine. D.) Increase in urine output.

A.) Increase in hemoglobin and hematocrit. Epoetin alfa (Procrit) is a man-made version of human erythropoietin (EPO) and is classified as a colony-stimulating factor used to treat anemia associated with chronic kidney disease (CKD). Increases in hemoglobin and hematocrit levels indicate an effective response.

A client is scheduled for an exercise radionuclide stress test. Which medication should the nurse withhold prior to sending the client for the test? A.) Nitrates. B.) Thyroid hormones. C.) Inhalers. D.) Antihypertensives.

A.) Nitrates.

A client arrives in the emergency department experiencing difficulty breathing. Which finding requires further assessment? A.) Use of accessory respiratory muscles. B.) Auscultation of crackles in lower lobes. C.) Flushed skin. D.) Production of white sputum

A.) Use of accessory respiratory muscles. A client who is experiencing dyspnea and is using accessory respiratory muscles with severe respiratory effort requires further assessment and management.

The nurse is assessing a burn victim who suffered destruction of the epidermis and some of the dermis of the entire right arm and half the length of the right leg. How should the nurse document the burn assessment findings? A.) Superficial, 18% TBSA. B.) Superficial partial-thickness, 18% TBSA. C.) Deep-partial thickness, 27% TBSA. D.) Full-thickness, 27% TBSA.

B.) Superficial partial-thickness, 18% TBSA A "superficial partial-thickness" burn involves destruction of the epidermis layer and some of the dermis layer. The total body surface area (%TBSA) is easily calculated by using the "rule of nines" method. In this case, involvement of one arm is calculated as 9% TBSA and one-half of a leg is 9% TBSA for a combined total of 18% TBSA. A total leg involvement is calculated as 18% TBSA.

The nurse is caring for a client in the surgical intensive care unit who received a bone marrow transplant. Which finding should the nurse report to the healthcare provider that indicates the possible onset of graft versus host disease (GVHD)? A.) Jaundice. B.) Polyuria. C.) Bradycardia. D.) Constipation

Graft versus host disease (GVHD) is due to the donor cells recognizing the recipient's cells as foreign, which leads to an immune response in target organs, such as the liver, skin, and gastrointestinal tract. The nurse should report signs of jaundice, maculopapular rash, severe diarrhea, and abdominal pain

A client who experienced an occlusive cerebral vascular accident is receiving warfarin. Which international normalized ratio (INR) result is therapeutic for this client? A.) 2.0 to 3.0. B.) 0.05 to 1.0. C.) 5 times the control value. D.) Equal to the control value.

A.) 2.0 to 3.0. The INR is the best laboratory result to evaluate the effectiveness of warfarin. The nurse should identify the therapeutic level of INR between 2 and 3.

The nurse is caring for a client who presents with stroke-like symptoms. The healthcare provider reviews the client's computerized axial tomography (CAT) scan and prescribes recombinant tissue plasminogen activator (rtPA) IV. Which information should the nurse obtain to determine if the client is a candidate for this treatment now? A.) What time the client's symptoms started. B.) When the client last ate a meal. C.) The client's family history of strokes. D.) The client's recent history of antibiotic therapy

A.) What time the client's symptoms started. Fibrinolytic therapy with intravenous rtPA is successful in reversing the symptoms of an acute thrombolic stroke confirmed on CAT scan. The time frame for the use of rtPA is before and up to 4.5 hours of the onset of symptoms. It is essential for the nurse to determine when the symptoms began before initiating therapy.

A client with diabetic ketoacidosis (DKA) is admitted to the intensive care unit. Which arterial blood gases (ABG) reflect the client's Kussmaul respiratory pattern? A.) pH 7.22, CO 2 31, pO 2 138, HCO 3 14. B.) pH 7.58, CO 2 28, pO 2 128, HCO 3 25. C.) pH 7.40, CO 2 45, pO 2 138, HCO 3 25. D.) pH 7.01, CO 2 28, pO 2 99, HCO 3 22.

A.) pH 7.22, CO 2 31, pO 2 138, HCO 3 14. Kussmauls respirations are a compensatory response to metabolic acidosis that occurs with DKA. The ABG changes include an acidotic pH of 7.22 and compensating CO2 of 31 due to bicarbonate loss of 14. (Normal ABG ranges are pH 7.35 to 7.45; pCO2 35 to 45 mmHg; HCO3 21 to 28 mEq/L, and pO2 80 to 100 mmHg.)

A client with a history of chronic alcoholism is admitted with pneumonia. The nurse inserts two large bore IV catheters andstarts an infusion of 0.9% sodium chlorideat 75 mL/hr and titrates the client's oxygen to 60% by non-rebreather mask. The cardiac monitor displays a sinus tachycardia with multifocal premature ventricular contractions. Which client's serum laboratory values requires immediate intervention by the nurse? A.) Sodium 138 mEq/L. B.) Hemoglobin 9 g/dL. C.) Magnesium 1.0 mg/dL. D.) Potassium 5.5 mEq/L.

C.) Magnesium 1.0 mg/dL. Normal magnesium level is 1.7 to 2.2 mg/dL.Hypomagnesium is critical and may cause a lethal ventricular arrhythmia, torsades de pointes, and requires immediate intervention.

