Critical care EAQ
The nurse is caring for four clients in an emergency department. Which client should be given least priority by the primary healthcare provider based on his/her condition? 1 Client with cardiac arrest 2 Client with abdominal pain 3 Client with multiple trauma 4 Client with closed extremity trauma
Client with closed extremity trauma Care for a client with closed extremity trauma could be delayed because it is considered less severe when compared to other client conditions and triaged in emergency severity index (ESI-4). Therefore this client is given least priority. The client with cardiac arrest is triaged under ESI-1 and should be seen immediately as the condition is more severe. The client with abdominal pain is triaged under ESI-3 and should be seen within 1 hour. The client with multiple trauma should be seen within 1 hour and is triaged under ESI-2.
A client is to be transferred from the coronary care unit to a progressive care unit. The client asks the nurse, "Are you sure I'm ready for this move?" What should the nurse determine that the client most likely is experiencing based on this statement? 1 Fear 2 Depression 3 Dependency 4 Ambivalence
Fear Fear of a recurrent myocardial infarction or sudden death is common when the client's environment is to be changed to one that appears less vigilant. Depression is exhibited by withdrawal, crying, anorexia, and apathy, and it usually becomes more evident after discharge from the hospital. Dependency is exhibited by an unwillingness to increase exercise or perform tasks. Ambivalence is exhibited by contrasting emotions; the client's statement does not demonstrate this.
A nurse is inserting a gastric tube and arranging for diagnostic studies for a client who sustained injuries after a bus accident. Which type of emergency assessment is being performed? 1 Disability 2 Breathing 3 Focused adjuncts 4 Giving comfort measures
Focused adjuncts
Which color tagged clients usually make up the greatest number in most large-scale multi-casualty situations, based on the disaster triage tag system? 1 Red 2 Black 3 Green 4 Yellow
Green Green-tags clients usually make up the greatest number in most large-scale multi-casualty situations. These clients have minor injuries and they may actually evacuate themselves from the mass casualty scene and go to the hospital in a private vehicle. Red-tagged clients have major injuries, black-tagged clients are expected and allowed to die, and yellow-tagged clients have major injuries. Clients belonging to these three categories usually do not make up the greatest number in most large-scale multi-casualty situations.
What is a common metabolic cause of hypothermia? 1 Seizure 2 Dehydration 3 Hypoglycemia 4 Hyperthyroidism
Hypoglycemia
The nurse is caring for four clients admitted at once under mass casualty conditions. Which client should be treated first? A- airway obstruction B- extensive full thickness burn C- open fracture D- closed fracture and abrasion
airway obstruction
After an acute coronary syndrome a client begins a supervised, progressive jogging regimen and asks the nurse how to tell whether it is helping. What is the best response by the nurse? 1 "Intermittent claudication will be reduced." 2 "Your breathing will become regular and shallow." 3 "Perspiration will be less when you run, and you'll use less energy." 4 "You will be able to run progressively longer distances before tiring."
"You will be able to run progressively longer distances before tiring." The ability to endure progressive activity indicates that collateral circulation has improved cardiopulmonary functioning. Intermittent claudication is related to peripheral arterial occlusive disease, not cardiopulmonary function. Breathing when jogging should be regular and deep to meet the oxygen demands of the body. Perspiration is an expected and desired adaptation to promote heat loss through evaporation.
The client is in atrial fibrillation. Which information should the nurse consider about atrial fibrillation when planning care for this client? 1 A loss of atrial kick 2 No physiologic changes 3 Increased cardiac output 4 Decreased risk of pulmonary embolism
A loss of atrial kick
A client has undergone nasal hypophysectomy surgery. During post-operative care, which finding indicates cerebrospinal leakage? 1 Dry mouth 2 Rigidity of neck muscles 3 Fall in blood pressure upon standing 4 A yellow edge around nasal discharge
A yellow edge around nasal discharge Nasal hypophysectomy is a surgical procedure performed to treat hyperpituitarism due to pituitary gland tumors. During postoperative care and follow-up, the appearance of light-yellow at the edge of otherwise clear nasal discharge in the dressing indicates leakage of cerebrospinal fluid (CSF). This is called the "halo sign" and is indicative of a CSF leak. Dry mouth after nasal hypophysectomy is normal because the client breathes through the mouth due to the nasal packing. Neck rigidity could be an indication of infection, such as meningitis following the surgery. A fall in blood pressure upon standing is called orthostatic hypotension and is a side effect of bromocriptine.
