Exam #1 Collective- Post Exam

E1 Which complications can result from prolonged deep sedation? (Select all that apply.) a.Pressure ulcers b.Thromboembolism c.Diarrhea d.Nosocomial pneumonia e.Delayed weaning from mechanical ventilation f.Hypertension

a.Pressure ulcers b.Thromboembolism d.Nosocomial pneumonia e.Delayed weaning from mechanical ventilation Over sedation can result in a multitude of complications. Prolonged deep sedation is associated with significant complications of immobility. Pressure ulcers, thromboembolism, gastric ileus, nosocomial pneumonia Delayed weaning from mechanical ventilation.

KEY CONCEPT CH #14 EXAM 1 Which of the following are mechanisms responsible for myocardial infarction (MI)? (Select all that apply.) a. Coronary artery thrombosis b. Plaque rupture c. Coronary artery spasm near the ruptured plaque d. Preinfarction angina e. Hyperlipidemia

ANS: A, B, C The three mechanisms that block the coronary artery and are responsible for the acute reduction in oxygen delivery to the myocardium are (1) plaque rupture (2) new coronary artery thrombosis (3) coronary artery spasm close to the ruptured plaque.

KEY CONCEPT E1 18. Which of the following are considerations when making the decision to allow family at the bedside during resuscitation efforts? (Select all that apply.) a. The patient's wishes b. Experience of the staff c. The family's need to participate in all aspects of the patient's care. d. State regulatory issues e. Seeing the resuscitation may confirm the impact of decisions made or delayed p. 157

ANS: A, B, C, E The decision to allow family members at the bedside during resuscitative efforts should be made by the family and caregivers and be based on needs and experiences. The family may become more aware of what is involved in decisions if they are present during procedures or resuscitative attempts. Seeing the steps of resuscitation may make clearer the impact of decisions made or delayed.

CH 9 KEY CONCEPT E1 7. When administering propofol over an extended period, what laboratory value should the nurse routinely monitor? a. Serum triglyceride level b. Sodium and potassium levels c. Platelet count d. Acid-base balance

ANS: A-Serum triglyceride level Prolonged use of propofol may cause an elevated triglyceride level because of its high lipid content. Page 140

KEY CONCEPT E1 12. Disagreement and distress among practitioners, nurse practitioners, and critical care nurses can lead to what issue? a. Moral indignation b. Ethical resentment c. Moral distress d. Interprofessional anguish

ANS: C-Moral distress Nurses and doctors frequently disagree about the futility of interventions. Sometimes nurses consider withdrawal before practitioners and patients do, and they then believe the care they are giving is unnecessary and possibly harmful. This issue is a serious one for critical care nurses because moral distress can lead to burnout. p. 156

KEY CONCEPT E1 4. Which assessment findings might indicate respiratory depression after opioid administration? a. Flushed, diaphoretic skin b. Shallow respirations with a rate of 24 breaths/min c. Tense, rigid posture d. Snoring Q1

ANS: D- Snoring Snoring is a warning sign. It can be a sign of respiratory depression associated with airway obstruction by the tongue, leading to hypoxemia and possibly to cardiorespiratory arrest. A patient snoring after the administration of an opioid requires the critical care nurse to observe closely. Page 127-128

E1 Which statements are true regarding pain assessment and management? (Select all that apply.) a. The single most important assessment tool available to the nurse is the patient's self-report. b. The only way to assess pain in patients unable to verbalize because of mechanical ventilation is through observation of behavioral indicators. c. The concept of equianalgesia uses morphine as a basis for dosage comparison for other medications. d. Transcutaneous electrical nerve stimulation and application of heat or cold therapy stimulate the nonpain sensory fibers. e. Meperidine, a synthetic form of morphine, is much stronger and is given at lower doses at less frequent intervals.

ANS: A, C, D Appropriate pain assessment is the foundation of effective pain treatment. Because pain is recognized as a subjective experience, the patient's self-report is considered the most valid measure for pain and should be obtained as often as possible. Unfortunately, in critical care, many factors, such as the administration of sedative agents, the use of mechanical ventilation, and altered levels of consciousness, may impact communication with patients. >>>These obstacles make pain assessment more complex. Meperidine (Demerol) is a less potent opioid with agonist effects similar to those of morphine. It is considered the weakest of the opioids, and it must be administered in large doses to be equivalent in action to morphine. Because the duration of action is short, dosing is frequent. Equianalgesic means approximately the same pain relief. Dosages in the equianalgesic chart for moderate to severe pain are not necessarily starting doses. The doses suggest a ratio for comparing the analgesia of one medication with another.

KEY CONCEPT CH #14 EXAM 1 E1 Which of the following clinical manifestations are indicative of left ventricular failure? (Select all that apply.) a. Cool, pale extremities b. Jugular venous distention c. Liver tenderness d. Weak peripheral pulses e. Rales

ANS: A, D, E Patients presenting with left ventricular failure have one of the following: (1) decreased exercise tolerance (2) fluid retention (3) discovery during an examination of noncardiac problems. Clinical manifestations of left ventricular failure include decreased peripheral perfusion with weak or diminished pulses; cool, pale extremities; and, in later stages, peripheral cyanosis

CH 15 E1 7. Which finding is a reliable indicator of reperfusion after fibrinolytic therapy? a. Dysrhythmias b. Q waves c. Elevated ST segments d. An immediate rapid decrease in cardiac biomarkers p. 373

ANS: A- Dysrhythmias Initially, when there is reperfusion, ischemic chest pain ceases abruptly as blood flow is restored. Another reliable indicator of reperfusion is the appearance of various "reperfusion" dysrhythmias. Premature ventricular contractions, bradycardias, heart block, ventricular tachycardia, and (rarely) ventricular fibrillation may occur. Reperfusion therapy is a medical treatment to restore blood flow, either through or around, blocked arteries, typically after a heart attack (myocardial infarction (MI)). Reperfusion therapy includes drugs and surgery. The drugs are thrombolytics and fibrinolytic used in a process called thrombolysis.

E1 16. The nurse is caring for a patient with patient-controlled analgesia (PCA). The patient's spouse asks about the advantages of using this type of pain management therapy. What should the nurse say to the spouse? a. "The method allows the patient to act preemptively by administering a bolus of medication when pain begins." b. "This method allows the patient to choose between an opioid and a nonopioid medication to control pain." c. "This method decreases the risk of respiratory depression and other side effects." d. "This method allows for the rise and fall of the blood level of the opioid." Page 130

ANS: A-"The method allows the patient to act preemptively by administering a bolus of medication when pain begins." The patient can self-administer a bolus of medication the moment the pain begins, acting preemptively. Allowing the patient to self-administer opioid doses does not diminish the role of the critical care nurse in pain management. The nurse advises about necessary changes to the prescription and continues to monitor the effects of the medication and doses. The patient is closely monitored during the first 2 hours of therapy and after every change in the prescription. If the patient's pain does not respond within the first 2 hours of therapy, a total reassessment of the pain state is essential. If the patient is pressing the button to bolus medication more often than the prescription, the dose may be insufficient to maintain pain control. Naloxone must be readily available to reverse adverse opiate respiratory effects.

