SOLE M1

A critically ill patient has a living will in the chart. The patient's condition has deteriorated, but the spouse wants "everything done," regardless of the patient's wishes. Which ethical principle is the spouse violating? a. Autonomy b. Beneficence c. Justice d. Nonmaleficence

A

What does an ABG test for?

ABG would indicate only hypoxemia and/or acid-base abnormalities.

A patient is admitted to the hospital with multiple trauma and extensive blood loss. The nurse assesses vital signs to be BP 80/50 mm Hg, heart rate 135 beats/min, respirations 36 breaths/min, cardiac output (CO) of 2 L/min, systemic vascular resistance of 3000 dynes/sec/cm-5, and a hematocrit of 20%. The nurse anticipates administration of which the following therapies or medications? A. Blood transfusion B. Furosemide C. Dobutamine infusion D. Dopamine hydrochloride infusion

A

As part of nursing management of a critically ill patient, orders are written to keep the head of the bed elevated at 30 degrees, awaken the patient from sedation each morning to assess readiness to wean from mechanical ventilation, and implement oral care protocols every 4 hours. These interventions are done as a group to reduce the risk of ventilator-associated pneumonia. This group of evidence-based interventions is often called a a. bundle of care. b. clinical practice guideline. c. patient safety goal. d. quality improvement initiative.

A

The nurse is a member of a committee to design a critical care unit in a new building. Which design trend would best facilitate family-centered care? A.Ensure that the patient's room is large enough and has adequate space for a sleeper sofa and storage for family members' personal belongings. B. Include a diagnostic suite in close proximity to the unit so that the patient does not have to travel far for testing. C. Incorporate a large waiting room on the top floor of the hospital with a scenic view and amenities such as coffee and tea. D. Provide access to a scenic garden for meditation.

A

Elderly patients who require critical care treatment are at risk for increased mortality, functional decline, or decreased quality of life after hospitalization. Assuming each of these patients was discharged from the hospital, which of the following patients is at greatest risk for decreased functional status and quality of life? A. A 70-year-old man who had coronary artery bypass surgery. He developed complications after surgery and had difficulty being weaned from mechanical ventilation. He required a tracheostomy and gastrostomy. He is being discharged to a long-term acute care hospital. He is a widower. B. A 79-year-old woman admitted for exacerbation of heart failure. She manages her care independently but needed diuretic medications adjusted. She states that she is compliant with her medications but sometimes forgets to take them. She lives with her 82-year-old spouse. Both consider themselves to be independent and support each other. C. A 90-year-old man admitted for a carotid endarterectomy. He lives in an assisted living facility (ALF) but is cognitively intact. He is the "social butterfly" at all of the events at the ALF. He is hospitalized for 4 days and discharged to the ALF. D. An 84-year-old woman who had stents placed to treat coronary artery occlusion. She has diabetes that has been managed, lives alone, and was driving prior to hospitalization. She was discharged home within 3 days of the procedure.

A

Patients often have recollections of the critical care experience. Which is likely to be the most common recollection of patients who required endotracheal intubation and mechanical ventilation? A. Difficulty in communicating B. Inability to get comfortable C. Pain D. Sleep disruption

A

Sleep often is disrupted for critically ill patients. Which nursing intervention is most appropriate to promote sleep and rest? A. Consult with the pharmacist to adjust medication times to allow periods of sleep or rest between intervals. B. Encourage family members to talk with the patient whenever they are present in the room. C. Keep the television on to provide white noise and distraction. D. Leave the lights on in the room so that the patient is not frightened of his or her surroundings.

A

The American Nurses Credential Center Magnet Recognition Program supports many actions to ensure that nurses are engaged and empowered to participate in ethical decision making. Which of the following would assist nurses in being involved in research studies? a. Education on protection of human subjects b. Participation of staff nurses on ethics committees c. Written descriptions of how nurses participate in ethics programs d. Written policies and procedures related to response to ethical issues

A

The charge nurse is supervising the care of four critical care patients being monitored using invasive hemodynamic modalities. Which patient should the charge nurse evaluate first? A. A patient in cardiogenic shock with a cardiac output (CO) of 2.0 L/min B. A patient with a pulmonary artery systolic pressure (PAP) of 20 mm Hg C. A hypovolemic patient with a central venous pressure (CVP) of 6 mm Hg D. A patient with a pulmonary artery occlusion pressure (PAOP) of 10 mm Hg

A

The nurse is caring for a 100-kg patient being monitored with a pulmonary artery catheter. The nurse assesses a blood pressure of 90/60 mm Hg, heart rate 110 beats/min, respirations 36/min, oxygen saturation of 89% on 3 L of oxygen via nasal cannula. Bilateral crackles are audible upon auscultation. Which hemodynamic value requires immediate action by the nurse? A. Cardiac index (CI) of 1.2 L/min/m3 B. Cardiac output (CO) of 4 L/min C. Pulmonary vascular resistance (PVR) of 80 dynes/sec/cm-5 D. Systemic vascular resistance (SVR) of 1400 dynes/sec/cm-5

A

The nurse is caring for a 70-kg patient in septic shock with a pulmonary artery catheter. Which hemodynamic value indicates an appropriate response to therapy aimed at enhancing oxygen delivery to the organs and tissues? A. Arterial lactate level of 1.0 mEq/L B. Cardiac output of 2.5 L/min C. Mixed venous (SvO2) of 40% D. Cardiac index of 1.5 L/min/m2

A

The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which action by the nurse best reduces the risk of catheter-related bloodstream infection (CRBSI)? A. Review daily the necessity of the central venous catheter. B. Cleanse the insertion site daily with isopropyl alcohol. C. Change the pressurized tubing system and flush bag daily. D. Maintain a pressure of 300 mm Hg on the flush bag.

A

The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which assessment finding 2 hours after insertion by the nurse warrants immediate action? A. Diminished breath sounds over left lung field B. Localized pain at catheter insertion site C. Measured central venous pressure of 5 mm Hg D. Slight bloody drainage around insertion site

A

Upon entering the room of a patient with a right radial arterial line, the nurse assesses the waveform to be slightly dampened and notices blood to be backed up into the pressure tubing. What is the best action by the nurse? A. Check the inflation volume of the flush system pressure bag. B. Disconnect the flush system from the arterial line catheter. C. Zero reference the transducer system at the phlebostatic axis. D. Reduce the number of stopcocks in the flush system tubing.

A

Which of the following assists the critical care nurse in ensuring that care is appropriate and based on research? a. Clinical practice guidelines b. Computerized physician order entry c. Consulting with advanced practice nurses d. Implementing Joint Commission National Patient Safety Goals

A

Which of the following professional organizations best supports critical care nursing practice? A. American Association of Critical-Care Nurses B. American Heart Association C. American Nurses Association D. Society of Critical Care Medicine

A

Which of the following statements about family assessment is false? A. Assessment of structure (who comprises the family) is the last step in assessment. B. Interaction among family members is assessed. C. It is important to assess communication among family members to understand roles. D. Ongoing assessment is important, because family functioning may change during the course of illness.

A

A patient has been prescribed nitroglycerin (NTG) in the ED for chest pain. In taking the health history, the nurse will be sure to verify whether the patient has taken medications before admission for: a) erectile dysfunction b) prostate enlargement c) asthma d) peripheral vascular disease

A A history of the patient's use of sildenafil citrate or similar medications taken for erectile dysfunction is necessary to know when considering NTG administration. These medications potentiate the hypotensive effects of nitrates; thus, concurrent use is contraindicated.

The patient presents to the ED with severe chest discomfort. A cardiac catheterization and angiography shows an 80% occlusion of the left main coronary artery. Which procedure will be most likely performed on this patient? a) CABG surgery b) Intracoronary stent placement c) PTCA d) Transmyocardial revascularization

A Coronary artery bypass graft surgery is indicated for significant left main coronary occlusion (>50%).

A patient has been diagnosed with Marfan syndrome. What information does the nurse plan to teach the patient about this condition? a) It is an autosomal dominant inherited disorder of connective tissue b) It is caused by a random genetic mutation and is not familial c) There are no drugs that help control the cardiac symptoms of the disease d) Contact sports are permitted if precautions against concussion are taken

A Marfan syndrome is an autosomal dominant inherited disorder of connective tissue with a definite familial pattern. Beta blockers and ACE inhibitors are commonly used to treat the condition.

A patient is admitted to the emergency department with clinical indications of an acute myocardial infarction. Symptoms began 3 hours ago. The facility does not have the capability for percutaneous coronary intervention. Given this scenario, what is the priority intervention in the treatment and nursing management of this patient? a) Administer thrombolytic therapy unless contraindicated b) Diurese aggressively and monitor daily weight c) Keep oxygen saturation levels to at least 88% d) Maintain HR above 100 bpm

A Medical treatment of AMI is aimed at relieving pain, providing adequate oxygenation to the myocardium, preventing platelet aggregation, and restoring blood flow to the myocardium through thrombolytic therapy or acute interventional therapy such as angioplasty. Because interventional cardiology is unavailable, thrombolytic therapy is indicated.

The patient is admitted with a suspected acute myocardial infarction (AMI). In assessing the 12-lead electrocardiogram (ECG) changes, which findings would indicate to the nurse that the patient is in the process of an evolving Q wave myocardial infarction (MI)? a) ST-segment elevation on ECG and elevated CPK-MB or troponin levels b) Depressed ST-segment on ECG and elevated total CPK c) Depressed ST-segment on ECG and normal cardiac enzymes d) Q wave on ECG with normal enzymes and troponin levels

A ST segment elevation and elevated cardiac enzymes are seen in Q wave MI.

A patient presents to the emergency department (ED) with chest pain that he has had for the past 2 hours. The patient is nauseated and diaphoretic, with dusky skin color. The electrocardiogram shows ST elevation in leads II, III, and aVF. Which therapeutic intervention would the nurse question? a) Emergency pacemaker insertion b) Emergent percutaneous coronary intervention c) Emergent thrombolytic therapy d) Immediate CABG surgery

A The goals of management of AMI are to dissolve the lesion that is occluding the coronary artery and to increase blood flow to the myocardium. Options include emergent percutaneous intervention, such as angioplasty, emergent coronary artery bypass graft surgery, or thrombolytic therapy if the patient has been symptomatic for less than 6 hours. No data in this scenario warrant insertion of a pacemaker.

The nurse is providing care to a patient on fibrinolytic therapy. Which statement from the patient warrants further assessment and intervention by the critical care nurse? a) "I have an incredible headache!" b) "There is blood on my toothbrush!" c) "Look at the bruises on my arms!" d) "My arm is bleeding where my IV is!"

A The nurse must continually monitor for clinical manifestations of bleeding. Mild gingival bleeding and oozing around venipuncture sites are common and not a cause for concern. The worst complication is intracranial bleeding. Any neurological signs and symptoms must be taken seriously, and all fibrinolytic and/or heparin therapies must be discontinued until this is ruled out.

A patient presents to the ED complaining of severe substernal chest pressure radiating to the left shoulder and back that started about 12 hours ago. The patient delayed coming to the ED, hoping the pain would go away. The patient's 12-lead ECG shows ST-segment depression in the inferior leads. Troponin and CK-MB are both elevated. What does the nurse understand about thrombolysis in this patient? a) The patient is not a candidate for thrombolysis b) The patient's history makes him a good candidate for thrombolysis c) Thrombolysis is appropriate for a candidate having a non-Q wave MI d) Thrombolysis should be started immediately

A To be eligible for thrombolysis, the patient must be symptomatic for less than 12 hours. Therefore, this patient is not a candidate for this therapy.

Family presence is encouraged during resuscitation and invasive procedures. Which findings about this practice have been reported in the literature? (Select all that apply.) A. Families benefit by witnessing that everything possible was done. B. Families report reduced anxiety and fear about what is being done to the patient. C. Presence encourages family members to seek litigation for improper care. D. Presence reduces nurses' involvement in explaining things to the family. E. Families report that staff conversations during this time were distressing.

A, B

The patient tells the nurse, "I didn't think I was having a heart attack because the pain was in my neck and back." The nurse explains: (Select all that apply.) a) "Pain can occur anywhere in the chest, neck, arms, or back. Don't hesitate to call the emergency medical services if you think it's a heart attack." b) "For many people chest pain from a heart attack occurs in the center of the chest, behind the breastbone." c) "The sooner the patient can get medical help, the less damage is likely to occur in case of a heart attack." d) "You need to make sure it's a heart attack before you call the emergency response personnel." e) "Often symptoms can be treated with nitroglycerin, so be sure to take several before calling 911."

