Chronic Exam
The nurse is providing care to a patient on fibrinolytic therapy. Which statement from the patient warrants further assessment and intervention by the critical care nurse? A. "I have an incredible headache!" B. "There is blood on my toothbrush!" C. "My arm is bleeding where my IV is!" D. "Look at the bruises on my arms!"
A. "I have an incredible headache!"
A patient at high risk for pulmonary embolism is receiving enoxaparin. The nurse explains to the patient: A. "This injection is being given to prevent blood clots from forming." B. "This medication will dissolve any blood clots you might get." C. "You should not be receiving this medication. I will contact the provider to get it stopped." D. "I'm going to contact the pharmacist to see if you can take this medication by mouth."
A. "This injection is being given to prevent blood clots from forming."
An unconscious client with an opioid overdose is triaged in the ED. ABG values reflect respiratory acidosis. Which of the following interventions address the cause of this client's respiratory acidosis? A. Administer naloxone B. Initiate BiPAP C. Administer salmeterol D. Give oxygen at 4 LPM
A. Administer naloxone
The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine injury who is complaining of a severe headache. The nurse assesses a blood pressure of 180/90 mm Hg, heart rate 60 beats/min, respirations 24 breaths/min, and 50 mL of urine via indwelling urinary catheter for the past 4 hours. What is the best action by the nurse? A. Assess for a kinked urinary catheter and assess for bowel impaction B. Encourage the patient to take slow, deep breaths. C. Notify the provider of the patient's blood pressure D. Administer acetaminophen as ordered for the headache
A. Assess for a kinked urinary catheter and assess for bowel impaction
Which nursing interventions would be appropriate after angioplasty? A. Assess pedal pulses on the involved limb every 15 minutes for 1 to 2 hours B. Elevate the head of the bed by 45 degrees for 6 hours C. Maintain NPO status for 12 hours D. Instruct the patient to bend his or her knee every 15 minutes while the sheath is in place
A. Assess pedal pulses on the involved limb every 15 minutes for 1 to 2 hours
The nurse has just received a patient from the emergency department with an admitting diagnosis of bacterial meningitis. To prevent the spread of nosocomial infections to other patients, what is the best action by the nurse? A. Implement droplet precautions upon admission B. Scrub the hub of all central line ports before use C. Wash hands thoroughly before leaving the room D. Dispose of all bloody dressings in biohazard bags
A. Implement droplet precautions upon admission
You are caring for a patient who is being turned prone as part of treatment for acute respiratory distress syndrome. You understand that the priority nursing concern for this patient is which of the following? A. Management and protection of the airway B. Psychological support to patient and family C. Prevention of gastric aspiration D. Prevention of skin breakdown and nerve damage
A. Management and protection of the airway
Identify the priority interventions for managing symptoms of an acute myocardial infarction (AMI) in the ED (select all that apply): A. Oxygen Therapy B. Administration of nitroglycerin (NTG) C. Dopamine infusion D. Transfusion of packed red blood cells E. Administration of morphine
A. Oxygen Therapy B. Administration of nitroglycerin (NTG) E. Administration of morphine
The nurse is caring for a mechanically ventilated patient with a sustained ICP of 18 mm Hg. The nurse needs to perform an hourly neurological assessment, suction the endotracheal tube, perform oral hygiene care, and reposition the patient to the left side. What is the best action by the nurse? A. Provide rest periods between nursing interventions B. Hyperoxygenate during endotracheal suctioning C. Elevate the patient's head of the bed 30 degrees D. Apply bilateral heel protectors after repositioning
A. Provide rest periods between nursing interventions
Which of the following acid-base disturbances commonly occurs with the hyperventilation and impaired gas exchange seen in severe exacerbation of asthma? A. Respiratory Acidosis B. Metabolic alkalosis C. Metabolic acidosis D. Respiratory alkalosis
A. Respiratory Acidosis
A nurse is caring for a client in the ICU who requires a ventilator. The nurse is aware that a ventilator may increase the risk of a pneumothorax in the client who uses it. Which best describes how this machine can cause a pneumothorax? A. The pressure from the ventilator causes a rupture in the lung tissue B. Increased oxygen delivered by the ventilator damages the lungs and leads to a pneumothorax C. The use of a ventilator is associated with an increase in the risk of infection, which ultimately breaks down lung tissue D. The endotracheal tube causes damage to the structures of the respiratory system, which leads to an air leak
A. The pressure from the ventilator causes a rupture in the lung tissue
Which of the following treatments may be used to dissolve a thrombus that is lodged in the pulmonary artery? A. Thrombolytics B. Heparin C. Embolectomy D. Aspirin
A. Thrombolytics
The nurse is caring for a patient with a diagnosis of pulmonary embolism. The nurse understands that the most common cause of a pulmonary embolus is A. deep vein thrombosis from lower extremities B. amniotic fluid embolus C. fat embolus from a long bone fracture D. vegetation that dislodges from an infected central venous catheter
A. deep vein thrombosis from lower extremities
When fluid is present in the alveoli, A. diffusion of oxygen and carbon dioxide is impaired. B. the patient is in heart failure. C. hypoventilation occurs. D. alveoli collapse, and atelectasis occurs.