A client is admitted to the emergency department with a flail chest after hitting the steering wheel during a motor vehicle collision. Which pathophysiological mechanism is associated with the client's condition? A.) Thoracic cage instability due to free-floating ribs and chest wall movement contrary to normal respirations. B.) Bronchial spasms that cause wheezing that is louder on exhalation than inhalation. C.) Increased pulmonary pressure causing coughing with large amounts of frothy sputum. D.) Chest constriction that causes severe shortness of breath that limits the ability to say more than a few words.

A.) Thoracic cage instability due to free-floating ribs and chest wall movement contrary to normal respirations. Trauma that disrupts the costal cartilage attachment of the ribs causing a flail chest which is manifested by free-floating ribs moving the chest wall inward with inhalation and outward with exhalation.

The nurse is assessing a client in the intensive care unit who underwent a Whipple procedure. Based on assessment findings, the healthcare provider suspects an anastomotic leak. Which procedure should the nurse prepare the client to expect the healthcare provider to prescribe to confirm this diagnosis? A.) Upper GI study with Gastrografin. B.) Endoscopic retrograde cholangiopancreatography. C.) Barium swallow. D.) Small bowel series.

A.) Upper GI study with Gastrografin An anastomotic leak post Whipple procedure can be confirmed with an upper GI study with Gastrografin (or a computerized tomography scan with contrast) to visualize the reconstruction of the gastrointestinal tract after pancreatic cancer surgery.

A client admitted with thyroid storm is placed on an intravenous esmolol drip. Which outcome should the nurse expect if the medication is effective? A.) Apical heart rate and blood pressure within normal range. B.) Respiratory rate within normal range. C.) Body temperature within normal range. D.) Thyroid stimulating hormone (TSH) within normal range

A.) Apical heart rate and blood pressure within normal range. Thyroid storm, thyrotoxic crisis, is an acute, life-threatening, hypermetabolic state induced by excessive release of thyroid hormones (THs). Esmolol is a beta-adrenergic blocker that decreasess the apical heart rate and blood pressure in a client with thyroid storm.

The nurse is admitting a client diagnosed with hyperosmolar hyperglycemic state (HHS) who is severely dehydrated. The client's vital signs are blood pressure 78/46 mmHg, pulse 130 beats/minute, respirations 22 breaths/minute, CVP 6, and MAP 58. Which intravenous solution should the nurse expect to administer to this client? A.) 0.9% sodium chloride (normal saline). B.) 0.45% sodium chloride (1/2 normal saline). C.) 5% dextrose in lactated ringers (D5LR). D.) 5% dextrose in 0.45% sodium chloride (D5 NS).

A.) 0.9% sodium chloride (normal saline). The client is demonstrating a sign of hypovolemic shock, the fluid of choice for fluid replacement is 0.9% sodium chloride (normal saline) with an initial bolus of one (1) liter of normal saline to replace the extracellular fluid volume deficit.

The nurse is planning care for a client with an intraventricular catheter monitoring device due to increased intracranial pressure (ICP). Which ICP reading indicates a successful outcome for this client? A.) 15 mm Hg. B.) 20 mm Hg. C.) 25 mm Hg. D.) 30 mm Hg.

A.) 15 mm Hg Intracranial pressures (ICP) above 20 mm Hg are associated with intracranial hypertension. An intraventricular catheter is placed to monitor ICP, which is normally maintained below 15 mm Hg to prevent brain damage.

A client is admitted to the intensive care unit with hematemesis related to esophageal varices. Which assessment finding should the nurse identify that is the result of an estimated blood loss at 35% of total blood volume? A.) Absent bowel sounds. B.) Coma. C.) Anuria. D.) Abdominal pain.

A.) Absent bowel sounds. Massive blood loss redirects a significant amount of blood flow to vital organs. A client who has lost 30% to 40% of the total blood volume will exhibit absent bowel sounds, lethargy, and increased serum potassium.

A client is extubated and placed on 40% oxygen via face mask. The nurse finds the client confused while attempting to get out of bed. Oxygen saturation is 96%. Which intervention should the nurse implement? A.) Administer a prn IV sedative. B.) Change mask to partial rebreather. C.) Limit visitors to immediate family. D.) Apply bilateral soft wrist restraints.

A.) Administer a prn IV sedative. The client is presenting with signs of altered sleep pattern in which a sedative will help the client rest. There are also several modifiable factors that cause sleep disruption in critically ill clients, such as noise, light, client care interactions, and medications.

A client is scheduled for a cardiac catheterization. Which intervention should the nurse perform prior to sending the client for the procedure? A.) Administer prescribed medications. B.) Insert an indwelling urinary catheter. C.) Teach about the effects of anesthesia. D.) Review total cholesterol and triglyceride levels.

A.) Administer prescribed medications. Prior to a cardiac catheterization, the nurse should administer the prescribed cardiac medications to prevent complications during the procedure.