A, B, C Angina may occur anywhere in the chest, neck, arms, or back, but the most commonly described is pain or pressure behind the sternum. The pain often radiates to the left arm but can also radiate down both arms and to the back, the shoulder, the jaw, and/or the neck. In the statement about treating symptoms with nitroglycerin, the word "several" is vague.

The critical care environment is often stressful to a critically ill patient. Identify stressors that are common. (Select all that apply.) A. Alarms that sound from various devices B. Bright fluorescent lighting C. Lack of day-night cues D. Sounds from the mechanical ventilator E. Visiting hours tailored to meet individual needs

A, B, C, D

The nurse is preparing for insertion of a pulmonary artery catheter (PAC). During insertion of the catheter, what are the priority nursing actions? (Select all that apply.) A. Allay the patient's anxiety by providing information about the procedure. B. Ensure that a sterile field is maintained during the insertion procedure. C. Inflate the balloon during the procedure when indicated by the provider. D. Monitor the patient's cardiac rhythm throughout the procedure. E. Obtain informed consent by informing the patient of procedural risks.

A, B, C, D

A patient is admitted with an acute myocardial infarction (AMI). The nurse monitors for which potential complications? (Select all that apply.) a) Cardiac dysrhythmias b) Heart failure c) Pericarditis d) Ventricular rupture e) Chest pain

A, B, C, D Dysrhythmias, heart failure, pericarditis and ventricular rupture are potential complications of AMI.

Most critically ill patients are at _________, and all should receive ________.

Most critically ill patients are at high risk for VTE, and all should receive prophylaxis.

Warning signs that can assist the critical care nurse in recognizing that an ethical dilemma may exist include which of the following? (Select all that apply.) a. Family members are confused about what is happening to the patient. b. Family members are in conflict as to the best treatment options. They disagree with one another and cannot come to consensus. c. The family asks that the patient not be told of treatment plans. d. The patient's condition has changed dramatically for the worse and is not responding to conventional treatment. e. The physician is considering the use of a medication that is not approved to treat the patient's condition.

A, B, C, D, E

Which of the following nursing activities demonstrates implementation of the AACN Standards of Professional Performance? (Select all that apply.) a. Attending a meeting of the local chapter of the American Association of Critical-Care Nurses in which a continuing education program on sepsis is being taught b. Collaborating with a pastoral services colleague to assist in meeting spiritual needs of the patient and family c. Participating on the unit's nurse practice council d. Posting an article from Critical Care Nurse on the management of venous thromboembolism for your colleagues to read e. Using evidence-based strategies to prevent ventilator-associated pneumonia

A, B, C, D, E

Which nursing actions are most important for a patient with a right radial arterial line? (Select all that apply.) A. Checking the circulation to the right hand every 2 hours B. Maintaining a pressurized flush solution to the arterial line setup C. Monitoring the waveform on the monitor for dampening D. Restraining all four extremities with soft limb restraints E. Ensuring all junctions remain tightly connected

A, B, C, E

Noise in the critical care unit can have negative effects on the patient. Which of the following interventions assists in reducing noise levels in the critical care setting? (Select all that apply.) A. Ask the family to bring in the patient's iPod or other device with favorite music. B. Invite a volunteer harpist to play on the unit on a regular basis. C. Remodel the unit to have two-patient rooms to facilitate nursing care. D. Remodel the unit to install acoustical ceiling tiles. E. Turn the volume of equipment alarms as low as they can be adjusted, and "off" if possible.

A, B, D

The nurse is caring for a patient with severe neurological impairment following a massive stroke. The physician has ordered tests to determine brain death. The nurse understands that criteria for brain death include (Select all that apply.) a. absence of cerebral blood flow. b. absence of brainstem reflexes on neurological examination. c. Cheyne-Stokes respirations. d. flat electroencephalogram. e. responding only to painful stimuli.

A, B, D

When performing an initial pulmonary artery occlusion pressure (PAOP), what are the best nursing actions? (Select all that apply.) A. Inflate the balloon for no more than 8 to 10 seconds while noting the waveform change. B. Inflate the balloon with air, recording the volume necessary to obtain a reading. C. Maintain the balloon in the inflated position for 8 hours following insertion. D. Zero reference and level the air-fluid interface of the transducer at the level of the phlebostatic axis. E. Inflate and deflate the balloon on an hourly schedule

A, B, D

Identify the priority interventions for managing symptoms of an acute myocardial infarction (AMI) in the ED. (Select all that apply.) a) Administration of morphine b) Administration of NTG c) Dopamine infusion d) Oxygen therapy e) Transfusion of PRBCs

A, B, D The initial pain of AMI is treated with morphine sulfate administered intravenously. NTG may be given to reduce the ischemic pain of AMI. NTG increases coronary perfusion because of its vasodilatory effects. Oxygen administration is important for assisting the myocardial tissue to continue its pumping activity and for repairing the damaged tissue around the site of the infarct.

The critical care environment is stressful to the patient. Which interventions assist in reducing this stress? (Select all that apply.) A. Adjust lighting to promote normal sleep-wake cycles. B. Provide clocks, calendars, and personal photos in the patient's room. C. Talk to the patient about other patients you are caring for on the unit. D. Tell the patient the day and time when you are providing routine nursing interventions. E. Allow unlimited visitation tailored to the patient's individual needs.

A, B, E

Which clinical manifestations are indicative of right ventricular failure? (Select all that apply.) a) JVD b) Peripheral edema c) Crackles audible in the lungs d) Weak peripheral pulses e) Hepatomegaly

A, B, E Jugular venous distension, liver tenderness, hepatomegaly, and peripheral edema are signs of right ventricular failure.

Which of the following is (are) official journal(s) of the American Association of Critical-Care Nurses? (Select all that apply.) a. American Journal of Critical Care b. Critical Care Clinics of North America c. Critical Care Nurse d. Critical Care Nursing Quarterly e. Critical Care Nursing Management

A, C

A patient with a 10-year history of heart failure presents to the emergency department reporting severe shortness of breath. Assessment reveals crackles throughout the lung fields and labored breathing. The patient takes beta blockers, ACE inhibitors, and diuretics as directed. What treatment strategies does the nurse plan to implement for immediate short-term management? (Select all that apply.) a) Dobutamine b) IABP c) Nesiritide d) Ventricular assist device e) Biventricular pacemaker

A, C This patient is showing signs and symptoms of an acute exacerbation of heart failure. Dobutamine and nesiritide are medications administered for acute short-term management; mechanical assist with an intraaortic balloon pump or insertion of a biventricular pacemaker also may be warranted as long-term therapy, but neither is appropriate for this acute exacerbation.

The nurse is caring for a patient whose condition has deteriorated and who is not responding to standard treatment. The physician calls for an ethical consultation with the family to discuss potential withdrawal of treatment versus aggressive treatment. The nurse understands that applying a model for ethical decision making involves which of the following? (Select all that apply.) a. Burden versus benefit b. Family's wishes c. Patient's wishes d. Potential outcomes of treatment options e. Cost savings of withdrawing treatment

A, C, D

During cardioversion, the nurse would synchronize the electrical charge to coincide with which wave of the ECG complex? A. P B. R C. S D. T

ANS: B During cardioversion, the electrical shock is synchronized to deliver shock on the R wave. This is to prevent the shock from being delivered during repolarization (T wave). Ventricular fibrillation may occur if the shock is delivered on the T wave.

Which of the following is a National Patient Safety Goal? (Select all that apply.) a. Accurately identify patients. b. Eliminate the use of patient restraints. c. Reconcile medications across the continuum of care. d. Reduce risks of health care-acquired infection. e. Reduce costs associated with hospitalization.

A, C, D

Which strategy is important in addressing issues associated with the aging workforce? (Select all that apply.) a. Allowing nurses to work flexible shift durations b. Encouraging older nurses to transfer to an outpatient setting that is less stressful c. Hiring nurse technicians who are available to assist with patient care, such as turning the patient d. Remodeling patient care rooms to include devices to assist in patient lifting e. Developing a staffing model that accurately reflects the unit's needs.

A, C, D

Which statements are true regarding the symptoms of an AMI? (Select all that apply.) a) Dysrhythmias are common occurrences b) Men have more atypical symptoms than women c) Midsternal chest pain is a common presenting symptom d) Some patients are asymptomatic e) Patients may complain of jaw or back pain

A, C, D, E Chest pain is a common presenting symptom in AMI. Dysrhythmias are commonly seen in AMI. Some individuals may have ischemic episodes without knowing it, thereby having a "silent" infarction. Women are more likely to have atypical signs and symptoms, such as shortness of breath, nausea and vomiting, and back or jaw pain.

It is important for critically ill patients to feel safe. Which nursing strategies help the patient to feel safe in the critical care setting? (Select all that apply.) A. Allow family members to remain at the bedside. B. Consult with the charge nurse before making any patient care decisions. C. Provide informal conversation by discussing your plans for after work. D. Respond promptly to call bells or other communication for assistance. E. Inform the patient that you have cared for many similar patients.

A, D

The nurse is caring for an 80-year-old patient who has been treated for gastrointestinal bleeding. The family has agreed to withhold additional treatment. The patient has a written advance directive specifying requests. The directive notes that the patient wants food and fluid to be continued. The nurse anticipates that several orders may be written to comply with this request, including which of the following? (Select all that apply.) a. "Do not resuscitate." b. Change antibiotic to a less expensive medication. c. Discontinue tube feeding. d. Stop any further blood transfusions. e. Water boluses every 4 hours with tube feeding.

A, D, E

The nurse is preparing to obtain a right atrial pressure (RAP/CVP) reading. What are the most appropriate nursing actions? (Select all that apply.) A. Compare measured pressures with other physiological parameters. B. Flush the central venous catheter with 20 mL of sterile saline. C. Inflate the balloon with 3 mL of air and record the pressure tracing. D. Obtain the right atrial pressure measurement during end exhalation. E. Zero reference the transducer system at the level of the phlebostatic axis.

A, D, E

To reduce relocation stress in patients transferring out of the intensive care unit, the nurse can (Select all that apply.) A. Ask the nurses on the intermediate care unit to give the family a tour of the new unit. B. Contact the intensivist to see if the patient can stay one additional day in the critical care unit so that he and his family can adjust better to the idea of a transfer. C. Ensure that the patient will be located near the nurses' station in the new unit. D. Invite the nurse who will be assuming the patient's care to meet with the patient and family in the critical care unit prior to transfer. E. Help the patient and family focus on the positive meaning of a transfer.

A, D, E

Which of the following strategies will assist in creating a healthy work environment for the critical care nurse? (Select all that apply.) a. Celebrating improved outcomes from a nurse-driven protocol with a pizza party b. Implementing a medication safety program designed by pharmacists c. Modifying the staffing pattern to ensure a 1:1 nurse/patient ratio d. Offering quarterly joint nurse-physician workshops to discuss unit issues e. Using the Situation-Background-Assessment-Recommendation (SBAR) technique for handoff communication

A, D, E

The patient is diagnosed with abrupt onset of supraventricular tachycardia (SVT). The nurse prepares which medication that has a short half-life and is recommended to treat symptomatic SVT? A. Adenosine B. Amiodarone C. Diltiazem D. Procainamide

ANS: A Adenosine is the initial drug of choice for the diagnosis and treatment of supraventricular dysrhythmias. Adenosine has an onset of action of 10 to 40 seconds and duration of 1 to 2 minutes; therefore, it is administered rapidly.

Laypersons should use which device to treat lethal ventricular dysrhythmias that occur outside a hospital setting? A. Automatic external defibrillator B. Carbon dioxide detector C. Pocket mask D. Transcutaneous pacemaker

ANS: A Because of the ease of use and efficacy in treating lethal ventricular dysrhythmias, automatic external defibrillators are recommended to be placed in a variety of public settings where they may be used by laypersons.

What is the major reason for using a treatment to lower body temperature after cardiac arrest to promote better neurological recovery? A. Hypothermia decreases the metabolic rate by 7% for each decrease of 1 C. B. Lower body temperatures are beneficial in patients with low blood pressure. C. Temperatures of 40 C may reduce neurological impairment. D. The lower body temperature leads to decreased oxygen delivery.

ANS: A Hypothermia decreases the metabolic rate by 6% to 7% for every decrease of 1 C in temperature; decreased metabolic rate may protect neurological function. Induced hypothermia to a core body temperature of 32o C to 34o C for 12 to 24 hours may be beneficial in reducing neurological impairment after cardiac arrest.

When doing manual ventilations during a code, the nurse would administer ventilations following which guideline? a. Approximately 8 to 10 breaths per minute b. During the fifth chest compression c. Every 3 seconds or 20 times per minute d. While compressions are stopped

ANS: A Manual ventilations are delivered one breath every 6 to 8 seconds or approximately 8 to 10 breaths per minute.

