Critical Care Final Exam

The primary purpose of monitoring bladder pressures in a client who has a distended abdomen after surgical bowel repair and received massive fluid resuscitation is to

indirectly detect intra-abdominal hypertension

A client with a traumatic brain injury hs an arterial blood pressure of 88/50, a CVP reading of 4, and intracranial pressure (ICP) reading of 14. Based on the assessments, the mot effective treatment at this time would be

0.9% NaCl fluid bolus

A client has sustained burns to the anterior and posterior surfaces of both arms, and the entire anterior surface of the right leg. Using the rule of nines, the nurse determines that the total burn surface area (TBSA) is?

27

A client is brought to ED by family following exposure to automobile exhaust in a closed garage. The client is lethargic, has flushed skin color, is breathing spontaneously at 12. The initial nursing priority for this client is

100% O2 non-rebreather mask

Amiodarone is available with 900 mg in 500 mL. To administer 1 mg/min to a client weighing 116 pounds, the nurse will set the infusion pump to deliver ___ mL/hr.

33.3

At the end of 30 minute breathing tial for a 75 kg adult client, the respiratory therapist documents spontaneous breathing parameters to evaluate for extubation. The nurse reports readiness for extubation for which assessment set?

400 mL, Propofol on hold, RR 20, RASS 0

The nurse is participating in the care of a client who has second and third degree burns on an estimated 40% of the skin surface. The client weighs 165 pounds. Using Parkland's formula, the nurse anticipates administration of approximately ___ mL of IV fluid during the first eight hours. (4ml(kg)(%))

6,000

A traumatic brain injury patient undergoing testing for brain death has orders for an apnea test to be performed. The nurse anticipates preparation for this procedure would include

ABG before and after

The client is receiving a beta-1 antagonist by intravenous route. If this therapy is effective, which physical change would the nurse most expect to find?

Decreased heart rate

A traumatic brain injury client has persistent increased intracranial pressure (ICP) after administration of 3% NaCl intravenous infusion, and drainage of CSF from their ventricular drain. The nurse understands that next steps to control ICP may include

High dosing of barbiturates to induce a comatose state

When assessing a client with a traumatic brain injury, the nurse suspects a subdural hematoma when symptoms include

Progressively decreasing level of consciousness

A client with a stab wound to the chest is brought to the ED. Which assessment finding would lead the nurse to suspect an open pneumothorax with this injury?

A sucking sound from the chest that occurs with inspiration

The nurse caring for a client with a blunt abdominal trauma that resulted in renal fracture recognizes that flank ecchymosis may be a sign of

Retroperitoneal bleeding

The nurse is assessing a client who has an obvious broken femur after a car crash, the nurse suspects fat emboli syndrome based on which set of symptoms

confusion, SOB, and increased RR

A client's assessment data includes central venous pressure (CVP) 17, distended neck veins, and coarse breath sounds that partly clear with coughing and deep breathing. From this information, the nurse suspects that the client has

high volume status

A client with complaints of substernal chest pain is admitted to emergency of a hospital without a cardiac catheterization lab is diagnosed as an ST segment elevated MI (STEMI). The physician orders alteplase (tPA) administration STAT. incorrect prioritization by the nurse would be

holding alteplase until aspirin, clopidogrel, and lovastatin are given

The nurse is assisting with emergency care at the scene for a victim who has burns to the lower extremities. After confirming airway status and breathing status, the next priority is

Establishing peripheral IV access

A client with an acute anterior wall STEMI is SOB and desaturating. Which value may be associated with cardiogenic shock causing pulmonary congestion/edema?

PCWP 20

An adult with an abdominal gunshot wound has been brought to the ED of a level 1 trauma center. The secondary assessment vital signs include temperature 35.5, BP 72/46, pulse 140, respirations 32. When replacing fluid volume which statement is true?

Packed red blood cell replacement is a priority

Teaching a client with a new ICD (implanted cardioverter-defibrillator), the nurse would include instructions that

Activities that raise the heart rate should be avoided or limited initially

A COPD client with right sided pneumonia is intubated and ventilated for acute respiratory failure, Type II. when planning care, the nurse anticipates

Administration of antibiotics and bronchodilators

The initial assessment of a traumatic brain injury client is a total GCS score of 7. Based on safety protocol, the treatment team correctly proceeds with

Airway management including endotracheal intubation

The nurse is admitting a client who has sustained burn injuries following a suicide bombing in a crowded mall. The client has facial burns and is wheezing. This client is at greatest initial risk for

Airway obstruction

An assault victim is brought to ED following a bar fight. Assessment reveals bleeding gums where several teeth are missing, and moderate bleeding from facial, back and chest injuries. After clearing the airway, the next intervention would be to

Apply a cervical collar to stabilize the neck area

A client's cardiac rhythm changes to the one shown in the rhythm strip below. The nex action with the highest priority is

