ECCO
After a subarachnoid hemorrhage, a patient is agitated and has a headache. The patient's UO was 1,500 ml in four hours, with BP 86/50 (62), HR 108, and serum Na 118. What two interventions should the nurse anticipate? Fluid restriction Vasopressin (ADH) 0.9% NS fluid bolus 0.45% NS infusion
0.9% NS fluid bolus
A nurse checks that a patient can remove the NIPPV mask in the event of emesis. What are other nursing care priorities for patients using NIPPV? Assess respiratory rate and depth, and changes in LOC Examine skin for breakdown across nasal bridge or any pressure points. Ensure that mask leakage is within manufacturer's limits Check for dryness or irritation of eyes, nasal passages, and upper airway
Assess respiratory rate and depth, and changes in LOC Examine skin for breakdown across nasal bridge or any pressure points. Check for dryness or irritation of eyes, nasal passages, and upper airway
Following a chest x-ray, for which report should the nurse notify the provider? Air bubbles are present in the stomach ETT is positioned in the right mainstem bronchus Trachea is midline Pneumonia is unresolved
ETT is positioned in the right mainstem bronchus
A patient with an EVD in place suddenly develops disorientation to place, and ICP suddenly increases from 15 to 22 mm Hg. EVD drainage system troubleshooting indicates no visible blockages and no CSF fluid fluctuation, and the EVD is no longer draining. Which of the following interventions is the highest priority? Re-level the EVD Flush the EVD tubing toward the patient Administer mannitol Inform the provider of the assessment and EVD status
Inform the provider of the assessment and EVD status
Which statement about hypothermia and rewarming after cardiac surgery is true? Initiate rewarming if patient's temperature falls below 35C(95F) Hypothermia increases risk of bleeding Initiate rewarming if patient's temperature falls below 36C(96.8F) Hypothermia decreases risk of bleeding
Initiate rewarming if patient's temperature falls below 35C(95F) Hypothermia increases risk of bleeding
A patient is admitted with traumatic spinal cord injury from a fall. What 3 immediate interventions should the nurse prioritize Maintain immobilization Assess skin integrity Assess circulation Maintain oxygenation and ventilation
Maintain immobilization Assess circulation Maintain oxygenation and ventilation
A patient with severe chronic mitral regurgitation develops severe dyspnea, pulmonary edema and hypertension. These symptoms indicate disease progression. For which therapy should the nurse prepare the patient? Metoprolol (Lopressor) Valve repair Warfarin (Coumadin) Balloon valvuloplasty
Valve repair
A patient is admitted after brain aneurysm clipping with BP 90/54, HR 110, CVP 1 mm Hg, UO 1,400 mL in four hours, serum Na+ 155, and serum osmolality 320. Which should the nurse anticipate? 0.45% NS bolus and infusion MRI Vaptan administration Dopamine at 5 mcg/kg/min
0.45% NS bolus and infusion
You are caring for an unconscious patient with traumatic brain injury from a motor vehicle crash. His alcohol and toxicology screen are negative, he has no facial fractures, and he's not receiving pain or sedation medication. Vital signs: BP 100/70 (80), HR 86 sinus rhythm, SpO2 95% with endotracheal tube secured. Upon application of painful stimuli with supraorbital notch pressure, the patient clenches fists, holds legs straight out, and bends arms inward toward the body. Fingers are bent and held on the chest. The nurse should document this response as: Normal flexor posturing Abnormal flexor posturing Localizing to painful stimuli Extensor posturing
Abnormal flexor posturing
A patient accidentally pulls out their ETT and is noted to have shallow spontaneous respirations, RR 10/min, The charge nurse has called for the medical response team. Which nursing action is needed immediately? Obtain ABGs Initiate O2 via nonrebreather mask Apply a bag-valve mask (BVN) resuscitator for ventilation Administer IV midazolam (Versed)
Apply a bag-valve mask (BVN) resuscitator for ventilation
A nurse finds that a patient does not move spontaneously or follow commands. To assess the patient's motor function, the nurse applies a central pain stimulus, without response. What is the nurse's next step? Assess pronator drift Apply symmetry stimulus Apply peripheral pain stimulus Assess startle response
Apply peripheral pain stimulus
Which of the following serum osmolality results is consistent with a patient who has developed fluid volume excess? A. 310 mOsm/kg - 299 mOsm/kg B. 287 mOsm/kg - 268 mOsm/kg C. 275 mOsm/kg - 292 mOsm/kg D. 265 mOsm/kg - 280 mOsm/kg
B. 287 mOsm/kg - 268 mOsm/kg
A patient arrives on your unit post-thoracotomy. Which intervention is essential to complete? Bedside swallow exam Resume diet Maintain SpO2 greater than 96% Maintain operative side-down position
Bedside swallow exam
A 75-year-old patient admitted from a chronic care facility with HHS is semi-comatose with severe dehydration. Fluids and IV regular insulin 0.1 units/kg/hr is initiated. What indicates the dose can be reduced to 0.05 units/kg/hr? Serum osmolality 310 mEq/L Beta hydroxybutyrate 0.4 mmol/L Serum potassium 4.8 mEq/L Blood glucose 285 mg/dL
Blood glucose 285 mg/dL
Which 2 interventions in a critically ill patient can contribute to insulin resistance? Calcium channel blocker infusion Using specialized IV tubing to prevent insulin adsorption Epinephrine infusion Flushing 20 mL insulin through tubing prior to initiation
Calcium channel blocker infusion Epinephrine infusion
A nurse caring for a patient with ARDS on BiPAP observes rapid progression of dyspnea and tachypnea with RR between 37 and 41. What intervention should the nurse anticipate? Increase EPAP by 50%-100% Observe for signs of decompensation Request order for stat chest x-ray Call emergency response team for intubation
Call emergency response team for intubation
A patient is to undergo CABG with a saphenous vein graft. Which preoperative test should the nurse anticipate? Coagulation profile Stress test Blood culture Urine culture
Coagulation profile
A patient after cardiac surgery has 200 ml/hr of bloody drainage from the chest tube for the past two hours. Packed RBCs were given in the OR. Which interventions should the nurse anticipate? Administer NS bolus and titrate MAP to 60-65 mm Hg Continue to monitor H&H every 2 hours and place patient flat Transfuse platelets and taper down sedation Control hypertension (HTN), and check coagulation studies
Control hypertension (HTN), and check coagulation studies
A patient on CRRT had 1,200 mL of ultrafiltrate in the past 24 hours; 2 L was anticipated. Presence of which sign/symptom should the nurse anticipate? Crackles Dry mucous membranes Decreased skin turgor Hypotension
Crackles
Which assessment finding should the nurse anticipate in a patient with dilated cardiomyopathy Normal ECG tracing Crackles on auscultation Hyperactive bowel sounds Urine output 0.5 mL/kg/hr
Crackles on auscultation
Which complication should the nurse observe for in a patient following bronchoscopy? Dysrhythmias GI bleeding Hyperoxia Tracheomalacia
Dysrhythmias
Which patient in the immediate postoperative period should be given a a NC or simple face mask? A patient requiring: FiO2 of 0.75 - 0.95 FiO2 of 0.4 or less Oxygen of greater than 15 L/min FiO2 of 0.55 - 0.90
FiO2 of 0.4 or less
A patient with a history of aortic regurgitation due to rheumatic fever develops severe dyspnea, fatigue, and pulmonary edema. Which should the nurse anticipate? Intra-aortic balloon pump (IABP) High-dose nitroglycerin (Tridil) Furosemide (Lasix) Metoprolol (Lopressor)
High-dose nitroglycerin (Tridil)
A patient has been receiving CRRT for the past week. Citrate is being used as the anticoagulant. For which of the following should the nurse observe? Hypocalcemia Hyperkalemia Hyponatremia Hyperphosphatemia
Hypocalcemia
A patient who sustained a prolonged hypotensive episode in the operating room is admitted on a norepinephrine infusion; MAP is being maintained >65 mm Hg. Which intervention is indicated to prevent further kidney injury? Maintain SpO2 90% with NC oxygen Identify nephrotoxic agents and discuss with pharmacist Maintain IV at a rate of 10 mL/hr Administer diuretics to increase urine output
Identify nephrotoxic agents and discuss with pharmacist
A nurse is infusing citrate for anticoagulation into the pre-filter side of a patient's CRRT circuit. What step should the nurse anticipate to reduce the patient's risk of hypocalcemia? Administer supplemental calcium before the procedure Infuse calcium into the line on the pre-filter side of the circuit Administer supplemental calcium post-CRRT Infuse calcium into the return line on the post-filter side of the circuit.
Infuse calcium into the return line on the post-filter side of the circuit.
