Final Evolve
A 33-year-old patient is admitted with closed head trauma following a motor vehicle crash. She has a signed organ donor card expressing her wish to become an organ donor. Brain death is established; however, her spouse refuses to sign consent for organ donation. Which ethical principle is being violated by her spouse? A. Autonomy B. Beneficence C. Justice D. Veracity
A
A patient is admitted to the critical care unit with an anion gap of 24 mEq/L. This laboratory finding is characteristic of which condition? A. DKA B. HHS C. Hypoglycemia D. SIADH
A
A patient with end-stage lung cancer with bone involvement has had nutritional support withdrawn and is actively dying. The nurse assesses the patient and observes a respiratory rate of 26 breaths per minute with use of accessory muscles. The patient's heart rate has increased from 86 beats per minute to 110 beats per minute. The patient grimaces when moved and is moaning, but is responsive to name. The patient is on a morphine drip with a titration protocol. What is the most appropriate nursing intervention for this patient? A. Administer an additional dose of intravenous morphine equal to the current infusion rate, and increase the infusion by 50% B. Contact the provider to request an order to give the patient an injection of 5 mg morphine IM, and reassess the patient in 10 minutes C. Increase the infusion by 50% and reassess the patient in 1 hour D. Maintain the infusion at the current rate
A
A restrained patient's status after a motor vehicle crash includes dyspnea, dysphagia, hoarseness, and complaints of severe chest pain. Upon assessment you note that the patient has weak femoral pulses. Which of the following complications and related diagnostic test should be considered? a. Aortic dissection and aortogram b. Cardiac tamponade and pericardiocentesis c. Liver laceration and focused assessment with sonography for trauma (FAST) d. Pulmonary contusion and chest x-ray
A
A trauma patient with a fractured forearm complains of extreme, throbbing pain at the fracture site and paresthesia in the fingers. Upon further assessment, you note that the forearm is extremely edematous, and you are now having difficulty palpating a radial pulse. You notify the physician immediately because you suspect: a. compartment syndrome b. fat emboli. c. Hypothermia. d. rhabdomyolysis.
A
After reviewing her patient assignments, the nurse recognizes a conflict of interest with one of the patients. Which action should the nurse take to resolve this conflict? A. The nurse should request a change in assignment if care of the assigned patient violates his or her ethical principles. B. The nurse should keep all assigned patients for the day. C. The nurse should ask other staff to provide care for the patient if a conflict arises with the patient. D. The nurse should maintain minimal contact with the patient throughout the shift.
A
An adult patient suffered an anterior wall myocardial infarction (MI) 4 days ago. Today the patient is experiencing dyspnea and sitting straight up in bed. The nurse's assessment includes bibasilar crackles, an S3 heart sound with a heart rate of 125 beats/min. What condition are these signs and symptoms consistent with? A. Heart failure B. Papillary muscle rupture C. Pericarditis D. Pulmonary embolism
A
An adult patient with terminal metastatic lung carcinoma experienced respiratory distress at home and was brought to the emergency department (ED) by emergency medical services. The patient is now in the critical care unit on a ventilator. His physician has discussed his poor prognosis and potential withdrawal of the ventilator with the patient's spouse. The spouse refuses to sign papers for termination of life support, stating, "I just want him to get better." This case is an example of: A. Medical futility B. Palliative care C. Terminal weaning D. Withholding of life-sustaining treatment
A
The American Association of Critical-Care Nurses (AACN) publishes a variety of journals, including which of the following? A. American Journal of Critical Care B. Critical Care Medicine C. Critical Care Nursing Quarterly D. Dimensions of Critical Care Nursing
A
The critical care nurse has just listened to a lecture on standards of professional performance. The nurse then agrees to serve as a preceptor for undergraduate nursing students who are scheduled for observation in the critical care unit. Which statement by the critical care nurse indicates an understanding of the standards of professional performance? A. Professional standards include contributing to the professional development of others." B. Professional standards include providing leadership in the practice setting." C. Professional standards include using clinical inquiry in practice." D. Professional standards include using skilled communication to collaborate with others.
A
The initial drug recommended at the onset of acute myocardial infarction (AMI) to reduce platelet aggregation is: A. aspirin. B. lidocaine. C. nitroglycerin. D. oxygen.
A
The nurse educator is presenting a lecture on crystalloid fluid replacement therapy in shock states. Which statement by a nurse indicates that the teaching has been effective? a. Lactated Ringer's should not be infused if lactic acidosis is severe. b. 3 mL of crystalloid is administered to replace 10 mL of blood loss. c. Administration of colloids is preferred over crystalloids. d. Solutions of 0.45% normal saline are used routinely in shock.
A
The nurse has attended a lecture on pain and anxiety. Which statement by the nurse indicates that teaching has been effective? A. "Pain and anxiety are cyclical, with each exacerbating the other." B. "Pain and anxiety are easily controlled with pain medication." C. "Pain and anxiety are mutually exclusive; only one can be experienced at a time." D. "Pain and anxiety are treated with sedative medications."