Assess level of consciousness and blood pressure

The nurse receives a client after significant blood loss from GI bleeding. Assessments reveal normothermia, MAP 60, UO 0.4, CVP 3, sinus tachycardia, and hemoglobin 6.8. The nurse prioritizes a need for

Packed red blood cells

A client diagnosed with a NSTEMI presents with epigastric pain over the past 24 hours, ECG ST-segment depression in anterior leads, and cardiac troponin level of 1.8. Vital signs and rhythm are stable. The highest priority for immediate care of this patient is

Preparing for immediate re-perfusion with percutaneous coronary intervention (PCI) or thrombolytic therapy

When teaching the chemistry department about treatment of chemical burns, the nurse explains that

Blisters should always be broken

In addition to hypothermia, which other symptoms would indicate a client is developing neurogenic shock?

Bradycardia and warm skin

A client's ECG monitor alarms for the following dysrhythmia. The nurse responds by placing the lowest priority on

Preparing sedation in expectation of the need for electrical cardioversion

While providing initial care for a client with a diagnosis of acute coronary syndrome, the nurse notes an allergy to beta blockers, and an ordered dose of metoprolol. The nurse provides an SBAR communication recommending the substitution of metoprolol with a(n)

Calcium channel blocker

Immediately following coronary artery bypass graft (CABG) surgery, the mediastinal chest tube abruptly stops draining and no drainage or clots are visible in the tubin. The nurse responds based on the understanding that

Cardiac tamponade can occur requiring urgent treatment by a physician

One hour following insertion of a pleural chest tube (CT) for treatment of pneumothorax for a chest stab wound, the nurse notes a small amount of new serous red drainage in the fluid collection chamber. The nurse correctly

Closely monitor

A client who was in a motor vehicle crash has a displaced pelvic fracture confirmed by X-ray. Which nursing plan of care will decrease risk of complications?

Confirm the fracture has been stabilized

Paramedics provide a report on a client who had a motor vehicle casht that was an abrupt acceleration-deceleration mechanism of injury caused by hitting a tree while unrestrained. The client struck their head on the windshield and was thrown backwards. The trauma team responds with the understanding that the highest risk of injury is

Coupe and contra-coupe contusions

During the first day pos trauma, an 80-kg traumatic brain injury victim is on mechanical ventilation with tidal volume 600 mL, FiO2 40%, assist control (AC) mode, rate (f) of 16, positive end expiratory pressure (PEEP) of 5. The respiratory rate is consistently 16, and respiratory alkalosis is noted on the ABG report. The best action at this time is to seek an order to

Decrease the ventilator breath rate (f)

A client with a traumatic brain injury is ordered intravenous vasopressin. The nurse understands this drug is used to treat which complication?

Diabetes Insipidus (DI)

A client develops a new onset of the rhythm noted below. Assessment reveals sudden complaints of significant dizziness, chest pressure, shortness of breath and BP 78/40. Which is the priority treatment?

Electrical cardioversion

A burn client has had a meshed, split thickness skin graft applied to the upper arm, over the inner antecubital joint. Immediate postoperative nursing interventions for the arm following this grafting procedure would include

Elevate the extremity above the level of the heart

While planning care for a traumatic brain injury patient, the nurse monitors for adequate cerebral tissue perfusion by setting a patient centered goal, such as maintaining the

ICP <22

While working with the trauma team, the nurse is guided by the understanding that the major goal during the primary survey of a trauma victim is

Identify and treat life-threatening injuries

The nurse is assessing a client with full thickness burns of the left leg. The left pedal pulse is not palpable and cannot be located with a Doppler device. Which action is the next priority?

Immediately notifying the physician of assessment findings

A client has suffered an electrocution burn. When dark concentrated urine is noted the nurse anticipates an order for

Increasing IV fluid rate

The nurse is explaining the different types of heart valve replacement options to the family members of a frail elderly client who requires an aortic valve replacement. For this client a

Mechanical valve requires 12 months of anticoagulation therapy

A client is receiving hydrotherapy treatment for a deep partial thickness burn. What is considered a priority intervention prior to this treatment?

Medicate client with pain meds at least 30 minutes prior to start of therapy

A client presents to ED with a BP of 255/170. The nurse caring for the client anticipates an order for administration of

Nitroprusside (Nipride) IV drip

A nurse is participating in the initial assessment and treatment of a patient with multiple injuries from a motor vehicle crash. Which action is part of the secondary survey phase of care?

Obtain medical history and allergy information

The nurse uses the Sequential Organ Failure Assessment (SOFA) to evaluate an elderly client admitted for pneumonia and possible sepsis. Sputum is + for bacteria; which other data set would indicate organ failure in this client?

