CRITICAL CARE EXAM 3

Which of the following medical conditions is least likely to predispose a patient to disseminated intravascular coagulation (DIC)?

D. acute renal failure.

The Berlin criteria for acute respiratory distress syndrome( ARDS) include?

D. all of the above. Acute onset within 1 week after clinical insult. bilateral pulmonary opacities not explained by other conditions. altered partial pressure of oxygen/fraction of inspired oxygen (PaO2/FiO2) ratio.

Possible treatments for acute respiratory failure (ARF) in the patient with chronic obstructive pulmonary disease (COPD) include?

D. all of the above. Noninvasive ventilation. bronchodilators. corticosteroids.

Which one of the following common diagnostic tests is most accurate in assessing kidney function?

D. creatinine clearance.

Early clinical signs of liver disease include all of the following except?

D. esophageal varices.

The nurse caring for a patient with an acute ischemic stroke anticipates?

D. identifying the precise time of stroke symptom onset when possible.

Which laboratory value indicates that the patient is under-resuscitated?

D. lactate of 5 mmol.

Acid-base regulation of the kidney is performed primarily in which section of the nephron?

D. proximal and distal tubules.

Which of the following would be seen in a patient with myxedema coma?

Decreased reflexes

A nurse is caring for a patient declared brain dead following a car crash in preparation for the harvesting of organs. The patient's urine output was 1050 mL in the last hour. What medication does the nurse prepare to administer?

Desmopressin acetate

Which of the following statements about mass casualty triage during a disaster is true?

Disaster victims with the greatest chances for survival receive priority for treatment.

What were the findings of the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT)?

Disparities exist between patients' care preferences and the actual care provided.

A patient with a 10-year history of heart failure presents to the emergency department reporting severe shortness of breath. Assessment reveals crackles throughout the lung fields and labored breathing. The patient takes beta blockers, ACE inhibitors, and diuretics as directed. What treatment strategies does the nurse plan to implement for immediate short-term management? (Select all that apply.)

Dobutamine. Intraaortic balloon pump. Nesiritide.

In an unconscious patient, eye movements are tested by the oculocephalic reflex. Which statements regarding the testing of this reflex are true? (Select all that apply.)

Doll's eyes absent indicate a disruption in normal brainstem processing. Doll's eyes present indicate brainstem activity. Eye movement in the opposite direction as the head when turned indicates an intact reflex. Increased intracranial pressure (ICP) is a contraindication to the assessment of this reflex. Presence of cervical injuries is a contraindication to the assessment of this reflex.

The nurse is caring for a mechanically ventilated patient. The nurse understands that strategies to prevent ventilator-associated pneumonia include which of the following? (Select all that apply.)

Drain condensate from the ventilator tubing away from the patient. Elevate the head of the bed 30 to 45 degrees. Perform regular oral care with chlorhexidine.

Patients at risk for the development of deep vein thrombosis may include?

E. all of the above. Those older than 75 years. those who are immobile for longer than 3 days. pregnant women, patients with burn injury.

An individual with type 2 diabetes who takes glipizide has begun a formal exercise program at a local gym. While exercising on the treadmill, the individual becomes pale, diaphoretic, shaky, and has a headache. The individual feels as though she is going to pass out. What is the individual's priority action?

Eat something with 15 g of simple carbohydrates.

An elderly female 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?

Elevated thyroid-stimulating hormone

Patients with burns may have mesh grafts or sheet grafts. Which of the following sites is most likely to have a sheet graft applied?

Face

A patient with a history of emphysema, diabetes, and hyperlipidemia is in the critical care unit on a ventilator. The nutrition assessment notes that the patient has a protein and vitamin deficiency and is underweight. Which formula for nutritional assessment is most appropriate?

Fiber-added formula

Which of the following is a high-priority nursing diagnosis for both diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome?

Fluid volume deficient

Select the strategies for preventing deep vein thrombosis (DVT) and pulmonary embolus (PE). (Select all that apply.)

Graduated compression stockings Heparin or low-molecular weight heparin for patients at risk Sequential compression devices

The nurse is caring for a patient who has a peptic ulcer. To treat the ulcer and prevent more ulcers from forming, the nurse should be prepared to administer?

H2-histamine receptor blockers.

The patient comes to the hospital complaining of headache, fever, and sore throat for the past 2 weeks and is concerned about acquired immune deficiency syndrome (AIDS). The patient's blood work shows the presence of HIV antibodies. The nurse should explain that?

HIV infection and AIDS are considered chronic diseases.

Factors associated with the development of nephrogenic diabetes insipidus include which of the following? (Select all that apply.)

Heredity. Medications. Sickle cell disease.

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

Higher serum glucose, higher osmolality, and no ketosis

Which of the following are common causes of sinus tachycardia? (Select all that apply.)

Hyperthyroidism. Hypovolemia. Heart Failure.

Complications common to patients receiving hemodialysis for acute kidney injury include which of the following? (Select all that apply.)

Hypotension Dysrhythmias

What is the major reason for using a treatment to lower body temperature after cardiac arrest to promote better neurological recovery?

Hypothermia decreases the metabolic rate by 7% for each decrease of 1 C.

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 of the following?

Hypovolemic shock

While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mm Hg and a CPP of 85 mm Hg. What is the best interpretation by the nurse?

ICP is high; CPP is normal.