A patient with right-sided HF is being treated. Which should the nurse expect if the patient is responding to therapy? Diminished pulses Bradycardia occurs JVD and edema resolve Hypotension occurs
JVD and edema resolve
What characteristic of generalized-onset epileptic seizures distinguishes them from focal onset seizures? Impaired consciousness Arrhythmic muscle jerks Loss of consciousness Clonic movement
Loss of consciousness
Which initial assessment findings in a trauma patient indicate a traumatic spinal cord injury? Glasgow Coma Scale score of 4 Loss of motor function Presence of hypothermia Loss of sensory function
Loss of motor function Loss of sensory function
A patient is admitted with diastolic dysfunction, dyspnea on exertion, and cough. Which therapy should the nurse anticipate? Metoprolol (Lopressor) Epinephrine Fluid bolus Digoxin (Lanoxin)
Metoprolol (Lopressor)
A patient with a history of CAD, HTN, and EF 35% is admitted with decompensated systolic heart failure. Which medication should the nurse anticipate? Norepinephrine (Levophed) Nifedipine (Procardia) Metoprolol (Lopressor) Phenylephrine (Neo-Synephrine)
Metoprolol (Lopressor)
A patient with systolic heart failure is being treated. Which response indicates the patient is responding to therapy? Decrease in ejection fraction (EF) Increase in weight Increase in HR Normalization of BP
Normalization of BP
In assessing the site of a patient's permanent HD access, a nurse finds the thrill or bruit absent. What intervention should the nurse perform immediately? Record finding; check site again in one hour Request order for anticoagulant therapy Notify provider immediately; surgery may be needed Palpate for presence of pulse in the affected extremity
Notify provider immediately; surgery may be needed
A nurse administer lisinopril (Zestril) to a patient with CKD, waits one hour, and then administers metoprolol (Lopressor). What is the purpose of this intervention? Clear contrast medium from kidneys Increase effectiveness of dialysis Increase tolerance of contrast medium Optimize response while maintaining hemodynamic stability.
Optimize response while maintaining hemodynamic stability
A patient is admitted post-TAVR with a transfemoral approach. Which findings related to the procedure leg should cause concern? Mild erythema and bounding pulses Pallor and pain Dependent rubor and downward flexion on Babinskis test Dorsalis pedis pulse 2+ and capillary refill <3 seconds
Pallor and pain
EtCO2 monitoring is indicated for which patient? Patient with normal respiratory rate and depth Patient receiving patient-controlled analgesia Patient with orders for palliative care Patient with decreased intracranial pressure
Patient receiving patient-controlled analgesia
A patient with an ischemic stroke is to receive rtPA. Which of the following should the nurse include in the process? Give antihypertensive medication to reach BP 140/90 (107) Give 25% of dose as initial bolus, and then 75% as infusion over 60 minutes Perform neurologic checks every 15 minutes for two hours. Monitor vital signs hourly during administration
Perform neurologic checks every 15 minutes for two hours.
Which 2 nursing interventions are performed post lumbar puncture? Position the patient in the lateral decubitus position Position the patient lying flat for a few hours Assess the patient for motor or sensory deficits Anticipate an order for a CT scan
Position the patient lying flat for a few hours Assess the patient for motor or sensory deficits
A patient admitted for new-onset seizures has elevated WBCs and increasing confusion. She places a towel over her eyes against the light and complains of neck stiffness. What other sign should the nurse observe for? Positive Brudzinski's sign Hypoglycemia Pupillary constriction Increased BP
Positive Brudzinski's sign
A nurse observes a patient's jugular venous distention, tachycardia, and hypotension {BP 72/50 (57)}. ECHO identifies a large pericardial effusion and onset of atrial collapse. What intervention should the nurse initially anticipate? Administer vasopressor Prepare for intubation and mechanical ventilation Prepare for pericardiocentesis Administer morphine IV push
Prepare for pericardiocentesis
A patient with 3 days of profuse vomiting and diarrhea is admitted with hypotension and dehydration. What type of kidney dysfunction is the patient most at risk for developing? Intrarenal Postrenal Prerenal None
Prerenal
Which patient is at greatest risk for development of torsades de pointes? A patient with a... QTc of 0.40 with hypercalcemia QTc of 0.52 with hypokalemia QTc of 0.44 with hyperphosphatemia QTc of 0.36 with hyponatremia
QTc of 0.52 with hypokalemia
A 70 kg (154.3 lb) patient has been on mechanical ventilation for two days. Which indicates readiness to wean? Spontaneous tidal volume 300 mL Rapid shallow breathing index 85 Negative Inspiratory Pressure (NIP) -15 cm H2O Vital capacity (VC) 500 mL
Rapid shallow breathing index 85
What interventions should the nurse be prepared to perform for a patient who is receiving an epinephrine infusion? Subcutaneous corrective insulin protocol Administration of IV glucocorticoids Regular insulin infusion for blood glucose greater than 180 mg/dL Hourly blood glucose checks
Regular insulin infusion for blood glucose greater than 180 mg/dL Hourly blood glucose checks
In performing an SAT, which assessment should prompt the nurse to restart sedation at half the previous dose and titrate to goal? Respiratory rate 38 per minute RASS of 0 (awake and calm) Oxygen saturation >90% MAP below 80 mm Hg
Respiratory rate 38 per minute
Your patient blinks and can move eyes up and down. Respirations are irregular with periods of apnea; gag reflex and motor movement of extremities are absent. What is your highest priority intervention? Monitor SpO2 Insert a nasogastric tube Secure the airway Prevent pressure ulcers
Secure the airway
Which findings in a patient in the acute recovery phase post-cardiac surgery indicate possible cardiac tamponade? Significant, abrupt decrease in mediastinal CT output; tachycardia Decreased ECG voltage; narrow pulse pressure Muffled heart sounds; decreased urine output and cardiac output/ Temperature greater than 36C (96.8F); sudden intense headache
Significant, abrupt decrease in mediastinal CT output; tachycardia Decreased ECG voltage; narrow pulse pressure Muffled heart sounds; decreased urine output and cardiac output/
A patient has a subarachnoid hemorrhage. For which of the following electrolyte abnormalities should the nurse observe? Magnesium 2.3 mEq/L (H) Potassium 5.3 mEq/L (H) Sodium 130 mEq/L (L) Calcium 8.5 mEq/L (L)
Sodium 130 mEq/L (L)
Which findings in a patient beginning cardiac rehab indicate the patient is tolerating the activity? SpO2 96% before and 94% during activity BP 96/76 (83) before and 107/79 (88) during activity SpO2 95, alert, only occasional dizziness Gait unsteady but continue activity
SpO2 96% before and 94% during activity BP 96/76 (83) before and 107/79 (88) during activity
A patient post-thoracotomy develops a right tension pneumothorax. Which sign or symptom should the nurse anticipate? Tachycardia Decreased breath sounds on the left side Moist cough Hypertension
Tachycardia
A patient with aortic stenosis on ECHO reports no symptoms. What developments should the nurse anticipate over time? The patient may respond well to treatment with ACE-I or ARBs The patient will develop dyspnea, fatigue on exertion, and chest pain The patient will likely develop pulmonary hypertension Surgical replacement or repair is indicated at the time of diagnosis
The patient will develop dyspnea, fatigue on exertion, and chest pain
A patient underwent cardiac surgery. Which should the nurse include in discharge education? Cardiac rehab enrollment if chest pain occurs at home Care for pacing wires Chest tube management Wound care
Wound care
A patient with a history of smoking and recent cocaine use, reports a stiff neck and severe headache. He hides his eyes from light and evidences decreasing LOC. What should the nurse suspect? Ischemic stroke Meningitis aSAH Intracranial hypertension
aSAH
Which patient has an indication for ventilatory replacement? A patient with ABG results of : pH 7.32, PaO2 68, PaCO2 44, HCO3 19, SaO2 90 pH 7.35, PaO2 80, PaCO2 45, HCO3 22, SaO2 93 pH 7.20, PaO2 58, PaCO2 55, HCO3 24, SaO2 88 pH 7.50, PaO2 75, PaCO2 43, HCO3 29, SaO2 92
pH 7.20, PaO2 58, PaCO2 55, HCO3 24, SaO2 88
Which ABG result requires provider be notified immediately? pH greater than 7.4 HCO3 greater than 25 pH less than 7.2 PaCO2 less than 40
pH less than 7.2
A patient with TBI has BP 96/50, HR 108, UO 525 mL/hr, Na 154. Patient is lethargic with poor skin turgor. Which should the nurse anticipate?
vasopressin
A patient with sepsis on CRRT is experiencing increased transmembrane pressures. Which should the nurse suspect? Fluid volume overload Recirculation of blood through the filter Filter clogging Air in the venous system
Filter clogging
In early status epilepticus, a patient experiences hyperglycemia. After 30 minutes of status epilepticus, what sequence of processes occur? Hypoxemia, hyperglycemia, hypertension Higher BP, hyperoxemia, low metabolism, hypotension Hypertension, hyperglycemia, hypotension Lower BP, hypoxemia; greater demand, hypoglycemia
Lower BP, hypoxemia; greater demand, hypoglycemia
A nurse observes dark maroon streaks on a patient's CRRT filter and notes that filter pressure has risen from 79 mm Hg to 160 mm Hg. What step should the nurse take? Nothing; this is an anticipated finding with CRRT Move replacement fluid from pre-filter to post-filter Move replacement fluid from post-filter to pre-filter Inject onto filter surface
Move replacement fluid from post-filter to pre-filter
A patient with sepsis is receiving CRRT. The patient's serum lactate has increased from 4.1 (H) to 6.2 (H) in the past 24 hours. Which action should the nurse anticipate? Changing the mode to CVVHD Increasing the ultrafiltration rate Changing to a bicarbonate-based replacement solution Moving the replacement solution from pre-filter to post-filter
Changing to a bicarbonate-based replacement solution
A patient with an external ventricular drain is noted to have a damped ICP waveform on the monitor. Which of the following is indicated? Lower the level of the collection drain Flush the system with the transducer flush device Check for air bubbles or debris in the drainage system Change the transducer
Check for air bubbles or debris in the drainage system
A patient with CKD is to have a permanent arteriovenous shunt placed. Which nursing intervention is indicated after the procedure? Implement measures to prevent pseudoaneurysm formation Check for presence of thrill/bruit Administer antihypertensive meds to keep MAP less than 60 mm Hg Initiate interventions to avoid swelling of the vein
Check for presence of thrill/bruit
A patient has a transvenous temporary pacemaker in place. Pacemaker spikes are noted on the ECG, but they are not followed by a P wave or QRS complex. Which is initially indicated? Reposition patient on the right side Increase the sensitivity (set mV to a lower number). Check the connections. Decrease the mS (output)
Check the connections.
