NURS 393 critical care practice test 2 (ch. 16, 26, 27, 43, & 67)
The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action should the nurse take next? a. Monitor ionized calcium level. b. Give oral calcium citrate tablets. c. Check parathyroid hormone level. d. Administer vitamin D supplements.
a. Monitor ionized calcium level.
The family of a patient newly diagnosed with hepatitis A asks the nurse what they can do to prevent becoming ill themselves. Which response by the nurse is most appropriate? "The hepatitis vaccine will provide immunity from this exposure and future exposures." "I am afraid there is nothing you can do since the patient was infectious before admission." "You will need to be tested first to make sure you don't have the virus before we can treat you." "An injection of immunoglobulin will need to be given to prevent or minimize the effects from this exposure."
"An injection of immunoglobulin will need to be given to prevent or minimize the effects from this exposure."
The nurse provides discharge instructions for a 64-year-old woman with ascites and peripheral edema related to cirrhosis. Which statement, if made by the patient, indicates teaching was effective? "It is safe to take acetaminophen up to four times a day for pain." "Lactulose (Cephulac) should be taken every day to prevent constipation." "Herbs and other spices should be used to season my foods instead of salt." "I will eat foods high in potassium while taking spironolactone (Aldactone)."
"Herbs and other spices should be used to season my foods instead of salt."
When teaching the patient with acute hepatitis C (HCV), the patient demonstrates understanding when the patient makes which statement? "I will use care when kissing my wife to prevent giving it to her." "I will need to take adofevir (Hepsera) to prevent chronic HCV." "Now that I have had HCV, I will have immunity and not get it again." "I will need to be checked for chronic HCV and other liver problems."
"I will need to be checked for chronic HCV and other liver problems."
The patient with cirrhosis is being taught self-care. Which statement indicates the patient needs more teaching? "If I notice a fast heart rate or irregular beats, this is normal for cirrhosis." "I need to take good care of my belly and ankle skin where it is swollen." "A scrotal support may be more comfortable when I have scrotal edema." "I can use pillows to support my head to help me breathe when I am in bed."
"If I notice a fast heart rate or irregular beats, this is normal for cirrhosis."
When caring for a patient with liver disease, the nurse recognizes the need to prevent bleeding resulting from altered clotting factors and rupture of varices. Which nursing interventions would be appropriate to achieve this outcome (select all that apply)? Use smallest gauge needle possible when giving injections or drawing blood. Teach patient to avoid straining at stool, vigorous blowing of nose, and coughing. Advise patient to use soft-bristle toothbrush and avoid ingestion of irritating food. Apply gentle pressure for the shortest possible time period after performing venipuncture. Instruct patient to avoid aspirin and NSAIDs to prevent hemorrhage when varices are present.
-Use smallest gauge needle possible when giving injections or drawing blood. -Teach patient to avoid straining at stool, vigorous blowing of nose, and coughing. -Advise patient to use soft-bristle toothbrush and avoid ingestion of irritating food. -Instruct patient to avoid aspirin and NSAIDs to prevent hemorrhage when varices are present.
The nurse is caring for a woman recently diagnosed with viral hepatitis A. Which individual should the nurse refer for an immunoglobin (IG) injection? A caregiver who lives in the same household with the patient A friend who delivers meals to the patient and family each week A relative with a history of hepatitis A who visits the patient daily A child living in the home who received the hepatitis A vaccine 3 months ago
A caregiver who lives in the same household with the patient
You're assessing a patient who is post-opt from a chest tube insertion. On assessment, you note there is 50 cc of serosanguinous fluid in the drainage chamber, fluctuation of water in the water seal chamber when the patient breathes in and out, and bubbling in the suction control chamber. Which of the following is the most appropriate nursing intervention?* A. Document your findings as normal. B. Assess for an air leak due to bubbling noted in the suction chamber. C. Notify the physician about the drainage. D. Milk the tubing to ensure patency of the tubes.