The nurse has just received a patient from the emergency department with an admitting diagnosis of bacterial meningitis. To prevent the spread of nosocomial infections to other patients, what is the best action by the nurse?

Implement droplet precautions upon admission.

The nurse is caring for a patient admitted with bacterial meningitis. Vital signs assessed by the nurse include blood pressure 110/70 mm Hg, heart rate 110 beats/min, respiratory rate 30 breaths/min, oxygen saturation (SpO2) 95% on supplemental oxygen at 3 L/min, and a temperature 103.5°F. What is the priority nursing action?

Implement seizure precautions.

Which of the following statements is true regarding oral care for the prevention of ventilator-associated pneumonia (VAP)? (Select all that apply.)

Implementing a comprehensive oral care program is an intervention for preventing VAP. Oral care protocols should include oral suctioning and brushing teeth. Protocols that include chlorhexidine gluconate have been effective in preventing VAP.

Which of the following are physiological effects of positive end-expiratory pressure (PEEP) used in the treatment of ARDS? (Select all that apply.)

Increases functional residual capacity. Prevents collapse of unstable alveoli. Improves arterial oxygenation. Opens collapsed alveoli.

Which of the following statements apply to trauma patients and their potential complications? (Select all that apply.)

Indwelling urinary catheters are a source of infection. Patients often develop infection and sepsis secondary to central line catheters. Pneumonia is often an adverse outcome of mechanical ventilation.

A patient with acute pancreatitis is started on parenteral nutrition. The student nurse listed possible interventions for this patient. Which intervention needs correction before finalizing the plan of care?

Infuse antibiotics through the intravenous line.

An acute exacerbation of asthma is treated with which of the following?

Inhaled bronchodilators and intravenous corticosteroids

Which of the following interventions would not be appropriate for a patient who is admitted with a suspected basilar skull fracture?

Insertion of a nasotracheal tube

Which of the following are components of the Institute for Healthcare Improvement's (IHI's) ventilator bundle? (Select all that apply.)

Interrupt sedation each day to assess readiness to extubate. Maintain head of bed at least 30 degrees of elevation. Provide deep vein thrombosis prophylaxis. Provide prophylaxis for peptic ulcer disease.

Rule of nines

Is the quickest method to initially calculate %tbsa. This technique divides the TBSA into areas representing 9% or multiples of 9%.

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

Lactated Ringer's bolus

The nurse is caring for a mechanically ventilated patient with a pulmonary artery catheter who is receiving continuous enteral tube feedings. When obtaining continuous hemodynamic monitoring measurements, what is the best nursing action?

Level and zero reference the air-fluid interface of the transducer with the patient's head of bed elevated to 30 degrees and record hemodynamic values.

Which complications may manifest after an electrical injury? (Select all that apply.)

Long bone fractures Cardiac dysrhythmias Compartment syndrome of extremities Dark brown urine Acute cataract formation Seizures

The nurse is caring for a patient whose ventilator settings include 15 cm H2O of positive end-expiratory pressure (PEEP). What complication does the nurse assess the patient for?

Low cardiac output secondary to increased intrathoracic pressure

The nurse receives a patient from the emergency department following a closed head injury. After insertion of an ventriculostomy, the nurse assesses the following vital signs: blood pressure 100/60 mm Hg, heart rate 52 beats/min, respiratory rate 24 breaths/min, oxygen saturation (SpO2) 97% on supplemental oxygen at 45% via Venturi mask, Glasgow Coma Scale score of 4, and intracranial pressure of 18 mm Hg. Which provider prescription should the nurse institute first?

Mannitol 1 g intravenous

Which of the following findings require immediate nursing interventions in a patient with a traumatic brain injury? (Select all that apply.)

Mean arterial pressure 48 mm Hg. Nonreactive pupils. Respiratory rate of 10 breaths/min. Open skull fracture.

The nurse assesses a patient with a skull fracture to have a Glasgow Coma Scale score of 3. Additional vital signs assessed by the nurse include blood pressure 100/70 mm Hg, heart rate 55 beats/min, respiratory rate 10 breaths/min, oxygen saturation (SpO2) 94% on oxygen at 3 L per nasal cannula. What is the priority nursing action?

Monitor the patient's airway patency.

A patient presents to the emergency department in acute respiratory failure secondary to community-acquired pneumonia. The patient has a history of chronic obstructive pulmonary disease. The nurse anticipates which treatment to facilitate ventilation?

Noninvasive positive-pressure ventilation (NPPV)

The nurse is providing insulin education for an elderly patient with long-standing diabetes. A prescription has been written for the patient to take 20 units of insulin glargine at 10 PM nightly. The nurse should instruct the patient that the peak of the insulin action for this agent is?

Peakless

While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the patient's left naris. What is the best nursing action?

Place a nasal drip pad under the nose.

When providing information on trauma prevention, it is important to realize that individuals age 35 to 54 years are most likely to experience which type of trauma incident?

Poisonings from prescription or illegal drugs

The patient is complaining of severe flank pain when he tries to urinate. His urinalysis shows sediment and crystals along with a few bacteria. Using this information along with the clinical picture, the nurse realizes that the patient's condition is?

Postrenal.

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

Potassium

Nursing priorities to prevent ineffective coagulation include which of the following? (Select all that apply.)

Prevention of hypothermia. Administration of fresh frozen plasma as ordered. Administration of calcium as ordered.

