Final Final

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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

Autonomic dysreflexia is characterized by an exaggerated response of the sympathetic nervous system to a variety of stimuli. Common causes of autonomic dysreflexia include: (Select all that apply.) A. bladder distention. B. fecal impaction. C. sinus bradycardia. D. urinary tract infection.

A, B

In the healthy individual, pain and anxiety: (Select all that apply.) a) activate the SNS. b) decrease stress levels. c) help remove one from harm. d) increase performance levels. e) limit SNS activity.

A, C, D

7. The nurse is caring for a 27-year-old patient with a diagnosis of head trauma. The nurse notes that the patient's urine output has increased tremendously over the past 18 hours. The nurse suspects that the patient may be developing: a. diabetes insipidus. b. diabetic ketoacidosis. c. hyperosmolar hyperglycemic syndrome. d. syndrome of inappropriate secretion of antidiuretic hormone.

16. The nurse is caring for a patient with a chemical burn injury. The priority nursing intervention is to: a. remove the patient's clothes and flush the area with water. b. apply saline compresses. c. contact a poison control center for directions on neutralizing agents. d. remove all jewelry.

8. The nurse is having difficulty inserting a large caliber intravenous catheter to facilitate fluid resuscitation to a hypotensive trauma patient. The nurse recommends which of the following emergency procedures to facilitate rapid fluid administration? a. Placement of an intraosseous catheter b. Placement of a central line placement c. Insertion of a femoral catheter by a trauma surgeon d. Rapid transfer to the operating room

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 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 in the ED for chest pain. In taking the health history, the nurse will be sure to verify whether the patient has taken medications prior to admission for: a. Erectile dysfunction b. Prostate enlargement c. Asthma d. Peripheral vascular disease

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 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 at least 88% d. Maintain heart rate above 100 beats/min

A patient is admitted to the hospital with multiple trauma and extensive blood loss. The nurse assesses vital signs to be BP 80/50 mm Hg, heart rate 135 beats/min, respirations 36 breaths/min, cardiac output (CO) of 2 L/min, systemic vascular resistance of 3000 dynes/sec/cm-5, and a hematocrit of 20%. The nurse anticipates administration of which the following therapies or medications? A. Blood transfusion B. Furosemide C. Dobutamine infusion D. Dopamine hydrochloride infusion

A patient presents to the ED complaining of severe substernal chest pressure radiating to his left shoulder and back that started about 12 hours ago. The patient delayed coming to the ED since he was 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. The hospital does not have the capability for percutaneous coronary intervention. Thrombolysis is one possible treatment. Based on these data, the nurse understands that? 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.

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.

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 receiving intravenous ibuprofen for pain management. The nurse recognizes which laboratory assessment to be a possible side effect of the ibuprofen? a) Creatinine: 3.1 mg/dL b) Platelet count 350,000 billion/L c) White blood count 13, 550 mm3 d) ALT 25 U/L

The nurse is listening to a lecture on the physiological consequences of acute respiratory distress syndrome (ARDS). Which statement indicates that teaching has been effective? a. "ARDS is associated with decreased compliance." b. "ARDS is associated with decreased physiological dead space." c. "ARDS is associated with increased resistance." d. "ARDS is associated with Pulmonary fibrosis."

The nurse is managing the blood pressure of a patient with a traumatic brain injury. When planning the care of this patient, which statement best represents appropriate blood pressure management? A. Cerebral perfusion pressure (CPP) should be sustained at least 70 mm Hg. B. Hypertension greater than 160 mm Hg is necessary to achieve adequate perfusion. C. Nimodipine reduces blood pressure through its effect on cerebral vessels. D. Nitrates are the vasopressors of choice with increased ICP.

The nurse is monitoring a patients intracranial pressure (ICP). While the nurse is providing hygiene measures, she observes that the ICP reading is sustained at 18 mm Hg. What is the priority nursing action? A. Cease stimulating the patient. B. Continue with hygiene measures. C. Lower the head of the bed to 10 degrees. D. Open the ICP monitor to continuous drainage.

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.

The patient is admitted with a suspected acute myocardial infarction (MI). 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's husband tells the nurse, "We didn't think she was having a heart attack because the pain was in her 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."

A B, C

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

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

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

The nurse is preparing for insertion of a pulmonary artery catheter (PAC). During insertion of the catheter, what are the priority nursing actions? (Select all that apply.) A. Allay the patient's anxiety by providing information about the procedure. B. Ensure that a sterile field is maintained during the insertion procedure. C. Inflate the balloon during the procedure when indicated by the provider. D. Monitor the patient's cardiac rhythm throughout the procedure. E. Obtain informed consent by informing the patient of procedural risks.

A, B, C, D

The possible P waveforms that are associated with junctional rhythms include which of the following? (Select all that apply.) a. No P wave b. Inverted P wave c. Shortened PR interval d. P wave after the QRS complex e. Normal P wave and PR interval

A, B, C, D

Which interventions are components of the ventilator bundle of care? Select all that apply. a. Daily assess the readiness for weaning/extubation. b. Elevate the head of the bed at least 30 degrees. c. Provide prophylaxis for deep vein thrombosis. d. Provide stress ulcer prophylaxis. e. Provide therapeutic paralysis.

A, B, C, D

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, B, C, D

Which interventions can the nurse use to facilitate communication with patients and families who are in the process of making decisions regarding end-of-life care options? (Select all that apply.) a) Communication of uniform messages from all health care team members b) An integrated plan of care that is developed collaboratively by the patient, family, and health care team c) Facilitation of continuity of care through accurate shift-to-shift and transfer reports d) Limitation of time for families to express feelings in order to control family grief e) Reassuring the patient and family that they will not be abandoned as the goals of care shift from aggressive treatment to comfort care

A, B, C, E

The nurse is caring for a postoperative patient in the critical care unit. The physician has ordered patient-controlled analgesia (PCA) for the patient. The nurse understands that the PCA: (Select all that apply.) a) is a safe and effective method for administering analgesia. b) has potentially fewer side effects than other routes of analgesic administration. c) is an ideal method to provide most critically ill patients some control over their treatment. d) provides good quality analgesia. e) doesn't work well without family assistance.

A, B, D

When performing an initial pulmonary artery occlusion pressure (PAOP), what are the best nursing actions? (Select all that apply.) A. Inflate the balloon for no more than 8 to 10 seconds while noting the waveform change. B. Inflate the balloon with air, recording the volume necessary to obtain a reading. C. Maintain the balloon in the inflated position for 8 hours following insertion. D. Zero reference and level the air-fluid interface of the transducer at the level of the phlebostatic axis. E. Inflate and deflate the balloon on an hourly schedule

A, B, D

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

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.

Select interventions that may be included during "terminal weaning" include which of the following? (Select all that apply.) a) Complete extubation following ventilator withdrawal b) Discontinuation of artificial ventilation but maintenance of the artificial airway c) Discontinuation of anxiolytic and pain medications d) Titration of ventilator support based upon blood gas determinations e) Titration of ventilator support to minimal levels based upon patient assessment of comfort

A, B, E

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 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

MULTIPLE RESPONSE 1. 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

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

4. Which of the following infection control strategies should the nurse implement to decrease the risk of infection in the burn-injured patient? (Select all that apply.) a. Apply topical antibacterial wound ointments/dressings. b. Change indwelling urinary catheter every 7 days. c. Daily assess the need for central IV catheters. d. Restrict family visitation. e. Maintain strict aseptic technique during burn wound management.

A, C, 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

When assessing the risk for stress ulcers after a coronary artery bypass graft (CABG) surgery, which factors would contribute to this risk? (Select all that apply.) A) Alcohol abuse or excess B) Age less than 70 years C) Incidence of postoperative hemorrhaging D) Need for vasodilators for postoperative hypertension E) Prolonged use of CRB

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

A patient in acute respiratory failure is experiencing carbon dioxide narcosis secondary to increased CO2 retention. What assessment finding should the nurse expect? a. Nasal flaring b. Paradoxical respirations c. Somnolence d. Suprasternal muscle retractions

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 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.

19. The nurse is assisting the patient to select foods from the menu that will promote wound healing. Which statement indicates the nurse's knowledge of nutritional goals? a. "Avoid foods that have saturated fats. Fats interfere with the ability of the burn wound to heal." b. "Choose foods that are high in protein, such as meat, eggs, and beans. These help the burns to heal." c. "It is important to choose foods like bread and pasta that are high in carbohydrates. These foods will give you energy and help you to heal faster." d. "Select foods that have lots of fiber, such as whole grains and fruits. These will promote removal of toxins from the body that interfere with healing."

A 53-year-old, 80-kg 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. During the nurse's 7 PM (1900) assessment, the patient is restless, heart rate has increased to 110 beats/min, respirations are 36 breaths/min, and blood pressure is 156/98 mm Hg. The cardiac monitor shows sinus tachycardia with 10 premature ventricular contractions (PVCs) per minute. Pulmonary artery pressures are elevated. The nurse suctions the patient and obtains pink, frothy secretions. Loud crackles are audible throughout lung fields. The nurse notifies the physician, who orders an ABG analysis, electrolyte levels, and a portable chest x-ray study. How does the nurse interpret the following blood gas levels? pH 7.28, PaCO2 46 mm Hg, Bicarbonate 22 mEq/L, PaO2 58 mm Hg, O2 saturation 88% a. Hypoxemia and compensated respiratory alkalosis b. Hypoxemia and uncompensated respiratory acidosis c. Normal arterial blood gas levels d. Normal oxygen level and partially compensated metabolic acidosis

A patient tells a nurse, My chest pain starts when I am resting and when I had a cardiac catheterization, the doctor said I was having vasospasms; Which of the following types of medications would the nurse anticipate would be utilized to treat the patients angina? A) A vasodilator such as nitroglycerin (NTG) B) A calcium channel blocking agent C) An antidysrhythmic such as lidocaine D) A beta adrenergic blocking agent

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

A patient who is undergoing withdrawal of mechanical ventilation appears anxious and agitated. The patient is on a continuous morphine infusion and has an additional order for lorazepam (Ativan) 1 to 2 mg IV as needed (prn). The patient has received no lorazepam (Ativan) during this course of illness. What is the most appropriate nursing intervention to control agitation? a) Administer fentanyl (Duragesic) 25 mg IV bolus. b) Administer lorazepam (Ativan) 1 mg IV now. c) Increase the rate of the morphine infusion by 50%. d) Request an order for a paralytic agent.

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. Murmur c. S1 heart sound d. S3 heart sound

The patient is receiving neuromuscular blockade. Which nursing assessment indicates a target level of paralysis? a) Glasgow Coma Scale score of 3 b) Train-of-four yields two twitches c) Bispectral index of 60 d) CAM-ICU positive

The patient's heart rate is 70 beats per minute, but the P waves come after the QRS complex. The nurse correctly determines that the patient's heart rhythm is a. a normal junctional rhythm. b. an accelerated junctional rhythm. c. a junctional tachycardia. d. atrial fibrillation.

Which comment by the patient indicates a good understanding of her 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 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

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

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

1. Fluid resuscitation is an important component of managing the trauma patient. Which of the following statements are true regarding the care of a trauma patient? (Select all that apply.) a. 5% Dextrose is recommended for rapid crystalloid infusion. b. IV fluids may need to be warmed to prevent hypothermia. c. Massive transfusions should be avoided to improve patient outcomes. d. Only fully cross-matched blood products are administered.

B, C

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

3. The nurse is assisting with endotracheal intubation and understands 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

B, C, D

4. It is important to prevent hypothermia in the trauma patient because hypothermia is associated with which of the following? (Select all that apply.) a. ARDS b. Coagulopathies c. Dysrhythmias d. Myocardial dysfunction

B, C, D

The charge nurse is reviewing the patients on the critical care floor. Which patients does the charge nurse anticipate as benefiting from noninvasive positive pressure ventilation? Select all that apply. a. Acute respiratory distress syndrome b. Chronic obstructive pulmonary disease exacerbation c. Obstructive sleep apnea d. Pulmonary edema

B, C, D

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

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 2 hours c. Monitor the vascular hemostatic device for signs of bleeding d. Instruct the patient bend his/her knee every 15 minutes while the sheath is in place

B, C, D

Which of the following situations may result in a low cardiac output and low cardiac index? (Select all that apply.) A. Exercise B. Hypovolemia C. Myocardial infarction D. Shock E. Fever

B, C, D

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, C, D

6. The nurse has been assigned the following patients. Which patients require assessment of blood glucose control as a nursing priority? (Select all that apply.) a. 18-year-old male who has undergone surgical correction of a fractured femur b. 29-year-old female who is undergoing evaluation for pheochromocytoma c. 43-year-old male with acute pancreatitis who is receiving total parenteral nutrition (TPN) d. 62-year-old morbidly obese female who underwent a hysterectomy for ovarian cancer e. 72-year-old female who is receiving intravenous (IV) steroids for an exacerbation of chronic obstructive pulmonary disease (COPD)

B, C, D, E

2. Which of the following factors increase the burn patient's risk for venous thromboembolism? (Select all that apply.) a. Burn injury less than 10% b. Bedrest c. Burns to lower extremities d. Electrical burn injury e. Delayed fluid resuscitation

B, C, E

Which of the following findings should cause the nurse to suspect that a post coronary artery bypass patient might be developing cardiac tamponade? (Select all that apply.) A) Widening pulse pressure B) Increased jugular vein distension C) Decreasing central venous pressure (CVP) D) Lack of pleural (chest) tube drainage E) Muffled heart sounds

B, D, E

2. Select all of the factors that may predispose the patient to respiratory acidosis. a. Anxiety and fear b. Central nervous system depression c. Diabetic ketoacidosis d. Nasogastric suctioning e. Overdose of sedatives

B, E

1. The optimal measurement of intravascular fluid status during the immediate fluid resuscitation phase of burn treatment is: a. blood urea nitrogen. b. daily weight. c. hourly intake and urine output. d. serum potassium.

1. Which of the following best defines the term traumatic injury? a. All trauma patients can be successfully rehabilitated. b. Traumatic injuries cause more deaths than heart disease and cancer. c. Alcohol consumption, drug abuse, or other substance abuse contribute to traumatic events. d. Trauma mainly affects the older adult population.

10. A 32-year-old patient is admitted to the critical care unit with a diagnosis of diabetic ketoacidosis. Following aggressive fluid resuscitation and intravenous (IV) insulin administration, the blood glucose begins to normalize. In addition to glucose monitoring, which of the following electrolytes requires close monitoring? a. Calcium b. Chloride c. Potassium d. Sodium.