A. Document your findings as normal.
A patient is recovering from a pneumothorax and has a chest tube present. Which of the following is an appropriate finding when assessing the chest tube drainage system?* A. Intermittent bubbling may be noted in the water seal chamber. B. 200 cc of drainage per hour is expected during recovery of a pneumothorax. C. The chest tube is positioned at the patient's chest level to facilitate drainage. D. All of these options are appropriate findings
A. Intermittent bubbling may be noted in the water seal chamber.
A 54-year-old patient admitted with diabetes mellitus, malnutrition, osteomyelitis, and alcohol abuse has a serum amylase level of 280 U/L and a serum lipase level of 310 U/L. To what diagnosis does the nurse attribute these findings? Malnutrition Osteomyelitis Alcohol abuse Diabetes mellitus
Alcohol abuse
What type of chest tube system does this statement describe? This chest drainage system has no water column to control suction but uses a suction monitor bellow that balances the wall suction and you can adjust water suction pressure using the rotary suction dial on the side of the system. It allows for higher suction pressure levels, has no bubbling sounds, and water does not evaporate from it as with other systems.* A. Mediastinal chest tube system B. Dry suction chest tube system C. Wet suction chest tube system D. Dry-Wet suction chest tube system
B. Dry suction chest tube system
A patient is about to have their chest tube removed by the physician. As the nurse assisting with the removal, which of the following actions will you perform? Select-all-that-apply:* A. Educate the patient how to take a deep breath out and inhale rapidly while the tube in being removed. B. Gather supplies needed which will include a petroleum gauze dressing per physician preference. C. Place the patient in Semi-Fowler's position. D. Have the patient take a deep breath, exhale, and bear down during removal of the tube. E. Pre-medicate prior to removal as ordered by the physician. F. Place the patient is prone position after removal.
B. Gather supplies needed which will include a petroleum gauze dressing per physician preference. C. Place the patient in Semi-Fowler's position. D. Have the patient take a deep breath, exhale, and bear down during removal of the tube. E. Pre-medicate prior to removal as ordered by the physician.
While helping a patient with a chest tube reposition in the bed, the chest tube becomes dislodged. What is your immediate nursing intervention?* A. Stay with the patient and monitor their vital signs while another nurse notifies the physician. B. Place a sterile dressing over the site and tape it on three sides and notify the physician. C. Attempt to re-insert the tube. D. Keep the site open to air and notify the physician.
B. Place a sterile dressing over the site and tape it on three sides and notify the physician.
A patient with a chest tube has no fluctuation of water in the water seal chamber. What could be the cause of this?* A. This is an expected finding. B. The lung may have re-expanded or there is a kink in the system. C. The system is broken and needs to be replaced. D. There is an air leak in the tubing.
B. The lung may have re-expanded or there is a kink in the system.
A patient is receiving positive pressure mechanical ventilation and has a chest tube. When assessing the water seal chamber what do you expect to find?* A. The water in the chamber will increase during inspiration and decrease during expiration. B. There will be continuous bubbling noted in the chamber. C. The water in the chamber will decrease during inspiration and increase during expiration. D. The water in the chamber will not move.
C. The water in the chamber will decrease during inspiration and increase during expiration.
You are providing care to a patient with a chest tube. On assessment of the drainage system, you note continuous bubbling in the water seal chamber and oscillation. Which of the following is the CORRECT nursing intervention for this type of finding? A. Reposition the patient because the tubing is kinked. B. Continue to monitor the drainage system. C. Increase the suction to the drainage system until the bubbling stops. D. Check the drainage system for an air leak.
D. Check the drainage system for an air leak.
The patient in room 2569 calls on the call light to tell you something is wrong with his chest tube. When you arrive to the room you note that the drainage system has fallen on its side and is leaking drainage onto the floor from a crack in the system. What is your next PRIORITY?* A. Place the patient in supine position and clamp the tubing. B. Notify the physician immediately. C. Disconnect the drainage system and get a new one. D. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system.
D. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system.
