Critical Care exam 2

Which objective has the highest priority and directs the nursing interventions for a client that is 5'8'', 220 lbs, who has severe flank pain, blood in urine, and a BP of 150/90mmHg. A. decrease pain B. decrease weight C. decrease hematuria D. decrease hypertension

A. decrease pain

You are developing a nursing care plan for a patient in the diuresis stage of AKI. What nursing diagnosis would you include in the care plan? A. excess fluid volume B. risk for electrolyte imbalance C. urinary retention D. Acute pain

B. risk for electrolyte imbalance

Which nursing action is important when a health care provider prescribes enalapril for a client? A. assess for hypokalemia B. Monitor for adverse effects C. Monitor blood pressure D. Assess the client for hypoglycemia

C. monitor blood pressure during therapy

During hemodialysis, the patient develops light-headedness and nausea. What should the nurse do first? a) Give hypertonic saline. b) Initiate a blood transfusion. c) Decrease the rate of fluid removal. d) Administer antiemetic medications.

C. decrease the rate of fluid removal

A client enters the ER complaining of severe chest pain. A myocardial infarction is suspected. A 12 lead ECG appears normal, but the doctor admits the client for further testing until cardiac enzyme studies are returned. All of the following will be included in the nursing care plan. Which activity has the highest priority? a) Monitoring vital signs. b) Completing a physical assessment. c) Monitor for dysrhythmias. d) Maintaining at least one IV access site.

C. monitor for dysrhythmias

Which of the following diagnostic tools is most commonly used to determine the location of myocardial damage? a) Cardiac catheterization b) Cardiac enzymes c) Echocardiogram d) 12 lead electrocardiogram (EKG)

D. 12 lead EKG

A patient with AKI has a urinary output of 350 mL/day. In addition, morning labs showed an increased BUN and creatinine level along with potassium level of 6 mEq/L. What type of diet ordered by the physician is most appropriate for this patient?

Low protein, low potassium, low sodium

IV heparin therapy is ordered for a client. While implementing this order, a nurse ensures that which of the following medications is available in the nursing unit? a) Vitamin K b) Aminocaproic acid c) Potassium chloride d) Protamine sulfate

Protamine sulfate

Which laboratory test provides evidence consistent with a client having renal impairment? Select all that apply. A. Serum albumin 4.7 g/dL B. serum creatinine 2.0 mg/dL C. serum potassium 5.9 mEq/dL D. serum cholesterol 120 mg/dL E. BUN 32 mg/dL

Serum creatinine, potassium, BUN

When teaching a client about propranolol hydrochloride, the nurse should base the information on the knowledge that propranolol hydrochloride: a) Blocks beta-adrenergic stimulation and thus causes decreased heart rate, myocardial contractility, and conduction. b) Increases norepinephrine secretion and thus decreases blood pressure and heart rate. c) Is a potent arterial and venous vasodilator that reduces peripheral vascular resistance and lowers blood pressure. d) Is an angiotensin-converting enzyme inhibitor that reduces blood pressure by blocking the conversion of angiotensin I to angiotensin II.

A

Which action by the nurse is a priority in the immediate postoperative period after splenectomy? Select all that apply. One, some, or all responses may be correct. a) Monitor heart rate b) Take blood pressure c) Listen to bowel sounds d) Check urine output e) Auscultate lung sounds f) Look for abdominal distention

A, B, D, E, F

The nurse teaches the client with angina about the common expected side effects of nitroglycerin, including: a) Headache b) High blood pressure c) Shortness of breath d) Stomach cramps

A. headache

When teaching a patient why spironolactone (Aldactone) and furosemide (Lasix) are prescribed together, the nurse bases teaching on the knowledge that: a) Moderate doses of two different types of diuretics are more effective than a large dose of one type. b) This combination promotes diuresis but decreases the risk of hypokalemia. c) This combination prevents dehydration and hypovolemia. d) Using two drugs increases osmolality of plasma and the glomerular filtration rate.

B

Which statement about continuous ambulatory peritoneal dialysis (CAPD) would be most important when teaching a patient new to the treatment? a) "Maintain a daily written record of blood pressure and weight." b) "It is essential that you maintain aseptic technique to prevent peritonitis." c) "You will be allowed a more liberal protein diet once you complete CAPD." d) "Continue regular medical and nursing follow-up visits while performing CAPD."