The nurse chooses which method and concentration of oxygen administration until intubation is established in a patient who has sustained a cardiopulmonary arrest? A. Bag-valve-mask at FiO2 of 100% B. Bag-valve-mask at FiO2 of 50% C. Mouth-to-mask ventilation with supplemental oxygen D. Non-rebreather mask at FiO2 of 100%

ANS: A Oxygen can be delivered via mouth to mask or with a bag-valve device connected to a mask or endotracheal tube. During resuscitation efforts, 100% oxygen is administered.

The patients monitor shows bradycardia (heart rate of 40 beats/min) and frequent premature ventricular contractions (PVCs) with a measured blood pressure of 85/50 mm Hg. The nurse anticipates the use of which drug? A. Atropine 0.5 to 1 mg intravenous push B. Dopamine dripcontinuous infusion C. Lidocaine 1 mg/kg intravenous push D. Transcutaneous pacemaker

ANS: A This patient is having PVCs secondary to bradycardia. Atropine is a first-line drug for bradycardia. Administer atropine, 0.5 mg IV every 3 to 5 minutes to a total dose of 3 mg. Atropine is not indicated in second-degree atrioventricular (AV) block type II or third-degree AV block.

The nurse is caring for a patient who is being turned prone as part of treatment for acute respiratory distress syndrome. The nurse understands that the priority nursing concern for this patient is which of the following? a. Management and protection of the airway b. Prevention of gastric aspiration c. Prevention of skin breakdown and nerve damage d. Psychological support to patient and family

ANS: A All are important, but protection of the airway is the most important intervention if the patient is placed in the prone position. DIF: Cognitive Level: Understand/Comprehension REF: p. 400 OBJ: Describe the pathophysiology of ARF. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

The etiology of noncardiogenic pulmonary edema in acute respiratory distress syndrome (ARDS) is related to damage to the a. alveolar-capillary membrane. b. left ventricle. c. mainstem bronchus. d. trachea.

ANS: A Damage to the alveolar-capillary membrane results in noncardiogenic pulmonary edema. None of the other responses apply. DIF: Cognitive Level: Understand/Comprehension REF: p. 397 OBJ: Describe the pathophysiology of ARF. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

Which of the following statements is true regarding venous thromboembolism (VTE) and pulmonary embolus (PE)? a. PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk factors for VTE. b. Bradycardia and hyperventilation are classic symptoms of PE. c. Dyspnea, chest pain, and hemoptysis occur in nearly all patients with PE. d. Most critically ill patients are at low risk for VTE and PE and do not require prophylaxis.

ANS: A PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk factors for VTE. Dyspnea, hemoptysis, and chest pain have been called the "classic" signs and symptoms for PE, but the three signs and symptoms actually occur in less than 20% of cases. Bradycardia and hyperventilation are not classic signs of PE. Most critically ill patients are at high risk for VTE, and all should receive prophylaxis. REF: p. 411 | Box 15-7

The patient with acute respiratory distress syndrome (ARDS) would exhibit which of the following symptoms? a. Decreasing PaO2 levels despite increased FiO2 administration b. Elevated alveolar surfactant levels c. Increased lung compliance with increased FiO2 administration d. Respiratory acidosis associated with hyperventilation

ANS: A Patients with ARDS often have hypoxemia refractory to treatment. Surfactant levels are often diminished in ARDS. Compliance decreases in ARDS. In early ARDS, hyperventilation may occur along with respiratory alkalosis. DIF: Cognitive Level: Understand/Comprehension REF: pp. 298-299 OBJ: Describe the pathophysiology of ARF. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

During rounds, the provider alerts the team that proning is being considered for a patient with acute respiratory distress syndrome. The nurse understands that proning is a. an optional treatment to improve ventilation. b. less of a risk for skin breakdown because the patient is face down. c. possible with minimal help from coworkers. d. used to provide continuous lateral rotational turning.

ANS: A Proning is considered to improve ventilation by shifting perfusion from the posterior bases of the lung to the anterior portion. The patient is not responding to treatment, and all options should be considered. The patient remains at risk for skin breakdown due to immobility; during proning, the risk is in the dependent areas, such as the face. Proning is a labor-intensive procedure, and the nurse needs help from team members to ensure a safe turn, including protection of the airway. Continuous lateral rotation is a therapy done in the supine position with a specialized bed. DIF: Cognitive Level: Apply/Application REF: p. 400 OBJ: Discuss medical management of the patient with acute respiratory failure. TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Physiological Integrity

Post-resuscitation goals include which of the following? (Select all that apply.) A. Control dysrhythmias B. Maintain airway C. Maintain blood pressure D. Wean off oxygen

ANS: A, B, C Post-resuscitation goals include optimizing tissue perfusion by airway, blood pressure maintenance, oxygenation, and control of dysrhythmias.

Select the strategies for preventing deep vein thrombosis (DVT) and pulmonary embolus (PE). (Select all that apply.) a. Graduated compression stockings b. Heparin or low-molecular weight heparin for patients at risk c. Sequential compression devices d. Strict bed rest e. Leg massage

ANS: A, B, C Graduated compression stockings, sequential compression devices, and anticoagulation can reduce the risk for DVT. Physical activity can also reduce the risk; bed rest increases the risk. Leg massage is not recommended. DIF: Cognitive Level: Understand/Comprehension REF: Box 15-8 OBJ: Formulate a plan of care for the patient with ARF. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

The nurse is caring for a patient in acute respiratory failure and understands that the patient should be positioned (Select all that apply.) a. high Fowler's. b. side lying with head of bed elevated. c. sitting in a chair. d. supine with the bed flat. e. Trendelenburg.

ANS: A, B, C Patients in respiratory distress are unable to tolerate a flat position. Trendelenburg would also be contraindicated as the weight of the organs on the lungs would inhibit movement. High Fowler's is appropriate. Side lying with head of bed elevated, sitting in a chair, and high Fowler's position are all appropriate ways to position the patient to facilitate gas exchange and comfort. DIF: Cognitive Level: Understand/Comprehension REF: p. 393 OBJ: Formulate a plan of care for the patient with ARF. TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

Which of the following are components of the Institute for Healthcare Improvement's (IHI's) ventilator bundle? (Select all that apply.) a. Interrupt sedation each day to assess readiness to extubate. b. Maintain head of bed at least 30 degrees of elevation. c. Provide deep vein thrombosis prophylaxis. d. Provide prophylaxis for peptic ulcer disease. e. Swab the mouth with foam swabs every 2 hours.

ANS: A, B, C, D Options A, B, C, and D are components of the IHI ventilator bundle. Oral care with chlorhexidine has recently been added to the IHI bundle. Swabbing alone provides comfort care. DIF: Cognitive Level: Apply/Application REF: p. 407 OBJ: Formulate a plan of care for the patient with ARF. TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

Which of the following are physiological effects of positive end-expiratory pressure (PEEP) used in the treatment of ARDS? (Select all that apply.) a. Increases functional residual capacity b. Prevents collapse of unstable alveoli c. Improves arterial oxygenation d. Opens collapsed alveoli e. Improves carbon dioxide retention

ANS: A, B, C, D Ventilatory support for ARDS typically includes PEEP to restore functional residual capacity, open collapsed alveoli, prevent collapse of unstable alveoli, and improve arterial oxygenation. PEEP does not improve CO2 retention. DIF: Cognitive Level: Understand/Comprehension REF: p. 400 OBJ: Discuss medical management of the patient with ARF. TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

A 74-year-old patient is admitted to the coronary care unit with an inferior wall myocardial infarction and develops symptomatic bradycardia with premature ventricular contractions every third beat (trigeminy). The nurse knows to prepare to administer which drug? A. Amiodarone B. Atropine C. Lidocaine D. Magnesium

ANS: B Atropine is used to increase the heart rate by decreasing the vagal tone. It is indicated for patients with symptomatic bradycardia.

Benefits of having the family present during resuscitation include which of the following? (Select all that apply.) A. Facilitates the grief process B. Letting family sees that everything is being done C. Sustaining patient-family relationships D. Allows the staff easy access to ask for organ transplant E. Provides a sense of closure

ANS: A, B, C, E Families who have been present during a code describe the benefits as knowing that everything possible was being done for their loved one, feeling supportive and helpful to the patient and staff, sustaining patient-family relationships, providing a sense of closure on a life shared together, and facilitating the grief process.

The nurse is caring for a patient with cystic fibrosis (CF) and understands that treatment consists of which of the following? (Select all that apply.) a. Airway clearance therapies b. Antibiotic therapy c. Nutritional support d. Tracheostomy e. Lung transplant

ANS: A, B, C, E The three cornerstones of care for a patient with CF are antibiotic therapy, airway clearance, and nutritional support. Lung transplant is a treatment modality for those who can get a match and who do not have current respiratory failure. A tracheostomy is not a standard treatment for CF. DIF: Cognitive Level: Apply/Application REF: pp. 413-414 OBJ: Discuss medical management of the patient with ARF. TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

A patient is admitted to the critical care unit with bradycardia at a heart rate of 39 beats/min and frequent premature ventricular contractions. Upon assessment, you note that she is lethargic and has complained of dizziness for the past 12 hours. Which of the following are acceptable treatments for symptomatic bradycardia? (Select all that apply.) A. Atropine B. Epinephrine C. Lidocaine D. Transcutaneous pacemaker

ANS: A, B, D Administer atropine, 0.5 mg IV every 3 to 5 minutes to a total dose of 3 mg for symptomatic bradycardia. Transcutaneous pacing is also indicated for symptomatic bradycardia unresponsive to atropine. Epinephrine is considered as well. Lidocaine is contraindicated in bradycardia because it can depress conduction, which would be detrimental with a heart rate of 39 beats/min.

The nurse is caring for a mechanically ventilated patient. The nurse understands that strategies to prevent ventilator-associated pneumonia include which of the following? (Select all that apply.) a. Drain condensate from the ventilator tubing away from the patient. b. Elevate the head of the bed 30 to 45 degrees. c. Instill normal saline as part of the suctioning procedure. d. Perform regular oral care with chlorhexidine. e. Awaken the patient daily to determine the need for continued ventilation.

ANS: A, B, D Condensate should be drained away from the patient to avoid drainage back into the patient's airway. Prevention guidelines recommend elevating the head of bed at 30 to 45 degrees. Regular antiseptic oral care, with an agent such as chlorhexidine, reduces oropharyngeal colonization. Daily "sedation holidays" help determine the need to continue mechanical ventilation. Normal saline is not recommended as part of the suctioning procedure, and it may increase the risk for infection. DIF: Cognitive Level: Understand/Comprehension REF: Box 15-5 OBJ: Formulate a plan of care for the patient with ARF. TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

Identify diagnostic criteria for ARDS. (Select all that apply.) a. Bilateral infiltrates on chest x-ray study b. Decreased cardiac output c. PaO2/ FiO2 ratio of less than 200 d. Pulmonary artery occlusion pressure (PAOP) of more than 18 mm Hg e. PAOP less than 18 mm Hg

ANS: A, C Diagnostic criteria for ARDS include bilateral infiltrates, or "white out," on chest x-ray study and a low PaO2/FiO2 ratio. Decreased cardiac output and a high PAOP are seen in pulmonary edema associated with cardiac causes. The PAOP description was deleted from the current definition. DIF: Cognitive Level: Remember/Knowledge REF: pp. 396-397 OBJ: Formulate a plan of care for the patient with ARF. TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

Which of the following statements about defibrillation are correct? (Select all that apply.) A. Early defibrillation (if warranted) is recommended before other actions. B. It is not necessary to ensure that personnel are clear of the patient if hands-off defibrillation is used. C. It is not necessary to synchronize the defibrillation shocks. D. Paddles/patches can be placed anteriorly and posteriorly on the chest.

ANS: A, C, D Defibrillation is indicated as soon as possible because early defibrillation and CPR increase the chance of survival. Regardless of the method of defibrillation, all personnel must avoid contact with the patient or bed during the shock delivery. Shocks are delivered without synchronization. Anterior paddle placement is used most often; however, the alternative method is anteroposterior placement.

The nurse should call the rapid response EMS for which patients? (Select all that apply.) A. 53-year-old with pneumonia and severe respiratory distress B. 17-year-old with apnea following a head injury C. 24-year-old experiencing a severe asthmatic attack with stridor D. 73-year-old patient with bradycardia of 40 beats per minute E. 52-year-old patient with no palpable pulse

ANS: A, C, D Rapid response teams (RRTs) or medical emergency teams focus on addressing changes in a patients clinical condition before a cardiopulmonary arrest occurs

The nurse knows that in advanced cardiac life support, the secondary survey includes steps A-B-C-D where D refers to: A. defibrillate. B. differential diagnosis. C. diltiazem intravenous push. D. do not resuscitate.