The health care provider orders lactulose for a patient with hepatic encephalopathy. The nurse will monitor for effectiveness of this medication for this patient by assessing what? Relief of constipation Relief of abdominal pain Decreased liver enzymes Decreased ammonia levels
Decreased ammonia levels
The condition of a patient who has cirrhosis of the liver has deteriorated. Which diagnostic study would help determine if the patient has developed liver cancer? Serum α-fetoprotein level Ventilation/perfusion scan Hepatic structure ultrasound Abdominal girth measurement
Hepatic structure ultrasound
A patient who has hepatitis B surface antigen (HBsAg) in the serum is being discharged with pain medication after knee surgery. Which medication order should the nurse question because it is most likely to cause hepatic complications? Tramadol (Ultram) Hydromorphone (Dilaudid) Oxycodone with aspirin (Percodan) Hydrocodone with acetaminophen (Vicodin)
Hydrocodone with acetaminophen (Vicodin)
When planning care for a patient with cirrhosis, the nurse will give highest priority to which nursing diagnosis? Impaired skin integrity related to edema, ascites, and pruritus Imbalanced nutrition: less than body requirements related to anorexia Excess fluid volume related to portal hypertension and hyperaldosteronism Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume
Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume
patient with type 2 diabetes and cirrhosis asks the nurse if it would be okay to take silymarin (milk thistle) to help minimize liver damage. The nurse responds based on what knowledge? Milk thistle may affect liver enzymes and thus alter drug metabolism. Milk thistle is generally safe in recommended doses for up to 10 years. There is unclear scientific evidence for the use of milk thistle in treating cirrhosis. Milk thistle may elevate the serum glucose levels and is thus contraindicated in diabetes.
Milk thistle may affect liver enzymes and thus alter drug metabolism.
The patient with a history of lung cancer and hepatitis C has developed liver failure and is considering liver transplantation. After the comprehensive evaluation, the nurse knows that which factor discovered may be a contraindication for liver transplantation? Has completed a college education Has been able to stop smoking cigarettes Has well-controlled type 1 diabetes mellitus The chest x-ray showed another lung cancer lesion.
The chest x-ray showed another lung cancer lesion.
The patient with cirrhosis has an increased abdominal girth from ascites. The nurse should know that this fluid gathers in the abdomen for which reasons (select all that apply)? There is decreased colloid oncotic pressure from the liver's inability to synthesize albumin. Hyperaldosteronism related to damaged hepatocytes increases sodium and fluid retention. Portal hypertension pushes proteins from the blood vessels, causing leaking into the peritoneal cavity. Osmoreceptors in the hypothalamus stimulate thirst, which causes the stimulation to take in fluids orally. Overactivity of the enlarged spleen results in increased removal of blood cells from the circulation, which decreases the vascular pressure.
There is decreased colloid oncotic pressure from the liver's inability to synthesize albumin. Correct Hyperaldosteronism related to damaged hepatocytes increases sodium and fluid retention. Correct Portal hypertension pushes proteins from the blood vessels, causing leaking into the peritoneal cavity. Correct
Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines and medications delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Flush a saline lock with normal saline. b. Verify blood products prior to administration. c. Remove the patient's central venous catheter. d. Titrate the flow rate of vasoactive IV medications.
a. Flush a saline lock with normal saline.
A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question? a. Infuse 5% dextrose in water at 125 mL/hr. b. Administer 3% saline at 50 mL/hr for a total of 200 mL. c. Administer IV morphine sulfate 4 mg every 2 hours PRN. d. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea.
a. Infuse 5% dextrose in water at 125 mL/hr.
A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion? a. Lung sounds b. Urinary output c. Peripheral pulses d. Peripheral edema
a. Lung sounds
The nurse completes discharge instructions for a patient with a total laryngectomy. Which statement by the patient indicates that additional instruction is needed? a. "I must keep the stoma covered with an occlusive dressing." b. "I need to have smoke and carbon monoxide detectors installed." c. "I can participate in my prior fitness activities except swimming." d. "I should wear a Medic-Alert bracelet to identify me as a neck breather."
a. "I must keep the stoma covered with an occlusive dressing."
A patient has a magnesium level of 1.3 mg/dL. Which assessment would help the nurse identify a likely cause of this value? a. Daily alcohol intake b. Dietary protein intake c. Multivitamin/mineral use d. Over-the-counter (OTC) laxative use
a. Daily alcohol intake
A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication? a. Digoxin (Lanoxin) 0.25 mg/day b. Metoprolol (Lopressor) 12.5 mg/day c. Ibuprofen (Motrin) 400 mg every 6 hours d. Lantus insulin 24 U subcutaneously every evening
a. Digoxin (Lanoxin) 0.25 mg/day
A nurse is caring for a patient who is orally intubated and receiving mechanical ventilation. To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care? a. Elevate head of bed to 30 to 45 degrees. b. Give enteral feedings at no more than 10 mL/hr. c. Suction the endotracheal tube every 2 to 4 hours. d. Limit the use of positive end-expiratory pressure.
a. Elevate head of bed to 30 to 45 degrees.
Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires action by the nurse? a. No sedative has been ordered for the patient. b. The patient does not respond to verbal stimulation. c. There is no cough or gag reflex when the patient is suctioned. d. The patient's oxygen saturation remains between 90% to 93%.
a. No sedative has been ordered for the patient.
A patient with renal failure who arrives for outpatient hemodialysis is unresponsive to questions and has decreased deep tendon reflexes. Family members report that the patient has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. Which action should the nurse take first? a. Notify the patient's health care provider. b. Obtain an order to draw a potassium level. c. Review the last magnesium level on the patient's chart. d. Teach the patient about magnesium-containing antacids.
a. Notify the patient's health care provider.
A nurse is caring for a patient with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation using synchronized intermittent mandatory ventilation (SIMV). The settings include fraction of inspired oxygen (FIO2) of 80%, tidal volume of 450, rate of 16/minute, and positive end-expiratory pressure (PEEP) of 5 cm. Which assessment finding is most important for the nurse to report to the health care provider? a. O2 saturation of 99% b. Heart rate 106 beats/minute c. Crackles audible at lung bases d. Respiratory rate 22 breaths/minute
a. O2 saturation of 99%
A nurse is caring for an obese patient with right lower lobe pneumonia. Which position will be best to improve gas exchange? a. On the left side b. On the right side c. In the tripod position d. In the high-Fowler's position
a. On the left side
Following a thyroidectomy, a patient complains of "a tingling feeling around my mouth." Which assessment should the nurse complete? a. Presence of the Chvostek's sign b. Abnormal serum potassium level c. Decreased thyroid hormone level d. Bleeding on the patient's dressing
a. Presence of the Chvostek's sign
The nurse is caring for a patient who is intubated and receiving positive pressure ventilation to treat acute respiratory distress syndrome (ARDS). Which finding is most important to report to the health care provider? a. Red-brown drainage from nasogastric tube b. Blood urea nitrogen (BUN) level 32 mg/dL c. Scattered coarse crackles heard throughout lungs d. Arterial blood gases: pH of 7.31, PaCO2 of 50, and PaO2 of 68
a. Red-brown drainage from nasogastric tube
When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patient's food tray? a. Skim milk b. Grape juice c. Mixed green salad d. Fried chicken breast
a. Skim milk
A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider? a. The patient is experiencing laryngeal stridor. b. The patient complains of generalized fatigue. c. The patient's bowels have not moved for 4 days. d. The patient has numbness and tingling of the lips.
a. The patient is experiencing laryngeal stridor.
When admitting a patient with possible respiratory failure and a high PaCO2, which assessment information should be immediately reported to the health care provider? a. The patient is very somnolent. b. The patient complains of weakness. c. The patient's blood pressure is 164/98. d. The patient's oxygen saturation is 90%.
a. The patient is very somnolent.
The nurse is caring for a patient who arrived in the emergency department with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action? a. The patient's PaO2 is 45 mm Hg. b. The patient's PaCO2 is 33 mm Hg. c. The patient's respirations are shallow. d. The patient's respiratory rate is 32 breaths/min.
a. The patient's PaO2 is 45 mm Hg.
When prone positioning is used for a patient with acute respiratory distress syndrome (ARDS), which information obtained by the nurse indicates that the positioning is effective? a. The patient's PaO2 is 89 mm Hg, and the SaO2 is 91%. b. Endotracheal suctioning results in clear mucous return. c. Sputum and blood cultures show no growth after 48 hours. d. The skin on the patient's back is intact and without redness.
a. The patient's PaO2 is 89 mm Hg, and the SaO2 is 91%.
