NUR 207 Final
A 55-year-old trauma patient hit the steering wheel and has a cardiac contusion. Which are potential complications of the injury? (Select all that apply.) A) Myocardial ischemia B) Dysrhythmias C) Hypotension D) Flail chest
A, B, C - A flail chest is commonly associated with rib fractures, which are not present in this patient. Cardiac contusions present with signs and symptoms of ineffective heart functioning, including dysrhythmias, decreased cardiac output (i.e., hypotension), and myocardial ischemia that may progress to infarction.
Which of the following nonpharmacological approaches by the nurse may be useful in the management of pain and anxiety in the critically ill patient? (Select all that apply.) A) Encouraging family members to bring familiar items from home B) Music therapy C) Guided imagery D) Involving family members in the patient's care E) Patient-controlled analgesia
A, B, C, D - All are correct except for patient-controlled analgesia, which is a pharmacological treatment.
Which stressors should the nurse anticipate the patient to have during the critical care experience? (Select all that apply.) A) Feelings of dread B) Difficulty sleeping C) Difficult communication D) Pain E) Thoughts of death and dying
A, B, C, D, E - Box 2-1 describes many stressors, including difficult communication, pain, feelings of dread, and thoughts of death and dying. Most patient's do not report difficulty sleeping as a stressor.
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) Junctional escape rhythm, rate of 45 B) Premature junctional beats C) Accelerated junctional rhythm, rate of 75 D) Junctional tachycardia, rate of 100
A - Junctional escape rhythm occurs when the dominant pacemaker, the SA node, fails to fire. The escape rhythm may consist of many successive beats, or it may occur as a single escape beat that follows a pause, such as a sinus pause. The normal intrinsic rate for the AV node and junctional tissue is 40 to 60 beats/min. An accelerated junctional rhythm has a rate between 60 and 100 beats/min, and the rate for junctional tachycardia is greater than 100 beats/min. Irritable areas in the AV node and junctional tissue can generate premature beats that are earlier than the next expected beat.
The patient, who is being treated for hypercholesterolemia, complains of hot flashes and a metallic taste in the mouth. The nurse educates the patient that this is a side effect of A) bile acid resins. B) statins. C) nicotinic acid. D) clopidogrel.
C - Common side effects of nicotinic acid include metallic taste in mouth, flushing, and increased feelings of warmth.
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) Lactated Ringer's (LR) B) 0.45% Normal Saline C) 5% dextrose D) Albumin
A - LR solution and 0.9% normal saline are isotonic solutions that are commonly infused to treat hypovolemia. Solutions of 5% dextrose in water and 0.45% normal saline are hypotonic and are not used for fluid resuscitation. Hypotonic solutions rapidly leave the intravascular space, causing interstitial and intracellular edema. A systematic review of 30 randomized controlled trials found no benefit in giving colloids (e.g., albumin) over crystalloids and recommended against the administration of colloids in most patient populations.
A temporary wound cover composed of a graft of skin transplanted from another human, living or dead, is called a(n) A) xenograft. B) allograft. C) biobrane. D) alloderm.
A - An allograft is transplanted skin from another human being. Alloderm is an allograft from another human being with cells removed that target the immune response. Biobrane is a nylon mesh dressing embedded with collagen. Xenograft is a skin graft from a different species.
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) Serum lactate level >6 mEq/L D) Mean arterial pressure >50 mm Hg
A - Early goal-directed therapy includes administration of IV fluids to keep the central venous pressure at 8 mm Hg or greater. Additional therapeutic end points include a heart rate at less than 110 beats/min and a mean arterial blood pressure at 65 mm Hg or greater. Serum lactate levels are elevated in sepsis; target levels should be <2.2 mEq/L.
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) Move the patient to a semiprivate room with another confused patient. C) Increase the amount of noise from equipment in the patient's room. D) Place the patient nearer to the nurses' station for observation.
A - Family members who reorient the patient help to increase pleasant sensory input to counteract the sensory overload. Increasing noise will add to sensory overload. Exposure to another confused patient may add to sensory overload. Increasing stimulation will add to sensory overload.
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) "Her respiratory center requires low O2 concentration to stimulate breathing." B) "Her alveoli cannot absorb higher levels of O2 because of the emphysema." C) "A nasal cannula will dry the mucous membranes and cause an increased risk of infection." D) "Her alveoli have been damaged and may rupture with higher doses of O2."
A - In patients with COPD, the respiratory drive is stimulated by hypoxemia, not increased levels of carbon dioxide. Administration of oxygen in high levels will impair the respiratory drive.
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) Multisystem organ failure and/or dysfunction B) Increased cerebral perfusion pressure C) Disseminated intravascular coagulation (DIC) D) Acute respiratory distress syndrome (ARDS)
A - Maldistribution of blood flow refers to the uneven distribution of flow to various organs and pooling of blood in the capillary beds. This impaired blood flow leads to impaired tissue perfusion and a decreased oxygen supply to the cells, all of which contribute to multiple organ failure. Damage to the type II pneumocytes leads to ARDS. Consumption of clotting factors may cause DIC. Low arterial blood pressure leads to decreased cerebral perfusion pressure.
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 very little to the pain response." B) "Nociceptors release histamine to help increase oxygenation." C) "Nociceptors adapt readily to the pain response to allow the body to adjust." D) "Nociceptors secrete serotonin to help ease pain and inflammation."
A - Nociceptors differ from other nerve receptors in the body in that they adapt very little to the pain response.
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 opioids B) Administration of bronchodilators C) Administration of neuromuscular blockade D) Administration of inhaled steroids
A - Opioids are a class of pharmacological agents that are beneficial in managing dyspnea during the final stages of life.
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) PQRST method C) Pain intensity (0 - 10) scale D) Visual Analog Scale (VAS)
A - The BPS is widely used to assess pain in adult patients who are nonverbal and unable to communicate. The other responses require cognition and communication.
