Critical Care Exam 2

The nurse is caring for a patient admitted with hypovolemic shock. The nurse palpates thready brachial pulses but is unable to auscultate a blood pressure. What is the best nursing action? 1. Assess the blood pressure palpation 2. Obtain an electronic blood pressure monitor 3. Record the blood pressure as "not assessable" 4. Estimate the systolic pressure as 60 mmHg

1. Assess the blood pressure palpation

The nurse providing postoperative care to a patient who underwent a transsphenoidal hypophysectomy for a benign pituitary tumor administers replacement hydrocortisone, thyroid hormone, and vasopressin. The nurse evaluates that the vasopressin replacement is effective when noting what assessment finding? 1. 2 liters of urine are produced in a 24-hour period. 2. The patient a core body temperature is 98.2° F (36.8° C). 3. Blood glucose is 110 mg/dL. 4. Urine specific gravity is decreasing.

1. 2 liters of urine are produced in a 24-hour period.

The nurse has been assigned the following patients. Which patients require assessment of blood glucose control as a nursing priority? (Select all that apply.) 1. 29-year-old who is undergoing evaluation for pheochromocytoma 2. 62-year-old morbidly obese female who underwent a hysterectomy for ovarian cancer 3. 72-year-old who is receiving intravenous (IV) steroids for an exacerbation of chronic obstructive pulmonary disease (COPD) 4. 18-year-old who has undergone surgical correction of a fractured femur 5. 43-year-old with acute pancreatitis who is receiving total parenteral nutrition (TPN)

1. 29-year-old who is undergoing evaluation for pheochromocytoma 2. 62-year-old morbidly obese female who underwent a hysterectomy for ovarian cancer 3. 72-year-old who is receiving intravenous (IV) steroids for an exacerbation of chronic 5. 43-year-old with acute pancreatitis who is receiving total parenteral nutrition (TPN)

Which patient being cared for in the emergency department is most at risk for developing hypovolemic shock? 1. A patient with a 2-day history of nausea, vomiting, and diarrhea 2. A patient with slight rectal bleeding from inflamed hemorrhoids 3. A patient admitted with abdominal pain and an elevated WBC count 4. A patient with a temperature of 102F and a general dermal rash

1. A patient with a 2-day history of N/V/D

A 20-year-old with a history of type 1diabetes and an eating disorder is found unconscious. In the emergency department, the following lab values are obtained:Glucose648 mg/dLpH6.88PaCO220 mm HgPaO295 mm HgHCO3- undetectableAnion gap>31Na+127 mEq/LK+ 3.5 mEq/LCreatinine1.8 mg/dLAfter the patient's airway and ventilation have been established, what is the next priority intervention for this patient? 1. Administration of a 1-L normal saline fluid bolus. 2. Administration of 0.1 unit of regular insulin IV push followed by an insulin infusion. 3. IV push administration of 1 amp of sodium bicarbonate. 4. Administration of 20 mEq KCl in 100 mL.

1. Administration of a 1-L normal saline fluid bolus.

The nurse is caring for a patient in septic shock. The nurse assesses the patient to have a blood pressure of 105/60 mm Hg, heart rate 110 beats/min, respiratory rate 32 breaths/min, oxygen saturation (SpO2) 95% on 45% supplemental oxygen via Venturi mask, and a temperature of 102 F. The physician orders stat administration of an antibiotic. Which additional physician order should the nurse complete first? 1. Blood cultures 2. Serum electrolytes 3. Foley insertion 4. Chest x-ray

1. Blood cultures

A college student was admitted to the emergency department after being found unconscious by a roommate. The roommate informs emergency medical personnel that the student has diabetes and has been experiencing flulike symptoms, including vomiting, since yesterday. The patient had been up all night studying for exams. The patient used the last diabetes testing supplies 3 days ago and has not had time to go to the pharmacy to refill prescription supplies. Based upon the history, which laboratory findings would be anticipated in this client? (Select all that apply.) 1. Blood glucose 524 mg/dL 2. HCO3- 10 mEq/L 3. pH 7.23 4. Blood glucose 43 mg/dL 5. PaCO2 37 mm Hg

