Exam 1

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A critically ill patient has a living will in the chart. The patient's condition has deteriorated, but the spouse wants "everything done," regardless of the patient's wishes. Which ethical principle is the spouse violating? a. Autonomy b. Beneficence c. Justice d. Nonmaleficence

A patient has been prescribed nitroglycerin (NTG) in the ED for chest pain. In taking the health history, the nurse will be sure to verify whether the patient has taken medications before admission for: a. erectile dysfunction. b. prostate enlargement. c. asthma. d. peripheral vascular disease.

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? A. High pulmonary artery diastolic pressure and low cardiac output B. Low pulmonary artery occlusive pressure and low cardiac output C. Low systemic vascular resistance and high cardiac output D. Normal cardiac output and low systemic vascular resistance

A patient is admitted to the cardiac surgical intensive care unit after cardiac surgery. Four hours after admission to the surgical intensive care unit at 4 PM, the patient has stable vital signs and normal arterial blood gases (ABGs), and is placed on a T-piece for ventilatory weaning. What interdisciplinary staff member does the nurse notify to assist in the care of this patient while preparing to give this patient diuretics? A. Respiratory therapist to adjust ventilator B. Social worker to notify family C. Phlebotomy to obtain another set of blood gasses D. Nursing assistant to help reposition the patient

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? a. Administer thrombolytic therapy unless contraindicated b. Diurese aggressively and monitor daily weight c. Keep oxygen saturation levels to at least 88% d. Maintain heart rate above 100 beats/min

A patient presents to the ED complaining of severe substernal chest pressure radiating to the left shoulder and back that started about 12 hours ago. The patient delayed coming to the ED, hoping the pain would go away. The patient's 12-lead ECG shows ST-segment depression in the inferior leads. Troponin and CK-MB are both elevated. What does the nurse understand about thrombolysis in this patient? a. The patient is not a candidate for thrombolysis. b. The patient's history makes him a good candidate for thrombolysis. c. Thrombolysis is appropriate for a candidate having a non-Q wave MI. d. Thrombolysis should be started immediately.

A patient presents to the emergency department (ED) with chest pain that he has had for the past 2 hours. The patient is nauseated and diaphoretic, with dusky skin color. The electrocardiogram shows ST elevation in leads II, III, and aVF. Which therapeutic intervention would the nurse question? a. Emergent pacemaker insertion b. Emergent percutaneous coronary intervention c. Emergent thrombolytic therapy d. Immediate coronary artery bypass graft surgery

A patient's endotracheal tube is not secured tightly. The respiratory care practitioner assists the nurse in taping the tube. After the tube is retaped, the nurse auscultates the patient's lungs and notes that the breath sounds over the left lung fields are absent. The nurse suspects that A. The endotracheal tube is in the right mainstem bronchus. B. The patient has a left pneumothorax. C. The patient has aspirated secretions during the procedure. D. The stethoscope earpiece is clogged with wax.

A patient's ventilator settings are adjusted to treat hypoxemia. The fraction of inspired oxygen is increased from 0.6 to 0.7, and the positive end-expiratory pressure is increased from 10 to 15 cm H2O. Shortly after these adjustments, the nurse notes that the patient's blood pressure drops from 120/76 mm Hg to 90/60 mm Hg. What is the most likely cause of this decrease in blood pressure? A. Decrease in cardiac output B. Hypovolemia C. Increase in venous return D. Oxygen toxicity

After receiving a handoff report from the night shift, the nurse completes the morning assessment of a patient with severe sepsis. Vital signs are: blood pressure 95/60 mm Hg, heart rate 110 beats/min, respirations 32 breaths/min, oxygen saturation (SpO2) 96% on 45% oxygen via Venturi mask, temperature 101.5° F, central venous pressure (CVP/RAP) 2 mm Hg, and urine output of 10 mL for the past hour. The nurse initiates which provider prescription first? A. Administer infusion of 500 mL 0.9% normal saline every 4 hours as needed if the CVP is less than 5 mm Hg. B. Increase supplemental oxygen therapy to maintain SpO2 greater than 94%. C. Administer 40 mg furosemide (Lasix) intravenous as needed if the urine output is less than 30 mL/hr. D. Administer acetaminophen (Tylenol) 650-mg suppository per rectum as needed to treat temperature greater than 101° F.

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 a. bundle of care. b. clinical practice guideline. c. patient safety goal. d. quality improvement initiative.

Elderly patients who require critical care treatment are at risk for increased mortality, functional decline, or decreased quality of life after hospitalization. Assuming each of these patients was discharged from the hospital, which of the following patients is at greatest risk for decreased functional status and quality of life? A. A 70-year-old man who had coronary artery bypass surgery. He developed complications after surgery and had difficulty being weaned from mechanical ventilation. He required a tracheostomy and gastrostomy. He is being discharged to a long-term acute care hospital. He is a widower. B. A 79-year-old woman admitted for exacerbation of heart failure. She manages her care independently but needed diuretic medications adjusted. She states that she is compliant with her medications but sometimes forgets to take them. She lives with her 82-year-old spouse. Both consider themselves to be independent and support each other. C. A 90-year-old man admitted for a carotid endarterectomy. He lives in an assisted living facility (ALF) but is cognitively intact. He is the "social butterfly" at all of the events at the ALF. He is hospitalized for 4 days and discharged to the ALF. D. An 84-year-old woman who had stents placed to treat coronary artery occlusion. She has diabetes that has been managed, lives alone, and was driving prior to hospitalization. She was discharged home within 3 days of the procedure.

Patients often have recollections of the critical care experience. Which is likely to be the most common recollection of patients who required endotracheal intubation and mechanical ventilation? A. Difficulty in communicating B. Inability to get comfortable C. Pain D. Sleep disruption

Sleep often is disrupted for critically ill patients. Which nursing intervention is most appropriate to promote sleep and rest? A. Consult with the pharmacist to adjust medication times to allow periods of sleep or rest between intervals. B. Encourage family members to talk with the patient whenever they are present in the room. C. Keep the television on to provide white noise and distraction. D. Leave the lights on in the room so that the patient is not frightened of his or her surroundings.

The American Nurses Credential Center Magnet Recognition Program supports many actions to ensure that nurses are engaged and empowered to participate in ethical decision making. Which of the following would assist nurses in being involved in research studies? a. Education on protection of human subjects b. Participation of staff nurses on ethics committees c. Written descriptions of how nurses participate in ethics programs d. Written policies and procedures related to response to ethical issues

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 patient's plan of care? A. Insertion of an 18-gauge peripheral intravenous line B. Application of cushioned heel protectors C. Implementation of fall precautions D. Implementation of universal precautions

The nurse is a member of a committee to design a critical care unit in a new building. Which design trend would best facilitate family-centered care? A.Ensure that the patient's room is large enough and has adequate space for a sleeper sofa and storage for family members' personal belongings. B. Include a diagnostic suite in close proximity to the unit so that the patient does not have to travel far for testing. C. Incorporate a large waiting room on the top floor of the hospital with a scenic view and amenities such as coffee and tea. D. Provide access to a scenic garden for meditation.

The nurse is caring for a mechanically ventilated patient following insertion of a left subclavian central venous catheter (CVC). Which action by the nurse best protects against the development of a central line-associated bloodstream infection (CLABSI)? A. Documentation of insertion date B. Elevation of the head of the bed C. Assessment for weaning readiness D. Appropriate sedation management

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? A. Dobutamine B. Furosemide C. Phenylephrine D. Sodium nitroprusside

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? A. Assess the blood pressure by Doppler. B. Estimate the systolic pressure as 60 mm Hg. C. Obtain an electronic blood pressure monitor. D. Record the blood pressure as "not assessable."

The nurse is caring for a patient following insertion of an intraaortic balloon pump (IABP) for cardiogenic shock unresponsive to pharmacotherapy. Which hemodynamic parameter best indicates an appropriate response to therapy? A. Cardiac index (CI) of 2.5 L/min/m2 B. Pulmonary artery diastolic pressure of 26 mm Hg C. Pulmonary artery occlusion pressure (PAOP) of 22 mm Hg D. Systemic vascular resistance (SVR) of 1600 dynes/sec/cm−5

The nurse is caring for a patient in cardiogenic shock 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? A. "The action of the machine will improve blood supply to the damaged heart." B. "The machine will beat for the damaged heart with every beat until it heals." C. "The machine will help cleanse the blood of impurities that might damage the heart." D. "The machine will remain in place until the patient is ready for a heart transplant."

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? A. Blood cultures B. Chest x-ray C. Foley insertion D. Serum electrolytes

The nurse is caring for a patient who is mechanically ventilated. As part of the nursing care, the nurse understands that A. Communication with intubated patients is often difficult. B. Controlled ventilation is the preferred mode for most patients. C. Patients with chronic obstructive pulmonary disease wean easily from mechanical ventilation. D. Wrist restraints are applied to all patients to avoid self-extubation.

The nurse is caring for a patient who is on a cardiac monitor. The nurse realizes that the sinus node is the pacemaker of the heart because it is a. the fastest pacemaker cell in the heart. b. the only pacemaker cell in the heart. c. the only cell that does not affect the cardiac cycle. d. located in the left side of the heart.

Which of the following statements about family assessment is false? A. Assessment of structure (who comprises the family) is the last step in assessment. B. Interaction among family members is assessed. C. It is important to assess communication among family members to understand roles. D. Ongoing assessment is important, because family functioning may change during the course of illness.