ANS: B The A-B-C-D (airway, breathing, circulation, differential diagnosis) in the Advanced Cardiac Life Support (ACLS) secondary survey involves the performance of more in-depth assessments and interventions. Differential diagnosis involves investigation into the cause of the arrest. If a reversible cause is identified, a specific therapy can be initiated.

t is determined that the patient needs a transcutaneous pacemaker until a transvenous pacemaker can be inserted. What is the most appropriate nursing intervention? A. Apply conductive gel to the skin. B. Provide adequate sedation and analgesia. C. Recheck leads to make sure that the rhythm is asystole. D. Set the milliamperes to 2 mA below the capture level.

ANS: B The alert patient who requires transcutaneous pacing may experience some discomfort. Because the skeletal muscles are stimulated, as well as the heart muscle, the patient may experience a tingling, twitching, or thumping feeling that ranges from mildly uncomfortable to intolerable. Sedation, analgesia, or both may be indicated.

The monitor technician notifies the nurse stat that the patient has a rapid, chaotic rhythm that looks like ventricular tachycardia. What is the nurses first action? A. Call a code overhead. B. Check the patient immediately. C. Go to the nurses station and look at the rhythm strip. D. Take the crash cart to the room.

ANS: B The first intervention in this situation is to assess unresponsiveness by checking the patient.

The nurse calculates the PaO2/FiO2 ratio for the following values: PaO2 is 78 mm Hg; FiO2 is 0.6 (60%). a. 46.8; meets criteria for ARDS b. 130; meets criteria for ARDS c. 468; normal lung function d. Not enough data to compute the ratio

ANS: B 78/0.60 = 130, which meets the criteria for ARDS. DIF: Cognitive Level: Analyze/Analysis REF: p. 396 Nursing Care Plan OBJ: Describe methods for assessing the patient with ARF. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

The nurse is assessing a patient with acute respiratory distress syndrome. An expected assessment is a. cardiac output of 10 L/min and low systemic vascular resistance. b. PAOP of 10 mm Hg and PaO2 of 55. c. PAOP of 20 mm Hg and cardiac output of 3 L/min. d. PAOP of 5 mm Hg and high systemic vascular resistance.

ANS: B A normal PAOP with hypoxemia is an expected assessment finding in ARDS although this has been deleted from the most current definition. Cardiac output of 10 L/min and low systemic vascular resistance are expected findings in sepsis. PAOP of 20 mm Hg and cardiac output of 3 L/min are expected findings in heart failure. PAOP of 5 mm Hg and high systemic vascular resistance are expected findings in hypovolemic shock. DIF: Cognitive Level: Analyze/Analysis REF: p. 396 Nursing Care Plan OBJ: Describe methods for assessing the patient with ARF. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

The nurse is caring for a postoperative patient with chronic obstructive pulmonary disease (COPD). Which assessment would be a cue to the patient developing postoperative pneumonia? a. Bradycardia b. Change in sputum characteristics c. Hypoventilation and respiratory acidosis d. Pursed-lip breathing

ANS: B Change in the character of sputum may signal the development of a respiratory infection in the patient with COPD. Additional symptoms include anxiety, wheezing, chest tightness, tachypnea, tachycardia, fatigue, malaise, confusion, fever, and sleeping difficulties. DIF: Cognitive Level: Analyze/Analysis REF: p. 402 OBJ: Formulate a plan of care for the patient with ARF. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

A patient at high risk for pulmonary embolism is receiving enoxaparin. The nurse explains to the patient: a. "I'm going to contact the pharmacist to see if you can take this medication by mouth." b. "This injection is being given to prevent blood clots from forming." c. "This medication will dissolve any blood clots you might get." d. "You should not be receiving this medication. I will contact the provider to get it stopped."

ANS: B Enoxaparin, or low-molecular weight heparin, is recommended for patients at high risk for PE. This patient is at high risk and the medication is indicated. It is given subcutaneously, not by mouth. The drug prevents clots from forming but does not dissolve them. DIF: Cognitive Level: Apply/Application REF: p. 411 | Box 15-8 OBJ: Discuss medical management of the patient with ARF. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

When fluid is present in the alveoli, a. alveoli collapse, and atelectasis occurs. b. diffusion of oxygen and carbon dioxide is impaired. c. hypoventilation occurs. d. the patient is in heart failure.

ANS: B Fluid prevents the diffusion of gases. It does not cause atelectasis or hypoventilation. Fluid can be present in the alveoli secondary to heart failure; however, there are other causes as well, such as acute respiratory distress syndrome. DIF: Cognitive Level: Understand/Comprehension REF: p. 391 OBJ: Describe the pathophysiology of ARF. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

The nurse is assessing a patient. Which assessment would cue the nurse to the potential of acute respiratory distress syndrome (ARDS)? a. Increased oxygen saturation via pulse oximetry b. Increased peak inspiratory pressure on the ventilator c. Normal chest radiograph with enlarged cardiac structures d. PaO2/FiO2 ratio >300

ANS: B Increased peak inspiratory pressures are often early indicators of ARDS. Oxygen saturation decreases in ARDS. Chest x-ray study will show progressive infiltrates. In ARDS, a PaO2/FiO2 ratio of less than 200 is a criterion. DIF: Cognitive Level: Apply/Application REF: p. 399 OBJ: Describe methods for assessing the patient with ARF. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

The patient has been admitted to a critical care unit with a diagnosis of acute myocardial infarction. Suddenly his monitor alarms and the screen shows a flat line. What action should the nurse take first? A. Administer epinephrine by intravenous push B. Begin chest compressions. C. Check patient for unresponsiveness. D. Defibrillate at 360 J.

ANS: C The first intervention is to assess unresponsiveness.

An acute exacerbation of asthma is treated with which of the following? a. Corticosteroids and theophylline by mouth b. Inhaled bronchodilators and intravenous corticosteroids c. Prone positioning or continuous lateral rotation d. Sedation and inhaled bronchodilators

ANS: B Inhaled bronchodilators and intravenous corticosteroids are standard treatment for the exacerbation of asthma; they promote dilation of the bronchioles and decreased inflammation of the airways. Proning and continuous lateral rotation are therapies to treat hypoxemia secondary to acute respiratory distress syndrome. Sedation is not recommended. DIF: Cognitive Level: Understand/Comprehension REF: p. 403 OBJ: Discuss medical management of the patient with ARF. TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

The nurse is discharging a patient home following treatment for community-acquired pneumonia. As part of the discharge teaching, the nurse instructs, a. "If you get the pneumococcal vaccine, you'll never get pneumonia again." b. "It is important for you to get an annual influenza shot to reduce your risk of pneumonia." c. "Stay away from cold, drafty places because that increases your risk of pneumonia when you get home." d. "Since you have been treated for pneumonia, you now have immunity from getting it in the future."

ANS: B The influenza vaccine reduces the risk of pneumonia by more than 50%. The pneumococcal vaccine is important but protects only against pneumococcal infection. Cold, drafty environments will not cause infection. Immunity for pneumonia does not occur as a result of getting it. DIF: Cognitive Level: Analyze/Analysis REF: p. 406 OBJ: Formulate a plan of care for the patient with ARF. TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

The nurse is caring for a patient with a diagnosis of pulmonary embolism. The nurse understands that the most common cause of a pulmonary embolus is a. amniotic fluid embolus. b. deep vein thrombosis from lower extremities. c. fat embolus from a long bone fracture. d. vegetation that dislodges from an infected central venous catheter.

ANS: B The most common cause of a pulmonary embolus is deep vein thrombosis. The other responses are less common causes. DIF: Cognitive Level: Remember/Knowledge REF: p. 410 OBJ: Describe methods for assessing the patient with ARF. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

Which code drugs can be given safely through an endotracheal tube? (Select all that apply.) A. Adenosine B. Atropine C. Epinephrine D. Vasopressin

ANS: B, C, D Medications that can be administered through the endotracheal tube until IV access is established are atropine, epinephrine, lidocaine, and vasopressin.

Which rhythm would be an emergency indication for the application of a transcutaneous pacemaker? A. Asystole B. Bradycardia (heart rate 40 beats/min) normotensive and alert C. Bradycardia (heart rate 50 beats/min) with hypotension and syncope D. Supraventricular tachycardia (heart rate 150 beats/min), hypotensive

ANS: C Transcutaneous (external noninvasive) cardiac pacing is used during emergencies to treat symptomatic bradycardia (hypotension, altered mental status, angina, pulmonary edema) that has not responded to atropine. This patient is symptomatic.

Which of the following statements is true regarding oral care for the prevention of ventilator-associated pneumonia (VAP)? (Select all that apply.) a. Tooth brushing is performed every 2 hours for the greatest effect. b. Implementing a comprehensive oral care program is an intervention for preventing VAP. c. Oral care protocols should include oral suctioning and brushing teeth. d. Protocols that include chlorhexidine gluconate have been effective in preventing VAP. e. Using oral swabs or toothettes are just as effective as brushing the teeth.

ANS: B, C, D A comprehensive oral care protocol is an intervention for preventing VAP. It includes oral suction, brushing teeth every 12 hours, and swabbing. Chlorhexidine gluconate has been effective in patients who have undergone cardiac surgery. Actual toothbrushing is vital to the VAP bundle. DIF: Cognitive Level: Apply/Application REF: Box 15-6 OBJ: Formulate a plan of care for the patient with ARF. TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity

A patient has been successfully converted from ventricular tachycardia with a pulse to a sinus rhythm. Upon further assessment, it is noted that she is hypotensive. The appropriate treatment for her hypotension may include:(Select all that apply.) A. adenosine. B. dopamine infusion. C. magnesium. D. normal saline infusion. E. sodium bicarbonate.

ANS: B, D The patient may need fluid resuscitation; dopamine is indicated for hypotension once hypovolemia has been corrected.

A patient is brought to the critical care unit after a motor vehicle crash. On admission, the patient is complaining of dyspnea and chest pain. Upon examination, the nurse notes a lack of breath sounds on the left side and a tracheal shift. What would be the most likely diagnosis? A. Pericardial tamponade B. Symptomatic bradycardia C. Tension pneumothorax D. Unstable tachycardia

ANS: C A tension pneumothorax occurs when air enters the pleural space but cannot escape. Pressure increases in the pleural space and causes the lung to collapse. Symptoms of a tension pneumothorax include dyspnea, chest pain, tachypnea, tachycardia, and jugular venous distention.

During a code, the nurse would place paddles for anterior defibrillation in what locations? A. Second intercostal space, left sternal border and fourth intercostal space, left midclavicular line B. Second intercostal space, right sternal border and fourth intercostal space, left midaxillary line C. Second intercostal space, right sternal border and fifth intercostal space, left midclavicular line D. Fourth intercostal space, right sternal border and fifth intercostal space, left midclavicular line

ANS: C Anterior paddle placement is used most often for defibrillation. In the anterior method, one paddle or adhesive electrode pad is placed at the second intercostal space to the right of the sternum, and the other paddle or adhesive electrode pad is placed at the fifth intercostal space, midaxillary line, to the left of the sternum.

A patient develops frequent ventricular ectopy. The nurse prepares to administer which drug? A. Adenosine B. Atropine C. Lidocaine D. Magnesium

ANS: C Lidocaine is an antidysrhythmic drug that suppresses ventricular ectopic activity.

The patient has pulseless electrical activity (PEA). The doctor decides that the cause of the PEA is pericardial tamponade. What is the most appropriate treatment for pericardial tamponade? A. Atropine B. Chest tube placement C. Pericardiocentesis D. Transcutaneous pacemaker

ANS: C Pericardiocentesis, or needle aspiration of pericardial fluid, is performed to alleviate the pressure around the heart.

The code team has just defibrillated a patient in ventricular fibrillation. Following CPR for 2 minutes, what is the next action to take? A. Administer amiodarone B. Administer lidocaine C. Assess rhythm and pulse. D. Prepare for transcutaneous pacing.

ANS: C Reassess the patient frequently. Check for return of pulse, spontaneous respirations, and blood pressure.

The patient has a transcutaneous pacemaker in place. Pacemaker spikes followed by QRS complexes are noted on the cardiac rhythm strip. To determine if the pacemaker is working, the nurse must do which of the following? A. Obtain a 12-lead electrocardiogram (ECG). B. Call for a pacemaker interrogation. C. Palpate the pulse. D. Run a 2-minute monitor strip for analysis.