A. diffusion of oxygen and carbon dioxide is impaired.
A strategy for preventing pulmonary embolism in patients at risk who cannot take anticoagulants is A. insertion of a vena cava filter B. administration of two aspirin tablets every 4 hours C. infusion of thrombolytics D. subcutaneous heparin administration every 12 hours
A. insertion of a vena cava filter
Which patient in the emergency department is the most at risk for developing hypovolemic shock? A. A patient with slight rectal bleeding from inflamed hemorrhoids B. A patient with a 2-day history of nausea, vomiting, and diarrhea C. A patient admitted with abdominal pain and an elevated white blood cell count D. A patient with a temperature of 102° F and a general dermal rash
B. A patient with a 2-day history of nausea, vomiting, and diarrhea
The patient with acute respiratory distress syndrome (ARDS) would exhibit which of the following symptoms? A. Respiratory acidosis associated with hyperventilation B. Decreasing PaO2 levels despite increased FiO2 administration C. Elevated alveolar surfactant levels D. Increased lung compliance with increased FiO2 administration
B. Decreasing PaO2 levels despite increased FiO2 administration
You are caring for a patient in the ED who came in via ambulance after a severe motor vehicle accident. Suddenly, your patient shouts with difficulty, "Awe! I have severe chest pain going around to my back! Please help me!" What do you anticipate is the medical condition? A. Fusiform aneurysm B. Dissecting aneurysm C. Pseudoaneurysm D. Saccular aneurysm
B. Dissecting aneurysm
A patient is having a cardiac evaluation to assess for possible valvular disease. Which study best identifies valvular function and measures the size of the cardiac chambers? A. Electrophysiology study B. Echocardiogram C. Cardiac catheterization D. 12-lead electrocardiogram
B. Echocardiogram
Which of the following are physiological effects of positive end-expiratory pressure (PEEP) used in the treatment of ARDS (select all that apply)? A. Improves carbon dioxide retention B. Increases functional residual capacity C. Prevents collapse of unstable alveoli D. Improves arterial oxygenation E. Opens collapsed alveoli
B. Increases functional residual capacity C. Prevents collapse of unstable alveoli D. Improves arterial oxygenation E. Opens collapsed alveoli
The nurse admits a patient to the ED with a suspected cervical spine injury. What is the priority nursing action? A. Keep the neck in the hyperextended position B. Maintain proper head and neck alignment C. Prepare for immediate endotracheal intubation D. Remove cervical collar upon arrival to the ED
B. Maintain proper head and neck alignment
The nurse receives a patient from the emergency department following a closed head injury. After insertion of a ventriculostomy, the nurse assesses the following vital signs: blood pressure 100/60 mm Hg, heart rate 52 beats/min, respiratory rate 24 breaths/min, oxygen saturation (SpO2) 97% on supplemental oxygen at 45% via Venturi mask, Glasgow Coma Scale score of 4, and intracranial pressure (ICP) of 18 mm Hg. Which order should the nurse institute first? A. Ancef 1 g intravenous B. Mannitol 1 g intravenous C. Portable chest x-ray D. Seizure precautions
B. Mannitol 1 g intravenous
While caring for a patient with a closed head injury, the nurse assesses the patient to be alert with a blood pressure 130/90 mm Hg, heart rate 60 beats/min, respirations 18 breaths/min, and a temperature of 102°F. To reduce the risk of increased intracranial pressure (ICP) in this patient, what is the priority? A. Maintain neutral head alignment and avoid extreme hip flexion B. Reduce ambient room temperature and administer antipyretics C. Insert an oral airway and monitor respiratory rate and depth D. Ensure adequate periods of rest between nursing interventions
B. Reduce ambient room temperature and administer antipyretics