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) improved cardiac filling time, allowing the patient to relax. C) the absence of ischemic heart disease. D) increased coronary artery filling time.
A - The fast heart rhythm may cause a decrease in cardiac output because of the shorter filling time for the ventricles. Vulnerable populations are those with ischemic heart disease who are adversely affected by the shorter time for coronary filling during diastole.
The patient is receiving continuous renal replacement therapy (CRRT). The nurse should become concerned when A) the ultrafiltrate is showing a pink tinge. B) the patient's temperature drops by one degree. C) there are no dark fibers in the hemofilter after 2 hours. D) the blood tubing becomes warm to touch.
A - The ultrafiltrate is assessed for blood (pink-tinged to frank blood), which is indicative of hemofilter membrane rupture. The CRRT system is frequently assessed to ensure filter and lines are visible at all times, kinks are avoided, and the blood tubing is warm to the touch. The hemofilter is assessed every 2 to 4 hours for clotting (as evidenced by dark fibers or a rapid decrease in the amount of ultrafiltration without a change in the patient's hemodynamic status). If clotting is suspected, the system is flushed with 50 to 100 mL of normal saline and observed for dark streaks or clots. Temperature is monitored because significant amounts of heat can be lost when blood is circulating through the extracorporeal circuit. Specialized devices to warm the dialysate or replacement fluid or rewarm the blood returning to patient are available.
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. The nurse anticipates a diagnosis of A) heart failure. B) pulmonary embolism. C) papillary muscle rupture. D) pericarditis.
A - These are classic signs of fluid overload and heart failure. Presence of a heart murmur, not the S3, might alert the nurse to a papillary muscle rupture. The patient with pericarditis may have chest pain and a pericardial friction rub. The patient with a pulmonary embolism has symptoms including difficulty in breathing, cyanosis, chest pain and possibly death.
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) Nitrates are the vasopressors of choice with increased ICP. C) Nimodipine reduces blood pressure through its effect on cerebral vessels. D) Hypertension greater than 160 mm Hg is necessary to achieve adequate perfusion.
A - To achieve adequate cerebral blood flow, cerebral perfusion pressure (CPP = MAP-ICP) should be at least 70 mm Hg. While hypotension may compromise cerebral blood flow, in the setting of increased intracranial pressure, hypertension (>160 mm Hg) can worsen cerebral edema by increasing microvascular pressure. Nimodipine is a calcium channel blocker that does not affect cerebral vasculature and is effective in providing quick, tight control of blood pressure.
Which interventions are appropriate to consider in the management of the geriatric trauma patient? (Select all that apply.) A) Ask the patient if he or she has fallen recently. B) Frequently assess for signs of acute delirium. C) Obtain a detailed list of current medications. D) Observe for signs of infection, primarily elevated temperature. E) Administer intravenous fluids rapidly to maintain blood pressure. F) Obtain a detailed medical history.
A, B, C, D, F - Geriatric trauma patients provide unique challenges related to changes in phsyiology associated with aging. Obtaining a fall history is important because falls are the primary mechanism of traumatic injury in the older adult. Obtaining a complete past and current medical history, including a list of current medications, is essential. Older patients are at a higher risk of fluid overload becauses of age-related changes in the cardiovascular system. Fluid resuscitation should be monitored closely to avoid complications of overresuscitation. Monitor the patient for acute delirium, as delirum increases morbidity and mortality of the older trauma patient. The immune system is less responsive with aging, thus placing this patient at higher risk of infection and less pronounced changes in body temperature when infection is present. Brain mass decreases with aging; thus, changes in neurological exam may progress gradually.
To maintain the patient's airway, which interventions are appropriate to implement with a trauma patient who sustained a spinal cord injury? (Select all that apply.) A) Maintain complete spinal immobilization. B) Avoid hyperextension of the neck. C) Insert an oral airway if patient is alert. D) Observe respiratory pattern. E) Observe depth of ventilation. F) Elevate the head of bed 30 degrees.
A, B, D, E - Maintaining a patent airway is an essential intervention in the care of the trauma patient. When the patient has a spinal cord injury, additional precautions are needed, including the following: (1) avoid hyperextension or rotation of the neck; (2) maintain spinal immobilization; (3) observe ventilatory effort, rate, depth, and effectiveness of breathing; (4) monitor motor and sensory function; and (5) anticipate the need for intubation and mechanical ventilation. Oral airways should not be inserted in an awake patient, as it will cause an airway obstruction. The patient's head of bed should remain flat, and spinal precautions should be taken.
Which of the following statements are true regarding chemical injuries? (Select all that apply.) A) Tissue damage continues until the chemical is completely removed or neutralized. B) Chemical burns are not as severe as thermal burns. C) Systemic effects such as CNS depression, pulmonary edema, and hypotension may occur. D) These injuries affect only the localized area of chemical contact. E) Depth of tissue injury is greatest from alkalies.
A, B, D, E - Systemic effects occur after burn injury as a result of release of chemical mediators. Chemicals can continue to cause tissue damage until removed or neutralized. Alkali agents cause the greatest tissue damage because of the protein denaturation and liquefaction that occur. Chemical burns can be more severe than thermal burns. Chemicals can be absorbed, causing wider injury than the area of contact.
Which of the following statements is correct regarding burn classification? (Select all that apply.) A) Partial-thickness burns involve injury to the dermal layer. B) Superficial burns involve only the epidermis. C) Full-thickness burns involve all layers of the skin down to the bone. D) Deep partial-thickness injuries involve destruction of epidermis and most of the dermis.
A, C - Deep partial thickness burns involve the epidermis and most of the dermis. Partial-thickness burns may extend to varying depths of the dermis. Superficial burns involve only the epidermis. Full-thickness injuries do not necessarily involve the bone but do involve deeper structures such as subcutaneous fat, fascia, and muscle
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? (Select all that apply.) A) Extreme anxiety and pain may lead to agitation. B) Pain and anxiety stimulate the parasympathetic nervous system. C) Patients may develop PTSD as a result of an ICU stay. D) Many critically ill patients experience panic and fear.