1. Blood glucose 524 mg/dL 2. HCO3- 10 mEq/L 3. pH 7.23

A patient diagnosed with type 1 diabetes 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 what possible complication? 1. Diabetic ketoacidosis 2. Hyperosmolar, hyperglycemic state 3. Hypoglycemia 4. Adrenal insufficiency

1. Diabetic ketoacidosis

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? 1. Dobutamine 2. Sodium nitroprusside 3. Phenylephrine 4. Furosemide

1. Dobutamine

Fifteen minutes after beginning a transfusion of O negative blood to a patient in shock, the nurse assesses a drop in the patients blood pressure to 60/40 mm Hg, heart rate 135 beats/min, respirations 40 breaths/min, and a temperature of 102 F. The nurse notes the new onset of hematuria in the patients Foley catheter. What are the priority nursing actions? (Select all that apply.) 1. Document the patient's response 2. Stop the infusion 3. Notify the blood bank 4. Administer acetaminophen 5. Notify the physician 6. Increase the rate of transfusion

1. Document the patient's response 2. Stop the infusion 3. Notify the blood bank 5. Notify the physician

What psychosocial factors may potentially contribute to the development of diabetic ketoacidosis? (Select all that apply.) 1. Eating disorder 2. Lack of financial resources 3. Altered sleep/rest patterns 4. Exposure to influenza 5. High levels of stress

1. Eating disorder 2. Lack of financial resources 3. Altered sleep/rest patterns 5. High levels of stress

An individual diagnosed with type 2 diabetes takes glipizide to control blood glucose has begun a formal exercise program at a local gym. While exercising on the treadmill, the individual becomes pale, diaphoretic, and shaky and reports having a headache and feels like passing out. What is the individual's priority action? 1. Eating something with 15 g of simple carbohydrates 2. Going to the first aid station to have glucose checked 3. Taking another dose of the oral agent 4. Drinking additional water to prevent dehydration

1. Eating something with 15 g of simple carbohydrates

A patient is admitted to the cardiac care unit with an acute anterior myocardial infarction. The nurse assesses the patient to be diaphoretic and tachypneic, with bilateral crackles throughout both lung fields. Following insertion of a pulmonary artery catheter by the physician, which hemodynamic values is the nurse most likely to assess? 1. High pulmonary artery diastolic pressure and low CO 2. Low pulmonary artery occlusive pressure and low CO 3. Low systemic vascular resistance and high CO 4. Normal CO and low systemic vascular resistance

1. High pulmonary artery diastolic pressure and low CO

What differences would you expect to see in patients experiencing hyperosmolar hyperglycemic syndrome rather than diabetic ketoacidosis? 1. Higher serum glucose, higher osmolality, and no ketosis 2. Lower serum glucose, lower osmolality, and greater ketosis 3. Higher serum glucose, higher osmolality, and greater ketosis 4. Lower serum glucose, lower osmolality, and milder ketosis

1. Higher serum glucose, higher osmolality, and no ketosis

A patient with long-standing type 1 diabetes presents to the emergency department with a loss of consciousness and seizure activity. The patient has a history of renal insufficiency, gastroparesis, and peripheral diabetic neuropathy. Emergency personnel reported a blood glucose of 32 mg/dL on scene. When providing discharge teaching for this patient and family, the nurse instructs on the need to do take what action? (Select all that apply.) 1. Increase home blood glucose monitoring and report patterns of hypoglycemia to the provider. 2. Perform blood glucose monitoring before exercising and driving. 3. Administer glucagon 1 mg intramuscularly any time the blood glucose is less than 70 mg/dL. 4. Administer 15 grams of carbohydrate orally for severe episodes of hypoglycemia. 5. Discontinue the insulin pump by removing the infusion set catheter

1. Increase home blood glucose monitoring and report patterns of hypoglycemia to the provider. 2. Perform blood glucose monitoring before exercising and driving. 4. Administer 15 grams of carbohydrate orally for severe episodes of hypoglycemia.

Which of the following are appropriate nursing interventions for the patient in myxedema coma? (Select all that apply.) 1. Initiate passive re-warming interventions. 2. Administer levothyroxine as ordered. 3. Monitor urine osmolality. 4. Encourage the intake of foods high in sodium. 5. Monitor airway and respiratory effort.

