capstone exams finals
Identify the sites for monitoring ICP. (Select all that apply.) Intraventricular space Epidural space Parenchyma Subdural space Jugular veins
Intraventricular space Epidural space Parenchyma Subdural space
How much of a size difference between the two pupils is still considered normal? 2.5 mm 2 mm 1 mm 1.5 mm
1 mm
Describe the pattern of electrical conduction in the heart.
1. SA node 2. Av node 3. Bundle of His 4. Right/left bundle branches 5. Pirkinje Fibers
Describe the blood flow of the heart.
1. Inferior and Superior Vena Cava 2. Right atrium 3. Tricuspid Valve 4. Right Ventricle 5. Pulmonary Valve 6. Pulmonary Artery 7. Pulmonary Vein 8. Left atrium 9. Mitral Valve 10. Left Ventricle 11. Aortic Valve 12. Aorta
ST segment monitoring for ischemia has gained increasing importance with the advent of thrombolytic therapy. The most accurate method for monitoring the existence of true ischemic changes is adjusting the gain control on bedside monitoring for best visualization. 12-lead ECG for confirmation. ST segment depression in leads overlying the ischemia. T-wave inversion in leads overlying the ischemia.
12-lead ECG for confirmation.
Which of the following platelet counts would be most indicative of a diagnosis of ITP? 35,000/mm3 28,000/mm3 110,000/mm3 72,000/mm3
28,000/mm3
Which of the following causes of hypoxemia is the result of blood passing through unventilated portions of the lungs? Drug overdose Intrapulmonary shunting Dead space ventilation Alveolar hypoventilation
Intrapulmonary shunting
Place the steps for analyzing arterial blood gases in the proper order.1. Assess HCO3- level for metabolic abnormalities.2. Assess PaO2 for hypoxemia.3. Examine PaCO2 for acidosis or alkalosis.4. Re-examine pH to determine level of compensation.5. Examine pH for acidemia or alkalemia. 5, 1, 2, 4, 3 1, 2, 4, 3, 5 2, 5, 3, 1, 4 1, 3, 4, 5, 2
2, 5, 3, 1, 4
Depending on the patient's risk for the recurrence of PE, a patient may be placed on warfarin for 1 to 3 months. 3 to 12 months. 3 to 6 months. 12 to 36 months.
3 to 12 months.
Which of the following is an abnormal finding in the analysis of the cerebrospinal fluid? Glucose of 60 mg/dL Protein of 20 mg/dL 30 red blood cells Clear and colorless
30 red blood cells
Place these pathophysiologic mechanisms of DIC in the order in which they occur.1. Activation of the fibrinolytic system2. Breakdown of thrombi; spontaneous hemorrhage3. Consumption of coagulation factors; failure of regulatory mechanisms4. Endothelial damage; release of tissue factor5. Thrombin formation; clots form along epithelial walls 2, 3, 1, 5, 4 4, 5, 3, 1, 2 4, 1, 3, 2, 5 5, 1, 2, 4, 3
4, 5, 3, 1, 2
Hydroxyurea is increased by what dosage until the maximum of 35 mg/kg is reached? 5 mg/kg every 12 weeks 5 mg/kg every 4 weeks 15 mg/kg every 15 weeks 10 mg/kg every 8 weeks
5 mg/kg every 12 weeks
The high-risk period for developing HIT is 5 to 10 hours after initiation of heparin. 30 to 60 days after initiation of heparin. 5 to 14 hours after initiation of heparin. 5 to 14 days after initiation of heparin.
5 to 14 days after initiation of heparin.
Which of the following are mechanisms responsible for a myocardial infarction (MI)? (Select all that apply.) Preinfarction angina Coronary artery spasm near the ruptured plaque Coronary artery thrombosis Hyperlipidemia Plaque rupture
Coronary artery spasm near the ruptured plaque Coronary artery thrombosis Plaque rupture
Which of the following patients would be considered hypoxemic? An 84-year-old man with a PaO2 of 96 A 50-year-old woman with a PaO2 of 65 A 70-year-old man with a PaO2 of 72 A 68-year-old woman with a PaO2 of 80
A 50-year-old woman with a PaO2 of 65
Which of the following patients would benefit from postural drainage? A patient with a heart murmur and jugular venous distention A patient with right-sided heart failure and pitting edema A patient with chronic bronchitis and congested cough A patient with asthma and audible wheezing
A patient with chronic bronchitis and congested cough
Which of the following conditions is associated between kidney failure and respiratory failure? (Select all that apply.) ARDS Increased urine output Decreased urine output Lower GFR Decreased blood flow to the kidneys
ARDS Decreased urine output Lower GFR Decreased blood flow to the kidneys
When assessing motor function, which of the following are correct? (Select all that apply.) Evaluation of deep tendon reflexes is an essential part of the nursing assessment. Lower extremity muscle tone is assessed by asking the patient to push or pull his or her foot against resistance. Abnormal extension, or decerebrate posturing, indicates a less positive outcome than abnormal flexion. When using noxious stimuli to elicit a motor response, each limb is tested separately. The presence of a Babinski reflex is an abnormal finding in an adult.
Abnormal extension, or decerebrate posturing, indicates a less positive outcome than abnormal flexion. When using noxious stimuli to elicit a motor response, each limb is tested separately. The presence of a Babinski reflex is an abnormal finding in an adult.
The nurse is caring for a patient in hypovolemic shock secondary to cirrhosis of the liver. The nurse understands that this type of shock results from shifting of fluid into the abdominal cavity. What is the resulting hypovolemia called? Relative hypovolemia Compensatory hypovolemia Absolute hypovolemia Distributive hypovolemia
Absolute hypovolemia
A patient is admitted with shortness of breath. Temperature is 39.5° C, blood pressure is 160/82 mm Hg, heart rate is 115 beats/min, and respiratory rate is 26 breaths/min. Chest radiography confirms the presence of right upper lobe pneumonia. Arterial blood gases reveal the following:pH 7.27PaCO2 64 mm HgHCO3 33 mEq/LPaO2 50 mm HgThese findings are indicative of which disorder? Restrictive lung disease ARDS Acute lung failure Obstructive lung disease
Acute lung failure
The nurse is caring for a patient in septic shock due secondary to pneumonia. The nurse knows that evidence-based guidelines for the treatment of septic shock include which interventions? (Select all that apply.) Administer 30 mL/kg crystalloid for hypotension or lactate greater than or equal to 4 mmol/L. Start enteral nutrition within the first 48 hours after diagnosis of septic shock. Administer low-dose dopamine to maintain urine output greater than 30 mL/h. Administer norepinephrine to maintain mean arterial pressure of 65 mm Hg. Perform an adrenocorticotropic hormone (ACTH) stimulation test to identify patients who need hydrocortisone
Administer 30 mL/kg crystalloid for hypotension or lactate greater than or equal to 4 mmol/L. Start enteral nutrition within the first 48 hours after diagnosis of septic shock. Administer norepinephrine to maintain mean arterial pressure of 65 mm Hg.
The nurse is caring for a patient with advanced COPD who reports feeling short of breath. The nurse notes that the patient's lung sounds are diminished bilaterally and the patient's pulse oximetry is 91% on 2 L/min oxygen via nasal cannula. What actions will the nurse take to make the patient more comfortable? (Select all that apply.) Administer the ordered nebulized bronchodilator. Elevate the head of the patient's bed to fully upright. Maintain eye contact and provide calm reassurance. Turn the patient onto the side for postural drainage. Increase the patient's oxygen to 4 L/min via nasal cannula. Suction the patient's airway using sterile technique.
Administer the ordered nebulized bronchodilator. Elevate the head of the patient's bed to fully upright. Maintain eye contact and provide calm reassurance.