The nurse is caring for a mechanically ventilated patient with a sustained ICP of 18 mm Hg. The nurse needs to perform an hourly neurological assessment, suction the endotracheal tube, perform oral hygiene care, and reposition the patient to the left side. What is the best action by the nurse?

Provide rest periods between nursing interventions.

While caring for a patient with a closed head injury, the nurse assesses the patient to be alert with a blood pressure 130/90 mm Hg, heart rate 60 beats/min, respirations 18 breaths/min, and a temperature of 102°F. To reduce the risk of increased intracranial pressure (ICP) in this patient, what is (are) the priority nursing action(s)?

Reduce ambient room temperature and administer antipyretics.

Which of the following statements about palliative care is accurate?

Reducing distressing symptoms is the primary goal of palliative care.

The nurse understands that negative-pressure wound therapy may be used in the treatment of partial-thickness burn wounds to do which of the following?

Remove excessive wound fluid and promote moist wound healing

Which of the following acid-base disturbances commonly occurs with the hyperventilation and impaired gas exchange seen in severe exacerbation of asthma?

Respiratory acidosis

The most common cause of acute kidney injury in critically ill patients is?

Sepsis.

The nurse is caring for a patient who has atrial fibrillation. Sequelae that place the patient at greater risk for mortality/morbidity include which of the following? (Select all that apply.)

Stroke Pulmonary emboli Decreased cardiac output

A renal transplant recipient presents to the outpatient transplant clinic with blood glucose values for the past 3 days exceeding 250 mg/dL. The patient takes prednisone 5 mg daily and tacrolimus (Prograf) 2 mg twice daily. Hemoglobin A1C level drawn the day of the clinic appointment was 8.5%. What is the best interpretation of this finding by the nurse?

The patient has developed posttransplant diabetes.

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?

The patient is at risk for developing hypovolemic shock.

Which of the following treatments may be used to dissolve a thrombus that is lodged in the pulmonary artery?

Thrombolytics

A patient presents to the emergency department with the following clinical signs: Pulse: 132 beats/min, Blood pressure: 88/50 mm Hg, Respiratory rate: 32 breaths/min Temperature: 104.8°F, Chest x-ray: Findings consistent with congestive heart failure Cardiac rhythm: Atrial fibrillation with rapid ventricular response These signs are consistent with which disorder?

Thyroid storm

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?

Titrate dopamine intravenously for blood pressure less than 90 mm Hg systolic.

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?

Titrate rate of blood administration to patient response.

A patient is being ventilated and has been started on enteral feedings with a nasogastric small-bore feeding tube. What is the primary reason the nurse must frequently assess tube placement?

To prevent aspiration of the feedings

The patient is in third-degree heart block (complete heart block) and is symptomatic. The treatment for this patient is which of the following? (Select all that apply.)

Transcutaneous pacemaker. Temporary transvenous pacemaker. Permanent pacemaker.

The nurse is caring for a patient with head trauma who was admitted to the surgical intensive care unit following a motorcycle crash. What is an important assessment that will assist the nurse in early identification of an endocrine disorder commonly associated with this condition?

Urine osmolality

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

Volume replacement and insulin infusion often correct the acidosis.

In the management of diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome, when is an intravenous (IV) solution that contains dextrose started?

When the blood glucose reaches 250 mg/dL

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

a decrease of 35 to 90 mg/dL compared with admitting values.

A 100-kg patient gets hemodialysis 3 days a week. In planning the care for this patient, the nurse recommends?

a diet of 2500 to 3500 kcal per day.

The patient is in need of immediate hemodialysis, but has no vascular access. The nurse prepares the patient for insertion of?

a percutaneous catheter at the bedside.

The nurse is caring for a patient who has circumferential full-thickness burns of his forearm. A priority in the plan of care is?

active or passive range-of-motion exercises every hour.

The patient has elevated blood urea nitrogen (BUN) and serum creatinine levels with a normal BUN/creatinine ratio. These levels most likely indicate?

acute kidney injury, such as acute tubular necrosis (ATN).

Conditions that produce acute kidney injury by directly acting on functioning kidney tissue are classified as intrarenal. The most common intrarenal condition is?

acute tubular necrosis (ATN).

The patient is diagnosed with acute kidney injury and has been getting dialysis 3 days per week. The patient complains of general malaise and is tachypneic. An arterial blood gas shows that the patient's pH is 7.19, with a PCO2 of 30 mm Hg and a bicarbonate level of 13 mEq/L. The nurse prepares to?

administer intravenous sodium bicarbonate.

The nurse is caring for a patient with acute pancreatitis. To provide adequate pain control, the nurse?

administers pain medication on a routine schedule.

A patient with a history of type 1 diabetes and an eating disorder is found unconscious. In the emergency department, the following lab values are obtained: Glucose: 648 mg/dL pH: 6.88,PaCO2: 20 mm Hg PaO2: 95 mm Hg HCO3 ̄: undetectable Anion gap: >31 Na+: 127 mEq/L K+: 3.5 mEq/L Creatinine: 1.8 mg/dL. After the patient's airway and ventilation have been established, the next priority for this patient is?

administration of a 1-L normal saline fluid bolus.

A patient requires pancuronium as part of treatment of refractive increased intracranial pressure. The nursing care for this patient includes: (Select all that apply.)

administration of sedatives concurrently with neuromuscular blockade. ensuring that deep vein thrombosis prophylaxis is initiated. providing interventions for eye care, oral care, and skin care.