A, C, D - Critically ill patients can develop agitation; many experience panic and fear; and PTSD has been reported after discharge from the ICU. Pain and anxiety stimulate the sympathetic nervous system.
In which circumstances should the nurse anticipate that patients should be transferred to specialized burn center for treatment? (Select all that apply.) A) Electrical burns, including lightning injury B) Burn patients with concomitant trauma C) Partial-thickness and full-thickness burns greater than 10% TBSA in patients over the age of 50 D) Burns involving the face, eyes, ears, hands, feet, perineum, major joints E) Inhalation injury
A, C, D, E - According to the American Burn Association, patients meeting the following criteria should be transferred to a burn referral center for optimal patient outcomes. 1. Partial-thickness and full-thickness burns greater than 10% of the total body surface area (TBSA) in patients under 10 years or over 50 years of age. 2. Partial-thickness and full-thickness burns greater than 20% BSA in other age groups. 3. Partial-thickness and full-thickness burns involving the face, eyes, ears, hands, feet, genitalia, or perineum or those that involve skin overlying major joints. 4. Electrical burns, including lightning injury (significant volumes of tissue beneath the surface may be injured and result in acute renal failure and other complications). 5. Significant chemical burns. 6. Inhalation injury. 7. Burn injury in patients with preexisting illness that could complicate management, prolong recovery, or affect mortality. 8. Any burn patient in whom concomitant trauma poses an increased risk of morbidity or mortality may be treated initially in a trauma center until stable before transfer to a burn center. 9. Children with burns seen in hospitals without qualified personnel or equipment for their care should be transferred to a burn center with these capabilities. 10. Burn injury in patients who will require special social and emotional or long-term rehabilitative support, including cases involving suspected child abuse and neglect.
Prevention of hypothermia is crucial in caring for trauma patients. Which treatments are appropriate for preventing hypothermia? (Select all that apply.) A) Warm fluids and blood products before or during administration. B) Leave the patient's clothing on, even if wet. C) Cover the patient with an external warming device. D) Administer cool humidified oxygen. E) Warm the room in the emergency department and critical care unit.
A, C, E - Oxygen should be warm and humidified to prevent hypothermia. External warming devices are effective in preventing or treating hypothermia. All of the patient's clothes should be removed so that the body can be inspected. Wet clothing increases the risk of hypothermia. After clothing is removed, the patient is warmed. Warming fluids and blood products reduces the risk of hypothermia. Warming the temperature in the rooms where care is provided is a strategy for preventing hypothermia.
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) Resolve conflicts among health care providers before the conference. 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) During the conference, encourage family members to talk about the patient's life.
B - An evidence-based practice to facilitate meeting information needs of the family is to encourage the family to write down questions before the conference. Family members should be encouraged to talk about the patient's life during the conference, but this will not assist in meeting information needs. Organizing a family conference at a time when most family members can attend is an evidence-based practice, but it does not assist in meeting needs for information. Conflicts among health care providers should be resolved before a family conference to ensure that all are focusing on the same goals and outcomes of the conference. This action does not assist in meeting information needs of the family.
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) Increase the infusion by 50% and reassess the patient in 1 hour. B) Administer an additional dose of intravenous morphine equal to the current infusion rate, and increase the infusion by 50%. C) 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. D) Maintain the infusion at the current rate.
B - Based on the Guidelines for Pharmacological Intervention During Withdrawal of Life Support, depicted in Figure 4-1, if the patient on a morphine infusion is experiencing pain, a bolus equal to the current infusion hourly rate should be administered for pain and the infusion rate increased by 50%. Boluses may be increased every 5 to 10 minutes based upon assessed findings. IM medications would be inappropriate when an IV infusion is running and would not provide immediate control of symptoms. A bolus is required before increasing the infusion rate of the pain medication. The current infusion rate is not providing adequate pain relief.
Which assessment finding indicates a burn injury below the glottis? A) Red or flushed cheeks B) Singed nasal hairs C) Soot particles in lung secretions D) Hoarseness
B - Carbonaceous secretions suggest inhalation injury below the glottis. Hoarseness suggests inhalation injury above the glottis. Red or flushed cheeks suggests carbon monoxide poisoning. Singed nasal hairs suggest inhalation injury above the glottis
The nurse is caring for a patient with possible distributive shock. Which should the nurse look for on assessment? A) Decreased cardiac output. B) Vasodilation and relative hypovolemia. C) Blood loss and actual hypovolemia. D) Third-spacing of fluids into peritoneal space.
B - Distributive shock presents with widespread vasodilation and decreased systemic vascular resistance that result in a relative hypovolemia. Blood loss is associated with hypovolemic shock. Decreased cardiac output is a primary cause of cardiogenic shock. Primary internal sequestration of fluids that causes internal fluid loss is associated with hypovolemic shock.
The nurse is educating a new RN on the therapeutic effect of head-of-the-bed elevation and neutral head and neck alignment on a patient with increased intracranial pressure (ICP). Which statement by the new RN indicates that teaching has been effective? A) "Head-of-the-bed elevation lowers ICP by maintaining an open airway." B) "Head-of-the-bed elevation lowers ICP by facilitating venous drainage and decreasing venous obstruction." C) "Head-of-the-bed elevation lowers ICP by reducing the risk of snoring." D) "Head-of-the-bed elevation lowers ICP by allowing for elevations in CO2 to dilate cerebral arteries."
B - Head-of-the-bed elevation and a neutral head position that avoids hyperextension or hyperflexion facilitate jugular venous drainage, helping to minimize increases in ICP. Elevated CO2 contributes to cerebral vessel vasodilation, which can increase cerebral blood volume and further elevate ICP. Maintaining an open airway alone does not minimize increases in ICP. Reducing the risk of snoring by maintaining an open airway alone does not minimize increases in ICP.