5. A 24-year-old unrestrained driver who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. The primary survey of this patient upon arrival to the ED: a. includes a cervical spine x-ray study to determine the presence of a fracture. b. involves turning the patient from side to side to get a look at his back. c. is done quickly in the first few minutes to get a baseline assessment and establish priorities. d. is a methodical head-to-toe assessment identifying injuries and treatment priorities.

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 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.

A mode of pressure-targeted ventilation that provides positive pressure to decrease the workload of spontaneous breathing through the endotracheal tube is: a. continuous positive airway pressure. b. positive end-expiratory pressure. c. pressure support ventilation. d. T-piece adapter.

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 enzymes (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 an angina attack. 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 chest discomfort and a possible UA/NSTEMI. Which of the following would be a contraindication to administration of GP-IIb- IIIA inhibitors to the patient? The patient had: A) A platelet count greater than 150,000 mm 3 . B) Major surgery in the last 6 months. C) A stroke within the past month. D) A creatinine level of 1.4 mg/dL.

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 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

A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg. Her blood pressure is 144/90 mm Hg, and her mean arterial pressure (MAP) is 108 mm Hg. What is the cerebral perfusion pressure (CPP)? a. 54 mm Hg b. 72 mm Hg c. 90 mm Hg d. 126 mm Hg

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.

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.

The assessment of pain and anxiety is a continuous process. When critically ill patients exhibit signs of anxiety, the nurse's first priority is to a) administer antianxiety medications as ordered. b) administer pain medication as ordered. c) identify and treat the underlying cause. d) reassess the patient's hourly to determine whether symptoms resolve on their own.

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 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

The patient is admitted with sinus pauses causing periods of loss of consciousness. The patient is asymptomatic, awake and alert, but fatigued. He answers questions appropriately. When admitting this patient, the nurse should first a. prepare the patient for temporary pacemaker insertion. b. prepare the patient for permanent pacemaker insertion. c. assess the patient's medication profile. d. apply transcutaneous pacemaker paddles.

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 presents to the ED with sudden severe sharp chest discomfort radiating to his back and down both arms, as well as numbness in his 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 patient's spouse is terrified by the prospect of removing life- sustaining treatments from the patient and asks why anyone would do that. The nurse explains, a) "It is to save you money so that you won't have such a large financial burden." b) "It will preserve limited resources for the hospital so that other patients may benefit from them." c) "It is to discontinue treatments that are not helping your loved one and that may be very uncomfortable." d) "We have done all we can for your loved one, and any more treatment would be futile."

The patient's wife asks the nurse if the angioplasty will remove all the buildup in the vessel walls so that the patient will be healthy again. The nurse explains: a. "The operation will remove all of the plaque, and if your husband exercises and diets he will be free of cardiac problems." b. "The surgery will remove all the buildup, but it will reaccumulate and he will probably need this surgery again this time next year." c. "The best outcome will be if 20% to 50% of the diameter of the vessel can be restored. Your husband will need to diet and exercise carefully to avoid further cardiac risk." d. "The surgeon will only be able to get 5% to 10% of the plaque, but this will bring about marked relief of your husband's symptoms."

Which of the following is an accurate description of the progression of events in an acute coronary syndrome (ACS)? A) A thin fibrin layer stabilizes the ruptured plaque and prevents the occlusion of coronary vessels when stable angina is present in ACS. B) When complete platelet occlusion occurs in a vessel, the ECG changes include nonspecific ST elevation without necrosis occurring in ACS. C) The growth of platelet-rich thrombi in the smaller vessels creates a blockage and is the cause for unstable angina symptoms in ACS. D) Sudden plaque buildup in a narrow vessel immediately leads to an acute myocardial infarction when stable angina is present in ACS.

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.

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

1. The correct order of actions in the management of the postoperative surgical trauma patient who has been admitted to the critical care unit after surgery is: _______________, _______________, _______________,_______________. (Put a comma and space between each answer choice.) a. Connect the patient to bedside monitor and mechanical ventilator. b. Obtain vital signs, rhythm, oxygen saturation, and neurological status. c. Assess airway, breathing, and circulation. d. Reassess and evaluate patency of IV lines, and adjust rate of fluid administration as ordered.

C, A, B, D

COMPLETION 1. 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: _______________, _______________, _______________, _______________? (Put a comma and space between each answer choice.) 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 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

C, D

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

3. Which of the following laboratory values would be more common in patients with diabetic ketoacidosis? a. Blood glucose >1000 mg/dL b. Negative ketones in the urine c. Normal anion gap d. pH 7.24

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 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.

Assess and interpret the following arterial blood gases: pH 7.48, PaCO2 33 mm Hg, HCO2 20 mEq/L, PaO2 85 mm Hg. a. Fully compensated metabolic acidosis; normal oxygenation b. Normal ventilation and oxygenation c. Partly compensated respiratory acidosis with hypoxemia d. Uncompensated respiratory alkalosis; normal oxygenation

The nurse is concerned that the patient will pull out the endotracheal tube. As part of the nursing management, the nurse obtains an order for a) arm binders or splints b) a higher dosage of lorazepam c) propofol d) soft wrist restraints

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.

2. Prevention of hypothermia is crucial in caring for trauma patients. The correct order of actions for the preparation for the trauma patient is: _______________, _______________, _______________, _______________. (Put a comma and space between each answer choice.) a. Remove wet clothing. b. Warm fluids and blood products before administration. c. Cover the patient with an external warming device. d. Warm the ED or intensive care unit (ICU) room before the patient's arrival.

D, A, C, B

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

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

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

Interpret the following rhythm: a. Normal sinus rhythm b. Sinus bradycardia c. Sinus tachycardia d. Sinus arrhythmia

Interpret the following rhythm: a. Atrial fibrillation b. Atrial flutter c. Atrial flutter with RVR d. Junctional escape rhythm

Interpret the following rhythm: a. Sinus rhythm with PACs b. Normal sinus rhythm c. Sinus tachycardia d. Sinus bradycardia

Nociceptors differ from other nerve receptors in the body in that they: a) adapt very little to continual pain response. b) inhibit the infiltration of neutrophils and eosinophils. c) play no role in the inflammatory response. d) transmit only the thermal stimuli.

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

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

Which of the following treatments should the nurse anticipate administering to a hypoxic patient admitted with exacerbation of COPD? a. Bag-valve-mask ventilation with oxygen at 15 L/min b. Continuous positive airway pressure (CPAP) via face mask c. Non-rebreather mask with 80% oxygen d. Oxygen via Venturi mask at 40% oxygen

Which statement is true regarding the effects of caring for dying patients on nurses? a) Attendance at funerals is inappropriate and will only create additional stress in nurses who are already at risk for burnout. b) Caring for dying patients is an expected part of nursing and will not affect the emotional health of the nurse if he or she maintains a professional approach with each patient and family. c) Most nurses who work with dying patients are able to balance care needs of patients with personal emotional needs. d) Provision of aggressive care to patients for whom they believe it is futile may result in personal ethical conflicts and burnout for nurses.

Interpret the following rhythm: a. Atrial flutter with variable conduction b. Ventricular fibrillation c. Atrial fibrillation d. Atrial flutter with RVR (rapid ventricular response)

Interpret the following rhythm: a. Atrial pacing b. Ventricular pacing c. Dual-chamber pacing d. Transcutaneous pacing

Interpret the following rhythm: a. Idioventricular rhythm b. Accelerated idioventricular rhythm c. Ventricular tachycardia d. Ventricular fibrillation

Interpret the following rhythm: a. Junctional rhythm b. An accelerated junctional rhythm c. A junctional tachycardia d. Atrial fibrillation

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.

The physician orders 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 primary mode of action for neuromuscular blocking agents used in the management of some ventilated patients is a) analgesia b) anticonvulsant therapy c) paralysis d) sedation

A statement that provides a legally recognized description of an individual's desires regarding care at the end of life is a (an) a) advance directive b) guardianship ad litem c) healthcare proxy d) power of attorney

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

Interpret the following rhythm: a. R-on-T phenomenon leading to ventricular fibrillation b. Sinus rhythm with multifocal premature ventricular contractions c. Nonsustained ventricular tachycardia d. Sinus rhythm with bigeminal premature ventricular contractions

Interpret the following rhythm: a. Sinus rhythm with multifocal premature ventricular contractions b. Sinus rhythm with unifocal premature ventricular contractions c. Sinus rhythm with bigeminal premature ventricular contractions d. Sinus rhythm with paired premature ventricular contractions (couplets)

10. A community-based external disaster is initiated after a tornado moved through the city. A nurse from the medical records review department arrives at the emergency department asking how she can assist. The best response by a nurse working for the trauma center would be to: a. assign the nurse administrative duties, such as obtaining patient demographic information. b. assign the nurse to a triage room with another nurse from the emergency department. c. thank the nurse but inform her to return to her department as her skill set is not a good match for patients' needs. d. have the nurse assist with transport of patients to procedural areas.

15. A 20-year-old female with a history of type 1diabetes and an eating disorder is found unconscious. In the emergency department, the following lab values are obtained: Glucose648 mg/dL pH6.88 PaCO220 mm Hg PaO295 mm Hg HCO3- undetectable Anion gap>31 Na+127 mEq/L K+ 3.5 mEq/L Creatinine1.8 mg/dL After the patient's airway and ventilation have been established, the next priority for this patient is: a. administration of a 1-L normal saline fluid bolus. b. administration of 0.1 unit of regular insulin IV push followed by an insulin infusion. c. administration of 20 mEq KCl in 100 mL. d. IV push administration of 1 amp of sodium bicarbonate.

18. A patient presents to the emergency department with suspected thyroid storm. The nurse should be alert to which of the following cardiac rhythms while providing care to this patient? a. Atrial fibrillation b. Idioventricular rhythm c. Junctional rhythm d. Sinus bradycardia

21. Which of the following would be seen in a patient with myxedema coma? a. Decreased reflexes b. Hyperthermia c. Hyperventilation d. Tachycardia

23. A 63-year-old patient is admitted with new onset fever; flulike symptoms; blisters over her arms, chest, and neck; and red, painful, oral mucous membranes. The patient should be further evaluated for which possible non-burn injured skin disorder? a. Toxic epidermal necrolysis b. Staphylococcal scalded skin syndrome c. Necrotizing soft tissue infection d. Graft versus host disease

27. The nurse is caring for a patient who suffered a head trauma following a fall. The patient's heart rate is 112 beats/min and blood pressure is 88/50 mm Hg. The patient has poor skin turgor and dry mucous membranes. The patient is confused and restless. The following laboratory values are reported: serum sodium is 115 mEq/L; blood urea nitrogen (BUN) 50 mg/dL; and creatinine 1.8 mg/dL. The findings are consistent with which disorder? a. Cerebral salt wasting b. Diabetes insipidus c. Syndrome of inappropriate secretion of antidiuretic hormone d. Thyroid storm

3. An 18-year-old unrestrained passenger who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. This patient should be treated at which level trauma center? a. Level I b. Level II c. Level III d. Level IV

6. A patient has been on daily, high-dose glucocorticoid therapy for the treatment of rheumatoid arthritis. His prescription runs out before his next appointment with his physician. Because he is asymptomatic, he thinks it is all right to withhold the medication for 3 days. What is likely to happen to this patient? a. He will go into adrenal crisis. b. He will go into thyroid storm. c. His autoimmune disease will go into remission. d. Nothing; it is appropriate to stop the medication for 3 days.

7. Which of the following interventions would not be appropriate for a patient who is admitted with a suspected basilar skull fracture? a. Insertion of a nasogastric tube b. Insertion of an indwelling urinary catheter c. Endotracheal intubation d. Placement of an oral airway

8. The nurse is caring for patient who has been struck by lightning. Because of the nature of the injury, the nurse assesses the patient for which of the following? a. Central nervous system deficits b. Contractures c. Infection d. Stress ulcers

A nurse is caring for a patient who has just started to bleed from her insertion site following a cardiac catheterization. What should be the nurses first response? The nurse should: A) Apply manual pressure to the site. B) Locate and apply a compression clamp. C) Apply a collagen patch or sheath. D) Administer vitamin K (AquaMEPHYTON).

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 nurse is discussing management of hypertension with a patient. Which of the following statements by the patient would indicate that the patient needs additional teaching about the relationship between hypertension and acute coronary syndrome (ACS)? A) My high blood pressure has no relationship to the severity of heart disease or its outcomes. B) Because I'm over 80, even a 20 mm Hg drop in my blood pressure can reduce my risk. C) High blood pressure will increase my bodys need for oxygen and increase my hearts workload. D) Controlling my blood pressure will decrease my risk of having a heart attack to some degree.

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 presents to the emergency department (ED) with chest pain that he has had for the past 2 hours. He is nauseous and diaphoretic, and his skin is dusky in 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 with metastatic lung carcinoma has been unresponsive to chemotherapy. The medical team has determined that there are no additional treatments available that will prolong life or improve the quality of life in any meaningful way. Despite the poor prognosis, the patient continues to receive chemotherapy and full nutritional support. This is an example of which end-of-life concept? a) Medical futility b) Palliative care c) Terminal weaning d) Withdrawal of treatment

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 .60 to .70, 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

A postsurgical patient is on a ventilator in the critical care unit. The patient has been tolerating the ventilator well and has not required any sedation. On assessment, the nurse notes the patient is tachycardic and hypertensive with an increased respiratory rate of 28 breaths/min. The patient has been suctioned recently via the endotracheal tube, and the airway is clear. The patient responds appropriately to the nurse's commands. The nurse should: a) assess the patient's level of pain. b) decrease the ventilator rate. c) provide sedation as ordered. d) suction the patient again.

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

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.

All of the patient's children are distressed by the possibility of removing life-support treatments from their mother. The child who is most upset tells the nurse, "This is the same as killing her! I thought you were supposed to help her!" The nurse explains to the family, a) "This is a process of allowing your mother to die naturally after the injuries that she sustained in a serious accident." b) "The hospital would never allow us to do that kind of thing." c) "Let's talk about this calmly, and I will explain why assisted suicide is appropriate in this case." d) "She's lived a long and productive life."

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.

Herniation syndromes can be life-threatening situations. Which syndrome causes the supratentorial contents to shift downward and compress vital centers of the brainstem? A. Central herniation B. Cingulate herniation C. Tonsillar herniation D. Uncal herniation

If the low-exhaled volume alarm is sounding on a mechanical ventilator, the nurse should: a. assess to see that the ventilator is attached to the endotracheal tube. b. contact the respiratory therapist to set the tidal volume at a higher level. c. extubate the patient and ventilate with a bag-valve device. d. see whether the patient is biting the endotracheal tube.