A
The nurse is attending an in-service presentation related to hospice care. Which of the following statements are accurate about hospice? (SATA) A. Hospice emphasizes comfort rather than cure from disease B. Hospice is a place to treat dying patients C. Hospice referrals are appropriate only for cancer patients D. Referrals to hospice are made to improve quality of life
A
The nurse is caring for a nonverbal critically ill adult patient who cannot communicate. Which pain scale should the nurse select to use with this patient? A. Behavioral pain scale (BPS) B. Pain intensity (0-10) scale C. PQRST method D. Visual Analog Scale (VAS)
A
The nurse is caring for a patient admitted with severe sepsis. The physician orders include the administration of large volumes of isotonic saline solution as part of early goal-directed therapy. Which of the following best represents a therapeutic end point for goal-directed fluid therapy? a. Central venous pressure >8 mm Hg b. Heart rate >60 beats/min c. Mean arterial pressure >50 mm Hg d. Serum lactate level >6 mEq/L
A
The nurse is caring for a patient who is being monitored with a central venous catheter. In preparing to record a right atrial pressure reading, what is most important for the nurse to keep in mind when recording an accurate value? A. Record the pressure at the end of expiration. B. Low pressures indicate ventricular dysfunction. C. High pressures are likely to indicate hypovolemia. D. Zero referencing is not needed before every recording.
A
The nurse is caring for a patient with a diagnosis of primary hyperthyroidism. Which lab results should the nurse anticipate on this patient? A. Low to normal TSH; elevated T3, T4 B. Low to normal TSH; normal T3, T4 C. High TSH; elevated T3, T4 D. High TSH; low T3, T4
A
The nurse is coordinating a conference to discuss end-of-life issues with the family. Which communication would be the most effective to both minimize legal actions against providers and relieve patient and family anxiety? A. Aims for all (patient, family, provider) to agree on the plan of care that is based on the patient's preferences B. Emphasized that the patient will not be abdomned if palliative care is the outcome of the conference C. Facilitates continuity of care if the patient is transferred D. Presents a clear and consistent message to the family
A
The nurse is educating a new RN on preparing a patient for assessment of cardiac output using an esophageal monitor. Which statement by the new RN indicates that teaching was effective? A. "The procedure involves a thin probe inserted into the esophagus." B. "Patients require deep sedation provided by an anesthesia provider." C. "The procedure immediately assesses right ventricular performance." D. "There are no absolute contraindications for the procedure."
A
The nurse notices ventricular tachycardia on the heart monitor. The nurse's first action should be to: A. determine patient responsiveness and presence of a pulse. B. immediately defibrillate the patient and provide CPR. C. administer intravenous amiodarone or lidocaine. D. cardiovert electrically into a more sustainable rhythm.
A
The patient is admitted with a heart rate of 144 beats/min and a blood pressure of 88/42 mm Hg. The patient complains of generalized weakness and fatigue. He states, "Just let me sleep." The nurse determines that the presence of the patient's symptoms is due to: A. decreased cardiac output. B. the absence of ischemic heart disease. C. improved cardiac filling time, allowing the patient to relax. D. increased coronary artery filling time.
A
The patient is complaining of midsternal chest discomfort and nausea. The nurse calls for a 12-lead ECG and notices that the ST segment is newly elevated in two related leads. The nurse should: A. call the provider because the ST segment may indicate myocardial injury. B. continue to monitor the patient, as the ST segment is nondiagnostic. C. monitor the patient for increased signs of GI upset. D. assure the patient that the ST elevations are normal and of no concern.
A
The patient presents to the emergency department with severe substernal chest discomfort. Cardiac enzymes are elevated and his ECG shows ST-segment depression in V2 and V3. This patient is most likely experiencing: A. non-Q-wave myocardial infarction (MI). B. pulmonary embolism. C. Q-wave myocardial infarction (MI). D. right ventricular infarction.
A
The patient with a pacemaker shows pacemaker spikes that are not followed by a QRS. The nurse interprets this as: A. failure to capture. B. failure to pace. C. failure to sense. D. demand mode.
A
What is the best understanding of mixed venous oxygen saturation by the nurse? A. An overall picture of oxygen delivery and oxygen consumption B. The amount of oxygen attached to each hemoglobin molecule C. The amount of oxygen perfusion taking place within the myocardium D. The amount of oxygen the lungs are able to mix with the blood
A
When checking a patient's pulmonary artery occlusion pressure, the nurse inflates the balloon as ordered, not inflating the balloon for more than 8 to 10 seconds. The patient asks the rationale behind the nurse's actions. Which statement should the nurse make? A. "Prolonged inflation can obstruct blood flow, resulting in ischemia." B. "Prolonged inflation increases the risk of catheter balloon rupture." C. "Prolonged inflation increases the likelihood of thermistor damage." D. "Prolonged inflation will reduce tension on the pulmonary artery wall."
A
Which intervention is most helpful in preventing sensory overload in critically ill patients? A. Encourage family members to assist in the reorientation of the patient B. Increase the amount of noise from equipment in the patient's room C. Move the patient to a semiprivate room with another confused patient D. Place the patient nearer to the nurses' station for observation
A
Which test should the nurse anticipate that the health care provider will order for the presence of adrenal insufficiency? A. Cortisol stimulation test B. Glucose tolerance test C. Vasopressin test D. Water deprivation test
A
Your patient was a passenger in a motor vehicle crash yesterday and suffered an open fracture of the femur. His condition was stable until an hour ago, when he began to complain of shortness of breath. His heart rate is 104 beats/min, respiratory rate is 30 breaths/min, BP is 90/60 mm Hg, and temperature is now 38.4°C. You suspect that he: a. has a fat embolism. b. has developed metabolic acidosis. c. is developing systemic inflammatory response syndrome (SIRS). d. is experiencing early multiple organ dysfunction syndrome (MODS).