The nurse is caring for a client diagnosed with systemic inflammatory response syndrome (SIRS) that is progressing to multiple organ dysfunction syndrome (MODS). Vital signs reveal a blood pressure of 65/34 and rapidly decreasing oxygen saturation levels. Which action is most important for the nurse to implement after the healthcare provider inserts a pulmonary artery (PA) catheter? A.) Administer prescribed vasopressors per infusion pump. B.) Evaluate telemetry for sudden onset of dysrhythmias. C.) Document hourly urine output and parental fluid intake. D.) Monitor integrity and output of nasogastric tube to intermittent suction

A.) Administer prescribed vasopressors per infusion pump Systemic decompensation due to systemic inflammatory response syndrome (SIRS) progresses to multiple organ dysfunction syndrome (MODS). Critically low blood pressure in a client with advanced SIRS is indicative of septic shock. The priority action is to administer prescribed vasopressors.

A client is admitted to the intensive care unit with hepatic encephalopathy secondary to cirrhosis. The client is lethargic and confused. The healthcare provider prescribes lactulose. Which finding indicates a positive response to the medication? A.) An increase in alertness and orientation. B.) Serum ammonia level 80 mcg/dL (47 mol/L). C.) Multiple diarrheal stools per day. D.) Decreased jaundice of skin and sclera.

A.) An increase in alertness and orientation. Hepatic dysfunction causes an elevated ammonia levels that cause mental status changes in clients with hepatic encephalopathy. Lactulose, an osmotic laxative and colonic acidifier, pulls ammonia from the serum into the gut to facilitate ammonia elimination. An improved mental state indicates a positive response to lactulose.

The nurse is caring for a client with end-stage liver disease who is actively dying. Some family members are tearful, while other family members are arguing. Which professional should the nurse consult to help the family? A.) Pastoral care services. B.) Security. C.) Health care provider. D.) Bereavement counselor.

A.) Pastoral care services. End-of-life issues can place a strain on the family. The nurse should contact a pastoral care associate to assist with spiritual and emotional needs of a family with a dying member.

A client is admitted to the intensive care unit with asthma and an upper respiratory infection. The client is experiencing severe bronchospasms and develops status asthmaticus. Which prescription should the nurse administer first? A.) Beta 2-antagonist. B.) Antihistamine. C.) Decongestant. D.) IV antibiotics.

A.) Beta 2-antagonist. Beta2-antagonists and corticosteroids are used to treat status asthmaticus. Beta2-antagonists facilitate smooth muscle relaxation, while steroids decrease inflammation of the airways and enhance the effects of beta2-antagonists.

The nurse is caring for a client with a chest tube placed in the right lower lobe due to pneumothorax. Which finding indicates to the nurse that the chest tube has been successful? A.) Clear breath sounds bilaterally. B.) Positive Hamman's sign. C.) Increased opacity on chest X-ray. D.) Hyperresonance of the right lower lobe.

A.) Clear breath sounds bilaterally.

A client is admitted to the intensive care unit after a sudden onset of sharp chest pain and shortness of breath. The healthcare provider suspects a pulmonary embolism and prescribes a pulmonary angiogram. Which additional assessment finding requires immediate intervention by the nurse? A.) Confusion and restlessness. B.) Blood tinged sputum. C.) Oxygen saturation 90 percent. D.) Nausea with projectile emesis.

A.) Confusion and restlessness Signs of confusion and restlessness are critical indications that the client is hypoxic due to poor oxygenation or airway occlusion.

The nurse is planning care for a client admitted to the intensive care unit with acute infected necrotizing pancreatitis. Which diagnostic procedure should the nurse prepare the client to expect the healthcare provider to prescribe? A.) Contrast-enhanced computed tomography (CT). B.) Endoscopic retrograde cholangiopancreatography (ERCP). C.) Abdominal radiography. D.) Abdominal ultrasound.

A.) Contrast-enhanced computed tomography (CT) Contrast-enhanced computed tomography (CT) is the imaging modality of choice to evaluate peripancreatic necrosis.

The nurse is developing the plan of care for a client who is receiving mechanical ventilation. Which intervention should the nurse include to prevent ventilator-associated pneumonia (VAP)? A.) Daily oral care with chlorhexidine. B.) Percussion and postural drainage. C.) Supine positioning. D.) Prophylactic antibiotic administration.

A.) Daily oral care with chlorhexidine The use of bundle methodology combines care delivery interventions proven effective in decreasing the risk of risk of ventilator-associated pneumonia (VAP) and optimizing client outcomes. Daily management interventionstarget endotracheal tube colonization and microaspiration and include oral decontamination with daily oral care with chlorhexidine.

The nurse is caring for a client who is receiving mechanical ventilation due to systemic inflammatory response syndrome (SIRS). Which intervention should the nurse include in the plan of care to meet the client's metabolic needs? A.) Give enteral nutrition. B.) Administer 0.9% sodium chloride. C.) Administer intravenous albumin. D.) Monitor prealbumin levels

A.) Give enteral nutrition. Systemic inflammatory response syndrome (SIRS) is related to systemic inflammation, organ dysfunction, and organ failure, which stresses and increases the demand for metabolic needs. The nurse should administer prescribed enteral feedings to meet these metabolic needs.