The nurse is caring for an 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 patient's skin is warm and flushed. What is the best interpretation of these findings by the nurse? A. The patient is developing neurogenic shock. B. The patient is experiencing an allergic reaction. C. The patient most likely has an elevated temperature. D. The vital signs are normal for this patient.

The nurse is providing care to a patient on fibrinolytic therapy. Which statement from the patient warrants further assessment and intervention by the critical care nurse? a. "I have an incredible headache!" b. "There is blood on my toothbrush!" c. "Look at the bruises on my arms!" d. "My arm is bleeding where my IV is!"

The nurse is reading the cardiac monitor and notes that the patient's heart rhythm is extremely irregular and that there are no discernible P waves. The ventricular rate is 90 beats per minute, and the patient is hemodynamically stable. The nurse realizes that the patient's rhythm is a. atrial fibrillation. b. atrial flutter. c. atrial flutter with rapid ventricular response. d. junctional escape rhythm.

The patient has a permanent pacemaker inserted. The provider has set the pacemaker to the demand mode at a rate of 60 beats per minute. The nurse realizes that a. the pacemaker will pace only if the patient's intrinsic heart rate is less than 60 beats per minute. b. the demand mode often competes with the patient's own rhythm. c. the demand mode places the patient at risk for the R-on-T phenomenon. d. the fixed-rate mode is safer and is the mode of choice.

The patient has an irregular heart rhythm. To determine an accurate heart rate, the nurse would first a. identify the markers on the ECG paper that indicate a 6-second strip. b. count the number of small boxes between two consecutive P waves. c. count the number of small boxes between two consecutive QRS complexes. d. divides the number of complexes in a 6-second strip by 10.

The patient is admitted with a suspected acute myocardial infarction (AMI). In assessing the 12-lead electrocardiogram (ECG) changes, which findings would indicate to the nurse that the patient is in the process of an evolving Q wave myocardial infarction (MI)? a. ST-segment elevation on ECG and elevated CPK-MB or troponin levels b. Depressed ST-segment on ECG and elevated total CPK c. Depressed ST-segment on ECG and normal cardiac enzymes d. Q wave on ECG with normal enzymes and troponin levels

The patient is having premature ventricular contractions (PVCs). The nurse's greatest concern should be: a. the proximity of the R wave of the PVC to the T wave of a normal beat. b. the fact that PVCs are occurring, because they are so rare. c. whether the number of PVCs is decreasing. d. whether the PVCs are wider than 0.12 seconds.

The patient presents to the ED with severe chest discomfort. A cardiac catheterization and angiography shows an 80% occlusion of the left main coronary artery. Which procedure will be most likely performed on this patient? a. Coronary artery bypass graft surgery b. Intracoronary stent placement c. Percutaneous transluminal coronary angioplasty (PTCA) d. Transmyocardial revascularization

The patient's heart rhythm shows an inverted P wave with a PR interval of 0.06 seconds. The heart rate is 54 beats per minute. The nurse recognizes the rhythm is due to the a. loss of sinus node activity. b. increased rate of the AV node. c. increased rate of the SA node. d. decreased rate of the AV node.

Which of the following assists the critical care nurse in ensuring that care is appropriate and based on research? a. Clinical practice guidelines b. Computerized physician order entry c. Consulting with advanced practice nurses d. Implementing Joint Commission National Patient Safety Goals

Which of the following professional organizations best supports critical care nursing practice? A. American Association of Critical-Care Nurses B. American Heart Association C. American Nurses Association D. Society of Critical Care Medicine

While monitoring a patient for signs of shock, the nurse understands which system assessment to be of priority? A. Central nervous system B. Gastrointestinal system C. Renal system D. Respiratory system

Family presence is encouraged during resuscitation and invasive procedures. Which findings about this practice have been reported in the literature? (Select all that apply.) A. Families benefit by witnessing that everything possible was done. B. Families report reduced anxiety and fear about what is being done to the patient. C. Presence encourages family members to seek litigation for improper care. D. Presence reduces nurses' involvement in explaining things to the family. E. Families report that staff conversations during this time were distressing.

A, B

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.) a. Dobutamine b. Intraaortic balloon pump c. Nesiritide d. Ventricular assist device e. Biventricular pacemaker

A, B, C

Which of the following are common causes of sinus tachycardia? (Select all that apply.) a. Hyperthyroidism b. Hypovolemia c. Hypothyroidism d. Heart Failure e. Sleep

A, B, D

The patient is admitted with a condition that requires cardiac rhythm monitoring. To apply the monitoring electrodes, the nurse must first a. apply a moist gel to the chest. b. make certain that the electrode gel is dry. c. avoid soaps to avoid skin irritation. d. clip chest hair if needed.

The patient tells the nurse, "I didn't think I was having a heart attack because the pain was in my neck and back." The nurse explains: (Select all that apply.) a. "Pain can occur anywhere in the chest, neck, arms, or back. Don't hesitate to call the emergency medical services if you think it's a heart attack." b. "For many people chest pain from a heart attack occurs in the center of the chest, behind the breastbone." c. "The sooner the patient can get medical help, the less damage is likely to occur in case of a heart attack." d. "You need to make sure it's a heart attack before you call the emergency response personnel." e. "Often symptoms can be treated with nitroglycerin, so be sure to take several before calling 911."

A, B, C

A patient is admitted with an acute myocardial infarction (AMI). The nurse monitors for which potential complications? (Select all that apply.) a. Cardiac dysrhythmias b. Heart failure c. Pericarditis d. Ventricular rupture e. Chest pain

A, B, C, D

Sinus bradycardia is a symptom of which of the following? (Select all that apply.) a. Calcium channel blocker medication b. Beta blocker medication c. Athletic conditioning d. Hypothermia e. Hyperthyroidism

A, B, C, D

The critical care environment is often stressful to a critically ill patient. Identify stressors that are common. (Select all that apply.) A. Alarms that sound from various devices B. Bright fluorescent lighting C. Lack of day-night cues D. Sounds from the mechanical ventilator E. Visiting hours tailored to meet individual needs

A, B, C, D

Warning signs that can assist the critical care nurse in recognizing that an ethical dilemma may exist include which of the following? (Select all that apply.) a. Family members are confused about what is happening to the patient. b. Family members are in conflict as to the best treatment options. They disagree with one another and cannot come to consensus. c. The family asks that the patient not be told of treatment plans. d. The patient's condition has changed dramatically for the worse and is not responding to conventional treatment. e. The physician is considering the use of a medication that is not approved to treat the patient's condition.

A, B, C, D, E

Which of the following nursing activities demonstrates implementation of the AACN Standards of Professional Performance? (Select all that apply.) a. Attending a meeting of the local chapter of the American Association of Critical-Care Nurses in which a continuing education program on sepsis is being taught b. Collaborating with a pastoral services colleague to assist in meeting spiritual needs of the patient and family c. Participating on the unit's nurse practice council d. Posting an article from Critical Care Nurse on the management of venous thromboembolism for your colleagues to read e. Using evidence-based strategies to prevent ventilator-associated pneumonia

A, B, C, D, E

Identify the priority interventions for managing symptoms of an acute myocardial infarction (AMI) in the ED. (Select all that apply.) a. Administration of morphine b. Administration of nitroglycerin (NTG) c. Dopamine infusion d. Oxygen therapy e. Transfusion of packed red blood cells

A, B, D

Noise in the critical care unit can have negative effects on the patient. Which of the following interventions assists in reducing noise levels in the critical care setting? (Select all that apply.) A. Ask the family to bring in the patient's iPod or other device with favorite music. B. Invite a volunteer harpist to play on the unit on a regular basis. C. Remodel the unit to have two-patient rooms to facilitate nursing care. D. Remodel the unit to install acoustical ceiling tiles. E. Turn the volume of equipment alarms as low as they can be adjusted, and "off" if possible.

A, B, D

The nurse is caring for a patient with severe neurological impairment following a massive stroke. The physician has ordered tests to determine brain death. The nurse understands that criteria for brain death include (Select all that apply.) a. absence of cerebral blood flow. b. absence of brainstem reflexes on neurological examination. c. Cheyne-Stokes respirations. d. flat electroencephalogram. e. responding only to painful stimuli.

A, B, D

The critical care environment is stressful to the patient. Which interventions assist in reducing this stress? (Select all that apply.) A. Adjust lighting to promote normal sleep-wake cycles. B. Provide clocks, calendars, and personal photos in the patient's room. C. Talk to the patient about other patients you are caring for on the unit. D. Tell the patient the day and time when you are providing routine nursing interventions. E. Allow unlimited visitation tailored to the patient's individual needs.

A, B, E

Which clinical manifestations are indicative of right ventricular failure? (Select all that apply.) a. Jugular venous distension b. Peripheral edema c. Crackles audible in the lungs d. Weak peripheral pulses e. Hepatomegaly

A, B, E

The normal width of the QRS complex is which of the following? (Select all that apply.) a. 0.06 to 0.10 seconds. b. 0.12 to 0.20 seconds. c. 1.5 to 2.5 small boxes. d. 3.0 to 5.0 small boxes. e. 0.04 seconds or greater.