A nurse caring for a patien postoperative cardiac valve replacement with a heterograft valve should anticipate administration of which medication(s)? Nitrates and calcium channel blockers ASA and warfarin (Coumadin) Warfarin (Coumadin) Daily ASA
Daily ASA
A patient is receiving IV calcium gluconate, IV insulin, IV D50, and oral polystyrene sulfonate (Kayexalate). What evidence of the treatment's effectiveness should the nurse assess for? Decreased potassium levels Decreased serum calcium levels Normalizing T waves Narrowed QRS
Decreased potassium levels Normalizing T waves Narrowed QRS
Which 3 nursing interventions do you anticipate for your patient prior to a cerebral angiogram? Ensure patent IV access Review labs for kidney function Anticipate orders for additional fluid administration Insert nasopharyngeal airway for procedural sedation
Ensure patent IV access Review labs for kidney function Anticipate orders for additional fluid administration
Bedside bronchoscopy is ordered for your patient with pneumonia. What 2 actions do you anticipate will be your role in the procedure Hand off report to the staff performing the bronchoscopy Ensure suction is available during the procedure Assess patient for levels of sedation and pain Providing oral fluids up to 15 minutes prior to the procedure
Ensure suction is available during the procedure Assess patient for levels of sedation and pain
A patient with traumatic brain injury is receiving norepinephrine to maintain CPP between 60 - 70 mm Hg. The patient's ICP waveform changes from P1 higher than P2 higher than P3, to P2 higher than P1 and P3. Which of the following interventions is most likely to affect the change in ICP waveform? Encourage the family to bring the patients 3-year-old brother for a visit Ensure the patient's neck is in neutral alignment. Lay the patient flat Decrease the norepinephrine dose
Ensure the patient's neck is in neutral alignment.
A nurse administers IV potassium chloride (KCl) via central line and at regular intervals monitors the K level and the ECG for QTc shortening. Which other step should the nurse take to evaluate the patient's response to KCl? Evaluate for development or resolution of ventricular dysrhythmias Evaluate for the development of pulmonary edema Monitor for the development of tetany Assess for hyperosmolar hypontremia
Evaluate for development or resolution of ventricular dysrhythmias
Which intervention should the nurse perform for a postsurgical patient who is receiving IV insulin? Stabilize blood glucose within 110-160 mg/dL Assess blood glucose levels every 6 hours Stabilize blood glucose within 70-140 mg/dL Evaluate potassium at regular intervals
Evaluate potassium at regular intervals
After a subarachnoid hemorrhage, a patient is agitated and has a headache. The patient's UO was 1,500 ml in four hours, with BP 86/50 (62), HR 108, and serum Na 118. What two interventions should the nurse anticipate? Fluid bolus of 0.9% NS Admin hypertonic saline Preparation for repeat CT with contrast Administration of vasopressin (ADH)
Fluid bolus of 0.9% NS Admin hypertonic saline
Assessment of a trauma patient with a spleen injury reveals BP at 85/54 (64) and varying; HR 135 sinus tachycardia; and UO 0.2 mL/kg/hour for the past three hours. What do these signs indicate? Trend toward fluid excess Excessive perfusion Tachypnea Fluid deficit
Fluid deficit
In assessing an unconscious patient who is noted to have new-onset sluggish pupillary light reflex, deficits in what other cranial nerve reflexes can indicate brainstem compression? Pain stimulus reflex Gag reflex Cough reflex Corneal reflex
Gag reflex Cough reflex Corneal reflex
Which 2 risk factors put a patient at risk for acute kidney injury? Hypotension Metoprolol administration Alcoholism Dehydration
Hypotension Dehydration
A patient post-TAVR is receiving aspirin and a PY212 antiplatelet medication. During discharge teaching, the patient would demonstrate understanding of the need for these medications by teaching back which statement? I understand the aspirin and P2Y12 antiplatelet medication will help reduce the risk of clots due to my valve surgery I understand these medications are necessary for only a few weeks I understand these medications can be stopped if I bleed too much I understand these medication are necessary due to my new valve
I understand the aspirin and P2Y12 antiplatelet medication will help reduce the risk of clots due to my valve surgery
In preparing a patient with heart failure for discharge, what statements indicate the patient and patient's family understand care after discharge? I'll fix meals according to a low-potassium diet I'll call the doctor if I gain five pounds in a week It's OK if I miss my diuretic now and then, it isn't always convenient to have to find a bathroom I'll begin to exercise to 3 weeks after I leave
I'll call the doctor if I gain five pounds in a week.
A patient with diabetes is admitted with DKA. After 1 hour of 0.9% NS with 20 mEq KCl/L and continuous infusion of IV regular insulin, the patient is reevaluated. What should the nurse anticipate? IV 1/2 NS with 20 mEq KCl/ L at 250 mL/hour KPhos IV 40 mEq over 1 hour Sodium bicarbonate 1 mEq/kg IV infusion over 1 hour Transition to subcutaneous insulin lispro (Humalog) every 4 hours
IV 1/2 NS with 20 mEq KCl/ L at 250 mL/hour
A patient with a three-day history of vomiting is admitted with BP 80/40 (53), HR 114 sinus tachycardia, dry mucous membranes, serum sodium 150, and serum osmo 300. The nurse should expect the administration of what to be first? Hypertonic fluids Isotonic fluids Hypotonic fluids Vasoactive agent
Isotonic fluids
Which intervention is indicated in the management of temporary HD access? Keep clamps tight Avoid heparin instillation Change dressing only when no longer occlusive Allow changes to neck position on the catheter side at 10 min/hour
Keep clamps tight.
What is the initial drug of choice for a patient with ischemic stroke who is not eligible for fibrinolysis with rtPA with a BP greater than 220/120 mm Hg? Labetalol (Trandate) Sodium Nitroprusside (Nipride) Nimodipine (Nimotop) Nitroglycerin (Tridil)
Labetalol (Trandate)
A patient with a history of alcoholism and malnutrition is admitted after two days of persistent diarrhea, with Temp 35 C (95 F). PT prolongation is noted on ECG. Labs are pending. Administration of which should the nurse anticipate? Calcium gluconate Calcium acetate (PhosLo) Sodium polystyrene sulfonate (Kayexalate) Magnesium supplementation
Magnesium supplementation
A patient with blunt traumatic brain injury has bruising behind the ears and persistent CSF leakage. Which of the following are goals of treatment? Maintain glucose at 110-140 mg/dL Maintain ICP at less than 20 mm Hg; Maintain a SBP greater than 90 mm Hg. Maintain SBP at less than 130 mm Hg
Maintain ICP at less than 20 mm Hg; Maintain a SBP greater than 90 mm Hg.
A patient is undergoing CRRT with citrate infused in the pre-filter side and calcium levels routinely monitored. What assessments would arouse suspicion that the filter is clotting? Maroon streaking in the filter Filter pressures >100 mm Hg from baseline Return pressures that steadily increase Negative access pressures that stay at baseline
Maroon streaking in the filter Filter pressures >100 mm Hg from baseline Return pressures that steadily increase
A patient reports chest pain and fainting while on a class hiking trip. What assessment findings would suggest hypertrophic cardiomyopathy? Mitral regurgitation murmur Harsh mid-systolic murmur at left sternal border Cough when patient is prone Ventricular basilar hypertrophy on transthoracic ECHO
Mitral regurgitation murmur Harsh mid-systolic murmur at left sternal border Ventricular basilar hypertrophy on transthoracic ECHO
A patient undergoes balloon valvuloplasty for mitral stenosis. Which is a post-procedure nursing care priority? Monitor for AV heart block Hydrate patient to improve renal clearance of contrast media Monitor for new murmurs (especially regurgitant murmurs) Maintain mean BP 75-80 Hg
Monitor for new murmurs (especially regurgitant murmurs)
A patient with type 2 diabetes managed with diet and exercise who takes metoprolol (Lopressor) is admitted for trauma after a motor vehicle crash. Medication reconciliation in collaboration with the pharmacist is complete. What intervention should the nurse anticipate? Monitor for symptoms of hypoglycemia Initiate parenteral nutrition within 24 hours of admission Anticipate orders for subcutaneous regular insulin Perform blood glucose checks every 4 hours
Monitor for symptoms of hypoglycemia
A patient with an ischemic stroke has undergone endovascular therapy. Which of the following should be included in the patient's plan of care? Monitor for the presence of groin, flank, or back pain. Change site dressing every four hours Obtain hourly vital signs for 24 hours Monitor for symptoms of abdominal aortic dissection
Monitor for the presence of groin, flank, or back pain.
