Quiz bank Adult II, CCN Midterm

The nurse is caring for a patient who has a Glasgow Coma Scale (GCS) score of 3. Discussions have been held with the family about withdrawing life support. Which statement by the nurse best describes requirements that must be met to sustain Centers for Medicare and Medicaid Services (CMS) Conditions of Participation?

"I need to notify the local Organ Procurement Organization of my patient's impending death."

The nurse reviews orders recently entered by the cardiologist. The medication orders includedobutamine (Dobutrex) 400 mg in 250 ml 5% dextrose in water titrated to keep cardiac index > 2 l/min/m2. Which of the following statements is correct?

"The cardiac index is the measurement specific to the patient's size or body area"

Dobutamine (Dobutrex)

*class*: beta-adrenergic agonist, inotropic *Indication*: short term management of heart failure *Action*: Dobutamine has a positive inotropic effect (increases cardiac output) with very little effect on heart rate. Stimulates Beta1 receptors in the heart. *Nursing Considerations*: - Monitor hemodynamics: hypertension, ↑HR, PVCs - Skin reactions may occur with hypersensitivity - Beta blockers may negate therapeutic effects of dobutamine - Monitor cardiac output - Monitor peripheral pulses before, during, and after therapy - DO NOT confuse dobutamine with dopamine

. The nurse is preparing for insertion of a pulmonary artery catheter (PAC). During insertion of the catheter, what are the priority nursing actions? (Select all that apply.)

-Allay the patients anxiety by providing information about the procedure. -Ensure that a sterile field is maintained during the insertion procedure. -Inflate the balloon during the procedure when indicated by the physician. -Monitor the patients cardiac rhythm throughout the entire procedure.

Psychological needs of families

-Allowing the family member be near the patient -Ensure the family receives assurance and accurate information -Have support available and make them feel comfortable and safe

hypovolemic shock

-Cause: Circulating Blood volume inadequate to fill vascular compartment = inadequate transport of O2 and nutrients -Risk factors Loss of blood, plasma, body fluids, intravascular fluid (i.e. third spacing/bowel obstruction) Burns -S&S: --Tachycardia, hypotension, tachypnea --Oliguria --Cool, pale skin, flat neck veins/all veins --Decreased LOC Change in hematocrit Increase hct = dehydration Decrease hct = blood loss

Compensatory Shock Stage

-Cause: compensatory mechanisms kick in to maintain blood flow (Sympathetic nervous system) Vasoconstriction Increased gluconeogenesis, ADH, renin-angiotensin-aldosterone Increased epinephrine & norepinephrine (SNS response) -Signs and Symptoms: Anxious/Restless/"sense of impending doom" Pale, cool, clammy skin Increase Respirations and HR Lowering BP

cardiogenic shock

-Cause: failure for heart to move enough blood forward Decreased myocardial contractility/CO Most heart problems cause it -S&S Most commonly bp will be low (dependent on the stage of shock??) Hemodynamic values CO ↓, CI ↓ RAP ↑ PAWP ↑ PVR ↑ SVR ↑ -Treatment Intra-aortic balloon pump Decrease work-load for heart allowing O2 consumption Improve coronary artery blood flow -Med: Dobutamine

Initial (subclinical hypo-perfusion state) shock stage

-Cause: inadequate O2 to organs & cells -Signs & Symptoms No obvious clinical signs: BP normal Slight decrease in CO and CI Slight increase in SVR

Sepsis and Septic Shock

-Cause: organism in blood = initiation of a systemic inflammatory response = vasodilation Can lead to SIRS, MODS, ARDS and DIC E coli, Staph (gram neg or positive?) -Signs and Symptoms --Hypotension --Tachycardia --Decreased skin perfusion: chills, diaphoresis --Decreased/no urine output --Lots of Edema or positive fluid balance --Decreased capillary refill/mottling --Change in mental status -Diagnosis --Suspected infection: cultures/lactate level 2+ SIRs --Evidence of at least one organ dysfunction --Sepsis Bundle 1. Measure lactate level (increased sepsis risk = >4.0 lactate 2. Obtain cultures prior to administration of antibiotics 2 stages Warm (hyperdynamic) = high CO and low peripheral vascular resistance (PVR) S&S: Fever, high RR, profound diuresis, mottled skin below knees. Cold (hypodynamic) = low CO and high PVR. Later phase. Nearly irreversible

Refractory shock stage

-Cause: prolonged inadequate tissue perfusion unresponsive to therapy Pooling in capillary bed -Signs and Symptoms Combined respiratory and metabolic acidosis = impending death Multi organ dysfunction syndrome (MODS) Progressive dysfunction of 2+ organ systems Primary MODS = direct injury Secondary MODS = response to altered immune/inflammatory response First 12-24 hrs after first insult -> ARDS then coagulopathy then renal, hepatic, and intestinal failure. Cardiovascular & neurological failure = death.

Progressive shock stage

-Cause: uncorrected due to failure of compensatory mechanisms Aerobic to anaerobic metabolism = increased lactic acid levels Irreversible tissue damage: aggressive intervention/resuscitation for pt to survive -Signs and Symptoms Systemic inflammatory response syndrome (SIRS) (2 of following criteria) Abnormal Temp outside of 36-38 Celsius HR >90 bpm Respiration > 20 breaths/min or PaCO2 < 32 mm Hg Abnormal WBC outside of 4,00-12,000

The nurse is caring for a mechanically ventilated patient and responds to a high inspiratory pressure alarm. Recognizing possible causes for the alarm, the nurse assesses for which of the following? (Select all that apply.)

-Coughing or attempting to talk -Kinks in the ventilator tubing -Need for suctioning

Nitroprusside (Nipride)

-Dec Preload; -Dec Afterload - mixed vasodilator -Monitor: hypoxia, thiocyanate poisoning -Relaxes vascular smooth muscle to reduce afterload & preload by producing NO -Also dilates coronary arteries

Ethics Committee Functions

-Develop policies & procedures -Education -Consultation & conflict resolution -Review ethics committee's effectiveness Hospitals have ethic committees that oversee and make decisions on difficult problems or situations that arise about making morally justified decisions -Families going against a patient's DNR orders

MI diagnosis

-EKG (STEMI) or elevated Troponin (non-STEMI) -the rapid development of myocardial tissue necrosis caused by imbalance of oxygen supply and demand *NonStemi may look different, they don't have characteristic ST elevation and therefore it may not be obvious the person is infarction Abnormal Troponin I & T and best detected in hours 3-8; normal Troponin I is < 0.03 ng/L and Troponin < 0.1 ng/L Classified under acute coronary syndrome with the 3 stages of angina -Causes: atherosclerosis, coronary embolism, coronary artery spasm, blunt force trauma, or cocaine use Classic s/sy: chest pain, SOB, diaphoresis, nausea, hypotension, dysrhythmia, and anxiety Diagnostic tests: 12 lead EKG showing ST elevation segments (fire hats), elevated cardiac enzymes (troponin I & T, CK-MB, and myoglobin) Cardiac catheterization MI medications nitrates-IV for 24 hours to reduce venous and arterial dilation, reduce myocardial oxygen demand, and relieve coronary artery spasm Beta-blockers (-LOL drugs) reduce myocardial oxygen demand; give within 8 hours and CCBs (amlodipine) can be given if BB not tolerated ACE inhibitors increase survival rate if started within 24 hours of symptoms (-pril drugs); ARBS can be given if ACEs (losartan) are not tolerated -Pain medication with narcotics to reduce pain and anxiety; morphine and fentanyl IV -Goals of MI treatment (slide 32) Early dx and tx Restore blood flow (PTCA, CABG, or thrombolytics) Reduce myocardial O2 demand (BB or CCB) Control or prevent dysrhythmias with BB or pacemaker Reduce MI mortality (ASA, antiplatelets) Manage severe pain/anxiety Supplemental O2 PRevent DVTs CARDIAC rehab

Warning signs that can assist the critical care nurse in recognizing that an ethical dilemma may exist include which of the following? (Select all that apply.)

