#2

The nurse is caring for a patient in cardiogenic shock being treated with an intra aortic balloon pump (IABP). The family inquires about the primary reason for the device. What is the best statement by the nurse to explain the IABP?

"The action of the machine will improve blood supply to the damaged heart."

A patient with type 1 diabetes who is receiving a continuous subcutaneous insulin infusion via an insulin pump contacts the clinic to report mechanical failure of the infusion pump. The nurse instructs the patient to begin monitoring for signs of:

hypoglycemia DKA

Having the patient in the prone positioning and the family asks why this method will improve the ventilation because of what

improve airflow to back side of the lungs

Nurse recognizes cellular hypoxia in progressive phase of shock, is manifested by which lab value?

increase in lactate

The nurse recognizes that the primary pathophysiology occurring in ARDS is

injury to the alveolar capillary membrane

The nurse is caring for a mechanically ventilated patient and is considering a tracheostomy because of failure to wean from the vent. What is a nurse's role in insertion?

it can be done at the bedside

The nurse has just completed an infusion of a 1000 mL bolus of 0.9% normal saline in a patient with severe sepsis. One hour later, which laboratory result requires immediate nursing action?

lactate of 6 mmol/L

A patient in septic shock has not responded to fluid resuscitation, as evidenced by a decreasing BP and cardiac output. The nurse anticipates the administration of

norepinephrine

Which of the following laboratory values would be more common in patients with diabetic ketoacidosis?

pH 7.24

The nurse is assigned to care for a patient who presented to the emergency department with diabetic ketoacidosis. A continuous insulin intravenous infusion is started, and hourly bedside glucose monitoring is ordered. The targeted blood glucose value after the first hour of therapy is:

A decrease of 50 to 75 mg/dL compared with admitting values (prevents cerebral edema)

The nurse is caring for a client in the hospital with a tracheostomy and what is a priority to have for the patient in case of emergency

A equal or smaller sized tracheostomy at bedside

Which patient being cared for in the emergency department is most at risk for developing hypovolemic shock?

A patient with a 2-day history of nausea, vomiting, and diarrhea (loss of fluids)

Which of the following patients is at the highest risk for hyperosmolar hyperglycemic syndrome?

An 83-year-old, long term care resident with type 2 diabetes who recently developed influenza

The nurse is assessing a patient with septic shock, what should be reported immediately?

Bilateral crackles in the lung

Ten minutes following administration of an antibiotic, the nurse assesses a patient to have edematous lips, hoarseness, and expiratory stridor. Vital signs assessed by the nurse include blood pressure 70/40 mm Hg, heart rate 130 beats/min, and respirations 36 breaths/min. What is the priority intervention?

Epinephrine 3 to 5 mL of a 1:10,000 solution intravenously (anaphylactic shock)

Client admitted to ed with chest trauma and 3 fx ribs, ABG values showing acute respiratory acidosis, which is a potential complication

Hypercapnic respiratory failure related to decrease ventilatory effort (respiratory acidosis)

Pt c/o SOB, crushing chest pain, HR 124, multifocal PVC, BP 182/144

Initiate a nitroprusside infusion

Transition the patient to subcutaneous insulin

Keep the drip on for 1 hour so the patient isn't in continually in DKA

The nurse is caring for a patient admitted with shock. The nurse understands which assessment findings best assess tissue perfusion in a patient in shock? (Select all that apply).

LOC BP Urine output

Which nursing diagnosis is a priority for a laryngectomy

Maintaining airway because of post surgical damage

Hypercapnic/hypoventilation respiratory failure occurs in what condition

OSA

A client ARDS with atelectasis (collapsed alveoli) what do we do?

PEEP - want to open the alveoli

The nurse has been administering 0.9% normal saline intravenous fluids in a patient with severe sepsis. To evaluate the effectiveness of fluid therapy, which physiological parameters would be most important for the nurse to assess?

RAP & urine output

When caring for a patient who developed ARDS as a result of a gram-negative urinary infection that became systemic, the nurse is asked by the patient's family how a urinary tract infection could cause lung damage. What is the best response to the family members?