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) hepatic failure. B) ileus. C) anemia. D) ascites.
B - Ileus is the result of decreased blood flow to the bowel. Redistribution of blood during acute burn shock does not cause anemia, ascites, or hepatic failure.
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) Solutions of 0.45% normal saline are used routinely in shock. B) actated Ringer's should not be infused if lactic acidosis is severe. C) 3 mL of crystalloid is administered to replace 10 mL of blood loss. D) Administration of colloids is preferred over crystalloids.
B - LR solutions contain lactate, which the liver converts to bicarbonate. If liver function is normal, this will counteract lactic acidosis. However, LR should not be infused if lactic acidosis is severe. To replace every 1 mL of blood loss, 3 mL of crystalloid is administered. There is no evidence to support colloid administration being more beneficial than crystalloid administration in shock states. Hypotonic solutions such as 0.45% normal saline are not administered in shock states as these solutions rapidly leave the intravascular space, causing interstitial and intracellular edema.
All burn patients are at increased risk for acute respiratory distress syndrome (ARDS) due to A) a decrease in cardiac output. B) increased capillary permeability. C) myoglobinemia. D) carboxyhemoglobinemia.
B - Overwhelming systemic inflammatory response syndrome (SIRS) and increased capillary permeability throughout the body, including the lungs, increase the risk of ARDS. Carboxyhemoglobinemia causes restlessness, confusion, and loss of consciousness. Decreased cardiac output decreases pulmonary blood flow but is not a direct cause of ARDS. Myoglobinemia causes acute kidney injury.
Immediate interventions in the treatment of a patient with burns from tar include which of the following? A) Remove clothing that has been in contact with the tar. B) Apply cool water. C) Try to remove tar that isn't well adhered to the skin. D) Apply ice over the tar/burn wounds.
B - Scald, tar, and asphalt burns are treated by immediate removal of the saturated clothing and cooling with water. No attempts should be made to remove adherent tar at the scene. Ice is never applied to wounds as it will further damage tissue by causing vasocontriction.
Lung-protective strategies for mechanical ventilation to treat acute respiratory distress syndrome while also preventing complications include which of the following? A) Positive end-expiratory pressure (PEEP) 25 cm H2O or higher B) Low tidal volume of 6 mL/kg ideal body weight C) High levels of sedation D) Oxygen levels (FiO2) 0.80-1.00
B - The target tidal volume is 6 mL/kg. High levels of sedation may be needed but are not a protective strategy. The target lung-protective oxygen level is 0.6. Lower levels of PEEP are desirable as the risk for barotrauma increases with higher levels of PEEP.
The provider has placed an esophagogastric balloon to tamponade bleeding varices. Of the three types of tubes used for tamponade, the A) treatment of gastric varices requires the Minnesota tube. B) Linton tube allows for gastric and esophageal suction. C) Sengstaken-Blakemore tube has the most lumens. D) Minnesota tube allows for aspiration of gastric contents.
B - Three types of tubes are used for tamponade: Sengstaken-Blakemore, Minnesota, and Linton tubes. The adult Sengstaken-Blakemore tube has three lumens: one for gastric aspiration, similar to that in a nasogastric tube; one for inflation of the esophageal balloon; and one for inflation of the gastric balloon. The Minnesota tube has an additional lumen that allows for aspiration of esophageal secretions. The Minnesota tube is commonly used because it allows for suction of secretions above and below the balloon. The Linton tube has a gastric balloon only, and lumens for gastric and esophageal suction; it is reserved for those with bleeding gastric varices.
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) Turn the patient every 2 hours. B) Refrain from giving the patient medications. C) Slowly wean the patient off the ventilator. D) Obtain signatures for "do not resuscitate" orders.
B - To withhold treatment is a decision not to administer selected treatments in cases in which care is considered futile. Withdrawal is a removal of treatments, such as mechanical ventilation. "Do not resuscitate" is a written order not to initiate life-support measures in the event of cardiopulmonary arrest. Turning the patient every two hours is not an example of withholding treatment.
The nurse is caring for a patient admitted with possible disseminated intravascular coagulation (DIC). Which laboratory test should the nurse anticipate that the health care provider will order? A) White blood count (WBC) B) Fibrin degradation product (FDP) C) Vitamin K level D) Complete blood count (CBC) with differential
B - When plasmin digests fibrinogen, fragments known as fibrin split products, or fibrin degradation products, are produced and function as potent anticoagulants. Fibrin split products are not normally present in the circulation but are seen in some hematological disorders, including DIC. The CBC reports the total RBC count and RBC indices, hematocrit, hemoglobin, WBC count and differential, platelet count, and cell morphologies; it does not detect clotting. WBCs play a key role in the defense against infectious organisms and foreign antigens, not clotting. Vitamin K deficiency is commonly associated with impaired hemostasis and bleeding, not clotting.
The patient with a pacemaker shows pacemaker spikes that are not followed by a QRS. The nurse interprets this as A) failure to sense. B) failure to capture. C) failure to pace. D) demand mode.
B - When the pacemaker generates an electrical impulse (pacer spike) and no depolarization is noted, it is described as failure to capture. Failure to pace or fire occurs when the pacemaker fails to initiate an electrical stimulus when it should fire. The problem is noted by absence of pacer spikes on the rhythm strip. Failure to sense manifests as pacer spikes that fall too closely to the patient's own rhythm, earlier than the programmed rate. The demand mode paces the heart when no intrinsic or native beat is sensed.
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) Dobutamine (Dobutrex) C) Phenylephrine (Neo-Synephrine) D) Nitroprusside (Nipride)
B - ositive inotropic agents such as dobutamine (Dobutrex) are given to increase the contractile force of the heart in cardiogenic shock. Dopamine (Intropin) is used primarily in low cardiac output states to restore vascular tone and increase blood pressure, but not in cardiogenic shock. Neo-Synephrine would be contraindicated in cardiogenic shock, as the vasoconstriction it produces would exacerbate cardiac ischemia. Nitroprusside (Nipride), used for preload and after load reduction, can improve cardiac performance in shock states by its reduction of systemic vascular resistance.