In which of the following situations would a health care surrogate or proxy assume the end-of-life decision-making role for a patient? a) When a dying patient requires extensive heavy sedation, such as benzodiazepines and narcotics, to control distressing symptoms b) When a dying patient who is competent requests to withdraw treatment against the wishes of the family c) When a dying patient who is competent requests to continue treatment against the recommendations of the health care team d) When a dying patient who is competent is receiving prn treatment for pain and anxiety

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 charge nurse is supervising the care of four critical care patients being monitored using invasive hemodynamic modalities. Which patient should the charge nurse evaluate first? A. A patient in cardiogenic shock with a cardiac output (CO) of 2.0 L/min B. A patient with a pulmonary artery systolic pressure (PAP) of 20 mm Hg C. A hypovolemic patient with a central venous pressure (CVP) of 6 mm Hg D. A patient with a pulmonary artery occlusion pressure (PAOP) of 10 mm Hg

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 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.

The etiology of pulmonary edema in acute respiratory distress syndrome is related to: a. damage to the alveolar-capillary membrane. b. decreased cardiac output. c. tension pneumothorax. d. volutrauma and hypoxemia.

The family is considering the withdrawal of life-sustaining measures from the patient. The nurse knows that ethical principles for withholding or withdrawing life- sustaining treatments include which of the following? a) Any treatment may be withdrawn and withheld, including nutrition, antibiotics, and blood products. b) Doses of analgesic and anxiolytic medications must be adjusted carefully and should not exceed usual recommended limits. c) Life-sustaining treatments may be withdrawn while a patient is receiving paralytic agents. d) The goal of withdrawal and withholding of treatments is to hasten death and thus relieve suffering.

The most important nursing intervention for patients who receive neuromuscular blocking agents is to a) administer sedatives in conjunction with the neuromuscular blocking agents. b) assess neurological status every 30 minutes. c) avoid interaction with the patient, because he or she won't be able to hear. d) restrain the patient to avoid self- extubation.

The nurse admits a patient to the critical care unit following a motorcycle crash. Assessment findings by the nurse include blood pressure 100/50 mm Hg, heart rate 58 beats/min, respiratory rate 30 breaths/min, and temperature of 100.5°. The patient is lethargic, responds to voice but falls asleep readily when not stimulated. Which nursing action is most important to include in this patient's plan of care? a. Frequent neurological assessments b. Side to side position changes c. Range of motion to extremities d. Frequent oropharyngeal suctioning

The nurse assesses a patient with a skull fracture to have a Glasgow Coma Scale score of 3. Additional vital signs assessed by the nurse include blood pressure 100/70 mm Hg, heart rate 55 beats/min, respiratory rate 10 breaths/min, oxygen saturation (SpO2) 94% on oxygen at 3 L per nasal cannula. What is the priority nursing action? a. Monitor the patient's airway patency. b. Elevate the head of the patient's bed. c. Increase supplemental oxygen delivery. d. Support bony prominences with padding.

The nurse has just received a patient from the emergency department with an admitting diagnosis of bacterial meningitis. To prevent the spread of nosocomial infections to other patients, what is the best action by the nurse? a. Implement droplet precautions upon admission. b. Wash hands thoroughly before leaving the room. c. Scrub the hub of all central line ports prior to use. d. Dispose of all bloody dressings in biohazard bags.

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 100-kg patient being monitored with a pulmonary artery catheter. The nurse assesses a blood pressure of 90/60 mm Hg, heart rate 110 beats/min, respirations 36/min, oxygen saturation of 89% on 3 L of oxygen via nasal cannula. Bilateral crackles are audible upon auscultation. Which hemodynamic value requires immediate action by the nurse? A. Cardiac index (CI) of 1.2 L/min/m3 B. Cardiac output (CO) of 4 L/min C. Pulmonary vascular resistance (PVR) of 80 dynes/sec/cm-5 D. Systemic vascular resistance (SVR) of 1400 dynes/sec/cm-5

The nurse is caring for a 70-kg patient in septic shock with a pulmonary artery catheter. Which hemodynamic value indicates an appropriate response to therapy aimed at enhancing oxygen delivery to the organs and tissues? A. Arterial lactate level of 1.0 mEq/L B. Cardiac output of 2.5 L/min C. Mixed venous (SvO2) of 40% D. Cardiac index of 1.5 L/min/m2

The nurse is caring for a critically ill trauma patient who is expected to be hospitalized for an extended period. Which of the following nursing interventions would improve the patient's well-being and reduce anxiety the most? a) Arrange for the patient's dog to be brought into the unit (per protocol). b) Provide aromatherapy with scents such as lavender that are known to help anxiety. c) Secure the harpist to come and play soothing music for an hour every afternoon. d) Wheel the patient out near the unit aquarium to observe the tropical fish.

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 at risk for respiratory failure. Which assessment findings would alert the nurse to potential respiratory failure? a. Anxiety and restlessness b. Cyanosis and hyperventilation c. Dyspnea and nasal flaring d. Hypertension and bradycardia

The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which action by the nurse best reduces the risk of catheter-related bloodstream infection (CRBSI)? A. Review daily the necessity of the central venous catheter. B. Cleanse the insertion site daily with isopropyl alcohol. C. Change the pressurized tubing system and flush bag daily. D. Maintain a pressure of 300 mm Hg on the flush bag.

The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which assessment finding 2 hours after insertion by the nurse warrants immediate action? A. Diminished breath sounds over left lung field B. Localized pain at catheter insertion site C. Measured central venous pressure of 5 mm Hg D. Slight bloody drainage around insertion site

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 who has positive end-expiratory pressure (PEEP) as an adjunct to the ventilation. When PEEP is increased, the nurse is prepared for which assessment finding? a. A decrease in cardiac output b. A decrease in inspiratory pressure c. An increase in tidal volume d. An increased work of breathing

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

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

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

The nurse is caring for a patient with a ruptured cerebral aneurysm. During initial assessment, the nurse notes that the cerebrospinal fluid draining into a ventriculostomy system is blood tinged. What is the best interpretation of this finding by the nurse? A. Cerebral aneurysms commonly rupture in the subarachnoid space. B. This assessment finding is indicative of developing cerebral meningitis. C. Patient movement has resulted in dislodgement of the catheter. D. Normal cerebral spinal fluid contains a small amount of visible blood.

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 preparing to administer 100 mg of phenytoin (Dilantin) to a patient in status epilepticus. To prevent patient complications, what is the best action by the nurse? a. Ensure patency of intravenous (IV) line. b. Mix drug with 0.9% normal saline. c. Evaluate serum K+ level. d. Obtain an IV infusion pump.

The nurse is preparing to admit a patient from the ED who has sustained a complete spinal cord lesion at the C5 level. When planning the patients care, which nursing intervention is most important? A. Perform hourly incentive spirometry. B. warming devices as needed. C. Give small, frequent feedings. D. with passive range of motion.

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. "My back is killing me!" 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 nurse receives a patient from the emergency department following a closed head injury. After insertion of an ventriculostomy, the nurse assesses the following vital signs: blood pressure 100/60 mm Hg, heart rate 52 beats/min, respiratory rate 24 breaths/min, oxygen saturation (SpO2) 97% on supplemental oxygen at 45% via Venturi mask, Glasgow Coma Scale score of 4, and intracranial pressure (ICP) of 18 mm Hg. Which physician order should the nurse institute first? a. Mannitol 1 g intravenous b. Portable chest x-ray c. Seizure precautions d. Ancef 1 g intravenous

The nurse responds to a high heart rate alarm for a patient in the neurological intensive care unit. The nurse arrives to find the patient sitting in a chair experiencing a tonic-clonic seizure. What is the best nursing action? a. Assist the patient to the floor and provide soft head support. b. Insert a nasogastric tube and connect to continuous wall suction. c. Open the patient's mouth and insert a padded tongue blade. d. Restrain the patient's extremities until the seizure subsides.

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 presents to the ED with severe chest discomfort. He is taken for cardiac catheterization and angiography that shows 80% occlusion of the left main coronary artery. Which procedure will be most likely followed? a. Coronary artery bypass graft surgery b. Intracoronary stent placement c. Percutaneous transluminal coronary angioplasty (PTCA) d. Transmyocardial revascularization

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

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.

To prevent any unwanted resuscitation after life-sustaining treatments have been withdrawn, the nurse should ensure that: a) "do not resuscitate" (DNR) orders are written before the discontinuation of the treatments. b) the family is not allowed to visit until the death occurs. c) DNR orders are written as soon as possible after the discontinuation of the treatments. d) the change-of-shift report includes the information that the patient is not to be resuscitated.

Upon entering the room of a patient with a right radial arterial line, the nurse assesses the waveform to be slightly dampened and notices blood to be backed up into the pressure tubing. What is the best action by the nurse? A. Check the inflation volume of the flush system pressure bag. B. Disconnect the flush system from the arterial line catheter. C. Zero reference the transducer system at the phlebostatic axis. D. Reduce the number of stopcocks in the flush system tubing.

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 devices is best suited to deliver 65% oxygen to a patient who is spontaneously breathing? a. Face mask with non-rebreathing reservoir b. Low-flow nasal cannula c. Simple face mask d. Venturi mask

Which of the following is true about a patient diagnosed with sinus arrhythmia? a. The heart rate varies, dependent on vagal tone and respiratory pattern. b. Immediate treatment is essential to prevent death. c. Sinus arrhythmia is not well tolerated by most patients. d. PR and QRS interval measurements are prolonged.

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.

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.

Which patient being cared for in the emergency department should the charge nurse evaluate first? a. A patient with a complete spinal injury at the C5 dermatome level b. A patient with a Glasgow Coma Scale score of 15 on 3-L nasal cannula c. An alert patient with a subdural bleed who is complaining of a headache d. An ischemic stroke patient with a blood pressure of 190/100 mm Hg

Which statement is consistent with societal views of dying in the United States? a) Dying is viewed as a failure on the part of the system and providers. b) Most Americans would prefer to die in a hospital to spare loved ones the burden of care. c) People die of distinct, complex illness for which a cure is always possible. d) The purpose of the health care system is to prevent disease and treat symptoms.

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

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

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).

1. Which of the following statements about the pain management of a burn victim are true? (Select all that apply.) a. Additional pain medication may be needed because of rapid body metabolism. b. Pain medication should be given before procedures such as debridement, dressing changes, and physical therapy. c. Patients with a history of drug and alcohol abuse will require higher doses of pain medication. d. The intramuscular route is preferred for pain medication administration.

A, B, C

2. Trauma patients are at high risk for multiple complications not only due to the mechanism of injury but also due to the patients' long-term management. Which of the following statements apply to trauma patients? (Select all that apply.) a. Indwelling urinary catheters are a source of infection. b. Patients often develop infection and sepsis secondary to central line catheters. c. Pneumonia is often an adverse outcome of mechanical ventilation. d. Wounds require sterile dressings to prevent infection.

A, B, C

Palliation may include (Select all that apply.) a) relieving pain. b) relieving nausea. c) psychological support. d) withdrawing life-support interventions. e) withholding tube feedings.

A, B, C

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, B, C

The nurse is assessing a patient for a possible pulmonary embolus. Assessment findings may include which of the following? Select all that apply. a. Acute onset of chest pain b. Hemoptysis c. Low oxygen saturation level d. Pleural friction rub

A, B, C

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, B, C

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, B, C

The patient has been in chronic heart failure for the past 10 years. He has been treated with beta-blockers and angiotensin-converting enzyme inhibitors as well as diuretics. His symptoms have recently worsened, and he presents to the ED with severe shortness of breath and crackles throughout his lung fields. His respirations are labored and arterial blood gases show that he is at risk for respiratory failure. Which of the following therapies may be used for acute, short-term management of the patient? (Select all that apply). a. Dobutamine b. Intraaortic balloon pump c. Nesiritide (Natrecor) d. Ventricular assist device

A, B, C

Which therapeutic interventions may be withdrawn or withheld from the terminally ill client? (Select all that apply.) a) Antibiotics b) Dialysis c) Nutrition d) Pain medications e) Simple nursing interventions such as repositioning and hygiene

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

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

The nurse is caring for a patient with status asthmaticus in the emergency department. The nurse anticipates what therapies to be ordered? Select all that apply. a. Inhaled anticholinergic agent b. Inhaled rapid-acting beta-2 agonists c. Oxygen administration d. Systemic corticosteroids

A, B, C, D

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, B, C, D

Factors in the critical care unit that may predispose the client to increased pain and anxiety include: (Select all that apply.) a) an endotracheal tube. b) frequent vital signs. c) monitor alarms. d) room temperature. e) hostile environment.

A, B, C, D, E

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

When providing palliative care, the nurse must keep in mind that the family may include which of the following? (Select all that apply.) a) Unmarried life partners of same sex b) Unmarried life partners of opposite sex c) Roommates d) Close friends e) Parents

A, B, C, D, E

Which of the following are accepted nonpharmacological approaches to managing pain and/or anxiety in critically ill patients? (Select all that apply.) a) Environmental manipulation b) Explanations of monitoring equipment c) Guided imagery d) Music therapy e) Provision of personal items

A, B, C, D, E

Which of the following factors predispose the critically ill patient to pain and anxiety? (Select all that apply.) a) Inability to communicate b) Invasive procedures c) Monitoring devices d) Nursing care e) Preexisting conditions

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

Which nursing actions are most important for a patient with a right radial arterial line? (Select all that apply.) A. Checking the circulation to the right hand every 2 hours B. Maintaining a pressurized flush solution to the arterial line setup C. Monitoring the waveform on the monitor for dampening D. Restraining all four extremities with soft limb restraints E. Ensuring all junctions remain tightly connected

A, B, C, E

In an unconscious patient, eye movements are tested by the oculocephalic response. Which statements regarding the testing of this reflex are true? (Select all that apply.) a. Doll's eyes absent indicate a disruption in normal brainstem processing. b. Doll's eyes present indicate brainstem activity. c. Eye movement in the opposite direction as the head when turned indicates an intact reflex. d. Eye movement in the same direction as the head when turned indicates an intact reflex. e. Increased intracranial pressure (ICP) is a contraindication to the assessment of this reflex. f. Presence of cervical injuries is a contraindication to the assessment of this reflex.