1. Initiate passive re-warming interventions. 2. Administer levothyroxine as ordered. 5. Monitor airway and respiratory effort

The emergency department nurse admits a patient following a motor vehicle collision. Vital signs include blood pressure 70/50 mm Hg, heart rate 140 beats/min, respiratory rate 36 breaths/min, temperature 101 F and oxygen saturation (SpO2) 95% on 3 L of oxygen per nasal cannula. Laboratory results include hemoglobin 6.0 g/dL, hematocrit 20%, and potassium 4.0 mEq/L. Based on this assessment, what is most important for the nurse to include in the patients plan of care? 1. Insertion of an 18-gauge peripheral intravenous line 2. Implementation of universal precautions 3. Implementation of fall precautions 4. Application of cushioned heel protectors

1. Insertion of an 18-gauge peripheral intravenous line

The nurse is caring for a patient admitted with severe sepsis. Vital signs assessed by the nurse include blood pressure 80/50 mm Hg, heart rate 120 beats/min, respirations 28 breaths/min, oral temperature of 102 F, and a right atrial pressure (RAP) of 1 mm Hg. Assuming physician orders, which intervention should the nurse carry out first? 1. Isotonic fluid challenge 2. IV antibiotic administration 3. Acetaminophen suppository 4. Blood cultures from two sites

1. Isotonic fluid challenge

A patient is admitted after collapsing at the end of a summer marathon. She 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? 1. Lactated Ringer's bolus 2. Packed red blood cells 3. Hypotonic saline solution 4. Human albumin infusion

1. Lactacted Ringer's bolus

The nurse has been administering 0.9% normal saline intravenous fluids as part of early goal-directed therapy protocols 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? 1. Right atrial pressure and urine output 2. Blood pressure and oral temperature 3. Oral temperature and capillary refill 4. Breath sounds and capillary refill

1. Right atrial pressure and urine output

Which of the following laboratory values would be found in a patient with syndrome of inappropriate secretion of antidiuretic hormone? 1. Serum sodium 115 mEq/L 2. Serum sodium 152 mEq/L 3. Serum potassium 5.8 mEq/L 4. Fasting blood glucose 156 mg/dL

1. Serum sodium 115 mEq/L

The nurse is caring for an 18-year-old 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 patients skin is warm and flushed. What is the best interpretation of these findings by the nurse? 1. The patient is developing neurogenic shock 2. The patient is experiencing an allergic reaction 3. The patient most likely has an elevated temperature 4. The vital signs are normal for this patient

1. The patient is developing neurogenic shock

The nurse is caring for a 70-kg patient in hypovolemic shock. Upon initial assessment, the nurse notes a blood pressure of 90/50 mm Hg, heart rate 125 beats/min, respirations 32 breaths/min, central venous pressure (CVP/RAP) of 3 mm Hg, and urine output of 5 mL during the past hour. Following physician rounds, the nurse reviews the orders and questions which order? 1. Titrate dopamine intravenously for blood pressure <90 mmHg systolic 2. Administer acetaminophen 650-mg suppository prn every 6h for pain 3. Administer furosemide 20mg IV every 4h for a CVP >20 mmHg 4. Complete neurological asessment every 4h for the next 24h

1. Titrate dopamine intravenously for blood pressure <90 mmHg systolic

Which of the following statements is true about the medical management of diabetic ketoacidosis? 1. Volume replacement and insulin infusion often correct the acidosis. 2. Sodium bicarbonate is a first-line medication for treatment. 3. Serum lactate levels are used to guide insulin administration. 4. The degree of acidosis is assessed through continuous pulse oximetry

1. Volume replacement and insulin infusion often correct the acidosis.

The nurse has just completed administration of a 1000-L bolus of 0.9% normal saline. The nurse assesses the patient to be slightly confused, with a mean arterial blood pressure (MAP) of 50 mm Hg, a heart rate of 110 beats/min, urine output of 10 mL for the past hour, and a central venous pressure (CVP/RAP) of 3 mm Hg. What is the best interpretation of these results by the nurse? 1. More time is needed to assess response 2. Patient response to therapy is appropriate 3. Values are normal for the patient condition 4. Additional interventions are indicated