A, C

Which of the following is (are) official journal(s) of the American Association of Critical-Care Nurses? (Select all that apply.) a. American Journal of Critical Care b. Critical Care Clinics of North America c. Critical Care Nurse d. Critical Care Nursing Quarterly e. Critical Care Nursing Management

A, C

The nurse is caring for a mechanically ventilated patient and responds to a high inspiratory pressure alarm. Recognizing possible causes for the alarm, the nurse assesses for which of the following? (Select all that apply.) A. Coughing or attempting to talk B. Disconnection from the ventilator C. Kinks in the ventilator tubing D. Need for suctioning E. Spontaneous breathing

A, C, D

The nurse is caring for a patient whose condition has deteriorated and who is not responding to standard treatment. The physician calls for an ethical consultation with the family to discuss potential withdrawal of treatment versus aggressive treatment. The nurse understands that applying a model for ethical decision making involves which of the following? (Select all that apply.) a. Burden versus benefit b. Family's wishes c. Patient's wishes d. Potential outcomes of treatment options e. Cost savings of withdrawing treatment

A, C, D

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.) a. Transcutaneous pacemaker b. Atropine IV c. Temporary transvenous pacemaker d. Permanent pacemaker e. Amiodarone IV

A, C, D

Which of the following is a National Patient Safety Goal? (Select all that apply.) a. Accurately identify patients. b. Eliminate the use of patient restraints. c. Reconcile medications across the continuum of care. d. Reduce risks of health care-acquired infection. e. Reduce costs associated with hospitalization.

A, C, D

Which strategy is important in addressing issues associated with the aging workforce? (Select all that apply.) a. Allowing nurses to work flexible shift durations b. Encouraging older nurses to transfer to an outpatient setting that is less stressful c. Hiring nurse technicians who are available to assist with patient care, such as turning the patient d. Remodeling patient care rooms to include devices to assist in patient lifting e. Developing a staffing model that accurately reflects the unit's needs.

A, C, D

Which statements are true regarding the symptoms of an AMI? (Select all that apply.) a. Dysrhythmias are common occurrences. b. Men have more atypical symptoms than women. c. Midsternal chest pain is a common presenting symptom. d. Some patients are asymptomatic. e. Patients may complain of jaw or back pain.

A, C, D, E

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.) a. Stroke b. Ashman beats c. Pulmonary emboli d. Prolonged PR interval e. Decreased cardiac output

A, C, E

The nurse is caring for a patient admitted with shock. The nurse understands which assessment findings best assess tissue perfusion in a patient in shock? (Select all that apply.) A. Blood pressure B. Heart rate C. Level of consciousness D. Pupil response E. Respirations F. Urine output

A, C, F

It is important for critically ill patients to feel safe. Which nursing strategies help the patient to feel safe in the critical care setting? (Select all that apply.) A. Allow family members to remain at the bedside. B. Consult with the charge nurse before making any patient care decisions. C. Provide informal conversation by discussing your plans for after work. D. Respond promptly to call bells or other communication for assistance. E. Inform the patient that you have cared for many similar patients.

A, D

The nurse is caring for an 80-year-old patient who has been treated for gastrointestinal bleeding. The family has agreed to withhold additional treatment. The patient has a written advance directive specifying requests. The directive notes that the patient wants food and fluid to be continued. The nurse anticipates that several orders may be written to comply with this request, including which of the following? (Select all that apply.) a. "Do not resuscitate." b. Change antibiotic to a less expensive medication. c. Discontinue tube feeding. d. Stop any further blood transfusions. e. Water boluses every 4 hours with tube feeding.

A, D, E

To reduce relocation stress in patients transferring out of the intensive care unit, the nurse can (Select all that apply.) A. Ask the nurses on the intermediate care unit to give the family a tour of the new unit. B. Contact the intensivist to see if the patient can stay one additional day in the critical care unit so that he and his family can adjust better to the idea of a transfer. C. Ensure that the patient will be located near the nurses' station in the new unit. D. Invite the nurse who will be assuming the patient's care to meet with the patient and family in the critical care unit prior to transfer. E. Help the patient and family focus on the positive meaning of a transfer.

A, D, E

Which of the following strategies will assist in creating a healthy work environment for the critical care nurse? (Select all that apply.) a. Celebrating improved outcomes from a nurse-driven protocol with a pizza party b. Implementing a medication safety program designed by pharmacists c. Modifying the staffing pattern to ensure a 1:1 nurse/patient ratio d. Offering quarterly joint nurse-physician workshops to discuss unit issues e. Using the Situation-Background-Assessment-Recommendation (SBAR) technique for handoff communication

A, D, E

The nurse is assisting with endotracheal intubation of the patient and recognizes that the procedure will be done in what order: _______________, _______________, _______________, _______________, _______________? A. Assess balloon on endotracheal tube for symmetry and leaks B. Assess lung fields for bilateral expansion C. Inflate balloon of endotracheal tube D. Insert endotracheal tube with laryngoscope and blade E. Suction oropharynx

A, E, D, C, B

Which of the following acid-base disturbances commonly occurs with the hyperventilation and impaired gas exchange seen in severe exacerbation of asthma? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

c. Respiratory acidosis

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? A. Diphenhydramine 50 mg intravenously B. Epinephrine 3 to 5 mL of a 1:10,000 solution intravenously C. Methylprednisolone 125 mg intravenously D. Ranitidine 50 mg intravenously

A PaCO2 of 48 mm Hg is associated with A. Hyperventilation. B. Hypoventilation. C. Increased absorption of O2. D. Increased excretion of HCO3.

A patient is admitted to the cardiac surgical intensive care unit after cardiac surgery with the following arterial blood gas (ABG) levels. What action by the nurse is best? pH: 7.4 PaCO2: 40 mm Hg Bicarbonate: 24 mEq/L PaO2: 95 mm Hg O2 saturation: 97% Respirations: 20 breaths/min A. Call the provider to request rapid intubation. B. Document the findings and continue to monitor. C. Request that another set of ABGs be drawn and run. D. Correlate the patient's O2 saturation with the ABGs.

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: A. Hypoxemia and compensated metabolic alkalosis. B. Hypoxemia and compensated respiratory acidosis. C. Normal oxygenation and partly compensated metabolic alkalosis. D. Normal oxygenation and uncompensated respiratory acidosis.

A patient is having a stent and asks why it is necessary after having an angioplasty. Which response by the nurse is best? a. "The angioplasty was a failure, and so this procedure has to be done to fix the heart vessel." b. "The stent is inserted to enhance the results of the angioplasty, by helping to keep the vessel open and prevent it from closing again." c. "This procedure is being done instead of using clot-dissolving medication to help keep the heart vessel open." d. "The stent will remove any clots that are in the vessel and protect the heart muscle from damage."

A patient is having difficulty weaning from mechanical ventilation. The nurse assesses the patient for which potential cause of this difficult weaning? A. Cardiac output of 6 L/min. B. Hemoglobin of 8 g/dL. C. Negative sputum culture and sensitivity. D. White blood cell count of 8000.

A patient was admitted in terminal heart failure and is not eligible for transplant. The family wants everything possible done to maintain life. Which procedure might be offered to the patient for this condition to increase the patient's quality of life? a. Intraaortic balloon pump (IABP) b. Left ventricular assist device (LVAD) c. Nothing, because the patient is in terminal heart failure d. Nothing additional; medical management is the only option

An essential aspect of teaching that may prevent recurrence of heart failure is a. notifying the provider if a 2-lb weight gain occurs in 24 hours. b. compliance with diuretic therapy. c. taking nitroglycerin if chest pain occurs. d. assessment of an apical pulse.

Critical illness often results in family conflicts. Which scenario is most likely to result in the greatest conflict? A. A 21-year-old college student of divorced parents hospitalized with multiple trauma. She resides with her mother. The parents are amicable with each other and have similar values. The father blames the daughter's boyfriend for causing the accident. B. A 36-year-old male admitted for a ruptured cerebral aneurysm. He has been living with his 34-year-old girlfriend for 8 years, and they have a 4-year-old daughter. He does not have a written advance directive. His parents arrive from out-of-state and are asked to make decisions about his health care. He has not seen them in over a year. C. A 58-year-old male admitted for coronary artery bypass surgery. He has been living with his same-sex partner for 20 years in a committed relationship. He has designated his sister, a registered nurse, as his health care proxy in a written advance directive. D. A 78-year-old female admitted with gastrointestinal bleeding. Her hemoglobin is decreasing to a critical level. She is a Jehovah's Witness and refuses the treatment of a blood transfusion. She is capable of making her own decisions and has a clearly written advance directive declining any transfusions. Her son is upset with her and tells her she is "committing suicide."

Family assessment can be challenging, and each nurse may obtain additional information regarding family structure and dynamics. What is the best way to share this information from shift to shift? A. Create an informal family information sheet that is kept on the bedside clipboard. That way, everyone can review it quickly when needed. B. Develop a standardized reporting form for family information that is incorporated into the patient's medical record and updated as needed. C. Require that the charge nurse have a detailed list of information about each patient and family member. Thus, someone on the unit is always knowledgeable about potential issues. D. Try to remember to discuss family structure and dynamics as part of the change-of-shift report.

Family members have a need for information. Which interventions best assist in meeting this need? A.Handing family members a pamphlet that explains all of the critical care equipment B. Providing a daily update of the patient's progress and facilitating communication with the intensivist C. Telling them that you are not permitted to give them a status report but that they can be present at 4:00 PM for family rounds with the intensivist D. Writing down a list of all new medications and doses and giving the list to family members during visitation

One of the early signs of hypoxemia on the nervous system is A. Cyanosis. B. Restlessness. C. Agitation. D. Tachypnea.

One of the functions of the atrioventricular (AV) node is to a. pace the heart if the ventricles fail. b. slow the impulse arriving from the SA node. c. send the impulse to the SA node. d. allow for ventricular filling during systole.

Oxygen saturation (SaO2) represents A. Alveolar oxygen tension. B. Oxygen that is chemically combined with hemoglobin. C. Oxygen that is physically dissolved in plasma. D. Total oxygen consumption.