A client is mechanically ventilated for respiratory failure and struggles to breathe. The client has a respiratory rate of 32, heart rate of 126, and O2 saturation of 98%. The nurse checks the circuit for leaks, assures the endotracheal tube is properly placed, and notifies the healthcare provider about the client's distress. Which prescription should the nurse implement? A.) Give sedation to allow the ventilator to adequately assist the client's respirations. B.) Increase the set rate of respirations of the ventilator. C.) Obtain arterial blood gases (ABGs) in one hour to evaluate the client's status. D.) Administer a paralytic agent to allow full ventilator support.

A.) Give sedation to allow the ventilator to adequately assist the client's respirations. The client is experiencing respiratory distress from fighting the ventilator. The nurse should administer a sedative to relax and calm the client, allowing the ventilator to provide adequate respiratory support

The nurse is providing care for a newly admitted client diagnosed with hepatic failure. Which interventions should the nursing perform while providing care for the client? (Select all that apply.) A.) Give stool softeners. Correct B.) Measure the abdominal girth. Correct C.) Encourage a high protein diet. D.) Monitor BUN, LFTs, PT/PTT levels. Correct E.) Take glucometer readings every 2 to 4 hours.

A.) Give stool softeners. B.) Measure the abdominal girth. D.) Monitor BUN, LFTs, PT/PTT levels. Clients with hepatic failure are at an increased risk of coagulation abnormalities causing an increased risk of bleeding; alteration in liver function; and the development of ascites from third spacing. The nurse should implement interventions to minimize the risk of bleeding such as stool softeners, and limited puncture sites into skin. The nurse should also limit the amount of protein intake, perform abdominal girths to assess for the development of ascites, and monitor lab work for coagulation discrepancies such as PT/PTT and liver function tests such as the BUN.

While caring for a client with a transvenous pacemaker, the nurse observes a sudden loss of myocardial capture. Which intervention is most important for the nurse to implement after notifying the healthcare provider? A.) Increase output on the generator to attempt recapture. B.) Flush the intravenous catheters to ensure patency. C.) Call for the emergency cart to be brought to the bedside. D.) Obtain a complete set of vital signs for healthcare provider.

A.) Increase output on the generator to attempt recapture. Loss of capture can signify that the pacing electrode has migrated out of position or perforated the right ventricle. The nurse should attempt to increase the output and notify the healthcare provider immediately.

A client with a transvenous pacemaker pacing at rate of 75 beats per minute reports sudden shortness of breath and chest pain. The cardiac monitor alarms and the nurse observes a regular rhythm at a rate of38 beats per minute. What action should the nurse implement? A.) Increase the output on the pacemaker generator. B.) Turn up the generator rate until capture is achieved. C.) Decrease the sensitivity and pacing threshold. D.) Tightentransvenous generator wire connections.

A.) Increase the output on the pacemaker generator The transvenous pacemaker is not capturing. The output should be increased immediately to provide more energy to the heart muscle. Turning up the rate and decreasing the sensitivity will not provide more energy to the heart muscle.

The nurse caring is caring for a client with advanced metastatic cancer that has not responded to treatment. The healthcare provider prescribes palliative care only. Which intervention should the nurse withhold? A.) Intubation with mechanical ventilation. B.) Around-the-clock pain medication. C.) Regular diet as tolerated. D.) Bronchodilators for shortness of breath.

A.) Intubation with mechanical ventilation. Palliative care provides clients with comfort measures as they near the end of life. When the healthcare provider prescribes palliative care only, the nurse should withhold life-saving interventions, such as intubation with mechanical ventilation.

A client in the intensive care unit (ICU) is receiving continuous renal replacement therapy (CRRT) due to acute kidney injury (AKI). The nurse detects blood leaking from the central venous catheter insertion site. Which action should the nurse perform after receiving elevated clotting time results? A.) Lower heparin dose. B.) Position client on back. C.) Decrease CRRT rate. D.) Obtain serum electrolytes.

A.) Lower heparin dose. Dual-lumen temporary hemodialysis catheters for continuous renal replacement therapy (CRRT) are placed by ultrasound guidance into the jugular vein and require anticoagulation therapy to maintain patency. If overt bleeding is observed at the central venous catheter insertion site and clotting times are elevated, the nurse should decrease the heparin dose per prescribed heparin protocol to maintain the vascular access and ensure efficient CRRT.

The nurse is caring for a client admitted to the surgical intensive care unit (ICU) after undergoing gastrointestinal surgery. Which intervention should the nurse include in the plan of care to minimize the risk for vomiting? A.) Maintain patency of nasogastric tube to low intermittent suction. B.) Provide a soft, bland diet with oral liquids, such as diluted juices. C.) Initiate Dextrose 5% in Lactated Ringer's (D 5LR) solution IV at 125 mL/hour. D.) Insert a rectal tube followed with progressive mobilization techniques.

A.) Maintain patency of nasogastric tube to low intermittent suction. Gastrointestinal (GI) surgery often requires postoperative nasogastric tube (NGT) insertion for low intermittent suction to prevent intestinal blockage due to absent or decreased peristalsis. The plan of care should include maintaining patency of the NGT to low intermittent suction, which empties the stomach and minimizes nausea and vomiting.

The nurse is planning care for a client in the surgical intensive care who is one day post liver transplant. Which intervention should the nurse include in the plan of care? A.) Monitor temperature every 4 hours. B.) Increase fresh fruits and vegetables in the diet. C.) Assist client to ambulate in the halls. D.) Assess lung sounds every 12 hours.