Which strategies should the nurse manager implement to improve collaboration in the critical care setting? (Select all that apply.) A) Exclude family members from rounds. B) Institute morning briefings. C) Initiate interdisciplinary rounds. D) Create joint programs for continuing education.
B, C, D - Including family members in rounds fosters collaboration with team members. These might be scheduled family rounds or the daily multiprofessional rounds.
The nurse is assessing a patient for suspected alcohol withdrawal and identifies which signs and symptoms as suspicious? (Select all that apply.) A) Low body temperature B) Nausea, vomiting, diarrhea C) Irritable, confused, hallucinations D) Seizures E) Somnolent, difficult to arouse F) Hypotension and tachycardia
B, C, D - Signs and symptoms of alcohol withdrawal include irritability, agitation, confusion, hallucinations and delusions, insomnia, anxiety and tremors, nausea, vomiting, diarrhea, diaphoresis, tachycardia and hypertension, fever, and seizures.
Which of the following statements is true about nonburn injuries? (Select all that apply.) A) Toxic epidermal necrolysis is most commonly caused by a drug reaction. B) The clinical picture of a nonburn injury is similar to that of a burn injury. C) Erythema multiforme is the most extensive type of exfoliative disorder. D) Necrotizing fasciitis is painless because underlying nerves have been destroyed. E) Staphylococcal scalding syndrome is skin sloughing caused by the staphylococcal toxin.
B, D - Severe nonburn injuries present a clinical picture similar to that of burn injuries. Staphylococcal scalding syndrome occurs as intraepidermal splitting with resultant skin sloughing; this response is a reaction to the staphylococcal toxin. Toxic epidermal necrolysis is frequently associated with a drug. Toxic epidermal necrolysis, not erythema multiforme, is the most extensive form of exfoliative disorder. Necrotizing fasciitis presents with pain out of proportion to the lesion.
The nurse is caring for a patient with a head injury. If autoregulation is lost, what should the nurse be most concerned for? A) Shunting of cerebrospinal fluid (CSF) blockage. B) Occurrence of central venous engorgement. C) Hypertension increasing cerebral blood flow. D) Unchanged cerebral blood flow.
C - Autoregulation is the ability of the cerebral vessels to adjust their diameter in response to arterial pressure changes within the brain. If mean arterial blood pressure rises, cerebral vessels will constrict to prevent excessive distension of the cerebral arteries. When autoregulation is lost, cerebral vessels are no longer able to regulate diameter and as a result hypertension increases cerebral perfusion pressure. Cerebral vessels may become engorged as a result of the loss of autoregulation. Cerebral blood flow is affected with the loss of autoregulation. Loss of autoregulation does not block CSF flow.
The nurse is caring for a patient in shock. Which is a priority action by the nurse? A) Prevent third-spacing of fluids. B) Support mechanical ventilation. C) Maintain adequate tissue perfusion. D) Ensure adequate cellular hydration.
C - Care of a patient in shock is directed toward correcting or reversing the altered circulatory component and reversing tissue hypoxia. Restoring circulating intravascular volume is the priority in improving tissue perfusion and oxygen delivery.
Poor patient outcomes after a traumatic injury are associated with A) chest tube placement for treatment of a hemothorax. B) immediate decompression of a tension pneumothorax. C) massive transfusions of blood products. D) intraosseous cannulation for intravenous fluid administration.
C - Current evidence suggests that patients receiving massive blood transfusions have poorer outcomes. Although a chest tube may be necessary in the treatment of trauma patients, it is not associated with poor patient outcomes. Immediate decompression of a tension pneumothorax is also not associated with poor patient outcomes. Intraosseous cannulation for intravenous fluid administration has not been shown to have adverse patient outcomes.
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) Frequent turning and early mobility, including ambulation if possible C) Daily interruption of sedation and assessment of readiness to wean/extubate D) Regular and frequent oral care
C - Daily assessment of readiness to extubate is the best approach for determining readiness to wean and for assisting in decreased duration of mechanical ventilation. Neuromuscular blockade prolongs mechanical ventilation. Turning and mobility are important interventions to prevent complications, but they do not necessarily affect duration of ventilation.
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 administer kayexalate to prevent potassium buildup." C) "I should monitor plasma blood glucose every hour." D) "I should implement a fluid restriction to prevent fluid overload."
C - Frequent blood glucose monitoring is necessary during an insulin infusion to ensure that blood glucose values are not dropping at a rate greater than 50 to 75 mg/dL. Arterial blood gases may be drawn periodically if the patient is acidotic. Values guide administration of sodium bicarbonate. Individuals with diabetes who are using intravenous insulin to control elevated glucose levels may require supplemental IV fluid to maintain vascular volume. Insulin promotes movement of potassium from the extracellular space to the intracellular space and will lower potassium levels. Hypokalemia is a concern with insulin treatment. Kayexalate promotes potassium loss.
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) hypovolemic shock. C) sepsis. D) extreme pain.
C - Hypovolemic shock occurs soon after burn injury as a result of dramatic fluid shift. Carbon monoxide poisoning would present with signs of acute hypoxemia. Extreme pain would cause a sympathetic response and behavioral symptoms. Sepsis is a significant risk factor for burn-injured patients but would not present this quickly after initial injury.
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 SVR; normal blood pressure C) High heart rate; low right atrial pressure D) High PAOP; low cardiac output
C - In septic shock, inflammatory mediators damage the endothelial cells that line blood vessels, producing profound vasodilation and increased capillary permeability. Initially this results in a high heart rate, hypotension, and low SVR, and subsequently in low right atrial pressure.