The VALUE mnemonic is a helpful strategy to enhance communication with family members of critically ill patients. Which of the following statements describes a VALUE strategy? A. View the family as guests on the unit. B. Acknowledge family emotions. C. Learn as much as you can about family structure and function. D. Use a trained interpreter if the family does not speak English.

The family members of a critically ill patient bring a copy of the patient's living will to the hospital, which identifies the patient's wishes regarding health care. You discuss contents of the living will with the patient's physician. This is an example of implementation of which of the AACN Standards of Professional Performance? a. Acquires and maintains current knowledge of practice b. Acts ethically on the behalf of the patient and family c. Considers factors related to safe patient care d. Uses clinical inquiry and integrates research findings in practice

The normal rate for the SA node when the patient is at rest is a. 40 to 60 beats per minute. b. 60 to 100 beats per minute. c. 20 to 40 beats per minute. d. more than100 beats per minute.

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? A. Patient response to therapy is appropriate. B. Additional interventions are indicated. C. More time is needed to assess response. D. Values are normal for the patient condition.

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? A. Creatinine 1.0 mg/dL B. Lactate 6 mmol/L C. Potassium 3.8 mEq/L D. Sodium 140 mEq/L

The nurse is administering intravenous norepinephrine at 5 mcg/kg/min via a 20-gauge peripheral intravenous (IV) catheter. Which assessment finding requires immediate action by the nurse? A. Blood pressure 100/60 mm Hg B. Swelling at the IV site C. Heart rate of 110 beats/min D. Central venous pressure (CVP) of 8 mm Hg

The nurse is assigned to care for a patient who is a non-native English speaker. What is the best way to communicate with the patient and family to provide updates and explain procedures? A. Conduct a Google search on the computer to identify resources for the patient and family in their native language. Print these for their use. B. Contact the hospital's interpreter service for someone to translate. C. Get in touch with one of the residents who you know is fluent in the native language and ask him if he can come up to the unit. D. Use the patient's 8-year-old child who is fluent in both English and the native language to translate for you.

The nurse is calculating the rate for a regular rhythm. There are 20 small boxes between each P wave and 20 small boxes between each R wave. What is the ventricular rate? a. 50 beats/min b. 75 beats/min c. 85 beats/min d. 100 beats/min

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? A. Administer acetaminophen 650-mg suppository prn every 6 hours for pain. B. Titrate dopamine intravenously for blood pressure less than 90 mm Hg systolic. C. Complete neurological assessment every 4 hours for the next 24 hours. D. Administer furosemide 20 mg IV every 4 hours for a CVP greater than or equal to 20 mm Hg.

The nurse is caring for a critically ill patient on mechanical ventilation. The physician identifies the need for a bronchoscopy, which requires informed consent. For the physician to obtain consent from the patient, the patient must be able to a. be weaned from mechanical ventilation. b. have knowledge and competence to make the decision. c. nod his head that it is okay to proceed. d. read and write in English.

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? A. Furosemide 20 mg intravenous (IV) every 4 hours as needed for CVP greater than or equal to ≥20 mm Hg B. Nitroglycerin infusion titrated at a rate of 5 to 10 mcg/min as needed for chest pain C. Dobutamine infusion at a rate of 2 to 20 mcg/kg/min as needed for CI less than 2 L/min/m2 D. Dopamine infusion at a rate of 5 to 10 mcg/kg/min to maintain a systolic BP of at least 90 mm Hg

The nurse is caring for a patient who has been declared brain dead. The patient is considered a potential organ donor. To proceed with donation, the nurse understands that a. a signed donor card mandates that organs be retrieved in the event of brain death. b. after brain death has been determined, perfusion and oxygenation of organs is maintained until organs can be removed in the operating room. c. the health care proxy does not need to give consent for the retrieval of organs. d. once a patient has been established as brain dead, life support is withdrawn and organs are retrieved.

The nurse is caring for a patient who is declared brain dead and is an organ donor. The following events occur: 1300 Diagnostic tests for brain death are completed. 1330 Intensivist reviews diagnostic test results and writes in the progress note that the patient is brain dead. 1400 Patient is taken to the operating room for organ retrieval. 1800 All organs have been retrieved for donation. The ventilator is discontinued. 1810 Cardiac monitor shows flatline. What is the official time of death recorded in the medical record? a. 1300 b. 1330 c. 1400 d. 1800 e. 1810

The nurse is caring for a patient with severe sepsis who was resuscitated with 3000 mL of lactated Ringer's 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? A. Blood transfusion with packed red blood cells is required. B. Hemoglobin and hematocrit results indicate hemodilution. C. Fluid resuscitation has resulted in fluid volume overload. D. Fluid resuscitation has resulted in third-spacing of fluid.

The nurse is caring for an elderly patient who is in cardiogenic shock. The patient has failed to respond to medical treatment. The intensivist in charge of the patient conducts a conference to explain that treatment options have been exhausted and to suggest that the patient be given a "do not resuscitate" status. This scenario illustrates the concept of a. brain death. b. futility. c. incompetence. d. life-prolonging procedures.

The nurse is examining the patient's cardiac rhythm strip in lead II and notices that all of the P waves are upright and look the same except one that has a different shape and is inverted. The nurse realizes that the P wave with the abnormal shape is probably a. from the SA node because all P waves come from the SA node. b. from some area in the atria other than the SA node. c. indicative of ventricular depolarization. d. normal even though it is inverted in lead II.

The nurse notices ventricular tachycardia on the heart monitor. When the patient is assessed, the patient is found to be unresponsive with no pulse. The nurse should a. treat with intravenous amiodarone or lidocaine. b. begin cardiopulmonary resuscitation and advanced life support. c. provide electrical cardioversion. d. ignore the rhythm because it is benign.

The nurse using cardiac monitoring understands that each horizontal box on the electrocardiogram (ECG) paper indicates a. 200 milliseconds or 0.20 seconds duration. b. 40 milliseconds or 0.04 seconds duration. c. 3 seconds duration. d. millivolts of amplitude.

The patient has undergone open chest surgery for coronary artery bypass grafting. One of the nurse's responsibilities is to monitor the patient for which common postoperative dysrhythmia? a. Second-degree heart block b. Atrial fibrillation or flutter c. Ventricular ectopy d. Premature junctional contractions

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: a. medications to lower heart rate. b. treatment to lower temperature. c. treatment to lower cardiac output. d. treatment to reduce heart rate.

The patient is admitted with an acute myocardial infarction (AMI). Three days later the nurse is concerned that the patient may have a papillary muscle rupture. Which assessment data may indicate a papillary muscle rupture? a. Gallop rhythm b. New murmur c. S1 heart sound d. S3 heart sound

The patient's spouse is feeling overwhelmed about cooking different dinners for the patient and the rest of the family to satisfy a cholesterol-reducing diet. Which response by the nurse is best? a. "It will be worth it to have a healthy spouse, won't it?" b. "The low-cholesterol diet is one from which everyone can benefit." c. "As long as you change at least a few things in the diet, it will be okay." d. "You can go on the diet with him, and then let the children eat whatever they want."

The rhythm on the cardiac monitor is showing numerous pacemaker spikes, but no P waves or QRS complexes following the spikes. The nurse recognizes this as: a. normal pacemaker function. b. failure to capture. c. failure to pace. d. failure to sense.

Which comment by the patient indicates a good understanding of a diagnosis of coronary heart disease? a. "I had a heart attack because I work too hard, and it puts too much strain on my heart." b. "The pain in my chest gets worse each time it happens. I think that there is more damage to my heart vessels as time goes on." c. "If I change my diet and exercise more, I should get over this and be healthy." d. "What kind of pills can you give me to get me over this and back to my lifestyle?"

Which intervention is appropriate to assist the patient in coping with admission to the critical care unit? A. Allowing unrestricted visiting by several family members at one time B. Explaining all procedures in easy-to-understand terms C. Providing back massage and mouth care D. Turning down the alarm volume on the cardiac monitor

Which nursing interventions would best support the family of a critically ill patient? A. Encourage family members to stay all night in case the patient needs them. B. Give a condition update each morning and whenever changes occur. C. Limit visitation from children into the critical care unit. D. Provide beverages and snacks in the waiting room.

Which of the following cardiac diagnostic tests would include monitoring the gag reflex before giving the patient anything to eat or drink? a. Barium swallow b. Transesophageal echocardiogram c. MUGA scan d. Stress test

You are caring for a critically ill patient whose urine output has been low for 2 consecutive hours. After a thorough patient assessment, you call the intensivist with report. Which information do you convey regarding background? a. Urine output of 40 mL/2 hours b. Current vital signs and history of aortic aneurysm repair 4 hours ago c. A statement that the patient is possibly hypovolemic d. A request for IV fluids

You work in an intermediate care unit and have asked to be involved in developing new guidelines to prevent pressure ulcers in your patient population. The nurse manager tells you that you do not yet have enough experience to be on the prevention task force and that your ideas will be rejected by others. This situation is an example a. a barrier to handoff communication. b. a work environment that is unhealthy. c. ineffective decision making. d. nursing practice that is not evidence-based.

The first critical care units were (Select all that apply.) a. burn units. b. coronary care units. c. recovery rooms. d. neonatal intensive care units. e. high-risk OB units.

B, C

The nurse utilizes which of the following strategies when encountering an ethical dilemma in practice? (Select all that apply.) a. Change-of-shift report updates b. Ethics consultation services c. Formal multiprofessional ethics committees d. Pastoral care services e. Social work consultation

B, C

Which nursing interventions would be appropriate after angioplasty? (Select all that apply.) a. Elevate the head of the bed by 45 degrees for 6 hours. b. Assess pedal pulses on the involved limb every 15 minutes for 1 to 2 hours. c. Monitor the vascular hemostatic device for signs of bleeding. d. Instruct the patient to bend his or her knee every 15 minutes while the sheath is in place. e. Maintain NPO status for 12 hours.