Which of the following therapeutic measures would be the most effective in treating hypoxemia in the presence of intrapulmonary shunting associated with ARDS? Restricting fluids to 500 mL per shift Sedating the patient to blunt noxious stimuli Increasing the FiO2 on the ventilator Administering positive-end expiratory pressure (PEEP)
Administering positive-end expiratory pressure (PEEP)
Which of the following therapeutic measures would be the most effective in treating hypoxemia in the presence of intrapulmonary shunting associated with ARDS? Sedating the patient to blunt noxious stimuli Increasing the FiO2 on the ventilator Restricting fluids to 500 mL per shift Administering positive-end expiratory pressure (PEEP)
Administering positive-end expiratory pressure (PEEP)
Which therapeutic measure would be the most effective in treating hypoxemia in the presence of intrapulmonary shunting associated with acute respiratory distress syndrome (ARDS)? Increasing the FiO2 on the ventilator Administering positive-end expiratory pressure (PEEP) Restricting fluids to 500 mL per shift Sedating the patient to blunt noxious stimuli
Administering positive-end expiratory pressure (PEEP)
Evidence-based guidelines for the treatment of septic shock include which of the following? (Select all that apply.) Administration of activated protein C Low-dose dopamine for renal protection Fluid resuscitation to maintain central venous pressure at 8 mm Hg or greater Achieve central venous oxygen saturation of 70% or more High-dose corticosteroids
Administration of activated protein C Fluid resuscitation to maintain central venous pressure at 8 mm Hg or greater Achieve central venous oxygen saturation of 70% or more
The nurse is performing a respiratory assessment on a patient. Which assessment findings indicate to the nurse that the patient has a history of long-standing chronic respiratory disease? (Select all that apply.) All of the patient's fingernails are noticeably clubbed. The patient's chest has equal antero-posterior and transverse diameters. The patient's forced vital capacity test result is 3.8 L of air. The patient reports puffiness of both feet when standing for long periods. The patient's lower legs have large areas of brownish spotted discoloration. The patient needs to sleep on at least four to five pillows at night.
All of the patient's fingernails are noticeably clubbed. The patient's chest has equal antero-posterior and transverse diameters. The patient needs to sleep on at least four to five pillows at night.
Mr. Z is admitted with acute lung failure. Which statement describes appropriate action for optimizing his oxygenation and ventilation? Allow Mr. Z to rest in between nursing interventions. Perform vigorous postural drainage and chest percussion to facilitate secretion clearance. Place Mr. Z in a supine position. Make sure Mr. Z coughs every 2 hours even if he has no secretions.
Allow Mr. Z to rest in between nursing interventions.
The patient is 72 hours postoperative for a coronary artery bypass graft (CABG). The patient's vital signs include temperature 103° F, heart rate 112, respiratory rate 22, blood pressure 134/78 mm Hg, and O2 saturation 94% on 3L nasal cannula. The nurse suspects that the patient has developed what problem? An infection. The doctor must be notified immediately Infection, which is common Post-op, and continues to monitor the patient Cardiac tamponade and notifies the doctor immediately Delirium caused by the elevated temperature
An infection. The doctor must be notified immediately
A patient has been in the progressive care unit for 3 days with a diagnosis of pneumonia. The patient is being treated with antibiotics, 50% oxygen, and vigorous pulmonary toilet. Which diagnostic testing result would indicate early progression of the patient's condition to acute respiratory distress syndrome? PaO2/FiO2 ratio of 325 Arterial PaCO2 of 58 mm Hg Arterial blood pH of 7.29 Arterial PaO2 of 58 mm Hg
Arterial PaO2 of 58 mm Hg
A patient with pneumonia has been in the unit for 3 days. The medical plan includes antibiotics and oxygen therapy. Which finding would indicate the patient is developing acute respiratory distress syndrome (ARDS)? High probability ventilation-perfusion scan. Chest radiography shows evidence of pulmonary hypertension Sputum cultures are positive for Streptococcus pneumoniae. Arterial blood gas analysis reveals a low PaO2 despite increases in supplemental oxygen.
Arterial blood gas analysis reveals a low PaO2 despite increases in supplemental oxygen.
What is the effect of preload on cardiac output? As preload increases, cardiac output increases. Increased preload has no effect on cardiac output. As preload increases, cardiac output increases until it overstretches the ventricle and cardiac output decreases. As preload increases, cardiac output decreases.
As preload increases, cardiac output increases until it overstretches the ventricle and cardiac output decreases.
Sickle cell anemia is not prevalent in persons of which descent? Middle Eastern West African Sole European Asian or Pacific Islander
Asian or Pacific Islander
A patient has sepsis and is placed on broad-spectrum antibiotics. Her temperature is 37.8°C. Her BUN level is elevated. She continues on vasopressor therapy. What other steps should be taken to protect the patient from inadequate organ perfusion? Notify the physician of access pressures. ncrease net ultrafiltrate of fluid. Discontinue vasopressor support. Assess the patient for blood loss and hypotension.
Assess the patient for blood loss and hypotension.
A patient's pulse oximeter alarm goes off. The monitor reads 82%. What is the first action the nurse should perform? Increase 02 to 4LPM via NC Assess the patient's condition. prepare to intubate turn off the pulse ox alarm
Assess the patient's condition.
A patient's pulse oximeter alarm goes off. The monitor reads 82%. What is the first action the nurse should perform? Prepare to intubate. Assess the patient's condition. Turn off the alarm and reapply the oximeter sensor. Increase O2 level to 4L/NC.
Assess the patient's condition.
A patient's pulse oximeter alarm goes off. The monitor reads 82%. What is the first action the nurse should perform? Prepare to intubate. Turn off the alarm and reapply the oximeter sensor. Assess the patient's condition. Increase O2 level to 4L/NC.
Assess the patient's condition.
The key to treatment of septic shock is finding the cause of the infection. Which of the following cultures are obtained before antibiotic therapy is initiated? (Select all that apply.) Blood cultures x 2 Sputum cultures CBC with differential Urine cultures Wound cultures
Blood cultures x 2 Sputum cultures Urine cultures Wound cultures
A patient has been on the medical floor for 1 week after a vaginal hysterectomy. A urinary catheter was inserted. Complete blood cell count results have revealed escalating white blood cell counts. The patient is transferred to the critical care unit when her condition deteriorates. Septic shock is diagnosed. Which of the following is the pathophysiologic mechanism that results in septic shock? Microorganisms invade organs such as the kidneys and heart. Increased white blood cells are released to fight invading bacteria. An increase of white blood cells leads to decreased red blood cell production and anemia. Bacterial toxins lead to vasodilation.
Bacterial toxins lead to vasodilation.
Decerebrate posturing (abnormal extension) indicates dysfunction in which area of the central nervous system? Thalamus Cerebellum Brainstem Cerebral cortex
Brainstem
A patient with acute respiratory failure may require a bronchodilator if which of the following occurs? Bronchospasms Fighting the ventilator Thick secretions Excessive secretions
Bronchospasms
A patient is admitted after a positive exercise treadmill test with a diagnosis of coronary artery disease (CAD) and stable angina. Radiographic tests show that the patient has blockage in the left main coronary artery and four other vessels. The nurse anticipates that the patient's treatment plan will include what treatment or procedure? TMTO Medical therapy TAVR CABG
CABG
A patient is admitted to the ICU after a positive exercise treadmill test with a diagnosis of CAD and stable angina. Radiographic test show that the patient has blockage in the left main coronary artery and four other vessels. The nurse anticipates that the patient will be scheduled for TAVR. medical therapy antianginal medications. CABG. PCI.
CABG.
Which of the following would be appropriate for treating hypocalcemia? Dialysis Calcium gluconate Sodium bicarbonate Insulin
Calcium gluconate
A client receiving thrombolytic therapy with a continuous infusion of alteplase suddenly becomes extremely anxious and reports itching. The nurse hears stridor and notes generalized urticaria and hypotension. Which interventions are a priority? Select all that apply. Administer protamine sulfate. Call for the Rapid Response Team (RRT). Administer diphenhydramine. Raise the head of the bed. 3. stop the infusion
Call for the Rapid Response Team (RRT). Administer diphenhydramine. stop the infusion
A patient has been admitted following a motor vehicle collision in which the patient sustained multiple abrasions and bruising across the chest. Suddenly, the patient complains of difficulty breathing, the O2 saturation has dropped dramatically, there are decreased breath sounds on the left, and it appears that there is some tracheal deviation. What would be your next logical action? Call the rapid response team and prepare for emergency insertion of a chest tube. Start the patient on O2 at 4 L/min nasal cannula and prepare an aminophylline drip. Notify the patient's practitioner and prepare for a stat V/Q scan. Notify the patient's practitioner of these changes.
Call the rapid response team and prepare for emergency insertion of a chest tube.
A patient has been on the medical floor for 1 week after a vaginal hysterectomy. A urinary catheter was inserted. Complete blood cell count results have revealed escalating white blood cell counts. The patient is transferred to the critical care unit when her condition deteriorates. Septic shock is diagnosed. A pulmonary artery catheter is placed. Which of the following hemodynamic values would you expect to find? Pulmonary artery wedge pressure of 23 mm Hg Systemic vascular resistance of 1100 Right atrial pressure of 17 mm Hg Cardiac output of 8 L/min
Cardiac output of 8 L/min
A trauma victim has sustained right rib fractures and pulmonary contusions. Auscultation reveals decreased breath sounds on the right side. Bulging intercostal muscles are noted on the right side. Heart rate (HR) is 130 beats/min, respiratory rate (RR) is 32 breaths/min, and breathing is labored. In addition to oxygen administration, what procedure should the nurse anticipate? Chest tube insertion Thoracentesis Emergent intubation Pericardiocentesis
Chest tube insertion
The respiratory pattern with rhythmic increase and decrease of rate and depth of respiration, then brief periods of apnea, is known as ataxic respirations. apneustic breathing. central neurogenic hyperventilation. Cheyne-Stokes respirations.