-Family members are confused about what is happening to the patient. -Family members are in conflict as to the best treatment options. They disagree with each other and cannot come to consensus. -The family asks that the patient not be told of treatment plans. -The patient's condition has changed dramatically for the worse and is not responding to conventional treatment -The physician is considering trying a medication that is not approved to treat the patient's condition.

The family of a critically ill patient has asked to discuss organ donation with the patient's nurse. When preparing to answer the family's questions, the nurse understands which concern(s) most often influence a family's decision to donate? (Select all that apply.)

-Fear that the potential donor may not be deceased -Concern over financial costs associated with donation -Donor disfigurement influences on funeral care -Fear of inferior medical care provided to donor

Define Critical care nursing

-Focuses on life-threatening problems actual or potential from severe illness, surgery or trauma -Happens in traditional ICU MICU, NICU, SICU, CICU (slide 9) -Nontraditional ER, post-anesthesia, telemetry, step-down, cath lab, rehab, long term care, home care (slide 10)

Placement of ETT

-Frequently check the numbers on the tube to make sure the tube has not shifted -Bilateral breath sounds heard over the stomach Visualization of ETT tube through the vocal cords -Ensure that a portable chest x-ray is done to confirm tube placement -Common in intubation is the tube going into the right bronchus because it is straighter causing breath sounds to be louder on the right. -CO2 detector- attaches to the end of the ETT tube to confirm tracheal vs. esophageal intubation

ETT management and suctioning

-Intubation of a tube into the trachea through either the nasal cavity or oral cavity -Oral care every 2 hours and assess for need of suctioning. Totally based off of pt assessment -Suctioning is used to ensure airway patency and used when there is increased coughing, respiratory distress, or decreased breath sounds -Suctioning procedure: (slides 105-106) -Hyperoxygenate before and after suctioning a trach as well with continuous mode on the vent -Explain to the patient what you are going to do -Do not instill NS!!! Associated with problems such as oxygen desaturation -Rather than NS, routinely use patient hydration and airway humidification -Insert catheter without suctioning and make 2-3 passes at most limiting to 10-15 seconds each; lean towards the lesser of the range of 10 seconds -Monitor for potential dysrhythmias -Remove with continuous suction and twisting motion of catheter -Continuously monitor response...HR, rhythm, SO2, color, RR

Meeting family needs in critical care

-Nurses influence pt and family satisfaction the most -Allow families to be involved in patient care (perform ROM exercises) -Allow flexible visitation of family including children and know hospital policies -Follow COVID guidelines -Advocate for hospital policies -Passcode to allow for release of information

heart failure (HF)

-S&S- can be right-sided (cor pulmonale) or left-side of heart affected S3 or S4 heart sounds Shortness of breath Fatigue, weakness Tachycardia, arrhythmias Cough, wheeze Pink-tinged mucus Peripheral edema Chest pain Crackles (left side) -Diagnosis- slide 59 shows the 4 stages of heart failure Stage 1 at risk of heart failure without symptoms Stage 2 structural heart disease: asymptomatic Stage 3 structural heart disease with prior or current symptoms mild ar moderate HF Stage 4 refractory heart disease requiring specialized interventions severe HF symptomatic at rest BNP primary diagnostic test of HF- brain natriuretic peptide is a cardiac hormone that is secreted by ventricular myocytes in response to wall stretch -Treatment-always provide supplemental oxygen and adequate ventilation First line drug choices:ACEI, ARBS, or BB *Diuretics: spironolactone, lasix *Consider inotropic meds:nesiritide, digoxin, milrinone, hydralazine, and amariodone Nitrates LVADS, intra ventricular pacing, IABP (balloon pump) Fluids & electrolytes DASH diet-foods less in Na and rich in K, Mg, and CA to help lower bp Fruits, vegetables, and whole grains Low fat or fat free dairy Fish, poultry, beans and nuts

Interdisciplinary Handoff Report

-Situation-background, assessment-recommendation-review: decreases errors -Do at the bedside -Collaboration to make sure everyone is on the same page

Care of lung recipient following transplant

-Suctioning of lungs to keep lungs viable in the case of lung transplant -No smoking and no COPD conditions to keep lungs viable for transplant -Post transplant management of the recipient includes starting immunosuppression medications during the surgery to decrease the risk of organ rejection -Monoclonal antibodies -Polyclonal antibodies -Calcineurin inhibitor -m Tor inhibitor -Antimetabolite -Corticosteroid -Priority education to the patient receiving a donor organ is to make sure they understand to take the -immunosuppressant medications as prescribed without exception everyday

Communication skills for the critical care nurse

-Tailored to the unique needs of the family -Therapeutic communication skills -Shift hand-off report SBAR-R: reduces error -Bundles of care-promotes pt safety & reduces errors (slide 26)

sedation vacation

-Wean patients off of medication and then do a Nuro assessment (only for a couple of hours) **Only way to do a real replacement** -Daily interruption or spontaneous awakening trial -Dependent on hospital policy it could be every shift or once a day -Evaluate patient's cognitive status -Reduce the sedation dose needed for what is needed for a calm. Cooperative patient -To access readiness for weaning Checking to orient pt and make sure they are not in a psychosis

Sv02

-mixed venous oxygen saturation 60-75% Provides an assessment of the balance between oxygen supply and demand and is measured in the pulmonary artery -Swans catheter to regulate patients closely with cardiac conditions -Higher values indicate increased O2 supply and decreased O2 demand

PEEP

-positive end expiratory pressure that holds the alveoli open; normal range is 3-5 cm typical on MV patients and referred to as physiological PEEP (slide 116) -PEEP is often added to decrease a high FiO2

Neurogenic shock

-rarest form -Nervous system affects vasomotor center in medulla = vasodilation w/ decreased vascular resistance, venous return, preload & CO = bradycardia form decreased sympathetic activity -Causes: Upper spinal cord trauma/disease, severe pain, hypoglycemia, spinal anesthesia Spinal shock - electrical silence of spinal cord = loss of motor, sensory & reflex -S&S: altered temp, skin color changes, hypertension, bradycardia, altered reflexes. -Treatment: Cooling/heating measures, hydration, steroids, proper body alignment (spinal immobilization)

The patient is admitted with an anterior wall myocardial infarction. With this diagnosis the nurse would expect to see ST segment elevation in leads V2,V3,V4 and what complications?

3rd degree heart block, heart failure, Left BBB

Electrocardiogram (ECG) paper contains a standardized grid where the horizontal axis measures time and the vertical axis measures voltage or amplitude. The nurse must understand that each horizontal box indicates:

40 milliseconds or 0.04 seconds duration.

The nurse is caring for a patient 5 days following clipping of an anterior communicating artery aneurysm for a subarachnoid hemorrhage. The nurse assesses the patient to be more lethargic than the previous hour with a blood pressure 95/50 mm Hg heart rate 10 beats/min. respiratory rate 20 breaths/min. oxygen sat. (SpO2) 95% on 3 L/min. oxygen via nasal cannula, and a temp. of 101.5 F. Which order should the nurse institute first?

500 mL albumin infusion intravenously

The nurse should call the Rapid Response Team for which patients? (select all that apply.)

53-year-old with pneumonia and severe respiratory distress 24-year-old experiencing a severe asthmatic attack with stridor 73-year-old patient with bradycardia of 40 breaths per minute

The nurse recognizes that which patient is likely to benefit most from patient- controlled analgesia?