The nurse explains to the new RN that angiotensin-converting enzyme inhibitors (ACE inhibitors) should be started within 24 hours of acute myocardial infarction (AMI). Which statement by the new RN indicates that teaching has been effective? A) "ACE inhibitors are started within 24 hours to prevent tachycardia." B) "ACE inhibitors are started within 24 hours to prevent myocardial stunning." C) "ACE inhibitors are started within 24 hours to prevent myocardial remodeling." D) "ACE inhibitors are started within 24 hours to prevent hibernating myocardium."
C - Myocardial remodeling is a process mediated by angiotensin II, aldosterone, catecholamine, adenosine, and inflammatory cytokines; it causes myocyte hypertrophy and loss of contractile function in the areas of the heart distant from the site of infarctions. ACE inhibitors should be ordered.
The etiology of pulmonary edema in acute respiratory distress syndrome is related to: A) tension pneumothorax. B) decreased cardiac output. C) damage to the alveolar-capillary membrane. D) volutrauma and hypoxemia.
C - Noncardiogenic pulmonary edema is seen in ARDS secondary to damage to the alveolar-capillary membrane. Decreased cardiac output, tension pneumothorax, volutrauma, and hypoxemia are not causes.
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 treated with sedative medications." B) "Pain and anxiety are mutually exclusive; only one can be experienced at a time." C) "Pain and anxiety are cyclical, with each exacerbating the other." D) "Pain and anxiety are easily controlled with pain medication."
C - Pain and anxiety are often interrelated and may be difficult to differentiate. The relationship between the two is cyclical, with each exacerbating the other.
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) Flail chest B) Cardiac tamponade C) Pulmonary contusion D) Hemothorax
C - Pulmonary contusion as a result of blunt chest trauma increases the risk for development of pneumonia, acute lung injury, and/or ARDS. Cardiac tamponade is life threatening if untreated, but it is not a common complication after blunt chest trauma. Flail chest and hemothorax may result with blunt chest trauma, but they are not common causes of death.
The nurse is listening to a lecture on the impact of decreased blood flow through the kidneys. Which statement by the nurse indicates that teaching has been effective? A) "Decreased kidney blood flow can lead to peripheral vasodilation." B) "Decreased kidney blood flow can lead to decreased systolic blood pressure." C) "Decreased kidney blood flow can lead to release of renin from the kidney." D) "Decreased kidney blood flow can lead to increased excretion of sodium and water."
C - Renin is released whenever blood flow through the afferent and efferent arterioles decreases. A decrease in the sodium ion concentration of the blood flowing past the specialized cells (e.g., in hypovolemia) also stimulates the release of renin. Renin activates the renin-angiotensin-aldosterone cascade, which ultimately results in angiotensin II production. Angiotensin II causes vasoconstriction and release of aldosterone from the adrenal glands, thereby raising blood pressure, increasing blood flow, and increasing sodium and water reabsorption in the distal tubule and collecting ducts.
The nurse is meeting with family members of a critically ill patient. Which statement best addresses the psychological needs of the family members? A) "There are coffee and cookies in the waiting room. Why don't you take a short break?" B) "I'm adjusting the alarms on the monitor to reduce the noise level in the 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) "It would help the patient if you can spend the night in the waiting room."
C - The need for information is the primary need of family members; providing daily updates is an excellent example of meeting family members' needs. Family members should be encouraged to get adequate rest; staying all night may increase stress and fatigue. If they do stay, many hospitals provide in-room sleeping arrangements. Providing food and space meets physical needs for family members.
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 80 mm Hg and PaCO2 50 mm Hg C) PaO2 55 mm Hg and PaCO2 55 mm Hg D) PaO2 75 mm Hg and PaCO2 40 mm
C - The patient with COPD typically has hypoxemia and an elevated carbon dioxide level.
The patient is admitted for general malaise and low urine output. The patient is alert and oriented and states that he has lost 5 pounds over the past few days. His heart rate is 124 beats/min. His blood pressure is 88/40 mm Hg. His mouth is dry and he has flat neck veins and poor skin turgor. The nurse interprets that his low urine output is due to A) uremia. B) intrarenal causes. C) prerenal causes. D) fluid overload.
C - The patient's general appearance is assessed for signs of uremia (retention of nitrogenous substances normally excreted by the kidneys), such as malaise, fatigue, disorientation, and drowsiness. The skin is assessed for color, texture, bruising, petechiae, and edema. The patient's hydration status is also carefully assessed. Current and admission body weight and intake and output information are evaluated. Skin turgor, mucous membranes, breath sounds, presence of edema, neck vein distension, and vital signs (blood pressure and heart rate) are all key indicators of fluid balance. An oliguric patient with weight loss, tachycardia, hypotension, dry mucous membranes, flat neck veins, and poor skin turgor may be volume depleted (prerenal cause). Weight gain, edema, distended neck veins, and hypertension in the presence of oliguria indicate fluid overload and suggest an intrarenal cause.
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) tension pneumothorax. B) myocardial infarction. C) pulmonary embolus. D) cardiac tamponade.
C - The patient's history and respiratory signs and symptoms indicate pulmonary embolus. The patient's signs and symptoms do not suggest a cardiac tamonade; however, given the patient's age, he may be evaluated for a possible myocardial infarction. His mechanism of injury and his 2 days postinjury make a tension pneumothorax less likely.
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) Increase the physiological reserve of the trauma patient. C) Provide adequate oxygenation and tissue perfusion. D) Ensure adequate fluid resuscitation.
C - The priority is to maintain adequate oxygenation and tissue perfusion through effective fluid resuscitation and management of the patient's airway and breathing. Decreasing the patient's risk for MODS is achieved by ensuring tissue perfusion and oxygenation. Increasing physiological reserve is not an initial priority in the management of the trauma patient.
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) rhabdomyolysis. B) hypothermia. C) compartment syndrome. D) fat emboli.