4. Additional interventions are indicated

Which laboratory values would be more common in patients with diabetic ketoacidosis? 1. pH 7.24 2. Negative ketones in the urine 3. Blood glucose >1000 mg/dL 4. Normal anion gap

1. pH 7.24

A patient has been on daily, high-dose glucocorticoid therapy for the treatment of rheumatoid arthritis. The prescription will run out three days before the patient's next appointment with the primary care provider (PCP). The patient is asymptomatic and thinks it is all right to miss the medication for the 3 days. What is the likely outcome of missing the doses? 1. The arthritis symptoms will remain unchanged 2. Adrenal crisis 3. Thyroid storm 4. Nothing; it is appropriate to stop the medication for 3 days

2. Adrenal crisis

The nurse is caring for a young adult patient admitted with shock. The nurse understands which assessment findings best assess tissue perfusion in a patient in shock? (Select all that apply.) 1. Pupil response 2. Blood pressure 3. Heart rate 4. Level of consciousness 5. Respirations 6. Urine output

2. Blood pressure 4. Level of consciousness 6. Urine output

What is a common cause of acute adrenal crisis? 1. Acute renal failure 2. Deficiency of corticosteroids 3. Overdose of testosterone 4. High doses of corticosteroids

2. Deficiency of corticosteroids

An older adult patient has presented to the emergency department with altered mental status, hypothermia, and clinical signs of heart failure. Myxedema is suspected. Which of the following laboratory findings support this diagnosis? 1. Elevated adrenocorticotropic hormone 2. Elevated thyroid-stimulating hormone 3. Elevated T3 and T4 4. Elevated cortisol levels

2. Elevated thyroid-stimulating hormone

The nurse is caring for a patient admitted to the critical care unit 48 hours ago with a diagnosis of severe sepsis. As part of this patients care plan, what intervention is most important for the nurse to discuss with the multidisciplinary care team? 1. Monitoring intake and output 2. Enteral feedings 3. Pain management 4. Frequent turning

2. Enteral feedings

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? 1. Ranitidine 50 mg intravenously 2. Epinephrine 3-5 mL of a 1:10,000 intravenously 3. Diphenhydramine 50 mg intravenously 4. Methylprednisolone 125 mg intravenously

2. Epinephrine 3-5 mL of a 1:10,000 intravenously

Which nursing diagnosis is a high-priority for both diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome? 1. Hyperthermia 2. Fluid volume deficient 3. Impaired nutrition, more than body requirements 4. Activity intolerance

2. Fluid volume deficient

During the initial stages of shock, what are the physiological effects of decreased cardiac output? 1. Increased parasympathetic stimulation 2. Increased sympathetic stimulation 3. High urine output 4. Arterial vasodilation

2. Increased sympathetic stimulation

Factors associated with the development of nephrogenic diabetes insipidus include which of the following? (Select all that apply.) 1. Pituitary tumors 2. Sickle cell disease 3. Meningitis 4. Heredity 5. Medications, including phenytoin and lithium carbonate

2. Sickle cell disease 4. Heredity 5. Medications, including phenytoin and lithium carbonate

A patient is admitted to the oncology unit with a small cell lung carcinoma. During the admission, the patient is noted to have a significant decrease in urine output accompanied by shortness of breath, edema, and mental status changes. The nurse is aware that this clinical presentation is consistent with what diagnosis? 1. Myxedema coma 2. Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) 3. Diabetes insipidus 4. Adrenal crisis

2. Syndrome of inappropriate secretion of antidiuretic hormone (SIADH)

The nurse is providing insulin education for an older adult patient with longstanding diabetes. An order has been written for the patient to take 20 units of insulin glargine at 10 PM nightly. The nurse should provide the patient with what information regarding the peak time for insulin action to occur? 1. 0800 2. There is no peak. 3. 0200 4. 0400

2. There is no peak.

The nurse is administering both crystalloid and colloid intravenous fluids as part of fluid resuscitation in a patient admitted in severe sepsis. What findings assessed by the nurse indicate an appropriate response to therapy? 1. Normal body temperature 2. Urine output of 0.5mL/kg/hr 3. Adequate pain management 4. Balanced intake and output