A nurse is administering hypertonic saline to a patient with cerebral salt-wasting syndrome and hyponatremia. Which two assessments are crucial for patient safety and evaluating response to this treatment? Monitor serum NA at regular intervals; Evaluate neurologic status Monitor ECG for narrowed QRS Check that serum aldosterone increases
Monitor serum NA at regular intervals; Evaluate neurologic status
A patient who underwent a transfemoral TAVR is coming to your unit post-procedure. Which care should the nurse anticipate? Administer NSAIDs for breakthrough pain Monitor the patient for retroperitoneal bleeding Check the brachial plexus injury Keep the HOB at 30-45 degrees immediately after sheath removal
Monitor the patient for retroperitoneal bleeding
For a patient post-TAVR with intraoperative atrioventricular heart block, which treatment plan should the nurse anticipate? Infusing epinephrine for 72 hours post -TAVR Monitoring for conduction abnormalities for 4-7 days post-TAVR Maintaining MAP at less than 75 Hg post-TAVR Implementing temporary pacing at a rate of 80 for 48 hours post-TAVR
Monitoring for conduction abnormalities for 4-7 days post-TAVR
A patient with multiple myeloma is admitted with hypotension, bradycardia with second-degree AV block, and abdominal pain. Labs include Ca 14.5, Mg 2.1, and PO4- 3.1. Which of the following should the nurse anticipate? Calcium gluconate 10% IV over 3 hours Magnesium 2 grams IV over 10 minutes Aluminum hydroxide (Amphojel) 30 mL every 12 hours NS infusion titrate to goal UO of 2-3 mL/kg/hr
NS infusion titrate to goal UO of 2-3 mL/kg/hr
A hemodynamically unstable patient with AKI is to undergo CVVH. Labs include lactate 8.0 (H), pH 7.2 (L), and CK 79,000 (H). What kind of replacement fluid should the nurse anticipate? NaHCO3- base Na 130 K 4.0 Lactate-based
NaHCO3- base
A patient is undergoing valve replacement due to endocarditis. Which should the nurse teach the patient to prepare for postoperative recovery? Risk of acute respiratory distress syndrome (ARDS) No need for postoperative anticoagulation Possibility for atrial dysfunction Need for thromboembolus prophylaxis
Need for thromboembolus prophylaxis
A nurse noted a high urine output, blood glucose of 650, and hypokalemia in a patient recovering from MI. Which other assessment led the nurse to anticipate treatment for HHS? Negative blood ketones Anion gap of 24 mEq/L Distended neck veins pH 7.25, HCO3- 18 mEq/L
Negative blood ketones
Mr. Kearley is on Day Two mechanical ventilation, and his FiO2 is 0.50. Which assessments indicate he is ready weaning? Negative inspiratory pressure (NIP) -24 cm H2O Vital capacity (VC) 8 Ml/KG abgS: Ph 7.36, PaCO2 38, HCO3- 24, SaO2 91% Spontaneous Vt 6 mL/kg
Negative inspiratory pressure (NIP) -24 cm H2O abgS: Ph 7.36, PaCO2 38, HCO3- 24, SaO2 91% Spontaneous Vt 6 mL/kg
A patient with exertional chest pain, dyspnea, and syncope is admitted. ECHO shows an enlarged basal portion of the septum. Which medication should the nurse avoid in hypertrophic cardiomyopathy? Nitrolgycerin (Tridil) Nicardipine (Cardene) Metoprolol (Lopressor) Amiodarone (Cordarone)
Nitrolgycerin (Tridil)
A patient developed sudden severe headache, trouble seeing out of the right eye, and unilateral weakness of the right leg. She was last seen normal 2 hours ago. Which of these should the nurse initially anticipate? Collaboration with physical therapy Administration of rTPA Consultation with opthalmology Performing a non-contrast CT
Performing a non-contrast CT
Which of the following patients with a history of diabetes is at the highest risk for development of hyperglycemia? A patient admitted with: MI receiving a beta blocker Hypertension receiving an ACE inhibitor GI bleeding receiving vasopressin (ADH) Sepsis receiving norepinephrine
Sepsis receiving norepinephrine
A patient with an ischemic stroke is receiving rtPA. For which of the following should the nurse observe? Heightened awareness Formation of clots in distal parts of extremities Hyperglycemia (blood glucose greater than 300 mg/dL) Severe headache
Severe headache
A postmenopausal woman undergoing significant tension at work and home is admitted with chest pain and dyspnea. Troponin is negative. ECG reveals changes in leads V3 and V4. ECHO confirms ballooning cardiac apex. She is diagnosed with stress-induced cardiomyopathy. Which factor differentiates stress-induced cardiomyopathy from other forms of cardiomyopathy? Symptoms of heart failure Progressive changes in the septum Short-term acute dysfunction Poor prognosis
Short-term acute dysfunction
Which intervention is needed for a patient on a continuous IV insulin infusion at 6 units/ hour and whose current glucose is 68 mg/ dL; last hourly glucose check was 142 mg/dL. Continue the insulin infusion at the current rate, and administer IV D10 Stop the insulin infusion and administer IV D50 emergently Decrease the insulin infusion dose by 1 unit hr, and administer IM glucagon Hold the insulin infusion for 1 hours, and restart the infusion at 4 units/hr
Stop the insulin infusion and administer IV D50 emergently
A patient with a hip fracture from a fall develops pleuritic chest pain, dyspnea, and dry cough. The patient's SPO2 is 90%. CTPA is positive for PE. The nurse should anticipate administration of which of the following? Unfractionated heparin Nitroglycerin (Tridil) Bronchodilator Cough suppressant
Unfractionated heparin
A patient is admitted with a subarachnoid hemorrhage. She is restless and agitated, and complaining of an ongoing headache 10/10. Which of the following changes in signs and symptoms requires an immediate call to the provider? Unresponsiveness to physical stimuli and sluggish pupillary response Decreased SBP with MAP still in ordered parameter Slight increase is restlessness but no change in agitation level Continuing headache with pain intensity of 9/10
Unresponsiveness to physical stimuli and sluggish pupillary response
Which statement is true? Volume ventilation delivers variable amounts of volume based on patient effort Volume ventilation delivers gas at a preset tidal volume Pressure ventilation delivers gas at a variable pressure based on ling compliance Pressure ventilation delivers a consistent minute volume
Volume ventilation delivers gas at a preset tidal volume.
