Critical Care #3
What is the most common cause of death in a burn patient after the first 7 days? A. Hypovolemia B. Hypotension C. Infection D. Injury inhalation
C. Infection
Which type of upper gastrointestinal bleeding can be caused by forceful vomiting? A. Peptic ulcer B. Esophageal varices C. Mallory-Weiss tears D. Dieulafoy's lesions
C. Mallory-Weiss tears
All of these criteria would prompt the nurse to call a rapid response team except: A. Respiratory rate of 35 B. SpO2 of 86% C. Acute confusion D. Blood pressure 118/70
D
When discontinuing parenteral nutrition, the nurse: A. Stops the TPN as soon as the order is written B. Tapers the TPN C. Monitors blood glucose D. Both B and C
D
Which of the following is a sign of hypertensive nephrosclerosis? A. Proteinuria B. Azotemia C. Hematuria D. All of the above
D
•What is an appropriate amount of maintenance fluids per day? A. 1 L B. 1.5 L C. 2 L D. 2.5 L
D
Is the following statement true or false? •In toxic ATN, nonoliguria occurs more often than with ischemic ATN.
True
Is the following statement true or false? •The term dry weight or ideal weight is used to express the weight at which fluid volume is in a normal range for a patient who is free of the symptoms of fluid imbalance.
True
A client is admitted to the burn unit after being transported from a facility a large distance away. The client has burns to the groin area and circumferential burns to both upper thighs. When assessing the client's legs distal to the wound site, the nurse should be cognizant of the risk of what complication? a.Ischemia b.Referred pain c.Cellulitis d.Venous thromboembolism (VTE)
a
A client is to have an amputation. The client is acutely ill and diagnosed with a gangrenous limb and related fever, disorientation, and electrolyte imbalances. Which of the following would be most important for the nurse to monitor in this client? a.Signs of sepsis b.Signs of nausea and vomiting c.Occurrence of allergic reactions d.Reduced urine output
a
A client who is septic has started shivering violently. Which nursing intervention is necessary to care for this client? a.Control the shivering. b.Place the client on a warming blanket. c.Keep the client dry and covered. d.Maintain the client in a supine position with legs elevated 12 inches.
a
A client who was severely burned begins to exhibit symptoms of renal failure during treatment. What physiologic process can cause acute renal failure? a.hemoconcentration b.anemia c.fluid, electrolyte status d.histamine
a
A client with sepsis is experiencing disseminated intravascular coagulation (DIC). The client is bleeding from mucous membranes, venipuncture sites, and the rectum. Blood is present in the urine. The nurse establishes the nursing diagnosis of Risk for deficient fluid volume related to bleeding. The most appropriate and measurable outcome for this client is that the client exhibits a.Urine output greater than or equal to 30 mL/hour b.Decreased bleeding c.Stable level of consciousness d.Systolic blood pressure greater than 70 mm Hg
a
A nurse is admitting a client to the postsurgical unit following a gastrostomy. When planning assessments, the nurse should be aware of what potential postoperative complication of a gastrostomy? a.Premature removal of the G tube b.Bowel perforation c.constipation d. Development of peptic ulcer disease (PUD)
a
An older adult client has been diagnosed with urosepsis and has a temperature of 39.7°C (103.4°F). The nurse must anticipate that the oxygen demands of the client's body will change in which direction and why? a.Increase due to an increase in metabolism b.Decrease due to a decrease in metabolism c.Increase due to a decrease in metabolism d.Decrease due to an increase in metabolism
a
An x-ray demonstrates a fracture in which the fragments of bone are driven inward. This type of fracture is referred to as a. depressed b.compound. c.comminuted. d.impacted.
a
During hemodialysis, toxins and wastes in the blood are removed by which of the following? a.Diffusion b.Osmosis c.Ultrafiltration d.Filtration
a
Medical and nursing interventions for patients who present with multiple injuries follow a sequence of treatment priorities. Which of the following is the first priority of care? a.Establish an airway. b.Prevent hypovolemic shock. c.Assess for head and neck injuries. d.Control hemorrhage.
a
The ED staff has been notified of the imminent arrival of a client who has been exposed to chlorine. The nurse should anticipate the need to address what nursing diagnosis? a.Impaired gas exchange b.Decreased cardiac output c.Chronic pain d.Excess fluid volume
a
The nurse is admitting a client to the medical unit after the client has been transferred from the emergency department. What is the nurse's priority action at this time? a.Meeting the urgent needs of the client b.Checking the admitting physician's prescriptions c.Obtaining a baseline set of vital signs d.Allowing the family to be with the client
a
Which elements of assessment of a traumatic musculoskeletal injury should be included when a client is evaluated. Select all that apply. a.All should be included. b.Observe for swelling, external bleeding, or bruising. c.Palpate the peripheral pulses. d.Check the sensation of the injured part.