59-year-old postop elective bariatric surgery

normal value of paO2 for ABG

80-100

The critical care nurse understands that cerebral perfusion pressure (CPP) is the amount of pressure needed to perfuse the brain. The nurse is caring for a patient with a head injury who has an intracranial pressure (ICP) of 18 mm Hg, a blood pressure of 144/90 mm Hg, and mean arterial pressure (MAP) of 108 mm Hg. What does the nurse calculate is the CPP?

90 mmHg

normal value of SaO2 for ABG

90-100

The transplant clinic coordinator is evaluating relatives of a patient with end-stage renal disease, whose blood type is A positive, for suitability as a living donor for kidney transplantation. Which family member best qualifies for evaluation?

A 35-year-old female with a history of food allergies; blood type O negative

Heparin induced thrombocytopenia HIT) is defined as:

A decrease of 50% or more from the highest platelet count after Heparin has been initiated, resulting in bleeding, hypercoagulability, and thrombosis.

The charge nurse is supervising care for a group of patients monitored with a variety of invasive hemodynamic devices. Which patient should the charge nurse evaluate first?

A patient in cardiogenic shock with cardiac output (CO) of 2.0 L/min

The critical care nurse is caring for several patients at risk for developing pyelonephritis? Which of the following risk factors will the nurse prioritize? (Select all that apply.)

A patient with diabetes mellitus. A patient with a neurogenic bladder. A patient with a history of known renal calculi. A patient who is 32 weeks gestation.

PAOP procedure

A pulmonary artery catheter (PAC) is used to measure the PAOP. To obtain the PAOP you inflate the distal balloon of the PAC. -Normal pressure is 8-12 mm Hg. AKA wedge pressure Nursing interventions give fluids Pt in supine with a 30 degree angle for HOB for insertion of PAC

Interpret EKG waveforms

A wide QRS complex is ventricular in nature Tall, narrow P waves = cor pulmonale P mitral is a notched P wave and indicates atrial enlargement

The nurse is caring for a patient who requires administration of neuromuscular blocking (NMB) agent to facilitate ventilation with non-traditional modes. The nurse understand that neuromuscular blocking agents require what additional intervention?

Complete analgesia

The nurse is caring for a 100-kg patient being monitored with a pulmonary artery catheter. The nurse assesses a blood pressure of 90/60 mm Hg, heart rate 110 beats/min, respirations 36/min, oxygen saturation of 89% on 3 L of oxygen via nasal cannula. Bilateral crackles are audible upon auscultation. Which hemodynamic value requires immediate action by the nurse?

A. Cardiac index (CI) of 1.2 L/min/m3

A nurse in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP?

Confusion Dilated Pupils Headache Decorticate posturing

The nurse is caring for a critically ill patient with terminal cancer. The monitor alarms and shows ventricular tachycardia. The patient does not have a "do not resuscitate" order written on the chart. What is the appropriate nursing action?

Initiate CPR and call a code.

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?

ACE inhibitors are started within 24 hours to prevent myocardial remodeling

Laboratory findings that are consistent with primary hyperthyroidism (Graves Disease) include:

Low TSH, elevated T3, and T4

The nurse is caring for a patient in the early stages of septic shock. The patient is slightly confused and flushed, with bounding peripheral pulses. Which hemodynamic values is the nurse most likely to assess?

Low systemic vascular resistance and high CO

The rapid respnse team key roles are: (SATA)

Assist the staff member with the transfer of the patient to a higher level of care i.e. critical care unit Assist the staff member assigned to the patient in an assessment and stabilize the patient Assist the staff member by bringing both needed equipment and personnel to the patient's bedside Educate and support the staff members

The nurse is caring for a patient admitted with cardiogenic shock. Hemodynamic readings obtained with a pulmonary artery catheter include a pulmonary artery occlusion pressure (PAOP) of 18 mm Hg and a cardiac index (CI) of 1.0 L/min/m2. What is the priority pharmacological intervention?

Dobutamine (Dobutrex)

A temporary wound cover composed of a graft of skin from another human, living or dead, is called a(N):

Allograft

Which of the following professional organizations best supports critical care nursing practice?

American Association of Critical Care nurses

The ICU nurse is planning care for a patient with postrenal AKI due to metastatic cancer. The patient's serum creatinine is 5.0. Which of the following interventions will be included in the plan of care? (SATA)

Assess the urine for blood Assess for signs and symptoms of pulmonary edema or heart failure provide a high protein diet monitor for intermitant anuria

Patients who receive infusions of multiple liters of crystalloid fluids are at high risk for:

Excessive third spacing of fluids and dilutional coagulopathies

The nurse is examining the patient's urinalysis and notices the presence of red blood cells and albumin, as well as nitrogenous products. The nurse knows that which of the following is true?

Albumin level greater than 30 mg is one indicator of kidney disease.

Which of the following symptoms would be most likely to occur first in a patient with compartment syndrome?

Extreme throbbing pain not proportional to the injury

ASA, ACE-I meds

ASA (drug caution code) - abbreviation on a medication that indicates it contains acetylsalicylic acid (aspirin). Intended to warn pt's w/ specific medical conditions 160-325 mg immediately intended to reduce mortality of MI; maintenance therapy is 75-150 mg risks: GI bleed

Which of the following assessment findings indicate that the patient with an acute spinal cord injury is experiencing spinal shock?

Absence of deep tendon reflexes below the level of injury Complete loss of sensory and motor activity below the level of injury

The ICU nurse is caring for a patient with a left renal calculus and an indwelling urinary catheter. Which of the following assessments is a priority for the nurse to report to the provider?

Absent urine output for one hour

The nurse is caring for a patient admitted to the emergency department is status epilepticus. Vital signs assessed by the nurse include blood pressure 160/100 mm Hg, heart rate 145 beats/min, oxygen saturation (SpO2) 96% on 100% supplemental oxygen by non-rebreather mask. After establishing an intravenous (IV) line, which physicaina order should the nurse implement first?

Administer lorazepam (Ativan)

Conflict of interest related to an ethical decision

An ethical dilemma or situation where conflict exists about making morally justified decisions Nurse focus: patient first, safety Persistent Vegetative state= a permanent, irreversible unconsciousness condition that demonstrates an absence of voluntary action or cognitive behavior or inability to communicate or interact with the environment -decorticate " into the core" ? Brain death= irreversible and complete cessation of brain function (table 3.2) - unable to take spontaneous breath

what is the best understanding of mixed venous oxygen saturation by the nurse?

An overall picture of oxygen delivery and oxygen consumption

A 45-year-old postsurgical patient on a ventilator in the critical care unit has been tolerating the ventilator well and has not required any sedation. The patient suddenly becomes tachycardia and hypertensive with a respiratory rate that has increased to 28 breath/min. The ventilator is set on synchronized intermittent mandatory ventilation (SIMV) at a rate of 10 breaths/min. The patient is suctioned via the endotracheal tube until the airway is clear. When the patient responds appropriately to the nurse's commands, what should be the nurse's next priority intervention be?

Assessing the patient's level of pain

a patient was wearing a seat belt when he was involved in a high speed head on collision, in the emergency room he develops dyspnea, dysphagia, hoarseness, and complains of severe chest pain. Upon assessment, he has weak bilateral femoral pulses. A stat chest x-ray shows a widening mediastinum. What is the most likely medical diagnosis?

Aortic dissection

The nurse is caring for a patient in spinal shock. Vital signs include blood pressure 100/70 mm Hg, heart rate 70 beats/min, respirations 24 breaths/min, oxygen saturation 95% on room air, and an oral temperature of 94.8° F. Which intervention is most important for the nurse to include in the patient's plan of care?

Application of slow rewarming measures

. The nurse is caring for a 70-kg patient in septic shock with a pulmonary artery catheter. Which hemodynamic value indicates an appropriate response to therapy aimed at enhancing oxygen delivery to the organs and tissues?