The nurse is caring for an elderly patient who is being admitted for anemia of unknown cause. The patient has been on multiple medications at home for various ailments. In assessing the patient's medication list, the nurse notes medications that may alter hemostasis, including which of the following? (Select all that apply.)

aminoglycosides. antiplatelet agents. cephalosporins. Sulfonamides.

The patient has yellow skin and low hemoglobin and hematocrit levels. The nurse should look for?

an elevated bilirubin level.

The patient is admitted with anemia and active bleeding. The nurse suspects intravascular disseminated coagulation (DIC). Definitive diagnosis of DIC is made by evidence of?

an increased D-dimer level.

During rounds, the provider alerts the team that proning is being considered for a patient with acute respiratory distress syndrome. The nurse understands that proning is?

an optional treatment to improve ventilation.

The nurse is caring for a patient receiving peritoneal dialysis. The patient suddenly complains of abdominal pain and chills. The patient's temperature is elevated. The nurse should?

assess peritoneal dialysate return.

The nurse is caring for a patient with liver disease. When assessing the patient's laboratory values, the nurse should?

assess the total bilirubin

The nurse is assessing a patient admitted with pancreatitis. In doing so, the nurse?

assesses symptoms that could indicate involvement of the stomach.

the patient's platelet count is 35,000/microliter. The provider prescribes administration of 10 units of single-donor platelets. After transfusion, the nurse can expect the patient's platelet count to be?

between 85,000/microliter and 135,000/microliter.

The patient is admitted with acute kidney injury from a postrenal cause. Acceptable treatments for that diagnosis include: (Select all that apply.)

bladder catheterization. ureteral stenting. placement of nephrostomy tubes.

Causes of anemia include which of the following: (Select all that apply.)

blood loss. impaired production of red blood cells. increased destruction of red blood cells.

The nurse is caring for a patient who has undergone skin grafting of the face and arms for burn wound treatment. A primary nursing diagnosis is?

body image disturbance.

As part of nursing management of a critically ill patient, orders are written to keep the head of the bed elevated at 30 degrees, awaken the patient from sedation each morning to assess readiness to wean from mechanical ventilation, and implement oral care protocols every 4 hours. These interventions are done as a group to reduce the risk of ventilator-associated pneumonia. This group of evidence-based interventions is often called a?

bundle of care.

The nurse is caring for a patient who is being treated for peptic ulcer disease. Suddenly, the patient yells that the pain has become extreme. The nurse notes that the patient's abdomen is rigid. The nurse should?

call the provider immediately.

The patient is admitted with reports of chronic fatigue and shortness of breath. The nurse notices that the patient is tachycardic and has multiple bruises and petechiae on the body and arms. The patient also complains of frequent nosebleeds. The nurse should evaluate the patient's?

complete blood count.

The nurse is caring for a patient with a diagnosis of pulmonary embolism. The nurse understands that the most common cause of a pulmonary embolus is?

deep vein thrombosis from lower extremities.

The nurse is caring for a 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?

diabetes insipidus.

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

diabetic ketoacidosis

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

diabetic ketoacidosis.

The patient is getting hemodialysis for the second time when he complains of a headache and nausea and, a little later, of becoming confused. The nurse realizes these are symptoms of?

dialysis disequilibrium syndrome.

The nurse knows that in advanced cardiac life support, the secondary survey includes steps A-B-C-D, in which "D" refers to?

differential diagnosis.

Infection by Helicobacter pylori bacteria is a major cause of?

duodenal ulcers

The ratio of helper T4 cell to suppressor T cells is normally 2:1. A lower-than-normal ratio may indicate acquired immunodeficiency syndrome (AIDS). This is because T4 cells?

enhance humoral immune response.

The patient is admitted with acute pancreatitis. The nurse should?

evaluate C-reactive protein as a gauge of severity.

The patient is in the critical care unit and will receive dialysis this morning. The nurse will (Select all that apply.)

evaluate morning laboratory results and report abnormal results. assess the dialysis access site and report abnormalities. weigh the patient to monitor fluid status.

The patient has a temporary percutaneous catheter in place for treatment of acute kidney injury. The catheter has been in place for 5 days. The nurse should?

evaluate the patient for signs and symptoms of infection.

The patient is admitted with anemia caused by blood loss and thrombocytopenia and has a platelet count of 22,000/microliter. The patient is scheduled for a transfusion of RBCs and a transfusion of platelets. The nurse should?

give the platelets before the RBCs.

The patient is admitted with acute pancreatitis and is demonstrating severe abdominal pain, vomiting, and ascites. Using the Ranson classification criteria, the nurse determines that this patient?

has a 15% chance of dying.

The nurse is assessing a patient being admitted with fatigue and shortness of breath as well as abdominal tenderness. The nurse notes that the patient is jaundiced; the physical examination reports an enlarged liver. The nurse suspects that the patient has?

hemolytic anemia.

Which three elements are commonly referred to as the "trauma triad of death?" (select all that apply)

hypothermia. acidosis. coagulopathy.

A patient is admitted to the progressive care unit with a diagnosis of community-acquired pneumonia. The patient has a history of chronic obstructive pulmonary disease and diabetes. A set of arterial blood gases obtained on admission without supplemental oxygen shows pH 7.35; PaCO2 55 mm Hg; bicarbonate 30 mEq/L; PaO2 65 mm Hg. These blood gases reflect:

hypoxemia and compensated respiratory acidosis.