KEY CONCEPT CH #14 4. One differentiating factor between stable angina and unstable angina is that stable angina a. responds predictably well to nitrates. c. has a low correlation to CAD. b. is not precipitated by activity. d. is a result of coronary artery spasm. Page 298 Q3

ANS: A-. responds predictably well to nitrates Pain control is achieved by rest and by sublingual nitroglycerin within 5 minutes. Stable angina is the result of fixed lesions (blockages) of more than 75% of the coronary artery lumen. Ischemia and chest pain occur when myocardial demand from exertion exceeds the fixed blood oxygen supply.

E1 21. A patient is admitted to the critical care unit with right- and left-sided heart failure. The nurse's assessment reveals that the patient has 3+ pitting edema on the sacrum, blood pressure of 176/98 mm Hg, and bilateral crackles in the lungs. The patient is experiencing shortness of breath and chest discomfort. Increased afterload is probably present related to the patient's blood pressure. Which therapeutic measure will most likely decrease afterload in this patient? a. Administration of vasodilators b. Placement in high Fowler position c. Elevation of extremities d. Increasing intravenous fluids

ANS: A-Administration of vasodilators Therapeutic management to decrease afterload is aimed at decreasing the work of the heart with the use of vasodilators. Placing the patient in high Fowler position will cause an increase in the workload of the heart. Elevation of the extremities will ease the venous return back to the heart. Increasing IV fluids will cause an increased workload on the heart. Page 179 Under Afterload Increased afterload includes vasoconstriction(increased systemic vascular resistance) The pt needs a Vasodialotor for therapeutic management of the heart.

E1 29. What two medications are commonly prescribed at discharge for patients who have had a coronary artery stent placed? a. Aspirin and prasugrel b. Aspirin and abciximab c. Clopidogrel and eptifibatide d. Tirofiban and tricagrelor

ANS: A-Aspirin and prasugrel Because platelet activation is a complex process involving multiple pathways, combination therapy with two or more agents has proven most effective. The current standard of care for percutaneous coronary intervention typically includes dual antiplatelet therapy with aspirin and a thienopyridine. These oral agents are administered before the procedure and continued at discharge. Abciximab, eptifibatide, and tirofiban are all intravenous antiplatelet agents. p. 376|Table 15-5

KEY CONCEPT CH #14 E1 17. Which of the following clinical manifestations is usually the first symptom of peripheral arterial disease (PAD)? a. Cramping when walking b. Pulmonary embolism c. Thrombophlebitis d. Cordlike veins Page 346

ANS: A-Cramping when walking Arterial occlusion obstructs blood flow to the distal extremity. The lack of blood flow produces ischemic muscle pain known as intermittent claudication. This cramping, aching pain while walking is often the first symptom of peripheral arterial occlusive disease. The pain is relieved by rest and may remain stable in occurrence and intensity for many years.

KEY CONCEPT E1 11. A patient was admitted 5 days ago and has just been weaned from mechanical ventilation. The patient suddenly becomes confused, seeing nonexistent animals in the room and pulling at the bedding. The nurse suspects the patient may be experiencing what issue? a. Delirium b. Hypoxemia c. Hypocalcemia d. Sedation withdrawal Q1

ANS: A-Delirium Delirium is represented by a global impairment of cognitive processes, usually of sudden onset, coupled with disorientation, impaired short-term memory, altered sensory perceptions (hallucinations), abnormal thought processes, and inappropriate behavior. There is no evidence provided that would indicate the patient is hypoxemic, hypocalcemic, or going through sedation withdrawal. Page 141

E1 5. A patient presents with atrial fibrillation, a heart rate of 156 beats/min, and a blood pressure of 124/76 mm Hg. The physician orders diltiazem, a calcium channel blocker, to be given slowly by intravenous push. Why did the physician choose this medication to treat this patient's atrial tachyarrhythmia? a. Diltiazem decreases the calcium influx into the AV nodal tissue and decreases the speed of impulse conduction. b. Diltiazem increases the calcium influx into the AV nodal tissue and decreases the speed of impulse conduction. c. Diltiazem decreases the calcium influx into the myocardial tissue and decreases the strength of heart contraction. d. Diltiazem increases the calcium influx into the myocardial tissue and decreases the strength of heart contraction.

ANS: A-Diltiazem decreases the calcium influx into the AV nodal tissue and decreases the speed of impulse conduction. Calcium channel-blocking drugs, such as verapamil and diltiazem, inhibit the inward Ca++ current into pacemaker tissue, especially the AV node. For this reason, they are used therapeutically to slow the rate of atrial tachydysrhythmias and protect the ventricle from excessive atrial impulses. Page 175- calcuim & actin combo results in mechanism known as cross bridging cycle= results in the myocardial contraction that spreads throughout the myocardium. Diltiazem decreases calcium = a decrease in impulse conduction. Iggy 629-630

1 Ch. 13-2 50. Which of the following has become the first-line hemodynamic assessment tool in the critical care unit? a. Echocardiogram b. Exercise stress test c. ECG d. 24-hour Holter monitor

ANS: A-Echocardiogram Echocardiography is quickly becoming a first-line hemodynamic assessment tool in critical care units. Echocardiography is used to detect structural heart abnormalities such as mitral valve stenosis and regurgitation, prolapse of mitral valve leaflets, aortic stenosis and insufficiency, hypertrophic cardiomyopathy, atrial septal defect, thoracic aortic dissection, cardiac tamponade, and pericardial effusion.

E1 26. The patient is 72 hours postoperative for a coronary artery bypass graft (CABG). The patient's vital signs include temperature 103° F, heart rate 112, respiratory rate 22, blood pressure 134/78 mm Hg, and O2 saturation 94% on the 3L nasal cannula. The nurse suspects that the patient has developed what problem? a. Infection and notifies the physician immediately b. Infection, which is common postoperatively, and monitors the patient's condition c. Cardiac tamponade and notifies the physician immediately d. Delirium caused by the elevated temperature

ANS: A-Infection and notifies the physician immediately Postoperative fever is fairly common after cardiopulmonary bypass. However, persistent temperature elevation to greater than 101° F (38.3° C) must be investigated. Sternal wound infections and infective endocarditis are the most devastating infectious complications, but leg wound infections, pneumonia, and urinary tract infections also can occur. A potentially lethal complication, cardiac tamponade may occur after surgery if blood accumulates in the mediastinal space, impairing the heart's ability to pump. Signs of tamponade include elevated and equalized filling pressures (eg, central venous pressure, pulmonary artery diastolic pressure, pulmonary artery occlusion pressure), decreased cardiac output, decreased blood pressure, jugular venous distention, pulsus paradoxus, muffled heart sounds, sudden cessation of chest tube drainage, and a widened cardiac silhouette on radiographs. The risk of delirium is increased in cardiac surgery patients, especially elderly patients, and is associated with increased mortality rates and reduced quality of life and cognitive function. Nursing staff can play a critical role in the prevention and recognition of delirium.