B

Which behavior would the nurse know is important to avoid in a 5-month-old child who had heart surgery to repair the defects associated with tetralogy of Fallot? a) Crying b) Coughing c) Straining at stool d) Unnecessary movement

C. straining at stool

Which client care would be permissible for the nurse to delegate to unlicensed assistive personnel (UAP) a) Playing with an infant who had a seizure 1 hour ago b) Bathing a child with an IV line and a PCA pump c) Taking VS of a child who had a prn albuterol nebulizer treatment 15 minutes ago d) Feeding an infant with RR 60/min who underwent cardiac surgery 1 day ago

Bathing a child with an IV line and a PCA pump

Which patient diagnosis or treatment is most consistent with prerenal acute kidney injury (AKI)? a) IV tobramycin b) Incompatible blood transfusion c) Poststreptococcal glomerulonephritis d) Dissecting abdominal aortic aneurysm

D. dissecting abdominal aortic aneurysm

The nurse administers IV magnesium sulfate to a client with preeclampsia. Which would cause the nurse to notify the healthcare provider? A. 2+ patellar reflex response B. Respiratory rate of 18 breaths/min C. Blood pressure of 112/76 mm/Hg D. Urine output of less than 100 ml in 4 hours

D. urine output less than 100 ml in 4 hours

Which patient below with acute kidney injury is in the oliguric stage of AKI: A. 56 year old male who has metabolic acidosis, decreased GFR, increased BUN, hyperkalemia, edema, and urinary output 350 mL/day B. 45 year old female with metabolic alkalosis, hypokalemia, normal GFR, increased BUN, edema, and urinary output 600 mL/day C. 39 year old male with metabolic acidosis, hyperkalemia, improving GFR, resolving edema, and urinary output 4 L/day D. 78 year old female with respiratory acidosis, increased GFR, decreased BUN, hypokalemia, and urinary output 550 mL/day

A

Which findings will the nurse expect when caring for a patient with chronic kidney disease (CKD)? Select all that apply. a) Anemia b) Dehydration c) Hypertension d) Hypercalcemia e) Increased fracture risk f) Elevated white blood cells

A, C, E

Which nursing assessment would be performed by a nurse before administering IV 40 mEq KCI/D5 100ml over 2 hours? Select all that apply. A. urinary output B. deep tendon reflexes C. last bowel movement D. ABG results E. Last serum potassium level F. Patency of IV access

A, E, F

Which intervention would the nurse plan for a client undergoing a renal scan? a) Administer furosemide before initial imaging b) Asking the client to fast before the scan c) Taking precautions related to radioactive exposure d) Telling the client to limit fluids after imaging

A. administer furosemide before initial imaging

A with stage 3 CKD is being taught about a low-potassium diet. The nurse knows the patient understands the diet when the patient selects which foods to eat? a) Apple, green beans, and a roast beef sandwich b) Granola made with dried fruits, nuts, and seeds c) Watermelon and ice cream with chocolate sauce d) Bran cereal with ½ banana and milk and orange juice

A. apple, green beans, and a roast beef sandwich

A client with myocardial infarction has been transferred from a coronary care unit to a general medical unit with cardiac monitoring via telemetry. A nurse plans to allow for which of the following client activities? a) Strict bed rest for 24 hours after transfer. b) Bathroom privileges and self-care activities. c) Unsupervised hallway ambulation with distances under 200 feet. d) Ad lib activities because the client is monitored.

B. Bathroom privileges and self-care activities

The physician refers the client with unstable angina for a cardiac catheterization. The nurse explains to the client that this procedure is being used in this specific case to: a) Open and dilate the blocked coronary arteries. b) Assess the extent of arterial blockage. c) Bypass obstructed vessels. d) Assess the functional adequacy of the valves and heart muscle.

B. assess the extent of arterial blockage

A client with no history of cardiovascular disease comes into the ambulatory clinic with flu-like symptoms. The client suddenly complains of chest pain. Which of the following questions would best help a nurse to discriminate pain caused by a non-cardiac problem? a) "Have you ever had this pain before?" b) "Can you describe the pain to me?" c) "Does the pain get worse when you breathe in?" d) "Can you rate the pain on a scale of 1-10, with ten (10) being the worst?"

C. Does the pain get worse when you breathe in

To evaluate a client's condition following cardiac catheterization, the nurse will palpate the pulse: a) In all extremities b) At the insertion site c) Distal to the catheter insertion d) Above the catheter insertion

C. distal to the catheter insertion

As an initial step in treating a client with angina, the physician prescribes nitroglycerin tablets, 0.3mg given sublingually. This drug's principal effects are produced by: a) Antispasmodic effect on the pericardium. b) Causing an increased myocardial oxygen demand. c) Vasodilation of peripheral vasculature. d) Improved conductivity in the myocardium.

C. vasodilation of peripheral vasculature

The nurse is assessing a newborn and suspects renal impairment. Which finding supports the nurse's suspicion? A. odorless urine B. colorless urine C. voids after 76 hours D. specific gravity of 1.02

C. voids after 76 hours

An older adult who has an endocrine disorder is scheduled for a diagnostic study with contrast medium. The nurse identifies that it is essential for which lab test to be performed before the procedure?

Creatinine clearance

Which information about a client who is in cardiac arrest and has been transported by ambulance to the emergency department is most important to communicate to the healthcare provider? a) The client is male and 86 years old. b) Nitroglycerin was taken before cardiac arrest. c) The client has a history of CAD and previous cardiac surgery. d) CPR was started 9 minutes after cardiac arrest.