Cheyne-Stokes respirations.
The respiratory pattern with rhythmic increase and decrease of rate and depth of respiration, then brief periods of apnea, is known as central neurogenic hyperventilation. apneustic breathing. ataxic respirations. Cheyne-Stokes respirations.
Cheyne-Stokes respirations.
On admission, a patient presents as follows: pH, 7.38; respiratory rate, 24 breaths/min, regular, pursed-lip breathing; PaO2, 66 mm Hg; heart rate, 112 beats/min, sinus tachycardia; PaCO2, 52 mm Hg; blood pressure, 110/68 mm Hg; HCO3-, 24 mEq/L; and SpO2, 90% on O2 2 L/min nasal cannula. Which of the following diagnoses would be most consistent with the above arterial blood gas values? Congestive heart failure Acute pulmonary embolism Acute myocardial infarction Chronic obstructive pulmonary disease
Chronic obstructive pulmonary disease
A patient is admitted with acute respiratory failure attributable to pneumonia. Smoking history reveals that the patient smoked two packs of cigarettes a day for 25 years, stopping 10 years ago. ABG values on the current ventilator settings are pH, 7.37; PaCO2, 50 mm Hg; and HCO3-, 27 mEq/L. Chest radiography reveals a large right pleural effusion. Which of the following is the correct interpretation of the patient's ABG values? Compensated metabolic alkalosis Uncompensated respiratory alkalosis Uncompensated metabolic acidosis Compensated respiratory acidosis
Compensated respiratory acidosis
Which of the following clinical manifestations are indicative of left ventricular failure? (Select all that apply.) Cool, pale extremities Liver tenderness Jugular venous distention Rales Weak peripheral pulses
Cool, pale extremities Rales Weak peripheral pulses
Which mechanisms responsible for a myocardial infarction (MI)? (Select all that apply.) Hypolipidemia Plaque rupture preinfarction indigestion plaque Coronary artery thrombosis
Correct! Plaque rupture You Answered coronary artery spasm near the ruptured plaque (she has this wrong but on the bank it is right) Correct! Coronary artery thrombosis
Presence of the grasp reflex in an adult indicates what type of damage? Brainstem Cortical Spinal cord CN III
Cortical
Presence of the grasp reflex in an adult indicates what type of damage? Brainstem Spinal cord Cortical CN III
Cortical
Which medications are not effective in the immediate treatment of acute anaphylaxis? Corticosteroids Epinephrine Vasopressors Diphenhydramine (Benadryl) IV
Corticosteroids
A patient was admitted to the critical care unit with gram-negative sepsis 5 days ago. Today there is continual oozing from his intravenous sites, and ecchymosis of the skin is noted beneath his automatic blood pressure cuff. On his laboratory work, his platelets are normal, and his international normalized ratio is elevated. What other laboratory value would be most valuable in definitively diagnosing the patient's condition? Fibrin split products White blood cell count Bleeding time D-Dimer level
D-Dimer level
Which of the following denotes the most serious prognosis? Decorticate posturing Decerebrate posturing GCS score of 14 Absence of Babinski reflex
Decerebrate posturing
Which of the following denotes the most serious prognosis? GCS score of 14 Decerebrate posturing Absence of Babinski reflex Decorticate posturing
Decerebrate posturing
Which of the following effects can be associated with physical exercise? (Select all that apply.) Decreased LDL cholesterol Decreased incidence of depression Decreased triglycerides Increased insulin resistance Increased HDL cholesterol
Decreased LDL cholesterol Decreased incidence of depression Decreased triglycerides Increased HDL cholesterol
Which of the following hemodynamic parameters supports the diagnosis of cardiogenic shock? Increased cardiac output Increased right atrial pressure Decreased cardiac index Decreased pulmonary artery wedge pressure
Decreased cardiac index
A patient has been admitted with hypovolemic shock due to blood loss. Which finding would the nurse expect to note to support this diagnosis? Decreased level of consciousness Bounding radial and pedal pulses Widening pulse pressure Distended neck veins
Decreased level of consciousness
A patient has been admitted with the diagnosis of acute respiratory distress syndrome (ARDS). Arterial blood gasses (ABGs) revealed an elevated pH and decreased PaCO2. The patient is becoming fatigued, and the practitioner orders a repeat ABG. Which set of results would be indicative of the patient's current condition? Decreased pH and elevated PaCO2 Decreased pH and decreased PaCO2 Elevated pH and decreased PaCO2 Elevated pH and elevated PaCO2
Decreased pH and elevated PaCO2
What effect does ventricular tachycardia have on cardiac output? Decreases cardiac output due to a decrease in afterload Increases cardiac output due to an increase in preload Decreases cardiac output due to a decrease in stroke volume Increases cardiac output due to an increase in ventricular filling time
Decreases cardiac output due to a decrease in stroke volume
A patient is admitted to the intensive care unit after she develops disseminated intravascular coagulation (DIC) after a vaginal delivery. DIC is known to occur in patients with retained placental fragments. What is the result of DIC? Depletion of clotting factors and excessive fibrinolysis, resulting in simultaneous microvascular clotting and hemorrhage Hypersensitive response to an antigen, resulting in anaphylaxis Vasodilatation, resulting in hypotension Septic shock, resulting in vasodilation and decreased perfusion
Depletion of clotting factors and excessive fibrinolysis, resulting in simultaneous microvascular clotting and hemorrhage
Which of the following signs or symptoms would be most consistent with the following values? pH, 7.20; pO2, 106 mm Hg; pCO2, 35 mm Hg; HCO3-, 11 mEq/L. Shortness of breath Peripheral cyanosis Diarrhea Central cyanosis
Diarrhea
A patient with a potassium level of 2.8 mEq/L is given 60 mEq over a 12-hour period, and a repeat potassium level is obtained after the bolus. The current potassium level is 2.9 mEq/L. Which of the following should now be considered? Drawing a serum magnesium level Monitoring the patient's urinary output Rechecking the potassium level Stopping the patient's Aldactone
Drawing a serum magnesium level
A patient with a potassium level of 2.8 mEq/L is given 60 mEq over a 12-hour period, and a repeat potassium level is obtained after the bolus. The current potassium level is 2.9 mEq/L. Which of the following should now be considered? Drawing a serum magnesium level Stopping the patient's Aldactone Monitoring the patient's urinary output Rechecking the potassium level
Drawing a serum magnesium level
A patient with a potassium level of 2.8 mEq/L is given 60 mEq over a 12-hour period, and a repeat potassium level is obtained after the bolus. The current potassium level is 2.9 mEq/L. Which of the following should now be considered? Monitoring the patient's urinary output Drawing a serum magnesium level Rechecking the potassium level Stopping the patient's Aldactone
Drawing a serum magnesium level
Pulmonary embolism, a serious complication of HIT, is manifested by which of the following clinical signs? Chest pain, pallor, and confusion Blanching of fingers and toes and loss of peripheral pulses Dyspnea, pleuritic pain, and rales Headache, impaired speech, and loss of motor function
Dyspnea, pleuritic pain, and rales
The nurse should anticipate which of the following as the most common complication after an MI? Dysrhythmias Pulmonary edema Deep vein thrombosis Cardiogenic shock
Dysrhythmias
The nurse should anticipate which of the following as the most common complication after an MI? Pulmonary edema Dysrhythmias Cardiogenic shock Deep vein thrombosis
Dysrhythmias
A patient is being admitted with cardiogenic shock secondary to acute heart failure. In addition to a diuretic, which medication would the nurse anticipate the practitioner ordering for the patient? Nitroglycerine Dobutamine Nitroprusside Epinephrine
Epinephrine
Which of the following drugs promotes bronchodilation and vasoconstriction? Solu-Medrol Epinephrine Atropine Gentamicin
Epinephrine
Which blood gas parameter is the acid-base component that reflects kidney function? PaCO2 HCO3- pH PaO2
HCO3-
The nurse is caring for a patient whose ABG results reveal the following: pH 7.56, PaCO2 32 mm Hg, HCO3 42 mEq/L, PaO2 90 mm Hg. Which condition will the nurse expect to see in the patient's chart as the underlying cause of these results? Respiratory failure caused by pneumonia with pleural effusions Gastroenteritis with severe nausea, vomiting, and diarrhea Widespread tissue ischemia caused by cardiogenic shock Hyperventilation after a panic attack
Gastroenteritis with severe nausea, vomiting, and diarrhea
Clinical manifestations of ITP include which of the following? (Select all that apply.) Gingival bleeding Retinal hemorrhage Fluid retention Petechial hemorrhages on legs Muscle cramps
Gingival bleeding Retinal hemorrhage Petechial hemorrhages on legs