The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy tube. Which action by the nurse would determine if the cuff has been properly inflated? a. Use a hand-held manometer to measure cuff pressure. b. Review the health record for the prescribed cuff pressure. c. Suction the patient through a fenestrated inner cannula to clear secretions. d. Insert the decannulation plug before removing the nonfenestrated inner cannula.
a. Use a hand-held manometer to measure cuff pressure.
In planning care for a patient with metastatic liver cancer, the nurse should include interventions that a. focus primarily on symptomatic and comfort measures. b. reassure the patient that chemotherapy offers a good prognosis. c. promote the patient's confidence that surgical excision of the tumor will be successful. d. provide information necessary for the patient to make decisions regarding liver transplantation. (Lewis 1042)
a. focus primarily on symptomatic and comfort measures.
A patient with acute respiratory distress syndrome (ARDS) and acute kidney injury has the following drugs ordered. Which drug should the nurse discuss with the health care provider before giving? a. gentamicin 60 mg IV b. pantoprazole (Protonix) 40 mg IV c. sucralfate (Carafate) 1 g per nasogastric tube d. methylprednisolone (Solu-Medrol) 60 mg IV
a. gentamicin 60 mg IV
A patient with hepatitis A is in the acute phase. The nurse plans care for the patient based on the knowledge that a. pruritus is a common problem with jaundice in this phase. b. the patient is most likely to transmit the disease during this phase. c. gastrointestinal symptoms are not as severe in hepatitis A as they are in hepatitis B. d. extrahepatic manifestations of glomerulonephritis and polyarteritis are common in this phase. (Lewis 1042)
a. pruritus is a common problem with jaundice in this phase.
A patient with new-onset confusion and hyponatremia is being admitted. When making room assignments, the charge nurse should take which action? a. Assign the patient to a semi-private room. b. Assign the patient to a room near the nurse's station. c. Place the patient in a room nearest to the water fountain. d. Place the patient on telemetry to monitor for peaked T waves..
b. Assign the patient to a room near the nurse's station.
A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a peripherally inserted central catheter was inserted. Which response by the nurse is accurate? a. "The prescribed infusion can be given more rapidly when the patient has a central line." b. "The hypertonic solution will be more rapidly diluted when given through a central line." c. "There is a decreased risk for infection when 25% dextrose is infused through a central line." d. "The required blood glucose monitoring is based on samples obtained from a central line."
b. "The hypertonic solution will be more rapidly diluted when given through a central line."
The nurse reviews the electronic health record for a patient scheduled for a total hip replacement. Which assessment data shown in the accompanying figure increase the patient's risk for respiratory complications after surgery? History Lab Data Physical Assessment *Age 81 H&H 11.8/38% *LCTA * Med/Surg history: Albumin 2.7 *Mildly confused: Recent 15lb weight loss, disoriented to date, Knee arthroscopy 3 oriented to person and place months ago a. Older age and anemia b. Albumin level and weight loss c. Recent arthroscopic procedure d. Confusion and disorientation to time
b. Albumin level and weight loss
The oxygen saturation (SpO2) for a patient with left lower lobe pneumonia is 90%. The patient has wheezes, a weak cough effort, and complains of fatigue. Which action should the nurse take next? a. Position the patient on the left side. b. Assist the patient with staged coughing. c. Place a humidifier in the patient's room. d. Schedule a 4-hour rest period for the patient.
b. Assist the patient with staged coughing.
A patient comes to the clinic complaining of frequent, watery stools for the past 2 days. Which action should the nurse take first? a. Obtain the baseline weight. b. Check the patient's blood pressure. c. Draw blood for serum electrolyte levels. d. Ask about extremity numbness or tingling.
b. Check the patient's blood pressure.
An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation? a. Pallor b. Edema c. Confusion d. Restlessness
b. Edema
A patient with respiratory failure has a respiratory rate of 6 breaths/min and an oxygen saturation (SpO2) of 88%. The patient is increasingly lethargic. Which intervention will the nurse anticipate? a. Administration of 100% O2 by non-rebreather mask b. Endotracheal intubation and positive pressure ventilation c. Insertion of a mini-tracheostomy with frequent suctioning d. Initiation of continuous positive pressure ventilation (CPAP)
b. Endotracheal intubation and positive pressure ventilation
A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction. The patient complains of anxiety and incisional pain. The patient's respiratory rate is 32 breaths/min, and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first? a. Check to make sure the nasogastric tube is patent. b. Give the patient the PRN IV morphine sulfate 4 mg. c. Notify the health care provider about the ABG results. d. Teach the patient how to take slow, deep breaths when anxious.
b. Give the patient the PRN IV morphine sulfate 4 mg.