B, C

Nursing strategies to help families cope with the stress of critical illness include: (Select all that apply.) A.. Asking the family to leave during the morning bath to promote the patient's privacy. B. Encouraging family members to make notes of questions they have for the physician during family rounds. C. If possible, providing continuity of nursing care. D. Providing a daily update of the patient's condition to the family spokesperson. E. Ensuring that a waiting room stocked with snacks is nearby.

B, C, D

The nurse is assisting with endotracheal intubation and understands that correct placement of the endotracheal tube in the trachea would be identified by which of the following? (Select all that apply.) A. Auscultation of air over the epigastrium B. Equal bilateral breath sounds upon auscultation C. Position above the carina verified by chest x-ray D. Positive detection of carbon dioxide (CO2) through CO2 detector devices E. Fogging of the endotracheal tube

B, C, D

A patient is having a cardiac evaluation to assess for possible valvular disease. Which study best identifies valvular function and measures the size of the cardiac chambers? a. 12-lead electrocardiogram b. Cardiac catheterization c. Echocardiogram d. Electrophysiology study

Select all of the factors that may predispose the patient to respiratory acidosis. (Select all that apply.) A. Anxiety and fear B. Central nervous system depression C. Diabetic ketoacidosis D. Nasogastric suctioning E. Overdose of sedatives

B, E

A 72-year-old woman is brought to the ED by her family. The family states that she's "just not herself." Her respirations are slightly labored, and her heart monitor shows sinus tachycardia (rate 110 beats/min) with frequent premature ventricular contractions (PVCs). She denies any chest pain, jaw pain, back discomfort, or nausea. Her troponin levels are elevated, and her 12-lead electrocardiogram (ECG) shows elevated ST segments in leads II, III, and aVF. The nurse knows that these symptoms are most likely associated with which diagnosis? a. Hypokalemia b. Non-Q wave MI c. Silent myocardial infarction d. Unstable angina

A nurse caring for a patient with neurological impairment often must use painful stimuli to elicit the patient's response. The nurse uses subtle measures of painful stimuli, such as nailbed pressure. She neither slaps the patient nor pinches the nipple to elicit a response to pain. In this scenario, the nurse is exemplifying the ethical principle of a. beneficence. b. fidelity. c. nonmaleficence. d. veracity.

A nurse has been working as a staff nurse in the surgical intensive care unit for 2 years and is interested in certification. Which credential would be most applicable for the nurse to seek? A. ACNPC-AG b. CNML c. CCRN d. PCCN

A nurse who plans care based on the patient's gender, ethnicity, spirituality, and lifestyle is said to a. be a moral advocate. b. facilitate learning. c. respond to diversity. d. use clinical judgment.

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? A. Human albumin infusion B. Hypotonic saline solution C. Lactated Ringer's bolus D. Packed red blood cells

A patient is admitted with an acute myocardial infarction (AMI). The nurse knows that an angiotensin-converting enzyme (ACE) inhibitor should be started within 24 hours to reduce the incidence of which process? a. Myocardial stunning b. Hibernating myocardium c. Myocardial remodeling d. Tachycardia

A patient is admitted with angina. The nurse anticipates which drug regimen to be initiated? a. ACE inhibitors and diuretics b. Morphine sulfate and oxygen c. Nitroglycerin, oxygen, and beta blockers d. Statins, bile acid, and nicotinic acid

A patient is admitted with the diagnosis of unstable angina. The nurse knows that the physiological mechanism present is most likely which of the following? a. Complete occlusion of a coronary artery b. Fatty streak within the intima of a coronary artery c. Partial occlusion of a coronary artery with a thrombus d. Vasospasm of a coronary artery

A patient is being mechanically ventilated in the synchronized intermittent mandatory ventilation mode at a rate of 4 breaths/min. His spontaneous respirations are 12 breaths/min. He receives a dose of morphine sulfate, and his spontaneous respirations decrease to 4 breaths/min. Which acid-base disturbance will likely occur? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

Comparing the patient's current (home) medications with those ordered during hospitalization and communicating a complete list of medications to the next provider when the patient is transferred within an organization or to another setting are strategies to: a. improve accuracy of patient identification. b. prevent errors related to look-alike and sound-alike medications. c. reconcile medications across the continuum of care. d. reduce harms associated with the administration of anticoagulants.

Family assessment is essential to meet family needs. Which of the following must be assessed first to assist the nurse in providing family-centered care? A. Assessment of patient and family's developmental stages and needs B. Description of the patient's home environment C. Identification of immediate family, extended family, and decision makers D. Observation and assessment of how family members function with each other

Ideally, an advance directive should be developed by the a. family if the patient is in critical condition. b. patient as part of the hospital admission process. c. patient before hospitalization. d. patient's health care surrogate.

Many critically ill patients experience anxiety. The nurse can reduce anxiety with which approach? A. Ask family members to limit their visitation to 2-hour periods in morning, afternoon, and evening. B. Explain the unit routine. C. Explain procedures before and while you are doing them. D. Suction Mr. J.'s endotracheal tube immediately when he starts to cough.

Open visitation policies are expected by many professional organizations. Which statement reflects adherence to current recommendations? A. Allow animals on the unit; however, these can only be "therapy" animals through the hospital's pet therapy program. B. Allow family visitation throughout the day except at change of shift and during rounds. C. Determine, in collaboration with the patient and family, who can visit and when. Facilitate open visitation policies. D. Permit open visitation by adults 18 years of age and older; limit visits of children to 1 hour.

The family of your critically ill patient tells you that they have not spoken with the physician in over 24 hours and that they have some questions they want clarified. During morning rounds, you convey this concern to the attending intensivist and arrange a meeting with the family at 4:00 PM. Which competency of critical care nursing does this represent? a. Advocacy and moral agency in solving ethical issues b. Clinical judgment and clinical reasoning skills c. Collaboration with patients, families, and team members d. Facilitation of learning for patients, families, and team members

The nurse caring for patients on cardiac monitors assesses the patient with a prolonged QT interval for a. electrolyte disturbances such as hypokalemia. b. symptomatic bradycardias. c. the development of lethal dysrhythmias. d. difficulty maintaining the blood pressure.

The nurse caring for patients with cardiac monitoring understands that when an electrical signal is aimed directly at the positive electrode, the inflection will be: a. negative. b. upside down. c. upright. d. equally positive and negative.

The nurse is assessing a patient with left-sided heart failure. Which symptom would the nurse expect to find? a. Dependent edema b. Distended neck veins c. Dyspnea and crackles d. Nausea and vomiting

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? A. Administer pain medication. B. Turn patient every 2 hours. C. Assess core body temperature. D. Apply bilateral heel protectors.

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 patient's care plan, what intervention is most important for the nurse to discuss with the multidisciplinary care team? A. Frequent turning B. Monitoring intake and output C. Enteral feedings D. Pain management

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 a. an organ donor. b. brain dead. c. in a persistent vegetative state. d. terminally ill.

The nurse is caring for a patient in cardiogenic shock who is being treated with an infusion of dobutamine. The physician's order calls for the nurse to titrate the infusion to achieve a cardiac index of greater than or equal to 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? A. Obtain a stat serum potassium level. B. Order a stat 12-lead electrocardiogram. C. Reduce the rate of dobutamine. D. Assess the patient's hourly urine output.

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 94.8° F. Which intervention is most important for the nurse to include in the patient's plan of care? A. Administration of atropine sulfate (Atropine) B. Application of 100% oxygen via face mask C. Application of slow rewarming measures D. Infusion of IV phenylephrine (Neo-Synephrine)

The nurse is caring for a patient who is not responding to medical treatment. The intensivist holds a conference with the family, and a decision is made to withdraw life support. The nurse's religious beliefs are not in agreement with the withdrawal of life support. However, the nurse assists with the process to avoid confronting the charge nurse. Afterward the nurse feels guilty for "killing the patient." This scenario is likely to cause a. abandonment. b. family stress. c. moral distress. d. negligence.

The nurse is caring for a patient who sustained a head injury and is unresponsive to painful stimuli. Which intervention is most appropriate while bathing the patient? A. Ask a family member to help you bathe the patient, and discuss the family structure with the family member during the procedure. B. Because the patient is unconscious, complete care as quickly and quietly as possible. C. Tell the patient the day and time, and that you are providing a bath. Reassure the patient that you are there. D. Turn the television on to the evening news so that you and the patient can be updated to current events.

The nurse is caring for a patient with an endotracheal tube. The nurse understands that endotracheal suctioning is needed to facilitate removal of secretions and that the procedure A. Decreases intracranial pressure. B. Depresses the cough reflex. C. Is done as indicated by patient assessment. D. Is more effective if preceded by saline instillation.

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? A. Administer blood transfusion over at least 4 hours. B. Notify the physician of the elevated temperature. C. Titrate rate of blood administration to patient response. D. Notify the physician of the patient's heart rate.

The nurse knows that which of the following statements about organ donation is true? a. Anyone who is comfortable approaching the family should discuss the option of organ donation. b. Brain death determination is required before organs can be retrieved for transplant. c. Donation of selected organs after cardiac death is ethically acceptable. d. Family members should consider the withdrawal of life support so that the patient can become an organ donor.