A patient has been newly diagnosed with stable angina. He tells the nurse he knows a lot about his diagnosis already because his father had the same diagnosis 15 years ago. The nurse asks him to state what he already knows about angina. Which response indicates the need for additional education? He can no longer get back massages He should take stool softeners to prevent straining He should stop smoking He can no longer drink colas or coffee
He can no longer get back massages
Which criteria are representative of the patient in normal sinus rhythm? Heart rate, 92 beats/min; rhythm irregular; PR interval, 0.16 second; QRS, 0.04 second Heart rate, 64 beats/min; rhythm regular; PR interval, 0.10 second; QRS, 0.04 second Heart rate, 88 beats/min; rhythm regular; PR interval, 0.18 second; QRS, 0.06 second Heart rate, 54 beats/min; rhythm regular; PR interval, 0.16 second; QRS, 0.08 second
Heart rate, 88 beats/min; rhythm regular; PR interval, 0.18 second; QRS, 0.06 second
Determination of oxygenation status by oxygen saturation alone is inadequate. What other value must be known? pH PaCO2 HCO3- Hemoglobin (Hgb)
Hemoglobin (Hgb)
The nurse helps a client cough and deep breathe after surgery. For coughing and deep breathing to be most effective, the nurse tells the client to assume which position? side lying supine with one pillow prone High fowler
High fowler
Which of the following values, when elevated, places the patient at lowest risk for CAD? Triglycerides High-density lipoproteins (HDLs) Low-density lipoproteins (LDLs) Very-low-density lipoproteins (VLDLs)
High-density lipoproteins (HDLs)
Which of the following findings confirms the diagnosis of a PE? Absence of vascular markings on the chest radiograph Negative pulmonary angiogram Low-probability V/Q scan High-probability V/Q scan
High-probability V/Q scan
Nursing interventions after angioplasty would include which of the following? (Select all that apply.) Hydration as a renal protection measure Educating the patient on the necessity of staying supine for 1 to 2 hours after the procedure Monitoring the vascular hemostatic device for signs of bleeding Assessing pedal pulses on the involved limb every 15 minutes for the first 2 hours after the procedure Elevating the head of the bed to 45 degrees
Hydration as a renal protection measure Monitoring the vascular hemostatic device for signs of bleeding Assessing pedal pulses on the involved limb every 15 minutes for the first 2 hours after the procedure
The nurse is caring for a patient in cardiogenic shock. The nurse recognizes that the patient's signs and symptoms are the result of what problem? Inability of the heart to pump blood forward Suppression of the sympathetic nervous system Loss of circulating volume and subsequent decreased venous return Disruption of the conduction system when reentry phenomenon occurs
Inability of the heart to pump blood forward
The nurse is caring for a patient who takes furosemide (Lasix) daily to treat congestive heart failure. The nurse will watch for which electrolyte imbalance that may occur as a result of this therapy? Hyperphosphatemia Hypokalemia Hypernatremia Hypocalcemia
Hypokalemia
A patient has developed septic shock. The nurse knows that the patient is at risk for gastrointestinal dysfunction. What happens to the gastrointestinal tract in the patient with septic shock? Lack of food ingestion leads to intestinal hypomotility Hypoperfusion results in loss of gut barrier function Anorexia leads to loss of gastric enzymes Low cardiac output causes decreased hydrochloric acid secretion
Hypoperfusion results in loss of gut barrier function
Considering anatomic location, which cranial nerve will be affected first by downward pressure onto the infratentorial structures? IX III X VI
III
Which of the following causes of hypoxemia is the result of blood passing through unventilated portions of the lungs? Alveolar hypoventilation Dead space ventilation Drug overdose Intrapulmonary shunting
Intrapulmonary shunting
The nurse is caring for a patient who is hospitalized for pneumonia. Which nursing diagnosis has the highest priority? Knowledge deficit r/t use of nebulizer and inhaled bronchodilators Ineffective airway clearance r/t thick secretions in trachea and bronchi Activity intolerance r/t generalized weakness and hypoxemia Imbalanced nutrition r/t poor appetite and increased metabolic needs
Ineffective airway clearance r/t thick secretions in trachea and bronchi
On admission, a patient presents with a respiratory rate of 28 breaths/min, heart rate of 108 beats/min in sinus tachycardia, and a blood pressure of 140/72 mm Hg. The patient's arterial blood gas (ABG) values on room air are PaO2, 60 mm Hg; pH, 7.32; PaCO2, 45 mm Hg; and , 26 mEq/L. What action should the nurse anticipate for this patient? Administer 1 ampule of sodium bicarbonate. Prepare for emergency intubation. Initiate capnography. Initiate oxygen therapy.
Initiate oxygen therapy.
A patient has been admitted with hypovolemic shock due to traumatic blood loss. Which nursing measure can best facilitate the administration of large volumes of fluid? Encouraging the patient to drink at least 240 mL of fluid each hour Positioning the patient in the Trendelenburg position Inserting a large-diameter peripheral intravenous catheter Administering intravenous fluids under pressure with a pressure bag
Inserting a large-diameter peripheral intravenous catheter
Which of the following interventions would be appropriate for ITP? Administering isotonic saline intravenously Instructing the patient to blow his or her nose carefully Instituting a heparin infusion of 1000 U/hr Removing heparin from hemodynamic pressure monitoring systems
Instructing the patient to blow his or her nose carefully
A patient was admitted following an aspiration event on the medical-surgical floor. The patient is receiving 40% oxygen via a simple facemask. The patient has become increasingly agitated and confused. The patient's oxygen saturation has dropped from 92% to 84%. The nurse notifies the practitioner about the change in the patient's condition. What interventions should the nurse anticipate? Orders for a sedative Intubation and mechanical ventilation Change in antibiotics orders Suction and reposition the patient
Intubation and mechanical ventilation
Which of the following statements best describes assessment of arousal? It measures content of consciousness and is a higher level function. It is an evaluation of the reticular activating system and its connection with the thalamus and the cerebral cortex. It becomes a valid parameter when the patient is able to respond to verbal stimuli, such as squeezing the hands on command. Noxious stimuli are not to be used as an assessment parameter.
It is an evaluation of the reticular activating system and its connection with the thalamus and the cerebral cortex.
A patient is admitted to the critical care unit with a subdural hematoma. The GCS is used to assess his level of consciousness. Which statement is true concerning the GCS? It is a sensitive tool for evaluation of an altered sensorium. It is the most critical assessment parameter to account for possible aphasia. It is considered equivalent to a complete neurologic examination. It provides data about level of consciousness only.
It provides data about level of consciousness only.
A patient has developed septic shock. The nurse knows that the clinical manifestations of ischemic hepatitis show up 1 to 2 days after the insult. Which finding would the nurse expect to note to support this diagnosis? Decreased serum transaminase Jaundice Elevated serum creatinine Decreased bilirubin
Jaundice
Which of the following cholesterol values indicates a heightened risk for the development of CAD? HDL cholesterol level of 30 mg/dL Triglyceride level of 120 mg/dL Total cholesterol level of 170 mg/dL LDL cholesterol level >190 mg/dL
LDL cholesterol level >190 mg/dL
A patient is admitted with a brain and spinal cord injury secondary to a motor vehicle crash. The nurse is monitoring the patient for signs of neurogenic shock. Clinical findings in neurogenic shock are related to which pathophysiologic process? Loss of sympathetic nervous system innervation Focal injury to cerebral hemispheres Injury to the hypothalamus Parasympathetic nervous system stimulation
Loss of sympathetic nervous system innervation
Which serum lipid value is a significant predictor of future acute MI in persons with established coronary artery atherosclerosis? Very-low-density lipoprotein Triglycerides High-density lipoprotein (HDL) Low-density lipoprotein (LDL)
Low-density lipoprotein (LDL)
Which clinical findings are consistent with sepsis diagnostic criteria? Select all that apply. Mean arterial pressure 65 mm Hg Urine output 50 mL/hr Hypoactive bowel sounds Systolic blood pressure 110 mm Hg Temperature of 102° F (38.9° C) Heart rate of 96 beats per minute
Mean arterial pressure 65 mm Hg Temperature of 102° F (38.9° C) Heart rate of 96 beats per minute
A nurse is providing care to a patient on fibrinolytic therapy. Which of the following statements from the patient warrants further assessment and intervention by the nurse? My back is killing me! My arms have bruises my arm is bleeding where my IV site is there's blood in my toothbrush
My back is killing me!