A nurse is caring for a client who sustained a transection of the spinal cord with no other injuries. The nurse continually monitors this client for which medical emergency? 1 Hemorrhage 2 Hypovolemic shock 3 Gastrointestinal atony 4 Autonomic hyperreflexia
Autonomic hyperreflexia Autonomic hyperreflexia, an uninhibited and exaggerated response of the autonomic nervous system to stimulation, results in a blood pressure greater than 200 mm Hg systolic; it is a medical emergency. While hemorrhage and hypovolemic shock could occur from the trauma, the scenario stated that no other injuries occurred. Although gastrointestinal atony can result from immobility, it is not a medical emergency.
A nurse observes a window washer falling 25 feet (7.6 m) to the ground. The nurse rushes to the scene and determines that the person is in cardiopulmonary arrest. What should the nurse do first? 1 Feel for a pulse 2 Begin chest compressions 3 Leave to call for assistance 4 Perform the abdominal thrust maneuver
Begin chest compressions According to the American Heart Association and Heart and Stroke Foundation of Canada for CPR, the first step is to feel for a pulse after unresponsiveness is established. In this case, it has been established the client has no pulse (cardiopulmonary arrest); therefore chest compressions are initiated. Do not leave the client to call for assistance. The abdominal thrust (Heimlich) maneuver is used to relieve airway obstruction and is not appropriate in this instance.
Which color tag will be given by the triage nurse to a client assigned to class IV, during a mass casualty situation? 1 Red 2 Black 3 Green 4 Yellow
Black A client considered class IV during triage in a mass casualty situation will be given a black tag. The red tag is associated with class I, green tag with class III, and yellow tag with class II.
The nurse is planning to triage clients according to emergency severity index (ESI). Which client should be triaged under ESI-1 based on threat to life and stability of vital functions? A chest pain resulting from ischemia B cardiac arrest C simple laceration D hip fracture
Cardiac arrest
A nurse on the high-risk unit is caring for a client with severe preeclampsia. Which intervention is the most effective in preventing a seizure? 1 Providing a plastic airway 2 Controlling external stimuli 3 Having emergency equipment available 4 Keeping calcium gluconate at the bedside
Controlling external stimuli Reducing lights, noise, and stimulation minimizes central nervous system irritability, which can trigger a seizure. A plastic airway will not prevent a seizure. Available emergency equipment will not prevent a seizure, although oxygen and suction equipment may be useful after a seizure. Calcium gluconate is the antidote for magnesium sulfate toxicity; it does not prevent seizures.
The nurse is caring for a client 4 days after the client was admitted to the hospital with burns on the trunk and arms. The nurse collaborates with the dietician to develop a dietary plan for the following day. Which plan will the nurse follow? 1 High caloric intake, liberal potassium intake, and 3 g protein/kg/day 2 High caloric intake, restricted potassium intake, and 1 g protein/kg/day 3 Moderate caloric intake, liberal potassium intake, and 3 g protein/kg/day 4 Moderate caloric intake, restricted potassium intake, and 1 g protein/kg/day
High caloric intake, liberal potassium intake, and 3 g protein/kg/day A high-calorie diet is needed for the increased metabolic rate associated with burns; the administration of potassium prevents hypokalemia, which can occur after the first 48 to 72 hours when potassium moves from the extracellular compartment into the intracellular compartment; protein promotes tissue repair. High caloric intake, restricted potassium intake, and 1 g protein/kg/day do not meet the body's needs for tissue repair; the protein and potassium are too limited. Moderate caloric intake, liberal potassium intake, and 3 g protein/kg/day do not meet the body's needs for tissue repair; the calories are too limited. Moderate caloric intake, restricted potassium intake, and 1 g protein/kg/day do not meet the body's needs for tissue repair; the calories, potassium, and protein are too limited.
