Critical Care Test 3

A client is admitted to the critical care unit with a diagnosis of diabetic ketoacidosis. Following aggressive fluid resuscitation and intravenous (IV) insulin administration, the blood glucose begins to normalize. In addition to glucose monitoring, which of the following electrolytes requires close monitoring? A. Potassium B. Chloride C. Sodium D. Calcium

A

A client is being ventilated and has been started on enteral feedings with a nasogastric small-bore feeding tube. What is the primary reason the nurse must frequently assess tube placement? A. To prevent aspiration of the feedings B. To maintain the patency of the feeding tube C. To monitor for skin breakdown on the nose D. To assess for paralytic ileus

A

A nurse examines the client's complete blood count with differential analysis and notices that the client's neutrophil percentage is elevated but that the lymphocytes percentage is lower than normal. The nurse knows that the drop in lymphocyte count in the differential is most likely due to what? A. the increase in neutrophil count B. a new viral infection C. the lack of immature neutrophils D. a decreased number of "bands"

A

A nurse is caring for a burn-injured client who weighs 154 pounds with the burn injury covering 50% of their body surface area. The nurse calculates the fluid needs for the first 24 hours after a burn injury using a standard fluid resuscitation formula of 4 mL/kg/% burn of intravenous (IV) fluid for the first 24 hours. The nurse plans to administer what amount of fluid in the first 24 hours? A. 14 L B. 7000 mL C. 28 L D. 2800 mL

A

A nurse is caring for a client who has multiple myeloma. The nurse assesses the client and is aware that the symptom most unique to this disease is ________________. A. bone pain B. night sweats C. fever D. lymph node enlargement

A

A nurse is caring for a client with syndrome of inappropriate secretion of antidiuretic hormone (SIADH). What laboratory values would the nurse expect to assess? A. Serum sodium 115 mEq/L B. Serum calcium 9.2 mg/dL C. Serum potassium 5.8 mEq/L D. Fasting blood glucose 156 mg/dL

A

A nurse is caring for a critically ill client with respiratory failure who is being treated with mechanical ventilation. What therapy to the client would the nurse anticipate to prevent stress ulcers? A. Proton pump inhibitors B. Vagal stimulation C. Cholinergic drugs D. Anti-diarrheal drugs

A

A nurse is conducting an admission assessment of an 82-year-old client who sustained a 12% burn from spilling hot coffee on the hand and arm. Which is a priority statement by the nurse? A. "Do you have a heart condition or heart failure?" B. "Have you had any surgeries?" C. "Do you have any drug or food allergies?" D. "Do you live alone?"

A

A nurse working in a trauma center administers blood products to a severely hemorrhaging trauma client in a 1:1:1 ratio. Which blood products are NOT included in this transfusion protocol? A. Whole blood B. Plasma C. Red blood cells D. Platelets

A

Select the physiological reasoning behind enteral therapy as the preferred source of nutritional therapy. A. Gut mucosa is preserved B. Gut overgrowth increases C. Gastroparesis increases D. Bacterial translocation increases

A

The nurse is assigned to care for a client who presented to the emergency department with diabetic ketoacidosis. A continuous insulin intravenous infusion is started, and hourly bedside glucose monitoring is prescribed. The targeted blood glucose value after the first hour of therapy is: A. a decrease of 50 to 75 mg/dL compared with admitting values. B. less than 200 mg/dL. C. 90 to 120 mg/dL. D. A decrease of 200 mg/dL compared with admitting values.

A

A 24-year-old unrestrained driver who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. The primary survey of this client upon arrival to the ED __________. A. includes a cervical spine x-ray study to determine the presence of a fracture B. is done quickly in the first few minutes to get a baseline assessment and establish priorities C. involves turning the client from side to side to get a look at their back D. is a methodical head-to-toe assessment identifying injuries and treatment priorities

B

A client has been on daily, high-dose glucocorticoid therapy for the treatment of rheumatoid arthritis. His prescription runs out before his next appointment with his physician. Because he is asymptomatic, he thinks it is all right to withhold the medication for 3 days. What is likely to happen to this client? A. Nothing; it is appropriate to stop the medication for 3 days. B. He will go into adrenal crisis. C. His autoimmune disease will go into remission. D. He will go into thyroid storm.

