!st test practice

The nurse is educating a new RN on the therapeutic effect of head-of-the-bed elevation and neutral head and neck alignment on a patient with increased intracranial pressure (ICP). Which statement by the new RN indicates that teaching has been effective?

"Head-of-the-bed elevation lowers ICP by facilitating venous drainage and decreasing venous obstruction. HOB elevation and a neutral head position that avoids hyperextension or hyperflexion facilitate jugular venous drainage, helping to minimize increases in ICP. Elevated CO2 contributes to cerebral vessel vasodilation, which can increase cerebral blood volume and further elevate ICP. Maintaining an open airway alone does not minimize increases in ICP. Reducing the risk of snoring by maintaining an open airway alone does not minimize increases in ICP.

In the emergency department (ED), which is the nursing priority in assessing the client with a spinal cord injury?

A. Patent airway

After receiving handoff report from the night shift, the nurse completes the morning assessment of a patient with severe sepsis. Vital sign assessment notes blood pressure 95/60 mm Hg, heart rate 110 beats/min, respirations 32 breaths/min, oxygen saturation (SpO2) 96% on 45% oxygen via Venturi mask, temperature 101.5° F, central venous pressure (CVP/RAP) 2 mm Hg, and urine output of 10 mL for the last hour. Given this report, the nurse obtains orders for treatment that include which of the following? (Select all that apply.)

Administer infusion of 500 mL 0.9% normal saline every 4 hours as needed if the CVP is <5 mm H Administer acetaminophen (Tylenol) 650 mg suppository per rectum as needed to treat temperature >101° F. Fluid volume resuscitation is a priority in patients with severe sepsis to maintain circulating blood volume and end organ perfusion and oxygenation. A 500-mL IV bolus of 0.9% normal saline is appropriate given the patient's CVP of 2 mm Hg and hourly urine output of 10 mL/hr. There is no evidence to support the need to increase supplemental oxygen. Administration of furosemide (Lasix) in the presence of a fluid volume deficit is contraindicated. The fever may need to be treated.

client is admitted into the emergency department with frontal-temporal pain, preceded by a visual disturbance. The client is upset and thinks it is a stroke. What does the nurse suspect may be occurring?

C. Classic migraine

The nurse is monitoring a patient's intracranial pressuere (ICP). While the nurse is providing hygiene measures, she observes that the ICP reading is sustained at 18 mm Hg. What is the priority nursing action?

Cease stimulating the patient. Sustained increases in ICP should be avoided. Nursing care activities should be spaced to prevent an increase in ICP. Actions that cause a sustained elevation in ICP should be avoided until ICP returns to baseline resting values. Elevating the head of the bed to 30 degrees or more can help reduce ICP. Continuous drainage of CSF fluid will result in herniation

Herniation syndromes can be life-threatening situations. Which syndrome causes the supratentorial contents to shift downward and compress vital centers of the brainstem?

Central herniation A downward shift of the cerebral hemispheres, basal ganglia, and diencephalon through the tentorial notch causes central herniation, which compresses the vital centers of the brainstem. This results in a shift of one cerebral hemisphere under the falx cerebri to the other cerebral hemisphere. Cerebellar tonsils are displaced through the foramen magnum, causing fatal damage to the respiratory and cardiac centers. Uncal herniation compresses the midbrain, causing dysfunction of the ipsilateral third nerve, resulting in unilateral pupil dilation.

The nurse is caring for a patient admitted with severe sepsis. The physician orders include the administration of large volumes of isotonic saline solution as part of early goal-directed therapy. Which of the following best represents a therapeutic end point for goal-directed fluid therapy?

Central venous pressure >8 mm Hg Early goal-directed therapy includes administration of IV fluids to keep the central venous pressure at 8 mm Hg or greater. Additional therapeutic end points include a heart rate at less than 110 beats/min and a mean arterial blood pressure at 65 mm Hg or greater. Serum lactate levels are elevated in sepsis; target levels should be

The nurse is managing the blood pressure of a patient with a traumatic brain injury. When planning the care of this patient, which statement best represents appropriate blood pressure management?

Cerebral perfusion pressure (CPP) should be sustained at least 70 mm Hg.

A client who has just undergone spinal surgery must be moved. How does the nurse plan to move this client?

D. Log rolling the client

The nurse admits a patient to the coronary care unit in cardiogenic shock. The nurse anticipates administering which medication in an effort to improve cardiac output by increasing the contractile force of the heart?