KEY CONCEPT Developing an organizational policy that supports unobstructed access to the ethics committee by health care team members is one example of a proactive approach to dealing with what issue? a.Moral distress b.Surrogate decision-makers c.Paternalism d.Patient advocacy Q1

ANS: A-Moral distress Every organization must develop policies that support unobstructed access to resources such as the ethics committees to mitigate the harmful effects of moral distress in the pursuit of creating a healthy work environment pp. 12-13-Box 2-1

E1 20. A patient is undergoing ventricular pacing via a transvenous pacing lead. The nurse notes a pacing artifact, but it is not followed by a QRS on the electrocardiogram (ECG) monitoring. Which nursing intervention may correct this situation? a. Position the patient on the left side b. Decrease the milliamperes as ordered c. Increase the rate as ordered d. Monitor the patient in a different lead

ANS: A-Position the patient on the left side The patient is experiencing "loss of capture," which most often can be attributed either to the: 1. Displacement of the pacing electrode 2. An increase in threshold as a result of drugs, metabolic disorders, electrolyte imbalances, or fibrosis or myocardial ischemia at the site of electrode placement. In many cases, increasing the output milliamperes (mA) may elicit capture. For transvenous leads, repositioning the patient to the left side may improve lead contact and restore capture. p. 365

E1 20. A sudden increase in left atrial pressure, acute pulmonary edema, and low cardiac output, caused by the ventricle contracts during systole, are all characteristics of: a. acute mitral regurgitation. b. aortic insufficiency. c. chronic mitral regurgitation. d. pericardial friction rub. Page-195

ANS: A-acute mitral regurgitation. Acute mitral regurgitation occurs when the ventricle contracts during systole and a jet of blood are sent in a retrograde manner to the left atrium, causing a sudden increase in left atrial pressure, acute pulmonary edema, and low CO and leading to cardiogenic shock. Chronic mitral regurgitation is auscultated in the mitral area and occurs during systole. It is high pitched and blowing, although the pitch and intensity vary, depending on the degree of regurgitation. As mitral regurgitation progresses, the murmur radiates more widely. Aortic insufficiency is an incompetent aortic valve. If the valve cusps do not maintain this seal, the sound of blood flowing back into the left ventricle during diastole is heard as a decrescendo, high-pitched, blowing murmur. A pericardial friction rub is a sound that can occur within 2 to 7 days after a myocardial infarction. The friction rub results from pericardial inflammation (pericarditis). Classically, a pericardial friction rub is a grating or scratching sound that is both systolic and diastolic, corresponding to cardiac motion within the pericardial sac.

CH 12 E1 3. The purpose of the Allen test is to a. assess adequate blood flow through the ulnar artery. b. occlude the brachial artery and evaluate hypoxemia to the hand. c. test the patency of an internal graft. d. determine the size of needle to be used for puncture.

ANS: A-assess adequate blood flow through the ulnar artery. The Allen test assesses the adequacy of blood flow to the hand through the ulnar artery. Page 190-Box 12.6 Before a radial artery is punctured or cannulated, the Allen test is preformed to assess blood flow to the hand & insure that it is adequate. This can be down both visually or by pulse oximetry-see Box 12.6

KEY CONCEPT CH #14 E1 9. Clinical manifestations of right-sided heart failure include a. elevated central venous pressure and sacral edema. b. pulmonary congestion and jugular venous distention. c. hypertension and chest pain. d. liver tenderness and pulmonary edema. Page 320

ANS: A-elevated central venous pressure and sacral edema. The common manifestations of right ventricular failure are the following: jugular venous distention, elevated central venous pressure, weakness, peripheral or sacral edema, hepatomegaly (enlarged liver), jaundice, and liver tenderness. Gastrointestinal symptoms include poor appetite, anorexia, nausea, and an uncomfortable feeling of fullness.

E1 8. When assessing a patient with PVCs, the nurse knows that the ectopic beat is multifocal because it appears??? (PVC=Premature Ventricular Contractions) a. in various shapes in the same lead. c. to widen the QRS width. b. with increasing frequency. d. In a specific pattern in the same lead.

ANS: A-in various shapes in the same lead. If the ventricular ectopic beats are of various shapes in the same lead, they are multifocal. Multifocal ventricular ectopics are more serious than unifocal ventricular ectopics because they indicate a greater area of irritable myocardial tissue and are more likely to deteriorate into ventricular tachycardia or fibrillation. Page-259 & 260 Fig 13.68A & 13.68B

KEY CONCEPT E1 Ch. 13-2 45. The patient has an HR of 84 beats/min and an SV of 65 mL. Calculate the CO. a. 149 mL c. 4650 mL b. 500 mL d. 5460 mL

ANS: D- 5460 mL Cardiac output (CO) is the product of heart rate (HR) multiplied by stroke volume (SV). SV is the volume of blood ejected by the heart during each beat (reported in milliliters). 84 x 65 = 5460 mL

KEY CONCEPT E1 Which patients would be a candidate for fibrinolytic therapy? (Select all that apply.) a. The patient's chest pain started 8 hours ago. She has a diagnosis of non-ST-elevation myocardial infarction (NSTEMI). b. The patient's chest pain started 3 hours ago, and her electrocardiogram (ECG) shows a new left bundle branch block. c. The patient presents to the emergency department with chest pain of 30 minutes' duration. She has a history of a cerebrovascular accident 1 month ago. d. The patient has a history of unstable angina. He has been experiencing chest pain with sudden onset. e. The patient's chest pain started 1 hour ago, and his ECG shows ST elevation.

ANS: B, E Eligibility criteria for administering fibrinolytic include chest pain of fewer than 12 hours' duration and persistent ST elevation. Exclusion criteria include recent surgery, cerebrovascular accident, and trauma. pp. 370-371

E1 Ch. 13-2 48. Ventricular tachycardia has which of the following hemodynamic effects? a. Decreased cardiac output from increased ventricular filling time b. Decreased cardiac output from decreased stroke volume c. Decreased cardiac output from increased preload d. Decreased cardiac output from decreased afterload

ANS: B- Decreased cardiac output from decreased stroke volume Tachycardia is detrimental to anyone with ischemic heart disease because it decreases the time for ventricular filling, decreases stroke volume, and compromises cardiac output. Tachycardia increases heart work and myocardial oxygen demand while decreasing oxygen supply by decreasing coronary artery filling time.