Trends in nutritional management of the patient with pancreatitis are changing. As a result, the nurse understands that?

immediate oral feeding in patients with mild pancreatitis may help recovery.

The nurse is caring for a patient admitted with a traumatic brain injury following a motor vehicle crash. Several weeks later, the patient is still ventilator dependent and unresponsive to stimulation but occasionally takes a spontaneous breath. The physician explains to the family that the patient has severe neurological impairment and is not expected to recover consciousness. The nurse recognizes that this patient is?

in a persistent vegetative state.

In patients with extensive burns, edema occurs in both burned and unburned areas because of?

increased capillary permeability.

Pain control is a nursing priority in patients with acute pancreatitis because pain?

increases pancreatic secretions.

Severity is determined by the type of?

injury, wound characteristics (depth, extent, body part burned), concomitant injuries, patient age, and preexisting health status.

A strategy for preventing pulmonary embolism in patients at risk who cannot take anticoagulants is?

insertion of a vena cava filter.

deep partial thickness burn

involve destruction of the epidermis and most of the dermis. May heal spontaneously within 2-4 week but are typically excised and grafted to reduce healing time and hospitalization.

partial thickness burn

involve injury to the second skin layer or dermal layer and further subdivided into superficial and deep classifications.

superficial partial thickness burn

involve the epidermis and a limited portion of the dermis, and heal by growth of undamaged basal cells within 7-10 days.

full thickness burn

involves destruction of all layers of skin down to or past the subcutaneous fat, fascia, muscles, or bone.

The nurse notes that the patient's neutrophil count is less than 500 cells/microliter. The nurse realizes that this patient is?

is at severe risk for infection.

The patient has a total white blood cell (WBC) count of 600 cells/microliter. The differential shows a normal neutrophil level of 70% with 5% bands. This patient?

is at severe risk for infection.

A 24-year-old unrestrained driver who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. The primary survey of this patient upon arrival to the ED?

is done quickly in the first few minutes to get a baseline assessment and establish priorities.

The nurse is caring for a patient with the diagnosis of sepsis. The patient is on a ventilator in the critical care unit, and is receiving a proton pump inhibitor (PPI) to reduce the risk for a stress ulcer. In this scenario, a stress ulcer is likely to be secondary to?

ischemia associated with sepsis.

The nurse understands that immunosurveillance is a function of?

killer T lymphocytes.

Nursing priorities for the management of acute pancreatitis include: (Select all that apply.)

managing respiratory dysfunction. assessing and maintaining electrolyte balance. utilizing supportive therapies aimed at decreasing gastrin release.

The nurse is assessing a patient being admitted for anemia. The nurse sees no overt signs of bleeding. The nurse understands that?

many patients have bleeding that is not obvious.

A patient admitted with severe burns to his face and hands is showing signs of extreme agitation. The nurse should explore the mechanism of burn injury possibly related to?

methamphetamine use.

The patient is admitted with pancreatitis and has severe ascites. In caring for this patient, the nurse should?

monitor the patient's blood pressure and evaluate for signs of dehydration.

When caring for a patient with HIV, the nurse should?

monitor the patient's medication regimen.

The nurse is caring for a patient with acute respiratory distress syndrome who is hypoxemic despite mechanical ventilation. The provider prescribes a nontraditional ventilator mode as part of treatment. Despite sedation and analgesia, the patient remains restless and appears to be in discomfort. The nurse informs the provider of this assessment and anticipates an order for?

neuromuscular blockade.

Acute kidney injury from postrenal etiology is caused by?

obstruction of the flow of urine.

The patient is admitted with generalized fatigue and low hemoglobin and hematocrit levels. The patient denies vomiting and states that the last bowel movement earlier that day was normal in color and consistency. However, because GI blood loss can be a cause of anemia, the nurse should expect to?

obtain a stool sample for guaiac testing.

Superficial burn (1st degree)

only the first layer of skin or the epidermis and heal typically within 3-5 days without treatment.

The patient's spouse is very upset because his loved one, who is near death, has dyspnea and restlessness. The nurse explains that there are some ways to decrease this discomfort, including?

opioid medications given as needed.

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

pH 7.24

The nurse is caring for a mechanically ventilated patient admitted with a traumatic brain injury. Which arterial blood gas value assessed by the nurse indicates optimal gas exchange for a patient with this type of injury?

pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg

The nurse is caring for a patient with severe pancreatitis who is orally intubated and on mechanical ventilation. The patient's calcium level this morning was 5.5 mg/dL. The nurse notifies the provider and?

places the patient on seizure precautions.

Accepted treatments for disseminated intravascular coagulation (DIC) may require (Select all that apply.)

platelet infusions. administration of fresh frozen plasma. cryoprecipitate. packed RBCs.

A patient with a history of pulmonary embolism is being worked up for a potential coagulopathy that increases the risk for clotting. The nurse understands that the provider may request a test for?

protein C deficiency.

The nurse is caring for a patient diagnosed with anemia. This morning's hematocrit level is 24%. Platelet level is 200,000/microliter. The nurse can expect to?

provide RBC transfusion because this level is below the normal threshold.

The patient is diagnosed with hepatitis. In caring for this patient, the nurse should?

provide rest, nutrition, and antiemetics if needed.