C - These signs and symptoms are characteristic of late signs of compartment syndrome. Fat emboli are associated with long-bone fractures and typically manifest pulmonary symptoms. These signs and symptoms are characteristic of compartment syndrome, not hypothermia. Rhabdomyolysis is associated with a crush injury and compartment syndrome. A clinical sign that may be noted by the nurse is dark tea-colored urine.
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) terminal condition. B) non-heart beating donor. C) persistent vegetative state. D) brain death.
C - This is the definition of persistent vegetative state. These individuals are not brain dead and are not necessarily terminal. A non-heart beating donor would be someone with cardiac death. See Table 3-2 for definitions.
After receiving handoff report from the night shift, the nurse completes the morning assessment of a patient with 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 100.5° 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? A) Increase supplemental oxygen therapy to 60% Venturi mask. B) Administer acetaminophen (Tylenol) 650 mg suppository per rectum. C) Administer at least 30 mL/kg of intravenous crystalloid fluid within the first 3 hours D) Administer 40 mg furosemide (Lasix) intravenously as needed if the urine output is less than 30 mL/hr.
C - ositive inotropic agents such as dobutamine (Dobutrex) are given to increase the contractile force of the heart in cardiogenic shock. Dopamine (Intropin) is used primarily in low cardiac output states to restore vascular tone and increase blood pressure, but not in cardiogenic shock. Neo-Synephrine would be contraindicated in cardiogenic shock, as the vasoconstriction it produces would exacerbate cardiac ischemia. Nitroprusside (Nipride), used for preload and after load reduction, can improve cardiac performance in shock states by its reduction of systemic vascular resistance.
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) wait for the patient to ask for medication and give it promptly. B) medicate routinely with pain/antianxiety medications to keep the patient comfortable. C) ask the patient frequently if he or she needs pain/antianxiety medication. D) identify and treat the underlying causes of pain and anxiety.
D - The priority nursing action is to assess what is causing the pain and/or anxiety and to try to remove the underlying cause.
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 maintain minimal contact with the patient throughout the shift. 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 request a change in assignment if care of the assigned patient violates his or her ethical principles.
D - A nurse can request a change in assignment if care of the patient violates his or her principles. However, care must be assumed by another nurse so that the patient is not abandoned. The nurse should take action to resolve the conflict instead of seeking intervention by other staff members or limiting exposure to the patient. The nurse should be fully present for each patient and ready to help when needed.
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) Presents a clear and consistent message to the family B) Facilitates continuity of care if the patient is transferred C) Emphasizes that the patient will not be abandoned if palliative care is the outcome of the conference D) Aims for all (patient, family, provider) to agree on the plan of care that is based on the patient's preferences
D - An important guideline for effective communication to facilitate end-of-life care is to aim for all to agree on the plan of treatment. The plan should be based on the known or perceived preferences of the patient. It is important for the family members to be assured that the patient will not be abandoned, but this action primarily provides reassurance. Continuity of care is important during patient transfer, but this action ensures that all information is conveyed, rather than relieving anxiety. A clear and consistent message should be provided to the family, but this is important to ensure that the health care team is in agreement as to treatment goals.
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) An increase in tidal volume B) An increased work of breathing C) A decrease in inspiratory pressure D) A decrease in cardiac output
D - Because PEEP increases intrathoracic pressure, cardiac output may decrease.
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) Glucocorticoids B) Proton pump inhibitors C) Colloids D) Vasopressors
D - Blood pressure may respond to IV fluids, but vasopressor therapy is often required to compensate for the loss of sympathetic innervation and resultant vasodilation. Colloid administration alone will not provide necessary vascular tone to support perfusion. Glucocorticoids are given in the early stages of spinal cord injury to reduce edema associated with injury and to improve outcomes. Proton pump inhibitors may be given to prevent stress ulcers.
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) Visitation shapes the critical care experience for the family but not the nurse. B) Allowing children to visit is stressful for the patient and the child. C) Restricted visitation prevents family exhaustion. D) Family presence during procedures promotes adaptation.
D - Family presence during procedures has been shown to promote adaptation and reduce fear and anxiety. Allowing children to visit should be determined on an individual basis. Research has not shown child visitation to be associated with negative effects. Restricted visitation will not prevent family exhaustion and adds to stress. Visitation shapes the critical care experience for both the family and the nurse.
The nurse is caring for a patient in neurogenic shock. Which should the nurse assess for? A) Hypertension B) Tachycardia C) Hypoventilation D) Vasodilation
D - In neurogenic shock, there is an interruption of impulse transmission or blockage of sympathetic outflow, resulting in vasodilation, inhibition of baroreceptor response, and impaired thermoregulation. Interruption of sympathetic nerve innervation would result in bradycardia. Interruption of sympathetic nerve innervation would result in hypotension. Hypoventilation is not a physiological mechanism.
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?2- 4 mEq/L. The nurse interprets the carbon dioxide reading is a result of A) dehydration. B) the formation of ketones. C) renal compensation for ketoacidosis. D) respiratory compensation for ketoacidosis.
D - Kussmaul's respirations are a compensatory mechanism for metabolic acidosis by "blowing off" carbonic acid in the form of carbon dioxide. Fluid volume abnormalities are not corrected by respiratory compensation mechanisms. The body compensates for metabolic acidosis by initially binding available bicarbonate and then producing extra bicarbonate. Ketone formation results from the breakdown of fats. Formation of ketones results in reduction of pH.
A major complication of an electrical burn injury is acute kidney injury caused by A) excessive fluid resuscitation. B) the direct effects of the electrical current as it traverses the intima of the kidney. C) the catabolic effect of the electrical current through the kidneys. D) the release of myoglobin, which can cause acute kidney injury.
D - Myoglobin is released by damaged tissue and causes damage to renal tubules, contributing to acute kidney injury. Fluid resuscitation promotes renal blood flow and does not contribute to acute kidney injury. Catabolism affects the entire body and is not isolated to renal dysfunction.