Arterial lactate level of 1.0 mEq/L

The nurse is caring for a patient with a diagnosis of acute myocardial infarction (AMI). Which medication should the nurse anticipate administering to the patient to reduce platelet aggregation?

Aspirin

An ICU nurse is planning care for a client who has Stage 4 chronic kidney disease. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

Assess for jugular vein distention Provide frequent mouth rinses Auscultate for a pleural friction rub. Monitor for dysrhythmias.

The ICU patient is on hourly intake and output (I&O) as well as daily weights. The nurse notes that total urine output is considerably less than intake over the last four hours, and daily weight is 1kg more than yesterday. The nurse should immediately perform what intervention?

Assess the patients lung sounds

The patient with a pacemaker shows pacemaker spikes that are not followed by a QRS. The nurse interprets this as:

Failure to capture

The only permanent type of skin grafting is:

Autograft skin applied as meshed grafts or sheet grafts

Humoral immunity is mediated by:

B lymphocytes

The nurse chooses which method and concentration of oxygen administration until intubation is established in a patient who has sustained a cardiopulmonary arrest?

Bag valve mask at FIO2 100%

The nurse is caring for a patient in the critical care unit who, after being declared brain dead, is being managed by the OPO transplant coordinator. Thirty minutes into the shift, assessment by the nurse includes a blood pressure 75/50 mm Hg, heart rate 85 beats/min, and respiratory rate 12 breaths/min via assist/control ventilation. The oxygen saturation (SpO2) is 99% and core temperature 98.6° F. Which physician order should the nurse implement first?

Begin phenylephrine (Neo-Synephrine) for systolic BP < 90 mm Hg

The nurse is caring for a patient in septic shock. The nurse assesses the patient to have a blood pressure of 105/60 mm Hg, heart rate 110 beats/min, respiratory rate 32 breaths/min, oxygen saturation (SpO2) 95% on 45% supplemental oxygen via Venturi mask, and a temperature of 102 F. The physician orders stat administration of an antibiotic. Which additional physician order should the nurse complete first?

Blood cultures

The surgical procedure that cuts the connecting tissue that surrounds organs to relieve tension and decompress tissue compartments thus restoring circulation to an area of tissue or muscle is called

Fasciotomy

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

Blood transfusion

As part of nursing management of a critically ill patient, orders are written to keep the head of the bed elevated at 30 degrees, awaken the patient from sedation each morning to assess readiness to wean from mechanical ventilation, and implement oral care protocols every 4 hours. These interventions are done as a group to reduce the risk of ventilator-associated pneumonia. This group of evidence-based interventions is often called a:

Bundle of Care

A nurse has been working as a staff nurse in the surgical intensive care unit for 2 years and is interested in certification. Which credential would be most applicable for her to seek?

CCRN

Weaning from mechanical ventilator

CPAP, pt has to be breathing on their own -Make sure the patient is ready, if they fail they become more dependent on the ventilator -Readiness to wean: improved hemodynamics, improved chest xray, adequate muscle strength, adequate ABGs without high FiO2 or PEEP, adequate LOC, reflexes intact, mental readiness to wean (slide 132) -Use protocol for weaning of vent -Patient rested and comfortable -Baseline parameters established: VS, ABG, ETCO2, pulse oximetry, and heart rhythm -Typical post OP weaning orders (not sure if we need to know these details--slide 134) -Criteria for discontinuing MV (slide 135) -Weaning modalities -CPAP-sets value, splints airway open for better gas exchange, and eases WOB -PS- pressure support

Which statements related to the management of unstable angina are true? (Select all that apply.)

Calcium channel blockers help to reduce symptoms. Early revascularization (e.g., angioplasty) may be helpful.

The nurse is caring for a patient following insertion of an intraaortic balloon pump (IABP) for cardiogenic shock unresponsive to pharmacotherapy. Which hemodynamic parameter best indicates an appropriate response to therapy?

Cardiac index (CI) of 2.5 L/min/m2

Care of donor patient

Care is focused on preserving organ function and viability, maintain hemodynamic stability, pulmonary function, maintain normothermia, maintain normal labs, and collaborate between OPO, physician, and RN Maintain bp Maintain acid-base balance Maintain serum glucose Treat coagulopathy and thrombocytopenia Treat anemia Mechanical ventilation maintained if appropriate Maintain fluids and electrolytes and tx polyuria Remember the best candidate is the younger person with the same blood type (it was a past quiz question) Other factors that organ donation depends on: the individual OPO, age of the recipient, the type of organ donation, how critical they are and the surgeon (per Motley) Cannot donate if one has uncontrolled HTN, diabetes, HIV, acute illnesses, hepatitis, or cancer

The patient has been admitted to a critical care unit with a diagnosis of acute myocardial infarction. Suddenly his monitor alarms and the screen shows a flat line. What action should the nurse take first?

Check patient for unresponsiveness

An adult patient suffered an anterior wall myocardial infarction (MI) 4 days ago. Today the patient is experiencing dyspnea and sitting straight up in bed. The nurse's assessment includes bibasilar crackles, an S3 heart sound with a heart rate of 125 beats/min. What condition are these signs and symptoms consistent with?

Congestive heart failure

The nurse is preparing to administer a maintenance dose of phenytoin to prevent seizures. The primary care provider orders phenytoin 500mg intravenous every 6 hours. What is the best action by the nurse?

Contact the primary care provider to discuss the maintenance dose in the order.

A nurse is caring for a patient who is diagnosed with idiopathic thrombocytopenic purpura(ITP). The nurse should notify the provider and report possible small-vessel clotting when which of the following is assessed?

Cyanotic nail beds

Ideally, an advance directive should be developed by the:

Patient, before illness or impairment occurs

The patient diagnosed with acute respiratory distress syndrome (ARDS) would exhibit which of the following symptoms?

Decreasing PaO2 levels despite increased FiO2 administration

The nurse admits a patient to the emergency department with new onset of slurred speech and right-side weakness. What is the priority nursing action to assure effective care?

Determine the time of symptom onset

Which statement reflects adherence to current recommendations concerning open visitation policies?

Determining in collaboration with the patient and family, who can visit and when

Family assessment can be challenging, and each nurse may obtain additional information regarding family structure and dynamics. What is the best way to share this information from shift to shift?

Develop a standardized reporting form for family information that is incorporated into the patient's medical record and updated as needed.

The nurse knows that in advanced cardiac life support, the secondary survey includes steps A-B-C-D where D refers to

Differential Diagnosis

Responsibilities of RN in organ donation

The role of the nurse is to notify the OPO (organ procurement organization) of a patient's impending death or a family's wish to donate a loved ones organs

infection by helicobacter pylori bacteria is a major cause of what type of ulcer?

Duodenal

The patient presents to the emergency department after having crushing chest pain for the past 5 hours. The ECG and laboratory work confirm suspicions of an acute myocardial infarction (AMI). Which findings would be the most conclusive that the patient is having an AMI? (Select all that apply.)

ECG changes with ST-elevation Elevated CK-MB isoenzymes Elevated serum troponin levels

Ten minutes following administration of an antibiotic, the nurse assesses a patient to have edematous lips, hoarseness, and expiratory stridor. Vital signs assessed by the nurse include blood pressure 70/40 mm Hg, heart rate 130 beats/min, and respirations 36 breaths/min. What is the priority intervention?

Epinephrine 3 to 5 mL of a 1:10,000 solution intravenously

A 30 year old make passenger in a motor vehicle accident(MVA) is life-flighted to a level 1 trauma center for emergency surgery. He has sustained a pelvic fracture and bilateral open femur fractures. He remains in stable condition until post op day 2 when he suddenly becomes short of breath, tachypneic, tachycardic, hypotensive, and develops a temperature of 101.8 F. PaO2 drops to 60 and the nurse notices a petechial rash across his chest and abdomen. The most likely cause of his symptoms is:

Fat embolism

A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care?