The patient is admitted with constipation. In anticipation of treatment, the nurse prepares to?

provide therapies that will innervate the autonomic nervous system.

The patient is admitted with acute pancreatitis and is later diagnosed as having a pseudocyst. The nurse realizes that?

pseudocysts may resolve spontaneously, so surgery may be delayed.

A definitive diagnosis of pulmonary embolism can be made by?

pulmonary angiogram.

The nurse is caring for a patient with an electrical injury. The nurse understands that patients with electrical injury are at a high risk for acute kidney injury secondary to?

release of myoglobin from injured tissues.

Continuous venovenous hemodialysis is used to?

remove plasma water and solutes by adding dialysate.

The patient is complaining of severe joint pain, as well as fatigue and shortness of breath. The nurse notices that the patient's joints are swollen and the legs are edematous. The nurse realizes that these are symptoms of?

sickle cell anemia.

The patient is admitted with neutropenia. The nurse should assess the patient frequently for?

signs of systemic infection.

The correct priority order of actions in prehospital primary survey for burn injuries is?

stop the burning process and prevent further injury. assess ABCs and cervical spine. provide oxygen therapy if smoke inhalation is suspected. make rapid head-to-toe assessment to rule out additional trauma.

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

syndrome of inappropriate secretion of antidiuretic hormone (SIADH).

The nurse is discharging a patient with asthma. As part of the discharge instruction, the nurse instructs the patient to prevent exacerbation by?

taking all asthma medications as prescribed.

An advantage of peritoneal dialysis is that?

the danger of hemorrhage is minimal.

The patient has a platelet count of 9,000/microliter. The nurse realizes that?

the patient is at great risk for fatal hemorrhage.

Continuous renal replacement therapy (CRRT) differs from conventional intermittent hemodialysis in that?

the process removes solutes and water slowly.

The nurse is managing the pain of a patient with burns. The provider has prescribed opiates to be given intramuscularly. The nurse contacts the provider to change the prescription to intravenous administration because?

tissue edema may interfere with drug absorption of injectable routes.

Lactulose is considered the first-line treatment for hepatic encephalopathy and works by?

trapping ammonia in the bowel for excretion.

The patient is admitted with a fever and rapid heart rate. The patient's temperature is 103 F (39.4 C). The nurse places the patient on a cardiac monitor and finds the patient's atrial and ventricular rates are above 105 beats per minute. P waves are clearly seen and appear normal in configuration. QRS complexes are normal in appearance and 0.08 seconds wide. The rhythm is regular, and blood pressure is normal. The nurse should focus on providing?

treatment to lower temperature.

Peritoneal dialysis is different from hemodialysis in that peritoneal dialysis?

uses the patient's own semipermeable membrane (peritoneal membrane).

Range-of-motion exercises, early ambulation, and adequate hydration are interventions to prevent?

venous thromboembolism.

The nurse is caring for a patient with cirrhosis of the liver. The nurse notes fresh blood starting to ooze from the patient's rectum and intravenous site. The nurse contacts the provider expecting a prescription for?

vitamin K injections.

Which of the following patients is at the greatest risk of developing acute kidney injury, A patient who?

was discharged 2 weeks earlier after aminoglycoside therapy of 2 weeks

The nurse is assisting the patient to select foods from the menu that will promote wound healing. Which statement indicates the nurse's knowledge of nutritional goals?

"Choose foods that are high in protein, such as meat, eggs, and beans. These help the burns to heal."

The nurse is educating a renal transplant patient about his immunosuppressant medication therapy. Which statement by the patient best indicates an appropriate understanding?

"Complications of these medications include diabetes, infection, hypertension, and bone loss."

The nurse is conducting an admission assessment of an 82-year-old patient who sustained a 12% burn from spilling hot coffee on the hand and arm. Which statement is of priority to assist in planning treatment?

"Do you have a heart condition or heart failure?"

The nurse is caring for a patient who has a Glasgow Coma Scale (GCS) score of 3. Discussions have been held with the family about withdrawing life support. Which statement by the nurse best describes requirements that must be met to sustain Centers for Medicare and Medicaid Services (CMS) Conditions of Participation?

"I need to notify the local Organ Procurement Organization of my patient's impending death."

The patient is admitted with severe abdominal pain due to pancreatitis. The patient asks the nurse, "What causes this? Why does it hurt so much?" The nurse should answer?

"Injury to certain cells in the pancreas causes it to digest (eat) itself, causing pain."

The nurse is caring for a patient with acute kidney injury who is being treated with hemodialysis. The patient asks if he will need dialysis for the rest of his life. Which of the following would be the best response?

"Recovery is possible, but it may take several months."

The nurse is planning care to meet the patient's pain management needs related to burn treatment. The patient is alert, oriented, and follows commands. The pain is worse during the day, when various treatments are scheduled. Which statement to the provider best indicates the nurse's knowledge of pain management for this patient?

"The patient's pain varies depending on the treatment given. Can we try patient-controlled analgesia to see if that helps the patient better?"

A patient at high risk for pulmonary embolism is receiving enoxaparin. The nurse explains to the patient?

"This injection is being given to prevent blood clots from forming."

Treatment and/or prevention of rhabdomyolysis in at-risk patients includes aggressive fluid resuscitation to achieve urine output of?

100 mL/hr.

15/15 rule

15 grams of sugar, wait 15 minutes then reassess.