D. CPR was started 9 minutes after cardiac arrest

Which client condition has the highest priority when assessed by the triage nurse in the emergency department? a) Simple fracture b) Renal flank pain c) Severe abdominal pain d) Chest pain with diaphoresis

D. chest pain with diaphoresis

The nurse preparing to give a dose of calcium acetate to a patient with chronic kidney disease (CKD). Which laboratory result will the nurse monitor to determine if the desired effect was achieved? a) Sodium b) Potassium c) Magnesium d) Phosphorus

D. phosphorus

A patient with stage 2 chronic kidney disease is scheduled for an outpatient diagnostic procedure using contrast media. Which priority action should the nurse perform? a) Assess the patient's hydration status. b) Insert a urinary catheter for the expected diuresis. c) Evaluate the patient's lower extremities for edema. d) Check the patient's urine for the presence of ketones.

A. assess the patient's hydration status

Following a treadmill test and cardiac catheterization, the client is found to have coronary artery disease, which is inoperative. He is referred to the cardiac rehabilitation unit. During his first visit to the unit he says that he doesn't understand why he needs to be there because there is nothing that can be done to make him better. The best nursing response is: a) "Cardiac rehabilitation is not a cure but can help restore you to many of your former activities." b) "Here we teach you to gradually change your lifestyle to accommodate your heart disease." c) "You are probably right but we can gradually increase your activities so that you can live a more active life." d) "Do you feel that you will have to make some changes in your life now?"

A

Which intervention is the priority nursing care for a client in the coronary care unit who develops "viselike" chest pain radiating to the neck with a blood pressure of 124/64 mm Hg, an irregular apical pulse of 64 beats per minute, and diaphoresis who is prescribed morphine sulfate 4 mg intravenous (IV) push stat and cardiac monitoring? a) relief of pain b) client teaching c) cardiac monitoring d) maintenance of bed rest

A. relief of pain

Which finding in a client who had coronary artery bypass graft (CABG) surgery 1 day previously is most important for the nurse to communicate to the health care provider? a) Temperature of 102o F b) 7/10 incisional pain c) SR with PR interval of 0.22 seconds d) 120mL blood in the collection chamber

A. temperature of 102

A patient with end-stage renal disease (ESRD) secondary to diabetes has arrived at the outpatient dialysis unit for hemodialysis. Which assessments should the nurse perform as a priority before, during, and after the treatment? a) Level of consciousness b) Blood pressure and fluid balance c) Temperature, heart rate, and blood pressure d) Assessment for signs and symptoms of infection

B. blood pressure and fluid balance

Which intervention would the nurse avoid in an infant with a congenital heart defect after cardiac catheterization? a) Offering fluids as tolerated. b) Performing range of motion exercises c) Monitoring the apical pulse for rate and rhythm d) Assessing the pulses distal to the catheterization site

B. performing range of motion exercises

Which client condition would the triage nurse assign the lowest nursing care priority? a) Stroke b) Skin rash c) Renal flank pain d) Displaced tendon

B. skin rash

Which nursing intervention is the priority when a child returns directly to the pediatric intensive care unit after cardiac surgery with O2 by face mask, a left chest tube attached to water-seal drainage, an intravenous line running of D5 ½ NS at 4 mL/h, and a double-lumen nasogastric tube connected to continuous suction with a cardiac monitor and a dressing on the left side of the chest? a) Auscultating breath sounds b) Testing level of consciousness c) Measuring drainage from both tubes d) Determining the suction pressure of the NG tube

B. testing level of consciousness

Which patients are at risk for acute intra-renal injury? A. 45 year old male with a renal calculus B. 65 year old male with benign prostatic hyperplasia C. 25 year old female receiving chemotherapy D. 36 year old female with renal artery stenosis E. 6 year old male with acute glomerulonephritis F. 87 year old male who is taking an aminoglycoside medication for an infection

C. chemotherapy, E. glomerulonephritis, F. Aminoglycoside medication

The provider has decided to use renal replacement therapy to remove large volumes of fluid from a patient who is hemodynamically unstable in the intensive care unit. The nurse should expect which treatment to be used for this patient? a) Hemodialysis (HD) three times per week b) Automated peritoneal dialysis (APD) c) Continuous venovenous hemofiltration (CVVH) d) Continuous ambulatory peritoneal dialysis (CAPD)

C. continuous venovenous hemofiltration (CVVH)

One hour after administering IV furosemide (Lasix) to a client with heart failure, a short burst of ventricular tachycardia appears on the cardiac monitor. Which of the following electrolyte imbalances should the nurse suspect? a) Hypocalcemia b) Hypermagnesemia c) Hypokalemia d) Hypernatremia

C. hypokalemia

Which test result would the nurse anticipate in the lab results of a client with a diagnosis of end stage renal disease? A. arterial pH of 7.5 B. hematocrit of 54% C. potassium of 6.3 mEq/L D. creatinine of 1.2 mg/dL

C. potassium of 6.3 mEq/L