Feed the client thickened liquids Place food on the unaffected side of the clients mouth teach the client to swallow with the neck flexed

The nurse is caring for a patient admitted to the Icu with possible disseminated intravascular couagulation (DIC). What specific laboratory test for DIC should the nurse identify and report?

Fibrin degradation product (FDP)

A patient is having complications from abdominal surgery and remains NPO. Because enteral tube feedings are not possible decision is made to initate parenteral feedings. What is the major complication for this therapy?

Fluid and electrolyte imbalaces and nosicomial infection

A patient is admitted to the ICU following complications from abdominal surgery. The patient must remain NPO. Because enteral tube feedings are contraindicated the decision is made to initiate total parenteral nutrition(TPN). What are the major complications of this therapy?

Fluid and electrolyte imbalance and refeeding syndrome

A nurse is caring for a client who has global aphasia(both receptive and expressive). Which of the following should the nurse include in the client's plan of care? (SATA)

Give instructions one step at a time Assist the client to use cards with pictures Speak to the client at a slow rate

A nurse is reviewing client laboratory data. The nurse should recognize that which of the following findings is expected for a client who has Stage 4 chronic kidney disease?

Glomerular filtration rate (GFR) 20 mL/min

A patient is admitted to the cardiac care unit with an acute anterior myocardial infarction. The nurse assesses the patient to be diaphoretic and tachypneic, with bilateral crackles throughout both lung fields. Following insertion of a pulmonary artery catheter by the physician, which hemodynamic values is the nurse most likely to assess?

High pulmonary artery diastolic pressure and low cardiac output

In Hyperosmolar hyperglycemic syndrome (HHS) the laboratory results are similar to diabetic ketoacidosis (DKA) but with these threee major exceptions. They are:

Higher serum glucose, higher osmolality, and minimal ketosis

Symptoms of Addison's disease include:

Hyperpigmentation of the skin, muscle weakness, fatigue, weight loss, hypotension

A nurse is caring for a client who has increased ICP following TBI. The neurosurgeon has ordered IV Mannitol. For which of the following adverse effects should the nurse monitor?

Hyponatremia

Family assessment is essential to meet family needs. Which of the following must be assessed first to assist the nurse in providing family-centered care?

Identification of immediate family, extended family, and decision makers

The nurse is caring for a patient who has spinal cord injury. The patient reports a severe headache and is sweating profusely. Vital signs include blood pressure 220/110 mmHg and an apical heart rate of 54 beats per min. Which of the following actions should the nurse take first?

Immediately sit the patient in an upright position to decrease ICP

A nurse is caring for a client who has experienced a right hemispheric stroke. The nurse should expect the client to have difficulty with which of the following? (SATA)

Impulse control Moving the left side Depth perception Situational awareness

A nurse is assessing a client. Which of the following findings indicates that the client has experienced a left-hemisphere stroke?

Inability to recognize familiar objects

The nurse caring for a patient following a subarachnoid hemorrhage, begins a nicardipine infusion. Baseline blood pressure assessed by the nurse is 170/100mm Hg. Five minutes after beginning the infusion at 5 mg/hr. the nurse assesses the patient's blood pressure to be 160/90 mm Hg. What is the best action by the nurse?

Increase the dose by 2.5 mg/ hr.

Which assessment would cue the nurse to the potential of acute respiratory distress syndrome (ARDS) in a patient admitted with respiratory distress?

Increased peak inspiratory pressure on the ventilator

During the initial stages of shock, what are the physiological effects of decreased cardiac output?

Increased sympathetic stimulation

Stages of Shock

Initial Compensatory Progressive Refractory

The patient with extensive burns, burn shock occurs because of:

Intravascular volume loss created by sudden fluid and solute shifts with increased capillary permeability and edema

A nurse is preparing to administer fentanyl to a patient who sustained deep partial thickness burns over 60% of his body 12 hours ago. The nurse will plan to use which route of medication administration?

Intravenous

While caring for a patient with a small bowel obstruction, the nurse assesses a pulmonary artery occlusion pressure (PAOP) of 1 mm Hg and hourly urine output of 5 mL. The nurse anticipates which therapeutic intervention?

Intravenous fluids

The nurse is caring for a patient admitted with severe sepsis. Vital signs assessed by the nurse include blood pressure 80/50 mm Hg, heart rate 120 beats/min, respirations 28 breaths/min, oral temperature of 102 F, and a right atrial pressure (RAP) of 1 mm Hg. Assuming physician orders, which intervention should the nurse carry out first?

Isotonic fluid challenge

*A nurse is caring for a client who was recently admitted to the emergency department following a head-on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, and a laceration on his forehead that is bleeding. Which of the following is the priority nursing action at this time?

Keep the client's neck stabilized in a c-collar

Assessment findings for a patient with myxedema coma includes:

Lethargy, bradycardia, peripheral and facial edema, constipation, and slow speech

The nurse is caring for a mechanically ventilated patient with a pulmonary artery catheter who is receiving continuous enteral tube feedings. When obtaining continuous hemodynamic monitoring measurements, what is the best nursing action?

Level and zero reference the air-fluid interface of the transducer with the patient's head of bed elevated to 30 degrees and record hemodynamic values.

The provider has placed an eophogagastric balloon to tamponade bleeding varices. Of the three types of tubes used for tamponade, the:

Linton tube has five lumens and is the most effective in controlling varices bleeding

The nurse is caring for a patient in the early stages of septic shock. The patient is slightly confused and flushed, with bounding peripheral pulses. Which Hemodynamic values is the nurse most likely to assess?

Low systemic vascular resistance and high cardiac output

The nurse is caring for a patient admitted with new onset of slurred speech, facial droop, and left-sided weakness 8 hours ago. Diagnostic computed tomography scan rules out the presence of an intracranial bleed. Which actions are most important to include in the patients pan of care?

Make frequent neurological assessments Maintain MAP less than 130mm Hg

Poor patient outcomes after a traumatic injury are associated with:

Massive blood transfusions

The patient was not wearing a seat belt and sustained multiple rib fractures after hitting the steering wheel of his car in a motor vehicle accident (MVA). The EMTs report that he is spontaneously breathing and his vital signs have been stable during transport. During the ER admission assessment, his oxygen saturation suddenly drops to 80% b/p to 84/50 and the nurse can no longer hear breath sounds on the left side of his chest. Further examination reveals a tracheal shift to the right. What immediate intervention does the nurse anticipate?

Needle throacostomy and chest tube insertion

A patient presents to the emergency department in acute respiratory failure secondary to community-acquired pneumonia. The patient has a history of chronic obstructive pulmonary disease. The nurse anticipates which treatment to facilitate ventilation?

Noninvasive positive-pressure ventilation (NPPV)

A family member approaches the nurse caring for their gravely ill son and states, "We want to donate our son's organs." What is the best action by the nurse?

Notify the organ procurement organization (OPO).

Mechanical ventilator management

Oral hygiene Q2 to prevent infection Knowing the high and low-pressure alarms High: occlusion, cough, water in line, patient biting tube Low: Anything that allows air to escape from system tubing lose or disconnected

Extraordinary care versus ordinary care

Ordinary care is common, non-invasive, and tested treatments Extraordinary care is complex, invasive and experimental Ordinary critical care is MV, invasive lines, and hemodialisis Extracorporeal membrane oxygenation (ECMO) is considered extraordinary care

A nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. Which of the following is the priority assessment?