Which of the following choices is an acceptable and recommended method of noxious stimulation? Nail bed pressure Sternal rub Supraorbital pressure Nipple pinch
Nail bed pressure
Which of the following oxygen administration devices can deliver oxygen concentrations of 90%? Partial rebreathing mask Nasal cannula Nonrebreathing mask Simple mask
Nonrebreathing mask
Which of the following oxygen administration devices can deliver oxygen concentrations of 90%? Partial rebreathing mask Nasal cannula Simple mask Nonrebreathing mask
Nonrebreathing mask
Name the rhythm of this strip. Hint: It's more common than you think...
Normal Sinus Rhythm
Which of the following levels would be classified as a low-flow system of oxygen administration? O2 via nasal catheter at a FiO2 range of 60% to 75% O2 via simple mask at 12 L/min. O2 via nasal cannula at 4 L/min O2 via transtracheal catheter at 10 L/min
O2 via nasal cannula at 4 L/min
The nurse is caring for a patient who what just admitted with septic shock. The nurse knows that certain interventions should be completed within 3 hours of time of presentation. Which intervention would be a priority for the nurse to implement upon receipt of a practitioner's order? Administer epinephrine Measure central venous pressure Administer fresh frozen plasma Obtain a serum lactate level
Obtain a serum lactate level
Hospital-acquired anemia is an increasing problem in critically ill patients. Which of the following nursing interventions can be most beneficial in preventing this problem? Obtaining smaller blood samples through the use of pediatric blood tubes and point-of-care testing Decreasing afterload through the use of vasodilators Using blood salvage devices Administering fluids and inotropic agents to optimize blood pressure
Obtaining smaller blood samples through the use of pediatric blood tubes and point-of-care testing
Patients with left-sided pneumonia may benefit from placing them in which of the following positions? On the right side On the left side Supine Reverse Trendelenburg
On the right side
Patients with left-sided pneumonia may benefit from placing them in which of the following positions? Supine On the right side On the left side Reverse Trendelenburg
On the right side
Which of the following auscultatory parameters may exist in the presence of hypovolemia? Vascular bruit Third or fourth heart sound Orthostatic hypotension Hypertension
Orthostatic hypotension
What is the preferred initial treatment of an acute myocardial infarction? Implanted cardioverter defibrillator PCI Fibrinolytic therapy CABG
PCI
A patient is recovering from acute lung failure. Which results would indicate compensated respiratory acidosis? PaO2 90 mm Hg, pH 7.25, PaCO2 55 mm Hg, HCO3- 22 mEq/L PaO2 90 mm Hg, pH 7.40, PaCO2 45 mm Hg, HCO3- 26 mEq/L PaO2 90 mm Hg, pH 7.37, PaCO2 60 mm Hg, HCO3- 39 mEq/L PaO2 90 mm Hg, pH 7.25, PaCO2 40 mm Hg, HCO3- 17 mEq/L
PaO2 90 mm Hg, pH 7.37, PaCO2 60 mm Hg, HCO3- 39 mEq/L
Which of the following diagnostic criteria is indicative of ARDS? Radiologic evidence of bibasilar atelectasis Pulmonary artery wedge pressure greater than 18 mm Hg PaO2/FiO2 ratio less than or equal to 200 mm Hg Increased static and dynamic compliance
PaO2/FiO2 ratio less than or equal to 200 mm Hg
A patient has been admitted with anaphylactic shock due to an unknown allergen. The nurse understands that the decrease in the patient's cardiac output is the result of which mechanism? Increased venous return Decreased myocardial contractility Peripheral vasodilation Increased alveolar ventilation
Peripheral vasodilation
With anaphylactic shock, which mechanism results in a decreased cardiac output? Peripheral vasodilation Decreased alveolar ventilation Fluid retention resulting in congestive heart failure Increased cardiac output
Peripheral vasodilation
Nursing management of the patient with acute lung failure includes which of the following interventions? (Select all that apply.) Pharmaceutical medications to control anxiety Performing percussion and postural drainage every 4 hours Controlling fever Providing adequate rest between treatments Positioning the patient with the least affected side up
Pharmaceutical medications to control anxiety Controlling fever Providing adequate rest between treatments Positioning the patient with the least affected side up
Which of the following assessment findings is most specific for acute onset of pulmonary edema? Pink, frothy sputum Pulmonary crackles Peripheral edema Elevated central venous pressure
Pink, frothy sputum
The nurse is admitting a patient with severe community-acquired pneumonia. Select all interventions that are appropriate for this patient. Place the patient on the monitor and obtain vital signs. Start a peripheral IV. Obtain sputum cultures and laboratory work. Start intravenous (IV) antibiotics.
Place the patient on the monitor and obtain vital signs. Start a peripheral IV. Obtain sputum cultures and laboratory work. Start intravenous (IV) antibiotics.
Nursing management of the patient with acute lung failure includes which of the following interventions? (Select all that apply.) Positioning the patient with the least affected side up Performing percussion and postural drainage every 4 hours Pharmaceutical medications to control anxiety Providing adequate rest between treatments Controlling fever
Positioning the patient with the least affected side up Pharmaceutical medications to control anxiety Providing adequate rest between treatments Controlling fever
Which of the following nursing interventions should be used to optimize oxygenation and ventilation in the patient with acute respiratory failure? Avoid hyperventilating the patient. Position the patient with the good lung up. Provide adequate rest and recovery time between procedures. Suction the patient every hour.
Provide adequate rest and recovery time between procedures.
On admission, a patient presents as follows: pH, 7.38; respiratory rate, 24 breaths/min, regular, pursed-lip breathing; PaO2, 66 mm Hg; heart rate, 112 beats/min, sinus tachycardia; PaCO2, 52 mm Hg; blood pressure, 110/68 mm Hg; HCO3-, 24 mEq/L; and SpO2, 90% on O2 2 L/min nasal cannula. What treatment would the physician or nurse practitioner likely order for this patient? Prepare for emergency intubation. Administer 1 ampule of sodium bicarbonate. Increase O2 to 6 L/min. Repeat ABG testing in 4 hours
Repeat ABG testing in 4 hours
On admission, a patient presents as follows: pH, 7.38; respiratory rate, 24 breaths/min, regular, pursed-lip breathing; PaO2, 66 mm Hg; heart rate, 112 beats/min, sinus tachycardia; PaCO2, 52 mm Hg; blood pressure, 110/68 mm Hg; HCO3-, 24 mEq/L; and SpO2, 90% on O2 2 L/min nasal cannula. What treatment would the physician or nurse practitioner likely order for this patient? Increase O2 to 6 L/min. Prepare for emergency intubation. Repeat ABG testing in 4 hours. Administer 1 ampule of sodium bicarbonate.
Repeat ABG testing in 4 hours.
Which clinical manifestation is associated with the exudative phase of acute respiratory distress syndrome (ARDS)? Cheyne Stoke crackles Increased work of breathing Increasing agitation Respiratory alkalosis
Respiratory alkalosis
A new-onset MI can be recognized by which of the following ECG changes? ST segment elevation Q waves Widened QRS Smaller R waves
ST segment elevation
A new-onset myocardial infarction (MI) can be recognized by what electrocardiogram (ECG) change? ST segment depression Widened QRS ST segment elevation Q wave
ST segment elevation
Which of the following arterial blood gas values would indicate a need for oxygen therapy? HCO3- of 24 mEq PaO2 of 80 mm Hg PaCO2 of 35 mm Hg SaO2 of 87%
SaO2 of 87%
Which of the following arterial blood gas values would indicate a need for oxygen therapy? HCO3- of 24 mEq SaO2 of 87% PaCO2 of 35 mm Hg PaO2 of 80 mm Hg
SaO2 of 87%
Which of the following arterial blood gas values would indicate a need for oxygen therapy? PaO2 of 80 mm Hg SaO2 of 87% PaCO2 of 35 mm Hg HCO3- of 24 mEq
SaO2 of 87%
A 52-year-old patient presents to the emergency department with reports of substernal chest pain. A history is taken; serum creatine kinase (CK) and lactate dehydrogenase (LDH) isoenzymes and serum lipid studies are ordered, as is a 12-lead ECG. Which of the following results is most significant in diagnosing an MI during the first 12 hours of chest pain? Patient history—substernal chest pain Serum enzymes—elevated LDH4 ECG—inverted T waves Serum enzymes—elevated CK-MB
Serum enzymes—elevated CK-MB
Which classification of dysrhythmia is most common with an inferior wall infarction in the first hour after ST segment elevation myocardial infarction (STEMI)? Sinus Bradycardia Multifocal PVCs Atrial Fibrillation Sinus Tachycardia
Sinus Bradycardia
Which medication is not recommended in the treatment of shock-related lactic acidosis? Sodium bicarbonate Glucose Large quantity of crystalloids fluids Vasoconstrictor
Sodium bicarbonate
A patient has been admitted with a neurologic disorder. With which disorder should the nurse be the most vigilant for the development of neurogenic shock? Brain tumor Spinal cord injury Guillain-Barré syndrome Ischemic stroke
Spinal cord injury
The nurse is caring for a patient with these vital signs: blood pressure 220/110, pulse 108, respiratory rate 24, temperature 103° F, and oxygen saturation of 94% on oxygen 2L nasal cannula. The patient is responsive and denies chest pain. The physician has ordered a work-up for coronary artery disease (CAD). These findings are suggestive of which diagnosis? silent ischemia prehypertension Stage 2 hypertension Stage 1 hypertension
Stage 2 hypertension
Which of the following cardiac enzymes is a highly specific biomarker for myocardial damage? CK-MB LDH Troponin T Troponin I
Troponin I
Which of the following cardiac enzymes is a highly specific biomarker for myocardial damage? Troponin T CK-MB Troponin I LDH
Troponin I
Which of the following patients would be a candidate for fibrinolytic therapy? (Select all that apply.) The patient has a history of unstable angina. He has been experiencing chest pain with sudden onset. The patient presents to the emergency department with chest pain of 30 minutes' duration. She has a history of cerebrovascular accident 1 month ago. The patient's chest pain started 8 hours ago. She has a diagnosis of NSTEMI. The patient's chest pain started 1 hour ago, and his ECG shows ST elevation. The patient's chest pain started 3 hours ago, and her ECG shows a new left bundle branch block.