A
The nurse needs to obtain a cardiac output measurement from a patient who has just had a pulmonary artery catheter inserted. What are important interventions for ensuring accurate pressure and cardiac output measurements? (SATA) A. Ensure rapid injection of fluid through the injectate port. B. Zero reference the transducer system at the phlebostatic axis. C. Inflate the pulmonary artery catheter balloon with 5 mL air. D. Use lactated Ringer's solution for the injectate.
A, B
The patient presents to the emergency department after having crushing chest pain for the past 5 hours. The ECG and laboratory work confirm suspicions of an acute myocardial infarction (AMI). Which findings would be the most conclusive that the patient is having an AMI? (Select all that apply.) A. ECG changes with ST-elevation B. Elevated CK-MB isoenzymes C. Elevated serum troponin levels D. Elevated urinary myoglobin level
A, B, C
Which statements related to the management of unstable angina are true? (Select all that apply.) A. Aspirin is given at the onset of each chest pain episode. B. Calcium channel blockers help to reduce symptoms. C. Early revascularization (e.g., angioplasty) may be helpful. D. It is best treated with rest and nitroglycerin.
A, B, C
Which strategies should the nurse manager implement to improve collaboration in the critical care setting? (SATA) A. Initiate interdisciplinary rounds B. Create joint programs for continuing education C. Institute morning briefings D. Exclude family members from rounds
A, B, C
The nurse is providing care to a critically ill patient at end of life. Which interventions are appropriate? (SATA) A. Assess family members' understanding of the condition and prognosis B. Educate family members about what will happen when life support is withdrawn C. Assure family members that the patient will not suffer D. Assure family members that the patient will not be abandoned E. Facilitate physician communication with the family F. Provide for visitation and presence of family and extended
A, B, C, D, E, F
Which stressors should the nurse anticipate the patient to have during the critical care experience? (SATA) A. Difficult communication B. Pain C. Feelings of dread D. Difficulty sleeping E. Thoughts of death and dying
A, B, C, E
Which treatments should the nurse anticipate as being withdrawn during the end of life? (SATA) A. Antibiotics B. Blood products C. Dialysis D. Frequent repositioning E. Enteral nutrition
A, B, C, E
Which potential causes of hypoglycemia should the nurse investigate in a diabetic patient? (Select all that apply) A. Addisonian crisis B. Excessive alcohol consumption C. Glucocorticoid treatment D. Liver disease E. Renal disease
A, B, D, E
Which treatments does the nurse prepare to withdraw during the end of life? (SATA) A. Fluids B. Mechanical Ventilation C. Morphine drip D. Provision of hygiene E. Vasopressors
A, B, E
After receiving handoff report from the night shift, the nurse completes the morning assessment of a patient with severe sepsis. Vital sign assessment notes 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 last hour. Given this report, the nurse obtains orders for treatment that include which of the following? Select all that apply. a. Administer infusion of 500 mL 0.9% normal saline every 4 hours as needed if the CVP is <5 mm Hg. b. Increase supplemental oxygen therapy to 60% Venturi mask. c. Administer 40 mg furosemide (Lasix) intravenously 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 >101° F.
A, D
Which nursing actions contain the elements of informed consent? (SATA) A. Scheduling time for the patient to meet with the health care provider B. Ensuring that the patient and family members understand what is to be done (competence) C. Obtaining voluntary permission for what is to be done D. Writing the consent on a standardized form
A,B,C
Which nursing actions indicate an understanding of ethical decisions? (SATA) A. Respecting the patient's wishes and goals B. Discussing burden versus benefit with the patient C. Being knowledgeable on relevant ethical principles D. Discussing potential outcomes of options with the patient
A,B,C,D
Which of the following nonpharmacological approaches by the nurse may be useful in the management of pain and anxiety in the critically ill patient? (SATA) A. Encouraging family members to bring familiar items from home B. Guided imagery C. Involving family members in the patient's care D. Music therapy E. Patient-controlled analgesia
A,B,C,D
The critical care nurse must demonstrate characteristics of ethical nursing practice, which include: (SATA) A. collaboration. B. compassion. C. disclosure. D. trust.
A,B,D
The nurse is caring for a patient experiencing pain, anxiety, and agitation. Which factors assist the nurse in creating a personalized care plan for this patient? (SATA) A. Extreme anxiety and pain may lead to agitation. B. Many critically ill patients experience panic and fear. C. Pain and anxiety stimulate the parasympathetic nervous system. D. Patients may develop PTSD as a result of an ICU stay.
A,B,D
What actions can the nurse manager take to promote a healthy work environment? (SATA) A. Acknowledge family contributions B. Limit staffing to reduce noise C. Be effective in decision making D. Give meaningful recognition to team members E. Encourage respect for one another
A,C,D,E
What actions can the nurse take to remain aware of current and emerging trends affecting practice and emerging trends affecting practice and patient care? (SATA) A. Read professional journals. B. Work in many areas of nursing. C. Join a journal club. D. Become involved in a unit-based council. E. Attend local professional meetings.
A,C,D,E
A patient with type 1 diabetes is admitted with altered mental status. The following arterial blood gas readings are obtained: pH 6.88; PaCO2 20 mm Hg; PaO2 98 mm Hg; HCO3- 4 mEq/L. The nurse interprets the carbon dioxide reading is a result of: A. dehydration B. respiratory compensation for keto-acidosis C. renal compensation for keto-acidosis D. the formation of ketones
B
A temporary wound cover composed of a graft of skin transplanted from another human, living or dead, is called a(n): a. alloderm b. allograft c. biobrane d. xenograft
B
Angiotensin-converting enzymes inhibitors (ACE inhibitors) should be started within 24 hours of acute myocardial infarction (AMI) to reduce the incidence of: A. hibernating myocardium. B. myocardial remodeling. C. myocardial stunning. D. tachycardia.