B

A client presents to the emergency department with the following clinical signs: Pulse: 132 beats/min, Blood pressure: 88/50 mm Hg, Respiratory rate: 32 breaths/min, Temperature: 104.8°F, Chest x-ray: Findings consistent with congestive heart failure, Cardiac rhythm: Atrial fibrillation with rapid ventricular response. These signs are consistent with what disorder? A. Adrenal crisis B. Thyroid storm C. Myxedema coma D. Syndrome of inappropriate secretion of antidiuretic hormone (SIADH)

B

A nurse at an outpatient office receives a call from a client with type I diabetes mellitus who is receiving a continuous subcutaneous insulin infusion via an insulin pump. The client reports mechanical failure of the infusion pump. The nurse instructs the client to begin monitoring for signs of ________________. A. Adrenal insufficiency B. Diabetic ketoacidosis C. Hypoglycemia D. Hyperosmolar, hyperglycemic state

B

A nurse is assisting a client to select foods from the menu that will promote wound healing. Which statement indicates the nurse's knowledge of nutritional goals? A. "It is important to choose foods such as bread and pasta that are high in carbohydrates. These foods will give you energy and help you to heal faster." B. "Choose foods that are high in protein, such as meat, eggs, and beans. These help the burns to heal." C. "Select foods that have lots of fiber, such as whole grains and fruits. These will promote removal of toxins from the body that interfere with healing." D. "Avoid foods that have saturated fats. Fats interfere with the ability of the burn wound to heal."

B

A nurse is caring for a client with alcoholism. The client experienced an upper GI bleed after an episode of forceful retching. What medical condition does the nurse anticipate? A. A GI bleed that is self-limiting with little actual blood loss B. A Mallory-Weiss tear, which is a longitudinal tear in the gastroesophageal mucosa. C. A Mallory-Weiss tear, which is treated with chewable aspirin D. A GI bleed that is not usually associated with alcohol intake

B

Clients with musculoskeletal injury are at increased risk for compartment syndrome. What is an initial symptom of a suspected compartment syndrome? A. Absence of pulse in affected extremity B. Severe, throbbing pain in the affected area C. Paresthesia in the affected area D. Pallor in the affected area

B

Critical to caring for the immunocompromised client is the understanding that ___________________. A. the immunocompromised client has normal white blood cell (WBC) physiology B. infection is the leading cause of death in these clients C. immune incompetence is symptomatic even without pathogen exposure D. the immunosuppression involves a single element or process

B

In hyperosmolar hyperglycemic syndrome, the laboratory results are similar to those of diabetic ketoacidosis, with three major exceptions. What differences would the nurse expect to see in clients with hyperosmolar hyperglycemic syndrome? A. Lower serum glucose, lower osmolality, and milder ketosis B. Higher serum glucose, higher osmolality, and no ketosis C. Lower serum glucose, lower osmolality, and greater ketosis D. Higher serum glucose, higher osmolality, and greater ketosis

B

What is the correct order of actions for a client starting enteral nutrition with a feeding tube? 1. obtain CXR 2. flush tube to verify patency 3. assess residuals 4. insert feeding tube 5. initiate tube feeding A. 1, 2, 4, 3, 5 B. 4, 1, 2, 5, 3 C. 1, 2, 4, 5, 3 D. 4, 1, 2, 3, 5

B

When assessing a client's bowel sounds, the nurse ______________. A. listens to the abdomen after palpation is done B. listens to bowel sounds before palpation C. places a pillow over the client's knees D. places the client in a relaxed prone position

B

When caring for a client who has malnutrition, the nurse knows that malnutrition contributes to infection risk in what way? A. Increasing blood glucose B. Impairing immune function C. Increasing drug interactions D. Hampering normal gastrointestinal motility

B

Which of the following statements about mass casualty triage during a disaster is true? A. Priority treatments and interventions focus primarily on young victims. B. Disaster victims with the greatest chances for survival receive priority for treatment. C. Color-coded systems in which green indicates the patient of greatest need are used during disasters. D. Once interventions have been initiated, health care providers cannot stop the treatment of disaster victims.