The patient's chest pain started 1 hour ago, and his ECG shows ST elevation. The patient's chest pain started 3 hours ago, and her ECG shows a new left bundle branch block.
The nurse is caring for a patient with sepsis due to necrotic tissue. The nurse knows that necrotic tissue can stimulate the inflammatory immune response. Which biochemical mediator is secreted in response to endotoxin or tissue injury? Platelet-activating factor Tumor necrosis factor Interleukin Arachidonic acid metabolite
Tumor necrosis factor
The patient's arterial blood gas (ABG) values on room air are PaO2, 40 mm Hg; pH, 7.10; PaCO2, 44 mm Hg; and , 16 mEq/L. What is the interpretation of the patient's ABG? Uncompensated metabolic acidosis Compensated metabolic alkalosis Compensated respiratory alkalosis Uncompensated respiratory acidosis
Uncompensated metabolic acidosis
A patient is admitted with signs and symptoms of a pulmonary embolus (PE). The diagnostic test most conclusive to determine this diagnosis is a(n) bronchoscopy. ABG. pulmonary function test. V/Q scan.
V/Q scan.
Identify the rhythm. Ventricular fibrillation Supraventricular tachycardia Ventricular tachycardia Torsades de pointes
Ventricular fibrillation
A patient in cardiogenic shock is being treated in the critical care unit. Which findings would the nurse expect to note in the patient to support this diagnosis? (Select all that apply.) Weak, thready pulse Decreased pulmonary artery occlusion pressure Increased right atrial pressure Heart rate greater than 100 beats/min Warm, dry skin
Weak, thready pulse Increased right atrial pressure Heart rate greater than 100 beats/min
Signs of hypovolemia in the trauma patient include distended neck veins. bounding radial and pedal pulses. a widening pulse pressure. a decreased level of consciousness.
a decreased level of consciousness.
A patient is admitted with acute respiratory failure attributable to pneumonia. Smoking history reveals that the patient smoked two packs of cigarettes a day for 25 years, stopping 10 years ago. ABG values on the current ventilator settings are pH, 7.37; PaCO2, 50 mm Hg; and HCO3-, 27 mEq/L. Chest radiograph reveals a large right pleural effusion. Intrapulmonary shunting value of 35% indicates normal gas exchange of venous blood. metabolic alkalosis. an abnormal finding indicative of a shunt-producing disorder. a serious and potentially life-threatening condition.
a serious and potentially life-threatening condition.
The patients at highest risk for neurogenic shock are those who have had Guillain-Barré syndrome. a spinal cord injury. a craniotomy. a stroke.
a spinal cord injury.
A vasoconstrictor used to treat shock is Dobutrex. adenosine. adrenaline. Nipride.
adrenaline.
Immunoglobulin E (IgE)-mediated anaphylactic shock occurs as a result of an antigen entering on a repeat exposure, triggering a secondary immune response. laryngeal edema. direct activation of mast cells. the systemic inflammatory response.
an antigen entering on a repeat exposure, triggering a secondary immune response.
Data concerning coronary artery disease (CAD) and specific risk factors have demonstrated an association between development of specific risk factors and CAD. no decisive correlation between risk factors and CAD. a low correlation of modifiable risk factors to CAD. the onset of CAD in middle age.
an association between development of specific risk factors and CAD.
The main cause of cardiogenic shock is an inability of the heart to pump blood forward. hypovolemia, resulting in decreased stroke volume. an inability of the heart to respond to inotropic agents. disruption of the conduction system when re-entry phenomenon occurs.
an inability of the heart to pump blood forward.
The nursing management plan for a patient with angina would include which intervention? immediate administration of antiplatelet therapy teaching the patient how to perform the valsalva maneuver administration of prophylactic lidocaine for ventricular ectopy assessment and documentation of chest pain episodes
assessment and documentation of chest pain episodes
Nursing management of the patient with angina is directed toward assessment and documentation of chest pain episodes. immediate administration of antiplatelet therapy. assessment of history of previous anginal episodes. administration of prophylactic lidocaine for ventricular ectopy.
assessment and documentation of chest pain episodes.
Nursing management of the patient with angina is directed toward assessment and documentation of chest pain episodes. administration of prophylactic lidocaine for ventricular ectopy. immediate administration of antiplatelet therapy. assessment of history of previous anginal episodes.
assessment and documentation of chest pain episodes.
Angiotensin-converting enzyme (ACE) inhibitors such as captopril (Capoten) and enalapril (Vasotec) decrease peripheral vascular resistance and decrease blood pressure by the mechanism of peripheral vasoconstriction and central vasodilation. blocking the conversion of angiotensin I to angiotensin II. direct arterial vasodilation. increased fluid excretion at the loop of Henle in the renal tubules.
blocking the conversion of angiotensin I to angiotensin II.
The clinical manifestations of the Cushing reflex are bradycardia, aphasia, and visual field disturbances. tachycardia, systolic hypotension, and tachypnea. headache, nuchal rigidity, and hyperthermia. bradycardia, systolic hypertension, and widening pulse pressure.
bradycardia, systolic hypertension, and widening pulse pressure.
The clinical manifestations of the Cushing reflex are headache, nuchal rigidity, and hyperthermia. bradycardia, systolic hypertension, and widening pulse pressure. tachycardia, systolic hypotension, and tachypnea. bradycardia, aphasia, and visual field disturbances.
bradycardia, systolic hypertension, and widening pulse pressure.
Medical management of a patient with status asthmaticus that supports oxygenation and ventilation include (Select all that apply.) bronchodilators. corticosteroids. oxygen therapy. antibiotics. intubation and mechanical ventilation.
bronchodilators. corticosteroids. oxygen therapy. intubation and mechanical ventilation.
Use of oxygen therapy in the patient who is hypercapnic may result in oxygen toxicity. pneumothorax. absorption atelectasis. carbon dioxide retention.
carbon dioxide retention.
Use of oxygen therapy in the patient who is hypercapnic may result in pneumothorax. carbon dioxide retention. oxygen toxicity. absorption atelectasis.
carbon dioxide retention.
A client is admitted to the emergency department with chest pain that is consistent with myocardial infarction based on elevated troponin levels. Heart sounds are normal. The nurse should alert the primary health care provider because the vital sign changes and client assessment are most consistent with which complication? Refer to chart: Dissecting thoracic aortic aneurysm pulmonary embolism cardiac tamponade cardiogenic shock
cardiogenic shock
A score of 6 on the Glasgow Coma Scale (GCS) indicates paraplegia. a vegetative state. coma. obtundation.
coma
On admission, a patient presents as follows: pH, 7.38; respiratory rate, 24 breaths/min, regular, pursed-lip breathing; PaO2, 66 mm Hg; heart rate, 112 beats/min, sinus tachycardia; PaCO2, 52 mm Hg; blood pressure, 110/68 mm Hg; HCO3-, 24 mEq/L; and SpO2, 90% on O2 2 L/min nasal cannula. These gases show compensated respiratory alkalosis. compensated metabolic acidosis. uncompensated metabolic alkalosis. uncompensated respiratory acidosis.
compensated metabolic acidosis.