B
Assessment findings the nurse should anticipate for a patient who is in myxedema coma include: A. hypotension, tachycardia, polydipsia, temperature 102° F. B. lethargy, edema, swollen tongue, abdominal distention. C. nervousness, increased T4, crackles, increased respirations. D. weight gain, seizures, dark yellow urine, frothy pink sputum.
B
If the sinus node were diseased or ischemic and no longer firing as the heart's primary pacemaker, the nurse would anticipate which normal compensatory mechanism? A. Premature Junctional beats B. Junctional escape rhythm, rate of 45 C. Junctional tachycardia, rate of 100 D. Accelerated junctional rhythm, rate of 75
B
In HHS, laboratory results are similar to those in DKA , but with three major exceptions. Which lab findings should the nurse anticipate in a patient with HHS? A. Higher serum glucose, higher osmolality, and greater ketosis B. Higher serum glucose, higher osmolality, and minimal ketosis C. Lower serum glucose, lower osmolality, and greater ketosis D. Lower serum glucose, lower osmolality, and minimal ketosis
B
Polydipsia, polyuria, abdominal pain, nausea, and "fruity" breath are typical findings in: A. Addison's disease B. DKA C. Hyperglycemia Hyperosmolar Syndrome D. Myxedema coma
B
The assessment of pain and anxiety is a continuous process. The first priority for treating pain and/or anxiety in the critical care setting is to: A. ask the patient frequently if he or she needs pain/antianxiety medication. B. identify and treat the underlying causes of pain and anxiety. C. medicate routinely with pain/antianxiety medications to keep the patient comfortable. D. wait for the patient to ask for medication and give it promptly.
B
The nurse has just listened to a lecture on how nociceptors differ from other nerve receptors in the body. Which statement by the nurse indicates that teaching has been effective? A. "Nociceptors adapt readily to the pain response to allow the body to adjust." B. "Nociceptors adapt very little to the pain response." C. "Nocicptors release histamine to help increase oxygenation." D. "Nociceptors secrete serotonin to help ease pain and inflammation."
B
The nurse is calculating the rate for a regular rhythm. There are 20 small boxes before each R wave. The nurse interprets the rate to be: A. 50 beats/min. B. 75 beats/min. C. 85 beats/min. D. 100 beats/min.
B
The nurse is caring for a client diagnosed with delirium. How should the nurse focus the patient assessment? A. Focus on keeping the patient medicated until transfer. B. Focus on keeping the patient safe. C. Focus on maintaining patency of the artificial airway. D. Focus on maximizing conversations with health care providers.
B
The nurse is caring for a patient in shock. Which is a priority action by the nurse? a. Ensure adequate cellular hydration. b. Maintain adequate tissue perfusion. c. Prevent third-spacing of fluids. d. Support mechanical ventilation.
B
The nurse is caring for a patient with a potential diagnosis of diabetic ketoacidosis (DKA). A hallmark of DKA is metabolic acidosis. The nurse should anticipate which treatment for this patient? A. Dialysis B. Insulin C. Normal saline IV D. Sodium bicarbonate replacement
B
The nurse is caring for an individual who is admitted for chest pain and shortness of breath. The patient states, "I can't believe I'm having chest pain. I'm a marathon runner and in good shape." During the night, the patient develops a sinus bradycardia with a heart rate of 40 beats/min. The nurse should: A. ignore this rate since the patient is an athlete. B. assess the patient for signs of decreased cardiac output. C. take the patient's temperature and expect to find hyperthermia. D. perform carotid massage (a maneuver to stimulate a vasovagal response).
B
The nurse is coordinating a family conference to discuss end-of-life decisions. Which nursing intervention will assist the family in meeting needs for information? A. During the conference, encourage family members to talk about the patient's life B. Encourage the family to write down questions before the conference C. Organize the conference at a time when most family members can attend D. Resolve conflicts among health care providers before the conference
B
The nurse is interested in pursuing critical care nursing practice as a career. After listening to an explanation of critical care nursing, which statement indicates understanding? A. Collaborative practice interferes with effective patient care." B. Critical care nurses coordinate care for critically ill patients in a variety of settings." C. Critical care nursing is defined as care rendered in an intensive care unit." D. Technological advances have had little effect on ethical dilemmas."
B
The nurse is interpreting a patient's cardiac rhythm and notes that the PR interval is 0.16 seconds long. The nurse determines that this PR interval indicates: A. slower-than-normal conduction from the SA node through the AV node. B. normal conduction from the SA node through the AV node. C. faster-than-normal conduction from the SA node through the AV node. D. abnormally fast depolarization of the atria and ventricles.
B
The nurse is on a committee related to family visitation in the critical care unit and discusses evidence to help in the planning. Which statement reflects evidence? A. Allowing children to visit is stressful for the patient and the child B. Family presence during procedures promotes adaptation C. Restricted visitation prevents family exhaustion D. Visitation shapes the critical care experience for the family but not the nurse
B
The nurse is participating on a committee to remodel the critical care unit and recommends which features to enhance care delivery and the patient-family experience? (SATA) A. Headwall systems that look like regular furniture B. Designated space for staff, administration, and education C. Rooms at least 100 sq. ft. in area D. Space for the family within the patient room
B
The patient has a temporary transvenous, demand-type ventricular pacemaker. The rate on the pacemaker is set at 60 beats/min. Which of the following situations would be of concern? A. A paced rhythm of 60 beats/min is seen on the monitor; no other waveforms are seen. B. A pacemaker spike is seen on the T wave of the preceding beat. C. The patient's inherent (own) rate falls to 58 and the pacemaker fires. D. The patient's inherent rate is 70 beats/min; no pacemaker spikes are seen.