Serious infections may cause stimulation of the body's inflammatory and immune systems, which, in turn, react abnormally with lung tissue

The nurse is caring for an athlete with a possible cervical spine (C5) injury following a diving accident. The nurse assesses a blood pressure of 70/50 mm Hg, heart rate 45 beats/min, and respirations 26 breaths/min. The patient's skin is warm and flushed. What is the best interpretation of these findings by the nurse?

The patient is developing neurogenic shock

Nursing intervention that is first when cardiogenic shock is suspected

beginning supplemental oxygen

Assessment finding in client at risk for ARDS, which should nurse report

bibasilar crackles in the lungs

The nurse is caring for a patient following insertion of an intra aortic balloon pump (IABP) for cardiogenic shock unresponsive to pharmacotherapy. Which hemodynamic parameter best indicates an appropriate response to therapy?

cardiac index of 2.5

Nurse caring for client with ARDS, what would nurse expect to find in this client

decreased SCVO2 (normal is 65-80)

Which of the following is a high nursing priority for a patient with DKA and HHS

dehydration - fluids

The nurse is caring for a patient admitted with cardiogenic shock. Hemodynamic readings obtained with a pulmonary artery catheter include a pulmonary artery occlusion pressure (PAOP) of 18 mm Hg and a cardiac index (CI) of 1.0 L/min/m2. What is the priority pharmacological intervention?

dobutamine

The nurse suspects the possible onset of ARDS in a susceptible patient who develops which of the following symptoms?

dyspnea restlessness mild hypoxemia

Clients admitted to ED suspect for shock, what's the first thing you do?

get a blood pressure

A patient is admitted after collapsing at the end of a summer marathon. The patient is lethargic, with a heart rate of 110 beats/min, respiratory rate of 30 breaths/ min, and a blood pressure of 78/46 mm Hg. The nurse anticipates administering which therapeutic intervention?

give LR

In hyperosmolar hyperglycemic syndrome, the laboratory results are similar to those of diabetic ketoacidosis, with three major exceptions. What differences would you expect to see in patients with hyperosmolar hyperglycemic syndrome?

higher serum glucose, higher osmolality, no ketosis

Tracheostomy coughing forcefully, and it becomes dislodged, what is the nurse's immediate action?

hold it open to protect the airway

Which nursing action is most important for a client with a tracheostomy before discharge?

how to suction/maintain their airway

Hypoxic respiratory failure in what conditions? SATA

pneumonia pulmonary edema CHF

A 32-year-old patient is admitted to the critical care unit with a diagnosis of diabetic ketoacidosis. Following aggressive fluid resuscitation and intravenous (IV) insulin administration, the blood glucose begins to normalize. In addition to glucose monitoring, which of the following electrolytes requires close monitoring?

potassium 5.8

A patient has been brought to the ED by the paramedics. The patient is suspected of having ARDS. What intervention should the nurse first anticipate?

prepare to intubate

A diabetic patient who has had vomiting and diarrhea for the past 3 days is admitted to the hospital with a blood glucose of 748 mg/ml (41.5 mmol/L) and a urinary output of 120 ml in the first hour. The vital signs are blood pressure (BP) 72/62; pulse 128, irregular and thready; respirations 38; and temperature 97° F (36.1° C). The patient is disoriented and lethargic with cold, clammy skin and cyanosis in the hands and feet. The nurse recognizes that the patient is experiencing:

progressive stage of hypovolemic shock (vasopressors next)

Which client responds to treatment as a result of a pathophysiological changes in ARDS

refractory hypoxemia

Client undergoing chemo is scheduled for radical neck dissection, SATA

self help groups manage nutritional support Treat for possible mucositis Post op nonverbal communication techniques

Nurse is planning to deflate the cuff of the trach, what do you want to do before that

suction !!!

When assessing client for hypoxia, nurse recognizes the first cardiovascular system alteration as:

tachycardia (assess HR)

Which of the following signs and symptoms would the nurse suspect SIRS?

tissue edema hypotension tachycardia

Which of the following statements is true about the medical management of diabetic ketoacidosis?

volume replacement and insulin infusion often correct the acidosis