An essential aspect of teaching that may prevent recurrence of heart failure is taking nitroglycerin if chest pain occurs. assessment of an apical pulse. notifying the physician if a 2-lb weight gain occurs in 24 hours. compliance with diuretic therapy.
compliance with diuretic therapy.
The initial history for the neurologically impaired patient needs to be comprehensive, including events preceding hospitalization. information that only the patient can provide. limited to the chief complaint. directed to level of consciousness and pupillary reaction.
comprehensive, including events preceding hospitalization.
Medical management of a patient with status asthmaticus that supports oxygenation and ventilation include (Select all that apply.) corticosteroids. antibiotics. bronchodilators. intubation and mechanical ventilation. oxygen therapy.
corticosteroids. bronchodilators. intubation and mechanical ventilation. oxygen therapy.
A patient is admitted to the critical care unit with a subdural hematoma. The GCS is used to assess his level of consciousness. In assessing the patient's best motor response, the movement that receives the lowest score is decerebrate posturing. localizing pain. withdrawing from pain. decorticate posturing.
decerebrate posturing.
What is the physiologic effect of left ventricular afterload reduction? increased filling pressures decreased left atrial tension decreased CO decreased SVR
decreased SVR
A patient has been admitted to the critical care unit with the diagnosis of acute respiratory distress syndrome (ARDS). Arterial blood gasses (ABGs) revealed an elevated pH and decreased PaCO2. The patient is becoming fatigued, and the health care provider orders a repeat ABG. The nurse anticipates the following results decreased pH and elevated PaCO2 decreased pH and decreased PaCO2 elevated pH and elevated PaCO2 elevated pH and decreased PaCO2
decreased pH and elevated PaCO2
A patient has been admitted to the critical care unit with the diagnosis of acute respiratory distress syndrome (ARDS). Arterial blood gasses (ABGs) revealed an elevated pH and decreased PaCO2. The patient is becoming fatigued, and the health care provider orders a repeat ABG. The nurse anticipates the following results elevated pH and decreased PaCO2 decreased pH and decreased PaCO2 elevated pH and elevated PaCO2 decreased pH and elevated PaCO2
decreased pH and elevated PaCO2
The physiologic effect of left ventricular afterload reduction is decreased left atrial tension. decreased systemic vascular resistance. increased filling pressures. decreased cardiac output.
decreased systemic vascular resistance.
A patient was admitted 3 days ago with an acute myocardial infarction (MI). The patient complains of fatigue, not sleeping the past two nights, and change in appetite. Based on these findings the nurse suspects the patient may be experiencing which problem? depression anxiety angina endocarditis
depression
The primary mechanism in the development of idiopathic thrombocytopenic purpura (ITP) is destruction of malignant cells through radiation or chemotherapy. destruction of platelets by lymphocytic antibodies. formation of heparin antibodies. damage to the endothelium.
destruction of platelets by lymphocytic antibodies.
Clinical manifestations of right-sided heart failure include elevated central venous pressure and sacral edema. hypertension and chest pain. pulmonary congestion and jugular venous distention. liver tenderness and pulmonary edema.
elevated central venous pressure and sacral edema.
Clinical manifestations of right-sided heart failure include pulmonary congestion and jugular venous distention. hypertension and chest pain. liver tenderness and pulmonary edema. elevated central venous pressure and sacral edema.
elevated central venous pressure and sacral edema.
A patient has been on the medical floor for 1 week after a vaginal hysterectomy. A urinary catheter was inserted. Complete blood cell count results have revealed escalating white blood cell counts. The patient is transferred to the critical care unit when her condition deteriorates. Septic shock is diagnosed. The medical management of the patient's condition is aimed toward discontinuing invasive monitoring as a possible cause of sepsis. administering vasodilator substances to increase blood flow to vital organs. finding and eradicating the cause of infection. limiting fluids to minimize the possibility of congestive heart failure.
finding and eradicating the cause of infection.
Testing of extraocular eye movements assesses function of the three cranial nerves of the eye. the ability of the eyes to accommodate to a closer moving object. pupillary response to light. the oculocephalic reflex.
function of the three cranial nerves of the eye.
Shock syndrome can best be described as a generalized systemic response to inadequate tissue perfusion. physiologic state resulting in hypotension and tachycardia. degenerative condition leading to death. condition occurring with hypovolemia that results in irreversible hypotension.
generalized systemic response to inadequate tissue perfusion.
Medication used to increase the level of fetal hemoglobin in the RBCs and reduce the concentration of sickle hemoglobin is known as transfusion therapy. oxygen. hydroxyurea. Kayexalate.
hydroxyurea.
The patient is 12 hours postoperative for a CABG. The patient's vital signs include: T 103° F, HR 112, RR 22, BP 134/78 mm Hg, and O2 sat 94% on 3L/NC. The nurse suspects that the patient has developed delirium caused by the elevated temperature. cardiac tamponade and notifies the physician immediately. infection, which is common postoperatively, and monitors the patient's condition. infection and notifies the physician immediately.
infection and notifies the physician immediately.
The nursing measure that can best enhance large volumes of fluid replacement in hypovolemic shock is forcing at least 240 mL of fluid each hour. insertion of a large-diameter peripheral intravenous catheter. administering intravenous lines under pressure. positioning the patient in the Trendelenburg position.
insertion of a large-diameter peripheral intravenous catheter.
The GCS is an invalid measure for the patient with intoxication. Parkinson disease. mental retardation. hemiplegia.
intoxication.
An oval pupil is indicative of intracranial hypertension. metabolic coma. cortical dysfunction. hydrocephalus.
intracranial hypertension.
The oculovestibular reflex, or cold caloric test, is a routine test of the nursing neurologic examination. should not be performed on an unconscious patient because of the risk of aspiration. is one of the final clinical assessments of brainstem function. has an abnormal response of rapid nystagmus-like deviation to the side of the body that is tested.
is one of the final clinical assessments of brainstem function.
The oculovestibular reflex, or cold caloric test, is a routine test of the nursing neurologic examination. has an abnormal response of rapid nystagmus-like deviation to the side of the body that is tested. should not be performed on an unconscious patient because of the risk of aspiration. is one of the final clinical assessments of brainstem function.
is one of the final clinical assessments of brainstem function.
Contractility of the left side of the heart is measured by left atrial pressure. left ventricular stroke work index. pulmonary artery wedge pressure. systemic vascular resistance.
left ventricular stroke work index.
The most important aspect of the neurologic examination is physical examination. medical history. pupillary responses. level of consciousness.
level of consciousness.
While starting an intravenous line on the right hand of an unconscious patient, the patient reaches over with his left hand and tries to remove the noxious stimuli. This response is called withdrawal. decorticate posturing. localization. decerebrate posturing.
localization.
A patient was admitted to the critical care unit with gram-negative sepsis 5 days ago. Today there is continual oozing from his intravenous sites, and ecchymosis of the skin is noted beneath his automatic blood pressure cuff. On his laboratory work, his platelets are normal, and his international normalized ratio is elevated. The primary treatment goal for this patient is to treat life-threatening metabolic disturbances. begin hypothermic therapy to prevent cerebral hemorrhage. suppress antibody response that is destroying platelets. maintain adequate organ perfusion.
maintain adequate organ perfusion.
Indications for the use of EEG include (Select all that apply.) all head injuries. metabolic encephalopathy. confirmation of brain death. cerebral infarct. altered consciousness.
metabolic encephalopathy. confirmation of brain death. cerebral infarct. altered consciousness.
The two most common causes of hospital-acquired pneumonia in the United States are Staphylococcus aureus and Pseudomonas aeruginosa methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa Klebsiella spp. and Enterobacter spp. Escherichia coli and Haemophilus influenzae
methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa
The most accurate and reliable control of FiO2 can be achieved through the use of a(n) air-entrainment mask. simple mask. nonrebreathing circuit (closed). nonrebreathing mask.
nonrebreathing circuit (closed).
The most accurate and reliable control of FiO2 can be achieved through the use of a(n) simple mask. nonrebreathing mask. nonrebreathing circuit (closed). air-entrainment mask.
nonrebreathing circuit (closed).
The patient's ICP reading has gradually climbed from 15 to 23 mm Hg. The nurse's primary action is to: notify the physician. place the patient in a high Fowler position to decrease the pressure. drain off 7 mm of CSF from the catheter. check level of consciousness.
notify the physician.