B
What action can the nurse manager initiate to promote collaboration? A. Implement weekly in-services presented by the intensivist. B. Institute multiprofessional bedside rounds one or two times per shift. C. Invite team members to after-work social events. D. Mandate attendance at multiprofessional meetings.
B
Which action by the nurse is an example of extraordinary care? A. Administering antibiotics on time B. Initiating hemodialysis C. Inserting an IV for hydration D. Ensuring proper nutrition
B
Which hemodynamic values should the nurse anticipate in a patient who is in the initial stages of septic shock state? a. Low heart rate; high blood pressure b. High heart rate; low right atrial pressure c. High PAOP; low cardiac output d. High SVR; normal blood pressure
B
The patient is admitted with the diagnosis of "Junctional Rhythm." The nurse places the patient on the cardiac monitor expecting to see: (SATA) A. P waves with a PR interval of 0.16 seconds. B. P waves with a PR interval less than 0.12 seconds. C. no P waves but a narrow QRS complex. D. P waves coming after the QRS complex. E. no P waves but a wide QRS complex.
B, C, D
The nurse has attended a lecture on pain. Which statement by the nurse indicates that teaching has been effective? (SATA) A. "Pain is a state of apprehension." B. "Pain is a strictly physiological experience." C. "Pain is often exacerbated by anxiety." D. "Pain is whatever the experiencing person says it is."
B,C,D
A 45-year-old male is visiting the wellness clinic and has been newly diagnosed as a stage I hypertensive patient. His blood pressure assessment over the past 6 months has consistently been 145/92 mm Hg. The patient asks, "What is blood pressure?" What is the best response by the nurse? A. "A complex measurement that should be discussed only with your physician." B. "A measurement that should be 120/80 mm Hg unless complications are present." C. "A measurement that takes into consideration the amount of blood your heart is pumping and the size of the vessel diameter the heart must pump against." D. "The amount of pressure exerted on the veins by the blood."
C
A 67-year-old female is admitted to the emergency department complaining of mid-back pain and shortness of breath for the preceding 2 hours. She also complains of nausea and states that she vomited twice before coming to the hospital. She denies any chest discomfort or arm pain. The presenting symptoms suggest that this patient may be: A. exhibiting flu symptoms. B. having an anxiety attack. C. having a myocardial infarction (MI). D. suffering from osteoporosis.
C
A 72-year-old patient fractured his pelvis in a motor vehicle crash 2 days ago. He suddenly becomes anxious and short of breath. His respiratory rate is 34 breaths/min, and he is complaining of midsternal chest pain. His oxygen saturation drops to 75%. You suspect a. cardiac tamponade. b. myocardial infarction. c. pulmonary embolus. d. tension pneumothorax.
C
As part of the nursing assessment, the nurse asks the family spokesperson, "Since you have such a large family, can you tell me how well everyone gets along?" This question is part of which assessment? A. Cultural assessment B. Developmental assessment C. Functional assessment D. Structural assessment
C
Kussmaul's respiration, the rapid deep breathing seen in DKA, is the body's effort to compensate for metabolic acidosis caused by: A. bicarbonate B. carbonic acid C. ketone bodies D. lactic acid
C
Poor patient outcomes after a traumatic injury are associated with a. chest tube placement for treatment of a hemothorax. b. immediate decompression of a tension pneumothorax. c. massive transfusions of blood products. d. intraosseous cannulation for intravenous fluid administration.
C
The charge nurse is making assignments for the critical care unit and assigns the experienced nurse to care for two complex patients. The novice nurse is assigned to care for the less complex patient. The charge nurse is basing assignments on which model of practice? A. Institute for Healthcare Improvement B. Quality and Safety Education for Nurses C. Synergy model D. Universal care
C
The nurse admits a patient to the coronary care unit in cardiogenic shock. The nurse anticipates administering which medication in an effort to improve cardiac output by increasing the contractile force of the heart? a. Dopamine (Intropin) b. Phenylephrine (Neo-Synephrine) c. Dobutamine (Dobutrex) d. Nitroprusside (Nipride)
C
The nurse has listened to a lecture on the management of pain in patients with a history of substance abuse. Which of the following statements by the nurse indicates that teaching has been effective? A. "Folic acid and thiamine administration may potentiate the action of pain medications." B. "Pain medications should be withheld to avoid addiction to the medications." C. "Patients may have a higher-than-normal dosage threshold to achieve therapeutic effects." D. "Withdrawal symptoms from drugs or alcohol do not occur if the patient is mechanically ventilated."
C
The nurse is caring for a patient who is unresponsive, unable to communicate, and has no voluntary action or cognition. The condition is considered permanent. The term for this condition is: A. brain death B. non-heart beating donor C. persistent vegetative state D. terminal condition
C
The nurse is caring for a patient with hypovolemia. Which large volume crystalloid solution should the nurse anticipate the health care provider to order? Select all that apply. a. 5% dextrose b. Albumin c. Lactated Ringer's (LR) d. Normal saline
C
The nurse is interested in reducing health care-associated infections. Which action should the nurse take to achieve this? A. Use two methods of client identification. B. Assess the client for suicidal risk. C. Wash hands before and after patient care. D. Perform a time-out before procedures.