E1 11. Which of the following statements regarding beta-blockers is correct? a. They increase heart rate and are contraindicated in tachydysrhythmias. b. They result in bronchospasm and should not be used in patients with chronic obstructive pulmonary disease (COPD). c. They increase cardiac output and help with left ventricular failure. d. They are helpful in increasing atrioventricular node conduction and are used in heart blocks. Q-3 & Test 1

ANS: B- Results in bronchospasm and should not be used in patients with chronic obstructive pulmonary disease (COPD). Knowledge of the effects of adrenergic-receptor stimulation allows for anticipation of not only the therapeutic responses brought about by beta-blockade but also the potential adverse effects of these agents. For example, bronchospasm can be precipitated by noncardioselective beta-blockers in a patient with chronic obstructive pulmonary disease secondary to blocking the effects of beta2 receptors in the lungs. p. 399

E1 15. A patient has been taking Demerol 50 mg tablets three times a day for the past 5 years for chronic back pain; however, the patient complains that the medication is not providing the same level of pain relief as it once did. Based on this statement the nurse suspects that the patient has developed what problem? a. Addiction b. Tolerance c. Physical dependence d. Physical withdrawal

ANS: B- Tolerance The patient has developed a tolerance to the medication. Tolerance is defined as a diminution of opioid effects over time. Addiction is defined by a pattern of compulsive drug use that is characterized by an incessant longing for an opioid and the need to use it for effects other than pain relief. Physical dependence to opioids may develop if the medication is given over a long period. Physical dependence is manifested by withdrawal symptoms when the opioid is abruptly stopped. Page 125

E1 15. Through what mechanism does enalapril decrease blood pressure? a. Direct arterial vasodilation b. Block the conversion of angiotensin I to angiotensin II c. Increase fluid excretion at the loop of Henle d. Peripheral vasoconstriction and central vasodilation. Test 1

ANS: B-Block the conversion of angiotensin I to angiotensin II Enalapril is an angiotensin-converting enzyme (ACE) inhibitors that produce vasodilation by blocking the conversion of angiotensin I to angiotensin II. Because angiotensin is a potent vasoconstrictor, limiting its production decreases peripheral vascular resistance. In contrast to the direct vasodilators and nifedipine, ACE inhibitors do not cause reflex tachycardia or induce sodium and water retention. p. 404

E1 9. Which mechanism is responsible for the augmentation of coronary arterial blood flow and increased myocardial oxygen supply seen with the intraaortic balloon pump? a. The vacuum created in the aorta as a result of balloon deflation b. Diastolic inflation with retrograde perfusion c. Forward flow to the peripheral circulation d. Inflation during systole to augment blood pressure Exam 1

ANS: B-Diastolic inflation with retrograde perfusion The blood volume in the aorta below the level of the balloon is propelled forward toward the peripheral vascular system, which may enhance renal perfusion. Subsequently, the deflation of the balloon just before the opening of the aortic valve creates a potential space or vacuum in the aorta, toward which blood flows unimpeded during ventricular ejection. This decreased resistance to left ventricular ejection, or decreased afterload, facilitates ventricular emptying and reduces myocardial oxygen demands. p. 391

KEY CONCEPT E1 5. Which of the following criteria are representative of the patient in normal sinus rhythm? a. Heart rate, 64 beats/min; rhythm regular; PR interval, 0.10 second; QRS, 0.04 second b. Heart rate, 88 beats/min; rhythm regular; PR interval, 0.18 second; QRS, 0.06 second c. Heart rate, 54 beats/min; rhythm regular; PR interval, 0.16 second; QRS, 0.08 second d. Heart rate, 92 beats/min; rhythm irregular; PR interval, 0.16 second; QRS, 0.04 second

ANS: B-Heart rate, 88 beats/min; rhythm regular; PR interval, 0.18 second; QRS, 0.06 second The parameters for normal sinus rhythm are heart rate, 60 to 100 beats/min; rhythm, regular; PR interval, 0.12 to 0.20 second; and QRS, 0.06 to 0.10 second. Page- 250-251 Page- Fig 13.56

E1 17. What is the most common complaint heard from families of dying patients? a. Poor nursing care b. Inadequate communication c. Lack of consistent plan of care d. Confusion among health care team members

ANS: B-Inadequate communication Communication seems to be the most common source of complaints in families across studies and should be at the center of efforts to improve end-of-life care. Families have commonly complained about infrequent physician communication, unmet communication needs in the shift from aggressive to end-of-life care, and lacking or inadequate communication. p. 151

CH 2 KEY CONCEPT E1 A patient's wife has been informed by the practitioner that her spouse has permanent quadriplegia. The wife states that she does not want anyone to tell the patient about his injury. The patient asks the nurse about what has happened. The nurse has conflicting emotions about how to handle the situation. What is the nurse experiencing? a.Autonomy b.Moral distress c.Moral doubt d.Moral courage

ANS: B-Moral Distress The nurse has been placed in a situation initially causing moral distress and is struggling with determining the ethically appropriate action to take. Moral courage is the freedom to advocate for oneself, patients, and peers. Autonomy is an ethical principle. Moral doubt is not part of the American Association of Critical-Care Nurses (AACN) framework. The 4A's to Rise Above Moral Distress Page 12

KEY CONCEPT E1 2. What are the neural processes of encoding and processing noxious stimuli associated with pain called? a. Perception b. Nociception c. Transduction d. Transmission

ANS: B-Nociception Nociception represents the neural processes of encoding and processing noxious stimuli necessary, but not sufficient, for pain. Transduction refers to mechanical (eg, surgical incision), thermal (eg, burn), or chemical (eg, toxic substance) stimuli that damage tissues. As a result of transduction, an action potential is produced and is transmitted by nociceptive nerve fibers in the spinal cord that reach higher centers of the brain. This is called transmission, and it represents the second process of nociception. Pain sensation transmitted by the nervous system (NS) pathway reaches the thalamus, and the pain sensation transmitted by the parasympathetic nervous system (PS) pathway reaches brainstem, hypothalamus, and thalamus. These parts of the central nervous system (CNS) contribute to the initial perception of pain. Page 115

KEY CONCEPT E1 10. Which portion of the ECG is most valuable in diagnosing atrioventricular (AV) conduction disturbances? a. P wave b. PR interval c. QRS complex d. QT interval Page- 267 & 268 3 degrees of AV (atrioventricular conduction) 1st @AV node=slow "P" wave conduction 2ndX2: Mobitz type 1 (Wenckebach block): @ AV conduction-Final "P "wave not conducted Mobitz type Two: @ Bundle of His (Purkinje fibers)-SINUS "P" waves are not conducted 3rd Complete heart block or AV dissociation: No atrial impulses conduct to the ventricles.