A patient's ICD defibrillates and the nurse assesses the patient's rhythm and vital signs. What should be the nurse's next step? Watch to see whether the ICD terminated the dysrhythmia Place a magnet over the ICD Turn off the ICD, and insert a new battery Change the ICD to standby mode
Watch to see whether the ICD terminated the dysrhythmia
A patient with diabetes who uses an insulin pump is concerned about not managing it during and after surgery. What explanation should the nurse provide about glucose management during and following surgery? We will discontinue your pump and transition to IV regular insulin infusion We will administer subcutaneous regular insulin if needed We will control your pump with your prescribed insulin type We will change the insulin in your pump to regular insulin
We will discontinue your pump and transition to IV regular insulin infusion
A nurse assesses a patient who just arrived to ICU post-cardiac surgery. CT output is 48 ml over 30 minutes, CVP 3 mmHg, BP 67/48(54), and urine output 2 ml/kg over the past hour. What initial intervention should the nurse anticipate? Administer 2 units of whole blood Administer isotonic fluids Strip chest tubes to improve patency Titrate vasopressors to MAP 65-85
Administer isotonic fluids
Mrs. Elinskas is admitted for acute CHF with sharp chest pain, diminished breath sounds, cough, and orthopnea Which intervention should the nurse anticipate? Initiating broad-spectrum antibiotics Obtaining D-Dimer Preparing patient for V/Q scan Administering furosemide (Lasix)
Administering furosemide (Lasix)
A patient with a history of cocaine use reports headache, blurred vision, severe chest pain, nausea, and vomiting. Vital signs are: BP 214/136, HR 106, RR 24. Which priority is initially indicated? Emergent ophthalmology consult Implement a chest pain protocol Initiation of anti-emetic therapy Administration of an antihypertensive
Administration of an antihypertensive
A patient has an aSAH and is responsive to verbal commands. Vital signs are BP 162/80(107), HR 96, RR 24, Temp 37.4C (99.3F). What intervention should the nurse anticipate? Intubation with induced hypercarbia and mild hypoxia Administration of antihypertensive medications Initiation of targeted temperature management Starting IV fluids at KVO rate
Administration of antihypertensive medications
A patient has had two episodes of generalized tonic-clonic movement, each lasting 3-4 minutes, 5 minutes apart, without recovery to baseline neurologic status. What treatment is indicated? Sliding scale insulin Administration of lorazepam Endotracheal intubation Titration of a vasopressor
Administration of lorazepam
A patient with history of seizure is returning from the bathroom when she has new-onset nausea and confusion, followed by greater muscle tone. What intervention is indicated? Assist the patient in laying down Apply oxygen with 100% non-rebreather mask Assess for memory loss and fatigue Administer lorazepam IV
Assist the patient in laying down
What are 3 nursing priorities for patient care before, during, or after thoracentesis? Assist with attaching tube to evacuation collection bottle Continually monitor vital signs and SpO2 Obtain post-procedure ultrasound Position patient sitting on or lying near edge of bed
Assist with attaching tube to evacuation collection bottle Continually monitor vital signs and SpO2 Position patient sitting on or lying near edge of bed
Which should the nurse include in preparing a patient for an electrophysiology study? "You'll see yourself in v tach on the screen" "The study calls for dye to be places in your IV" "You will be sedated for the procedure" "Since you will be awake, you can eat a light breakfast"
"You will be sedated for the procedure"
An 85-year-old patient is admitted with dehydration. Fluid resuscitation has been initiated. Serum glucose is 250, and blood ketones are negative. What is this patient's target serum glucose level? 70-110 mg/dL 110-140 mg/dL 180-200 mg/dL 140-180 mg/dL
140-180 mg/dL
Which of the following patients should the nurse anticipate as most likely to develop hyponatremia and hypo-osmolality? A patient: Who developed diabetes insipidus Who sustained an ischemic stroke With neuroadrenal cancer 2 days post severe traumatic brain injury
2 days post severe traumatic brain injury
An intubated patient, IV 0.45% NS with 20 mEq KCl/L, with liver failure has a blood glucose of 55 mg/dl. What initial intervention should the nurse anticipate? 10 units regular insulin, subcutaneous route 15 mL D50 IM 5 unites glucagon, subcutaneous route 25ml of d 50 IV
25ml of d 50 IV
Use the net fluid removal formula to calculate this hour's net fluid removal for this patient: IV fl 80 mL/hr; O: chest tube 60 mL/hr; NG tube 40 mL/hr; remove 50 mL/hr. [(net intake) - (net output) + ordered fluid removal] = fluid removal rate 10 mL 30 mL 35 mL 60 mL
30 mL
Which is the chief symptom of diffuse axonal injury in a patient with traumatic brain injury? Seizure Abnormal posturing Unilateral weakness Visual or speech disturbances
Abnormal posturing
A patient has the following ABG results: pH 7.25, PaCO2 43, PaO2 80, SaO2 91%, and HCO3- 18. What is the most likely underlying cause? Acute kidney injury COPD exacerbation Overconsumption of antacids Respiratory failure
Acute kidney injury
Assessment of a patient reveals a new mitral systolic murmur, cool and pale extremities with delayed capillary refill time, and a rapidly deteriorating BP with signs of cardiogenic shock. What condition should the nurse anticipate? Acute coronary syndrome Acute mitral regurgitation Pulmonary embolus Pulmonary hypertension
Acute mitral regurgitation
In caring for a patient who underwent CABG with a saphenous vein graft, the nurse should anticipate which postoperative intervention(s)? Elevate donor extremity, and administer nitrate Administer ASA within first six hours, and elevate donor leg Administer calcium channel block within first six hours Administer nitrates and calcium channel blocker
Administer ASA within first six hours, and elevate donor leg
A patient with kidney dysfunction has increasing confusion, BP 102/70 (81) lying, 86/68 (74) sitting, HR 118 sinus tachycardia, and UO 0.1 mL/kg/hr. What intervention should the nurse expect first? Administer IV LR in boluses of 250-500 mL Assess for ATN Request order for lisinopril (Prinivil) Administer IV 0.45% NS as a continuous infusion
Administer IV LR in boluses of 250-500 mL
A patient who sustained a traumatic spinal cord injury in a motor vehicle crash is admitted. The patient reports low of movement and sensation below the waist. BP is 88/45(59). What is the initial priority? Administer IV fluids Administer NSAIDs to decrease inflammation Prepare for endotracheal intubation Anticipate an electromyogram to assess for motor deficits
Administer IV fluids
A patient with a stab wound to the chest has VS: BP 80/40 (53), HR 112, and RR 24. Diminished heart sounds, dizziness, JVD, and weak pulses are noted. Which should the nurse anticipate? Administer fluid bolus Infuse dopamine Position patient in High Fowler's Prepare for pericardiocentesis
Administer fluid bolus Prepare for pericardiocentesis
A patient with creatinine clearance 60 mL/min is to undergo diagnostic testing with contrast. Which measure is indicated to prevent further injury to the kidney? Administration of pre- and post-procedure IV fluids Collaboration with provider to perform test without contrast IV loop diuretic administration Administration of erythropoietin
Administration of pre- and post-procedure IV fluids
A patient with creatinine clearance 60 mL/min is to undergo diagnostic testing with contrast. Which measure is indicated to prevent further renal injury? Administration of erythropoetin Administration of pre- and post-procedure IV fluids Collaboration with provider to perform test without contrast IV loop diuretic administration
Administration of pre- and post-procedure IV fluids
A nurse notes bradycardia in a patient admitted with subarachnoid hemorrhage and vomiting. What medications may increase the patient's risk of sudden cardiac death due to long QT syndrome? Anticholinergics or phosphodiesterase inhibitors Acetaminophen or calcium channel blockers ACE inhibitors or anticonvulsants Antibiotics or antidysrhythmics
Antibiotics or antidysrhythmics
A patient with skull fracture has WBC 14,00 mm^3 (was 11,000 mm^3), is more lethargic, and wants the room dark. In flexing the patient's neck, you note involuntary flexion of knees and hips. What is anticipated? Emergent endotracheal intubation Antimicrobial therapy Observation for cranial nerve X dysfunction Application of a C-collar
Antimicrobial therapy
Which of the following central pain stimuli should the nurse use to assess motor function in a patient who is unconscious and who has facial fractures? Apply supraorbital pressure Apply pressure to the nailbed Apply vigorous sternal rubbing Apply trapezius squeeze
Apply trapezius squeeze
When a nurse asks a patient's name, The patient replies with the name of the town where the hospital is located. When asked what day it is, he replies "house." Shown a hairbrush and asked to name it, he replies "dog." What other step(s) should the nurse take to evaluate the patient's language functioning? Ask the patient to raise 1 arm slowly Point to the patient's arm while asking him to lift the arm slowly Ask the patient to squeeze your hand Lift your arm slowly while asking the patient to lift his arm
Ask the patient to raise 1 arm slowly
A patient post-pneumonectomy arrives on your unit with a clamped chest tube on the operative side. Which action do you anticipate? Unclamp and attach chest tube drainage to suction Maintain clamp and anticipate immediate chest tube removal Assess chest drain and chest tube for bleeding Assess chest drain water seal for an air leak
Assess chest drain and chest tube for bleeding
A nurse finds no CSF in a patient's EVD collection chamber. Assessment reveals the drain stopcock is open to drain. What two other assessment should the nurse perform? Assess fluctuation of the CSF in the drain by raising the drainage system briefly Assess drain tubing for presence of visible blockages Assess for pulsations or fluctuations in the tubing Assess level of drain relative to phlebostatic axis
Assess drain tubing for presence of visible blockages Assess for pulsations or fluctuations in the tubing
Which of the following should the nurse perform immediately after insertion of the ICP monitoring device is completed? Position the patient flat Assess neurologic status and compare to assessment before insertion. Irrigate the insertion site with an antibiotic solution Ensure that the transducer is at the level of the phlebostatic axis
Assess neurologic status and compare to assessment before insertion.
Which of the following is a nursing care priority for a patient who underwent TAVR through a transaxillary approach? Observe and record CT output Immobilize the arm on the procedure side for 24 hours Assess sensory and motor function in the arm on the procedure side. Keep systolic BP <90 mm Hg
Assess sensory and motor function in the arm on the procedure side.