Which of the following ABG values represents uncompensated metabolic acidosis? pH, 7.52; PaCO2, 38 mm Hg; HCO3-, 29 mEq/L pH, 7.22; PaCO2, 42 mm Hg; HCO3-, 18 mEq/L pH, 7.36; PaCO2, 33 mm Hg; HCO3-, 18 mEq/L pH, 7.29; PaCO2, 57 mm Hg; HCO3-, 22 mEq/L
pH, 7.22; PaCO2, 42 mm Hg; HCO3-, 18 mEq/L
Which ABG values reflect compensation? pH, 7.48; PaCO2, 30 mm Hg; HCO3, 22 mEq/L pH, 7.30; PaCO2, 32 mm Hg; HCO3 -18 mEq/L pH, 7.26; PaCO2, 55 mm Hg; HCO3 24 mEq/L pH, 7.38; PaCO2, 58 mm Hg; HCO3, 30 mEq/L
pH, 7.38; PaCO2, 58 mm Hg; HCO3, 30 mEq/L
Which of the following ABG values reflects compensation? pH, 7.38; PaCO2, 58 mm Hg; HCO3-, 30 mEq/L pH, 7.30; PaCO2, 32 mm Hg; HCO3-, 18 mEq/L pH, 7.26; PaCO2, 55 mm Hg; HCO3-, 24 mEq/L pH, 7.48; PaCO2, 30 mm Hg; HCO3-, 22 mEq/L
pH, 7.38; PaCO2, 58 mm Hg; HCO3-, 30 mEq/L
With an intact oculocephalic reflex, the patient's eyes move in the same direction the head is turned. patient's eyes remain midline. doll's eye reflex is absent. patient's eyes move in the opposite direction to the movement of the patient's head.
patient's eyes move in the opposite direction to the movement of the patient's head.
Laboratory values for DIC show abnormalities in liver function tests. blood glucose levels. platelet counts. tests for renal function.
platelet counts.
Aspiration can best be prevented by assessing the patient's level of consciousness. positioning a patient in a semirecumbent position. observing the amount given in the tube feeding. encouraging the patient to cough and to breathe deeply.
positioning a patient in a semirecumbent position.
The major hemodynamic consequence of a massive pulmonary embolus is increased systemic vascular resistance leading to left heart failure. pulmonary hypertension leading to right heart failure. embolism to the internal carotids leading to a stroke. portal vein blockage leading to ascites.
pulmonary hypertension leading to right heart failure.
The major hemodynamic consequence of a massive pulmonary embolus is pulmonary hypertension leading to right heart failure. increased systemic vascular resistance leading to left heart failure. embolism to the internal carotids leading to a stroke. portal vein blockage leading to ascites.
pulmonary hypertension leading to right heart failure.
A patient with ventricular fibrillation (VF) is pulseless. diaphoretic. hypertensive. bradypneic.
pulseless
What major clinical finding present in a patient with ventricular fibrillation (VF) diaphoresis pulseless hypertension Bradycardia
pulseless
A patient with ventricular fibrillation (VF) is diaphoretic. hypertensive. bradypneic. pulseless.
pulseless.
Hypovolemic shock that results from an internal shifting of fluid from the intravascular space to the extravascular space is known as distributive hypovolemia. compensatory hypovolemia. relative hypovolemia. absolute hypovolemi
relative hypovolemia.
when a paramedic give a patient a brown paper bag, it's because they have what type of acid base imbalance? respiratory alkalosis metabolic acidosis respiratory acidosis metabolic bicarbonate
respiratory alkalosis
The most common cause of disseminated intravascular coagulation (DIC) is sepsis caused by gram-negative organisms. burns. sickle cell anemia. sepsis caused by gram-positive organisms.
sepsis caused by gram-negative organisms.
A patient is admitted into the critical care unit with symptoms of a low-grade fever, joint pain, tachycardia, hepatomegaly, photophobia, and an inability to follow commands. The patient is becoming more agitated and complaining of pain. The nurse suspects that the patient has DIC. heparin-induced thrombocytopenia. sickle cell anemia. ITP.
sickle cell anemia.
A patient was admitted in acute lung failure. The patient is receiving 40% oxygen via a simple facemask. The morning chest radiography study reveals right lower lobe pneumonia. Which test would the nurse expect the practitioner to order to identify the infectious pathogen? wound culture of surgical site CBC with differential urine specimen sputum gram stain and culture
sputum gram stain and culture
Which statement regarding the difference between stable and unstable angina is accurate? stable angina is not precipitated by activities stable angina responds predictably well to nitrates stable angina is a result of coronary artery relaxation
stable angina responds predictably well to nitrates
The predominant form of percutaneous coronary intervention (PCI) is directional coronary atherectomy (DCA). stents. Rotablator. balloon angioplasty (PTCA).
stents.
A critically injured patient can be aroused only by vigorous and continuous external stimuli. The patient's level of consciousness is considered obtunded. comatose. stuporous. lethargic.
stuporous.
A patient is admitted for palliative care for end-stage heart failure. The nurse's primary goal is to increase activity tolerance. to increase cardiac output related to alteration of contractility. symptom management and relief of pain. to reverse heart failure with the use of diuretics.
symptom management and relief of pain.
The most common presenting signs and symptoms associated with PEs are tachycardia and tachypnea. right ventricular failure and fever apprehension and dyspnea. hemoptysis and evidence of deep vein thromboses.
tachycardia and tachypnea.
Before performing the doll's eye or oculocephalic reflex, the nurse must verify the depth and rate of respiration. a physician's order to perform the maneuver. the absence of cervical injury. the patient's ability to follow a verbal command.
the absence of cervical injury.
Before performing the doll's eye or oculocephalic reflex, the nurse must verify the depth and rate of respiration. the absence of cervical injury. a physician's order to perform the maneuver. the patient's ability to follow a verbal command.
the absence of cervical injury.
The rationale for giving the patient additional fluids after a cardiac catheterization is that fluids help keep the femoral vein from clotting at the puncture site. the radiopaque contrast acts as an osmotic diuretic. fluids increase cardiac output. the patient had a nothing-by-mouth order before the procedure.
the radiopaque contrast acts as an osmotic diuretic.
The most common site for sepsis and septic shock is the genitourinary system. the gastrointestinal system. the respiratory system. the circulatory system.
the respiratory system.
Which statement about coronary artery disease (CAD) is accurate? there is an association between development of specific risk factors and CAD. The lower the C-reactive protein, the higher the risk for a coronary event The onset of CAD occurs sooner in middle age women than it does on men the same age There is a low correlation between modifiable risk factors and CAD
there is an association between development of specific risk factors and CAD.
the nurse is teaching a patient with COPD purse lip breathing. The underlying purpose for this type of breathing is: to promote deep relaxation to enhance inspiratory capacity to strengthen oral musculature to prevent air trapping
to prevent air trapping
A patient presents with the following values: pH, 7.20; pO2, 106 mm Hg; pCO2, 35 mm Hg; and HCO3-, 11 mEq/L. These values are most consistent with uncompensated metabolic alkalosis. uncompensated respiratory acidosis. uncompensated respiratory alkalosis. uncompensated metabolic acidosis.
uncompensated metabolic acidosis.
A patient's assessment data present as follows: pH, 7.10; PaCO2, 60 mm Hg; PaO2, 40 mm Hg; HCO3-, 24 mEq/L; RR, 34 breaths/min; HR, 128 beats/min; and BP, 180/92 mm Hg. This condition is best described as uncompensated respiratory acidosis. uncompensated metabolic acidosis. compensated metabolic acidosis.
uncompensated respiratory acidosis.
A patient with diagnosis of CAD with chest pain is admitted into the critical care unit. The patient is suddenly awakened with severe chest pain. Three nitroglycerin sublingual tablets are administered 5 minutes apart without relief. A 12-lead ECG reveals nonspecific ST segment elevation. This patient probably has silent ischemia. Prinzmetal angina. stable angina. unstable angina.
unstable angina.
Supplemental oxygen administration is usually effective in treating hypoxemia related to physiologic shunting. ventilation/perfusion mismatching. hypercapnia with a PaCO2 of 35 mm Hg. dead space ventilation.
ventilation/perfusion mismatching.
Supplemental oxygen administration is usually effective in treating hypoxemia related to ventilation/perfusion mismatching. hypercapnia with a PaCO2 of 35 mm Hg. dead space ventilation. physiologic shunting.
ventilation/perfusion mismatching.
Symptoms of late stages of intracranial hypertension include decreased intracranial pressure. increased perfusion pressure across the blood-brain barrier. decreased perfusion of cerebral tissue. widening pulse pressure values.
widening pulse pressure values.
Symptoms of late stages of intracranial hypertension include decreased intracranial pressure. widening pulse pressure values. increased perfusion pressure across the blood-brain barrier. decreased perfusion of cerebral tissue.
widening pulse pressure values.
Why do women have higher mortality rates from acute myocardial infarction (MI) than men? women have smaller hearts than men women have more risk factors for CAD than men. women wait longer to seek medical care
women wait longer to seek medical care