2. Urine output of 0.5 mL/kg/hr

In the management of diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome, when is an intravenous (IV) solution that contains dextrose started? 1. Never; normal saline is the only appropriate solution in diabetes management 2. When the blood glucose reaches 250 mg/dL 3. When the blood sugar reaches 70 mg/dL 4. When the blood sugar reaches 150 mg/dL

2. When the blood glucose reaches 250 mg/dL

The nurse is caring for a patient in the early stages of septic shock. The patient is slightly confused and flushed, with bounding peripheral pulses. Which hemodynamic values is the nurse most likely to assess? 1. pH 7.4, CO2 40, HCO3 24 2. pH 7.3, CO2 45, HCO3 18 3. pH 7.35, CO2 40, HCO3 22 4. pH 7.45, CO2 45, HCO3 26

2. pH 7.3, CO2 45, HCO3 18

The nurse is caring for a patient in cardiogenic shock who is being treated with an intraaortic 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? 1. "The machine will remain in place until the patient is ready for a heart transplant." 2. "The machine will help cleanse the blood of impurities that might damage the heart." 3. "The action of the machine will improve blood supply to the damaged heart." 4. "The machine will beat for the damaged heart with every beat until it heals."

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

Mechanisms for development of diabetes insipidus include which of the following? (Select all that apply.) 1. Water deprivation 2. ADH replacement therapy 3. ADH insensitivity 4. ADH deficiency 5. ADH excess

3. ADH insensitivity 4. ADH deficiency

The nurse is caring for a patient in spinal shock. Vital signs include blood pressure 100/70 mm Hg, heart rate 70 beats/min, respirations 24 breaths/min, oxygen saturation 95% on room air, and an oral temperature of 96.8 F. Which intervention is most important for the nurse to include in the patients plan of care? 1. Application of 100% oxygen via facemask 2. Infusion of IV phenylephrine 3. Application of slow rewarming measures 4. Administration of atropine sulfate

3. Application of slow rewarming measures

Which of the following would be seen in a patient with myxedema coma? 1. Tachycardia 2. Hyperthermia 3. Decreased reflexes 4. Hyperventilation

3. Decreased reflexes

The nurse is caring for a mechanically ventilated patient following insertion of a left subclavian central venous catheter (CVC). What action by the nurse best protects against the development of a central lineassociated bloodstream infection (CLABSI)? 1. Appropriate sedation management 2. Assessment for weaning readiness 3. Documentation of insertion date 4. Elevation of the head of the bed

3. Documentation of insertion date

A patient diagnosed with pancreatic cancer has been admitted to the critical care unit with clinical signs consistent with syndrome of inappropriate secretion of antidiuretic hormone. The nurse anticipates that clinical management of this condition will include what intervention? 1. Administration of exogenous vasopressin 2. Low sodium diet 3. Fluid restriction 4. Administration of 3% normal saline

3. Fluid restriction

What is the most significant clinical finding of acute adrenal crisis associated with fluid and electrolyte balance? 1. Hyperglycemia. 2. Hypernatremia 3. Hyperkalemia 4. Fluid volume excess

3. Hyperkalemia

The nurse is caring for a patient in the early stages of septic shock. The patient is slightly confused and flushed, with bounding peripheral pulses. Which hemodynamic values is the nurse most likely to assess? 1. Low PAOP and low CO 2. High PAOP and high CO 3. Low SVR and high CO 4. High SVR and low CO

3. Low SVR and high CO

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? 1. Calcium 2. Sodium. 3. Potassium 4. Chloride

3. Potassium

A patient presents to the emergency department (ED) with the following clinical signs:Pulse: 132 beats/minBlood pressure: 88/50 mm HgRespiratory rate: 32 breaths/minTemperature: 104.8° FChest x-ray: Findings consistent with congestive heart failureCardiac rhythm: Atrial fibrillation with rapid ventricular response. These signs are consistent with which disorder? 1. Myxedema coma 2. Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) 3. Thyroid storm 4. Adrenal crisis