P/F ratio 220, bilirubin elevated

The nurse calculates P/F ratio daily to assess gas exchange status for patients on mechanical ventilation. Which set of client data indicates the lowest gas exchange and greatest amount of oxygen shunting? (greatest shunt= lowest ventilation= lowest P/F)

P/F ratio 250

The nurse is providing care for a traumatic brain injury patient receiving continuous IV midazolam (Versed) to achieve deep sedation. When performing a neurological assessment for this patient, the best indication of neurological status is assessment of

Pupil response to light

A nurse is assisting with disaster triage at the scene of a bridge collapse. Assessment of victim reveals lethargy, respiratory rate of 24, and pulse rate of 118. When asked to squeeze the nurse's hand, the victim is unable to do so. Using mass casualty triage guidelines, the victim should receive a

Red tag for immediate transportation

For a client with multiple penetrating stab wounds, the nurse understands the extended focused assessment sonogram for trauma (eFAST) test would be least useful in detecting

Retroperitoneal fluid

A client's third day post-surgical bowel resection QSOFA score increases to 2 and the nurse notes these lab results have become abnormal; the bilirubin level has increased to 3.3, and creatinine level doubled to 2. Based on these lab results, the RN should suspect __ and monitor for ___.

Sepsis, further organ dysfunction

A client's cardiac alarm sounds, and the nurse notes the rhythm below. Initial assessment reveals unconsciousness and no pulse. Following AHA guidelines, after calling for help what are the next two priority actions?

Start chest compressions and defibrillate as soon as possible

The nurse is teaching a client how to use an Epi-Pen to treat anaphylaxis for a bee sting. The client asks the nurse how this will help. The best response is to explain, the epinephrine is needed quickly

To constrict blood vessels and increase blood pressure

To determine if a client with a subarachnoid hemorrhage is experiencing cerebral vasospasms, the nurse consults the results of the

Transcranial Doppler (TCD)

When preparing discharge instructions for a client diagnosed with a mild concussion, the nurse includes which correct statement?

Treat your headache with acetaminophen as needed

The nurse finds an elderly client on the floor with a visible head injury. After establishing airway, breathing and circulation, the nurse places the highest priority on

Using voice, touch, or pain to determine level of consciousness

When providing care for a client on mechanical ventilation with a traumatic brain injury (TBI), the nurse observes increased agitation and pulling on wrist restraints. The nurse responds by taking the next priority actions of

Verbal reassurance and assessment of neuro and oxygenation status

Match the cardiac disturbance on the right with the expected treatment on the left.

· Check serum K and MG- normal sinus rhythm with PVCs · Synchronized cardioversion- unstable SVT · Atropine 0.5-1 mg IVP- symptomatic sinus bradycardia · Immediate defibrillation- ventricular fibrillation (VF) · No treatment necessary- sinus rhythm with first degree heart block

The nurse is caring for a client who had a coronary artery bypass graft (CABG) post op day one. Priority interventions for this patient would include

encouraging coughing and deep breathing and using incentive spirometer

A pulmonary artery catheter is placed in a hypotensive client following a motor vehicle crash. Initial readings include: right atrial pressure (RAP) 1, pulmonary artery pressure (PAP) 15/5, pulmonary capillary wedge pressure (PCWP) 2, cardiac output (CO) 3.9, cardiac index (CI) 2.1. The nurse prioritizes the need for

fluid volume replacement to increase preload

The nurse interprets arterial blood gas results: pH 7.44, PaCo2 32, PaO2 80, HCo3 18 as

fully compensated metabolic alkalosis

Which treatment modality has been associated with the greatest improvement in survival rates in acute respiratory distress syndrome (ARDS, resp. Failure type 1)

lung protective ventilation (LPV), low tidal volume

A client's lab result reflects significant hypokalemia, the nurse is aware that this maybe a contributing factor to the rhythm seen on the strip below identified as

normal sinus rhythm with multi-focal pvcs

A client presents to ED with complaints of leg pain following a deep puncture wound to the thigh. Initial assessment reveals necrotic tissue surrounding the wound and purulent drainage. The nurse places the highest priority on

obtaining wound and blood cultures

Which ABG result would relate to a client with diagnosis of septic shock and a trend of elevated lactate acid levels?

pH 7.22, PaCO2 38, HCO3 16

A trauma victim with chest injury demonstrates hypotension, jugular vein distension, SpO2 of 91% on 40% facemask, heart rate 120, pulse pressure 20 (trending down), respiratory rate 24, the nurse suspects the complication of

pericardial tamponade

Select all the signs suggestive of compartment syndrome after a compression injury of the forearm

· Complaints of pain rated as 10/10 · Shiny tense swollen skin on the forearm · Numbness and/or tingling in the forearm · Sensory loss-loss of 2 point discrimination

When teaching a client who received three drug eluting stents (DES) following coronary angioplasty, the nurse explains that this type of stent

requires a regimen of aspirin and clopidogrel for at least 12 months

A client admitted following an acute right sided myocardial infarction, develops second degree heart block, Type II. Assessment reveals MAP is 60 and an altered level of consciousness

· Prepare for temporary transcutaneous pacing if atropine resistant · Request a fluid bolus · Document a rhythm strip and notify the physician