Which nursing intervention is indicated immediately after the patient is intubated emergently? Change ventilator settings based on patient tolerance Obtain ABGs Assess vital signs Obtain baseline sputum culture
Assess vital signs
A patient with a hemothorax and newly inserted chest tube with drainage system is admitted from the ED. Which intervention should the nurse anticipate? Prepare for needle decompression Observe for purulent drainage Attach chest tube drain to wall suction Clamp chest tube every 4 hours to check for an air leak
Attach chest tube drain to wall suction
A patient underwent CABG with cardiopulmonary bypass. Which statement about fluid requirements is true? Due to vasoconstriction, IV fluids are not needed within the first 24 hours Fluids should be given based on patient thirst Because of SIRS, the need for IV fluids should be expected in the first 24 hours Since cardioplegia was used, no additional fluids are required
Because of SIRS, the need for IV fluids should be expected in the first 24 hours
A patient is admitted with tachycardia, wheezing, and a nonproductive cough. Which treatment(s) should the nurse anticipate? NIPPV Metoprolol (Lopressor) Bronchodilators Antibiotics
Bronchodilators
A patient has declining SpO2 despite supplemental O2 and uncompensated respiratory acidosis. What is the priority action? Repeat ABG Initiate bronchodilator treatment Initiate NIPPV Call the provider immediately
Call the provider immediately
For a patient with mitral stenosis, which 3 interventions should the nurse anticipate to manager the patient' new onset atrial fibrillation? Catheter or surgical ablation for persistent atrial fibrillation Maintenance of ventricular rate at 100-200 bpm Warfarin (Coumadin) Cardioversion with or without antidysrhythmic medication
Catheter or surgical ablation for persistent atrial fibrillation Warfarin (Coumadin) Cardioversion with or without antidysrhythmic medication
A patient has a epicardial temporary pacemaker in place at a rate of 70 and mA of 6. The patient's rhythm is junctional with a rate of 55. No pacemaker spikes are noted on the ECG. Which is initially indicated. Increase the mV on the sensitivity dial Change the batteries Increase the pacemaker rate Increase the mA (output)
Change the batteries
What incision care interventions should a nurse use while monitoring a post-cardiac surgery patient's incisions and access sites? Maintain OR dressings until the surgeon removes them or until day of discharge Provide prophylactic antibiotics while the patient is hospitalized Apply topical antibiotic ointment daily until incisions heal Clean incision with saline, betadine, or chlorhexidine
Clean incision with saline, betadine, or chlorhexidine
A patient is recovering from an ischemic stroke. Which of the following interventions should the nurse anticipate? Teach the patient to always dress in layers in case of unexpected cold exposure Refer for a psychiatric evaluation to manage anxiety Collaborate with physical therapy to decrease falls risk. Recommend use of a transcutaneous electrical nerve stimulation (TENS) unit for residual weakness
Collaborate with physical therapy to decrease falls risk.
A skier who collided with a tree is placed in a cervical collar and admitted for head injury. What potential cause of increased ICP should the nurse observe for? Hyperemia due to jugular vein dilation Compression of parenchyma due to decreased BP Compression on the jugular veins due to cervical collar tightness Pressure on back of head due to lack of movement
Compression on the jugular veins due to cervical collar tightness
A nurse is preparing to initiate vasopressor therapy in a patient who is undergoing CRRT with BP 86/45 (59) and HR 120 sinus tachycardia. What step should the nurse take before beginning the therapy? Consider possible fluid volume deficit Adjust timing of dose to CVVHDF schedule Check for increase in patient's daily weights Verify patient has not undergone SCUF within 48 hours
Consider possible fluid volume deficit
When administering metformin (Glucophage) to a patient who is scheduled for a procedure with contrast, what steps should a nurse take? Evaluate patient's weight every other day Consult the critical care pharmacist; Anticipate hypertonic saline IV prior to procedure Ensure metformin held 24 hours pre-procedure and 48 hours post-procedure.
Consult the critical care pharmacist Ensure metformin held 24 hours pre-procedure and 48 hours post-procedure.
The goal of administering osmotherapy is to: Decrease cerebral edema Increase urine output Decrease serum osmolality Shift fluid into the interstitial space
Decrease cerebral edema
A patient with SIADH has the following lab results: serum sodium 128 mEq/L (L), serum osmolality 275 mOsm/kg H2O (L), and hematocrit 32% (L). Which of the following interventions should the nurse anticipate? NS bolus 250 mL each over 15 minutes x 4 (total of 1 L over 60 minutes) Decrease of IV fluids to 10 mL/hr D5 0.45% NS at 150 mL/hr Transfusion of 2 units packed red blood cells
Decrease of IV fluids to 10 mL/hr
On a patient's ICP waveform, the P2 wave is higher and more rounded than the P1 wave. What is the significance of this finding? Increased intracranial compliance; patient responding to treatment Variance may be within normal limits; compare with baselines P1 and P2 Decreased intracranial compliance; patient may be unable to compensate for intracranial volume changes. Decreased ICP; inform provider
Decreased intracranial compliance; patient may be unable to compensate for intracranial volume changes.
Assessment of a patient with CKD who is scheduled for dialysis reveals pitting edema and crackles throughout both lungs. What other signs should the nurse expect to see in this patient? Poor skin turgor and increased BUN, Cr levels Decreased BUN, Cr levels and increased urine output Dry mucous membranes and increased urine output Decreased urine output, and increased BUN, Cr levels
Decreased urine output, and increased BUN, Cr levels
How does early mobility benefit a patient in the acute recovery phase post-cardiac surgery? Decreases overall length of stay Improves oxygenation and pulmonary function Counters risk for complications due to bed rest Reduces risk of bleeding
Decreases overall length of stay Improves oxygenation and pulmonary function Counters risk for complications due to bed rest
Serum osmolality is used to assess a patient's volume status. Which 2 conditions alter the serum osmolality? Ischemic stroke Diabetes insipidus (DI) Myocardial infarction Syndrome of inappropriate antidiuretic hormone (SIADH)
Diabetes insipidus (DI) Syndrome of inappropriate antidiuretic hormone (SIADH)
What assessment findings, in addition to dyspnea and fatigue, should the nurse anticipate in a patient with systolic heart failure? Decreased right atrial pressure Murmur of tricuspid regurgitation Edema and ascites Bradycardia
Edema and ascites
A patient with a history of sarcoidosis is admitted with increased dyspnea, exercise intolerance, and fatigue. Decreased cardiac output is noted as a result of restrictive cardiomyopathy. Which 3 nursing interventions are necessary for these patients? Elevate legs when out of bed Educate on potassium restriction Encourage ambulation Educate on stress reduction
Elevate legs when out of bed Encourage ambulation Educate on stress reduction
A patient who fell and sustained a traumatic brain injury is admitted. The patient is unconscious and has a GCS score of 6. Which of these is the main priority? Repositioning the patient every two hours Administration of isotonic fluids at KVO rate Endotracheal intubation Preparing for MRI
Endotracheal intubation
Which intervention prevents complications for a patient experiencing neuromuscular blockade while undergoing mechanical ventilation? Hold neuromuscular blockade for neurological assessment hourly Ensure VTE and stress ulcer prophylaxis Perform chest physiotherapy Monitor Sedation level using the RASS
Ensure VTE and stress ulcer prophylaxis
A patient with a history of COPD and pulmonary hypertension on conventional therapy develops worsening symptoms. Cardiac catheterization reveals elevated pulmonary vascular resistance and the PA pressure does not respond to calcium channel blockers or PDE-5 inhibitors. Which should the nurse initially anticipate? Phenylephrine (Neosynephrine) Nitroglycerin (Tridil) Epoprostenol (Veletril) Albuterol (Ventolin)
Epoprostenol (Veletril)
Which of these are priority interventions for patients receiving PD? Evaluate patient weight daily Encourage increased fluid intake Ensure safe accessing and de-accessing of peritoneal catheter Evaluate ultrafiltrate for color and clarity
Evaluate patient weight daily Ensure safe accessing and de-accessing of peritoneal catheter Evaluate ultrafiltrate for color and clarity
A patient with a history of hypertension reports nausea, "a terrible headache," and numbness and weakness of the right arm and leg. What neurologic event should the nurse suspect? Ischemic stroke Hemorrhagic stroke Cranial artery spasm Bacterial meningitis
Hemorrhagic stroke
a patient with diabetes and chronic kidney disease receiving metformin is to undergo diagnostic testing with contrast. Which measure is anticipated to prevent further injury to the kidney? Administration of IV loop diuretic Hold metformin 24 hours before, and for 48 hours after procedure Administration of pre- and post-procedure IV sodium bicarbonate Administration of intra-procedure IV fluids
Hold metformin 24 hours before, and for 48 hours after procedure
In which instance, in a patient on invasive ventilation, should a nurse anticipate the use of vecuronium (Norcuron) or another neuromuscular blocking agent (NMBA) with sedation and analgesia In ventilator dyssynchrony with acute respiratory distress syndrome (ARDS) With synchronized intermittent mandatory ventilation (SIMV) For PaO2 less than 80 mm Hg When the patient fails the SAT
In ventilator dyssynchrony with acute respiratory distress syndrome (ARDS)
What vital sign assessments herald impending brainstem herniation? Increased SBP w/widening pulse pressure, increased temperature, and tachycardia Increased SBP w/widening pulse pressure, changes in respirations, and bradycardia Deceased SBP w/narrowing pulse pressure, tachycardia, and normal respirations Increased DBP w/narrowing pulse pressure, tachycardia, and changes in respirations
Increased SBP w/widening pulse pressure, changes in respirations, and bradycardia
A patient on CVVHDF is receiving post-filter replacement solution. Which of the following should the nurse anticipate? Increased ultrafiltration rate Increased need for anticoagulation Increased convection Decreased solute removal
Increased need for anticoagulation
A nurse assesses a patient with hemorrhagic stroke and finds a GCS score of 6. What order should the nurse anticipate? CBC and a coagulation profile CT scan with contrast Intubation IV glucose
Intubation
A patient with hypertension reports partial loss of vision in her left eye and numbness in her left arm. She does not have a headache. What process should the nurse suspect? Transient ischemic attack (TIA) Ischemic stroke Horner's syndrome Hemorrhagic stroke
Ischemic stroke
A patient with a recent MI reports stabbing chest pain that increases with deep breathing and is relieved by leaning forward. SpO2 is 94%. Which should the nurse initially anticipate? Corticosteroids NSAIDs/ASA Pericardiocentesis Nitroglycerin
NSAIDs/ASA
A patient with bronchogenic carcinoma is admitted with lethargy and confusion. Serum sodium is 118. Which intervention should the nurse anticipate? Monitoring for effects of hyperkalemia Desmopressin nasal spray Na+ increase by 0.5 mEq/L/hr with hypertonic saline IV 0.45% NS at 150 mL/hr
Na+ increase by 0.5 mEq/L/hr with hypertonic saline
For which sign of symptom should a nurse stop the SBT of a patient weaning from mechanical ventilation? PIP 25 cm H2O SpO2 89% RR 31 Patient becomes confused
Patient becomes confused
A patient is undergoing CABG using the radial artery. Which should the nurse anticipate? Teaching about increased risk for sternal infection Performing an Allen's test Development of edema Checking pedal pulses on the affected side
Performing an Allen's test
A patient with hyperkalemia needs Continuous venovenous hemofiltration CVVH. The nurse considers running replacement fluid pre-filter to prevent clogging. What is the disadvantage of running it pre-filter? Requires use of separate CRRT ultrafiltrate calculations Reduces time needed on CRRT Reduces clearance by as much as one-third when dialysate is not used Potential filter leaking
Reduces clearance by as much as one-third when dialysate is not used
A patient with diabetes is admitted with sepsis Na 135, K 4.4, Phos 2.5 BUN 33 Cr 1.2 glucose 625, pH 7.15, HCO3 9.8 blood ketones positive. The nurse should anticipate administration of which medication? Regular insulin IV infusion at 0.1 units/kg/hr IV 0.9% NS at 15 mL/hr Potassium phosphate IV infusion over 2 hours Sodium bicarbonate 2 mEq/kg IV infusion over 1 hour
Regular insulin IV infusion at 0.1 units/kg/hr
What requirements must be met before transitioning a critically ill patient from continuous regular IV insulin to basal and prandial subcutaneous insulin? Regular insulin is being infused at a low rate The patient's glucose is stable. The patient's glucose is at a target level. Continuous regular IV insulin has become less effective
Regular insulin is being infused at a low rate The patient's glucose is stable. The patient's glucose is at a target level.