C
The nurse is interpreting the rhythm strip of a patient and measures the QRS complex as being three small boxes in width. The nurse interprets this width as: A. 0.04 seconds. B. 0.10 seconds. C. 0.12 seconds. D. 0.16 seconds.
C
The nurse is making rounds on a busy orthopedic floor. Which statement about pain does the nurse use to guide in pain assessments of patients? A. Anxiety can cause an increase in pain level, whereas pain has no effect on anxiety. B. Anxiety can occur without increasing pain. C. Anxiety is not associated with tissue injury. D. Pain can occur without increasing anxiety.
C
The nurse is meeting with family members of a critically ill patient. Which statement best addresses the psychological needs of the family members? A. "I'm adjusting the alarms on the monitor to reduce the noise level in the room" B. "It would help the patient if you can spend the night in the waiting room" C. "The team has just made rounds on the patient. We are going to begin weaning the patient from the ventilator today since the patient's oxygen is improving" D. "There are coffee and cookies in the waiting room. Why don't you take a short break?"
C
The nurse is preparing a patient for withdrawal from the ventilator. Which action by the nurse shows competence in managing dyspnea during terminal weaning? A. Administration of bronchodilators B. Administration of inhaled steroids C. Administration of opioids D. Administration of neuromuscular blockade
C
The nurse is speaking with the patient when the monitor shows that the patient is in ventricular fibrillation (VF). The nurse should: A. immediately defibrillate the patient. B. initiate basic life-support protocols and call for help. C. assess the patient and check the patient's monitor leads. D. initiate advanced life-support protocols as soon as possible.
C
The patient complains of being lightheaded and feeling a "fluttering" in his chest. The nurse places the patient on the heart monitor and notices an atrial tachycardia at a rate of 160 beats/min. The patient's blood pressure has dropped from 128/76 mm Hg to 92/46 mm Hg but appears stable at the lower pressure. The nurse should: A. prepare the patient for asynchronized defibrillation. B. give the patient digitalis IV and then call the provider. C. call the provider and prepare the patient for medical or electrical cardioversion. D. withhold beta blockers and calcium channel blockers.
C
The patient, who is being treated for hypercholesterolemia, complains of hot flashes and a metallic taste in the mouth. These are common side effects of: A. bile acid resins. B. clopidogrel. C. nicotinic acid. D. statins.
C
What is the best action by the nurse to level and zero a hemodynamic monitoring system transducer? A. Level the air-fluid interface of the zeroing transducer at the height of the patient's mattress. B. Position the air-fluid interface of the zeroing transducer at the fifth intercostal space,midclavicular line. C. Position the air-fluid interface of the zeroing transducer at the phlebostatic axis (fourth intercostal space, midaxillary line). D. Level the air-fluid interface of the zeroing transducer at the second intercostal space, anterior-axillary line.
C
When an electrical signal in the heart is aimed directly at the positive electrode, the nurse interprets that the deflection seen on the 12-lead ECG or rhythm strip will be: A. equiphasic. B. negative. C. positive. D. invisible.
C
Which intervention is important in meeting the needs of family members of critically ill patients? A. Allow a minister to meet with the family only in the waiting room B. Allow the family to visit the patient in large groups whenever they wish C. Encourage family members to participate in small activities of patient care, such as range-of-motion exercises D. Tell the family that "everything will be ok. The patient has the best team in the hospital"
C
Pleasant sensory stimuli in the critical care unit can be promoted by which interventions? (SATA) A. Conversing with another nurse about another patient's condition B. Discussing other patients' conditions within hearing range C. Moving the patient's bed to facilitate looking out the window D. Providing a clock, calendar, and family pictures in the room E. Asking, "Do you know what day it is?"
C, D
The patient is admitted with an anterior wall myocardial infarction. With this diagnosis, the nurse would expect to see Q waves in which leads? A. II B. III C. V3 D. V4 E. aVF
C, D
The family has decided to withdraw life support. Which actions by the nurse are consistent with this decision? (SATA) A. Beginning continuous renal replacement therapy B. Discontinuing comfort measures C. Initiating "do not resuscitate" orders D. Stopping tube feedings E. Weaning the patient from mechanical ventilation
C,D,E
A patient is complaining of midsternal chest discomfort radiating down the right arm. The discomfort has been present for about 5 minutes. The patient is also asthmatic and allergic to calcium channel blockers. The medication of choice for this patient at this time is: A. isoptin. B. metoprolol. C. nifedipine. D. nitroglycerin sublingual.
D
Handoff communication is essential in reducing errors. Which action can the nurse take to reduce errors in communication? A. Begin the practice of bedside shift report between nurses. B. Seek information on crew resource management training. C. Initiate a system of forms and checklists to convey information during rounds. D. Implement strategies to control noise during transfer report of a patient.