A.) Monitor temperature every 4 hours. Clients undergoing organ transplantation are receiving immunosuppressant medications, which increase the risk of infection. The plan of care should include monitoring for signs of infection and obtaining the client's temperature every 4 hours around the clock.

A client's assessment reveals S3 and S4 heart sounds, pulmonary crackles, blood pressure 86/52 mmHg, heart rate 110 beats/minute, and a respiratory rate 18 breaths/minute. The hemodynamic monitor readings reveals a decrease in the height of the waveform, stroke volume of 34 mL, and a central venous pressure of 10 mmHg. How should the nurse calculate the cardiac output for this client? A.) Multiply (34 mL) X (110 beats/minute). B.) Multiply (110 beats/minute) X (52 mmHg). C.) Multiply (52 mmHg) X 2, plus (86 mmHg)/ divided by 3. D.) Multiply (10 mmHg) X (110 beats/minute)/ divided by 2.

A.) Multiply (34 mL) X (110 beats/minute) The cardiac output is determined by multiplying the (stroke volume) X the (heart rate). The cardiac output for this client would be (34 mL) X (110 beats/minute) = 3740 mL/minute (3.74 L/minute). The normal cardiac output is 4-8 L/minute.

The post anesthesia care unit (PACU) nurse transfers a client to the intensive care unit (ICU) and reports that the client received morphine sulfate 4 mg IV for pain of 8 on a scale of 1 to 10. On assessment in the ICU, the nurse observes that the client is somnolent, difficult to arouse, and has a respiratory rate is 6 breaths/minute. Which prescription should the nurse implement? A.) Naloxone. B.) Morphine sulfate. C.) Albuterol. D.) Fentanyl.

A.) Naloxone. The client is experiencing respiratory depression from the morphine. The nurse should administer naloxone, the antidote for narcotic overdose.

An intubated client is in the process of being weaned off ventilator support. The client's baseline parameters are temperature 98.2 F (36.8 C), heart rate 88 beats/minute, respirations 14 breaths/minute, blood pressure 112/78 mmHg, and oxygen saturation 94%. Which assessment findings would indicate to the nurse that the client is tolerating the weaning procedure? (Select all that apply.) A.) Oxygen saturation is 91% B.) Slight nasal flaring is present. C.) Heart rate is 97 beats/minute. D.) Work of breathing is done by client E.) Respiratory rate is 36 breaths/minute.

A.) Oxygen saturation is 91% C.) Heart rate is 97 beats/minute. D.) Work of breathing is done by client Criteria that indicates a client is tolerating weaning off ventilator support are respirations greater than 8 breaths/minute, but less than 35 breaths/minute; oxygen saturation above 90%; heart rate that does not increase more than 20% from baseline heart rate; most of the work of breathing is performed by the client; and no signs of accessory muscles are used for breathing.

A client is admitted to the intensive care unit due to a sharp blow to the head after a fall while ice skating. Which assessment finding should the nurse report to the healthcare provider that is consistent with increased intracranial pressure? A.) Papilledema. B.) Lump at the site of injury. C.) Unilateral ptosis. D.) Onsert of a headache.

A.) Papilledema. Papilledema is observed via ophthalmoscopic view of swelling around the optic disc, which results from increased intracranial pressure (ICP) in the cerebral vault. The nurse should report signs of increased ICP to the healthcare provider immediately.

The nurse is analyzing an arterial blood gas of a client who is mechanically ventilated. The ABG results are pH 7.32; paCO2 50 mmHg; HCO3 30mEq/liter. How should the nurse interpret this blood gas? A.) Partially compensated respiratory acidosis. B.) Partially compensated respiratory alkalosis. C.) Partially compensated metabolic acidosis. D.) Partially compensated metabolic alkalosis.

A.) Partially compensated respiratory acidosis The normal arterial blood gas (ABG) levels are pH: 7.35-7.45; paCO2: 35-45 mmHg; HCO3: 22-26 mEq/liter. In partially compensated respiratory acidosis because the pH is not within normal limits, compensation is attempting to correct the pH. In compensation, the opposite of the disorder compensates to bring the pH to normal range. In this case, the HCO3 is elevated to compensate for the paCO2.

The nurse is assessing a client who underwent a transsphenoidal hypophysectomy. Which assessment finding indicates the client is experiencing a postoperative cerebrospinal fluid (CSF) leak? A.) Persistent postnasal drip with clear nasal drainage. B.) Oxygen saturation level of 92%. C.) Urine specific gravity 1.018. D.) Nausea with a decreased appetite

A.) Persistent postnasal drip with clear nasal drainage. The surgical entry for a transsphenoidal hypophysectomy is via the nasal passage through the sphenoid sinus to access the pituitary gland. A nasal drip pad is placed under the nares to evaluate for bleeding or leakage of cerebrospinal fluid (CSF) that can result from the surgical procedure in which the dura mater is punctured. Persistent nasal drip with clear drainage is a sign of a CSF leak, and immediate intervention is required.