While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient's oxygen saturation (SpO2) from 94% to 88%. Which action should the nurse take? a. Suction the patient's oropharynx. b. Increase the prescribed O2 flow rate. c. Instruct the patient to cough and deep breathe. d. Help the patient to sit in a more upright position.
b. Increase the prescribed O2 flow rate.
Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Administer IV antibiotics through the implantable port. b. Monitor the IV sites for redness, swelling, or tenderness. c. Remove the patient's nontunneled subclavian central venous catheter. d. Adjust the flow rate of the 0.9% normal saline in the peripheral IV line.
b. Monitor the IV sites for redness, swelling, or tenderness.
A patient admitted with acute respiratory failure has ineffective airway clearance related to thick secretions. Which nursing intervention would specifically address this patient problem? a. Encourage use of the incentive spirometer. b. Offer the patient fluids at frequent intervals. c. Teach the patient the importance of ambulation. d. Titrate oxygen level to keep O2 saturation above 93%.
b. Offer the patient fluids at frequent intervals.
Which actions should the nurse start to reduce the risk for ventilator-associated pneumonia (VAP) (select all that apply)? a. Obtain arterial blood gases daily. b. Provide a "sedation holiday" daily. c. Give prescribed pantoprazole (Protonix). d. Elevate the head of the bed to at least 30°. e. Provide oral care with chlorhexidine (0.12%) solution daily.
b. Provide a "sedation holiday" daily. c. Give prescribed pantoprazole (Protonix). d. Elevate the head of the bed to at least 30°. e. Provide oral care with chlorhexidine (0.12%) solution daily.
A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding? a. Serum hematocrit of 42% b. Serum sodium level of 120 mg/dL c. Reported weight gain of 2.2 lb (1 kg) d. Urinary output of 280 mL during past 8 hours
b. Serum sodium level of 120 mg/dL
Which nursing action could the registered nurse (RN) working in a skilled care hospital unit delegate to an experienced licensed practical/vocational nurse (LPN/LVN) caring for a patient with a permanent tracheostomy? a. Assess the patient's risk for aspiration. b. Suction the tracheostomy when directed. c. Teach the patient to provide tracheostomy self-care. d. Determine the need for tracheostomy tube replacement.
b. Suction the tracheostomy when directed.
A nurse is caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP). Which assessment finding by the nurse indicates that the PEEP may need to be reduced? a. The patient's PaO2 is 50 mm Hg and the SaO2 is 88%. b. The patient has subcutaneous emphysema on the upper thorax. c. The patient has bronchial breath sounds in both the lung fields. d. The patient has a first-degree atrioventricular heart block with a rate of 58 beats/min.
b. The patient has subcutaneous emphysema on the upper thorax.
The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate? a. Avoid using friction when cleaning around the CVAD insertion site. b. Use the push-pause method to flush the CVAD after giving medications. c. Obtain an order from the health care provider to change CVAD dressing. d. Position the patient's face toward the CVAD during injection cap changes.
b. Use the push-pause method to flush the CVAD after giving medications.
The patient with advanced cirrhosis asks why his abdomen is so swollen. The nurse's response is based on the knowledge that a. a lack of clotting factors promotes the collection of blood in the abdominal cavity. b. portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space. c. decreased peristalsis in the GI tract contributes to gas formation and distention of the bowel. d. bile salts in the blood irritate the peritoneal membranes, causing edema and pocketing of fluid. (Lewis 1042)
b. portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space.
A patient has been told that she has elevated liver enzymes caused by nonalcoholic fatty liver disease (NAFLD). The nursing teaching plan should include a. having genetic testing done. b. recommending a heart-healthy diet. c. the necessity to reduce weight rapidly. d. avoiding alcohol until liver enzymes return to normal. (Lewis 1042)
b. recommending a heart-healthy diet.