Oxygen saturation

ARDS (acute respiratory distress syndrome)

PCWP <18, CXR with bilateral pulmonary infiltrates, PaCO2:FiO2 ratio <200 Leads to: Increased lung weight Loss of aerated lung tissue w/ hypoxemia & bilateral radiographic opacities Increased mixed venous blood, increased physiological dead space Decreased lung compliance -> respiratory failure 3 phases (no improvement = MODS) (s.14) Acute phase (w/in 1-week injury) Uncontrolled exudative (puss-like/clear fluid) Inflammatory process w/ pulmonary edema Proliferative phase (4-21 days post-injury) Pulmonary edema resolves & fibrin matrix forms -> progressive hypoxemia Fibrotic phase (2-3wks post-delivery) Decreased functional residual capacity and right to left shunting Inflammation & edema become worse Airway narrow increase airway resistance & increased atelectasis Interventions Combined/dual ventilation Airway Pressure release ventilation (APRV) - inverse ratio, pressure-controlled intermittent mandatory ventilation. Synchronized w/ spontaneous breathing mainly used in ARDS

Specific assessment for neurovascular integrity of a patient with extremity injury includes:

Pain, pallor, pulses, paresthesia, paralysis

A patient who develops hypotension, pulsus paradoxus, muffled or distant heart sounds, and elevated venous pressure (beck's triad) has:

Pericardial tamponade

A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention?

Place the bedside table on the right side of the bed

When checking a patient's pulmonary artery occlusion pressure, the nurse inflates the balloon as ordered, not inflating the balloon for more than 8 to 10 seconds. Which of the following is the reason for the nurse's action?

Prolonged inflation of the balloon can obstruct blood flow, resulting in ischemia of the pulmonary artery

A nurse is assessing a client who has a seizure disorder. The client reports he thinks he is about to have a seizure. Which of the following actions should the nurse implement? (Select all that apply)

Protect the clients head with padding Provide privacy loosen the clients clothing move the furniture away from the client Ease the client to the floor if standing

During cardioversion, the nurse would synchronize the electrical charge to coincide with which wave of the ECG complex?

R

The nurse is monitoring a patient with a pulmonary artery catheter. In preparing to record a PAP reading, what is most important for recording an accurate reading on a patient who is spontaneously breathing?

Record the pressure at the end of expiration

The nurse is caring for a patient who has sustained blunt trauma to the left flank area and is evaluating the patient's urinalysis results. What related assessment findings should concern the nurse?

Red blood cells and albumin are found in the urine

The nurse is caring for a patient in cardiogenic shock who is being treated with an infusion of dobutamine. The physician's order calls for the nurse to titrate the infusion to achieve a cardiac index of >2.5 L/min/m2 . The nurse measures a cardiac output, and the calculated cardiac index for the patient is 4.6 L/min/m2 . What is the best action by the nurse?

Reduce the rate of the IV Dobutamine

A nurse is assessing a client who has prerenal AKI. Which of the following findings should the nurse expect? (Select all that apply.)

Reduced Urine output Elevated blood creatinine

The nurse is caring for a patient who has a C4 spinal cord injury. The nurse should recognize the patient is at greatest risk for which of the following complications?

Respiratory compromise

The nurse has been administering 0.9% normal saline intravenous fluids as part of early goal-directed therapy protocols in a patient with severe sepsis. To evaluate the effectiveness of fluid therapy, which physiological parameters would be most important for the nurse to assess?

Right atrial pressure and urine output

Based on a knowledge of the Trimodal Distribution of Death caused by traumatic injury, the third peak is caused by:

Sepsis, ARDS, increased ICP, MODS

Which of the following may result in low cardiac output and low caridac index? (SATA)

Shock HYpovelemia MI

A patient in acute respiratory failure is experiencing carbon dioxide narcosis secondary to increased CO2 retention. What assessment finding should the nurse expect?

Somnolence

An ICU nurse is planning care for a client who has prerenal acute kidney injury (AKI) following abdominal aortic aneurysm repair. Urinary output is 60 mL in the past 2 hr, and blood pressure is 92/58 mm Hg. The nurse should anticipate which of the following interventions?

Start an IV fluid challenge of NS.

Causes of metabolic acidosis

Starvation, dehydration, diarrhea, shock, renal failure, and diabetic ketoacidosis.

The nurse is caring for a patient diagnosed with atrial fibrillation. Complications that place the patient at greater risk for mortality/morbidity include which of the following? (SATA)

Stroke PE decrease cardiac output

All burns patients are at risk for acute respiratory distress syndrome (ARDS) due to:

Systemic inflammatory response Increased capillary permeability

A nurse is assessing a patient who has sustained deep partial-thickness burns over 40% of her body 24 hours ago. Which of the following findings common during this phase? (SATA)

Temp 36.1 C (97 F) hyperkalemia hyponatremia

Following insertion of a central venous catheter, the nurse obtains a stat chest x-ray film to verify proper catheter placement. The radiologist reports to the nurse: The tip of the catheter is located in the superior vena cava. What is the best interpretation of these results by the nurse?

The distal tip of the catheter is in the appropriate position.

Hematopoiesis is defined as:

The formation and maturation of blood cells.

A patient is admitted to the critical care unit following coronary artery bypass surgery. Two hours postoperatively the nurse assesses the following information pulse is 120 beats/min. blood pressure is 70/50 mm Hg pulmonary artery diastolic pressure is 2 mm Hg cardiac output is 4L/min urine output is 250 mL/hr, chest drainage is 200 mL/hr. What is the best interpretation by the nurse?

The patient is at risk for developing hypovelemic shock

The nurse is caring for an 18-year-old athlete with a possible cervical spine (C5) injury following a diving accident. The nurse assesses a blood pressure of 70/50 mm Hg, heart rate 45 beats/min, and respirations 26 breaths/min. The patients skin is warm and flushed. What is the best interpretation of these findings by the nurse?

The patient is developing neurogenic shock.

how does continuous renal replacement therapy (CRRT) differ from conventional intermittent hemodialysis?

The process removes solutes and water slowly and over a longer period of time

A major complication of an electrical burn is acute renal injury caused by:

The release of myoglobin from damaged tissue that causes acute kidney damage

Nociceptors differ from other nerve receptors in the body in what way?

They adapt very little to the pain response

The critical care nurse is assessing a patient who is day 2 postop and showing signs of early sepsis. Over the past few hours the patient has become increasingly anxious and agitated. The patient has become tachypneic, tachycardic, diaphorectic, feverish, and starts to display hand tremors. On auscultation the nurse hears new bilateral rales and an S3. What condition does the nurse suspect this patient as having developed?

Thyrotoxic crisis(Thryroid Storm)

The critical care nurse understands that lactulose is the first-line treatment for hepatic encephalopathy and works by what process?

Trapping ammonia in the bowel for excretion

A patient has coronary artery bypass graft surgery and is transported to the surgical intensive care unit at noon. He is placed on mechanical ventilation. Interpret his initial arterial blood gas levels: pH 7.31 PaCO2 48 mm Hg Bicarbonate 22 mEq/L PaO2 115 mm HgO2 saturation 99%

Uncompensated respiratory acidosis; hyperoxygenated

Vtach

Unstable- cardioversion stable- meds or cardioversion Priority action: is the patient stable with a pulse or unstable symptomatic with a pulse or without? Number one concern is pt is going to code: cardiovert or meds

A patient is in the maintenance phase of renal failure. Which of the following coplications does the nurse look for?