D
Spinal cord injury causes a loss of sympathetic output, resulting in distributive shock with hypotension and bradycardia. Although blood pressure may respond to fluid resuscitation, what other therapy may be required to compensate for loss of sympathetic innervation? a. Colloids b. Glucocorticoids c. Proton pump inhibitors d. Vasopressors
D
The family of a critically ill patient whose care has been deemed futile has decided to withhold treatments. Which action should the nurse take to initiate the family's wishes? A. Obtain signatures for "do not resuscitate" orders. B. Turn the patient every 2 hours. C. Slowly wean the patient off the ventilator. D. Refrain from giving the patient medications
D
The hypothyroid state in secondary hypothyroidism is often caused by: A. age-related changes B. pregnancy C. destruction of the thyroid by radiation D. pituitary gland dysfunction
D
The most important reason for the nurse to develop effective communication skills is to: A. collaborate with team members during interdisciplinary rounds. B. develop skills in patient/family education. C. ensure that the hospital is meeting Joint Commission requirements. D. promote patient safety and reduce errors.
D
The most sensitive cardiac enzyme to assess myocardial necrosis is: A. CK. B. CK-MB. C. potassium. D. troponin I.
D
The multiprofessional team is considering a withdrawal of life support from a patient but needs to conduct a comprehensive assessment. Which medication does the nurse know to discontinue before withdrawal of life-sustaining treatments in order to allow for a comprehensive patient assessment? A. Antibiotic B. Benzodiazepine C. Opiate D. Paralytic agent
D
The nurse has just listened to a lecture on the hospital's ethics committee. Which statement indicates that the teaching has been effective? A. "Its members consist only of physicians and nurses." B. "It deals with generalities instead of specific issues." C. "Its goal is to protect the hospital's interests." D. "It serves to educate and to develop guidelines."
D
The nurse is caring for a patient in neurogenic shock. Which should the nurse assess for? a. Tachycardia b. Hypertension c. Hypoventilation d. Vasodilation
D
The nurse is caring for a patient who has blood pooling in the capillary bed and arterial blood pressure too low to support perfusion of vital organs. Which symptoms should the nurse assess for? a. Acute respiratory distress syndrome (ARDS) b. Disseminated intravascular coagulation (DIC) c. Increased cerebral perfusion pressure d. Multisystem organ failure and/or dysfunction
D
The nurse is caring for a patient with possible distributive shock. Which should the nurse look for on assessment? a. Blood loss and actual hypovolemia. b. Decreased cardiac output. c. Third-spacing of fluids into peritoneal space. d. Vasodilation and relative hypovolemia.
D
The nurse is educating a new RN in the care of a diabetic patient. The nurse is anticpating that the patient will need a continuous infusion of intravenous insulin. Which statement by the new RN indicates that teaching has been effective? A. "Arterial blood gas should be monitored every 4 hours to assess bicarbonate." B. "I should implement a fluid restriction to prevent fluid overload." C. "I should administer kayexalate to prevent potassium buildup." D. "I should monitor plasma blood glucose every hour."
D
The nurse is orienting a new RN to the ICU. The nurse begins to review orders recently entered by the cardiologist and to explain their rationale to the new RN. Medication orders include dobutamine (Dobutrex) 400 mg in 250 mL 5% dextrose in water titrated to keep cardiac index >2 L/min/m2. Which statement by the new RN indicates that teaching has been effective? A. "The cardiac index is the amount of blood pumped out by a ventricle per minute." B. "The cardiac index is the amount of blood ejected with each ventricular contraction." C. "The cardiac index is the pressure created by the volume of blood in the left heart." D. "The cardiac index is the measurement specific to the patient's size or body area."
D
The nurse is working in the emergency department when a patient arrives who has experienced chest trauma. Which condition should the nurse be the most concerned with for this patient? a. Cardiac tamponade b. Flail chest c. Hemothorax d. Pulmonary contusion
D
The nurse manager is reviewing the World Health Organization's guidelines on noise in the critical care environment. How does the nurse manager interpret these guidelines? A. Noise can be eliminated with acoustic ceiling tiles B. Noise can be minimized by shutting off alarms C. Noise is something the nurse just has to deal with D. Noise levels often exceed recommended levels
D
The primary priority for the critical care nurse with regard to the trauma patient is which of the following? a. Decrease the patient's risk for multiple organ dysfunction syndrome. b. Ensure adequate fluid resuscitation. c. Increase the physiological reserve of the trauma patient. d. Provide adequate oxygenation and tissue perfusion.
D
The trauma patient presenting with left lower rib fractures develops left upper quadrant tenderness, hypotension, and referred pain to the left shoulder. You suspect: a. bowel obstruction. b. cardiac tamponade. c. pulmonary contusion. d. splenic injury
D
What is the best action by the nurse to accurately record a thermodilution cardiac output (CO)? A. Place the patient prone, enter the computation constant, and obtain four successive measurements. B. Place the patient prone, elevate the backrest 30 degrees, and obtain three successive measurements. C. Place the patient supine, enter the computation constant, and obtain one value with the head of the bed elevated at 45 degrees. D. Position the patient supine, obtain three values within 10% of each other, and calculate the average cardiac output.