A, B, C, E, F

3. The nurse is caring for a patient with burns to the hands, feet, and major joints. The nurse plans care to include which of the following? (Select all that apply.) a. Applying splints that maintain the extremity in an extended position b. Implementing passive or active range-of-motion exercises c. Keeping the limbs as immobile as possible d. Wrapping fingers and toes individually with bandages

A, B, D

6. An autograft is used to optimally treat a partial- or full-thickness wound that: (Select all that apply.) a. involves a joint. b. involves the face, hands, or feet. c. is infected. d. requires more than 2 weeks for healing.

A, B, D

6. Which interventions can the nurse implement to assist the patient's family in coping with the traumatic event? (Select all that apply.) a. Establish a family spokesperson and communication system. b. Ask the family about their normal coping mechanisms. c. Limit visitation to set times throughout the day. d. Coordinate a family conference.

A, B, D

7. Nursing priorities to prevent ineffective coagulation include which of the following? (Select all that apply.) a. Prevention of hypothermia b. Administration of fresh frozen plasma as ordered c. Administration of potassium as ordered d. Administration of calcium as ordered

A, B, D

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

A, B, D

In the critically ill patient, an incomplete assessment and/or management of pain or anxiety may be hampered by which of the following? (Select all that apply.) a) Administration of neuromuscular blocking agents b) Delirium c) Effective nurse communication and assessment skills d) Nonverbal patients e) Ventilated patient

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 multidisciplinary team would identify which of the following goals for initial collaborative management of a patient with an acute coronary event (ACS)? (Select all that apply.) A) Maximize coronary artery blood flow. B) Limit the size of infarction by decreasing oxygen demands. C) Strengthen the heart by increasing activity as soon as possible. D) Balance oxygen demand with supply. E) Prevent dysrhythmias with prophylactic antidysrhythmic medications.

A, B, D

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, 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

4. What psychosocial factors may potentially contribute to the development of diabetic ketoacidosis? (Select all that apply.) a. Altered sleep/rest patterns b. Eating disorder c. Exposure to influenza d. High levels of stress e. Lack of financial resources

A, B, D, E

Anxiety differs from pain in that: (Select all that apply.) a) it is confined to neurological processes in the brain b) it is linked to reward and punishment centers in the limbic system c) it is subjective d) there is no actual tissue injury e) it can be increased by noise and light

A, B, D, E

Choose the items that are common to both pain and anxiety. (Select all that apply.) a) Cyclical exacerbation of one another b) Require good nursing assessment for proper treatment c) Response only to real phenomena d) Subjective in nature e) Perception may be influenced by prior experience

A, B, D, 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

5. Which complications may manifest after an electrical injury? (Select all that apply.) a. Long bone fractures b. Cardiac dysrhythmias c. Hypertension d. Compartment syndrome of extremities e. Dark brown urine f. Peptic ulcer disease g. Acute cataract formation h. Seizures

A, B, D, E, G, H

5. Factors associated with the development of nephrogenic diabetes insipidus include which of the following? (Select all that apply.) a. Heredity b. Medications, including phenytoin (Dilantin) and lithium carbonate c. Meningitis d. Pituitary tumors e. Sickle cell disease

A, B, E

2. Mechanisms for development of diabetes insipidus include which of the following? (Select all that apply.) a. ADH deficiency b. ADH excess c. ADH insensitivity d. ADH replacement therapy e. Water deprivation

A, C

5. Which of the following patients would require greater amounts of fluid resuscitation to prevent acute kidney injury associated with rhabdomyolysis? (Select all that apply.) a. Crush injury to right arm b. Gunshot wound to the abdomen c. Lightning strike of the left arm and chest d. Pulmonary contusion and rib fracture

A, C

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, C

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

The nurse is caring for a patient admitted with new onset of slurred speech, facial droop, and left-sided weakness 8 hours ago. Diagnostic computed tomography scan rules out the presence of an intracranial bleed. Which actions are most important to include in the patient's plan of care? (Select all that apply.) a. Make frequent neurological assessments. b. Maintain CO2 level at 50 mm Hg. c. Maintain MAP less than 130 mm Hg. d. Prepare for thrombolytic administration. e. Restrain affected limb to prevent injury.

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

1. Which of the following are appropriate nursing interventions for the patient in myxedema coma? (Select all that apply.) a. Administer levothyroxine (Synthroid) as ordered. b. Encourage the intake of foods high in sodium. c. Initiate passive rewarming interventions. d. Monitor airway and respiratory effort. e. Monitor urine osmolality.

A, C, D

3. During the assessment of a patient after a high-speed motor vehicle crash, which of the following findings would increase the nurse's suspicion of a pulmonary contusion? (Select all that apply.) a. Chest wall ecchymosis b. Diminished or absent breath sounds c. Pink-tinged or blood secretions d. Signs of hypoxia on room air

A, C, D

8. Which of the following findings require immediate nursing interventions related to the assessment of a patient with a traumatic brain injury? (Select all that apply.) a. Mean arterial pressure 48 mm Hg b. Elevated serum blood alcohol level c. Non-reactive pupils d. Respiratory rate of 10 breaths per minute

A, C, D

A patient requires pancuronium as part of treatment of refractive increased intracranial pressure. The nursing care for this patient includes: (Select all that apply.) a) administration of sedatives concurrently with neuromuscular blockade. b) dangling the patient's feet over the edge of the bed and assisting the patient to sit up in a chair at least twice each day. c) ensuring that deep vein thrombosis prophylaxis is initiated. d) providing interventions for eye care, oral care, and skin care. e) ensuring good nutrition with frequent feedings throughout the day.

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 of the following statements regarding pain and anxiety are true? (Select all that apply.) a) Anxiety is a state marked by apprehension, agitation, autonomic arousal, and/or fearful withdrawal. b) Critically ill patients often experience anxiety, but they rarely experience pain. c) Pain and anxiety are often interrelated and may be difficult to differentiate because their physiological and behavioral manifestations are similar. d) Pain is defined by each patient; it is whatever the person experiencing the pain says it is. e) While anxiety is unpleasant, it does not contribute to mortality or morbidity of the critically ill patient.

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.

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

The nurse is assessing the critically ill patient for delirium. The nurse recognizes which characteristics that indicate hyperactive delirium? (Select all that apply.) a) Agitation b) Apathy c) Biting d) Hitting e) Restlessness

A, C, D, E

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 a patient who is intubated and on a ventilator following extensive abdominal surgery. Although the patient is responsive, the nurse is not able to read the patient's lips as the patient attempts to mouth the words. Which of the following assessment tools would be the most appropriate for the nurse to use when assessing the patient's pain level? (Select all that apply.) a) The FACES scale b) Pain Intensity Scale c) The PQRST method d) the VAS e) the CAM tool

A, D

Which of the following are nursing interventions to prevent ventilator-associated pneumonia (VAP)? Select all that apply. a. Elevate the head of bed to at least 30 degrees. b. Intubate the patient with an endotracheal tube with continuous subglottic aspiration of secretions. c. Maintain a deep level of sedation. d. Provide regular oral care, including the use of chlorhexidine.

A, D

Which statements best represent optimal fluid administration for the management of increased intracranial pressure? (Select all that apply.) A. Normal saline (0.9%) is recommended for fluid volume resuscitation. B. The goal is to keep serum osmolality greater than 320 mOsm/L. C. 0.45% saline solution is acceptable for fluid volume resuscitation. D. Hypotonic solutions are avoided to prevent an increase in cerebral edema.

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

The nurse is preparing to obtain a right atrial pressure (RAP/CVP) reading. What are the most appropriate nursing actions? (Select all that apply.) A. Compare measured pressures with other physiological parameters. B. Flush the central venous catheter with 20 mL of sterile saline. C. Inflate the balloon with 3 mL of air and record the pressure tracing. D. Obtain the right atrial pressure measurement during end exhalation. E. Zero reference the transducer system at the level of the phlebostatic axis.

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

2. The nurse is assisting with endotracheal intubation of the patient and recognizes that the procedure will be done in what order: _______________, _______________, _______________, _______________, _______________? (Put a comma and space between each answer choice.) 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

1. A patient with type 1 diabetes who is receiving a continuous subcutaneous insulin infusion via an insulin pump contacts the clinic to report mechanical failure of the infusion pump. The nurse instructs the patient to begin monitoring for signs of: a. adrenal insufficiency. b. diabetic ketoacidosis. c. hyperosmolar, hyperglycemic state. d. hypoglycemia.

10. When paramedics notice singed hairs in the nose of a burn patient, it is recommended that the patient be intubated. What is the reasoning for the immediate intubation? a. Carbon monoxide poisoning always occurs when soot is visible. b. Inhalation injury above the glottis may cause significant edema that obstructs the airway. c. The patient will have a copious amount of mucus that will need to be suctioned. d. The singed hairs and soot in the nostrils will cause dysfunction of cilia in the airways.

12. An elderly individual from an assisted living facility presents with severe scald burns to the buttocks and back of the thighs. The caregiver from the ALF accompanies the patient to the emergency department and states that the bath water was "too hot" and that the "patient sat in the water too long." What should the nurse do? a. Ask the caregiver at what temperature the water heater is set in the home. b. Ask the caregiver to step out while examining the patient's burn injury. c. Immediately contact the police to report the suspected elder abuse. d. Ask the caregiver to describe exactly how the injury occurred.

13. Silver is used as an ingredient in many burn dressings because it: a. stimulates tissue granulation. b. is effective against a wide spectrum of wound pathogens. c. provides topical pain relief. d. stimulates wound healing.

14. An individual with type 2 diabetes who takes glipizide (Glucotrol) to control her blood glucose has begun a formal exercise program at a local gym. While exercising on the treadmill, she becomes pale, diaphoretic, and shaky. She has a headache and feels as though she is going to pass out. What is the individual's priority action? a. Drink additional water to prevent dehydration. b. Eat something with 15 g of simple carbohydrates. c. Go to the first aid station to have glucose checked. d. Take another dose of the oral agent.

14. The nurse understands that negative-pressure wound therapy may be used in the treatment of partial-thickness burn wounds to do which of the following? a. Maintain a closed wound system to decrease the risk of infection. b. Remove excessive wound fluid and promote moist wound healing. c. Increase patient mobility with large burn wounds. d. Quantify wound drainage amount for more accurate output assessment.

16. Acute adrenal crisis is caused by: a. acute renal failure. b. deficiency of corticosteroids. c. high doses of corticosteroids. d. overdose of testosterone.

16. During the treatment and management of the trauma patient, maintaining tissue perfusion, oxygenation, and nutritional support are strategies to prevent: a. disseminated intravascular coagulation. b. multisystem organ dysfunction. c. septic shock. d. wound infection.

17. Patients with burns may have mesh grafts or sheet grafts. Which of the following sites is most likely to have a sheet graft applied? a. Arm b. Face c. Leg d. Chest

17. Range-of-motion exercises, early ambulation, and adequate hydration are interventions to prevent: a. catheter-associated infection. b. venous thromboembolism. c. fat embolism. d. nosocomial pneumonia.

18. The nurse is caring for a patient who has undergone skin grafting of the face and arms for burn wound treatment. A primary nursing diagnosis is: a. altered nutrition, less than body requirements. b. body image disturbance. c. decreased cardiac output. d. fluid volume deficit.

2. When providing information on trauma prevention, it is important to realize that individuals age 35 to 54 years are most likely to experience which type of trauma incident? a. High-speed motor vehicle crashes b. Poisonings from prescription or illegal drugs c. Violent or domestic traumatic altercations d. Work-related falls

20. A burn patient in the rehabilitation phase of injury is increasingly anxious and unable to sleep. The nurse should consult with the provider to further assess the patient for: a. acute delirium. b. posttraumatic stress disorder. c. suicidal intentions. d. bipolar disorder.

20. Which of the following statements about mass casualty triage during a disaster is true? a. Priority treatments and interventions focus primarily on young victims. b. Disaster victims with the greatest chances for survival receive priority for treatment. c. Once interventions have been initiated, healthcare providers cannot stop the treatment of disaster victims. d. Color-coded systems in which green indicates the patient of greatest need are used during disasters.

21. A 36-year-old driver was pulled from a car after it collided with a tree and the gas tank exploded. What assessment data suggest the patient suffered tissue damage consistent with a blast injury? a. Blood pressure 82/60, heart rate 122, respiratory rate 28. b. Crackles (rales) on auscultation of bilateral lung fields. c. Responsive only to painful stimuli. d. Irregular heart rate and rhythm.

22. The nurse is caring for a patient who underwent pituitary surgery 12 hours ago. The nurse will give priority to monitoring the patient carefully for which of the following? a. Congestive heart failure b. Hypovolemic shock c. Infection d. Volume overload

24. A(An) ____________________ often produces a superficial cutaneous injury but may cause cardiopulmonary arrest and transient but severe central nervous system deficits. a. chemical burn b. electrical burn c. heat burn d. infection

28. A patient with newly diagnosed type 1 diabetes is being transitioned from an infusion of intravenous (IV) regular insulin to an intensive insulin therapy regimen of insulin glargine (Lantus) and insulin aspart (NovoLog). How should the nurse manage this transition in insulin delivery? a. Administer the insulin glargine and continue the IV insulin infusion for 24 hours. b. Administer the insulin glargine and discontinue the IV infusion in several hours. c. Discontinue the IV infusion and administer the insulin aspart with the next meal. d. Discontinue the IV infusion and administer the Lantus insulin at bedtime.

4. Which of the following injuries would result in a greater likelihood of internal organ damage and risk for infection? a. A fall from a 6-foot ladder onto the grass b. A shotgun wound to the abdomen c. A knife wound to the right chest d. A motor vehicle crash in which the driver hits the steering wheel

4. Which of the following is a high-priority nursing diagnosis for both diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome? a. Activity intolerance b. Fluid volume deficient c. Hyperthermia d. Impaired nutrition, more than body requirements

5. The nurse is caring for a patient who has circumferential full-thickness burns of his forearm? A priority in the plan of care is : a. Keeping the extremity in a dependent position b. Active and passive range of motion every hour. c. Preparing for an escharotomy as a prophylactic measure d. Splinting the forearm

7. A patient admitted with severe burns to his face and hands is showing signs of extreme agitation. The nurse should explore the mechanism of burn injury possibly related to: a. excessive alcohol use. b. methamphetamine use. c. posttraumatic stress disorder. d. subacute delirium.

A 53-year-old, 80-kg 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. During the nurse's 7 PM (1900) assessment, the patient is restless, heart rate has increased to 110 beats/min, respirations are 36 breaths/min, and blood pressure is 156/98 mm Hg. The cardiac monitor shows sinus tachycardia with 10 premature ventricular contractions (PVCs) per minute. Pulmonary artery pressures are elevated. The nurse suctions the patient and obtains pink, frothy secretions. Loud crackles are audible throughout lung fields. The nurse notifies the physician, who orders an ABG analysis, electrolyte levels, and a portable chest x-ray study. In communicating with the physician, which statement indicates the nurse understands what is likely occurring with the patient? a. "May we have an order for cardiac enzymes? This patient is exhibiting signs of a myocardial infarction." b. "My assessment indicates potential fluid overload." c. "The patient is having frequent PVCs that are compromising the cardiac output." d. "The patient is having a hypertensive crisis; what medications would you like to order?"

A 65-year-old 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 PaCO2 of 48 mm Hg is associated with: a. hyperventilation. b. hypoventilation. c. increased absorption of O2. d. increased excretion of HCO3.

A nurse is teaching a patient with coronary artery disease about his prescribed nitroglycerin therapy. Which of the following statements, if made by the patient, would indicate that he needs further teaching? A) I should not take nitroglycerin if I have taken Viagra. B) I'll put a couple of tablets in a plastic bag in my pocket so I have them with me all the time. C) If the pain doesnt go away I can take a second tablet after 5 minutes. D) I should try to sit or lie down when I take the nitroglycerin.

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."

A patient is being discharged after an MI taking lisinopril 10 mg daily. Which of the following instructions is most appropriate for the nurse to give to the patient? A) Avoid crossing your legs B) Change your position slowly when going from lying to sitting C) Cut down on your sodium intake to 1,500 mg/day D) Weigh yourself at least three times a week

A patient is having difficulty weaning from mechanical ventilation. The nurse assesses the patient for a potential cause of this difficult weaning, which includes: 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 says to his nurse, Ive never heard of an acute coronary syndrome. Please explain what happened to me. The nurse should respond, Acute coronary syndrome is: A) Another name for a myocardial infarction (MI) or heart attack B) A group of disorders that result in insufficient oxygen supply to the heart. C) The second leading cause of death in the United States; D) A type of abnormal heart rhythm.

A patient with end-stage heart failure is experiencing considerable dyspnea. Appropriate palliative management of this symptom includes: a) administration of midazolam (Versed). b) administration of morphine. c) an increase in the amount of oxygen being delivered to the patient. d) aggressive use of inotropic and vasoactive medications to improve heart function.

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

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

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

An essential aspect of teaching that may prevent recurrence of heart failure is: a. notifying the physician 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.

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.

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

Following insertion of a pulmonary artery catheter (PAC), the provider requests the nurse obtain a blood sample for mixed venous oxygen saturation (SvO2). Which action by the nurse best ensures the obtained value is accurate? A. Zero referencing the transducer at the level of the phlebostatic axis following insertion B. Calibrating the system with a central venous blood sample and arterial blood gas value C. Ensuring patency of the catheter using a 0.9% normal saline solution pressurized at 300 mm Hg D. Using noncompliant pressure tubing that is no longer than 36 to 48 inches and has minimal stopcocks

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

Interpret the following rhythm: a. Atrial pacing b. Ventricular pacing c. Dual-chamber pacing d. Transcutaneous pacing

Interpret the following rhythm: a. First-degree AV block b. Second-degree AV block Mobitz I (Wenckebach phenomenon) c. Second-degree AV block Mobitz II d. Third-degree AV block (complete heart block)

Interpret the following rhythm: a. Sinus rhythm with multifocal premature ventricular contractions b. Sinus rhythm with unifocal premature ventricular contractions c. Sinus rhythm with trigeminal premature ventricular contractions d. Sinus rhythm with paired premature ventricular contractions (couplets)

Interpret the following rhythm: a. Normal sinus rhythm b. Sinus bradycardia c. Sinus tachycardia d. Sinus arrhythmia

Lung-protective strategies for mechanical ventilation to treat acute respiratory distress syndrome while also preventing complications include which of the following? a. High levels of sedation b. Low tidal volume of 6 mL/kg ideal body weight c. Oxygen levels (FiO2) 0.80-1.00 d. Positive end-expiratory pressure (PEEP) 25 cm H2O or higher

One of the early signs of the effect of hypoxemia on the nervous system is: a. cyanosis. b. restlessness. c. tachycardia. 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.

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

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

The ECG of a patient receiving tPA for a myocardial infarction shows that the ST segment has returned to baseline. How should the nurse interpret this finding? A) The myocardial injury is evolving. B) The blocked artery has been reperfused. C) The patient has become more relaxed. D) The spasm in the coronary artery has resolved.

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.

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 most critical element of effective early end-of-life decision making is a) control of distressing symptoms, such as nausea, anxiety, and pain. b) effective communication among the patient, family, and health care team throughout the course of the illness. c) organizational support of palliative care principles. d) the relocation of the dying patient from the critical care unit to a lower level of care.

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 admits a patient to the emergency department (ED) with a suspected cervical spine injury. What is the priority nursing action? a. Keep the neck in the hyperextended position. b. Maintain proper head and neck alignment. c. Prepare for immediate endotracheal intubation. d. Remove cervical collar upon arrival to the ED.

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

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

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 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.

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

The nurse is assessing the patient's pain using the Critical Care Pain Observation Tool. Which of the following assessments would indicate the greatest likelihood of pain and need for nursing intervention? a) Absence of vocal sounds b) Fighting the ventilator c) Moving legs in bed d) Relaxed muscles in upper extremities

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 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 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 mechanically ventilated patient being monitored with a left radial arterial line. During the inspiratory phase of ventilation, the nurse assesses a 20 mm Hg decrease in arterial blood pressure. What is the best interpretation of this finding by the nurse? A. The mechanical ventilator is malfunctioning. B. The patient may require fluid resuscitation. C. The arterial line may need to be replaced. D. The left limb may have reduced perfusion.

The nurse is caring for a mechanically ventilated patient with acute respiratory failure. Which intervention is most beneficial in reducing the duration of mechanical ventilation and its complications? a. Administration of neuromuscular blockade b. Daily interruption of sedation and assessment of readiness to wean/extubate c. Frequent turning and early mobility, including ambulation if possible d. Regular and frequent oral care

The nurse is caring for a patient 3 days following a complete cervical spine injury at the C3 level. The patient is in spinal shock. Following emergent intubation and mechanical ventilation, what is the priority nursing action? a. Maintain body temperature. b. Monitor blood pressure. c. Pad all bony prominences. d. Use proper hand washing.

The nurse is caring for a patient admitted to the emergency department in status epilepticus. Vital signs assessed by the nurse include blood pressure 160/100 mm Hg, heart rate 145 beats/min, respiratory rate 36 breaths/min, oxygen saturation (SpO2) 96% on 100% supplemental oxygen by non-rebreather mask. After establishing an intravenous (IV) line, which order by the physician should the nurse implement first? a. Obtain stat serum electrolytes. b. Administer lorazepam (Ativan). c. Obtain stat portable chest x-ray. d. Administer phenytoin (Dilantin).

The nurse is caring for a patient admitted with a subarachnoid hemorrhage following surgical repair of the aneurysm. Assessment by the nurse notes blood pressure 90/60 mm Hg, heart rate 115 beats/min, respiratory rate 28 breaths/min, oxygen saturation (SpO2) 99% on supplemental oxygen at 3L/min by cannula, a Glasgow Coma Score of 4, and a central venous pressure (CVP) of 2 mm Hg. After reviewing the physician orders, which order is of the highest priority? a. Lasix 20 mg intravenous push as needed b. 500 mL albumin intravenous infusion c. Decadron 10 mg intravenous push d. Dilantin 50 mg intravenous push

The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine injury who is complaining of a severe headache. The nurse assesses a blood pressure of 180/90 mm Hg, heart rate 60 beats/min, respirations 24 breaths/min, and 50 mL of urine via indwelling urinary catheter for the past 4 hours. What is the best action by the nurse? a. Administer acetaminophen as ordered for the headache. b. Assess for a kinked urinary catheter and assess for bowel impaction. c. Encourage the patient to take slow, deep breaths. d. Notify the physician of the patient's blood pressure.

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 has had an arterial line inserted. To reduce the risk of complications, what is the priority nursing intervention? A. Apply a pressure dressing to the insertion site. B. Ensure that all tubing connections are tightened. C. Obtain a portable x-ray to confirm placement. D. Restrain the affected extremity for 24 hours.

The nurse is caring for a patient with a left subclavian central venous catheter (CVC) and a left radial arterial line. Which assessment finding by the nurse requires immediate action? A. A dampened arterial line waveform B. Numbness and tingling in the left hand C. Slight bloody drainage at subclavian insertion site D. Slight redness at subclavian insertion site

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

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 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

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 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."

The nurse is discussing the Dietary Approaches to Stop Hypertension (DASH) program with a patient and his spouse. They are overwhelmed and ask if there is one measure recommended by the program that would have the biggest impact so they can start with that measure first. The nurse should suggest: A) Controlling diabetes to an A1C less than 7%. B) Decreasing their sodium intake to less than 1,500 mg/day. C) Increasing their intake of dairy products. D) Losing weight.

The nurse is drawing labs on a patient with COPD in the critical care unit. Which baseline arterial blood gases (ABGs) should the nurse expect for this patient? a. PaO2 50 mm Hg and PaCO2 35 mm Hg b. PaO2 55 mm Hg and PaCO2 55 mm Hg c. PaO2 80 mm Hg and PaCO2 50 mm Hg d. PaO2 75 mm Hg and PaCO2 40 mm Hg

The nurse is educating a patient's family member about a pulmonary artery catheter (PAC). Which statement by the family member best indicates understanding of the purpose of the PAC? A. "The catheter will provide multiple sites to give intravenous fluid." B. "The catheter will allow the provider to better manage fluid therapy." C. "The catheter tip comes to rest inside my brother's pulmonary artery." D. "The catheter will be in position until the heart has a chance to heal."

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 is preparing to measure the thermodilution cardiac output (TdCO) in a patient being monitored with a pulmonary artery catheter. Which action by the nurse best ensures the safety of the patient? A. Ensure the transducer system is zero referenced at the level of the phlebostatic axis. B. Avoid infusing vasoactive agents in the port used to obtain the TdCO measurement. C. Maintain a pressure of 300 mm Hg on the flush solution using a pressure bag. D. Limit the length of the noncompliant pressure tubing to a maximum 48 inches.

The nurse is to administer 100 mg phenytoin (Dilantin) intravenous (IV). Vital signs assessed by the nurse include blood pressure 90/60 mm Hg, heart rate 52 beats/min, respiratory rate 18 breaths/min, and oxygen saturation (SpO2) 99% on supplemental oxygen at 3 L/min by cannula. To prevent complications, what is the best action by the nurse? a. Administer over 2 minutes. b. Administer over 5 minutes. c. Mix medication with 0.9% normal saline. d. Administer via central line.

The nurse notes the following rhythm on the heart monitor. The patient is unresponsive and not breathing. The nurse should a. treat with intravenous amiodarone or lidocaine. b. provide emergent basic and advanced life support. c. provide electrical cardioversion. d. ignore the rhythm because it is benign.

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 returns from the cardiac catheterization laboratory with a patient following insertion of a pulmonary artery catheter and assists in transferring the patient from the stretcher to the bed. Before obtaining a cardiac output, which action is most important for the nurse to complete? A. Document a pulmonary artery catheter occlusion pressure. B. Zero reference the transducer system at the phlebostatic axis. C. Inflate the pulmonary artery catheter balloon with 1 mL air. D. Inject 10 mL of 0.9% normal saline into the proximal port

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 nurse wishes to assess the quality of a patient's pain. Which of the following questions is appropriate to obtain this assessment if the patient is able to give a verbal response? a) "Is the pain constant or intermittent?" b) "Is the pain sharp, dull, or crushing?" c) "What makes the pain better? Worse?" d) "When did the pain start?"

The nurse, caring for a patient following a subarachnoid hemorrhage, begins a nicardipine (Cardene) infusion. Baseline blood pressure assessed by the nurse is 170/100 mm Hg. Five minutes after beginning the infusion at 5 mg/hr, the nurse assesses the patient's blood pressure to be 160/90 mm Hg. What is the best action by the nurse? a. Stop the infusion for 5 minutes. b. Increase the dose by 2.5 mg/hr. c. Notify the physician of the BP. d. Begin weaning the infusion.

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

24. Which of the following laboratory values would be found in a patient with syndrome of inappropriate secretion of antidiuretic hormone? a. Fasting blood glucose 156 mg/dL b. Serum potassium 5.8 mEq/L c. Serum sodium 115 mEq/L d. Serum sodium 152 mEq/L

The patient's spouse is very upset because his loved one, who is near death, has dyspnea and restlessness. The nurse explains that there are some ways to decrease this discomfort, including: a) respiratory therapy treatments. b) opioid medications given as needed. c) incentive spirometry d) increased hydration

The patient's spouse tells the nurse that there is no point in continuing to visit at the bedside because the patient is unresponsive. The best response by the nurse is a) "You're right. Your loved one is not aware of anything now." b) "This seems to be very difficult for you." c) "I'll call you if she starts responding again." d) "Why don't you check to see if any other family member would like to visit?"

The patient's wife is confused about the scheduling of a stent insertion. She says that she thought the angioplasty was surgery to fix her husband's heart problem. The nurse explains to her: 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."

The patient's wife is feeling overwhelmed and tells the nurse that she doesn't know if she can manage to cook different dinners for her husband and the rest of the family to satisfy his cholesterol-reducing diet. The nurse tells her: a. "It will be worth it to have him healthy, 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 just let the children eat whatever they want."

The physician orders fosphenytoin (Cerebyx), 1.5 g intravenous (IV) loading dose for a 75-kg patient in status epilepticus. What is the most important action by the nurse? a. Contact the admitting physician. b. Administer drug over 10 minutes. c. Mix medication with 0.9% normal saline. d. Administer via central line.

The provider writes an order to discontinue a patient's left radial arterial line. When discontinuing the patient's invasive line, what is the priority nursing action? A. Apply an air occlusion dressing to insertion site. B. Apply pressure to the insertion site for 5 minutes. C. Elevate the affected limb on pillows for 24 hours. D. Keep the patient's wrist in a neutral position.

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.