You are caring for a patient in cardiogenic shock who is being treated with an infusion of dobutamine. The physician's order indicates to titrate the infusion to achieve a cardiac index of greater than or equal to 2.5 L/min/m2. You measure a cardiac output and note that the calculated cardiac index for your patient is 4.6 L/min/m2. What is your best action? A. Assess your patients hourly urine output B. Reduce the rate of dobutamine C. Order a state 12 lead EKG per protocol D. Obtain a stat serum potassium per protocol
B. Reduce the rate of dobutamine
The provider has opted to treat a patient with a complete spinal cord injury with Solumedrol. The provider orders 30 mg/kg over 15 minutes followed in 45 minutes with an infusion of 5.4 mg/kg/hr for 23 hours. What is the total 24-hour dose for the 70-kg patient? A. 2,478 mg B. 12,750 mg C. 10,794 mg D. 5,000 mg
C. 10,794 mg
The nurse calculates the PaO2/FiO2 ratio for the following values: PaO2 is 78 mm Hg; FiO2 is 0.6 (60%) and determines it to be: A. 46.8; meets criteria for ARDS B. Not enough data to compute the ratio C. 130; meets criteria for ARDS D. 468; normal lung function
C. 130; meets criteria for ARDS
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 of 85/50 mm Hg, heart rate 110 beats/min, respiratory rate 20 breaths/min, oxygen saturation (SpO2) 95% on 3 L/min oxygen via nasal cannula, and a temperature of 101.5°F. Which provider prescription should the nurse institute first? A. Acetaminophen (Tylenol) 650 mg per rectum B. Blood cultures (2 specimens) for temperature >101°F C. 500 mL albumin infusion intravenously D. Decadron 20 mg intravenous push every 4 hours
C. 500 mL albumin infusion intravenously
A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg. The blood pressure is 144/90 mm Hg, and mean arterial pressure (MAP) is 108 mm Hg. What is the cerebral perfusion pressure (CPP)? A. 54 mm Hg B. 72 mm Hg C. 90 mm Hg D. 126 mm Hg
C. 90 mm Hg
After receiving the handoff report from the day shift charge nurse, which patient should the evening charge nurse assess first? A. A patient with meningitis complaining of photophobia B. A mechanically ventilated patient with a GCS of 6 C. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104°F D. A patient with bacterial meningitis on droplet precautions
C. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104°F
The emergency department nurse admits a patient following a motor vehicle collision. Vital signs include blood pressure 70/50 mm Hg, heart rate 140 beats/min, respiratory rate 36 breaths/min, temperature 101° F and oxygen saturation (SpO2)95% on 3 L of oxygen per nasal cannula. Laboratory results include hemoglobin 6.0 g/dL, hematocrit 20%, and potassium 4.0 mEq/L. Based on this assessment, what is most important for the nurse to include in the patient's plan of care? A. Application of cushioned heel protectors B. Implementation of universal precautions C. Insertion of an 18-gauge peripheral intravenous line D. Implementation of fall precautions
C. Insertion of an 18-gauge peripheral intravenous line
The nurse assesses a patient with a skull fracture to have a Glasgow Coma Scale score of 3. Additional vital signs assessed by the nurse include blood pressure 100/70 mm Hg, heart rate 55 beats/min, respiratory rate 10 breaths/min, oxygen saturation (SpO2) 94% on oxygen at 3 L per nasal cannula. What is the priority nursing action? A. Increase supplemental oxygen delivery B. Support bony prominences with padding C. Monitor the patient's airway patency D. Elevate the head of the patient's bed
C. Monitor the patient's airway patency
The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at the scene briefly but is now conscious upon arrival at the emergency department with a GCS score of 15. One hour later, the nurse assesses a GCS score of 3. A. Elevate the head of the bed B. Stimulate the patient hourly C. Notify the provider immediately D. Continue to monitor the patient
C. Notify the provider immediately
A patient has elevated blood lipids. The nurse anticipates which classification of drugs to be prescribed for the patient? A. Nitroglycerin B. Beta blockers C. Statins D. Antibiotics
C. Statins
The etiology of noncardiogenic pulmonary edema in acute respiratory distress syndrome (ARDS) is related to damage to the A. trachea. B. mainstem bronchus. C. alveolar-capillary membrane. D. left ventricle.