A patient with acute hepatitis B is being discharged in 2 days. In the discharge teaching plan the nurse should include instructions to a. avoid alcohol for the first 3 weeks. b. use a condom during sexual intercourse. c. have family members get an injection of immunoglobulin. d. follow a low-protein, moderate-carbohydrate, moderate-fat diet. (Lewis 1042)
b. use a condom during sexual intercourse.
A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, "Will I be able to talk normally after surgery?" What is the most accurate response by the nurse? a. "You will breathe through a permanent opening in your neck, but you will not be able to communicate orally." b. "You won't be able to talk right after surgery, but you will be able to speak again after the tracheostomy tube is removed." c. "You will have a permanent opening into your neck, and you will need rehabilitation for some type of voice restoration." d. "You won't be able to speak as you used to, but there are artificial voice devices that will give you the ability to speak normally."
c. "You will have a permanent opening into your neck, and you will need rehabilitation for some type of voice restoration."
Which diagnostic test will provide the nurse with the most specific information to evaluate the effectiveness of interventions for a patient with ventilatory failure? a. Chest x-ray b. O2 saturation c. Arterial blood gas analysis d. Central venous pressure monitoring
c. Arterial blood gas analysis
A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action should the nurse include in the plan of care in collaboration with the speech therapist? a. Leave the tracheostomy inner cannula inserted at all times. b. Place the decannulation cap in the tube before cuff deflation. c. Assess the ability to swallow before using the fenestrated tube. d. Inflate the tracheostomy cuff during use of the fenestrated tube.
c. Assess the ability to swallow before using the fenestrated tube.
After a laryngectomy, a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first? a. Arrange for arterial blood gases to be drawn immediately. b. Cover stoma with sterile gauze and ventilate through stoma. c. Attempt to reinsert the tracheostomy tube with the obturator in place. d. Assess the patient's oxygen saturation and notify the health care provider.
c. Attempt to reinsert the tracheostomy tube with the obturator in place.
A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient complains of "just blowing up" and has peripheral edema and shortness of breath. Which assessment should the nurse complete first? a. Skin turgor b. Heart sounds c. Mental status d. Capillary refill
c. Mental status
A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient has peripheral edema and shortness of breath. Which assessment should the nurse complete first? a. Skin turgor b. Heart sounds c. Mental status d. Capillary refill
c. Mental status
An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately? a. K+ 3.4 mEq/L (3.4 mmol/L) c. Na+ 154 mEq/L (154 mmol/L) b. Ca+2 7.8 mg/dL (1.95 mmol/L) d. PO4-3 4.8 mg/dL (1.55 mmol/L)
c. Na+ 154 mEq/L (154 mmol/L)
The nurse assesses vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature of 101.2° F, blood pressure of 90/56 mm Hg, pulse of 92 beats/min, and respirations of 34 breaths/min. Which action should the nurse take next? a. Give the scheduled IV antibiotic. b. Give the PRN acetaminophen (Tylenol). c. Obtain oxygen saturation using pulse oximetry. d. Notify the health care provider of the patient's vital signs.
c. Obtain oxygen saturation using pulse oximetry.
The nurse is caring for an older patient who was hospitalized 2 days earlier with community-acquired pneumonia. Which assessment information is most important to communicate to the health care provider? a. Persistent cough of blood-tinged sputum. b. Scattered crackles in the posterior lung bases. c. Oxygen saturation 90% on 100% O2 by nonrebreather mask. d. Temperature 101.5° F (38.6° C) after 2 days of IV antibiotics.
c. Oxygen saturation 90% on 100% O2 by nonrebreather mask.
The nurse has just auscultated coarse crackles bilaterally on a patient with a tracheostomy tube in place. If the patient is unsuccessful in coughing up secretions, what action should the nurse take? a. Encourage increased incentive spirometer use. b. Encourage the patient to increase oral fluid intake. c. Put on sterile gloves and use a sterile catheter to suction. d. Preoxygenate the patient for 3 minutes before suctioning.
c. Put on sterile gloves and use a sterile catheter to suction.