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) Opiate B) Antibiotic C) Benzodiazepine D) Paralytic agent
D - Paralytic agents must be discontinued before the withdrawal of life-sustaining treatments. Following the discontinuation of the drug, the patient must demonstrate sufficient motor activity to allow for a comprehensive assessment. Antibiotics may be discontinued during the end of life, but this is not a requirement. Benzodiazepines reduce anxiety that may accompany the dying process. Continuation of this therapy until death or symptom relief would be appropriate as a palliative care intervention aimed at reducing suffering. Opiates are used to manage pain and dyspnea that may accompany the dying process. Continuation of this therapy until death or symptom relief would be appropriate as a palliative care intervention aimed at reducing suffering.
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) Pulmonary contusion and chest x-ray B) Liver laceration and focused assessment with sonography for trauma (FAST) C) Cardiac tamponade and pericardiocentesis D) Aortic dissection and aortogram
D - Signs of aortic disruption include weak femoral pulses, dysphagia, dyspnea, hoarseness, and severe pain. A chest x-ray study may demonstrate a widened mediastinum, tracheal deviation to the right, depressed left mainstem bronchus, first and second rib fractures, and left hemothorax. The diagnosis is confirmed by an aortogram. Cardiac tamponade presents with pulsus paradoxus and decreased cardiac output with poor venous return; a pericardiocentesis is the treatment of choice. Depending on the severity of the liver laceration, the pateint will present with right upper quadrant abdominal pain and tenderness and hypotension. FAST is used to diagnosis hepatic injury and intraabdominal bleeding. Pulmonary contusion will present primarily with signs and symptoms of poor oxygenation, and a chest x-ray may not be helpful in diagnosing this condition.
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) Suprasternal muscle retractions D) Somnolence
D - Somnolence, lethargy, and coma are seen with CO2 retention. Nasal flaring, paradoxical respirations, and muscle retracts are seen with respiratory muscle fatigue (clinical alert).
The trauma patient presenting with left lower rib fractures develops left upper quadrant tenderness, hypotension, and referred pain to the left shoulder. You suspect A) bowel obstruction. B) cardiac tamponade. C) pulmonary contusion. D) splenic injury.
D - Splenic injury occurs most often as a result of blunt trauma to the abdomen. However, penetrating trauma to the left upper quadrant of the abdomen or fracture of the anterior left lower ribs also contributes to splenic injuries. The patient may present with left upper quadrant tenderness, peritoneal irritation, and/or referred pain to the left shoulder (Kehr's sign). Hypotension or signs of hypovolemic shock may also be noted. The patient's injury and associated signs and symptoms suggest an injury to the spleen rather than cardiac, bowel, or pulmonary 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 rehabilitative phase." B) "The most crucial phase of burn treatment is the emergent phase." C) "The most crucial phase of burn treatment is the acute phase." D) "The most crucial phase of burn treatment is the resuscitative phase."
D - The acute and rehabilitation phases will not progress if the resuscitative phase is not successful; the greatest physiological insults tend to occur during this time. The acute phase follows the resuscitative phase; during this time the fluid shifts have stabilized and the patient tends to be more hemodynamically stable. There is no "emergent" phase of burn care. The rehabilitative phase begins after the acute phase ends; the patient is most stable during this time.
A 53-year-old patient has kidney and ureteral stones and is hospitalized for urinary retention and severe flank pain. The nurse interprets the level of kidney injury to be A) intrarenal. B) acute tubular necrosis. C) Prerenal. D) postrenal.
D - The etiology of acute kidney injury (AKI) is classified as prerenal, postrenal, or intrarenal. Classification depends on where the precipitating factor exerts its pathophysiological effect on the kidney. Acute kidney injury resulting from obstruction of the flow of urine is classified as postrenal, or obstructive renal injury. Obstruction can occur at any point along the urinary system. Conditions that result in AKI by interfering with renal perfusion are classified as prerenal. Most prerenal causes of AKI are related to intravascular volume depletion, decreased cardiac output, renal vasoconstriction, or pharmacological agents that impair autoregulation and GFR. These conditions reduce the glomerular perfusion and the GFR, and the kidneys are hypoperfused. Conditions that produce AKI by directly acting on functioning kidney tissue (either the glomerulus or the renal tubules) are classified as intrarenal. The most common intrarenal condition is acute tubular necrosis (ATN).
The patient is admitted with generalized edema and hypertension. The patient states that his urine output has been less than normal. An indwelling urinary catheter is inserted, but very little urine is obtained. The patient has distended neck veins, and his blood pressure is 210/110 mm Hg. The nurse interprets that the patient's fluid retention is due to A) volume depletion. B) uremia. C) prerenal causes. D) intrarenal causes.
D - The patient's general appearance is assessed for signs of uremia (retention of nitrogenous substances normally excreted by the kidneys), such as malaise, fatigue, disorientation, and drowsiness. The skin is assessed for color, texture, bruising, petechiae, and edema. The patient's hydration status is also carefully assessed. Current and admission body weight and intake and output information are evaluated. Skin turgor, mucous membranes, breath sounds, presence of edema, neck vein distension, and vital signs (blood pressure and heart rate) are all key indicators of fluid balance. An oliguric patient with weight loss, tachycardia, hypotension, dry mucous membranes, flat neck veins, and poor skin turgor may be volume depleted (prerenal cause). Weight gain, edema, distended neck veins, and hypertension in the presence of oliguria indicate fluid overload and suggest an intrarenal cause.
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) Universal care C) Quality and Safety Education for Nurses D) Synergy model
D - The synergy model of care states that the needs of patients and families influence and drive competencies of nurses, which improves client care. The Institute for Healthcare Improvement is an organization aimed at creating a safer health care environment. Quality and Safety Education for Nurses is an initiative to implement quality and safety content in nursing education programs. Universal care is a model of delivery in which patients remain on one unit and the level of nursing assignment changes.