ANS: B-PR interval The PR interval is an indicator of atrioventricular nodal function. The P wave represents atrial depolarization. The QRS complex represents ventricular depolarization, corresponding to phase 0 of the ventricular action potential. The QT interval is measured from the beginning of the QRS complex to the end of the T wave and indicates the total time interval from the onset of depolarization to the completion of repolarization.

E1 KEY CONCEPT 13. Which of the following patients is MOST likely to be experiencing a life-threatening opioid side effect? a. Patient with respiratory rate of 10 breaths/min who is breathing deeply b. Patient with a respiratory rate of 8 breaths/min who is snoring c. Patient with blood pressure of 150/75 mm Hg and heart rate of 102 beats/min d. Patient with a temperature of 100.5° F who is asleep but easily roused

ANS: B-Patient with a respiratory rate of 8 breaths/min who is snoring Although no universal definition of respiratory depression exists, it is usually described in terms of decreased respiratory rate (fewer than 8 or 10 breaths/min), decreased SpO2 levels, or elevated ETCO2 levels. A change in the patient's level of consciousness or snoring is a warning sign. It can be a sign of respiratory depression associated with airway obstruction by the tongue, leading to hypoxemia and possibly to cardiorespiratory arrest. A patient snoring after the administration of an opioid requires the critical care nurse to observe closely. Page 128

E1 28. What is the preferred initial treatment of an acute myocardial infarction? a. Fibrinolytic therapy b. Percutaneous coronary intervention (PCI) c. Coronary artery bypass surgery (CABG) d. Implanted Cardioverter Defibrillator (ICD)

ANS: B-Percutaneous coronary intervention (PCI) Percutaneous coronary intervention (PCI) is now preferred as the initial method of treatment for acute myocardial infarction (MI; primary PCI). PCI includes balloon angioplasty, atherectomy, and stent implantation, as well as a number of adjunctive devices used to facilitate successful revascularization in coronary vessels. p. 374

E1 13. A patient was admitted 5 days ago and has just been weaned from mechanical ventilation. The patient suddenly becomes confused, seeing nonexistent animals in the room and pulling at the bedding. What parameter should be monitored while the patient is haloperidol? a. Sedation level b. QTc-interval c. Oxygen saturation level d. Brain waves

ANS: B-QTc-interval Electrocardiogram (ECG) monitoring is recommended because haloperidol use can produce dose-dependent QTc-interval prolongation, with an increased incidence of ventricular dysrhythmias. BIS monitoring is indicated for deep sedation use. Page 141

E1 A practitioner and nurse are performing a dressing change on an unresponsive patient in room 14. The practitioner asks the nurse for an update on the patient in room 13. Which action should the nurse take next? a.Give the update to the practitioner. b.Refuse to give the update because of Health Insurance Portability and Accountability Act (HIPAA) requirements. c.Give the update because the is patient's unconscious. d.Refuse to give the update because of Occupational Safety and Health Administration (OSHA) requirements.

ANS: B-Refuse to give the update because of Health Insurance Portability and Accountability Act (HIPAA) requirements. Most specific to critical care clinicians is the privacy and confidentiality related to protection of health care data. This has implications when interacting with family members and others and the often very close work environments, tight working spaces, and emergency situations. A patient's unconscious state is not a reason for another patient's care to be discussed in his or her presence. Research shows hearing is the last sense to deteriorate. Occupational Safety and Health Administration (OSHA) has to do with safety in the workplace, not privacy and confidentiality.

CH 11 E1 2. The atrioventricular (AV) node delays the conduction impulse from the atria (0.8-1.2 seconds) for which of the following reasons? a. To limit the amount of blood that fills the ventricle from the atria b. To provide time for the ventricles to fill during diastole c. To limit the number of signals the ventricles receive in some rhythms d. To allow the atria to rest between signals

ANS: B-To provide time for the ventricles to fill during diastole The AV node delays the conduction impulse from the atria (0.8-1.2 seconds) to provide time for the ventricles to fill during diastole. Page 165- The AV node is located in an area known as the Koch's Triangle & the AV node also controls the CONDUCTION IMPULSE transmitted from the atria to the ventricles.

KEY CONCEPT E1 Ch. 13-2 66. What is the effect of preload on cardiac output? a. As preload increases, cardiac output increases. b. As preload increases, cardiac output decreases. c. As preload increases, cardiac output increases until it overstretches the ventricle and cardiac output decreases. d. Increased preload has no effect on cardiac output.

ANS: C-As preload increases, cardiac output increases until it overstretches the ventricle and cardiac output decreases. According to the Frank-Starling law of the heart, if preload increases stroke volume, then cardiac output may increase. If, however, preload causes excessive left ventricular stretch, it can actually decrease cardiac output and may result in congestive heart failure.

KEY CONCEPT E1 25. Which of the following cardiac enzymes is a highly specific biomarker for myocardial damage? a. CK-MB b. Troponin I c. Troponin T d. LDH Page 271- Troponin I is found only in the cardiac muscle, it is a highley specific biomarker for myocardial damage. creatine kinase CK-MB is most significant in diagnosing an MI during the first 12 hours of chest pain Q2

ANS: B-Troponin I Because cTnI is found only in cardiac muscle, it is a highly specific biomarker for myocardial damage, considerably more specific than CK-MB. As a consequence, patients with a positive cTnI result and a negative CK-MB result usually rule in an acute myocardial infarction (MI). A negative cTnI result that remains negative many hours after an episode of chest pain is a strong indicator that the patient is not experiencing an acute MI. Even with a negative cTnI result, symptoms of chest pain still indicate that the patient should have a comprehensive cardiac evaluation to determine if there is an underlying CAD present that may later lead to complications.

CH #14 E1 10. An essential aspect of teaching that may prevent recurrence of heart failure is a. notifying the physician if a 2-lb weight gain occurs in 24 hours. b. compliance with diuretic therapy. c. taking nitroglycerin if chest pain occurs. d. assessment of an apical pulse. Page 326

ANS: B-compliance with diuretic therapy. Primary topics of education include (1) the importance of daily weight (2) fluid restrictions (3) written information about the multiple medications used to control the symptoms of heart failure. Reduction or cessation of diuretics usually results in sodium and water retention, which may precipitate heart failure.