3. Thyroid storm

A patient who experienced head trauma was admitted to the surgical intensive care unit following a motorcycle crash. What assessment that will assist the nurse in early identification of an endocrine disorder commonly associated with this condition? 1. Daily weight 2. Lung sound auscultation 3. Urine osmolality 4. Fingerstick glucose

3. Urine osmolality

A continuous insulin intravenous infusion is started, and hourly bedside glucose monitoring is ordered for a patient who presented to the emergency department experiencing diabetic ketoacidosis. What is the targeted blood glucose value after the first hour of therapy? 1. A decrease of 25 to 50 mg/dL compared with admitting values 2. Less than 200 mg/dL 3. 70 to 120 mg/dL 4. A decrease of 50 to 75 mg/dL compared with admitting values

4. A decrease of 50 to 75 mg/dL compared with admitting values

A patient with newly diagnosed type 1 diabetes is being transitioned from an infusion of intravenous (IV) regular insulin to an intensive insulin therapy regimen of insulin glargine and insulin aspart. How should the nurse manage this transition in insulin delivery? 1. Administer the insulin glargine and continue the IV insulin infusion for 24 hours. 2. Discontinue the IV infusion and administer the glargine insulin at bedtime. 3. Discontinue the IV infusion and administer the insulin aspart with the next meal. 4. Administer the insulin glargine and discontinue the IV infusion in several hours.

4. Administer the insulin glargine and discontinue the IV infusion in several hours.

Which of the following patients is at the highest risk for hyperosmolar hyperglycemic syndrome? 1. A 45-year-old woman with type 1 diabetes who forgets to take her insulin in the morning 2. An 18-year-old college student with type 1 diabetes who exercises excessively 3. A 75-year-old man with type 2 diabetes and coronary artery disease who has recently started on insulin injections 4. An 83-year-old, long-term care resident with type 2 diabetes and advanced Alzheimer's disease who recently developed influenza

4. An 83-year-old, long-term care resident with type 2 diabetes and advanced Alzheimer's disease who recently developed influenza

The nurse is caring for a patient admitted following a motor vehicle crash. Over the past 2 hours, the patient has received 6 units of packed red blood cells and 4 units of fresh frozen plasma by rapid infusion. To prevent complications, what is the priority nursing intervention? 1. Administer pain medication 2. Turn patient q2h 3. Apply bilateral heel protectors 4. Assess core body temperature

4. Assess core body temperature

A patient presents to the emergency department with suspected thyroid storm. The nurse should be alert to monitoring for what cardiac rhythm while providing care to this patient? 1. Junctional rhythm 2. Idioventricular rhythm 3. Sinus bradycardia 4. Atrial fibrillation

4. Atrial fibrillation

While monitoring a patient for signs of shock, the nurse understands which system assessment to be of priority? 1. Respiratory 2. Gastrointestinal 3. Renal 4. CNS

4. CNS

The nurse is caring for a patient in cardiogenic shock who is being treated with an intraaortic 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? 1. Systemic vascular resistance (SVR) of 1600 dynes/sec/cm5 2. Pulmonary artery occlusion pressure (PAOP) of 22 mmHg 3. Pulmonary arter diastolic pressure of 26 mmHg 4. Cardiac index (CI) of 2.5 L/min/m2

4. Cardiac index (CI) of 2.5 L/min/m2

The nurse caring for a patient who experienced a head trauma following a fall notes that the patient's heart rate is 112 beats/min and blood pressure is 88/50 mm Hg. The patient has poor skin turgor, dry mucous membranes and appears confused and restless. The following laboratory values are reported: serum sodium is 115 mEq/L; blood urea nitrogen (BUN) 50 mg/dL; and creatinine 1.8 mg/dL. The findings are consistent with which disorder? 1. Syndrome of inappropriate secretion of antidiuretic hormone 2. Thyroid storm 3. Diabetes insipidus 4. Cerebral salt wasting

4. Cerebral salt wasting

The nurse is caring for a 27-year-old patient with a diagnosis of head trauma. The nurse notes that the patient's urine output has increased tremendously over the past 18 hours. The nurse suspects that the patient may be developing what complication of the injury? 1. Hyperosmolar hyperglycemic syndrome 2. Diabetic ketoacidosis 3. Syndrome of inappropriate secretion of antidiuretic hormone 4. Diabetes insipidus