ANS: C The electrical and mechanical effectiveness of pacing is assessed. The electrical activity is noted by a pacemaker spike that indicates that the pacemaker is initiating electrical activity. The spike is followed by a broad QRS complex. Mechanical activity is noted by palpating a pulse during electrical activity.

A strategy for preventing pulmonary embolism in patients at risk who cannot take anticoagulants is.... a. administration of two aspirin tablets every 4 hours. b. infusion of thrombolytics. c. insertion of a vena cava filter. d. subcutaneous heparin administration every 12 hours.

ANS: C A filter may be inserted as a prevention measure in patients who are at high risk for pulmonary embolism. Aspirin is not a preventive therapy. Thrombolytics are given to treat, not prevent, pulmonary embolism. Heparin is administered as a prophylaxis in acute care settings. Coumadin is given for long-term prevention in patients at high risk for VTE. DIF: Cognitive Level: Apply/Application REF: p. 412 OBJ: Discuss medical management of the patient with ARF. TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

The basic underlying pathophysiology of acute respiratory distress syndrome results in a. a decrease in the number of white blood cells available. b. damage to the right mainstem bronchus. c. damage to the type II pneumocytes, which produce surfactant. d. decreased capillary permeability.

ANS: C Acute respiratory distress syndrome results in damage to the pneumocytes, increased capillary permeability, and noncardiogenic pulmonary edema. DIF: Cognitive Level: Understand/Comprehension REF: p. 398 | Figure 15-2 OBJ: Describe the pathophysiology of ARF. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

Which of the following acid-base disturbances commonly occurs with the hyperventilation and impaired gas exchange seen in severe exacerbation of asthma? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

ANS: C Although the patient with a severe exacerbation of asthma hyperventilates, gas exchange is impaired, which causes respiratory acidosis. DIF: Cognitive Level: Understand/Comprehension REF: p. 404 OBJ: Describe the pathophysiology of ARF. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

The nurse is discharging a patient with asthma. As part of the discharge instruction, the nurse instructs the patient to prevent exacerbation by: a. obtaining an appointment for follow-up pulmonary function studies 1 week after discharge. b. limiting activity until the patient is able to climb two flights of stairs. c. taking all asthma medications as prescribed. d. taking medications on a "prn" basis according to symptoms.

ANS: C Exacerbation of asthma is often related to not adhering to the therapeutic regimen; patient teaching is essential. Follow-up studies will be determined by the physician. Activity is based on the patient's activity tolerance and is not limited. Medications are taken regularly to avoid exacerbation. Only rescue medications are used on a prn basis. DIF: Cognitive Level: Analyze/Analysis REF: p. 405 OBJ: Formulate a plan of care for the patient with ARF. TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

A patient presents to the emergency department in acute respiratory failure secondary to community-acquired pneumonia. The patient has a history of chronic obstructive pulmonary disease. The nurse anticipates which treatment to facilitate ventilation? a. Emergency tracheostomy and mechanical ventilation b. Mechanical ventilation via an endotracheal tube c. Noninvasive positive-pressure ventilation (NPPV) d. Oxygen at 100% via bag-valve-mask device

ANS: C Noninvasive measures are often recommended in the initial treatment of the patient with chronic obstructive pulmonary disease to prevent intubation and ventilator dependence. The history of chronic obstructive pulmonary disease increases the risk for ventilator dependence, so noninvasive options are a priority. Bag-valve ventilation with 100% oxygen is not required at this time and could depress the respiratory drive that exists. Emergency tracheostomy is not indicated, as there is no indication of an obstructed airway. DIF: Cognitive Level: Analyze/Analysis REF: p. 414 OBJ: Discuss medical management of the patient with ARF. TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity

The nurse is caring for a patient with acute respiratory distress syndrome who is hypoxemic despite mechanical ventilation. The provider prescribes a nontraditional ventilator mode as part of treatment. Despite sedation and analgesia, the patient remains restless and appears to be in discomfort. The nurse informs the provider of this assessment and anticipates an order for a. continuous lateral rotation therapy. b. guided imagery. c. neuromuscular blockade. d. prone positioning.

ANS: C Paralysis and additional sedation may be needed if the patient requires nontraditional ventilation. Guided imagery is an excellent nonpharmacological approach to manage anxiety; however, the nontraditional mode of ventilation usually requires that the patient receive neuromuscular blockade. Prone positioning is a treatment for refractory hypoxemia but not indicated to treat this patient, who is restless and appears to be in discomfort. Lateral rotation is not a mode of ventilation; it is used as part of a progressive mobility program for critically ill patients. DIF: Cognitive Level: Analyze/Analysis REF: p. 400 OBJ: Discuss medical management of the patient with ARF. TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity.

A definitive diagnosis of pulmonary embolism can be made by a. arterial blood gas (ABG) analysis. b. chest x-ray examination. c. pulmonary angiogram. d. ventilation-perfusion scanning.

ANS: C The angiogram is one test that can confirm pulmonary embolism. A spiral CT scan is the other definitive test. Both tests have the limitation of not always being able to visualize small emboli in distal vessels. ABG would indicate only hypoxemia and/or acid-base abnormalities. A chest x-ray study is inconclusive. A ventilation-perfusion scan is inconclusive. DIF: Cognitive Level: Understand/Comprehension REF: p. 412 OBJ: Discuss medical management of the patient with ARF. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

Ventricular fibrillation should initially be treated by which of the following? (Select all that apply.) A. Administration of amiodarone, followed by defibrillation at 360 J B. Atropine 1 mg, followed by defibrillation at 200 J C. Defibrillation at 200 J with biphasic defibrillation D. Defibrillation at 360 J with monophasic defibrillation

ANS: C, D If a biphasic defibrillator is available, use the dose at which that defibrillator has been shown to be effective for terminating VF (typically 120 to 200 J). If the dose is not known, use 200 J. If a monophasic defibrillator is available, use an initial shock of 360 J and use 360 J for subsequent shocks.

The nurse needs to evaluate arterial blood gases before the administration of which drug? A. Calcium chloride B. Magnesium sulfate C. Potassium D. Sodium bicarbonate

ANS: D Bicarbonate therapy should be guided by the bicarbonate concentration or calculated base deficit from arterial blood gas analysis or laboratory measurement.

A 90-year-old nursing home patient is admitted to the critical care unit with a severe case of pneumonia. No living will or designation of healthcare surrogate is noted on the chart. In the event this patient needs intubation and/or cardiopulmonary resuscitation, what should be the nurses action? A. Activate the code team, but initiate a slow code. B. Call the nursing home to determine the patients or familys wishes. C. Code the patient for 5 minutes and then cease efforts. D. Initiate intubation and/or cardiopulmonary resuscitation efforts.

ANS: D In the absence of a written order from a physician to withhold resuscitative measures, resuscitation efforts must be initiated if indicated.

During a code situation, the nurse would prepare to use which preferred intravenous fluid? A. 5% Dextrose in 0.45 normal saline B. 5% Dextrose in water C. Dopamine infusion D. Normal saline

ANS: D Normal saline is the preferred intravenous fluid during resuscitation efforts because it expands intravascular volume better than infusions containing dextrose.

In assessing a patient, the nurse understands that an early sign of hypoxemia is a. clubbing of nail beds. b. cyanosis. c. hypotension. d. restlessness.

ANS: D Central nervous system signs, such as restlessness, are early indications of low oxygen levels. Clubbing is a sign of chronic hypoxemia. Cyanosis is a late sign of hypoxemia. Tachycardia and increased blood pressure, not hypotension, may be seen early in hypoxemia. DIF: Cognitive Level: Understand/Comprehension REF: p. 392 OBJ: Describe methods for assessing the patient with ARF. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

The nurse is concerned that a patient is at increased risk of developing a pulmonary embolus and develops a plan of care for prevention to include which of the following? a. Antiseptic oral care b. Bed rest with head of bed elevated c. Coughing and deep breathing d. Mobility

ANS: D Mobility helps to prevent deep vein thrombosis and pulmonary embolus. Oral care, head of bed elevation, and coughing and deep breathing assist in preventing pneumonia. DIF: Cognitive Level: Apply/Application REF: p. 411 | Box 15-7 OBJ: Formulate a plan of care for the patient with ARF. TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity

The nurse is caring for a patient with acute respiratory failure and identifies "Risk for Ineffective Airway Clearance" as a nursing diagnosis. A nursing intervention relevant to this diagnosis is to a. elevate the head of the bed to 30 degrees. b. obtain an order for venous thromboembolism prophylaxis. c. provide adequate sedation. d. reposition the patient every 2 hours.

ANS: D Repositioning the patient will facilitate mobilization of secretions. Elevating the head of bed is an intervention to prevent infection. Venous thromboembolism prophylaxis is ordered to prevent complications of immobility. Sedation is an intervention to manage anxiety, and administration of sedatives increases the risk for retained secretions. REF: p. 396

The VALUE mnemonic is a helpful strategy to enhance communication with family members of critically ill patients. Which of the following statements describes a VALUE strategy? A. View the family as guests on the unit. B. Acknowledge family emotions. C. Learn as much as you can about family structure and function. D. Use a trained interpreter if the family does not speak English.

B

Critical illness often results in family conflicts. Which scenario is most likely to result in the greatest conflict? A. A 21-year-old college student of divorced parents hospitalized with multiple trauma. She resides with her mother. The parents are amicable with each other and have similar values. The father blames the daughter's boyfriend for causing the accident. B. A 36-year-old male admitted for a ruptured cerebral aneurysm. He has been living with his 34-year-old girlfriend for 8 years, and they have a 4-year-old daughter. He does not have a written advance directive. His parents arrive from out-of-state and are asked to make decisions about his health care. He has not seen them in over a year. C. A 58-year-old male admitted for coronary artery bypass surgery. He has been living with his same-sex partner for 20 years in a committed relationship. He has designated his sister, a registered nurse, as his health care proxy in a written advance directive. D. A 78-year-old female admitted with gastrointestinal bleeding. Her hemoglobin is decreasing to a critical level. She is a Jehovah's Witness and refuses the treatment of a blood transfusion. She is capable of making her own decisions and has a clearly written advance directive declining any transfusions. Her son is upset with her and tells her she is "committing suicide."

B

Family assessment can be challenging, and each nurse may obtain additional information regarding family structure and dynamics. What is the best way to share this information from shift to shift? A. Create an informal family information sheet that is kept on the bedside clipboard. That way, everyone can review it quickly when needed. B. Develop a standardized reporting form for family information that is incorporated into the patient's medical record and updated as needed. C. Require that the charge nurse have a detailed list of information about each patient and family member. Thus, someone on the unit is always knowledgeable about potential issues. D. Try to remember to discuss family structure and dynamics as part of the change-of-shift report.

B

Family members have a need for information. Which interventions best assist in meeting this need? A.Handing family members a pamphlet that explains all of the critical care equipment B. Providing a daily update of the patient's progress and facilitating communication with the intensivist C. Telling them that you are not permitted to give them a status report but that they can be present at 4:00 PM for family rounds with the intensivist D. Writing down a list of all new medications and doses and giving the list to family members during visitation

B

Following insertion of a pulmonary artery catheter (PAC), the provider requests the nurse obtain a blood sample for mixed venous oxygen saturation (SvO2). Which action by the nurse best ensures the obtained value is accurate? A. Zero referencing the transducer at the level of the phlebostatic axis following insertion B. Calibrating the system with a central venous blood sample and arterial blood gas value C. Ensuring patency of the catheter using a 0.9% normal saline solution pressurized at 300 mm Hg D. Using noncompliant pressure tubing that is no longer than 36 to 48 inches and has minimal stopcocks

B

The family members of a critically ill patient bring a copy of the patient's living will to the hospital, which identifies the patient's wishes regarding health care. You discuss contents of the living will with the patient's physician. This is an example of implementation of which of the AACN Standards of Professional Performance? a. Acquires and maintains current knowledge of practice b. Acts ethically on the behalf of the patient and family c. Considers factors related to safe patient care d. Uses clinical inquiry and integrates research findings in practice

B

The nurse is assigned to care for a patient who is a non-native English speaker. What is the best way to communicate with the patient and family to provide updates and explain procedures? A. Conduct a Google search on the computer to identify resources for the patient and family in their native language. Print these for their use. B. Contact the hospital's interpreter service for someone to translate. C. Get in touch with one of the residents who you know is fluent in the native language and ask him if he can come up to the unit. D. Use the patient's 8-year-old child who is fluent in both English and the native language to translate for you.