a
Which factor may contribute to compartment syndrome? a.Hemorrhage b.Macular lesion c.Venous thromboembolus d.Disuse syndrome
a
Which of the following is a term used to describe a soft tissue injury produced by a blunt force? a.Contusion b.Sprain c.Strain d.Hematoma
a
The nurse is admitting a patient with a penetrating abdominal injury from a knife wound. What should the nursing measures for a penetrating abdominal injury include? (Select all that apply.) a.Assessing for manifestations of hemorrhage b.Covering any protruding viscera with sterile dressings soaked in normal saline solution c.Looking for any associated chest injuries d.Exploring the abdominal wound with a gloved finger e.Irrigating the wound with normal saline and a syringe
abc
A client is lethargic with a systolic blood pressure of 74, heart rate of 162 beats/min, and rapid, shallow respirations. Crackles are audible in the lungs. The nurse assesses frequently for which of the following? Select all answers that apply. a.Increased paCO² levels b.Reports of chest pain c.Loss in consciousness d.Ecchymoses and petechiae e.Decreases in liver enzymes
abcd
A nurse on the renal unit is caring for a client who will soon begin peritoneal dialysis. The family of the client asks for education about the peritoneal dialysis catheter that has been placed in the client's peritoneum. The nurse explains the three sections of the catheter and talks about the two cuffs on the dialysis catheter. What would the nurse explain about the cuffs? Select all that apply. a.The cuffs are made of Dacron polyester. b.The cuffs stabilize the catheter. c.The cuffs prevent the dialysate from leaking. d.The cuffs provide a barrier against microorganisms. e.The cuffs absorb dialysate
abcd
Which of the following are associated with compartment syndrome? Select all that apply. a.Trauma from accidents b.Surgery c.Casts d.Tight bandages e.Crushing injuries
abcde
A client with end-stage kidney disease is scheduled to begin hemodialysis. The nurse is working with the client to adapt the client's diet to maximize the therapeutic effect and minimize the risks of complications. The client's diet should include which of the following modifications? Select all that apply. a.Decreased protein intake b.Decreased sodium intake c.Increased potassium intake d.Fluid restriction e.Vitamin D supplementation
abd
A client is admitted with a new onset of pyloric obstruction. What client symptoms should the nurse anticipate? Select all that apply. a.Anorexia b.Nausea and vomiting c.Diarrhea d.Weight loss e.Epigastric fullness
abe
The nurse caring for the patient in shock recognizes which physiologic responses that are common to all shock states? (Select all that apply.) a.Increased intravascular volume b.Activation of the inflammatory response c.Hypoperfusion of tissues d.Must produce energy through anaerobic metabolism e.Increase in cellular Activity
acd
A team of nurses are reviewing the similarities and differences between the different classifications of shock. Which subclassifications of distributive shock should the nurses identify? Select all that apply. a.Anaphylactic b.Hypovolemic c.Cardiogenic d.Septic e.Neurogenic
ade
The intensive care nurse is responsible for the care of a client who is in shock. What cardiac signs or symptoms would suggest to the nurse that the client may be experiencing acute organ dysfunction? Select all that apply. a.Drop in systolic blood pressure of ≥40 mm Hg from baselines b.Hypotension that responds to bolus fluid resuscitation c.Exaggerated response to vasoactive medications d.Serum lactate >4 mmol/L e.Mean arterial pressure (MAP) of ˂65 mm Hg
ade
A male client with multiple injuries is brought to the ED by ambulance. He has had his airway stabilized and is breathing on his own. The ED nurse does not see any active bleeding, but should suspect internal hemorrhage based on what finding? a.Absence of bruising at contusion sites b.Rapid pulse and decreased capillary refill c.Increased BP with narrowed pulse pressure d.Sudden diaphoresis
b
After a car accident, a client is admitted to an acute care facility with multiple traumatic injuries, including a fractured pelvis. For 24 to 48 hours after the accident, the nurse must monitor the client closely for which potential complication of a fractured pelvis? a.Compartment syndrome b.Fat embolism c.Infection d.Volkmann's ischemic contracture
b
The nurse is monitoring a patient who sustained an open fracture of the left hip. What type of shock should the nurse be aware can occur with this type of injury? a.Cardiogenic b.Hypovolemic c.Neurogenic d.Septicemic
b
A nurse is creating a care plan for a client who is receiving parenteral nutrition. The client's care plan should include nursing actions relevant to what potential complications? Select all that apply. a. Dumping syndrome b. Clotted or displaced catheter c. Pneumothorax d. Hyperglycemia e. Line sepsis
b,c,d,e
A client is scheduled to receive a 25% dextrose solution of parenteral nutrition. What actions are a priority for the nurse to perform prior to administration? Select all that apply. a. Assess for patency of the peripheral intravenous site b. Ensure availability of an infusion pump c. Ensure completion of baseline monitoring of the complete blood count (CBC) and chemistry panel d. Administer the intravenous antibiotic in the same tubing as the parenteral nutrition e. Place a 1.5-micron filter on the tubing
b,c,e
The nurse is caring for a patient with a medical history of untreated CKD that has progressed to ESKD. Which of the following serum values and associated signs and symptoms will the nurse expect the patient to exhibit? Select all that apply. a.Magnesium 1.5 mg/dL; mood changes and insomnia b.Calcium 7.5 mg/dL; hypotension and irritability c.Chloride 90 mEq/L; irritability and seizures d.Potassium 6.4 mEq/L; dysrhythmias and abdominal distention e.Phosphate 5.0 mg/dL; tachycardia and nausea and emesis