During the first 48 hours after a client has sustained a thermal injury, which conditions should the nurse assess for? 1 Hypokalemia and hyponatremia 2 Hyperkalemia and hyponatremia 3 Hypokalemia and hypernatremia 4 Hyperkalemia and hypernatremia
Hyperkalemia and hyponatremia
The nurse is caring for a client who is admitted to the birthing unit with a diagnosis of abruptio placentae. Which complication associated with a placental abruption should the nurse carefully monitor this client for? 1 Cerebral hemorrhage 2 Pulmonary edema 3 Impending seizures 4 Hypovolemic shock
Hypovolemic shock With abruptio placentae, uterine bleeding can result in massive internal hemorrhage, causing hypovolemic shock. A cerebral hemorrhage may occur with a dangerously high blood pressure; there is no information indicating the presence of a dangerously high blood pressure. Pulmonary edema may occur with severe preeclampsia or heart disease, and seizures are associated with severe preeclampsia; there is no information indicating the presence of these conditions.
Which is an example of an internal disaster in a hospital? 1 A hurricane 2 Oil spill from a marine oil tanker 3 Loss of communications capabilities 4 Malfunction of a nuclear reactor with radiation exposure
Loss of communications capabilities Loss of critical utilities, such as communications capabilities, is an internal disaster. A hurricane is an external natural disaster. An oil spill from a marine oil tanker and malfunction of a nuclear reactor with radiation exposure are examples of technologic external disasters.
A client had a craniotomy for excision of a brain tumor. After surgery, the nurse monitors the client for increased intracranial pressure. Which clinical finding supports an increase in intracranial pressure? 1 Thready, weak pulse 2 Narrowing pulse pressure 3 Regular, shallow breathing 4 Lowered level of consciousness
Lowered level of consciousness Altered consciousness is the first sign of increased intracranial pressure. An increase in intracranial pressure causes impaired cerebral blood flow affecting the cells of the cerebral cortex, which results in a decreased level of consciousness. As the intracranial pressure increases, it places pressure on the thalamus, hypothalamus, pons, and medulla, resulting in a slow pulse. A widening pulse pressure occurs because of an increase in the systolic pressure. As the intracranial pressure increases, it places pressure on the thalamus, hypothalamus, pons, and medulla, resulting in irregular respirations that progress to deep, rapid breathing alternating with periods of apnea (Cheyne-Stokes respirations).
An infant of a diabetic mother is admitted to the neonatal intensive care unit. What is the priority nursing intervention for this infant? 1 Clamping the cord a second time 2 Obtaining heel blood to test the glucose level 3 Starting an intravenous (IV) infusion of glucose in water 4 Instilling an ophthalmic antibiotic to prevent an eye infection
Obtaining heel blood to test the glucose level Hypoglycemia may be present because of the sudden withdrawal of maternal glucose and increased fetal insulin production, which continues after birth. The umbilical vein may be needed to start an IV; it should not be damaged. An IV infusion of glucose should not be started until the blood glucose level has been determined. Instilling an antibiotic into the eyes can be delayed until the blood glucose level has been determined.
While mopping the kitchen floor, a client at 37 weeks' gestation experiences a sudden sharp pain in her abdomen with a period of fetal hyperactivity. When the client arrives at the prenatal clinic, the nurse examines her and detects fundal tenderness and a small amount of dark-red bleeding. What does the nurse conclude is the probable cause of these clinical manifestations? 1 True labor 2 Placenta previa 3 Partial abruptio placentae 4 Abdominal muscular injury
Partial abruptio placentae
The nurse is assigning disaster triage tags to clients after a bomb explosion. Which client requires immediate treatment in the emergency department according to disaster triage tag system? Color of tag: A- yellow B-Red C-Green D- black
Red
The victims of a terrorist attack involving sarin are brought to the emergency department. Which statement does the nurse know to be true regarding the characteristics of sarin? 1 Sarin causes skin burns and blisters. 2 Sarin can cause death within minutes of exposure. 3 A garlic-like odor and brown color are characteristics of sarin. 4 A single dose of pralidoxime chloride (2-PAM chloride) reverses the effects of long-term sarin exposure.