Uremia, hyperkalemia, infection

Pacemakers of the heart

Wandering pacemakers- 3 types of different looking P's and HR < 100 ex: lung or heart disease MAT-multifocal atrial tachycardia; same as WAP but HR >100 ex COPD PAT paroxysmal atrial tachycardia; occurs suddenly and comes and goes. HR is 150-250 bpm Atrial pacemaker (single chamber) an abnormal P wave followed by a normal QRS Ventricular pacemaker (single chamber) wide QRS (ventricular capture) AV sequential pacemaker (dual chamber) an abnormal P wave followed by a second spike producing a wide QRS (ventricular chamber) Causes of pacemaker malfunction box 80.3 (slide 87) Failure to capture- lead disconnection, break, or displacement Exit block Battery depletion Failure to pace- pacemaker fails to fire an electrical stimulus when it should fire Types of temporary pacemakers: transcutaneous and transvenous Pacing will be external such as pads or the wires if temporary Permanent pacemakers

respiratory failure

a condition in which the level of oxygen in the blood becomes dangerously low or the level of carbon dioxide becomes dangerously high -Types: (both develop over min-hrs w/out compensatory mechanisms to activate) (s. 4) 1. Oxygenation failure = hypoxemia w/out a rise in CO2 levels 2. Ventilation Failure = hypercapnia and hypoxemia Cause: Possible obstruction = slow breathing & no effort Open airway w/out support -S&S Late, unconsciousness & apnea = Respiratory failure Airway blocked = slow breathing = abnormal sounds = bradycardia = no response = cyanosis Early S&S anxiety & restlessness = Respiratory distress Open airway w/out support = tachypnea = effort = clear sounds = tachycardia = agitated = pale -Interventions Maintain patient airway Increase O2 delivery Decrease O2 demand

Which of the following patients is at greatest risk for developing rhabdomyolysis secondary to a trauma injury?

a patient who sustained a crush injury to his bilateral lover legs

pulmonary edema

accumulation of fluid in the lungs fluid in alveoli and the pulmonary system becomes full and engorged and reduces the amount of lung tissue available for gas exchange -Definition: damage to the alveolar-capillary membrane causing increased pulmonary vascular permeability -Symptoms: pink, frothy sputum aka blood tinged (cardinal sign) Other symptoms: extreme dyspnea Cyanosis Severe anxiety Diaphoresis pallor

normal value HCO2 for ABG

acid < 22-26 >alkaline

normal value of pH for ABG

acid<7.35-7.45>alkaline

normal value PaCO2 for ABG

alkaline<35-45>acid

A patient is admitted to the ICU with an upper GI bleed following an episode of forceful retching associated with excessive alcohol intake. The nurse suspects a Mallory-Weiss tear. Which of the following correctly describes a Mallory-Weiss tear?

an acute longitudinal tear in the gastroesophageal mucosa that results in arterial bleeding

The patient has been on the progressive care unit for the past 7 days with the diagnosis of liver failure. The nurse notes that the patient has developed a flapping tremor of the hands. The nurse understands that this is:

an early sign of hepatic encephalopathy caused by increased serum ammonia levels

Atrial Fibrillation (A-Fib)

an irregular and often very fast heart rate originating from abnormal conduction in the atria most common dysrhythmia from multiple foci in the atria aka atrial quivering (slide 47- 48 chapter 8 dysrhythmias) Irregularly irregular Clots likely traveling to other areas (PEs, strokes, occlusion of blood to a limb) Decreased cardiac output from loss of atrial kick Increased rate causes decreased filling time which reduces CO; HR will be very high Tx: synchronized cardioversion

Causes of respiratory acidosis

aspiration, atelectasis, abdominal distention, drug overdose, CNS disease, pleural/lung disease, trauma Tx: spirometry, deep breathing, pain control, ventilation

The nurse is working on the night shift when she notices sinus bradycardia on the patients cardiac monitor. The nurse should:

assess for hemodynamic instability.

The nurse is reading the cardiac monitor and notes that the patients heart rhythm is extremely irregular and there are no discernible P waves. The ventricular rate is 90 beats per minute, and the patient is hemodynamically stable. The nurse realizes that the patients rhythm is:

atrial fibrillation.

The nurse notices ventricular tachycardia on the heart monitor. When the patient is assessed, the patient is found to be unresponsive with no pulse. The nurse should:

begin cardiopulmonary resuscitation and advanced life support.

Carbon dioxide narcosis

central nervous system insensitivity to carbon dioxide as a respiratory stimulant resulting from chronically elevated levels of carbon dioxide in blood

What is the focus of the synergy model of practice?

considering the needs of patients and their families, which drives nursing competency

A nurse is interested in pursuing critical care nursing practice as a career and understands that:

critical care nurses coordinate care for critically ill patients in a variety of settings

The patients heart rate is 165 beats per minute. His cardiac monitor shows a rapid rate with narrow QRS complexes. The P waves cannot be seen, but the rhythm is regular. The patients blood pressure has dropped from 124/62 to 78/30. His skin is cold and diaphoretic and he is complaining of nausea. The nurse prepares the patient for:

emergent cardioversion.

a critical care nurse is assessing a new patient on admission with acute pancreatitis. Which of the following findings should the nurse expect to find?

epigastric pain radiating to the back Cullen's sign abdominal guarding and distension grey turner's sign

The patient has a permanent pacemaker in place with a demand rate set at 60 beats/min. The cardiac monitor is showing a heart rate of 44 beats/min with no pacemaker spikes. The nurse realizes this as:

failure to pace.

The nurse is examining the patients cardiac rhythm strip in lead II and notices that all of the P waves are upright and look the same except one that has a different shape and is inverted. The nurse realizes that the P wave with the abnormal shape is probably:

from some area in the atria other than the SA node.

The nurse is caring for an elderly patient who is in cardiogenic shock. The patient has failed to respond to medical treatment. The intensivist in charge of the patient conducts a conference to explain that they have exhausted treatment options and suggest that the patient be made a "do not resuscitate" status. This scenario illustrates the concept of:

futility

Causes of respiratory alkalosis

hyperventilation, sepsis, asthma, PE, DKA, infection, stroke, toxins, lung dz Tx: pain control, CO2 rebreathing

A patient has sustained deep partial- thickness burns over 60 % of her body. Shortly after admission to the burn unit her blood pressure rapidly drops to 70 mm Hg systolic. The nurse understands that this hypotensive state is due primarily to:

hypovolemic shock

A 65-year-old patient is admitted to the progressive care unit with a diagnosis of community-acquired pneumonia. The patient has a history of chronic obstructive pulmonary disease and diabetes. A set of arterial blood gases obtained on admission without supplemental oxygen shows pH 7.35; PaCO2 55 mm Hg; bicarbonate 30 mEq/L; PaO2 65 mm Hg. These blood gases reflect what condition:

hypoxemia and compensated respiratory acidosis.

An ICU patient is receiving enteral tube feedings and is at risk for developing drug-nutrient interactions affecting the bioavailability of certain medications. The nurse recognizes which drug as having the potential for a drug-nutrient interaction?

phenytoin

Stable angina

predictable and consistent pain that occurs on exertion and is relieved by rest and/or nitroglycerin

The nurse is caring for a patient admitted with a traumatic brain injury following a motor vehicle crash. The patient's Glasgow Coma Score is 3 and intermittently withdraws when painful stimuli are introduced. The patient is ventilator dependent and occasionally takes a spontaneous breath. The physician explains to the family that the patient has severe neurological impairment and he does not expect the patient to recover consciousness. The nurse recognizes that this patient is:

in a persistent vegetative state.

The nurse is planning care for an adult patient who sustained severe burn injuries two days ago. Which of the following interventions will the nurse include in the plan of care?

increase dietary proteins Screen and limit visitors prohibit fresh flowers in the room

The nurse is admitting a patient who has sustained burns over 35% of his total body surface area. During the assessment, the nurse notices that the patient's voice is hoarse and he has developed a brassy cough. These are indications of what condition?

inhalation injury

A patient's status worsens and needs mechanical ventilation. The pulmonologist wants the patient to receive 10 breaths/min from the ventilator but wants to encourage the patient to breathe spontaneously in between the mechanical breaths at his own tidal volume. This mode of ventilation is called:

intermittent mandatory ventilation

The nurse is caring for a patient with an endotracheal tube. The nurse understands that endotracheal suctioning is needed to facilitate removal of secretions and that the procedure:

is done as indicated by patient assessment.