E1 29. The most common complication of a central venous catheter (CVC) is a. air embolus. b. infection. c. thrombus formation. d. pneumothorax. Page-210

ANS: B-infection. Infection related to the use of CVCs is a major problem. The incidence of infection strongly correlates with the length of time the CVC has been inserted, with longer insertion times leading to a higher infection rate. The risk of air embolus, although uncommon, is always present for a patient with a central venous line in place. Air can enter during insertion through a disconnected or broken catheter by means of an open stopcock, or air can enter along the path of a removed CVC. Unfortunately, clot formation (thrombus) at the CVC site is common. Thrombus formation is not uniform; it may involve the development of a fibrin sleeve around the catheter, or the thrombus may be attached directly to the vessel wall. Pneumothorax has a higher occurrence during placement of a CVC than during removal.

E1 8. A 68-year-old patient is admitted to the critical care unit with reports of midchest pressure radiating into the jaw and shortness of breath when walking up stairs. The patient is admitted with a diagnosis of "rule out myocardial infarction." The history portion of the assessment should be guided by a.medical history. b. presenting symptoms. c. history of prior surgeries. d. a review of systems.

ANS: B-presenting symptoms For a patient in acute distress, the history taking is shortened to just a few questions about the patient's chief complaint, precipitating events, and current medications. For a patient who is not in obvious distress, the history focuses on the following four areas: review of the patient's present illness; overview of the patient's general cardiovascular status Review of the patient's general health status, including a family history of coronary artery disease (CAD), hypertension, diabetes, peripheral arterial disease, or stroke Survey of the patient's lifestyle, including risk factors for CAD.

E1 Truth-telling is an example of what ethical principle? a.Justice b.Beneficence c.Autonomy d.Nonmaleficence

ANS: C-Autonomy Truth-telling is an example of autonomy. p. 15-Box 2-2

CH 13 E1 1. A patient with a serum potassium level of 6.8 mEq/L may exhibit electrocardiographic changes of a. a prominent U wave. b. tall, peaked T waves. c. a narrowed QRS. d. sudden ventricular dysrhythmias. Q2 EXAM 1

ANS: B-tall, peaked T waves. Normal serum potassium levels are 3.5 to 4.5 mEq/L. Tall, narrow peaked T waves are usually, although not uniquely, associated with early hyperkalemia And are followed by a prolongation of the PR interval, loss of the P wave, widening of the QRS complex, heart block, and asystole. Severely elevated serum potassium (greater than 8 mEq/L) causes a wide QRS tachycardia. Page 271-under hypomagnesemia Page 271-Fig- 13.85 of hypokalemia on the ekg

E1 6. The major key to the clinical significance of atrial flutter is the a. atrial rate. b. ventricular response rate. c. PR interval. d. QRS duration. Page 254 & 255 Fig 13.62

ANS: B-ventricular response rate. The major factor underlying atrial flutter symptoms is the ventricular response rate. If the atrial rate is 300 and the atrioventricular (AV) conduction ratio is 4:1, the ventricular response rate is 75 beats/min and should be well tolerated. If, on the other hand, the atrial rate is 300 beats/min but the AV conduction ratio is 2:1, the corresponding ventricular rate of 150 beats/min may cause angina, acute heart failure, or other signs of cardiac decompensation.

CH #14 EXAM 1 E1 30. A patient is admitted for palliative care for end-stage heart failure. The nurse's primary goal is a. to reverse heart failure with the use of diuretics. b. to increase activity tolerance. c. symptom management and relief of pain. d. to increase cardiac output related to alteration of contractility.

ANS: C- symptom management and relief of pain. The primary aim of palliative care is symptom management and the relief of suffering. Fundamental to all symptom management strategies for heart failure is the optimization of medications, according to current guidelines. p. 325

CH 14 KEY CONCEPT CH #14 1. Data concerning coronary artery disease (CAD) and specific risk factors have demonstrated a. A low correlation of modifiable risk factors to CAD. b. The onset of CAD in middle age. c. An association between the development of specific risk factors and CAD. d. No decisive correlation between risk factors and CAD. Page 290 Q3- which statement about coronary artery disease (CAD) is accurate?

ANS: C-An association between the development of specific risk factors and CAD. Research and epidemiologic data collected during the past 50 years have demonstrated a strong association between specific risk factors and the development of CAD. In general, CAD symptoms are seen in persons age 45 years and older. Primary cardiovascular risk factors are different in men and women, with women having higher rates of diabetes and hypertension compared with men.

E1 14. Haloperidol is traditionally been used to manage which symptom? a. Anxiety b. Dyspnea c. Delirium d. Pain

ANS: C-Delirium Delirium is commonly observed in critically ill patients and in those approaching death. Haloperidol and benzodiazepines (such as midazolam, lorazepam) have traditionally been used to manage delirium but have side effects that can be problematic. More recently, atypical antipsychotics have proven equally effective without troubling side effects of other drug classes. Dyspnea is best managed with close evaluation of the patient and the use of opioids, sedatives, and nonpharmacologic interventions (oxygen, positioning, and increased ambient air flow). Benzodiazepines, especially midazolam with its rapid onset and short half-life, are frequently used to treat anxiety. Morphine is the most common drug used for pain management. p. 154

E1 KEY CONCEPT 18. The patient has received ketamine for its analgesic effects. The patient suddenly states, "I feel like I am floating and can see everything you are doing. I am not in control." What is this response called? a. Hallucination state b. Guided imagery c. Dissociative state d. Adverse event

ANS: C-Dissociative state Before administering ketamine, the dissociative state should be explained to the patient. Dissociative state refers to the feelings of separateness from the environment, loss of control, hallucinations, and vivid dreams. The use of benzodiazepines (eg, midazolam) can reduce the incidence of this unpleasant effect. Page 130

KEY CONCEPT A practitioner is suggesting treatments to a patient that are contrary to the patient's preferences. What is this practice called? a.Invaluable deficiency b.Physiologic uselessness c.Ethical futility d.Situational insufficiency Q1

ANS: C-Ethical futility Ethical futility is treatment that will not serve the underlying interests, values, and preferences of the patient such as when a practitioner's idea of benefit is contrary to the values and preferences of the patient. Page 18

E1 11. Why use a specific pain intensity scale in the critical care unit? a. It eliminates the subjective component from the assessment. b. It focuses on the objective component of the assessment. c. It provides consistency of assessment and management. d. It provides a way to interpret physiologic indicators. Q1

ANS: C-It provides consistency of assessment and management. Many critical care units use a specific pain intensity scale because a single tool provides consistency of assessment, management, and documentation. A pain intensity scale is useful in the critical care environment. Asking the patient to grade his or her pain on a scale of 0 to 10 is a consistent method and aids the nurse in objectifying the subjective nature of the patient's pain. However, the patient's tool preference should be considered. Page 123

E1 21. Which serum lipid value is a significant predictor of future acute MI in persons with established coronary artery atherosclerosis? a. High-density lipoprotein (HDL) b. Triglycerides c. Low-density lipoprotein (LDL) d. Very-low-density lipoprotein

ANS: C-Low-density lipoprotein (LDL) Both the LDL-C and total serum cholesterol levels are directly correlated with risk for coronary artery disease, and high levels of each are significant predictors of future acute myocardial infarction in persons with established coronary artery atherosclerosis. LDL-C is the major atherogenic lipoprotein and thus is the primary target for cholesterol-lowering efforts. Page 292 Page 291-Table 14.2

E1 Ch. 13-2 46. After an MI, a patient presents with an increasing frequency of PVCs. The patient's heart rate is 110 beats/min, and ECG indicates a sinus rhythm with up to five unifocal PVCs per minute. Which of the following should be done? The patient is alert and responsive and denies any chest pain or dyspnea. a. Administer lidocaine 100 mg bolus IV push stat. b. Administer Cardizem 20 mg IV push stat. c. Notify the physician and monitor the patient closely. d. Nothing; PVCs are expected in this patient.