4. Diabetes insipidus

The nurse is caring for a patient with severe sepsis who was resuscitated with 3000 mL of lactated Ringer solution over the past 4 hours. Morning laboratory results show a hemoglobin of 8 g/dL and hematocrit of 28%. What is the best interpretation of these findings by the nurse? 1. Blood transfusion with packed red blood cells is required 2. Fluid resuscitation has resulted in fluid volume overload 3. Fluid resuscitation has resulted in third spacing of fluid 4. Hemoglobin and hematocrit results indicate hemodilution

4. Hemoglobin and hematocrit results indicate hemodilution

The nurse is caring for a patient who underwent pituitary surgery 12 hours ago. The nurse will give priority to monitoring the patient carefully for which possible complication? 1. Infection 2. Volume overload 3. Congestive heart failure 4. Hypovolemic shock

4. Hypovolemic shock

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? 1. Sodium 140 mEq/L 2. Creatinine 1.0 mg/dL 3. Potassium 3.8 mEq/L 4. Lactate 6 mmol/L

4. Lactate 6 mmol/L

The nurse is caring for a patient in cardiogenic shock experiencing chest pain. Hemodynamic values assessed by the nurse include a cardiac index (CI) of 2.5 L/min/m2, heart rate of 70 beats/min, and a systemic vascular resistance (SVR) of 2200 dynes/sec/cm-5. Upon review of physician orders, which order is most appropriate for the nurse to initiate? 1. Dopamine infusion at a rate of 5-10 mcg/kg/m to maintain a systolic BP of at least 90 mmHg 2. Dobutamine infusion at a rate of 2-20 mcg/kg/m as needed for CI <2 L/min/m2 3. Furosemide 20 mg intravenous every 4h as needed for CVP >20 mmHg 4. Nitroglycerin infusion titrated at a rate of 5-10 mcg/min as needed for chest pain

4. Nitroglycerin infusion titrated at a rate of 5-10 mcg/min as needed for chest pain

The nurse is caring for a patient in cardiogenic shock who is being treated with an infusion of dobutamine (Dobutrex). The physicians order calls for the nurse to titrate the infusion to achieve a cardiac index of >2.5 L/min/m2. The nurse measures a cardiac output, and the calculated cardiac index for the patient is 4.6 L/min/m2. What is the best action by the nurse? 1. Assess the patient's hourly urine output 2. Obtain a stat serum potassium level 3. Order a stat 12-lead electrocardiogram 4. Reduce the rate of dobutamine

4. Reduce the rate of dobutamine

The nurse is administering intravenous norepinephrine (Levophed) at 5 mcg/kg/min via a 20-gauge peripheral intravenous (IV) catheter. What assessment finding requires immediate action by the nurse? 1. Central venous pressure (CVP) of 8 mmHg 2. Blood pressure of 100/60 mmHg 3. Heart rate of 110 beats/min 4. Swelling at the IV site

4. Swelling at the IV site

A patient is admitted to the critical care unit following coronary artery bypass surgery. Two hours postoperatively, the nurse assesses the following information: pulse is 120 beats/min; blood pressure is 70/50 mm Hg; pulmonary artery diastolic pressure is 2 mm Hg; cardiac output is 4 L/min; urine output is 250 mL/hr; chest drainage is 200 mL/hr. What is the best interpretation by the nurse? 1. The patient is at risk for developing cardiogenic shock 2. The patient is at risk for developing fluid volume overload 3. The assessed values are within normal limits 4. The patient is at risk for developing hypovolemic shock

4. The patient is at risk for developing hypovolemic shock

The nurse is starting to administer a unit of packed red blood cells (PRBCs) to a patient admitted in hypovolemic shock secondary to hemorrhage. Vital signs include blood pressure 60/40 mm Hg, heart rate 150 beats/min, respirations 42 breaths/min, and temperature 100.6 F. What is the best action by the nurse? 1. Notify the physician of the elevated temperature 2. Administer blood transfusion over at least 4 hours 3. Notify the physician of the patients heart rate 4. Titrate rate of blood transfusion to patient response

4. Titrate rate of blood transfusion to patient response