C. alveolar-capillary membrane.
A patient is having a stent placed and asks why it is necessary after having an angioplasty. Which response by the nurse is best? A. "The stent will remove any clots that are in the vessel and protect the heart muscle from damage." B. "This procedure is being done instead of using cholesterol-lowering medication to help keep the heart vessel open." C. "The angioplasty was a failure, so this procedure has to be done to fix the heart vessel." D. "The stent is inserted to enhance the results of the angioplasty, by helping to keep the vessel open and prevent it from closing again."
D. "The stent is inserted to enhance the results of the angioplasty, by helping to keep the vessel open and prevent it from closing again."
The nurse admits a patient to the emergency department with new onset of slurred speech and right-sided weakness. What is the priority nursing action? A. Assess the patient's general orientation B. Determine the patient's drug allergies C. Assess for the presence of a headache D. Determine the time of symptom onset
D. Determine the time of symptom onset
You are caring for a patient admitted with severe sepsis. Vital signs assessed are blood pressure 80/50 mm Hg, heart rate 120 beats/min, respirations 28 breaths/min, oral temperature of 102° F, and a right atrial pressure (RAP) of 1 mm Hg. Which intervention should you carry out first? A. Blood cultures from two sites B. Acetaminophen suppository C. IV antibiotic administration D. Isotonic fluid challenge
D. Isotonic fluid challenge
You completed an infusion of a 1000 mL bolus of normal saline to your patient with severe sepsis. One hour later, which laboratory result would require your immediate attention? A. Potassium 3.8 mEq/L B. Sodium 140 mEq/L C. Creatinine 1.0 mg/dL D. Lactate 6 mmol/L
D. Lactate 6 mmol/L
A patient is admitted with an acute myocardial infarction (AMI). The nurse knows that an angiotensin-converting enzyme (ACE) inhibitor should be started within 24 hours to reduce the incidence of which process? A. Hibernating myocardium B. Myocardial stunning C. Tachycardia D. Myocardial remodeling
D. Myocardial remodeling
A patient presents to the emergency department (ED) with chest pain that he has had for the past 2 hours. The patient is nauseated and diaphoretic, with dusky skin color. The electrocardiogram shows ST elevation in leads II, III, and aVF. Which therapeutic intervention would the nurse question? A. Emergent thrombolytic therapy B. Emergent percutaneous coronary intervention C. Immediate coronary artery bypass graft surgery D. Permanent pacemaker insertion
D. Permanent pacemaker insertion
The nurse is caring for a patient who has a diminished level of consciousness and who is mechanically ventilated. While performing endotracheal suctioning, the patient reaches up in an attempt to grab the suction catheter. What is the best interpretation by the nurse? A. The patient is exhibiting extension posturing B. The patient is withdrawing to stimulation C. The patient is exhibiting flexion posturing D. The patient is exhibiting purposeful movement
D. The patient is exhibiting purposeful movement
You are caring for an athlete with a possible cervical spine (C5) injury following a diving accident. You assess a blood pressure of 70/50 mm Hg, heart rate 45 beats/min, and respirations 26 breaths/min. Your patient's skin is warm and flushed. What is your best interpretation of these findings? A. Your patient is experiencing an allergic reaction. B. The vital signs are normal for your patient. C. Your patient most likely has an elevated temperature. D. Your patient is developing neurogenic shock.
D. Your patient is developing neurogenic shock.
During rounds, the provider alerts the team that proning is being considered for a patient with acute respiratory distress syndrome. The nurse understands that proning is A. possible with minimal help from coworkers. B. less of a risk for skin breakdown because the patient is face down. C. used to provide continuous lateral rotational turning. D. an optional treatment to improve ventilation.
D. an optional treatment to improve ventilation.
The nurse is caring for a patient with acute respiratory distress syndrome who is hypoxemic despite mechanical ventilation. The provider prescribes 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 provider of this assessment and anticipates an order for A. continuous lateral rotation therapy. B. prone positioning. C. guided imagery. D. neuromuscular blockade.
D. neuromuscular blockade.
The nurse is caring for a mechanically ventilated patient admitted with a traumatic brain injury. Which arterial blood gas value assessed by the nurse indicates optimal gas exchange for a patient with this type of injury? A. pH 7.38; PaCO2 40 mm Hg; HCO3 24 mEq/L; PaO2 70 mm Hg B. pH 7.38; PaCO2 28 mm Hg; HCO3 26 mEq/L; PaO2 65 mm Hg C. pH 7.38; PaCO2 55 mm Hg; HCO3 22 mEq/L; PaO2 85 mm Hg D. pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg
D. pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg
