Final Test 4
The nurse is caring for a patient who is being evaluated clinically for brain death by MD. Which assessment findings by the nurse support brain death?
Absence of corneal reflex
Which of the following statements about pain control of a burn victim are true? Select All
Aditional pain management may be needed due to rapid body metabolism. Pain meds should be given before procedures such as: debridement, dressing changes and PT Patients with a hx of drug and alcohol abuse may need higher dosages of pain medication
Pt. declared dead, and is being managed by the OPO transplant coordinator. Thirty minutes into the shift assessment by the nurse includes a blood pressure of 75/50, 85, 12, 99% and core temp is 93.8. Which order should the nurse implement first?
Begin phenylephrine (Neo-synephrine) for systolic BP <90 mm Hg
Which laboratory test best predicts the potential for organ rejection in transplant recipients?
HLA histocompatibility
The pt. has a GCS of 3 and discussions have been held with the family about withdrawing life support. Which statement by the nurse best describes requirements that must be met to sustain Centers for Medicare and Medicaid Services (CMS) Conditions of Participation
I need to notify TransLife (OPO) of my patient's impending death
fluid resuscitation is an important component of managing the trauma patient. Which of the following statements are true regarding the care of the trauma patient?
IV fluids may need to be warmed to prevent hypothermia massive transfusions should be avoided to improve patient outcomes
A patient presents to the outpatient clinic stating, "I would like to donate one of my kidneys." what is the best response by the nurse?
Let us orient you to the process required to become a donor
The nurse is educating a renal transplant patient about his immunosuppressant medication therapy. Which statement by the pt best indicates an appropriate understanding?
My doctors may try to stop my steroids soon after my transplant
When providing information on trauma prevention, it is important to realize that individuals age 35-54 years are most likely to experience which type of trauma incident?
Poisonings from prescription or illegal drugs
which transplant patient being cared for by the nurse requires immediate intervention?
a 2 hour post op liver transplant with a CVP of 1 mm Hg
Pt. presented to ED with diabetic ketoacidosis. Continuous IV of insulin is started and hourly CBG's are ordered. Targeted blood glucose after first hour of monitoring is
a decrease of 50-75 mg/dL compared to admitting values
which of the following best describes the term traumatic injury
alcohol consumption, drug abuse or other substance abuse contribute to traumatic events
A temporary wound cover composed of graft skin transplanted from another human living or dead is called
allograft
Which interventions are appropriate to consider in the management of the geriatric trauma patient
ask the patient if he or she has fallen recently obtain a detailed medical history frequently assess for signs of acute delirium obtain a detailed list of current medications
Metronidazole is being given to treat hepatic encephalopathy. When administering this medication, the nurse
assesses the patient for epigastric discomfort
Which statement best describes functions of the organ procurement organization?
consent for organ donation management of organ donor evaluation of transplant candidate
When preparing to answer the family's questions, the nurse understands which concerns most often influence a family's decision to donate organs?
donor disfigurement influences on funeral care fear of inferior medical care provider to donor fear that the potential donor may not be deceased concern over financial costs assoc. with donation
Which interventions can the nurse implement to assist the pt's family in coping with the traumatic event?
establish a family spokesperson and communication system ask the family about their normal coping mechanisms coordinate a family conference
Pt. is admited with acute pancreatitis. The nurse should
evaluate C-reactive protein to gauge severity
Diabetes medications that may independently increase a patients risk for hypoglycemia include
exenatide (Byetta) glimepiride (Amaryl) pramlintide (Symlin) sitagliptin (Januvia)
Factors associated with the development of nephrogenic diabetes insipidous include which of the following? Select All
hereditary medications such as: dilantin and lithium carbonate sickle cell disease
The most significant clinical finding of acute adrenal crisis is associated with fluid and electrolyte balance is?
hyperkalemia
in a trauma patient, symptoms of decreased cardiac output are commonly caused by
hypovolemia
in patients with extensive burns, edema occurs in both burned and unburned areas because of
increased capillary permeability
the nursing care plan for a patient with diabetic ketoacidosis includes diagnoses of which of the following?
ineffective breathing pattern ineffective therapeutic management nutrition, less than body requirements, imbalance
The patient is ordered to have large volume gastric lavage. The nurse will most likely need to?
insert a large bore nasogastric tube
a pt 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
intraabdominal hypertension
When assessing bowel sounds the nurse
listens for 5 minutes before noting "absent bowel sounds"
nursing priorities for management of acute pancreatitis include? Select all
managing respiratory dysfunction assessing and maintaining electrolyte imbalance utilizing supportive therapies aimed at decreasing gastrin release
poor patient outcomes after a traumatic injury are associated with
massive transfusions of blood products
Pt. is admitted with acute pancreatitis and severe ascites. The nurse should
monitor BP and evaluate for signs of dehydration
which statements best describes the role of the acute care nurse in the organ donation process?
notify the OPO in cases of impending death
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 Lantus at 10pm nightly. The nurse should instruct the pt. that the peak of the insulin action for this agent is?
peakless
while the patient is receiving a continuous infusion of IV insulin, treatment includes
plasma blood glucose monitoring every hour
the nurse has admitted a pt to the ED following a fall from a first-floor hotel balcony. The patient is 22 years old and smells of alcohol. The pt begins to vomit in the ED. Which of the following interventions is most appropriate?
prepare to suction the oropharynx while maintaining cervical spine immobilization
The primary priority for the critical care nurse with regard to the trauma patient is which of the following?
provide adequate oxygenation and tissue perfusion
When caring for a patient with upper GI bleeding, the nurse assesses for which of the following?
severity of blood loss hemodynamic stability necessity for fluid recussitation
Various pharmacological therapies have been researched in the treatment of acute pancreatitis and have shown that
somatostatin is ineffective in the treatment of pancreatitis
The nurse is caring for a pt complaining of abdominal pain. The nurse notes the pt abd is more distended then it was this morning. Nurse understands that:
the pt may have trapped air or fluid in the abd cavity
treatment and/or prevention of rhabdomyolysis in at risk pt. includes aggresive fluid ressucitation to achieve urine output of
100 mL/hr
Nurse is caring for a burn injured pt who weighs 154 pounds, the burn covers 50% of his body. Nurse calculates fluid needs by formula 4mL/kg/% burn of IV fluid for first 24 hrs. Nurse plans to administer what amount of fluid in the first 24 hr?
14 L
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?
indwelling urinary catheters are a source of infection patients often develop infection and sepsis secondary to central line catheters pneumonia is often an adverse outcome of mechanical vent
A 24 yr old unrestrained driver who sustained multiple traumatic injuries from a MVC has a blood pressure of 80/60 at the scene. Primary survey of this patient upon arrival to ED
is done quickly in the first few minutes to get a baseline assessment and establish priorities
A family member of a gravely ill son and states "we want to donate our sons organs" What is the best action by the nurse?
notify the organ procurement organization
Nurse is caring for a pt. with acute pancreatitis who is orally intubated and vented. Pt. calcium this morning was 5.5. The nurse notifies the provider and
places the pt. on seizure precautions
Nursing priorities to prevent ineffective coagulation include which of the following?
prevention of hypothermia administration of FFP as ordered administration of calcium as ordered
a hallmark finding suggesting burn injury below the glottis is
soot particles in lung secretions
Which of the following statements are true regarding chemical injuries?
systemic effects such as CNS depression, pulmonary edema, and hypotension may occur. tissue damage continues until the chemical is completely removed or neutralized depth of tissue injury is greatest from alkalies
The nurse obtains initial vital signs on a patient 2 weeks posttransplant who presents for follow-up monitoring to the outpatient transplant clinic. Which assessment finding by the nurse requires immediate action?
tenderness over graft site
in caring for a pt with hepatitis, it is important for the nurse to understand that
universal precautions should be followed to prevent the spread of the virus