bcd
The nurse recognizes that many risk factors exist for the development of hypovolemic shock. Which are considered "internal" risk factors? Select all that apply. a.Vomiting b.Burns c.Diarrhea d.Dehydration e.Trauma
bd
A client is admitted to the ICU after a motor vehicle accident. On the second day of the hospital admission, the client develops acute kidney injury. The client is hemodynamically unstable, and renal replacement therapy is needed to manage the client's hypervolemia and hyperkalemia. Which of the following therapies will the client's hemodynamic status best tolerate? a.Hemodialysis b.Peritoneal dialysis c.Continuous venovenous hemodialysis (CVVHD) d.Plasmapheresis
c
A client with a fractured femur presenting to the ED exhibits cool, moist skin, increased heart rate, and falling BP. The care team should consider the possibility of what complication of the client's injuries? a.Myocardial infarction b.Hypoglycemia c.Hemorrhage d.Peritonitis
c
A nurse is developing a care plan for a client recovering from a serious thermal burn. After maintaining respirations, the nurse knows that the most important immediate goal of therapy is: a.planning for the client's rehabilitation and discharge. b.providing emotional support to the client and family. c.maintaining the client's fluid, electrolyte, and acid-base balance. d.preserving full range of motion in all affected joints.
c
A nurse is evaluating a client's drop in mean arterial pressure to 50 mm Hg during progressive shock. What client assessment would follow with the drop in pressure? a.rapid respirations b.bradycardia c.low urine output d.constipation
c
A patient has experienced blunt abdominal trauma from a motor vehicle crash. The nurse assesses the patient, knowing that which organ is the most frequently injured solid abdominal organ? a.Duodenum b.Large bowel c.Liver d.Pancreas
c
For a patient who is experiencing multiple injuries, which sequence of medical or nursing management would the nurse identify as a priority? a.Assess for head injuries, control hemorrhage, establish an airway, prevent hypovolemic shock. b.Control hemorrhage, prevent hypovolemic shock, establish an airway, assess for head injuries. c.establish an airway, control hemorrhage, prevent hypovolemic shock, assess for head injuries. d.Prevent hypovolemic shock, assess for head injuries, establish an airway, control hemorrhage.
c
Which nursing diagnosis takes highest priority for a client with a compound fracture? a.Imbalanced nutrition: Less than body requirements related to immobility b.Impaired physical mobility related to trauma c.Risk for infection related to effects of trauma d.Activity intolerance related to weight-bearing limitations
c
Which shock state requires careful administration of fluids? A. Septic B. Neurogenic C. Anaphylactic D. Cardiogenic
c
Which type of shock state does not cause a relative hypovolemia? A. Hypovolemic B. Anaphylactic C. Cardiogenic D. Distributive
c
A nurse is providing care to clients who were involved in an explosion and have sustained secondary blast injuries. Which types of injuries would the nurse expect to find? Select all that apply. a.Head injuries b.Crush injuries c.Penetrating trauma d.Traumatic amputations e.Exacerbation of pre-existing conditions
cd
A client has been burned significantly in a workplace accident. Which conditions create the need for immediate intensive care by specifically trained personnel? Select all that apply. a.Wound care b.Nutritional support c.Fluid loss d.Fluid shift e.Hypotension
cde
A nurse consults with the health care provider about inotropic agents for a client in cardiogenic shock. Which medications would improve the client's contractility? Select all that apply. a.nitroglycerin b.nitroprusside c.dobutamine d.dopamine e.epinephrine
cde
A client is brought to the ED by paramedics, who report that the client has partial-thickness burns on the chest and legs. The client has also suffered smoke inhalation. What is the priority in the care of a client who has been burned and suffered smoke inhalation? a.Pain b.Fluid balance c.Anxiety and fear d.Airway management
d
An immunocompromised older adult has developed a urinary tract infection and the care team recognizes the need to prevent an exacerbation of the client's infection that could result in urosepsis and septic shock. What action should the nurse perform to reduce the client's risk of septic shock? a.Apply an antibiotic ointment to the client's mucous membranes, as prescribed. b.Perform passive range-of-motion exercises unless contraindicated c.Initiate total parenteral nutrition (TPN) d.Remove invasive devices as soon as they are no longer needed
d
An intensive care nurse is aware of the need to identify patients who may be at risk of developing disseminated intravascular coagulation (DIC). Which ICU client most likely faces the highest risk of DIC? a.A client with extensive burns b.A client who has a diagnosis of acute respiratory distress syndrome c.A client who suffered multiple trauma in a workplace accident d.A client who is being treated for septic shock
d
The nurse cares for a client with superficial partial-thickness burn injuries to the lower extremities. The client is ordered IV morphine for pain. The nurse understands narcotics are given via IV during the initial management of pain because a.the client can experience nausea and emesis when given oral medications. b.pain resulting from a burn injury requires relief by the fastest route available. c.bleeding may occur at injection sites when the intramuscular route is used. d. tissue edema may interfere with drug absorption via other routes.