The nurse is caring for a client admitted to the critical care unit after sustaining injuries in a motor vehicle collision. Which admission assessment finding indicative of a possible splenic rupture should the nurse report to the healthcare provider? A.) Positive Kehr's sign. B.) Positive Grey Turner's sign. C.) Pain at McBurney's point. D.) Rebound tenderness and rigidity.

A.) Positive Kehr's sign. Signs of splenic rupture include referred pain to the left shoulder, which is known as a positive Kehr's sign, which the nurse should report immediately.

The healthcare provider prescribed propofol IV and succinylcholine IV for a client who is being prepared for intubation. Which action should the nurse implement to assist the healthcare provider during administration of these two drugs? A.) Prepare propofol for sedation before giving succinylcholine, a paralytic. B.) Succinylcholine should be prepared for administration first. C.) Mix both medications at the same time in the same syringe. D.) Question the administration and refused to provide propofol.

A.) Prepare propofol for sedation before giving succinylcholine, a paralytic. Propofol, a sedative-hypnotic, is used to sedate a client during induction of anesthesia, and succinylcholine is a paralytic drug used to prevent laryngospasm during intubation and to prevent the client's resistance to intubation. The client should be sedated before being paralyzed, which can be very stressful to the client who is not able to move, breathe, or talk. The nurse should prepare propofol for the administration by the healthcare provider first, then succinylcholine can be given by the healthcare provider.

The nurse is providing care to an intubated client diagnosed with acute respiratory distress syndrome. The nurse should place the client in which position? A.) Prone. B.) Supine. C.) Semi-fowlers. D.) Trendelenburg.

A.) Prone. An intubated client diagnosed with acute respiratory distress syndrome is generally placed in the prone position for 16 hours per day. This is an ideal position for the intubated client. This position removes the weight of the heart and abdomen away from the lungs and improves the oxygenation of the lungs.

The nurse is caring for a client admitted to the critical care unit for treatment of near-drowning in salt water. Which finding should the nurse report to the healthcare provider immediately? A.) Rales or crackles over all lung fields. B.) Bradycardia. C.) Elevated blood alcohol level. D.) Elevated blood pressure.

A.) Rales or crackles over all lung fields. Salt water drownings cause fluid to move from the vascular space into the alveoli due to the hypertonicity of the salt water, which leads to pulmonary edema. The breath sounds consistent with pulmonary edema are rales or crackles, described as discontinuous short bubbling sounds corresponding to the splashing of the fluid in the alveoli during breathing that should be reported to the healthcare provider immediately.

A client in the intensive care unit begins to manifest seizure activity while the unlicensed assistive personnel (UAP) is providing a bedbath. The UAP pulls the emergency call bell and calls for help. Which action by the UAP should the nurse correct? A.) Restraining the client's extremities. B.) Loosening restrictive clothing. C.) Padding the raised side rails. D.) Placing the client in a lateral position

A.) Restraining the client's extremities. A client should be protected as much as possible during seizure activity. The nurse should direct the UAP to refrain from restricting the client's extremities with restraints, which can cause injury to the client and the person who is holding or applying restraints on the client.

The nurse is monitoring the renal function of a client in the intensive care unit (ICU). The client is receiving vancomycin and ceftriaxone for sepsis. Which finding indicates the onset of acute kidney injury (AKI)? A.) Serum creatinine 2.8 mg/dL or 247 umol/L (SI units). B.) Cloudy malodorous urine. C.) Urine output 1,000 mL/24 hours. D.) Peripheral edema of lower extremities.

A.) Serum creatinine 2.8 mg/dL or 247 umol/L (SI units). A client who is receiving vancomycin and ceftriaxone is at an increased risk for acute kidney injury (AKI). The client's renal function is compromised as evidenced by a serum creatinine of 2.8 mg/dL (247 umol/L) above normal range of 0.6 to 1.2 mg/dL (53 to 106 umol/L) and supports a AKI.

The nurse applies external self-adhesive pacemaker pads to the chest of a client who has symptomatic bradycardia that has been unresponsive to several doses of atropine sulfate (Atropine). The nurse is setting the pacemaker rate and level of energy. Which nursing intervention is most important when setting the pacemaker to obtain myocardial capture? A.) Slowly increase the mA setting until capture is present. B.) Set the mA an additional 2 mA above where capture began. C.) Put the pacemaker in the demand mode. D.) Program the pacemaker rate to match the client's intrinsic rate.

A.) Slowly increase the mA setting until capture is present. The mA setting controls the amount of energy output. Slowly increasing the mA setting will allow the nurse to stop at the lowest amount of energy that consistently results in myocardial capture and contraction. Using the lowest amount of energy will also minimize discomfort.

The nurse is assigned to care for a client with IV fluids infusing at 100 mL/hr and a nasogastric tube with enteral feedings infusing at 60 mL/hr. The client is mechanically ventilated with 40% FiO2. Peak inspiratory pressures were 24 cm H 2O fours ago and are now 62 cm H 2O. What intervention should the nurse implement? A.) Suction the endotracheal tube. B.) Decrease the IV to 50 mL/hr. C.) Turn off the enteral feedings. D.) Increase the FiO 2 to 100%.