The nurse notes that the patient's arterial blood gas levels indicate hypoxemia. The patient is not intubated and has a respiratory rate of 22 breaths/min. The nurse's first intervention to relieve hypoxemia is to: A. Call the provider for an emergency intubation procedure. B. Obtain an order for bilevel positive airway pressure (BiPAP). C. Notify the provider of values and obtain a prescription for oxygen. D. Suction secretions from the oropharynx.

The nurse notices that the patient has a first-degree AV block. Everything else about the rhythm is normal. The nurse should a. prepare to place the patient on a transcutaneous pacemaker. b. give the patient atropine to shorten the PR interval. c. monitor the rhythm and patient's condition. d. give the patient an antiarrhythmic medication.

The nurse understands that in a third-degree AV block a. every P wave is conducted to the ventricles. b. some P waves are conducted to the ventricles. c. none of the P waves are conducted to the ventricles. d. the PR interval is prolonged.

The patient has a permanent pacemaker in place with a demand rate set at 60 beats/min. The cardiac monitor is showing a heart rate of 44 beats/min with no pacemaker spikes. The nurse recognizes this as: a. normal pacemaker function. b. failure to capture. c. failure to pace. d. failure to sense.

The patient is admitted with recurrent supraventricular tachycardia that the cardiologist believes to be related to an accessory conduction pathway or a reentry pathway. The nurse anticipates which procedure to be planned for this patient? a. Implantable cardioverter-defibrillator placement b. Permanent pacemaker insertion c. Radiofrequency catheter ablation d. Temporary transvenous pacemaker placement

The patient is asymptomatic but is diagnosed with second-degree heart block Mobitz I. The patient is on digitalis medication at home. The nurse should expect that a. the patient has had an anterior wall myocardial infarction. b. the physician will order the digitalis to be continued in the hospital. c. a digitalis level would be ordered upon admission. d. the patient will require a transcutaneous pacemaker.

The patient is scheduled to have a permanent pacemaker implanted. The patient asks the nurse, "How long will the battery in this thing last?" The nurse should answer, a. "Life expectancy is about 1 year. Then it will need to be replaced." b. "Pacemaker batteries can last up to 25 years with constant use." c. "Battery life varies depending on usage, but it can last up to 10 years." d. "Pacemakers are used to treat temporary problems, so the batteries don't last long."

The patient presents to the ED with sudden, severe sharp chest discomfort, radiating to the back and down both arms, as well as numbness in the left arm. While taking the patient's vital signs, the nurse notices a 30-point discrepancy in systolic blood pressure between the right and left arm. Based on these findings, the nurse should: a. contact the physician and report the cardiac enzyme results. b. contact the physician and prepare the patient for thrombolytic therapy. c. contact the physician immediately and begin prepping the patient for surgery. d. give the patient aspirin and heparin.

The primary mode of action of neuromuscular blocking agents is A. Analgesia. B. Anticonvulsant. C. Paralysis. D. Sedation.

The provider prescribes a pharmacological stress test for a patient with activity intolerance. The nurse would anticipate that the drug of choice would be a. dopamine. b. dobutamine. c. adenosine. d. atropine.

The synergy model of practice focuses on a. allowing unrestricted visiting for the patient 24 hours a day. b. holistic and alternative therapies. c. the needs of patients and their families, which drive nursing competency. d. patients' needs for energy and support.

The vision of the American Association of Critical-Care Nurses is a health care system driven by a. a healthy work environment. b. care from a multiprofessional team under the direction of a critical care physician. c. the needs of critically ill patients and families. d. respectful, healing, and humane environments.

When addressing an ethical dilemma, contextual, physiological, and personal factors of the situation must be considered. Which of the following is an example of a personal factor? a. The hospital has a policy that everyone must have an advance directive on the chart. b. The patient has lost 20 pounds in the past month and is fatigued all the time. c. The patient has told you what quality of life means and his or her wishes. d. The physician considers care to be futile in a given situation.

When assessing the patient for hypoxemia, the nurse recognizes that an early sign of the effect of hypoxemia on the cardiovascular system is A. Heart block. B. Restlessness. C. Tachycardia. D. Tachypnea.

Which intervention about visitation in the critical care unit is true? A. The majority of critical care nurses implement restricted visiting hours to allow the patient to rest. B. Children should never be permitted to visit a critically ill family member. C. Visitation that is individualized to the needs of patients and family members is ideal. D. Visiting hours should always be unrestricted.

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

Which statement regarding ethical concepts is true? a. A living will is the same as a health care proxy. b. A signed donor card ensures that organ donation will occur in the event of brain death. c. A surrogate is a competent adult designated by a person to make health care decisions in the event the person is incapacitated. d. A persistent vegetative state is the same as brain death in most states.

While instructing a patient on what occurs with a myocardial infarction, the nurse plans to explain which process? a. Coronary artery spasm. b. Decreased blood flow (ischemia). c. Death of cardiac muscle from lack of oxygen (tissue necrosis). d. Sporadic decrease in oxygen to the heart (transient oxygen imbalance).

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? A. The assessed values are within normal limits. B. The patient is at risk for developing cardiogenic shock. C. The patient is at risk for developing fluid volume overload. D. The patient is at risk for developing hypovolemic shock.

The nurse is caring for a mechanically ventilated patient and is charting outside the patient's room when the ventilator alarm sounds. What is the priority order for the nurse to complete these actions: _______________, _______________, _______________, _______________? A. Check quickly for possible causes of the alarm that can be fixed B. After troubleshooting, connect back to mechanical ventilator and reassess patient C. Go to patient's bedside D. Manually ventilate the patient while getting a respiratory therapist

C, A, D, B

Acute myocardial infarction (AMI) can be classified as which of the following? (Select all that apply.) a. Angina b. Nonischemic c. Non-Q wave d. Q wave e. Frequent PVCs

C, D

Which scenarios contribute to effective handoff communication at change of shift? (Select all that apply.) a. The nephrology consultant physician is making rounds and asks you for an update on the patient's status and to assist in placing a central line for hemodialysis. b. The noise level is high because twice as many staff members are present and everyone is giving report in the nurses' station. c. The unit has decided to use a standardized checklist/tool for change-of-shift reports and patient transfers. d. You and the oncoming nurse conduct a standardized report at the patient's bedside and review key assessment findings. e. The off-going nurse is giving the patient medications at the same time as giving handoff report to the oncoming nurse.

C, D

9. The constant noise of a ventilator, monitor alarms, and infusion pumps predisposes the patient to: A. Anxiety. B. Pain. C. Powerlessness. D. Sensory overload.

A patient has coronary artery bypass graft surgery and is transported to the surgical intensive care unit at noon and is placed on mechanical ventilation. Interpret the initial arterial blood gas levels pH: 7.31 PaCO2: 48 mm Hg Bicarbonate: 22 mEq/L PaO2: 115 mm Hg O2 saturation: 99% A. Normal arterial blood gas levels with a high oxygen level B. Partly compensated respiratory acidosis; normal oxygen C. Uncompensated metabolic acidosis with high oxygen levels D. Uncompensated respiratory acidosis; hyperoxygenated

A patient has elevated blood lipids. The nurse anticipates which classification of drugs to be prescribed for the patient? a. Bile acid resins b. Nicotinic acid c. Nitroglycerin d. Statins

The nurse notices sinus bradycardia on the patient's cardiac monitor. The nurse should a. give atropine to increase heart rate. b. begin transcutaneous pacing of the patient. c. start a dopamine infusion to stimulate heart function. d. assess for hemodynamic instability.

A patient is having an emergent coronary intervention, and the nurse is starting an infusion of abciximab. The patient asks what the purpose of this drug is. What response by the nurse is best? a. "This will help prevent chest pain until the intervention is complete." b. "This medication dries oral and respiratory secretions during the procedure." c. "This is a mild sedative and amnesic agent, so you'll be very relaxed." d. "This drug helps prevent blood clotting and is often used for this procedure."

A patient presents to the emergency department demonstrating agitation and complaining of numbness and tingling in his fingers. His arterial blood gas levels reveal the following: pH 7.51, PaCO2 25, HCO3 25. The nurse interprets these blood gas values as: A. Compensated metabolic alkalosis. B. Normal values. C. Uncompensated respiratory acidosis. D. Uncompensated respiratory alkalosis.

A specific request made by a competent person that directs medical care related to life-prolonging procedures in the event that person loses capacity to make decisions is called a a. "do not resuscitate" order. b. health care proxy. c. informed consent. d. living will.

Changing visitation policies can be challenging. The nurse manager recognizes which of the following as an effective strategy for promoting changes in practice? A. Ask the clinical nurse specialist to lead a journal club on open visitation after each nurse is tasked to read one research article about visitation. B. Discuss the pros and cons of open visitation at the next staff meeting. C. Invite the nurses with the most experience to develop a revised policy. D. Task the unit-based nurse practice council to invite volunteers to serve on the council to revise the current policy toward more liberal visitation.

Current guidelines recommend the oral route for endotracheal intubation. The rationale for this recommendation is that nasotracheal intubation is associated with a greater risk for A. Basilar skull fracture. B. Cervical hyperextension. C. Impaired ability to "mouth" words. D. Sinusitis and infection.

During the initial stages of shock, what are the physiological effects of decreased cardiac output? A. Arterial vasodilation B. High urine output C. Increased parasympathetic stimulation D. Increased sympathetic stimulation

Percutaneous coronary intervention is contraindicated for patients with lesions in which coronary artery? a. Right coronary artery b. Left coronary artery c. Circumflex d. Left main coronary artery

Positive end-expiratory pressure (PEEP) is a mode of ventilatory assistance that produces the following condition: A. Each time the patient initiates a breath, the ventilator delivers a full preset tidal volume. B. For each spontaneous breath taken by the patient, the tidal volume is determined by the patient's ability to generate negative pressure. C. The patient must have a respiratory drive, or no breaths will be delivered. D. There is pressure remaining in the lungs at the end of expiration that is measured in cm H2O.