d
The nurse is administering colloids to a client during the first 6 hours of septic shock. What is the client's central venous pressure reading goal? a.1 to 3 mm Hg b.4 to 5 mm Hg c.6 to 7 mm Hg d.8 to 12 mm Hg
d
Which term refers to injuries that occur when a person is caught between objects, run over by a moving vehicle, or compressed by machinery? a.Blunt trauma b.Penetrating abdominal injuries c.Intra-abdominal injuries d.Crush injuries
d
Is the following statement true or false? Pelvic fractures are low priority in the patient with trauma.
false
Which of the following acute kidney failure category is a result of renal hypoperfusion? A. Prerenal B. Intrarenal C. Postrenal D. None of the above
A
•The process of glycogenolysis is A. Glycogen breakdown B. Synthesis of proteins C. Breakdown of fats D. Storage of glucose
A
All of the following are risk factors for diverticulosis except: A. High-fiber diet B. ASA/NSAIDs C. Advanced age D. Constipation
A. High-fiber diet
A 13-year-old is being admitted to the ED after falling from a roof and sustaining blunt abdominal injuries. To assess for internal injury in the client's peritoneum, the nurse should anticipate what diagnostic test? a.Radiograph b.Computed tomography (CT) scan c.Complete blood count (CBC) d.Barium swallow
B
Which route of administration is best for long-term use? A. Nasogastric B. Jejunostomy C. Nasoduodenal D. Nasojejunal
B
•Headache, nausea, restlessness, and mild mental impairment when uremia is corrected too rapidly may be due to which of the following? A. Hypovolemia B. Dialysis dysequilibrium C. Hypertension D. Hypotension
B
What is the most common cause of abdominal trauma? A. Falls B. MVC C. Sports D. Assault
B. MVC
A detailed head-to-toe assessment is done during which survey? A. Primary B. Secondary C. Tertiary
B. Secondary
What is the preferred method of confirming the placement of a nasogastric tube? A. Air bolus B. Observation of aspirate C. Abdominal radiograph D. Measuring aspirate pH
C
•All of these contribute to mortality rates except: A. Failure in planning B. Failure to communicate C. Failure to wait to call an RRT D. Failure to recognize the deteriorating patient condition
C
A patient has sustained second- and third-degree burns to his entire left arm and both legs anteriorly. Using the rule of nines, what is the percentage of body area with burn injury? A. 18% B. 21.5% C. 24% D. 27%
D. 27%
Which of the following findings of the urine studies would indicate ATN? A. Normal sedimentation B. Few hyaline casts C. Muddy-brown granular casts D. Tubular epithelial cells E. Both C and D
E
A nursing instructor is preparing a class about gastrointestinal intubation. Which of the following would the instructor include as reason for this procedure? Select all that apply. a.Remove gas and fluids from the stomach b.Diagnose gastrointestinal motility disorders c.Flush ingested toxins from the stomach d.Evaluate for masses in the large colon eAdminister nutritional substances
abc
The nurse assesses a patient in compensatory shock whose lungs have decompensated. What clinical manifestations would the nurse expect to find? (Select all that apply.) a.A heart rate >100 bpm b.Crackles c.Lethargy and mental confusion d.Respirations <15 breaths/min e.Compensatory respiratory acidosis
abc
Hypoperfusion, hypercoagulability, and activation of the inflammatory response are common to all shock states.
true
Is the following statement true or false? Gallstones are responsible for 40% of pancreatitis cases.
true
Is the following statement true or false? •Adult patients must maintain a urinary output of 0.5 mL/kg/h.
true
Is the following statement true or false? •The COBRA act of 1985 is also known as the "antidumping" law.
true