A.) Suction the endotracheal tube. Normal peak inspiratory pressures (PIP) are 25 to 30 cm H2O. When the lung compliance is restricted, the PIP increases and immediate intervention is required. A kink in the ventilator tubing or secretions in the endotracheal tube will cause an increase in the PIP.

A client arrives in the emergency department with a gunshot wound to the chest. The client is short of breath, has tracheal deviation to the unaffected side of the chest, and an O2 saturation of 84%. Which pathophysiologic process is precipitating the client's findings? A.) Tension pneumothorax. B.) Flail chest. C.) Pulmonary contusion. D.) Acute respiratory distress syndrome

A.) Tension pneumothorax A gunshot wound that penetrates the chest wall allows air to enter the pleural space causing respiratory distress due to a tension pneumothorax that shifts the trachea from midline and to the unaffected side of the chest.

The nurse is caring for a client admitted to the intensive care unit with full-thickness burns covering 20% of the body. A family member states that the burns do not look too bad and asks why the healthcare provider is being so aggressive with treatment. Which response should the nurse provide? A.) Treatment is provided for extensive burns which can manifest more damage after the first 24 hours of shock. B.) Consult with the health care provider about specific questions about therapy to alleviate your concerns. C.) Burns appearance and depth provides guidelines for the appropriate treatment being provided. D.) Treatment is approached cautiously because of the type of burn the client sustained.

A.) Treatment is provided for extensive burns which can manifest more damage after the first 24 hours of shock. The nurse should address the family member's concerns by explaining the reason for the aggressive plan of care. The standard of care for burns is to initiate aggressive care for clients with burn injuries in the first 24 hours of initial shock.

The nurse is caring for a client in the critical care unit admitted with hypovolemic shock. The nurse administers intravenous fluids and vasopressors and assesses vital signs. Which finding indicates the client is responding to the treatment regimen? A.) Urine output 1,000 mL/24 hours. B.) Mean arterial pressure 60 mmHg. C.) PaCO 2 greater than 45. D.) Consuming 25% of meals provided.

A.) Urine output 1,000 mL/24 hours In hypovolemic shock, hypoperfusion to the kidneys decreases urine formation and causes oliguria. Effective response to treatment is demonstrated by urine output greater than 30 mL/hour or 1,000 mL/24 hours.

The nurse is providing care for a client who is comatose following a cardiac arrest 24-hours ago. Which physical assessment finding should the nurse determine to be a predictor of a poor outcome? A.) Lack of response to a sternal rub. B.) Lack of corneal or papillary response. C.) Lack of purposeful motor movement. D.) Lack of response to verbal stimulation.

B.) Lack of corneal or papillary response. The two best predictors of poor outcomes for a comatose client who has experienced a cardiac arrest are lack of corneal or papillary response at 24-hours and lack of motor movement at 72-hours.

The nurse is assisting the healthcare provider with the insertion of a pulmonary artery catheter for a client. The nurse should place the client in which position for this procedure? A.) Right lateral. B.) Semi-Fowler. C.) Trendelenberg. D.) Dorsal recumbent.

C.) Trendelenberg Placing the client in the Trendelenburg position promotes easier venous filling in the upper body to facilitate insertion of the catheter into the jugular vein and minimizes the occurrence of an air embolism during the procedure.

After extensive chemotherapy, a client requires a right thoracotomy for removal of the middle and lower lobes. The nurse is assessing the two chest tubes that are attached to a chest drainage system to re-establish negative pleural pressure. Which finding provides the earliest indication that the client is experiencing chest tube displacement? A.) Increased serousangious chest tube drainage. B.) Diminished right lower lobe breath sounds. C.) Air bubbles noted in the air leak meter. D.) Reports of intense pain at insertion site

B.) Diminished right lower lobe breath sounds. Diminished or absent lung sounds indicate that the lung is being inadequately ventilated, which can be a result of chest tube dislodgement.

The nurse is providing care for a client on a ventilator who is demonstrating a tracheal shift to the right, decreased breath sounds on the left side, tachycardia and hypotension. Which action should the nurse implement first? A.) Instill 5 mL normal saline into the endotracheal tube and suction until clear of mucus plugs. B.) Disconnect the endotracheal tube from the ventilator and ventilate with a bag-valve device. C.) Contact respiratory therapy to increase the PIP and PEEP pressures, and the FiO 2 liters per minute. D.) Verify the ventilator settings and check all the ventilator tubing for kinking and connections for air leaks

B.) Disconnect the endotracheal tube from the ventilator and ventilate with a bag-valve device A ventilated client who is demonstrating signs of a tension pneumothorax should be disconnected from the ventilator and ventilated with a bag-valve device until a needle decompression is performed or a chest tube inserted. A tracheal shift, decreased breath sounds accompanied with tachycardia and hypotension are signs of a tension pneumothorax.

One day after receiving a heart valve replacement, a client is extubated and placed on 40% oxygen via face mask. The nurse balances and calibrates the pulmonary artery catheter prior to documenting the client's values. Which intervention is most important for the nurse to implement? A.) Monitor and record hourly pulmonary artery pressures and wedge pressures. B.) Identify a spontaneous wedged catheter waveform and ensure the balloon is deflated. C.) Expel air from the balloon syringe and reconnect the empty balloon syringe to the catheter. D.) Disconnect the syringe from the balloon inflation port to ensure the balloon is deflated.