Which nursing intervention would need to be corrected on a care plan for a patient in order to be consistent with the principles of effective end-of-life care? a) Control of distressing symptoms such as dyspnea, nausea, and pain through the use of pharmacological and nonpharmacological interventions b) Limitation of visitation to reduce the emotional distress experienced by family members c) Patient and family education on anticipated patient responses to withdrawal of therapy d) Provision of spiritual care resources as desired by the patient and family

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

Which of the following is appropriate in collaborative management of a patients pulmonary status following coronary artery bypass graft surgery? A) Keeping the patient intubated for at least 48 hours to maximize gas exchange B) Mobilizing the patient as soon as possible to prevent atelectasis and venous stasis C) Evaluating readiness for extubation based on guidelines: PO 2 less than 80 mm Hg with an FiO 2 greater than 40% and a PCO 2 greater than 45 D) Extubating when the patient is arousible to noxious stimuli and shows increased effort for spontaneous breathing

Which of the following statements about palliative care is accurate? a) Withholding and withdrawing life- sustaining treatment are distinctly different in the eyes of the legal community. b) Reducing distressing symptoms is the primary goal of palliative care. c) Only the patient can determine what constitutes palliative care for him or her. d) Withdrawing life-sustaining treatments is considered euthanasia in most states.

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

Which of the following would be most helpful to the nurse in determining whether the chest pain of a patient who has just entered the emergency department is cardiac in origin? A) Gathering a complete medical history B) Performing a 12-lead ECG C) Administering NTG to see if the pain goes away D) Asking the patient if performing a Valsalva maneuver reduces the pain

While caring for a patient with a small bowel obstruction, the nurse assesses a pulmonary artery occlusion pressure (PAOP) of 1 mm Hg and hourly urine output of 5 mL. The nurse anticipates which therapeutic intervention? A. Diuretics B. Intravenous fluids C. Negative inotropic agents D. Vasopressors

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.

To increase patient compliance and reduce postoperative complications, the nurse should include which of the following topics in the preoperative teaching for a patient who is to have a coronary artery bypass graft (CABG)? (Select all that apply.) A) Reasons for cooling blankets in post-op period B) Equipment used: IVs, Foley, pacer wires, chest tubes, NG tubes, ECG leads C) Drug management: need for sedation when intubated, pain med through PCA D) Alternate methods for communicating when intubated E) Reasons and techniques of turning, coughing, and deep-breathing once extubated

B, C, D, E

3. A college student was admitted to the emergency department after being found unconscious by a roommate. The roommate informs emergency medical personnel that the student has diabetes and has been experiencing flulike symptoms, including vomiting, since yesterday. The patient had been up all night studying for exams. The patient used the last diabetes testing supplies 3 days ago and has not had time to go to the pharmacy to refill prescription supplies. Based upon the history, which laboratory findings would be anticipated in this client? (Select all that apply.) a. Blood glucose 43 mg/dL b. Blood glucose 524 mg/dL c. HCO3- 10 mEq/L d. PaCO2 37 mm Hg e. pH 7.23

B, C, E

7. A patient with long-standing type 1 diabetes presents to the emergency department with a loss of consciousness and seizure activity. The patient has a history of renal insufficiency, gastroparesis, and peripheral diabetic neuropathy. Emergency personnel reported a blood glucose of 32 mg/dL on scene. When providing discharge teaching for this patient and family, the nurse instructs on the need to do which of the following? (Select all that apply.) a. Administer glucagon 1 mg intramuscularly any time the blood glucose is less than 70 mg/dL. b. Administer 15 grams of carbohydrate orally for severe episodes of hypoglycemia. c. Discontinue the insulin pump by removing the infusion set catheter. d. Increase home blood glucose monitoring and report patterns of hypoglycemia to the provider. e. Perform blood glucose monitoring before exercising and driving.

B, D, E

11. A near-infrared spectroscopy (NIRS) probe is placed in a trauma patient during the resuscitation phase to: a. assess severity of metabolic acidosis. b. determine intraperitoneal bleeding. c. determine tissue oxygenation. d. prevent complications of over-resuscitation.

11. A patient with a 60% burn in the acute phase of treatment develops a tense abdomen, decreasing urine output, hypercapnia, and hypoxemia. Based on this assessment, the nurse anticipates interventions to evaluate and treat the patient for: a. acute kidney injury. b. acute respiratory distress syndrome. c. intraabdominal hypertension. d. disseminated intravascular coagulation disorder.

14. Which of the following patients have the greatest risk of developing acute respiratory distress syndrome (ARDS) after traumatic injury? a. A patient who has a closed head injury with a decreased level of consciousness b. A patient who has a fractured femur and is currently in traction c. A patient who has received large volumes of fluid and/or blood replacement d. A patient who has underlying chronic obstructive pulmonary disease

17. The most significant clinical finding of acute adrenal crisis associated with fluid and electrolyte balance is: a. fluid volume excess. b. hyperglycemia. c. hyperkalemia d. hypernatremia

19. Treatment and/or prevention of rhabdomyolysis in at-risk patients includes aggressive fluid resuscitation to achieve urine output of: a. 30 mL/hr. b. 50 mL/hr. c. 100 mL/hr. d. 300 mL/hr.

2. In patients with extensive burns, edema occurs in both burned and unburned areas because of: a. catecholamine-induced vasoconstriction. b. decreased glomerular filtration. c. increased capillary permeability. d. loss of integument barrier.

22. The nurse is conducting an admission assessment of an 82-year-old patient who sustained a 12% burn from spilling hot coffee on the hand and arm. Which statement is of priority to assist in planning treatment? a. "Do you live alone?" b. "Do you have any drug or food allergies?" c. "Do you have a heart condition or heart failure?" d. "Have you had any surgeries?"

25. A patient with pancreatic cancer has been admitted to the critical care unit with clinical signs consistent with syndrome of inappropriate secretion of antidiuretic hormone. The nurse anticipates that clinical management of this condition will include: a. administration of 3% normal saline. b. administration of exogenous vasopressin. c. fluid restriction. d. low sodium diet.

3. Tissue damage from burn injury activates an inflammatory response that increases the patient's risk for: a. acute kidney injury. b. acute respiratory distress syndrome. c. infection. d. stress ulcers.

5. The nurse is assigned to care for a patient who presented to the emergency department with diabetic ketoacidosis. A continuous insulin intravenous infusion is started, and hourly bedside glucose monitoring is ordered. The targeted blood glucose value after the first hour of therapy is: a. 70 to 120 mg/dL. b. a decrease of 25 to 50 mg/dL compared with admitting values. c. a decrease of 50 to 75 mg/dL compared with admitting values. d. less than 200 mg/dL.

6. The nurse has admitted a patient to the ED following a fall from a first-floor hotel balcony. The patient is 22 years old and smells of alcohol. The patient begins to vomit in the ED. Which of the following interventions is most appropriate? a. Insert an oral airway to prevent aspiration and to protect the airway. b. Offer the patient an emesis basin so that you can measure the amount of emesis. c. Prepare to suction the oropharynx while maintaining cervical spine immobilization. d. Send a specimen of the emesis to the laboratory for analysis of blood alcohol content.

6. The patient asks the nurse if the placement of the autograft over his full-thickness burn will be the only surgical intervention needed to close his wound. The nurse's best response would be: a. "Unfortunately, an autograft skin is a temporary graft and a second surgery will be needed to close the wound." b. "An autograft is a biological dressing that will eventually be replaced by your body generating new tissue." c. "Yes, an autograft will transfer your own skin from one area of your body to cover the burn wound." d. "Unfortunately, autografts frequently do not adhere well to burn wounds and a xenograft will be necessary to close the wound."

9. In the trauma patient, symptoms of decreased cardiac output are most commonly caused by: a. cardiac contusion. b. cardiogenic shock. c. hypovolemia. d. pericardial tamponade.

A 53-year-old, 80-kg patient is admitted to the cardiac surgical intensive care unit after cardiac surgery with the following arterial blood gas (ABG) levels. What is the nurse's interpretation of these values? pH 7.4, PaCO2 40 mm Hg, Bicarbonate 24 mEq/L, PaO2 95 mm Hg, O2 saturation 97%, Respirations 20 breaths per minute a. Compensated metabolic acidosis b. Metabolic alkalosis c. Normal ABG values d. Respiratory acidosis

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 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

A patient with coronary artery disease 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

A patient's status worsens and needs mechanical ventilation. The pulmonologist wants the patient to receive 10 breaths/min from the ventilator but wants to encourage the patient to breathe spontaneously in between the mechanical breaths at his own tidal volume. This mode of ventilation is called: a. assist/control ventilation b. controlled ventilation c. intermittent mandatory ventilation d. positive end-expiratory pressure

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.

After pulmonary artery catheter insertion, the nurse assesses a pulmonary artery pressure of 45/25 mm Hg, a pulmonary artery occlusion pressure (PAOP) of 20 mm Hg, a cardiac output of 2.6 L/min and a cardiac index of 1.9 L/min/m2. Which provider order is of the highest priority? A. Apply 50% oxygen via Venturi mask. B. Insert an indwelling urinary catheter. C. Begin a dobutamine infusion. D. Obtain stat cardiac enzymes and troponin.

An 80-year- old woman has arrived in the ED. The ED physician is questioning whether she has had an MI although she is not displaying the classic chest pain. Which of the following symptoms might cause him to suspect that she was experiencing an MI? A) Jaw and/or tooth pain B) Confusion accompanied by hypotension C) Generalized fatigue accompanied by dyspnea and diaphoresis D) Dyspnea accompanied by crackles in all lobes

Both the electroencephalogram (EEG) monitor and the Bispectral Index Score (BIS) or Patient State Index (PSI) analyzer monitors are used to assess patient sedation levels in critically ill patients. The BIS and PSI monitors are simpler to use because they a) can be used only on heavily sedated patients. b) can be used only on pediatric patients. c) provide raw EEG data and a numeric value. d) require only five leads.

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

Following insertion of a central venous catheter, the nurse obtains a stat chest x-ray film to verify proper catheter placement. The radiologist reports to the nurse: "The tip of the catheter is located in the superior vena cava." What is the best interpretation of these results by the nurse? A. The catheter is not positioned correctly and should be removed. B. The catheter position increases the risk of ventricular dysrhythmias. C. The distal tip of the catheter is in the appropriate position. D. The physician should be called to advance the catheter into the pulmonary artery.

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.

Interpret the following rhythm: a. Atrial pacing b. Ventricular pacing c. Dual-chamber pacing d. Transcutaneous pacing

Interpret the following rhythm: a. First-degree AV block b. Second-degree AV block Mobitz I (Wenckebach phenomenon) c. Second-degree AV block Mobitz II d. Third-degree AV block (complete heart block)

Interpret the following rhythm: a. Normal pacemaker function b. Failure to capture c. Failure to pace d. Failure to sense

Interpret the following rhythm: a. Normal sinus rhythm b. Sinus bradycardia c. Sinus tachycardia d. Sinus arrhythmia

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.

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

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.

Neuromuscular blocking agents are used in the management of some ventilated patients. Their primary mode of action is: a. analgesia. b. anticonvulsant. c. paralysis. d. sedation.

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.

The cardiologist has told the patient and family that the diagnosis is hypertrophic cardiomyopathy. Later they ask the nurse what the patient did wrong to cause this condition. The nurse explains: a. "This is a result of a high-cholesterol diet and poor exercise habits." b. "The heart has not been getting enough aerobic exercise and has developed this condition. In cardiac rehabilitation they will work with the patient to strengthen his heart through special exercises." c. "This is an inherited condition. You should give serious consideration to having family members screened for it." d. "This is a result of clot formation in the blood vessels in the heart. We will need to use medications to reduce the risk of further clotting."

The charge nurse is supervising care for a group of patients monitored with a variety of invasive hemodynamic devices. Which patient should the charge nurse evaluate first? A. A patient with a central venous pressure (RAP/CVP) of 6 mm Hg and 40 mL of urine output in the past hour B. A patient with a left radial arterial line with a BP of 110/60 mm Hg and slightly dampened arterial waveform C. A patient with a pulmonary artery occlusion pressure of 25 mm Hg and an oxygen saturation of 89% on 3 L of oxygen via nasal cannula D. A patient with a pulmonary artery pressure of 25/10 mm Hg and an oxygen saturation of 94% on 2 L of oxygen via nasal cannula

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 pain levels in a critically ill patient using the Behavioral Pain Scale. The nurse recognizes __________ as indicating the greatest level of pain. a) brow lowering b) eyelid closing c) grimacing d) relaxed facial expression

The nurse is assessing the exhaled tidal volume (EVT) in a mechanically ventilated patient. The rationale for this assessment is to: a. assess for tension pneumothorax. b. assess the level of positive end-expiratory pressure. c. compare the tidal volume delivered with the tidal volume prescribed. d. determine the patient's work of breathing.

The nurse is assisting in weaning a patient from long-term mechanical ventilation. Which action should the nurse be prepared to take? a. Slowly wean over several hours using a T-piece. b. Expect that the patient will not be affected by fever or abdominal distension. c. Wean the patient by protocol-driven methods. d. Wean the patient while the patient's family is present in the room.

The nurse is caring for a mechanically ventilated patient admitted with a traumatic brain injury. Which arterial blood gas value assessed by the nurse indicates optimal gas exchange for a patient with this type of injury? a. pH 7.38; PaCO2 55 mm Hg; HCO3 22 mEq/L; PaO2 85 mm Hg b. pH 7.38; PaCO2 40 mm Hg; HCO3 24 mEq/L; PaO2 70 mm Hg c. pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg d. pH 7.38; PaCO2 28 mm Hg; HCO3 26 mEq/L; PaO2 65 mm Hg

The nurse is caring for a mechanically ventilated patient with a brain injury. Arterial blood gas values indicate a PaCO2 of 60 mm Hg. The nurse understands this value to have which effect on cerebral blood flow? a. Altered cerebral spinal fluid production and reabsorption b. Decreased cerebral blood volume due to vessel constriction c. Increased cerebral blood volume due to vessel dilation d. No effect on cerebral blood flow (PaCO2 of 60 mm Hg is normal)

The nurse is caring for a mechanically ventilated patient with a pulmonary artery catheter who is receiving continuous enteral tube feedings. When obtaining continuous hemodynamic monitoring measurements, what is the best nursing action? A. Do not document hemodynamic values until the patient can be placed in the supine position. B. Level and zero reference the air-fluid interface of the transducer with the patient in the supine position and record hemodynamic values. C. Level and zero reference the air-fluid interface of the transducer with the patient's head of bed elevated to 30 degrees and record hemodynamic values. D. Level and zero reference the air-fluid interface of the transducer with the patient supine in the side-lying position and record hemodynamic values.