B

The nurse is caring for a critically ill patient on mechanical ventilation. The physician identifies the need for a bronchoscopy, which requires informed consent. For the physician to obtain consent from the patient, the patient must be able to a. be weaned from mechanical ventilation. b. have knowledge and competence to make the decision. c. nod his head that it is okay to proceed. d. read and write in English.

B

The nurse is caring for a mechanically ventilated patient being monitored with a left radial arterial line. During the inspiratory phase of ventilation, the nurse assesses a 20 mm Hg decrease in arterial blood pressure. What is the best interpretation of this finding by the nurse? A. The mechanical ventilator is malfunctioning. B. The patient may require fluid resuscitation. C. The arterial line may need to be replaced. D. The left limb may have reduced perfusion.

B

The nurse is caring for a patient who has been declared brain dead. The patient is considered a potential organ donor. To proceed with donation, the nurse understands that a. a signed donor card mandates that organs be retrieved in the event of brain death. b. after brain death has been determined, perfusion and oxygenation of organs is maintained until organs can be removed in the operating room. c. the health care proxy does not need to give consent for the retrieval of organs. d. once a patient has been established as brain dead, life support is withdrawn and organs are retrieved.

B

The nurse is caring for a patient who has had an arterial line inserted. To reduce the risk of complications, what is the priority nursing intervention? A. Apply a pressure dressing to the insertion site. B. Ensure that all tubing connections are tightened. C. Obtain a portable x-ray to confirm placement. D. Restrain the affected extremity for 24 hours.

B

The nurse is caring for a patient who is declared brain dead and is an organ donor. The following events occur: 1300 Diagnostic tests for brain death are completed. 1330 Intensivist reviews diagnostic test results and writes in the progress note that the patient is brain dead. 1400 Patient is taken to the operating room for organ retrieval. 1800 All organs have been retrieved for donation. The ventilator is discontinued. 1810 Cardiac monitor shows flatline. What is the official time of death recorded in the medical record? a. 1300 b. 1330 c. 1400 d. 1800 e. 1810

B

The nurse is caring for a patient with a left subclavian central venous catheter (CVC) and a left radial arterial line. Which assessment finding by the nurse requires immediate action? A. A dampened arterial line waveform B. Numbness and tingling in the left hand C. Slight bloody drainage at subclavian insertion site D. Slight redness at subclavian insertion site

B

The nurse is caring for an elderly patient who is in cardiogenic shock. The patient has failed to respond to medical treatment. The intensivist in charge of the patient conducts a conference to explain that treatment options have been exhausted and to suggest that the patient be given a "do not resuscitate" status. This scenario illustrates the concept of a. brain death. b. futility. c. incompetence. d. life-prolonging procedures.

B

The nurse is educating a patient's family member about a pulmonary artery catheter (PAC). Which statement by the family member best indicates understanding of the purpose of the PAC? A. "The catheter will provide multiple sites to give intravenous fluid." B. "The catheter will allow the provider to better manage fluid therapy." C. "The catheter tip comes to rest inside my brother's pulmonary artery." D. "The catheter will be in position until the heart has a chance to heal."

B

The nurse is preparing to measure the thermodilution cardiac output (TdCO) in a patient being monitored with a pulmonary artery catheter. Which action by the nurse best ensures the safety of the patient? A. Ensure the transducer system is zero referenced at the level of the phlebostatic axis. B. Avoid infusing vasoactive agents in the port used to obtain the TdCO measurement. C. Maintain a pressure of 300 mm Hg on the flush solution using a pressure bag. D. Limit the length of the noncompliant pressure tubing to a maximum 48 inches.

B

The nurse returns from the cardiac catheterization laboratory with a patient following insertion of a pulmonary artery catheter and assists in transferring the patient from the stretcher to the bed. Before obtaining a cardiac output, which action is most important for the nurse to complete? A. Document a pulmonary artery catheter occlusion pressure. B. Zero reference the transducer system at the phlebostatic axis. C. Inflate the pulmonary artery catheter balloon with 1 mL air. D. Inject 10 mL of 0.9% normal saline into the proximal port

B

The provider writes an order to discontinue a patient's left radial arterial line. When discontinuing the patient's invasive line, what is the priority nursing action? A. Apply an air occlusion dressing to insertion site. B. Apply pressure to the insertion site for 5 minutes. C. Elevate the affected limb on pillows for 24 hours. D. Keep the patient's wrist in a neutral position.

B

Which intervention is appropriate to assist the patient in coping with admission to the critical care unit? A. Allowing unrestricted visiting by several family members at one time B. Explaining all procedures in easy-to-understand terms C. Providing back massage and mouth care D. Turning down the alarm volume on the cardiac monitor

B

Which nursing interventions would best support the family of a critically ill patient? A. Encourage family members to stay all night in case the patient needs them. B. Give a condition update each morning and whenever changes occur. C. Limit visitation from children into the critical care unit. D. Provide beverages and snacks in the waiting room.

B

While caring for a patient with a small bowel obstruction, the nurse assesses a pulmonary artery occlusion pressure (PAOP) of 1 mm Hg and hourly urine output of 5 mL. The nurse anticipates which therapeutic intervention? A. Diuretics B. Intravenous fluids C. Negative inotropic agents D. Vasopressors

B

You are caring for a critically ill patient whose urine output has been low for 2 consecutive hours. After a thorough patient assessment, you call the intensivist with report. Which information do you convey regarding background? a. Urine output of 40 mL/2 hours b. Current vital signs and history of aortic aneurysm repair 4 hours ago c. A statement that the patient is possibly hypovolemic d. A request for IV fluids

B

You work in an intermediate care unit and have asked to be involved in developing new guidelines to prevent pressure ulcers in your patient population. The nurse manager tells you that you do not yet have enough experience to be on the prevention task force and that your ideas will be rejected by others. This situation is an example a. a barrier to handoff communication. b. a work environment that is unhealthy. c. ineffective decision making. d. nursing practice that is not evidence-based.

B

The patient has undergone open chest surgery for coronary artery bypass grafting. One of the nurse's responsibilities is to monitor the patient for which common postoperative dysrhythmia? a) Second-degree heart block b) Atrial fibrillation or flutter c) Ventricular ectopy d) Premature junctional contractions

B Atrial fibrillation and flutter are dysrhythmias common after cardiac surgery.

Which comment by the patient indicates a good understanding of a diagnosis of coronary heart disease? a) "I had a heart attack because I work too hard, and it puts too much strain on my heart." b) "The pain in my chest gets worse each time it happens. I think that there is more damage to my heart vessels as time goes on." c) "If I change my diet and exercise more, I should get over this and be healthy." d) "What kind of pills can you give me to get me over this and back to my lifestyle?"

B Coronary heart disease is a progressive atherosclerotic disorder of the coronary arteries that results in narrowing or complete occlusion. Stress and strain can increase the heart's oxygen demands but do not typically cause coronary artery disease. Coronary artery disease is a chronic illness. The patient asking for pills and a return to a previous lifestyle does not understand how risk factors lead to coronary artery disease.

Which of the following cardiac diagnostic tests would include monitoring the gag reflex before giving the patient anything to eat or drink? a) Barium swallow b) Transesophageal echocardiogram c) MUGA scan d) Stress test

B In transesophageal echocardiography, an ultrasound probe is fitted on the end of a flexible gastroscope, which is inserted into the posterior pharynx and advanced into the esophagus. After the procedure, the patient is unable to eat until the gag reflex returns.

A patient was admitted in terminal heart failure and is not eligible for transplant. The family wants everything possible done to maintain life. Which procedure might be offered to the patient for this condition to increase the patient's quality of life? a) IABP b) LVAD c) Nothing, because the patient is in terminal heart failure d) Nothing additional; medical management is the only option

B LVADs are capable of partial to complete circulatory support for short- to long-term use. At present, the LVAD is therapy for patients with terminal heart failure. It would provide better management than medical therapy alone.

An essential aspect of teaching that may prevent recurrence of heart failure is a) notifying the provider if a 2-lb weight gain occurs in 24 hours b) compliance with diuretic therapy c) taking nitroglycerin if chest pain occurs d) assessment of an apical pulse

B Reduction or cessation of diuretics usually results in sodium and water retention, which may precipitate heart failure.

The patient's spouse is feeling overwhelmed about cooking different dinners for the patient and the rest of the family to satisfy a cholesterol-reducing diet. Which response by the nurse is best? a) "It will be worth it to have a healthy spouse, won't it?" b) "The low-cholesterol diet is one from which everyone can benefit." c) "As long as you change at least a few things in the diet, it will be okay." d) "You can go on the diet with him, and then let the children eat whatever they want."

B Some cardiologists advocate a reduction of the low-density lipoprotein goal to the 50 to 70 mg/dL range for everyone, not only those with a known cardiovascular disease. It will be easier if the family members all eat the same type of meal, so the nurse should suggest this option.

A patient is having a stent and asks why it is necessary after having an angioplasty. Which response by the nurse is best? a) "The angioplasty was a failure, and so this procedure has to be done to fix the heart vessel." b) "The stent is inserted to enhance the results of the angioplasty, by helping to keep the vessel open and prevent it from closing again." c) "This procedure is being done instead of using clot-dissolving medication to help keep the heart vessel open." d) "The stent will remove any clots that are in the vessel and protect the heart muscle from damage."

B Stents are inserted to optimize the results of other treatments for acute vessel closure (percutaneous transluminal coronary angioplasty, atherectomy, fibrinolytics) and to prevent restenosis

The patient is admitted with an acute myocardial infarction (AMI). Three days later the nurse is concerned that the patient may have a papillary muscle rupture. Which assessment data may indicate a papillary muscle rupture? a) Gallop rhythm b) New murmur c) S1 heart sound d) S3 heart sound

B The presence of a new murmur warrants special attention, particularly in a patient with an AMI.

The first critical care units were (Select all that apply.) a. burn units. b. coronary care units. c. recovery rooms. d. neonatal intensive care units. e. high-risk OB units.

B, C

The nurse utilizes which of the following strategies when encountering an ethical dilemma in practice? (Select all that apply.) a. Change-of-shift report updates b. Ethics consultation services c. Formal multiprofessional ethics committees d. Pastoral care services e. Social work consultation

B, C

Which nursing interventions would be appropriate after angioplasty? (Select all that apply.) a) Elevate the head of the bed by 45 degrees for 6 hours b) Assess pedal pulses on the involved limb every 15 minutes for 1 to 2 hours c) Monitor the vascular hemostatic device for signs of bleeding d) Instruct the patient to bend his or her knee every 15 minutes while the sheath is in place e) Maintain NPO status for 12 hours

B, C The head of the bed must not be elevated more than 30 degrees, and the patient should be instructed to keep the affected leg straight. Bed rest is 6 to 8 hours in duration, unless a vascular hemostatic device is used. The nurse observes the patient for bleeding or swelling at the puncture site and frequently assesses adequacy of circulation to the involved extremity. NPO status does not need to be maintained after the patient is fully alert.

Nursing strategies to help families cope with the stress of critical illness include: (Select all that apply.) A.. Asking the family to leave during the morning bath to promote the patient's privacy. B. Encouraging family members to make notes of questions they have for the physician during family rounds. C. If possible, providing continuity of nursing care. D. Providing a daily update of the patient's condition to the family spokesperson. E. Ensuring that a waiting room stocked with snacks is nearby.

B, C, D

Which of the following situations may result in a low cardiac output and low cardiac index? (Select all that apply.) A. Exercise B. Hypovolemia C. Myocardial infarction D. Shock E. Fever

B, C, D

A nurse caring for a patient with neurological impairment often must use painful stimuli to elicit the patient's response. The nurse uses subtle measures of painful stimuli, such as nailbed pressure. She neither slaps the patient nor pinches the nipple to elicit a response to pain. In this scenario, the nurse is exemplifying the ethical principle of a. beneficence. b. fidelity. c. nonmaleficence. d. veracity.

C

A nurse has been working as a staff nurse in the surgical intensive care unit for 2 years and is interested in certification. Which credential would be most applicable for the nurse to seek? A. ACNPC-AG b. CNML c. CCRN d. PCCN

C

A nurse who plans care based on the patient's gender, ethnicity, spirituality, and lifestyle is said to a. be a moral advocate. b. facilitate learning. c. respond to diversity. d. use clinical judgment.

C

After pulmonary artery catheter insertion, the nurse assesses a pulmonary artery pressure of 45/25 mm Hg, a pulmonary artery occlusion pressure (PAOP) of 20 mm Hg, a cardiac output of 2.6 L/min and a cardiac index of 1.9 L/min/m2. Which provider order is of the highest priority? A. Apply 50% oxygen via Venturi mask. B. Insert an indwelling urinary catheter. C. Begin a dobutamine infusion. D. Obtain stat cardiac enzymes and troponin.