ANS: C-Notify the physician and monitor the patient closely. Although premature ventricular contractions (PVCs) are frequently present after myocardial infarction, they are not always benign. In individuals with underlying heart disease, PVCs or episodes of self-terminating ventricular tachycardia (VT) are potentially malignant. Nonsustained VT is defined as three or more consecutive premature ventricular beats at a rate faster than 110 beats/min lasting less than 30 seconds. The patient does not appear symptomatic from the PVCs at this time; therefore, lidocaine is not indicated. Cardizem is not prescribed for ventricular ectopy.

KEY CONCEPT E1 By what action can critical care nurses best enhance the principle of autonomy? a. Presenting only the information to prevent relapse in a patient b. Assisting with only tasks that cannot be done by the patient c. Providing the patient with all of the information and facts d.Guiding the patient toward the best choices for care

ANS: C-Providing the patient with all of the information and facts Patients and families must have all the information about a certain situation to make an autonomous decision that is best for them. Page 15-16

E1 20. A patient is admitted to the critical care unit with right- and left-sided heart failure. The nurse's assessment reveals that the patient has 3+ pitting edema on the sacrum, blood pressure of 176/98 mm Hg, and bilateral crackles in the lungs. The patient is experiencing shortness of breath and chest discomfort. On the basis of this information, how would the nurse evaluate the patient's preload status? a. The patient is hypovolemic and has too little preload. b. The patient is experiencing CHF and has too little preload. c. The patient is experiencing heart failure and has too much preload. d. The patient is hypertensive and the preload is not a factor.

ANS: C-The patient is experiencing heart failure and has too much preload. Whereas a patient with hypovolemia has too little preload, a patient with heart failure has too much preload. Page-178 & 179

22. Why are vasopressors used cautiously in the treatment of critical care patients? a. They cause vasoconstriction of the smooth muscles. b. They cause vasodilation of the smooth muscles. c. They increase afterload. d. They decrease preload. Exam 1

ANS: C-They increase afterload. Vasopressors are not widely used in the treatment of critically ill cardiac patients because the dramatic increase in afterload is taxing to a damaged heart. Vasopressin, also known as antidiuretic hormone, has become popular in the critical care setting for its vasoconstrictive effects. At higher doses, vasopressin directly stimulates V1 receptors in vascular smooth muscle, resulting in vasoconstriction of capillaries and small arterioles. p. 405

KEY CONCEPT E1 Ch. 13-2 44. Which of the following is most often found in ventricular dysrhythmias? a. Retrograde P waves b. No P waves c. Wide QRS complexes d.An inverted T wave Page

ANS: C-Wide QRS complexes Ventricular dysrhythmias result from an ectopic focus in any portion of the ventricular myocardium. The usual conduction pathway through the ventricles is not used, and the wave of depolarization must spread from cell to cell. As a result, the QRS complex is prolonged and is always greater than 0.12 second. It is the width of the QRS, not the height, that is important in the diagnosis of ventricular ectopy.

KEY CONCEPT E1 15. The mean arterial pressure (MAP) is calculated by a. averaging three of the patient's blood pressure readings over a 6-hour period. b. dividing the systolic pressure by the diastolic pressure. c. adding the systolic pressure and two diastolic pressures and then dividing by 3. d. dividing the diastolic pressure by the pulse pressure.

ANS: C-adding the systolic pressure and two diastolic pressures and then dividing by 3. The mean arterial pressure is one-third systole and two-thirds diastole. Page 169 Page 170-Fig 11.15 Page 201-202 Page 203 Table 13.1

11. The outermost layer of the artery that helps strengthen and shape the vessel is the? (Trick question) a. tunica. b. intima. c. adventitia. d. media. The outer most layer of the Arterie-Specifically called tunica externa or/and tunica adventitia Just the word tunica alone is not correct

ANS: C-adventitia. The adventitia is the outermost layer of the artery that helps strengthen and shape the vessel. The media is the middle layer that is made up of smooth muscle and elastic tissue. The intima is the innermost layer consists of a thin lining of endothelium and a small amount of elastic tissue. Page 169

CH #14 E1 24. A patient with a diagnosis of CAD with chest pain is admitted into the critical care unit. The patient is suddenly awakened with severe chest pain. Three nitroglycerin sublingual tablets are administered 5 minutes apart without relief. A 12-lead ECG reveals nonspecific ST-segment elevation. This patient probably has? a. silent ischemia. b. stable angina. c. unstable angina. d. Prinzmetal angina.

ANS: C-unstable angina. Unstable angina usually is more intense than stable angina, may awaken the person from sleep, or may necessitate more than nitrates for pain relief. A change in the level or frequency of symptoms requires immediate medical evaluation. Severe angina that persists for more than 5 minutes, worsens in intensity, and is not relieved by one nitroglycerin tablet is a medical emergency. Patients become used to the pattern of this type of angina and may describe it as "my usual chest pain." Pain control should be achieved within 5 minutes of rest and by taking sublingual nitroglycerin. Stable angina is predictable and caused by similar precipitating factors each time; typically, it is exercise-induced. Silent ischemia describes a situation in which objective evidence of ischemia is observed on an electrocardiographic monitor but the person does not complain of anginal symptoms. Variant unstable angina, or Prinzmetal angina, is caused by a dynamic obstruction from intense vasoconstriction of a coronary artery. Spasm can occur with or without atherosclerotic lesions. Variant angina commonly occurs when the individual is at rest, and it is often cyclic, occurring at the same time every day.

CH #14 E1 7. The most frequent dysrhythmia seen initially with sudden cardiac death is a. premature ventricular contractions. b. ventricular fibrillation. c. ventricular tachycardia. d. asystole.