A patient who had a total laryngectomy has a nursing diagnosis of hopelessness related to loss of control of personal care. Which information obtained by the nurse indicates that this identified problem is resolving? a. The patient allows the nurse to suction the tracheostomy. b. The patient's spouse provides the daily tracheostomy care. c. The patient asks how to clean the tracheostomy stoma and tube. d. The patient uses a communication board to request "No Visitors."
c. The patient asks how to clean the tracheostomy stoma and tube.
During change-of-shift report on a medical unit, the nurse learns that a patient with aspiration pneumonia who was admitted with respiratory distress has become increasingly agitated. Which action should the nurse take first? a. Give the prescribed PRN sedative drug. b. Offer reassurance and reorient the patient. c. Use pulse oximetry to check the oxygen saturation. d. Notify the health care provider about the patient's status.
c. Use pulse oximetry to check the oxygen saturation.
Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective? a. "I will try to drink at least 8 glasses of water every day." b. "I will use a salt substitute to decrease my sodium intake." c. "I will increase my intake of potassium-containing foods." d. "I will drink apple juice instead of orange juice for breakfast."
d. "I will drink apple juice instead of orange juice for breakfast."
After receiving change-of-shift report on a medical unit, which patient should the nurse assess first? a. A patient with cystic fibrosis who has thick, green-colored sputum b. A patient with pneumonia who has crackles bilaterally in the lung bases c. A patient with emphysema who has an oxygen saturation of 90% to 92% d. A patient with septicemia who has intercostal and suprasternal retractions
d. A patient with septicemia who has intercostal and suprasternal retractions
The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take? a. Give the prescribed PRN lorazepam (Ativan). b. Encourage the patient to take deep slow breaths. c. Start the prescribed PRN oxygen at 2 to 4 L/min. d. Administer the prescribed normal saline bolus and insulin.
d. Administer the prescribed normal saline bolus and insulin.
When assessing a patient with chronic obstructive pulmonary disease (COPD), the nurse finds a new onset of agitation and confusion. Which action should the nurse take first? a. Observe for facial symmetry. b. Notify the health care provider. c. Attempt to calm and reorient the patient. d. Assess oxygenation using pulse oximetry.
d. Assess oxygenation using pulse oximetry.
The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan? a. Maintain the patient on bed rest. b. Auscultate lung sounds every 4 hours. c. Monitor for Trousseau's and Chvostek's signs. d. Encourage fluid intake up to 4000 mL every day.
d. Encourage fluid intake up to 4000 mL every day.
Which nursing interventions included in the care of a mechanically ventilated patient with acute respiratory failure can the registered nurse (RN) delegate to an experienced licensed practical/vocational nurse (LPN/LVN) working in the intensive care unit? a. Assess breath sounds every hour. b. Monitor central venous pressures. c. Place patient in the prone position. d. Insert an indwelling urinary catheter.
d. Insert an indwelling urinary catheter.
A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a right pneumothorax. Which collaborative action will the nurse anticipate next? a. Increase the tidal volume and respiratory rate. b. Decrease the fraction of inspired oxygen (FIO2). c. Perform endotracheal suctioning more frequently. d. Lower the positive end-expiratory pressure (PEEP).
d. Lower the positive end-expiratory pressure (PEEP).
A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis
d. Respiratory alkalosis
A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. Which action is appropriate for the nurse to take? a. Assess for facial muscle spasms. b. Ask the patient about loose stools. c. Recommend the patient avoid drinking orange juice with meals. d. Suggest that the health care provider order a basic metabolic panel.
d. Suggest that the health care provider order a basic metabolic panel.
A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department complaining of shortness of breath and dyspnea on minimal exertion. Which assessment finding by the nurse is most important to report to the health care provider? a. The patient has bibasilar lung crackles. b. The patient is sitting in the tripod position. c. The patient's pulse oximetry indicates a 91% O2 saturation. d. The patient's respirations have dropped to 10 breaths/minute.
d. The patient's respirations have dropped to 10 breaths/minute.
A patient develops increasing dyspnea and hypoxemia 2 days after heart surgery. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by heart failure, the nurse will plan to assist with a. obtaining a ventilation-perfusion scan. b. drawing blood for arterial blood gases. c. positioning the patient for a chest x-ray. d. insertion of a pulmonary artery catheter.
d. insertion of a pulmonary artery catheter.