Pulse oximetry measures A. Arterial blood gases. B. Hemoglobin values. C. Oxygen consumption. D. Oxygen saturation.

The AACN Standards for Acute and Critical Care Nursing Practice use what framework to guide critical care nursing practice? a. Evidence-based practice b. Healthy work environment c. National Patient Safety Goals d. Nursing process

The amount of effort needed to maintain a given level of ventilation is termed A. Compliance. B. Resistance. C. Tidal volume. D. Work of breathing.

The charge nurse is responsible for making the patient assignments on the critical care unit. An experienced, certified nurse is assigned to care for the acutely ill patient with sepsis who also requires continuous renal replacement therapy and mechanical ventilation. The nurse with less than 1 year of experience is assigned to two patients who are more stable. This assignment reflects implementation of the a. crew resource management model. b. National Patient Safety Goals. c. Quality and Safety Education for Nurses (QSEN) model. d. synergy model of practice.

The critical care nurse wants a better understanding of when to initiate an ethics consult. After attending an educational program, the nurse understands that the following situation would require an ethics consultation: a. Conflict has occurred between the physician and family regarding treatment decisions. A family conference is held, and the family and physician agree to a treatment plan that includes aggressive treatment for 24 hours followed by reevaluation. b. Family members disagree as to a patient's course of treatment. The patient has designated a health care proxy and has a written advance directive. c. Patient postoperative coronary artery bypass surgery who sustained a cardiopulmonary arrest in the operating room. He was successfully resuscitated, but now is not responding to treatment. He has a written advance directive, and his wife is present. d. Patient with multiple trauma and is not responding to treatment. No family members are known, and the health care team is debating if care is futile.

The intensive care nurse is working on a committee to reduce noise in the unit. Which recommendation should the nurse propose first? A. Change telephones to blinking lights instead of audible ringtones. B. Invest in call lights that page the nursing staff instead of beeping. C. Recommend that nurses turn off cardiac monitors on stable patients. D. Soundproof the pneumatic tube system.

The main purpose of certification is to a. assure the consumer that you will not make a mistake. b. prepare for graduate school. c. promote magnet status for your facility. d. validate knowledge of critical care nursing.

The most important outcome of effective communication is to a. demonstrate caring practices to family members. b. ensure that patient teaching is done. c. meet the diversity needs of patients. d. reduce patient errors.

The nurse has been administering 0.9% normal saline intravenous fluids 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? A. Breath sounds and capillary refill B. Blood pressure and oral temperature C. Oral temperature and capillary refill D. Right atrial pressure and urine output

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? A. Normal body temperature B. Balanced intake and output C. Adequate pain management D. Urine output of 0.5 mL/kg/hr

The nurse is caring for a critically ill patient with terminal cancer. The monitor alarms and shows a potentially lethal rhythm. The patient has no pulse. The patient does not have a "do not resuscitate" order written on the chart. What is the appropriate nursing action? a. Contact the attending physician immediately to determine if CPR should be initiated. b. Contact the family immediately to determine if they want CPR to be started. c. Give emergency medications but withhold intubation. d. Initiate CPR and call a code.

The nurse is caring for a mechanically ventilated patient and notes the high pressure alarm sounding. The nurse cannot quickly identify the cause of the alarm and notes the patient's oxygen saturation is decreasing and heart rate and respiratory rate are increasing. The nurse's priority action is to A. Ask the respiratory therapist to get a new ventilator. B. Call the rapid response team to assess the patient. C. Continue to find the cause of the alarm and fix it. D. Manually ventilate the patient while calling for a respiratory therapist.

The nurse is caring for a mechanically ventilated patient. The providers are considering performing a tracheostomy because the patient is having difficulty weaning from mechanical ventilation. Related to tracheostomy, the nurse understands which of the following? A. Patient outcomes are better if the tracheostomy is done within a week of intubation. B. Percutaneous tracheostomy can be done safely at the bedside by the respiratory therapist. C. Procedures performed in the operating room are associated with fewer complications. D. The greatest risk after a percutaneous tracheostomy is accidental decannulation.

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. Which intervention should the nurse carry out first? A. Acetaminophen suppository B. Blood cultures from two sites C. IV antibiotic administration D. Isotonic fluid challenge

The nurse is caring for a patient admitted with the early stages of septic shock. The nurse assesses the patient to be tachypneic, with a respiratory rate of 32 breaths/min. Arterial blood gas values assessed on admission are pH 7.50, CO2 28 mm Hg, HCO3 26. Which diagnostic study result reviewed by the nurse indicates progression of the shock state? A. pH 7.40, CO2 40, HCO3 24 B. pH 7.45, CO2 45, HCO3 26 C. pH 7.35, CO2 40, HCO3 22 D. pH 7.30, CO2 45, HCO3 18

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? A. High pulmonary artery occlusive pressure and high cardiac output B. High systemic vascular resistance and low cardiac output C. Low pulmonary artery occlusive pressure and low cardiac output D. Low systemic vascular resistance and high cardiac output

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? A. Fluid overload secondary to decreased venous return B. High cardiac index secondary to more efficient ventricular function C. Hypoxemia secondary to prolonged positive pressure at expiration D. Low cardiac output secondary to increased intrathoracic pressure

The nurse is talking with the patient when the monitor alarms and shows a wavy baseline without a PQRST complex. The nurse should a. defibrillate the patient immediately. b. initiate basic life support. c. initiate advanced life support. d. assess the patient and the electrical leads.

The patient's heart rate is 165 beats per minute. The cardiac monitor shows a rapid rate with narrow QRS complexes. The P waves cannot be seen, but the rhythm is regular. The patient's blood pressure has dropped from 124/62 mm Hg to 78/30 mm Hg. The patient's skin is cold and diaphoretic, and the patient is complaining of nausea. The nurse prepares the patient for a. administration of beta blockers. b. administration of atropine. c. transcutaneous pacemaker insertion. d. emergent cardioversion.

The provider orders the following mechanical ventilation settings for a patient who weighs 75 kg. The patient's spontaneous respiratory rate is 22 breaths/min. Which arterial blood gas abnormality may occur if the patient continues to be tachypneic at these ventilator settings? Settings: Tidal volume: 600 mL (8 mL per kg) FiO2: 0.5 Respiratory rate: 14 breaths/min Mode assist/control Positive end-expiratory pressure: 10 cm H2O A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

The spouse of a patient who is hospitalized in the critical care unit following resuscitation for a sudden cardiac arrest at work demands to meet with the nursing manager. The spouse demands, "I want you to reassign us to another nurse. His current nurse is not in the room enough to make sure everything is okay." The nurse recognizes that this response most likely is due to the spouse's A. Desire to pursue a lawsuit if the assignment is not changed. B. Inability to participate in the husband's care. C. Lack of prior experience in a critical care setting. D. Sense of loss of control of the situation.

Which of the following organizations requires a mechanism for addressing ethical issues? a. American Association of Critical-Care Nurses b. American Hospital Association c. Society of Critical Care Medicine d. The Joint Commission

Which of the following statements about resuscitation is true? a. Family members should never be present during resuscitation. b. It is not necessary for a physician to write "do not resuscitate" orders in the chart if a patient has a health care surrogate. c. "Slow codes" are ethical and should be considered in futile situations if advanced directives are unavailable. d. Withholding "extraordinary" resuscitation is legal and ethical if specified in advance directives and physician orders.

Which of the following statements describes the core concept of the synergy model of practice? a. All nurses must be certified in order to have the synergy model implemented. b. Family members must be included in daily interdisciplinary rounds. c. Nurses and physicians must work collaboratively and synergistically to influence care. d. Unique needs of patients and their families influence nursing competencies.

Fifteen minutes after beginning a transfusion of O negative blood to a patient in shock, the nurse assesses a drop in the patient's 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 patient's Foley catheter. What are the priority nursing actions? (Select all that apply.) A. Administer acetaminophen. B. Document the patient's response. C. Increase the rate of transfusion. D. Notify the blood bank. E. Notify the provider. F. Stop the transfusion.

D, E, F

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.) a. Airway clearance therapies b. Antibiotic therapy c. Nutritional support d. Tracheostomy

a. Airway clearance therapies b. Antibiotic therapy c. Nutritional support

Identify diagnostic criteria for ARDS. (Select all that apply.) a. Bilateral infiltrates on chest x-ray study b. Decreased cardiac output c. PaO2/ FiO2 ratio of less than 200 d. Pulmonary artery occlusion pressure (PAOP) of more than 18 mm Hg

a. Bilateral infiltrates on chest x-ray study c. PaO2/ FiO2 ratio of less than 200

The patient with acute respiratory distress syndrome (ARDS) would exhibit which of the following symptoms? a. Decreasing PaO2 levels despite increased FiO2 administration b. Elevated alveolar surfactant levels c. Increased lung compliance with increased FiO2 administration d. Respiratory acidosis associated with hyperventilation

a. Decreasing PaO2 levels despite increased FiO2 administration

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.) a. Drain condensate from the ventilator tubing away from the patient. b. Elevate the head of the bed 30 to 45 degrees. c. Instill normal saline as part of the suctioning procedure. d. Perform regular oral care with chlorhexidine.