Patient is on CVVHDF and dark red streaks are assessed on the filter. The filter pressure is 150 mm Hg greater than when initiated and the high filter pressure alarms. Which action is indicated? Rinse back the blood, and change the CRRT circuit Administer citrate pre-filter, and change the filter Move replacement solution to post-filter Decrease the frequency of flushing the system
Rinse back the blood, and change the CRRT circuit
While weaning a patient from short-term ventilation, the nurse should observe for which indications that the patient is not tolerating the weaning? SpO2 falling below 88% RR 32 Decreasing spontaneous Vt RR 40
SpO2 falling below 88% Decreasing spontaneous Vt RR 40
Ms. Julie Gadley passed the SAT safety screen and began the SAT. The propofol has been off for 30 minutes. Fentanyl is at 50 mcg/hr. Her pain and agitation scores include CPOT 7 and RASS +3 (very agitated). Her vital signs are BP 92/56 (68), HR 125, and RR 38. Then ventilator is alarming for high PIP. What nursing actions are indicated? Collaborate with the RT to increase the ventilator alarm parameter Discontinue the fentanyl and initiate morphine drip Start vasopressor for hypotension Stop the SAT and restart propofol at half the previous dose.
Stop the SAT and restart propofol at half the previous dose.
A patient is on mechanical ventilation and the SAT is in progress. The patient develops RR 36 and SpO2 87%. Which is indicated? Call RT to increase the FiO2 Administer flumazenil (Romazicon) Stop the SAT and restart sedation at half the pretrial rate. Obtain an order for a neuromuscular blocking agents (NMBA)
Stop the SAT and restart sedation at half the pretrial rate.
A patient with a history of atherosclerosis and hypertension reports sudden inability to walk. For which other symptom should the nurse observe? Repetitive movements on strong side Hyperglycemia Sudden unilateral facial numbness Trouble concentrating on specific thoughts
Sudden unilateral facial numbness
A patient has indication for synchronized cardioversion? A patient with: Ventricular tachycardia with BP 100/60 (73) Supraventricular tachycardia with chest pain Atrial fibrillation with a history of VTE Sinus bradycardia with mental status changes
Supraventricular tachycardia with chest pain
Positioning the patient post-pneumonectomy should include which 2 interventions: Tilting the patient side to side every 2 hours Head of bed flat as tolerated Operative side lying 90 degrees lateral position Head of bed 30 degrees as tolerated
Tilting the patient side to side every 2 hours Head of bed 30 degrees as tolerated
You are doing pre-operative teaching for a patient scheduled for a video-assisted thorascopic surgery (VATS). What two things should you tell the patient? During VATS: Infection risk is slightly higher Tissue can be collected for biopsy An open approach is needed to remove fluid Smaller incisions result in less pain
Tissue can be collected for biopsy Smaller incisions result in less pain
A patient with sepsis received vancomycin (Vancocin), had a CT scan with contrast, and is diagnosed with AKI. Current vitals on norepinephrine at 0.1 mcg/kg/min: HR 88 sinus rhythm, BP 70/40 (50), UO 0.3 mL/kg/hr; lab values: BUN: creatinine 15:1, serum Osmo 292 (N) and hematocrit 30%. Which is indicated? Anticipate transfusion of 1 unit packed red blood cells Administer prn order for furosemide (Lasix) Maintain IV at 15 mL/hr Titrate vasopressors to maintain MAP greater than 65 mm Hg
Titrate vasopressors to maintain MAP greater than 65 mm Hg
A patient with sepsis received vancomycin (Vancocin), had a CT scan with contrast, and is diagnosed with AKI. Current vitals on norepinephrine at 0.1 mcg/kg/min: HR 88 sinus rhythm, BP 70/40 (50), UO 0.3 mL/kg/hr; lab values: BUN: creatinine 15:1, serum Osmo 292 (N) and hematocrit 30%. Which is indicated? Titrate vasopressors to maintain MAP greater than 65 mm Hg. Transfuse 1 unit packed red blood cells Administer furosemide (Lasix) Maintain IV at 15 mL/hr
Titrate vasopressors to maintain MAP greater than 65 mm Hg.
A nurse finds a patient unresponsive and without a palpable pulse. Which of the following assessments is an indication for defibrillation? Ventricular fibrillation Cyanosis Pulse oximeter below 80 Asystole
Ventricular fibrillation
Mr. DeMontel is admitted after a thoracotomy. He has a chest tube drainage system to his left chest with orders for suction at -20 cm H2O. What is the priority nursing assessment? Maintain patient on bed rest Check the suction chamber for air leaks Ensure suction level changes as patient inhales and exhales Verify that the chest tube connection is secured
Verify that the chest tube connection is secured.
A patient with type 2 diabetes who is receiving TPN is started on continuous regular IV insulin. Which treatment priority should the nurse anticipate? Vigilant monitoring of blood glucose Subcutaneous administration of insulin Maintenance of bed rest Consideration of reduced dosage of insulin
Vigilant monitoring of blood glucose
Which patient has an indication for oxygen therapy with a low-flow device? A patient: With severe hypoxemia With carbon monoxide poisoning Who is postoperative for brain tumor removal With smoke inhalation
Who is postoperative for brain tumor removal
A patient with tumor lysis syndrome reports nausea, abdominal cramps, numbness, tingling, and muscle weakness. The K is 7.2 and the ECG rhythm strip shows tall tented T waves. What other ECG findings should the nurse anticipate at this time? Widened QRS, prolonged PR Ventricular fibrillation Atrial fibrillation with rapid ventricular response Shortened PR and QT intervals
Widened QRS, prolonged PR
Which patient most likely to have indication for non-rebreather mask? A patient: Who is postoperative lobectomy With COPD With carbon monoxide poisoning With asthma exacerbation
With carbon monoxide poisoning
Which condition may affect pulse oximetry accuracy? Room with dim lighting Cardiac arrest H&H 8 & 24 Peripheral vasodilation
Cardiac arrest
In a patient with pulmonary embolism, which sequelae should the nurse anticipate? Cardiac ischemia Increased coronary perfusion Right ventricular failure Hypoxemia
Cardiac ischemia Right ventricular failure Hypoxemia
Which is indicated for patients requiring ongoing tracheostomy management? Keep a spare tracheostomy at the bedside. Prepare for tube replacement every month Keep cuff pressure at 50 cm H2O Instill normal saline (NS) into tracheostomy to loosen secretions
Keep a spare tracheostomy at the bedside.
A patient with pulmonary artery hypertension is receiving epoprostenol. Which intervention is indicated? Warm the bag to room temperature before hanging If that patient reports shortness of breath, stop the infusion immediately Obtain pulmonary hemodynamics before hanging each new bag Have the next bag's tubing primed in advance
Have the next bag's tubing primed in advance
A patient who underwent a thoracotomy is admitted. Which intervention is indicated? Encourage use of incentive spirometer every 4 hours while patient is awake Maintain on bed rest for 48 hours Maintain patency of chest drainage system Position patient only on nonoperative side
Maintain patency of chest drainage system
A patient with a massive cerebral hemorrhage is admitted. The patient is comatose. Pupils have become dilated and no longer react to light. The breathing pattern has become irregular. Vital signs: BP 170/66 (101), HR 40 and irregular, RR 16 and irregular. Administration of which of the following should the nurse anticipate? Hydralazine (Apresoline) Mannitol (Osmitrol) Metoprolol (Lopressor) Atropine sulfate
Mannitol (Osmitrol)
In a patient with a subarachnoid hemorrhage, what is the purpose of a transcranial Doppler (TCD) test? Measure blood flow velocity to assess for vasospasm. Assess extent of hemorrhage Identify venous thrombosis Help predict extent of neurologic damage
Measure blood flow velocity to assess for vasospasm.
A patient is on positive pressure ventilation (PPV) for acute respiratory distress syndrome (ARDS). Which action is indicated? Decrease the PEEP to maintain SpO2 to atleast 90% Increase VT to 10 mL/kg to maintain minute volume Decrease expiratory time Monitor for blood-tinged sputum and crackles.
Monitor for blood-tinged sputum and crackles.
A patient has just been intubated for respiratory failure. What are 3 nursing priorities for managing this patient? Obtain sputum cultures Monitor vital signs Verify ventilator settings Assess for pain and agitation
Monitor vital signs Verify ventilator settings Assess for pain and agitation
After evaluating LOC and mental status for a patient 6 hours past stroke, a nurse should complete the patient's neurologic exam by evaluating which other functions? Motor function Pupil size and reactivity Hearing acuity Orientation and basic communication
Motor function Pupil size and reactivity Orientation and basic communication
Patients with intrapulmonary shunting have collapsed airways and alveoli. Which intervention helps open the collapsed airway? Positive pressure (invasive or noninvasive) Air entrainment mask Nonrebreather mask Nasal cannula
Positive pressure (invasive or noninvasive)
A patient with a hemothorax is admitted. Which intervention should the nurse anticipate? Administer furosemide (Lasix) Prepare for chest tube insertion Anticipate daily chest x-ray Transfuse 1 unit of packed red blood cells
Prepare for chest tube insertion
Which form of mechanical ventilation should a nurse anticipate for a patient with acute respiratory distress syndrome (ARDS) who has PaO2 51 mm Hg? Continuous positive airway pressure (CPAP) Pressure controlled ventilation (PCV) Synchronized intermittent mandatory ventilation (SIMV) Pressure support ventilation (PSV)
Pressure controlled ventilation (PCV)
In caring for a patient on mechanical ventilation which strategy should a nurse anticipate to prevent volutrauma and barotrauma? Use Vt less than 6-10 mL/kg of PBW (4-6 mL/kg of PBW in ARDS patients). Monitor peak inspiratory pressure to ensure >35 cm H2O Decrease expiratory time Maximize PEEP
Use Vt less than 6-10 mL/kg of PBW (4-6 mL/kg of PBW in ARDS patients).
A patient reports sudden onset of chest pain, and dyspnea. Which 3 assessment findings would differentiate whether the cause is ACS or pericarditis? Pericarditis pain often accompanied by severe headache ACS pain is not usually accompanied by fever Pericarditis chest pain increases with inspiration ACS chest pain doesn't alter when patient changes position
ACS pain is not usually accompanied by fever Pericarditis chest pain increases with inspiration ACS chest pain doesn't alter when patient changes position
A patient admitted 48 hours ago has a temperature of 38.9 (102 F), cough with purulent sputum, crackles that don't clear and decreased right lower lobe breath sounds. Broad-spectrum antibiotics Furosemide (Lasix) Reposition patient with HOB 10-15 degrees Reposition patient on right side
Broad-spectrum antibiotics
A patient is admitted with COPD exacerbation. ABGs are: pH 7.28, PaO2 60 mm Hg, PaCO2 76 mm Hg, HCO3^- 27 mEq/L, and SaO2 86% on FiO2 50% via air entrainment device. Which treatment would you anticipate next? Endotracheal intubation NIPPV High-flow nasal cannula Nonrebreather mask
NIPPV
A patient with COPD on positive pressure ventilation reports sudden chest pain. The nurse observes tracheal deviation, tachycardia, and shortness of breath. What 3 other conditions should the nurse expect? Increased PaO2 levels with decreased PaCO2 levels Decreased PaO2 levels with decreased PaCO2 levels Decreased chest excursion on 1 side Decreased SaO2 level
Decreased PaO2 levels with decreased PaCO2 levels Decreased chest excursion on 1 side Decreased SaO2 level
A patient with a large brain tumor is admitted. She initially reported a headache and suddenly became unresponsive to all stimuli. Pupils are no longer reactive to light. The heart rate is decreasing, and the SBP is elevated with a widened pulse pressure. The provider has been notified and is on the way to the bedside. Which of the following is immediately indicated to temporarily reduce increased ICP? Hyperventilate the patient Intubate and place the patient on a T-piece Administer IV fluid bolus of 0.45% NS Administer atropine 0.5 mg IV
Hyperventilate the patient
A nurse observes that a patient admitted for trauma is lethargic, with PaO2 57 mm Hg. The presence of which other factor should lead the nurse to anticipate endotracheal intubation? History of asthma Impaired ability to swallow PaCO2 42 mm Hg RR 25
Impaired ability to swallow
In caring for a patient on mechanical ventilation, how can a nurse reduce over-sedation, immobility, and the development of delirium? Monitor hourly EtCO2 Implement ABCDEF bundle Maintain circadian rhythm Initiate neuromuscular blockade
Implement ABCDEF bundle
A patient has a transcutaneous pacemaker. Which action should the nurse implement when a pacemaker spike occurs but is not followed by ventricular complex? Assess the heart rate Increase the mA Increase the mV Assess the ECG lead placement
Increase the mA
A patient who underwent a pneumonectomy is admitted. For which complication should the nurse observe? Hypovolemia Decrease capillary permeability Heightened awareness Increased cough with frothy sputum
Increased cough with frothy sputum
A patient with a stroke and aspiration now has respiratory distress and is on NIPPV with FiO2 0.50. ABG reveals pH 7.30, PaO2 57, PaCO2 50, SaO2 89%, HCO3 27 and P/F 150 which is the priority action? Initiate emergency response team Call the provider immediately Implement permissive hypercapnia Increase FiO2 to 0.80
Initiate emergency response team
Which 3 practices should the nurse perform in caring for a patient who has an ETT? Prevent breakdown of skin near ETT Suction the ETT routinely Help patients who are awake to communicate using validated methods Document ETT position at teeth or nares
Prevent breakdown of skin near ETT Help patients who are awake to communicate using validated methods Document ETT position at teeth or nares
A patient with respiratory failure following cardiac surgery has crackles in bilateral posterior lower lobes and a temperature of 38.6 C (101.5 F) and is on 4L/min NC. Which three interventions will promote normal respiratory function? Promote effective coughing Reduce anxiety Avoid tachypnea Keep PaO2 > 60 mm Hg
Promote effective coughing Reduce anxiety Keep PaO2 > 60 mm Hg
A patient is admitted after sustaining traumatic brain injury in a motorcycle crash. The patent's GCS score on admission is E 2, M 3, V 1T = 6T. Which of the following should the nurse perform to prepare the patient for ICP monitoring? Explain the rationale for the sterile flush system for the transducer Position the patient supine and flat Reassess the patient's neurologic status Explain the meaning of the ICP waveforms to the family
Reassess the patient's neurologic status
A patient is ready for extubation. Which intervention is indicated? Administer midazolam (Versed) IV Deflate the balloon and suction subglottic area Insert an oropharyngeal airway Remove the ETT at end of inspiration
Remove the ETT at end of inspiration
A patient is admitted following a drug overdose. The patient does not open eyes upon verbal request but localizes to a trapezius muscle squeeze without opening eyes. The nurse should document the patient's mental status as: Responsive to verbal stimuli Responsive to painful stimuli Unresponsive Alert
Responsive to painful stimuli
A patient has been on mechanical ventilation for 2 days. After 2 hours on an SBT, RR is 7, and SpO2 is 90%. Which is indicated? Ask RT to increase the FiO2 Stop the trial and place the patient back on ventilator Suction the patient via the ET Elevate the head of the bed
Stop the trial and place the patient back on ventilator.
A patient is admitted after an unwitnessed cardiac arrest at home. Review the EMR. What criterion is anticipated as part of the decision-making process to support declaration of death by neurologic criteria? Pupils are sluggishly reactive to light Eyelids tremble when a piece of cotton swab touches the cornea A very weak cough occurs when the patient is suctioned via the endotracheal tube The PaCO2 increases to 68 when off ventilator for 8 minutes.
The PaCO2 increases to 68 when off ventilator for 8 minutes.