The nurse is caring for a patient 5 days following clipping of an anterior communicating artery aneurysm for a subarachnoid hemorrhage. The nurse assesses the patient to be more lethargic than the previous hour with a blood pressure 95/50 mm Hg, heart rate 110 beats/min, respiratory rate 20 breaths/min, oxygen saturation (SpO2) 95% on 3 L/min oxygen via nasal cannula, and a temperature of 101.5° F. Which physician order should the nurse institute first? a. Blood cultures (2 specimens) for temperature > 101° F b. Acetaminophen (Tylenol) 650 mg per rectum c. 500 mL albumin infusion intravenously d. Decadron 20 mg intravenous push every 4 hours

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 spinal cord injury. Upon assessment, the nurse notes a complete loss of motor and sensory function below the patients nipple line. What is the best understanding of this assessment finding by the nurse? A. Anterior cord lesion B. Central cord lesion. C. Complete cord lesion. D. Brown-Séquard syndrome

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 admitted with bacterial meningitis. Vital signs assessed by the nurse include blood pressure 110/70 mm Hg, heart rate 110 beats/min, respiratory rate 30 breaths/min, oxygen saturation (SpO2) 95% on supplemental oxygen at 3 L/min, and a temperature 103.5° F. What is the priority nursing action? a. Elevate the head of the bed 30 degrees. b. Keep lights dim at all times. c. Implement seizure precautions. d. Maintain bedrest at all times.

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 in the ICU. Lab results show a PaCO2 greater than 45 mm Hg. How should the nurse interpret this? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

The nurse is caring for a patient who has a diminished level of consciousness and who is mechanically ventilated. While performing endotracheal suctioning, the patient reaches up in an attempt to grab the suction catheter. What is the best interpretation by the nurse? a. The patient is exhibiting extension posturing. b. The patient is exhibiting flexion posturing. c. The patient is exhibiting purposeful movement. d. The patient is withdrawing to stimulation.

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 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.

The nurse is caring for a patient with an arterial monitoring system. The nurse assesses the patient's noninvasive cuff blood pressure to be 70/40 mm Hg. The arterial blood pressure measurement via an intraarterial catheter in the same arm is assessed by the nurse to be 108/70 mm Hg. What is the best action by the nurse? A. Activate the rapid response system. B. Place the patient in Trendelenburg position. C. Assess the cuff for proper arm size. D. Administer 0.9% normal saline bolus.

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 to loosen secretions.

The nurse is caring for a patient with hyperactive delirium. The nurse focuses interventions toward keeping the patient: a) comfortable b) nourished c) safe d) sedated

The nurse is caring for four patients on the progressive care unit. Which patient is at greatest risk for developing delirium? a) 36-year-old recovering from a motor vehicle crash; being treated with an evidence-based alcohol withdrawal protocol. b) 54-year-old postoperative aortic aneurysm resection with a 40 pack-year history of smoking c) 86-year-old from nursing home with dementia, postoperative from colon resection, still being mechanically ventilated d) 95-year-old with community-acquired pneumonia; family has brought in eyeglasses and hearing aid

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.

The nurse is preparing to administer a routine dose of phenytoin (Dilantin). The physician orders phenytoin (Dilantin) 500 mg intravenous every 6 hours. What is the best action by the nurse? a. Administer over 2 minutes. b. Administer with 0.9% normal saline intravenous. c. Contact the physician. d. Assess cardiac rhythm.

The physician has opted to treat a patient with a complete spinal cord injury with glucocorticoids. The physician orders 30 mg/kg over 15 minutes followed in 45 minutes with an infusion of 5.4 mg/kg/min for 23 hours. What is the total 24-hour dose for the 70-kg patient? a. 2478 mg b. 5000 mg c. 10,794 mg d. 12,750 mg

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 physician for an emergency intubation procedure. b. obtain an order for bilevel positive airway pressure (BiPAP). c. notify the provider of values and obtain order 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 recognizes that which patient is likely to benefit most from patient-controlled analgesia (PCA)? a) Patient with a C4 fracture and quadriplegia b) Patient with a femur fracture and closed head injury c) Postoperative patient who had elective bariatric surgery d) Postoperative cardiac surgery patient with mild dementia

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 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 provider prescribes a pulmonary artery occlusive pressure reading (PAOP) for a patient being monitored with a pulmonary artery catheter. Immediately after obtaining an occlusive pressure, the nurse notes the change in waveform indicated on the strip below. What are the best actions by the nurse? A. Turn the patient to the left side; obtain a stat portable chest x-ray. B. Place the patient supine; repeat zero referencing of the system. C. Document the wedge pressure; continue to monitor the patient. D. Perform an immediate dynamic response test; obtain a chest x-ray.

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.

Under normal circumstances the cerebral vasculature exhibits pressure and chemical autoregulation. What happens when autoregulation is lost? A. Central venous engorgement occurs. B. Cerebral blood flow is not affected. C. Hypertension increases cerebral blood flow. D. Shunting of cerebrospinal fluid (CSF) is blocked.

What is the therapeutic effect of head-of-the-bed elevation and neutral head and neck alignment on increased intracranial pressure (ICP)? A. Lowering ICP by allowing for elevations in CO2 to dilate cerebral arteries B. Lowering ICP by facilitating venous drainage and decreasing venous obstruction C. Lowering ICP by maintaining an open airway D. Lowering ICP by reducing the risk of snoring

What were the findings of the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT)? a) Clear communication is typical in the relationships between most patients and health care providers. b) Critical care units often meet the needs of dying patients and their families. c) Disparities exist between patients' care preferences and the actual care provided. d) Pain and suffering of patients at end of life is well controlled in the hospital.

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 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

Which of the following lab findings would the nurse review to validate a diagnosis of a myocardial infarction (MI) that was suspected of occurring approximately 3 hours earlier? A) CK B) Troponin T assay C) Myoglobin D) PTT

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 is true regarding the impact of culture on end-of-life decision making? a) Cultural beliefs should not take precedence over health care team decisions. b) It is easy and common to assess cultural beliefs affecting end-of-life care in the intensive care unit. c) Culture and religious beliefs may affect end-of-life decision making. d) Perspectives regarding end-of-life care are similar between and within religious groups.

Which statement made by a staff nurse identifying guidelines for palliative care would need to be corrected? a) Basic nursing care is a critical element in palliative care management. b) Common conditions that require palliative management are nausea, agitation, and sleep disturbance. c) Palliative care practices are reserved for the dying client. d) Palliative care practices relieve symptoms that negatively affect the quality of life of a patient.

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 caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the patient's left naris. What is the best nursing action? a. Have the patient blow the nose until clear. b. Insert bilateral cotton nasal packing. c. Place a nasal drip pad under the nose. d. Suction the left nares until the drainage clears.

While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mm Hg and a CPP of 85 mm Hg. What is the best interpretation by the nurse? a. Both pressures are high. b. Both pressures are low. c. ICP is high; CPP is normal. d. ICP is high; CPP is low.

While inflating the balloon of a pulmonary artery catheter (PAC) with 1.0 mL of air to obtain a pulmonary artery occlusion pressure (PAOP), the nurse encounters resistance. What is the best nursing action? A. Add an additional 0.5 mL of air to the balloon and repeat the procedure. B. Advance the catheter with the balloon deflated and repeat the procedure. C. Deflate the balloon and obtain a chest x-ray study to determine line placement. D. Lock the balloon in the inflated position, and flush the distal port of the PAC with normal saline.

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).

4. The nurse is caring for a burn-injured patient who weighs 154 pounds, and the burn injury covers 50% of his body surface area. The nurse calculates the fluid needs for the first 24 hours after a burn injury using a standard fluid resuscitation formula of 4 mL/kg/% burn of intravenous (IV) fluid for the first 24 hours. The nurse plans to administer what amount of fluid in the first 24 hours? a. 2800 mL b. 7000 mL c. 14 L d. 28 L

C (154 pounds/2.2 = 70 kg 4 ´ 70 kg ´ 50 = 14,000 mL, or 14 liters.)

Nonpharmacological approaches to pain and/or anxiety that may best meet the needs of critically ill patients include: (Select all that apply.) a) anaerobic exercise. b) art therapy. c) guided imagery. d) music therapy. e) animal therapy.

C, D, E

The nurse is preparing to monitor intracranial pressure (ICP) with a fluid-filled monitoring system. The nurse understands which principles and/or components to be essential when implementing ICP monitoring? (Select all that apply.) a. Use of a heparin flush solution b. Manually flushing the device "prn" c. Recording ICP as a "mean" value d. Use of a pressurized flush system e. Zero referencing the transducer system

C, E

11. A patient is admitted to the oncology unit with a small cell lung carcinoma. During the admission, the patient is noted to have a significant decrease in urine output accompanied by shortness of breath, edema, and mental status changes. The nurse is aware that this clinical presentation is consistent with: a. adrenal crisis. b. diabetes insipidus. c. myxedema coma. d. syndrome of inappropriate secretion of antidiuretic hormone (SIADH).

12. In hyperosmolar hyperglycemic syndrome, the laboratory results are similar to those of diabetic ketoacidosis, with three major exceptions. What differences would you expect to see in patients with hyperosmolar hyperglycemic syndrome? a. Lower serum glucose, lower osmolality, and greater ketosis b. Lower serum glucose, lower osmolality, and milder ketosis c. Higher serum glucose, higher osmolality, and greater ketosis d. Higher serum glucose, higher osmolality, and no ketosis

12. The need for fluid resuscitation can be assessed best in the trauma patient by monitoring and trending which of the following tests? a. Arterial oxygen saturation b. Hourly urine output c. Mean arterial pressure d. Serum lactate levels

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.

13. The nurse is caring for a patient who sustained rib fractures after hitting the steering wheel of his car. The patient is spontaneously breathing and receiving oxygen via a face mask; the oxygen saturation is 95%. During the nurse's assessment, the oxygen saturation drops to 80%. The patient's blood pressure has dropped from 128/76 mm Hg to 84/60 mm Hg. The nurse assesses that breath sounds are absent throughout the left lung fields. The nurse notifies the physician and anticipates: a. administration of lactated Ringer's solution (1 L) wide open. b. chest x-ray study to determine the etiology of the symptoms. c. endotracheal intubation and mechanical ventilation. d. needle thoracostomy and chest tube insertion.

13. Which of the following statements is true about the medical management of diabetic ketoacidosis? a. Serum lactate levels are used to guide insulin administration. b. Sodium bicarbonate is a first-line medication for treatment. c. The degree of acidosis is assessed through continuous pulse oximetry. d. Volume replacement and insulin infusion often correct the acidosis.

15. Patients with musculoskeletal injury are at increased risk for compartment syndrome. What is an initial symptom of a suspected compartment syndrome? a. Absence of pulse in affected extremity b. Pallor in the affected area c. Paresthesia in the affected area d. Severe, throbbing pain in the affected area

15. The nurse is caring for a patient with an electrical injury. The nurse understands that patients with electrical injury are at a high risk for acute kidney injury secondary to: a. hypervolemia from burn resuscitation. b. increased incidence of ureteral stones. c. nephrotoxic antibiotics for prevention of infection. d. release of myoglobin from injured tissues.

18. Which of the following interventions is a strategy to prevent fat embolism syndrome? a. Administer lipid-lowering statin medications. b. Intubate the patient early after the injury to provide mechanical ventilation. c. Provide prophylaxis with low-molecular weight heparin. d. Stabilize extremity fractures early.

19. An elderly female patient has presented to the emergency department with altered mental status, hypothermia, and clinical signs of heart failure. Myxedema is suspected. Which of the following laboratory findings support this diagnosis? a. Elevated adrenocorticotropic hormone b. Elevated cortisol levels c. Elevated T3 and T4 d. Elevated thyroid-stimulating hormone

2. Which of the following patients is at the highest risk for hyperosmolar hyperglycemic syndrome? a. An 18-year-old college student with type 1 diabetes who exercises excessively b. A 45-year-old woman with type 1 diabetes who forgets to take her insulin in the morning c. A 75-year-old man with type 2 diabetes and coronary artery disease who has recently started on insulin injections d. An 83-year-old, long-term care resident with type 2 diabetes and advanced Alzheimer's disease who recently developed influenza

20. A patient presents to the emergency department (ED) with the following clinical signs: Pulse: 132 beats/min Blood pressure: 88/50 mm Hg Respiratory rate: 32 breaths/min Temperature: 104.8° F Chest x-ray: Findings consistent with congestive heart failure Cardiac rhythm: Atrial fibrillation with rapid ventricular response These signs are consistent with which disorder? a. Adrenal crisis b. Myxedema coma c. Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) d. Thyroid storm

21. The nurse is planning care to meet the patient's pain management needs related to burn treatment. The patient is alert, oriented, and follows commands. The pain is worse during the day when various treatments are scheduled. Which statement to the physician best indicates the nurse's knowledge of pain management for this patient? a. "Can we ask the music therapist to come by each morning to see if that will help the patient's pain? b. "The patient's pain is often unrelieved. I suggest that we also add benzodiazepines to the opioids around the clock." c. "The patient's pain is often unrelieved. It would be best if we can schedule the opioids around the clock." d. "The patient's pain varies depending on the treatment given. Can we try patient-controlled analgesia to see if that helps the patient better?"

23. The nurse is caring for a patient with head trauma who was admitted to the surgical intensive care unit following a motorcycle crash. What is an important assessment that will assist the nurse in early identification of an endocrine disorder commonly associated with this condition? a. Daily weight b. Fingerstick glucose c. Lung sound auscultation d. Urine osmolality

26. The nurse is providing insulin education for an elderly patient with longstanding diabetes. An order has been written for the patient to take 20 units of insulin glargine (Lantus) at 10 PM nightly. The nurse should instruct the patient that the peak of the insulin action for this agent is: a. 0200. b. 0400. c. 0800. d. peakless.

8. The nurse is providing postoperative care to a patient who underwent a transsphenoidal hypophysectomy for a benign pituitary tumor. The nurse administers replacement hydrocortisone, thyroid hormone, and vasopressin. The nurse evaluates that the vasopressin replacement is effective when: a. the patient's blood glucose is 110 mg/dL. b. the patient maintains a core body temperature of 98.2° F (36.8° C). c. the patient's urine specific gravity decreases. d. 2 liters of urine are produced in a 24-hour period.

9. In the management of diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome, when is an intravenous (IV) solution that contains dextrose started? a. Never; normal saline is the only appropriate solution in diabetes management b. When the blood sugar reaches 70 mg/dL c. When the blood sugar reaches 150 mg/dL d. When the blood glucose reaches 250 mg/dL

9. The nurse is providing care to manage the pain of a patient with burns. The physician has ordered opiates to be given intramuscularly. The nurse contacts the physician to change the order to intravenous administration because: a. intramuscular injections cause additional skin disruption. b. burn pain is so severe it requires relief by the fastest route available. c. hypermetabolism limits effectiveness of medications administered intramuscularly. d. tissue edema may interfere with drug absorption of injectable routes.