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

Select the strategies for preventing deep vein thrombosis (DVT) and pulmonary embolus (PE). (Select all that apply.) a. Graduated compression stockings b. Heparin or low-molecular weight heparin for patients at risk c. Sequential compression devices d. Strict bed rest

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

Which of the following are physiological effects of positive end-expiratory pressure (PEEP) used in the treatment of ARDS? (Select all that apply.) a. Increase functional residual capacity b. Prevent collapse of unstable alveoli c. Improve arterial oxygenation d. Open collapsed alveoli

a. Increase functional residual capacity b. Prevent collapse of unstable alveoli c. Improve arterial oxygenation d. Open collapsed alveoli

Which of the following are components of the Institute for Healthcare Improvement's (IHI's) ventilator bundle? (Select all that apply.) a. Interrupt sedation each day to assess readiness to extubate. b. Maintain head of bed at least 30 degrees elevation. c. Provide deep vein thrombosis prophylaxis. d. Provide prophylaxis for peptic ulcer disease. e. Swab the mouth with foam swabs every 2 hours.

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

The nurse is caring for a patient who is being turned prone as part of treatment for acute respiratory distress syndrome. The nurse understands that the priority nursing concern for this patient is which of the following? a. Management and protection of the airway b. Prevention of gastric aspiration c. Prevention of skin breakdown and nerve damage d. Psychological support to patient and family

a. Management and protection of the airway

Which of the following statements is true regarding venous thromboembolism (VTE) and pulmonary embolus (PE)? a. PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk factors for VTE. b. Bradycardia and hyperventilation are classic symptoms of PE. c. Dyspnea, chest pain, and hemoptysis occur in nearly all patients with PE. d. Most critically ill patients are at low risk for VTE and PE and do not require prophylaxis.

a. PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk factors for VTE.

The etiology of noncardiogenic pulmonary edema in acute respiratory distress syndrome (ARDS) is related to damage to the: a. alveolar-capillary membrane. b. left ventricle. c. mainstem bronchus. d. trachea.

a. alveolar-capillary membrane.

During rounds, the physician alerts the team that proning is being considered for a patient with acute respiratory distress syndrome. The nurse understands that proning is: a. an optional treatment if the PaO2/FiO2 ratio is less 100. b. less of a risk for skin breakdown because the patient is face down. c. possible with minimal help from co-workers. d. used to provide continuous lateral rotational turning.

a. an optional treatment if the PaO2/FiO2 ratio is less 100.

The nurse is caring for a patient in acute respiratory failure and understands that the patient should be positioned: (Select all that apply.) a. high Fowler's. b. side lying with head of bed elevated. c. sitting in a chair. d. supine with the bed flat.

a. high Fowler's. b. side lying with head of bed elevated. c. sitting in a chair.

The nurse is discharging a patient home following treatment for community-acquired pneumonia. As part of the discharge teaching, the nurse instructs: a. "If you get the pneumococcal vaccine, you'll never get pneumonia again." b. "It is important for you to get an annual influenza shot to reduce your risk of pneumonia." c. "Stay away from cold, drafty places because that increases your risk of pneumonia when you get home." d. "Since you have been treated for pneumonia, you now have immunity from getting it in the future."

b. "It is important for you to get an annual influenza shot to reduce your risk of pneumonia."

A patient at high risk for pulmonary embolism is receiving Lovenox. The nurse explains to the patient: a. "I'm going to contact the pharmacist to see if you can take this medication by mouth." b. "This injection is being given to prevent blood clots from forming." c. "This medication will dissolve any blood clots you might get." d. "You should not be receiving this medication. I will contact the physician to get it stopped."

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

The nurse calculates the PaO2/FiO2 ratio for the following values: PaO2 is 78 mm Hg; FiO2 is 0.6 (60%). a. 46.8; meets criteria for ARDS b. 130; meets criteria for ARDS c. 468; normal lung function d. Not enough data to compute the ratio

b. 130; meets criteria for ARDS

The nurse is caring for a postoperative patient with chronic obstructive pulmonary disease (COPD). Which assessment would be a cue to the patient developing postoperative pneumonia? a. Bradycardia b. Change in sputum characteristics c. Hypoventilation and respiratory acidosis d. Pursed-lip breathing

b. Change in sputum characteristics

The nurse assesses a patient who is admitted for an overdose of sedatives. The nurse expects to find which acid-base alteration? a. Hyperventilation and respiratory acidosis b. Hypoventilation and respiratory acidosis c. Hypoventilation and respiratory alkalosis d. Respiratory acidosis and normal oxygen levels

b. Hypoventilation and respiratory acidosis

Which of the following statements is true regarding oral care for the prevention of ventilator-associated pneumonia (VAP)? (Select all that apply.) a. Tooth brushing is performed every 2 hours for the greatest effect. b. Implementing a comprehensive oral care program is an intervention for preventing VAP. c. Oral care protocols should include oral suctioning and brushing teeth. d. Protocols that include chlorhexidine gluconate have been effective in preventing VAP.

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

The nurse is assessing a patient. Which assessment would cue the nurse to the potential of acute respiratory distress syndrome (ARDS)? a. Increased oxygen saturation via pulse oximetry b. Increased peak inspiratory pressure on the ventilator c. Normal chest radiograph with enlarged cardiac structures d. PaO2/FiO2 ratio > 300

b. Increased peak inspiratory pressure on the ventilator

An acute exacerbation of asthma is treated with which of the following? a. Corticosteroids and theophylline by mouth b. Inhaled bronchodilators and intravenous corticosteroids c. Prone positioning or continuous lateral rotation d. Sedation and inhaled bronchodilators

b. Inhaled bronchodilators and intravenous corticosteroids

The nurse is assessing a patient with acute respiratory distress syndrome. An expected assessment is: a. cardiac output of 10 L/min and low systemic vascular resistance. b. PAOP of 10 mm Hg and PaO2 of 55. c. PAOP of 20 mm Hg and cardiac output of 3 L/min. d. PAOP of 5 mm Hg and high systemic vascular resistance.

b. PAOP of 10 mm Hg and PaO2 of 55.

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: a. amniotic fluid embolus. b. deep vein thrombosis from lower extremities. c. fat embolus from a long bone fracture. d. vegetation that dislodges from an infected central venous catheter.

b. deep vein thrombosis from lower extremities.

When fluid is present in the alveoli: a. alveoli collapse and atelectasis occurs. b. diffusion of oxygen and carbon dioxide is impaired. c. hypoventilation occurs. d. the patient is in heart failure.

b. diffusion of oxygen and carbon dioxide is impaired.

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? a. Emergency tracheostomy and mechanical ventilation b. Mechanical ventilation via an endotracheal tube c. Noninvasive positive-pressure ventilation (NPPV) d. Oxygen at 100% via bag-valve-mask device

c. Noninvasive positive-pressure ventilation (NPPV)

Intrapulmonary shunting refers to: a. alveoli that are not perfused. b. blood that is shunted from the left side of the heart to the right and causes heart failure. c. blood that is shunted from the right side of the heart to the left without oxygenation. d. shunting of blood supply to only one lung.

c. blood that is shunted from the right side of the heart to the left without oxygenation.

The basic underlying pathophysiology of acute respiratory distress syndrome results from: a. a decrease in the number of white blood cells available. b. damage to the right mainstem bronchus. c. damage to the type II pneumocytes, which produce surfactant. d. decreased capillary permeability.

c. damage to the type II pneumocytes, which produce surfactant.

A strategy for preventing thromboembolism in patients at risk who cannot take anticoagulants is: a. administration of two aspirin tablets every 4 hours. b. infusion of thrombolytics. c. insertion of a vena cava filter. d. subcutaneous heparin administration every 12 hours.

c. insertion of a vena cava filter.

The nurse is caring for a patient with acute respiratory distress syndrome who is hypoxemic despite mechanical ventilation. The physician orders 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 physician of this assessment and anticipates an order for: a. continuous lateral rotation therapy. b. guided imagery. c. neuromuscular blockade. d. prone positioning.

c. neuromuscular blockade.

A definitive diagnosis of pulmonary embolism can be made by: a. arterial blood gas (ABG) analysis. b. chest x-ray examination. c. pulmonary angiogram. d. ventilation-perfusion scanning.

c. pulmonary angiogram.

The nurse is discharging a patient with asthma. As part of the discharge instruction, the nurse instructs the patient to prevent exacerbation by: a. obtaining an appointment for follow-up pulmonary function studies 1 week after discharge. b. limiting activity until patient is able to climb two flights of stairs. c. taking all asthma medications as prescribed. d. taking medications on a "prn" basis according to symptoms.

c. taking all asthma medications as prescribed.

The nurse is concerned that a patient is at increased risk of developing a pulmonary embolus and develops a plan of care for prevention to include which of the following? a. Antiseptic oral care b. Bed rest with head of bed elevated c. Coughing and deep breathing d. Mobility

d. Mobility

The nurse is caring for a patient with acute respiratory failure and identifies "Risk for Ineffective Airway Clearance" as a nursing diagnosis. A nursing intervention relevant to this diagnosis is: a. Elevate head of bed to 30 degrees. b. Obtain order for venous thromboembolism prophylaxis. c. Provide adequate sedation. d. Reposition patient every 2 hours.

d. Reposition patient every 2 hours.

Which of the following treatments may be used to dissolve a thrombus that is lodged in the pulmonary artery? a. Aspirin b. Embolectomy c. Heparin d. Thrombolytics

d. Thrombolytics

In assessing a patient, the nurse understands that an early sign of hypoxemia is: a. clubbing of nail beds b. cyanosis c. hypotension d. restlessness

d. restlessness

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