B

Which of the following would be seen in a client with myxedema crisis? A. Hyperventilation B. Decreased reflexes C. Hyperthermia D. Tachycardia

B

A nurse is caring for a client in the ED following a fall from a first-floor hotel balcony. The client smells of alcohol and begins to vomit in the ED. What is a priority intervention by the nurse? A. Send a specimen of the emesis to the laboratory for analysis of blood alcohol content. B. Insert an oral airway to prevent aspiration and to protect the airway. C. Prepare to suction the oropharynx while maintaining cervical spine immobilization. D. Offer the patient an emesis basin so that you can measure the amount of emesis.

C

A nurse is caring for a client on intravenous lipid therapy. Which intervention is critical for the nurse to perform? A. Hold lipids when administering antibiotics through the same line. B. Maintain elevation of the head of the bed. C. Change the tubing every 24 hours. D. Assess glucose levels every 6 hours.

C

A nurse is caring for a client who has a peptic ulcer. To treat the ulcer and prevent more ulcers from forming, the nurse should be prepared to administer ______________. A. Vitamin B12 B. Gastrin C. H2-histamine receptor blockers D. Vagal stimulation

C

A nurse is caring for a client who is newly diagnosed with type 1 diabetes mellitus and is being transitioned from an infusion of intravenous (IV) regular insulin to an intensive insulin therapy regimen of insulin glargine and insulin aspart (Novolog). How should the nurse manage this transition of insulin delivery? A. Discontinue the IV infusion and administer the Lantus insulin at bedtime. B. Administer the insulin glargine and continue the IV insulin infusion for 24 hours. C. Administer the insulin glargine and discontinue the IV infusion in several hours. D. Discontinue the IV infusion and administer the insulin aspart with the next meal.

C

A nurse is caring for a client who sustained multiple traumas. The nurse knows that symptoms of decreased cardiac output are most commonly caused by: A. Cardiac contusion B. Pericardial tamponade C. Hypovolemia D. Cardiogenic shock

C

A nurse is caring for a client with acute pancreatitis. What are the nursing priorities for the management of acute pancreatitis? A. Treating hypoglycemia B. Stimulating gastric content motility into the duodenum C. Assessing and maintaining electrolyte balance D. Withholding analgesics that could mask abdominal discomfort

C

A nurse is caring for client who complains of general malaise, fatigue, and shortness of breath since having a cold 6 weeks earlier. The nurse should expect the provider to request a ___________. A. lymph node biopsy B. differential blood count only C. complete blood count (CBC) with differential D. bone marrow biopsy

C

The nurse is caring for a client who is passing bright red blood rectally. What is the purpose for the nurse to insert a nasogastric tube? A. Obtain samples for guaiac to confirm current bleeding B. Visually determine the presence of occult bleeding C. Rule out massive upper GI bleeding D. Detect the presence of melena in the stomach

C

The nurse is caring for a client with a diagnosis of head trauma. The nurse notes that the client's urine output has increased tremendously over the past 18 hours. The nurse suspects that the client may be developing: A. Hyperosmolar hyperglycemic syndrome B. Syndrome of inappropriate secretion of antidiuretic hormone C. Diabetes insipidus D. Diabetic ketoacidosis

C

The nurse is caring for a client with severe pancreatitis who is orally intubated and on mechanical ventilation. The client's calcium level this morning was 5.5 mg/dL. After the nurse notifies the provider, what is a priority nursing action? A. Withhold any further calcium treatments B. Anticipate that the provider will come and remove the endotracheal tube C. Place the client on seizure precautions D. Place an oral airway at the bedside