C

Comparing the patient's current (home) medications with those ordered during hospitalization and communicating a complete list of medications to the next provider when the patient is transferred within an organization or to another setting are strategies to: a. improve accuracy of patient identification. b. prevent errors related to look-alike and sound-alike medications. c. reconcile medications across the continuum of care. d. reduce harms associated with the administration of anticoagulants.

C

Family assessment is essential to meet family needs. Which of the following must be assessed first to assist the nurse in providing family-centered care? A. Assessment of patient and family's developmental stages and needs B. Description of the patient's home environment C. Identification of immediate family, extended family, and decision makers D. Observation and assessment of how family members function with each other

C

Following insertion of a central venous catheter, the nurse obtains a stat chest x-ray film to verify proper catheter placement. The radiologist reports to the nurse: "The tip of the catheter is located in the superior vena cava." What is the best interpretation of these results by the nurse? A. The catheter is not positioned correctly and should be removed. B. The catheter position increases the risk of ventricular dysrhythmias. C. The distal tip of the catheter is in the appropriate position. D. The physician should be called to advance the catheter into the pulmonary artery.

C

Ideally, an advance directive should be developed by the a. family if the patient is in critical condition. b. patient as part of the hospital admission process. c. patient before hospitalization. d. patient's health care surrogate.

C

Many critically ill patients experience anxiety. The nurse can reduce anxiety with which approach? A. Ask family members to limit their visitation to 2-hour periods in morning, afternoon, and evening. B. Explain the unit routine. C. Explain procedures before and while you are doing them. D. Suction Mr. J.'s endotracheal tube immediately when he starts to cough.

C

Open visitation policies are expected by many professional organizations. Which statement reflects adherence to current recommendations? A. Allow animals on the unit; however, these can only be "therapy" animals through the hospital's pet therapy program. B. Allow family visitation throughout the day except at change of shift and during rounds. C. Determine, in collaboration with the patient and family, who can visit and when. Facilitate open visitation policies. D. Permit open visitation by adults 18 years of age and older; limit visits of children to 1 hour.

C

The charge nurse is supervising care for a group of patients monitored with a variety of invasive hemodynamic devices. Which patient should the charge nurse evaluate first? A. A patient with a central venous pressure (RAP/CVP) of 6 mm Hg and 40 mL of urine output in the past hour B. A patient with a left radial arterial line with a BP of 110/60 mm Hg and slightly dampened arterial waveform C. A patient with a pulmonary artery occlusion pressure of 25 mm Hg and an oxygen saturation of 89% on 3 L of oxygen via nasal cannula D. A patient with a pulmonary artery pressure of 25/10 mm Hg and an oxygen saturation of 94% on 2 L of oxygen via nasal cannula

C

The family of your critically ill patient tells you that they have not spoken with the physician in over 24 hours and that they have some questions they want clarified. During morning rounds, you convey this concern to the attending intensivist and arrange a meeting with the family at 4:00 PM. Which competency of critical care nursing does this represent? a. Advocacy and moral agency in solving ethical issues b. Clinical judgment and clinical reasoning skills c. Collaboration with patients, families, and team members d. Facilitation of learning for patients, families, and team members

C

The nurse is caring for a mechanically ventilated patient with a pulmonary artery catheter who is receiving continuous enteral tube feedings. When obtaining continuous hemodynamic monitoring measurements, what is the best nursing action? A. Do not document hemodynamic values until the patient can be placed in the supine position. B. Level and zero reference the air-fluid interface of the transducer with the patient in the supine position and record hemodynamic values. C. Level and zero reference the air-fluid interface of the transducer with the patient's head of bed elevated to 30 degrees and record hemodynamic values. D. Level and zero reference the air-fluid interface of the transducer with the patient supine in the side-lying position and record hemodynamic values.

C

The nurse is caring for a patient admitted with a traumatic brain injury following a motor vehicle crash. Several weeks later, the patient is still ventilator dependent and unresponsive to stimulation but occasionally takes a spontaneous breath. The physician explains to the family that the patient has severe neurological impairment and is not expected to recover consciousness. The nurse recognizes that this patient is a. an organ donor. b. brain dead. c. in a persistent vegetative state. d. terminally ill.

C

The nurse is caring for a patient who is not responding to medical treatment. The intensivist holds a conference with the family, and a decision is made to withdraw life support. The nurse's religious beliefs are not in agreement with the withdrawal of life support. However, the nurse assists with the process to avoid confronting the charge nurse. Afterward the nurse feels guilty for "killing the patient." This scenario is likely to cause a. abandonment. b. family stress. c. moral distress. d. negligence.

C

The nurse is caring for a patient who sustained a head injury and is unresponsive to painful stimuli. Which intervention is most appropriate while bathing the patient? A. Ask a family member to help you bathe the patient, and discuss the family structure with the family member during the procedure. B. Because the patient is unconscious, complete care as quickly and quietly as possible. C. Tell the patient the day and time, and that you are providing a bath. Reassure the patient that you are there. D. Turn the television on to the evening news so that you and the patient can be updated to current events.

C

The nurse is caring for a patient with an arterial monitoring system. The nurse assesses the patient's noninvasive cuff blood pressure to be 70/40 mm Hg. The arterial blood pressure measurement via an intraarterial catheter in the same arm is assessed by the nurse to be 108/70 mm Hg. What is the best action by the nurse? A. Activate the rapid response system. B. Place the patient in Trendelenburg position. C. Assess the cuff for proper arm size. D. Administer 0.9% normal saline bolus.

C

The nurse knows that which of the following statements about organ donation is true? a. Anyone who is comfortable approaching the family should discuss the option of organ donation. b. Brain death determination is required before organs can be retrieved for transplant. c. Donation of selected organs after cardiac death is ethically acceptable. d. Family members should consider the withdrawal of life support so that the patient can become an organ donor.

C

The provider prescribes a pulmonary artery occlusive pressure reading (PAOP) for a patient being monitored with a pulmonary artery catheter. Immediately after obtaining an occlusive pressure, the nurse notes the change in waveform indicated on the strip below. What are the best actions by the nurse? A. Turn the patient to the left side; obtain a stat portable chest x-ray. B. Place the patient supine; repeat zero referencing of the system. C. Document the wedge pressure; continue to monitor the patient. D. Perform an immediate dynamic response test; obtain a chest x-ray.

C

The synergy model of practice focuses on a. allowing unrestricted visiting for the patient 24 hours a day. b. holistic and alternative therapies. c. the needs of patients and their families, which drive nursing competency. d. patients' needs for energy and support.

C

The vision of the American Association of Critical-Care Nurses is a health care system driven by a. a healthy work environment. b. care from a multiprofessional team under the direction of a critical care physician. c. the needs of critically ill patients and families. d. respectful, healing, and humane environments.

C

When addressing an ethical dilemma, contextual, physiological, and personal factors of the situation must be considered. Which of the following is an example of a personal factor? a. The hospital has a policy that everyone must have an advance directive on the chart. b. The patient has lost 20 pounds in the past month and is fatigued all the time. c. The patient has told you what quality of life means and his or her wishes. d. The physician considers care to be futile in a given situation.

C

Which intervention about visitation in the critical care unit is true? A. The majority of critical care nurses implement restricted visiting hours to allow the patient to rest. B. Children should never be permitted to visit a critically ill family member. C. Visitation that is individualized to the needs of patients and family members is ideal. D. Visiting hours should always be unrestricted.

C

Which statement regarding ethical concepts is true? a. A living will is the same as a health care proxy. b. A signed donor card ensures that organ donation will occur in the event of brain death. c. A surrogate is a competent adult designated by a person to make health care decisions in the event the person is incapacitated. d. A persistent vegetative state is the same as brain death in most states.

C

While inflating the balloon of a pulmonary artery catheter (PAC) with 1.0 mL of air to obtain a pulmonary artery occlusion pressure (PAOP), the nurse encounters resistance. What is the best nursing action? A. Add an additional 0.5 mL of air to the balloon and repeat the procedure. B. Advance the catheter with the balloon deflated and repeat the procedure. C. Deflate the balloon and obtain a chest x-ray study to determine line placement. D. Lock the balloon in the inflated position, and flush the distal port of the PAC with normal saline.

C

While instructing a patient on what occurs with a myocardial infarction, the nurse plans to explain which process? a) Coronary artery spasm b) Decreased blood flow (ischemia) c) Death of cardiac muscle from lack of oxygen (tissue necrosis) d) Sporadic decrease in oxygen to the heart (transient oxygen imbalance)

C Acute myocardial infarction is death (tissue necrosis) of the myocardium that is caused by lack of blood supply from the occlusion of a coronary artery and its branches.

A patient is admitted with angina. The nurse anticipates which drug regimen to be initiated? a) ACE inhibitors and diuretics b) Morphine sulfate and oxygen c) Nitroglycerin, oxygen, and betablockers d) Statins, bile acid, and nictonic acid

C Conservative intervention for the patient experiencing angina includes nitrates, beta blockers, and oxygen.

A patient is having a cardiac evaluation to assess for possible valvular disease. Which study best identifies valvular function and measures the size of the cardiac chambers? a) 12-lead electrocardiogram b) Cardiac catheterization c) Echocardiogram d) Electrophysiology study

C Echocardiography is a noninvasive, acoustic imaging procedure and involves the use of ultrasound to visualize the cardiac structures and the motion and function of cardiac valves and chambers.

The provider prescribes a pharmacological stress test for a patient with activity intolerance. The nurse would anticipate that the drug of choice would be a) dopamine b) dobutamine c) adenosine d) atropine

C If a patient is unable physically to perform the exercise, a pharmacological stress test can be done. Adenosine is preferred over dobutamine because of its short duration of action and because reversal agents are not needed. Dopamine and atropine are not used.

The nurse is assessing a patient with left-sided heart failure. Which symptom would the nurse expect to find? a) Dependent edema b) Distended neck veins c) Dyspnea and crackles d) Nausea nd vomiting

C In left-sided heart failure, signs and symptoms are related to pulmonary congestion. Dependent edema and distended neck veins are related to right-sided heart failure.

A patient is admitted with the diagnosis of unstable angina. The nurse knows that the physiological mechanism present is most likely which of the following? a) Complete occlusion of a coronary artery b) Fatty streak within the intima of a coronary artery c) Partial occlusion of a coronary artery with a thrombus d) Vasospasm of a coronary artery

C In unstable angina, some blood continues to flow through the affected coronary artery; however, flow is diminished related to partial occlusion.

A patient is admitted with an acute myocardial infarction (AMI). The nurse knows that an angiotensin-converting enzyme (ACE) inhibitor should be started within 24 hours to reduce the incidence of which process? a) Myocardial stunning b) Hibernating myocardium c) Myocardial remodeling d) Tachycardia

C Myocardial remodeling is a process mediated by angiotensin II, aldosterone, catecholamine, adenosine, and inflammatory cytokines; it causes myocyte hypertrophy and loss of contractile function in the areas of the heart distant from the site of infarctions. ACE inhibitors reduce the incidence of remodeling.

The patient is admitted with recurrent supraventricular tachycardia that the cardiologist believes to be related to an accessory conduction pathway or a reentry pathway. The nurse anticipates which procedure to be planned for this patient? a) Implantable cardioverter-defibrillator placement b) Permanent pacemaker insertion c) Radiofrequency catheter ablation d) Temporary transvenous pacemaker placement

C Radiofrequency catheter ablation is a method of interrupting a supraventricular tachycardia, a dysrhythmia caused by a reentry circuit, and an abnormal conduction pathway.

A 72-year-old woman is brought to the ED by her family. The family states that she's "just not herself." Her respirations are slightly labored, and her heart monitor shows sinus tachycardia (rate 110 beats/min) with frequent premature ventricular contractions (PVCs). She denies any chest pain, jaw pain, back discomfort, or nausea. Her troponin levels are elevated, and her 12-lead electrocardiogram (ECG) shows elevated ST segments in leads II, III, and aVF. The nurse knows that these symptoms are most likely associated with which diagnosis? a) Hypokalemia b) Non-Q wave MI c) Silent myocardial infarction d) Unstable angina

C Some individuals may have ischemic episodes without knowing it, thereby having a "silent" infarction.