Desired patient outcomes for immunocompromised patient related to medical and nursing interventions include absence of infection, negative cultures, and an absolute neutrophil count of?

1500 cells/microliter or higher.

The nurse has been assigned the following patients. Which patients require assessment of blood glucose control as a nursing priority? (Select all that apply.)

29-year-old female who is undergoing evaluation for pheochromocytoma 43-year-old male with acute pancreatitis who is receiving total parenteral nutrition (TPN) 62-year-old morbidly obese female who underwent a hysterectomy for ovarian cancer 72-year-old female who is receiving intravenous (IV) steroids for an exacerbation of chronic obstructive pulmonary disease (COPD)

The nurse should call the rapid response team for which patients? (Select all that apply)

53-year-old with pneumonia and severe respiratory distress 24-year-old experiencing a severe asthma attack with stridor 73-year-old patient with bradycardia of 40 beats per minute

The patient's serum creatinine level is 0.7 mg/dL. The expected BUN level should be?

7 to 14 mg/dL.

The charge nurse is reviewing the status of patients in the critical care unit. Regarding which patient should the nurse notify the organ procurement organization to evaluate for possible organ donation?

A 36-year-old patient with a Glasgow Coma Scale score of 3 with no activity on electroencephalogram

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

A patient with a 2-day history of nausea, vomiting, and diarrhea

What medications are prescribed to patients recently diagnosed with peptic ulcer disease (PUD) for Helicobacter pylori?

A. Esomeprazole, amoxicillin, and clarithromycin.

A construction worker is admitted after falling approximately 15 feet from scaffolding. What diagnostic intervention does the nurse anticipate in the care of this trauma patient to evaluate sources of potential bleeding?

A. FAST or E-FAST.

Initial fluid resuscitation requirements are calculated based on the following parameters?

A. age, total body surface area burned, patient weight, and cause of burn injury.

Based on kidney disease improving global outcomes (KDIGO) acute kidney injury (AKI) guidelines, oliguria is defined as urine output?

A. less than 0.5 ml/kg/h

Which of the following statements is true regarding thyroid storm?

A. marked tachycardia may be observed.

A patient is admitted to the critical care unit with a diagnosis of possible meningitis. Action the nurse anticipates include all of the following except?

A. placing the patient on contact precautions.

all of the following are true about the brainstem functions except:

A. the brainstem is responsible for temperature control. (pg.338)

Mechanisms for development of diabetes insipidus include which of the following? (Select all that apply.)

ADH deficiency. ADH insensitivity.

Secondary immunodeficiency involves the loss of a previously functional immune defense system, which can be caused by (Select all that apply.)

AIDS. aging. nutritional deficiencies. immunosuppressive therapies

The most common reasons for initiating dialysis in acute kidney injury include which of the following? (Select all that apply.)

Acidosis Volume overload Hyperkalemia Uremia

The nurse has just completed administration of a 500 mL bolus of 0.9% normal saline in a patient with hypovolemic shock. 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?

Additional interventions are indicated.

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 which of the following? (Select all that apply.)

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

Which of the following are appropriate nursing interventions for the patient in myxedema coma? (Select all that apply.)

Administer levothyroxine as prescribed. Initiate passive rewarming interventions. Monitor airway and respiratory effort.

The nurse is caring for a patient admitted to the emergency department in status epilepticus. Vital signs assessed by the nurse include blood pressure 160/100 mm Hg, heart rate 145 beats/min, respiratory rate 36 breaths/min, oxygen saturation (SpO2) 96% on 100% supplemental oxygen by non-rebreather mask. After establishing an intravenous (IV) line, which prescription by the provider should the nurse implement first?

Administer lorazepam.

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?

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

A patient is admitted to the emergency department with clinical indications of an acute myocardial infarction. Symptoms began 3 hours ago. The facility does not have the capability for percutaneous coronary intervention. Given this scenario, what is the priority intervention in the treatment and nursing management of this patient?

Administer thrombolytic therapy unless contraindicated

The nurse is caring for a patient with cystic fibrosis (CF) and understands that treatment consists of which of the following? (Select all that apply.)

Airway clearance therapies. Antibiotic therapy. Nutritional support. Lung transplant.

What psychosocial factors may potentially contribute to the development of diabetic ketoacidosis? (Select all that apply.)

Altered sleep/rest patterns. Eating disorder. High levels of stress. Lack of financial resources

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

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

A reduction in the number of circulating RBCs or hemoglobin, which leads to inadequate oxygenation of tissues, is known as?

Anemia.

The nurse is caring for a patient with burns to the hands, feet, and major joints. The nurse plans care to include which of the following? (Select all that apply.)

Applying splints that maintain the extremity in an extended position. Implementing passive or active range-of-motion exercises. Wrapping fingers and toes individually with bandages.

An elderly individual from an assisted-living facility (ALF) presents with severe scald burns to the buttocks and back of the thighs. The caregiver from the ALF accompanies the patient to the emergency department and states that the bath water was "too hot" and that the "patient sat in the water too long." What should the nurse do?

Ask the caregiver to step out while examining the patient's burn injury.

The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine injury who is complaining of a severe headache. The nurse assesses a blood pressure of 180/90 mm Hg, heart rate 60 beats/min, respirations 24 breaths/min, and 50 mL of urine via indwelling urinary catheter for the past 4 hours. What is the best action by the nurse?