Designed healthcare surrogates should base healthcare decisions on: a) personal beliefs and values b) recommendations of family members and friends c) recommendations of the physician and health care team d) wishes previously expressed by the patient

A 75-year-old patient, who suffered a massive stroke 3 weeks ago, has been unresponsive and has required ventilatory support since the time of the stroke. The physician has approached the spouse regarding placement of a permanent feeding tube. The spouse states that the patient never wanted to be kept alive by tubes and personally didn't want what was being done. After holding a family conference with the spouse, the medical team concurs, and the feeding tube is not placed. This situation is an example of a) euthanasia b) palliative care c) withdrawal of life support d) withholding life support

A nurse is evaluating a patients understanding after he was diagnosed with a myocardial infarction. Which of the following would indicate that the patient did not understand important information and needs additional teaching? A) A heart attack is the same as a myocardial infarction (MI). B) A heart attack causes tissue death and that part of the heart may not pump as well. C) A heart attack in the anterior wall of the heart can be very serious because a large portion of the heart may not pump as well. D) Angina always leads first to decreased blood flow to the heart muscle and then to tissue death.

A nurse is preparing to administer the first 5-mg dose of metoprolol to a patient who is 12 hours post MI. For which of the following findings should the nurse withhold administration of the medication? A) Blood pressure of 110/65 B) PR interval 0.12 second C) Serum potassium 3.9 mEq/L D) Sinus bradycardia 52 beats per minute

A patient has coronary artery bypass graft surgery and is transported to the surgical intensive care unit at noon. He is placed on mechanical ventilation. Interpret his 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

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 respirations decrease to 4 breaths/min. What adjustments may need to be made to the patient's ventilator settings? a. Add positive end-expiratory pressure (PEEP). b. Add pressure support. c. Change to assist/control ventilation at a rate of 4 breaths/min. d. Increase the synchronized intermittent mandatory ventilation respiratory rate.

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 patient presents to the emergency department in acute respiratory distress. She has a long-standing history of COPD. Which of the following positions should the nurse place this patient in for optimal tissue perfusion? a. Prone on a stretcher b. In a recliner, leaning back as far as it will go c. Side-lying with head of bed at 15 degrees d. Stretcher with head of bed as high as it will go

A patient starting cardiac rehabilitation will work with the rehabilitation team to meet all of the following goals except: A) Taking control of his life through healthy choices. B) Managing his symptoms by monitoring his exercise. C) Reducing risks by controlling the modifiable risk factors. D) Stabilizing any severe depression that developed post MI.

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.

After receiving the hand-off report from the day shift charge nurse, which patient should the evening charge nurse assess first? a. A patient with meningitis complaining of photophobia b. A mechanically ventilated patient with a GCS of 6 c. A patient with bacterial meningitis on droplet precautions d. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104° F

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.

During insertion of a pulmonary artery catheter, the provider asks the nurse to assist by inflating the balloon with 1.5 mL of air. As the provider advances the catheter, the nurse notices premature ventricular contractions on the monitor. What is the best action by the nurse? A. Deflate the balloon while slowly withdrawing the catheter. B. Instruct the patient to cough and deep-breathe forcefully. C. Inflate the catheter balloon with an additional 1 mL of air. D. Ensure lidocaine hydrochloride (IV) is immediately available.

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

Following angioplasty, a patient develops the following: hematuria,hypotension, tachycardia, a drop in hemoglobin and Hematocrit, and a decrease in oxygen saturation. Which of the following is most likely to be responsible for the symptoms? A) Reaction to vasovagal stimulation B) Myocardial ischemia C) Peripheral emboli distal to the insertion site D) Overanticoagulation

In a patient with increased intracranial pressure (ICP), which of the following cranial nerves would be assessed for consensual light response, elevation of the eyelids, and eye movement? A. I, IX, X B. II, V, VII C. II, VI, X D. III, IV, VI

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

In caring for a patient who is intubated with an endotracheal tube, which complication should the nurse assess for? a. Community-acquired pneumonia b. Oxygen toxicity c. Tension pneumothorax d. Tube placed in the right mainstem bronchus

Interpret the following rhythm: a. First-degree AV block b. Second-degree AV block Mobitz I (Wenckebach phenomenon) c. Second-degree AV block Mobitz II d. Third-degree AV block (complete heart block)

Interpret the following rhythm: a. Normal pacemaker function b. Failure to capture c. Failure to pace d. Failure to sense

Interpret the following rhythm: a. Normal sinus rhythm b. Sinus rhythm with second-degree AV block c. Complete heart block d. Sinus rhythm with first-degree AV block

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.

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

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 best way to monitor agitation and effectiveness of treating it in the critically ill patient is to use a/the: a) Confusion Assessment Method (CAM- ICU). b) FACES assessment tool. c) Glasgow Coma Scale. d) Richmond Agitation Sedation Scale.

The charge nurse has a pulse contour cardiac output monitoring system available for use in the surgical intensive care unit. For which patient is use of this device most appropriate? A. A patient with a history of aortic insufficiency admitted with a postoperative myocardial infarction B. A mechanically ventilated patient with cardiogenic shock being treated with an intraaortic balloon pump C.A patient with a history of atrial fibrillation having frequent episodes of paroxysmal supraventricular tachycardia D. A mechanically ventilated patient admitted following repair of an acute bowel obstruction

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 nurse is caring for a patient with an ICP of 18 mm Hg and a GCS score of 3. Following the administration of mannitol (Osmitrol), which assessment finding by the nurse requires further action? a. ICP of 10 mm Hg b. CPP of 70 mm Hg c. GCS score of 5 d. CVP of 2 mm Hg

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 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

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 admits a patient to the emergency department with new onset of slurred speech and right-sided weakness. What is the priority nursing action? a. Assess for the presence of a headache. b. Assess the patient's general orientation. c. Determine the patient's drug allergies. d. Determine the time of symptom onset.

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 with a sustained ICP of 18 mm Hg. The nurse needs to perform an hourly neurological assessment, suction the endotracheal tube, perform oral hygiene care, and reposition the patient to the left side. What is the best action by the nurse? a. Hyperoxygenate during endotracheal suctioning. b. Elevate the patient's head of the bed 30 degrees. c. Apply bilateral heel protectors after repositioning. d. Provide rest periods between nursing interventions.

The nurse is caring for a mechanically ventilated patient. The physicians 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 to the ED following a fall from a 10-foot ladder. Upon admission, the nurse assesses the patient to be awake, alert, and moving all four extremities. The nurse also notes bruising behind the left ear and straw-colored drainage from the left nare. What is the most appropriate nursing action? a. Insert bilateral ear plugs. b. Monitor airway patency. c. Maintain neutral head position. d. Apply a small nasal drip pad.

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 receiving a benzodiazepine intermittently. The nurse understands that the best way to administer such drugs is to: a) administer around the clock, rather than as needed, to ensure constant sedation. b) administer the medications through the feeding tube to prevent complications. c) give the highest allowable dose for the greatest effect. d) give the highest allowable dose for the greatest effect.

The nurse is caring for a patient who requires administration of a neuromuscular blocking agent to facilitate ventilation with nontraditional modes. The nurse understands that NMBAs provide: a) antianxiety effects b) complete analgesia c) high levels of sedation d) no sedation or analgesia

The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at the scene briefly but is now conscious upon arrival at the emergency department (ED) with a GCS score of 15. One hour later, the nurse assesses a GCS score of 3. What is the priority nursing action? a. Stimulate the patient hourly. b. Continue to monitor the patient. c. Elevate the head of the bed. d. Notify the physician immediately.

The nurse is caring for a patient whose ventilator settings include 15 cm H2O of positive end-expiratory pressure (PEEP). The nurse understands that although beneficial, PEEP may result in: 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 caring for a patient with a left radial arterial line and a pulmonary artery catheter inserted into the right subclavian vein. Which action by the nurse best ensures the safety of the patient being monitored with invasive hemodynamic monitoring lines? A. Document all waveform values. B. Limit the pressure tubing length. C. Zero reference the system daily. D. Ensure alarm limits are turned on.

The nurse is caring for a patient with a pulmonary artery catheter. Assessment findings include a blood pressure of 85/40 mm Hg, heart rate of 125 beats/min, respiratory rate 35 breaths/min, and arterial oxygen saturation (SpO2) of 90% on a 50% Venturi mask. Hemodynamic values include a cardiac output (CO) of 1.0 L/min, central venous pressure (CVP) of 1 mm Hg, and a pulmonary artery occlusion pressure (PAOP) of 3 mm Hg. The nurse questions which of the following physician's orders? A. Titrate supplemental oxygen to achieve a SpO2 ≥94%. B. Infuse 500 mL 0.9% normal saline over 1 hour. C. Obtain arterial blood gas and serum electrolytes. D. Administer furosemide (Lasix) 20 mg intravenously.

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.

The nurse is caring for a patient with an admitting diagnosis of congestive heart failure. While attempting to obtain a pulmonary artery occlusion pressure in the supine position, the patient becomes anxious and tachypneic. What is the best action by the nurse? A. Limit the patient's supine position to no more than 10 seconds. B. Administer antianxiety medications while recording the pressure. C. Encourage the patient to take slow, deep breaths while supine. D. Elevate the head of the bed 45 degrees while recording pressures.

The nurse is caring for a patient with an assessed Glasgow Coma Scale score of 3. What is the best understanding of this finding? A. Coma scale score is a direct result of dysfunction of the cerebellum. B. Damage to the patient's corpus callosum has led to a comatose state. C. A Glasgow Coma Scale score of less than 3 indicates a semi-comatose state. D. There is impairment of the reticular activating system (RAS), resulting in coma.

The nurse is concerned about the risk of alcohol withdrawal syndrome in a postoperative patient. Which statement by the nurse indicates understanding of management of this patient? a) "Alcohol withdrawal is common; we see it all of the time in the trauma unit." b) "There is no way to assess for alcohol withdrawal." c) "This patient will require less pain medication." d) "We have initiated the alcohol withdrawal protocol."

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

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."

The nurse is orienting a new RN in the care of a patient with respiratory distress due to emphysema. The patient is being treated with O2 via a Venturi mask with 35% oxygen. Which statement by the new RN indicates that teaching has been effective, when the nurse questions the new RN about the use of the Venturi mask? a. "A nasal cannula will dry the mucous membranes and cause an increased risk of infection." b. "Her alveoli cannot absorb higher levels of O2 because of the emphysema." c. "Her alveoli have been damaged and may rupture with higher doses of O2." d. "Her respiratory center requires low O2 concentration to stimulate breathing."

The nurse is preparing to obtain a pulmonary artery occlusion pressure (PAOP) reading for a patient who is mechanically ventilated. Ensuring that the air-fluid interface is at the level of the phlebostatic axis, what is the best nursing action? A. Place the patient in the supine position and record the PAOP immediately after exhalation. B. Place the patient in the supine position and document the average PAOP obtained after three measurements. C. Place the patient with the head of bed elevated 30 degrees and document the average PAOP pressure obtained. D. Place the patient with the head of bed elevated 30 degrees and record the PAOP just before the increase in pressures during inhalation.

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

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.

The nurse prepares to suction the endotracheal tube of an intubated patient. Which action is important for the nurse to take? a. Set the suction vacuum as high as possible. b. Instill normal saline before the procedure. c. Avoid hyperoxygenation during the procedure. d. Keep suction time to less than 10 to 15 seconds.

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 is alert and talking when the nurse notices the following rhythm. The patient's blood pressure is 90/44 mm Hg. The nurse should a. defibrillate immediately. b. begin basic life support. c. begin advanced life support. d. treat with intravenous amiodarone or lidocaine.

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 physician orders the following mechanical ventilation settings for a patient who weighs 75 kg. The patient's spontaneous respiratory rate is 22 breaths/min. What 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 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.

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.

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

When a patient says, The chest pain occurs each time I play basketball; it does not occur when I am sleeping; and it improves when I take those pills under my tongue; the pain will most likely be classified as: A) Variant or Prinzmetals angina. B) Undifferentiated angina. C) Unstable angina. D) Stable angina.

Which of the following explanations of the relationship of being overweight to (ACS) should the nurse include when presenting a healthy heart program to a community group? A) Excessive weight will result in a decrease in low-density lipoproteins (LDL) that is linked to ACS. B) Extra weight can lead to diabetes insipidus that will increase the risk for ACS. C) Losing as little as 5% of ones body weight will significantly lower the risk for ACS. D) Obesity, a BMI of greater than 30, increases the risk for ACS at a greater rate than just being overweight.

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.

While caring for a patient with a closed head injury, the nurse assesses the patient to be alert with a blood pressure 130/90 mm Hg, heart rate 60 beats/min, respirations 18 breaths/min, and a temperature of 102° F. To reduce the risk of increased intracranial pressure (ICP) in this patient, what is (are) the priority nursing action(s)? a. Ensure adequate periods of rest between nursing interventions. b. Insert an oral airway and monitor respiratory rate and depth. c. Maintain neutral head alignment and avoid extreme hip flexion. d. Reduce ambient room temperature and administer antipyretics.

While caring for a patient with a pulmonary artery catheter, the nurse notes the pulmonary artery occlusion pressure (PAOP) to be significantly higher than previously recorded values. The nurse assesses respirations to be unlabored at 16 breaths/min, oxygen saturation of 98% on 3 L of oxygen via nasal cannula, and lungs clear to auscultation bilaterally. What is the priority nursing action? A. Increase supplemental oxygen and notify respiratory therapy. B. Notify the provider immediately of the assessment findings. C. Obtain a stat chest x-ray film to verify proper catheter placement. D. Zero reference and level the catheter at the phlebostatic axis.

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.

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

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

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

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.

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."

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

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 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

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.

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

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

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

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.

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.

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.

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."

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

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

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.

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

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."

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.

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.

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.

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.

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

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."

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

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

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

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

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.

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

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.

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."

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.

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.

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.

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).

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

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."

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.

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

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

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.

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.

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."

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.

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

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

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)

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."

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

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

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.

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.

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?"

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.

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.

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.

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.

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.

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"

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.

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.

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

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.

The most sensitive cardiac enzyme to assess myocardial necrosis is: A. CK. B. CK-MB. C. potassium. D. troponin I.

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

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."

The nurse is caring for a patient in neurogenic shock. Which should the nurse assess for? a. Tachycardia b. Hypertension c. Hypoventilation d. Vasodilation

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

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.

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."

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

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.

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

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