C

What factor is related to primary immunodeficiency? A. Nutritional deficiencies B. Aging C. A single gene defect D. Malignancies

C

What is a high-priority nursing diagnosis for both diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome? A. Hyperthermia B. Activity intolerance C. Fluid volume deficient D. Impaired nutrition, more than body requirements

C

A client is admitted with sepsis and active bleeding. The nurse suspects disseminated intravascular coagulation (DIC) when considering what finding? A. a decrease in fibrin degradation products. B. low fibrinogen levels. C. thrombocytopenia. D. an increased D-dimer level.

D

A client is admitted with the diagnosis of GI bleeding. The client's heart rate is 140 beats per minute, and the blood pressure is 84/44 mm Hg. The nurse knows that these values may indicate what? A. Increased blood flow to the skin lungs, and liver. B. Resolution of hypovolemic shock C. A need for hourly vital signs D. Significant amount of blood loss

D

A client is receiving enteral feedings and reports fullness and abdominal discomfort to the nurse. What is a priority action by the nurse? A. Continue the tube feeding B. Connect the feeding tube to suction C. Decrease the tube feeding D. Assess the patient's gastric residual

D

A client is receiving hydrocortisone sodium succinate for adrenal crisis. What other medication does the nurse prepare to administer? A. Propranolol B. Regular insulin C. Canagliflozin D. A proton pump inhibitor

D

A nurse cares for a client who enters the hospital complaining of headache, fever, and sore throat for the past 2 weeks and is concerned about acquired immune deficiency syndrome (AIDS). The client's blood work shows the presence of HIV antibodies. What statement by the nurse is correct? A. "Very few people with HIV develop AIDS." B. "HIV is an acute disease with a short prognosis." C. "HIV symptoms will continue throughout the patient's life." D. "HIV infection and AIDS are considered chronic diseases."

D

A nurse considers what primary component, the oxygen-carrying molecule, within erythrocytes when caring for a client with anemia? A. 2,3-Diphosphoglycerate B. A reticulocyte C. Erythropoietin D. Hemoglobin

D

A nurse is caring for a client who sustained rib fractures after hitting the steering wheel of the car during a motor vehicle crash. The client is spontaneously breathing and receiving oxygen via a face mask; the oxygen saturation is 95%. During the nurse's assessment, the oxygen saturation drops to 80%. The client's blood pressure has dropped from 128/76 mm Hg to 84/60 mm Hg. The nurse determines that breath sounds are absent throughout the left lung fields. What would the nurse anticipate? A. Endotracheal intubation and mechanical ventilation B. Administration of Lactated Ringer's solution (1 L) wide open C. Chest x-ray study to determine the etiology of the symptoms D. Needle thoracostomy and chest tube insertion

D

A nurse is caring for a client with anemia. The nurse sees no overt signs of bleeding. The nurse understands that ________________. A. mucous membranes have a high threshold for bleeding B. capillaries in mucous membranes lie deep in the membrane C. all clients with bleeding disorders demonstrate active bleeding D. many clients have bleeding that is not obvious

D

A nurse is caring for a client with neutropenia. What is a priority assessment the nurse should perform on this client? A. a drop in temperature from its normal set point. B. the absence of chills. C. bradycardia. D. signs of systemic infection.

D

A nurse is having difficulty inserting a large caliber intravenous catheter to facilitate fluid resuscitation to a trauma client with hypotension. The nurse recommends which of the following emergency procedures to facilitate rapid fluid administration? A. Rapid transfer to the operating room B. Insertion of a femoral catheter by a trauma surgeon C. Placement of a central line D. Placement of an intraosseous catheter

D

A nurse notices singed hairs in the nose of a client who sustained a significant burn. The nurse knows the client should be intubated for what reason? A. The patient will have a copious amount of mucus that will need to be suctioned. B. The singed hairs and soot in the nostrils will cause dysfunction of cilia in the airways. C. Carbon monoxide poisoning always occurs when soot is visible. D. Inhalation injury above the glottis may cause significant edema that obstructs the airway.