The patient presents to the ED with sudden, severe sharp chest discomfort, radiating to the back and down both arms, as well as numbness in the left arm. While taking the patient's vital signs, the nurse notices a 30-point discrepancy in systolic blood pressure between the right and left arm. Based on these findings, the nurse should: a) contact the physician and report the cardiac enzyme results b) contact the physician and prepare the patient for thrombolytic therapy c) contact the physician immediately and begin prepping the patient for surgery d) give the patient aspirin and heparin

C These symptoms indicate the possibility of acute aortic dissection. Symptoms often mimic those of AMI or pulmonary embolism. Aortic dissection is a surgical emergency. Signs and symptoms include chest pain and arm paresthesia.

Which scenarios contribute to effective handoff communication at change of shift? (Select all that apply.) a. The nephrology consultant physician is making rounds and asks you for an update on the patient's status and to assist in placing a central line for hemodialysis. b. The noise level is high because twice as many staff members are present and everyone is giving report in the nurses' station. c. The unit has decided to use a standardized checklist/tool for change-of-shift reports and patient transfers. d. You and the oncoming nurse conduct a standardized report at the patient's bedside and review key assessment findings. e. The off-going nurse is giving the patient medications at the same time as giving handoff report to the oncoming nurse.

C, D

Acute myocardial infarction (AMI) can be classified as which of the following? (Select all that apply.) a) Angina b) Nonischemic c) Non-Q wave d) Q wave e) Frequent PVCs

C, D AMI can be classified as Q wave or non-Q wave.

PNA dx studies

CXR show local or diffuse infiltrates, CS cultures abg = hypoxemia and hypocap

9. The constant noise of a ventilator, monitor alarms, and infusion pumps predisposes the patient to: A. Anxiety. B. Pain. C. Powerlessness. D. Sensory overload.

D

A specific request made by a competent person that directs medical care related to life-prolonging procedures in the event that person loses capacity to make decisions is called a a. "do not resuscitate" order. b. health care proxy. c. informed consent. d. living will.

D

Changing visitation policies can be challenging. The nurse manager recognizes which of the following as an effective strategy for promoting changes in practice? A. Ask the clinical nurse specialist to lead a journal club on open visitation after each nurse is tasked to read one research article about visitation. B. Discuss the pros and cons of open visitation at the next staff meeting. C. Invite the nurses with the most experience to develop a revised policy. D. Task the unit-based nurse practice council to invite volunteers to serve on the council to revise the current policy toward more liberal visitation.

D

During insertion of a pulmonary artery catheter, the provider asks the nurse to assist by inflating the balloon with 1.5 mL of air. As the provider advances the catheter, the nurse notices premature ventricular contractions on the monitor. What is the best action by the nurse? A. Deflate the balloon while slowly withdrawing the catheter. B. Instruct the patient to cough and deep-breathe forcefully. C. Inflate the catheter balloon with an additional 1 mL of air. D. Ensure lidocaine hydrochloride (IV) is immediately available.

D

The AACN Standards for Acute and Critical Care Nursing Practice use what framework to guide critical care nursing practice? a. Evidence-based practice b. Healthy work environment c. National Patient Safety Goals d. Nursing process

D

The charge nurse has a pulse contour cardiac output monitoring system available for use in the surgical intensive care unit. For which patient is use of this device most appropriate? A. A patient with a history of aortic insufficiency admitted with a postoperative myocardial infarction B. A mechanically ventilated patient with cardiogenic shock being treated with an intraaortic balloon pump C.A patient with a history of atrial fibrillation having frequent episodes of paroxysmal supraventricular tachycardia D. A mechanically ventilated patient admitted following repair of an acute bowel obstruction

D

The charge nurse is responsible for making the patient assignments on the critical care unit. An experienced, certified nurse is assigned to care for the acutely ill patient with sepsis who also requires continuous renal replacement therapy and mechanical ventilation. The nurse with less than 1 year of experience is assigned to two patients who are more stable. This assignment reflects implementation of the a. crew resource management model. b. National Patient Safety Goals. c. Quality and Safety Education for Nurses (QSEN) model. d. synergy model of practice.

D

The critical care nurse wants a better understanding of when to initiate an ethics consult. After attending an educational program, the nurse understands that the following situation would require an ethics consultation: a. Conflict has occurred between the physician and family regarding treatment decisions. A family conference is held, and the family and physician agree to a treatment plan that includes aggressive treatment for 24 hours followed by reevaluation. b. Family members disagree as to a patient's course of treatment. The patient has designated a health care proxy and has a written advance directive. c. Patient postoperative coronary artery bypass surgery who sustained a cardiopulmonary arrest in the operating room. He was successfully resuscitated, but now is not responding to treatment. He has a written advance directive, and his wife is present. d. Patient with multiple trauma and is not responding to treatment. No family members are known, and the health care team is debating if care is futile.

D

The intensive care nurse is working on a committee to reduce noise in the unit. Which recommendation should the nurse propose first? A. Change telephones to blinking lights instead of audible ringtones. B. Invest in call lights that page the nursing staff instead of beeping. C. Recommend that nurses turn off cardiac monitors on stable patients. D. Soundproof the pneumatic tube system.

D

The main purpose of certification is to a. assure the consumer that you will not make a mistake. b. prepare for graduate school. c. promote magnet status for your facility. d. validate knowledge of critical care nursing.

D

The most important outcome of effective communication is to a. demonstrate caring practices to family members. b. ensure that patient teaching is done. c. meet the diversity needs of patients. d. reduce patient errors.

D

The nurse is caring for a critically ill patient with terminal cancer. The monitor alarms and shows a potentially lethal rhythm. The patient has no pulse. The patient does not have a "do not resuscitate" order written on the chart. What is the appropriate nursing action? a. Contact the attending physician immediately to determine if CPR should be initiated. b. Contact the family immediately to determine if they want CPR to be started. c. Give emergency medications but withhold intubation. d. Initiate CPR and call a code.

D

The nurse is caring for a patient with a left radial arterial line and a pulmonary artery catheter inserted into the right subclavian vein. Which action by the nurse best ensures the safety of the patient being monitored with invasive hemodynamic monitoring lines? A. Document all waveform values. B. Limit the pressure tubing length. C. Zero reference the system daily. D. Ensure alarm limits are turned on.

D

The nurse is caring for a patient with a pulmonary artery catheter. Assessment findings include a blood pressure of 85/40 mm Hg, heart rate of 125 beats/min, respiratory rate 35 breaths/min, and arterial oxygen saturation (SpO2) of 90% on a 50% Venturi mask. Hemodynamic values include a cardiac output (CO) of 1.0 L/min, central venous pressure (CVP) of 1 mm Hg, and a pulmonary artery occlusion pressure (PAOP) of 3 mm Hg. The nurse questions which of the following physician's orders? A. Titrate supplemental oxygen to achieve a SpO2 ≥94%. B. Infuse 500 mL 0.9% normal saline over 1 hour. C. Obtain arterial blood gas and serum electrolytes. D. Administer furosemide (Lasix) 20 mg intravenously.

D

The nurse is caring for a patient with an admitting diagnosis of congestive heart failure. While attempting to obtain a pulmonary artery occlusion pressure in the supine position, the patient becomes anxious and tachypneic. What is the best action by the nurse? A. Limit the patient's supine position to no more than 10 seconds. B. Administer antianxiety medications while recording the pressure. C. Encourage the patient to take slow, deep breaths while supine. D. Elevate the head of the bed 45 degrees while recording pressures.

D

The nurse is preparing to obtain a pulmonary artery occlusion pressure (PAOP) reading for a patient who is mechanically ventilated. Ensuring that the air-fluid interface is at the level of the phlebostatic axis, what is the best nursing action? A. Place the patient in the supine position and record the PAOP immediately after exhalation. B. Place the patient in the supine position and document the average PAOP obtained after three measurements. C. Place the patient with the head of bed elevated 30 degrees and document the average PAOP pressure obtained. D. Place the patient with the head of bed elevated 30 degrees and record the PAOP just before the increase in pressures during inhalation.

D

The spouse of a patient who is hospitalized in the critical care unit following resuscitation for a sudden cardiac arrest at work demands to meet with the nursing manager. The spouse demands, "I want you to reassign us to another nurse. His current nurse is not in the room enough to make sure everything is okay." The nurse recognizes that this response most likely is due to the spouse's A. Desire to pursue a lawsuit if the assignment is not changed. B. Inability to participate in the husband's care. C. Lack of prior experience in a critical care setting. D. Sense of loss of control of the situation.

D

Which of the following organizations requires a mechanism for addressing ethical issues? a. American Association of Critical-Care Nurses b. American Hospital Association c. Society of Critical Care Medicine d. The Joint Commission

D

Which of the following statements about resuscitation is true? a. Family members should never be present during resuscitation. b. It is not necessary for a physician to write "do not resuscitate" orders in the chart if a patient has a health care surrogate. c. "Slow codes" are ethical and should be considered in futile situations if advanced directives are unavailable. d. Withholding "extraordinary" resuscitation is legal and ethical if specified in advance directives and physician orders.

D

Which of the following statements describes the core concept of the synergy model of practice? a. All nurses must be certified in order to have the synergy model implemented. b. Family members must be included in daily interdisciplinary rounds. c. Nurses and physicians must work collaboratively and synergistically to influence care. d. Unique needs of patients and their families influence nursing competencies.

D

While caring for a patient with a pulmonary artery catheter, the nurse notes the pulmonary artery occlusion pressure (PAOP) to be significantly higher than previously recorded values. The nurse assesses respirations to be unlabored at 16 breaths/min, oxygen saturation of 98% on 3 L of oxygen via nasal cannula, and lungs clear to auscultation bilaterally. What is the priority nursing action? A. Increase supplemental oxygen and notify respiratory therapy. B. Notify the provider immediately of the assessment findings. C. Obtain a stat chest x-ray film to verify proper catheter placement. D. Zero reference and level the catheter at the phlebostatic axis.

D

A patient is having an emergent coronary intervention, and the nurse is starting an infusion of abciximab. The patient asks what the purpose of this drug is. What response by the nurse is best? a) "This will help prevent chest pain until the intervention is complete." b) "This medication dries oral and respiratory secretions during the procedure." c) "This is a mild sedative and amnesic agent, so you'll be very relaxed." d) "This drug helps prevent blood clotting and is often used for this procedure."

D Abciximab is a glycoprotein IIb/IIIc inhibitor and antiplatelet agent. It is used to prevent clotting in acute coronary syndromes and coronary intervention patients.

Percutaneous coronary intervention is contraindicated for patients with lesions in which coronary artery? a) Right coronary artery b) Left coronary artery c) Circumflex d) Left main coronary artery

D Stenosis of the left mainstem artery is considered unacceptable for percutaneous intervention.

A patient has elevated blood lipids. The nurse anticipates which classification of drugs to be prescribed for the patient? a) Bile acid resins b) Nicotinic acid c) Nitroglycerin d) Statins

D The statins have been found to lower low-density lipoproteins (LDLs) more than other types of lipid-lowering drugs such as bile acid resins and nicotinic acid.

_____, _______, and _______ have been called the "classic" signs and symptoms for PE, but the three signs and symptoms actually occur in less than ____%of cases.

Dyspnea, hemoptysis, and chest pain have been called the "classic" signs and symptoms for PE, but the three signs and symptoms actually occur in less than 20% of cases.

___________ often early indicators of ARDS. What are the dx of ARDS?

Increased peak inspiratory pressures are often early indicators of ARDS. Oxygen saturation decreases in ARDS. Chest x-ray study will show progressive infiltrates. In ARDS, a PaO2/FiO2 ratio of less than 200 is a criterion.

_______ helps to prevent ______ and __________.

Mobility helps to prevent deep vein thrombosis and pulmonary embolus.

_________ are often recommended in the ______treatment of the patient with __________ to prevent _________. The history of ________ increases the risk for _______, so _______ options are a priority.

Noninvasive measures are often recommended in the initial treatment of the patient with chronic obstructive pulmonary disease to prevent intubation and ventilator dependence. The history of chronic obstructive pulmonary disease increases the risk for ventilator dependence, so noninvasive options are a priority.

_______, ________, _______, assist in preventing pneumonia.

Oral care, head of bed elevation, and coughing and deep breathing assist in preventing pneumonia.

Sedation is an intervention to _________, and administration of ________ increases the risk for _______.

Sedation is an intervention to manage anxiety, and administration of sedatives increases the risk for retained secretions.

PNA sxs norm and for the elderly

fever, cough, dyspnea, tachnypnea,purulent sputum, hemoptyis, WBC greater 15K, pleuritic chest pain, auscultate crackles and rhonchi

Elevating the HOB is used to prevent _______

infections

repositioning helps to ________

mobilize secretions

What helps prevent pneumonia?

oral care, elevate HOB, coughing and deep breathing

Tests to confirm PE and their limitations

spiral CT and pulmonary angiogram. Cannot visualize small clots in distal vessels.