Assess for a kinked urinary catheter and assess for bowel impaction.

The nurse is caring for a patient who is receiving several cardiac medications designed to stimulate the sympathetic nervous system, vitamin B12, and an H2 blocker. The nurse should do which of the following?

Assess for signs of peptic ulcer.

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?

Assess the blood pressure by Doppler.

The patient is admitted to the unit with the diagnosis of rhabdomyolysis. The patient is started on intravenous (IV) fluids and IV mannitol. What action by the nurse is best?

Assess the patient's lungs.

A patient with severe burns had a dietitian consultation for nutritional support. The patient weighs 145 pounds. What recommendations by the dietitian does the nurse anticipate initiating? (Select all that apply.)

At least 2307 kcal/day. Juven formula.

A patient presents to the emergency department with suspected thyroid storm. The nurse should be alert to which of the following cardiac rhythms while providing care to this patient?

Atrial fibrillation

The term used to describe an increase in blood urea nitrogen (BUN) and serum creatinine is?

Azotemia.

A superficial partial-thickness (second-degree) burn is characterized by?

B. Blistered skin with pink or most base.

Lung-protective ventilation strategies include?

B. Vt at 4-8 ml/kg predicted ideal body weight.

What is responsible for maintaining the body's oncotic pressure?

B. albumin.

A provider orders a cosyntropin test to assess adrenal status. Which of the following statements is true regarding the test?

B. dexamethasone administration does not affect cortisol values and can be administered in emergency situations.

Which of the following activities may help decrease increased intracranial pressure?

B. head elevation to 30 degrees.

An immunocompromised patient has a high risk of developing a life threatening infection. An awareness of abnormal laboratory results can be key to early detection and intervention. The term shift to the left is indicative of an acute bacterial infection and observed with the following laboratory results?

B. increased number of band neutrophils compared to mature neutrophils.

Which patient symptom requires further urgent evaluation to address possible compartment syndrome?

B. increasing pain.

Glomerular filtration rate is directly influenced by?

B. mean arterial pressure.

When the patient's hematological and immunological systems are compromised, it is not uncommon to require transfusions of several different types of blood products. What patient condition would warrant the administration of platelets as the first consideration?

B. thrombocytopenia

The palmar surface, including the fingers, of the patient's hand represents what percent of his or her total body surface area?

B.1%

Which of the following factors increase the burn patient's risk for venous thromboembolism? (Select all that apply.)

Bed rest. Burns to lower extremities. Delayed fluid resuscitation.

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 flu like 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.)

Blood glucose: 524 mg/dL HCO3—: 10 mEq/L pH:7.23

Evidence based interventions for the prevention of ventilator-associated pneumonia (VAP) include?

C. Regular antiseptic oral care.

An elderly patient presented to a hospital's emergency department with a chief complaint of constipation for 1 week. The patient has a medical history of hypertension, diabetes, and hyperlipidemia. The patient had been taking calcium supplements for a year. What should the nurse perform first?

C. assess the patient for abdominal pain and usual diet.

Which of the following assessment findings indicate that the patient with an acute cervical spinal cord injury is experiencing neurogenic shock?

C. blood pressure of 84/56 mm hg and heart rate of 41 beats/min.

The critical care nurse has just completed the second blood glucose bed-side assessment. The results of both of the blood glucose values are as follows: 315 mg at 0900 and 350 mg at 1300. What is the priority in terms of nursing actions given the findings?

C. notify the provider, as two consecutive blood glucose measurements are greater than 300 mg in a 12 hour period.

The primary goal of continuous venovenous hemofiltration(CVVH) is to?

C. optimize fluid balance

The key purpose of the primary survey is to?

C. quickly identify and treat the greatest life-threatening emergencies.

Upon admission to the critical care unit, the patient's serum potassium is 8.1 mEq. Tall peaked T waves, prolonged QRS duration, and bradycardia are noted. Which pharmacological intervention would be most appropriate for this situation?

C.calcium chloride 5-10 ml of a 10% solution given by slow IV injection.

The nurse is caring for a patient with an ICP of 18 mm Hg and a GCS score of 3. Following the administration of mannitol (Osmitrol), which assessment finding by the nurse requires further action?

CVP of 2 mm Hg

The nurse is caring for a patient who suffered a head trauma following a fall. The patient's heart rate is 112 beats/min and blood pressure is 88/50 mm Hg. The patient has poor skin turgor and dry mucous membranes. The patient is 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?

Cerebral salt wasting

The nurse is caring for a patient receiving intravenous ibuprofen for pain management. The nurse recognizes which laboratory assessment to be a possible side effect of the ibuprofen?

Creatinine: 3.1 mg/dL

Which of the following patients would require greater amounts of fluid resuscitation to prevent acute kidney injury associated with rhabdomyolysis? (Select all that apply.)

Crush injury to right arm Lightning strike of the left arm and chest

Following an assessment of the blood glucose via fingerstick, a value of 54 mg was obtained on critical care patient. What is the priority intervention using the 15/15 rule for glucose management?

D. 1 tablespoon (15 grams) of sugar and repeat fingerstick in 15 minutes to determine effectiveness of intervention.

Appropriate initial management of a patient with a documented inhalation injury includes?

D. 100% humidified oxygen to decrease carboxyhemoglobin levels.

An example of a pathological reflex in an adult is?

D. Babinski reflex