D

In clients with extensive burns, edema occurs in both burned and unburned areas because of ____________. A. catecholamine-induced vasoconstriction B. loss of integument barrier C. decreased glomerular filtration D. increased capillary permeability

D

The nurse is caring for a client who underwent pituitary surgery 12 hours ago. The nurse will give priority to monitoring the client carefully for which of the following? A. Volume overload B. Congestive heart failure C. Infection D. Hypovolemic shock

D

The nurse is caring for a client with head trauma who was admitted to the surgical intensive care unit following a motorcycle crash. What is an important assessment that will assist the nurse in early identification of an endocrine disorder commonly associated with this condition? A. Fingerstick glucose B. Daily weight C. Lung sound auscultation D. Urine osmolality

D

The process by which the body actively produces cells and mediators that result in the destruction of the antigen is called _______________. A. autoimmunity B. recognition of self as nonself C. passive immunity D. active immunity

D

Two types of specific immune responses exist: humoral immunity and cell-mediated immunity. What is true about these responses? A. They are nonspecific immune responses. B. They are producers of antigens. C. They are mutually exclusive. D. They work together to provide immunity.

D

What priority nursing action should the nurse consider when caring for a client with HIV? A. Assure the client that infections are not a major problem at this point B. Inform the client that the disease does not affect the respiratory system C. Avoid assessment of the mouth, as infections in the mouth are rare D. Monitor the client's medication regimen.

D

Which of the following interventions is a strategy to prevent fat embolism syndrome? A. Administer lipid-lowering statin medications. B. Provide prophylaxis with low-molecular weight heparin. C. Intubate the patient early after the injury to provide mechanical ventilation. D. Stabilize extremity fractures early.

D

A nurse is caring for a client with a wound. What is the purpose for exudate to form at the wound site (select all that apply)? Dilute toxins Produce a fever Deliver proteins Carry away toxins

Dilute toxins Deliver proteins Carry away toxins

It is important to prevent hypothermia in the trauma client because hypothermia is associated with which of the following (select all that apply)? ARDS Myocardial dysfunction Coagulopathies Dysrhythmias Fat embolism

Myocardial dysfunction Coagulopathies Dysrhythmias

A nurse is caring for a client with total parenteral nutrition. Which statements about total parenteral nutrition are correct (select all that apply)? Total parenteral nutrition is administered through a feeding tube and pump Total parenteral nutrition with added lipids provides adequate levels of protein, carbohydrates, and fats Fingerstick glucose levels are assessed every 6 hours and prn Assessing fluid volume status and preventing infection are important nursing considerations

Total parenteral nutrition with added lipids provides adequate levels of protein, carbohydrates, and fats Fingerstick glucose levels are assessed every 6 hours and prn Assessing fluid volume status and preventing infection are important nursing considerations

The number of white blood cells (WBCs) is increased in circumstances such as ___________ (select all that apply). inflammation malnutrition immune disease invasion by pathogenic organism allergy

inflammation invasion by pathogenic organism allergy

A college student was admitted to the emergency department after being found unconscious by a roommate. The roommate informs emergency medical personnel that the student has diabetes and has been experiencing flu-like symptoms, including vomiting, since yesterday. The client had been up all night studying for exams. The client used the last diabetes testing supplies 3 days ago and has not had time to go to the pharmacy to refill prescription supplies. Based upon the history, which laboratory findings would the nurse anticipate in this client (select all that apply)? PaCO2: 37 mm Hg pH: 7.23 Blood glucose: 524 mg/dL HCO3: 10 mEq/L Blood glucose: 43 mg/dL

pH: 7.23 Blood glucose: 524 mg/dL HCO3: 10 mEq/L