D
What is the best position for the nurse to place the patient in to obtain a right atrial pressure measurement? A. Left side-lying with the head of the bed elevated 30 degrees B. Prone, lying on the abdomen with slight head elevation C. Right side-lying with the head of the bed elevated 30 degrees D. Supine, either flat or with the head of the bed no more than 60 degrees
D
A patient with a long-standing history of rheumatoid arthritis suddenly discontinued high-dose corticosteroid therapy. Which of the following assessment findings should the nurse anticipate? (Select all that apply) A. Bradycardia B. Hypertension C. Hypokalemia D. Hypotension E. Tachycardia
D, E
Immediate interventions in the treatment of a patient with burns from tar include which of the following? a. Apply cool water. b. Remove clothing that has been in contact with the tar. c. Try to remove tar that isn't well adhered to the skin. d. Apply ice over the tar/burn wounds.
a, b
When obtaining report on a trauma pateint, which question would be helpful in determining potential injuries associated with the mechanism of injury? (SATA) a. Was the patient wearing a seat belt? b. Where was the patient in the car? c. Where are the family members? d. Was fluid resuscitation initiated?
a, b
In which circumstances should the nurse anticipate that patients should be transferred to specialized burn center for treatment? a. Partial-thickness and full-thickness burns greater than 10% TBSA in patients over the age of 50 b. Burns involving the face, eyes, ears, hands, feet, perineum, major joints c. Inhalation injury d. Electrical burns, including lightning injury e. Burn patients with concomitant trauma
a, b, c, d, e
Which interventions are appropriate to consider in the management of the geriatric trauma patient? (SATA) a. Ask the patient if he or she has fallen recently. b. Obtain a detailed medical history. c. Administer intravenous fluids rapidly to maintain blood pressure. d. Frequently assess for signs of acute delirium. e. Observe for signs of infection, primarily elevated temperature. f. Obtain a detailed list of current medications.
a, b, d, f
The nurse is assessing a patient for suspected alcohol withdrawal and identifies which signs and symptoms as suspicious? (SATA) a.Irritable, confused, hallucinations b. Nausea, vomiting, diarrhea c. Hypotension and tachycardia d. Low body temperature e. Seizures f. Somnolent, difficult to arouse
a, b, e
To maintain the patient's airway, which interventions are appropriate to implement with a trauma patient who sustained a spinal cord injury? (SATA) a. Avoid hyperextension of the neck. b. Observe respiratory pattern. c. Insert an oral airway if patient is alert. d. Elevate the head of bed 30 degrees. e. Observe depth of ventilation. f. Maintain complete spinal immobilization.
a, b, e, f
Which of the following statements is correct regarding burn classification? a. Deep partial-thickness injuries involve destruction of epidermis and most of the dermis. b. Full-thickness burns involve all layers of the skin down to the bone. c. Partial-thickness burns involve injury to the dermal layer. d. Superficial burns involve only the epidermis.
a, c, d
Which of the following statements is true about nonburn injuries? a. The clinical picture of a nonburn injury is similar to that of a burn injury. b. Erythema multiforme is the most extensive type of exfoliative disorder. c. Necrotizing fasciitis is painless because underlying nerves have been destroyed. d. Staphylococcal scalding syndrome is skin sloughing caused by the staphylococcal toxin. e. Toxic epidermal necrolysis is most commonly caused by a drug reaction.
a, d, e
A 55-year-old trauma patient hit the steering wheel and has a cardiac contusion. Which are potential complications of the injury? (SATA) a. Flail chest b. Dysrhythmias c. Hypotension d. Myocardial ischemia
b, c, d
Prevention of hypothermia is crucial in caring for trauma patients. Which treatments are appropriate for preventing hypothermia? (SATA) a. Administer cool humidified oxygen. b. Cover the patient with an external warming device. c. Leave the patient's clothing on, even if wet. d. Warm fluids and blood products before or during administration. e. Warm the room in the emergency department and critical care unit.
b, d, e
Which of the following statements are true regarding chemical injuries? a. Chemical burns are not as severe as thermal burns. b. Systemic effects such as CNS depression, pulmonary edema, and hypotension may occur. c. These injuries affect only the localized area of chemical contact. d. Tissue damage continues until the chemical is completely removed or neutralized. e. Depth of tissue injury is greatest from alkalies.
b, d, e
A patient has sustained deep partial-thickness and full-thickness burns over 60% of her body. Shortly after admission, her blood pressure drops rapidly to a systolic pressure of 70 mm Hg. You know this is primarily due to: a. carbon monoxide poisoning. b. extreme pain. c. hypovolemic shock. d. sepsis.
c
All burn patients are at increased risk for acute respiratory distress syndrome (ARDS) due to: a. carboxyhemoglobinemia b. a decrease in cardiac output c. increased capillary permeability d. myoglobinemia
c
Ischemia to the gastrointestinal system may be caused by redistribution of blood to the brain and heart. The potential physiological effect of this is: a. anemia b. ascites c. ileus d. hepatic failure
c
Your patient weighs 60 kg and has a 40% total body surface area (TBSA) burn injury. Fluid resuscitation orders are for 4 mL/kg/% burn of a lactated Ringer's solution. What volume should the nurse anticipate infusing during the first 8 hours? a. 2400 mL b. 3600 mL c. 4800 mL d. 9600 mL
c
A major complication of an electrical burn injury is acute kidney injury caused by: a. excessive fluid resuscitation b. the catabolic effect of the electrical current through the kidneys. c. the direct effects of the electrical current as it traverses the intima of the kidney. d. the release of myoglobin, which can cause acute kidney injury.
d
The nurse is listening to a lecture about the most crucial phase of treatment in burn care. Which statement by the nurse indicates that teaching has been effective? a. "The most crucial phase of burn treatment is the acute phase." b. "The most crucial phase of burn treatment is the emergent phase." c. "The most crucial phase of burn treatment is the rehabilitative phase." d. "The most crucial phase of burn treatment is the resuscitative phase."
d
Which assessment finding indicates a burn injury below the glottis? a. Hoarseness b. Red or flushed cheeks c. Singed nasal hairs d. Soot particles in lung secretions
d