Sarin can cause death within minutes of exposure. Sarin is a highly toxic nerve gas that can cause death within minutes of exposure. Mustard gas causes skin burns and blisters. A garlic-like odor and brown color are characteristics of mustard gas. While pralidoxime chloride (2-PAM chloride) is used as an antidote for nerve agent poisoning, multiple doses may be needed to reverse the effects of nerve agents; also, sarin is highly toxic and can cause death within minutes of exposure.
A nurse is monitoring a client who is having a computed tomography (CT) scan of the brain with contrast. Which response indicates that the client is having an untoward reaction to the contrast medium? 1 Pelvic warmth 2 Feeling flushed 3 Shortness of breath 4 Salty taste in the mouth
Shortness of breath An untoward response to the iodinated dye used as a contrast is anaphylaxis, a life-threatening allergic response. Anaphylaxis is manifested by respiratory distress, hypotension, and shock; counteractive measures must be instituted. A feeling of warmth or flushing is an expected minor side effect. A salty taste is an expected minor side effect.
The nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which is the priority concern of the nurse when caring for this client? 1 Fluid volume 2 Skin integrity 3 Physical mobility 4 Urinary elimination
Skin integrity Necrotizing fasciitis destroys subcutaneous tissue and fascia and predisposes the client to infection and sepsis. Although fluid volume and physical mobility are important, they are not the primary concern at this time. Necrotizing fasciitis is a problem of the integumentary, not the urinary, system.
During a vertex vaginal birth the nurse notes meconium-stained amniotic fluid. What is the priority nursing intervention for the newborn? 1 Stimulating crying 2 Suctioning the airway 3 Using an Ambu bag with oxygen support 4 Placing the infant in the reverse Trendelenburg position
Suctioning the airway Suctioning must be done to minimize the possibility of the aspiration of meconium into the lungs. If the newborn cries before being suctioned, meconium may be aspirated. If the newborn is bagged, any meconium present will be forced into the lungs. If the newborn is positioned in reverse Trendelenburg, meconium may be aspirated.
At 10 hours of age a newborn has a large amount of mucus in the nasopharynx and becomes cyanotic. What is the nurse's initial action? 1 Suctioning the mouth 2 Administering oxygen 3 Notifying the practitioner 4 Inserting an endotracheal tube
Suctioning the mouth To maintain a patent airway and promote respiration and gaseous exchange, the nurse must remove mucus from the newborn's mouth and pharynx. If the airway is obstructed, oxygenation is useless; suctioning is the priority. The practitioner should be notified if oral suctioning does not clear the airway. Insertion of an endotracheal tube is an emergency measure that may be required if the nurse's initial action does not clear the airway.
A client is admitted with severe burns. The nurse is caring for the client 36 hours after the client's admission and identifies the client's potassium level of 6.0 mEq/L (6.0 mmol/L). Which drink will the nurse recommend be included in the client's diet? 1 Milk 2 Tea 3 Orange juice 4 Tomato juice
Tea The client is hyperkalemic, and potassium intake should be limited; tea is very low in potassium. Milk, orange juice, and tomato juice are all high-potassium foods and should be avoided.
Why is the Glasgow Coma Scale used by the nurse while performing an assessment in a traumatized client? 1 To assess patency of airway 2 To assess level of consciousness 3 To assess breathing abnormalities 4 To assess circulatory abnormalities
To assess level of consciousness The nurse uses the Glasgow Coma Scale while performing a primary survey of a traumatized client to assess the level of consciousness. Patency of airway is assessed by manually checking the client's oral cavity. Breathing abnormalities are assessed by checking the chest wall of the client. Circulatory abnormalities are assessed by checking the blood volume.
Which color of cerebrospinal fluid (CSF) may indicate subarachnoid hemorrhage in the client? 1 Hazy 2 Yellow 3 Brown 4 Colorless
yellow The yellow color of CSF can be attributed to the hemolysis of the red blood cells (RBC), which leads to increased production of bilirubin. Other causes include subarachnoid hemorrhage, jaundice, increased CSF protein, hypercarotenemia, or hemoglobinemia. Hazy or unclear CSF is indicative of an elevated white blood cell count due to infections. If the CSF has a brown color it is indicative of the presence of methemoglobin, indicating a previous meningeal hemorrhage. A colorless color indicates a normal finding.