B.) Identify a spontaneous wedged catheter waveform and ensure the balloon is deflated. Unless the nurse is obtaining wedge pressures, the pulmonary artery waveform should not appear wedged. This is an indication that the catheter has migrated into the pulmonary artery and requires immediate intervention to ensure no air is in the balloon, causing an occlusion of the pulmonary artery.

he critical care nurse is providing care for a client diagnosed clinically brain dead and identified as an organ donor. Which are the nurse's priorities in providing care? (Select all that apply.) A.) Sustaining a state of hypothermia. B.) Maintaining a normal blood pressure. C.) Ensuring adequate oxygenation and ventilation. D.) Treating any coagulopathy, thrombocytopenia and anemia. E.) Monitoring arterial blood gases and serum electrolytes levels.

B.) Maintaining a normal blood pressure. C.) Ensuring adequate oxygenation and ventilation. D.) Treating any coagulopathy, thrombocytopenia and anemia. E.) Monitoring arterial blood gases and serum electrolytes levels. Once an identified organ donor has been declared clinically brain dead, the primary focus of care changes from preserving life to preserving organ functioning. This is done by maintaining normal blood pressures, fluid levels, electrolytes levels, serum glucose levels, and normothermia. Mechanical ventilation is provided to maintain adequate oxygenation and normal acid-base balance. If needed, pharmaceutical support is provided for the treatment of anemia, coagulopathy, thrombocytopenia, and diabetes insipidus. Physiological changes occur to bodily functions as the result of decreased perfusion within the brain.

The nurse is caring for a client who presents with stroke-like symptoms. The healthcare provider reviews the client's computerized axial tomography (CAT) scan and prescribes recombinant tissue plasminogen activator (rtPA) IV. Which information should the nurse obtain to determine if the client is a candidate for this treatment now? A.) Identify the underlying cause of this condition. B.) Prepare to administer desmopressin (DDAVP). C.) Decrease the intravenous fluids to a maintenance rate. D.) Replace fluid losses with D5W every shift

B.) Prepare to administer desmopressin (DDAVP). Neurogenic diabetes insipidus (DI) is a condition that can occur when there is trauma to the brain such as tumors or injury to the brain in particular the pituitary or hypothalamus area. DI can also occur with cerebral edema present. The antidiuretic hormone deficiency occurs rapidly and results in polyuria, anywhere between 5- 40 liters of urine/24 hours. The client demonstrates signs and symptoms of hypovolemia. Electrolyte imbalances include hypernatremia, along with hypokalemia and hypercalcemia when it is neurogenic etiology. Clients with neurogenic DI are primarily controlled through administration of exogenous ADH preparations, of which desmopressin (DDAVP) is most commonly used. Fluid output is carefully monitored and fluids are replaced every hour.

Four days after a client is admitted with an acute anteroseptal myocardial infarction, the nurse is preparing to transfer the client to an intermediate care unit. The client suddenly reports shortness of breath with minimal activity and chest pain. Which intervention should the nurse implement next? A.) Evaluate leads V 1, V 2, and V 3for Q waves. B.) Assessfor bilateraljugular vein distention. C.) Auscultate for pansystolic murmur at left sternal border. D.) Monitor for premature ventricular contractions.

C.) Auscultate for pansystolic murmur at left sternal border A pansystolic murmur at the left sternal border is indicative of a ruptured interventricular septum and requires immediate intervention. Ventricular septal rupture results from full thickness infarction of the interventricular septum followed by necrosis that results in a septal rupture. The rupture can start out as small as a pin hole.

The nurse is analyzing an arterial blood gas (ABG) of a client who is mechanically ventilated. The ABG results are pH 7.17; paCO2 70 mmHg; HCO3 20 mEq/L. The nurse would understand that which is the likely cause of these results? A.) Respiratory rate is too slow, causing respiratory acidosis. B.) Respiratory rate is too rapid, causing respiratory alkalosis. C.) Diarrhea has caused metabolic acidosis. D.) Vomiting and has caused metabolic alkalosis.

C.) Diarrhea has caused metabolic acidosis. The normal arterial blood gas (ABG) levels are pH: 7.35-7.45; paCO2: 35-45 mmHg; HCO3: 22-26 mEq/liter. In metabolic acidosis, the pH is decreased and the HCO3 is decreased. Diarrhea causes a loss of base which, then leads to metabolic acidosis.

While waiting on lab results, the trauma nurse begins transfusing a unit of O- (negative) packed red blood cells to an unconscious client who suffered a massive blood loss. Within the first 5 minutes of the transfusion, the client becomes dyspneic and develops stridor, nasal drip and coughing. What action should the nurse take next? A.) Warm the blood as it infuses. B.) Slow down the blood's infusion rate. C.) Infuse the blood with normal saline. D.) Stop the infusion of blood.

D.) Stop the infusion of blood. The client's antibodies are reacting to the antigens present in the donated blood, thus initiating the T-lymphocytes to activate an immune response. During an emergency situation when there is no time for typing and cross-matching of a client's blood, clients are infused with O- (negative) blood while waiting for units of blood from the blood bank that were typed and cross-matched with the client's blood.