Dobutamine (Dobutrex) Positive inotropic agents such as dobutamine (Dobutrex) are given to increase the contractile force of the heart in cardiogenic shock. Dopamine (Intropin) is used primarily in low cardiac output states to restore vascular tone and increase blood pressure, but not in cardiogenic shock. Neo-Synephrine would be contraindicated in cardiogenic shock, as the vasoconstriction it produces would exacerbate cardiac ischemia. Nitroprusside (Nipride), used for preload and after load reduction, can improve cardiac performance in shock states by its reduction of systemic vascular resistance.

Which hemodynamic values should the nurse anticipate in a patient who is in the initial stages of septic shock state?

High heart rate; low right atrial pressure In septic shock, inflammatory mediators damage the endothelial cells that line blood vessels, producing profound vasodilation and increased capillary permeability. Initially this results in a high heart rate, hypotension, and low SVR, and subsequently in low right atrial pressure.

The nurse is caring for a patient with a head injury. If autoregulation is lost, what should the nurse be most concerned for?

Hypertension increasing cerebral blood flow.

The nurse is caring for a patient with hypovolemia. Which large volume crystalloid solution should the nurse anticipate the health care provider to order? (Select all that apply.)

Lactated Ringer's (LR) Correct Normal saline LR solution and 0.9% normal saline are isotonic solutions that are commonly infused to treat hypovolemia. Solutions of 5% dextrose in water and 0.45% normal saline are hypotonic and are not used for fluid resuscitation. Hypotonic solutions rapidly leave the intravascular space, causing interstitial and intracellular edema. A systematic review of 30 randomized controlled trials found no benefit in giving colloids (e.g., albumin) over crystalloids and recommended against the administration of colloids in most patient populations.

The nurse educator is presenting a lecture on crystalloid fluid replacement therapy in shock states. Which statement by a nurse indicates that the teaching has been effective?

Lactated Ringer's should not be infused if lactic acidosis is severe. LR solutions contain lactate, which the liver converts to bicarbonate. If liver function is normal, this will counteract lactic acidosis. However, LR should not be infused if lactic acidosis is severe. To replace every 1 mL of blood loss, 3 mL of crystalloid is administered. There is no evidence to support colloid administration being more beneficial than crystalloid administration in shock states. Hypotonic solutions such as 0.45% normal saline are not administered in shock states as these solutions rapidly leave the intravascular space, causing interstitial and intracellular edema.

The nurse is caring for a patient in shock. Which is a priority action by the nurse?

Maintain adequate tissue perfusion. Care of a patient in shock is directed toward correcting or reversing the altered circulatory component and reversing tissue hypoxia. Restoring circulating intravascular volume is the priority in improving tissue perfusion and oxygen delivery

The nurse is caring for a patient who has blood pooling in the capillary bed and arterial blood pressure too low to support perfusion of vital organs. Which symptoms should the nurse assess for?

Multisystem organ failure and/or dysfunction Maldistribution of blood flow refers to the uneven distribution of flow to various organs and pooling of blood in the capillary beds. This impaired blood flow leads to impaired tissue perfusion and a decreased oxygen supply to the cells, all of which contribute to multiple organ failure. Damage to the type II pneumocytes leads to ARDS. Consumption of clotting factors may cause DIC. Low arterial blood pressure leads to decreased cerebral perfusion pressure.

A client is admitted with a spinal cord injury at the seventh cervical vertebra secondary to a gunshot wound. Which nursing intervention is the priority for this client's care?

Positioning the client to maximize ventilation potential

The nurse is administering the intake assessment for a newly admitted client with a history of seizures. The client suddenly begins to seize. What does the nurse do next?

Positions the client on the side.

To prevent the leading cause of death for clients with spinal cord injury, collaboration with which component of the health care team is a nursing priority?

Respiratory therapy

What is the best position for the nurse to place the patient in to obtain a right atrial pressure measurement?

Supine, either flat or with the head of the bed no more than 60 degrees

The nurse is caring for a patient in neurogenic shock. Which should the nurse assess for?

Vasodilation In neurogenic shock, there is an interruption of impulse transmission or blockage of sympathetic outflow, resulting in vasodilation, inhibition of baroreceptor response, and impaired thermoregulation. Interruption of sympathetic nerve innervation would result in bradycardia. Interruption of sympathetic nerve innervation would result in hypotension. Hypoventilation is not a physiological mechanism.

The nurse is caring for a patient with possible distributive shock. Which should the nurse look for on assessment?

Vasodilation and relative hypovolemia. Distributive shock presents with widespread vasodilation and decreased systemic vascular resistance that result in a relative hypovolemia. Blood loss is associated with hypovolemic shock. Decreased cardiac output is a primary cause of cardiogenic shock. Primary internal sequestration of fluids that causes internal fluid loss is associated with hypovolemic shock.

The nurse has received report on a group of clients. Which client requires the nurse's attention first?

Young adult who has experienced four tonic-clonic seizures within the past 30 minutes