The critical care nurse is caring for a patient with the diagnosis of septic shock. The patient is on a ventilator and is receiving a proton pump inhibitor(PPI) to reduce the risk for a stress ulcer. In this scenario, a stress ulcer is likely secondary to what condition?

ischemia associated with hypotension

A nurse is caring for a client who just experienced a generalized seizure. Which of the following actions should the nurse perform first?

keep the client in the side-lying position

An 18-year-old female sustains multiple injuries from a motor vehicle accident (MVA) and has a blood pressure of 80/60 at the scene. This patient should be transported and treated at which level of trauma center?

level I or II

The nurse is caring for a patient whose ventilator settings include 15 cm H2O of positive end-expiratory pressure (PEEP). The nurse understands that although beneficial, PEEP may result in:

low cardiac output secondary to increased intrathoracic pressure

Accuracy in reading PAC values

measure and mark phlebostatic axis, zero the numbers on the monitor to atmospheric pressure, turn stopcock to off and put sterile cap on stopcock Transducer location aligned to patient Patient should be in supine position with HOB no more than 20-30 degrees For spontaneous breathing record PAOP and PAP at end-diastole and end expiration For mechanical ventilation record PAP and PAOP during inhalation

The nurse knows that the most important factor required to meet optimal nutritional outcomes is:

metabloic needs

The nurse is caring for a patient who is not responding to medical treatment. The intensivist holds a conference with the family, and a decision is made to withdraw life support. The nurse's religious beliefs are not in agreement with withdrawal. However, she assists with the process to avoid confronting the charge nurse. Afterward she feels guilty and believes she "killed the patient." This scenario is likely to cause:

moral distress.

A nurse is caring for a patient who experienced a cervical spine injury 24 hr ago. Which of the following prescriptions should the nurse clarify with the provider?

muscle relaxants

Which code drugs can be given safely through an endotracheal tube? (Select all that apply)

naloxone atropine vasopressin epinephrine lidocaine

The nurse is caring for a patient with acute respiratory distress syndrome who is hypoxemic despite mechanical ventilation. The physician orders a nontraditional ventilator mode as part of treatment. Despite sedation and analgesia, the patient remains restless and appears to be in discomfort. The nurse informs the physician of this assessment and anticipates an order for:

neuromuscular blockade.

silent angina

no symptoms, objective changes ECG

The nurse understands that in a third-degree AV block:

none of the P waves are conducted to the ventricles.

unstable angina

not relieved by nitro or rest

pulmonary embolism (PE)

occlusion in the pulmonary circulation, most often caused by a blood clot -S&S Sudden SOB & Chest/back pain Low O2 saturation, Tachycardia, arrhythmias, fever Cough, wheezing, hemoptysis (spitting up blood from lungs) lightheaded/dizzy, anxiety Cyanosis (blue colored skin), diaphoresis

The ER nurse is completing an assessment of a patient admitted with GERD. Which of the following is an expected finding?

painful swallowing

S/S of decreased CO

pale, extremities become cold, shunting blood to core, weak peripheral pulses, oliguria, hypotension, decreased mental status

a patient with a history of coronary artery disease is admitted with the diagnosis of unstable angina. The nurse knows that the physiological mechanism present is most likely which of the following?

partial occlusion of a coronary artery with a thrombus

The patient is day 3 post MI and awakens from a deep sleep complaining of chest pain that is relieved when he sits up and leans forward. When the nurse auscultates his heart and lung sounds she hears a pericardial friction rub. A 12 lead EKG shows diverse concave ST-segment elevation and flattened T waves. Suddenly the patient develops signs and symptoms of cardiogenic shock. What emergency procedure does the nurse anticipate?

pericardiocentesis

The nurse is planning care for a client who is in the acute phase of a spinal cord injury (SCI) repair involving a T12 fracture. The client has no muscle control of the lower limbs, bowel, or bladder. which of the following should be the nurses highest priority?

prevention of further damage to the spinal cord

Various pharmacological therapies have been researched in the treatment of acute pancreatitis and have shown that:

prophylactic systemic antibiotics help prevent septic complications

Both the electroencephalogram (EEG) monitor and the Bispectral Index Score (BIS) or Patient State Index (PSI) analyzer monitors are used to assess patient sedation levels in critically ill patients. The BIS and PSI monitors are simpler to use because they:

provide raw EEG data and a numeric value

The critical care nurse is caring for a mechanically ventilated patient with a sustained ICP of 18mm Hg. The nurse needs to perform an hourly neurological assessment, suction the endotracheal tube, perform oral hygiene care, and reposition the patient to the left side. What is the priority consideration when prividing care to this patient?

provide rest periods between nursing interventions

A critical care nurse is completing an assessment on a patient who has suspected acute stomach perforation due to a peptic ulcer. Which of the following findings should the nurse expect to find? (SAA)

rebound tenderness rigid abdomen hypotension tachycardia

ACE-I: -pril meds;

reduce preload, after load and decrease bp if started 24 hours from symptom onset. An alternative to ACEIs are ARBS

The most critical phase of burn assessment and treatment is the

resuscitative phase

The constant noise of a ventilator monitor alarms and infusion pumps predisposes the pt to what form of stress

sensory overload

When assessing the patient for hypoxemia, the nurse recognizes that an early sign of the effect of hypoxemia on the cardiovascular system is:

tachycardia.

CO

the amount of blood the heart pumps a minute; 4-8 L/min is normal

A patient's endotracheal tube is not secured tightly. The respiratory care practitioner assists the nurse in taping the tube. After the tube is retaped, the nurse auscultates the patient's lungs and notes that the breath sounds over the left lung fields are absent. The nurse suspects that:

the endotracheal tube is in the right mainstem bronchus.

The patient is having premature ventricular contractions (PVCs). The nurses greatest concern should be:

the proximity of the R wave of the PVC to the T wave of a normal beat.

The patient is admitted with a fever and rapid heart rate. The patients temperature is 103 F (39.4 C).The nurse places the patient on a cardiac monitor and finds the patients atrial and ventricular rates are above 105 beats per minute. P waves are clearly seen and appear normal in configuration. QRS complexes are normal in appearance and 0.08 seconds wide. The rhythm is regular, and blood pressure is normal. The nurse should focus on providing:

treatment to lower temperature.

Atropine Sulfate

use as first line defense in sinus bradycardia 0.5mg every 3-5 minutes as needed MAX is 3mg ( think alive gets 0.5) do not use if hypothermia

The ICU nurse is admitting a patient who has acute bleeding esophageal varices. The nurse expects an order for which medication?

vasopressin

Causes of metabolic alkalosis

volume loss, K loss, excessive diuresis, GI loss Tx: volume replace (NaCl solution and K replacement)

The nurse is assisting in weaning a patient from long-term mechanical ventilation. Which action should the nurse be prepared to take?

wean the patient by standard protocol-driven methods

Assessment of Families

• Interviews and other methods as used in individual therapy are common • Ask who the family includes -stress can be passed from family to patient and have a negative impact on outcomes -making sure family expectations are realistic (adaptive vs. maladaptive) -assessment of resources and social service for getting resources Structural- most important; identifies family members and their roles (decision maker, peacekeeper) Ethnicity, religion, and spirituality Developmental- stages, tasks, and attachment. What stage of life are they in? Functional- how they interact with each other within the family