ANS: C-ventricular tachycardia. When the onset of symptoms is rapid, the most likely mechanism of death is ventricular tachycardia, which degenerates into ventricular fibrillation. Page 315

E1 4. ST segment monitoring for ischemia has gained increasing importance with the advent of thrombolytic therapy. The most accurate method for monitoring the existence of true ischemic changes is: a. T-wave inversion in leads overlying the ischemia. b. ST segment depression in leads overlying the ischemia. c. adjusting the gain control on bedside monitoring for best visualization. d. 12-lead ECG for confirmation.

ANS: D-12-lead ECG for confirmation. Cardiac biomarkers are proteins that are released from damaged myocardial cells. The initial elevation of cTnI, cTnT, and CK-MB occurs 3 to 6 hours after the acute myocardial damage. This means that if an individual comes to the emergency department as soon as chest pain is experienced, the biomarkers will not have risen. For this reason, it is a clinical practice to diagnose an acute myocardial infarction by 12-lead electrocardiography and clinical symptoms without waiting for the elevation of cardiac biomarkers. Page 271- Cardiac biomarkers Page 272-Natriuretic biomarkers Page 273-Fig 13.87

CH 10 E1 3. The patient's condition has deteriorated to the point where she can no longer make decisions about her own care. Which nursing interventions would be most appropriate? a. Obtain a verbal do-not-resuscitate (DNR) order from the practitioner. b. Continue caring for the patient as originally ordered because she obviously wanted this. c. Consult the hospital attorney for recommendations on how to proceed. d. Discuss with the family what the patient's wishes would be if she could make those decisions herself.

ANS: D-Discuss with the family what the patient's wishes would be if she could make those decisions herself. If the patient is not able to make end-of-life decisions for herself, her family members should be approached to discuss the next steps because they may have insight into what her wishes would be. p. 149

KEY CONCEPT E1 Which statement regarding the CODE OF ETHIC FOR NURSING is accurate? a. The Code of Ethics for Nurses is usurped by state or federal laws. b.It allows the nurse to focus on the good of society rather than the uniqueness of the patient. c.The Code of Ethics for Nurses was recently adopted by the American Nurses Association. d.It provides society with a set of expectations of the nursing profession. Q1

ANS: D-It provides society with a set of expectations of the nursing profession. The Code of Ethics for Nursing provides a framework for the nurse to follow in ethical decision making and provides society with a set of expectations of the profession. Page 19

KEY CONCEPT CH #14 E1 23. Which of the following cholesterol values indicates a heightened risk for the development of CAD? a. A total cholesterol level of 170 mg/dL c. Triglyceride level of 120 mg/dL b. HDL cholesterol level of 30 mg/dL d. LDL cholesterol level >190 mg/dL Page 291

ANS: D-LDL cholesterol level >190 mg/dL Low-density lipoprotein (LDL) cholesterol is usually described as the "bad cholesterol" because high levels are associated with an increased risk of acute coronary syndrome (ACS), stroke, and peripheral arterial disease (PAD). High LDL levels initiate the atherosclerotic process by infiltrating the vessel wall and binding to the matrix of cells beneath the endothelium. Total cholesterol levels below 200 are considered normal. High-density lipoprotein (HDL) cholesterol levels below 40 are at low risk of coronary artery disease. Triglyceride levels below 150 are considered normal.

KEY CONCEPT E1 What is the systematic decision-making model used by nurses termed? a.Nursing diagnosis b.Nursing interventions c.Nursing evaluations d.Nursing process Q-1

ANS: D-Nursing process The nursing process is a systematic decision-making model that is cyclic, not linear. An essential and distinguishing feature of any nursing diagnosis is that it describes a health condition. Nursing interventions constitute the treatment approach to an identified health alteration. Evaluation of attainment of the expected patient outcomes occurs formally at intervals designated in the outcome criteria.

CH 8 KEY CONCEPT 1. Which statement best describes the concept of pain? a. Pain is an uncomfortable experience present only in the patient with an intact nervous system. b. Pain is an unpleasant experience accompanied by crying and tachycardia. c. Pain is activation of the sympathetic nervous system from an injury. d. Pain is whatever the patient experiencing it says it is, occurring when that patient says it does .Q1

ANS: D-Pain is whatever the patient experiencing it says it is, occurring when that patient says it does . Pain is described as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. This definition emphasizes the subjective and multidimensional nature of pain. More specifically, the subjective characteristic implies that pain is whatever the person experiencing it says it is and that it exists whenever he or she says it does. Page 114

KEY CONCEPT E1 Ch. 13-2 39. A new-onset MI can be recognized by which of the following ECG changes? a. Q waves c. Widened QRS b. Smaller R waves d. ST segment elevation Page 301

ANS: D-ST segment elevation Any change from baseline is expressed in millimeters and may indicate myocardial ischemia (one small box equals 1 mm). ST segment elevation of 1 to 2 mm is associated with acute myocardial injury, preinfarction, and pericarditis. ST segment depression (decrease from baseline more of 1 to 2 mm) is associated with myocardial ischemia. Widened QRS complexes are indicative of ventricular depolarization abnormalities such as bundle branch blocks and ventricular dysrhythmias. Q waves and smaller R waves are indications usually present 24 hours to 1 week after the myocardial infarction is completely evolved; they represent necrosis.

E1 11. Which of the following findings would be indicative reasons to abort an exercise stress test? a. The ventricular axis of +90 b. Increase in blood pressure c. Inverted U wave d. ST-segment depression or elevation

ANS: D-ST-segment depression or elevation Signs that can alert the nurse to stop the test include ST segment elevation equal to or greater than 1.0 mm (one small box) or ST depression equal to or greater than 2.0 mm (2 small boxes). Blood pressure is expected to rise during exercise, but a systolic blood pressure greater than 250 mm Hg or a diastolic blood pressure greater than 115 mm Hg is considered high enough to stop the test. Parameters for ventricular axis in degrees are ?2-30° to +90°. Left-axis deviation is present if the axis falls between ?2-30° and ?2-90°.

KEY CONCEPT E1 14. What is the most common contributing factor to the development of delirium in critically ill patients? a.Sensory overload b.Hypoxemia c.Electrolyte disturbances d.Sleep deprivation

ANS: D-Sleep deprivation Delirium is frequently associated with a critical illness. The provision of adequate sleep and early mobilization are recommended to reduce the incidence of delirium. Page 141

E1 14. A patient is admitted with left-sided heart failure and blood pressure of 220/118 mm Hg. Which drug will be most effective in decreasing the blood pressure and reducing afterload? a. Dopamine b. Verapamil c. Propranolol d. Sodium nitroprusside Test 1

ANS: D-Sodium nitroprusside Sodium nitroprusside (Nipride) is a potent, rapidly acting venous and arterial vasodilator, particularly suitable for rapid reduction of blood pressure in hypertensive emergencies and perioperatively. It also is effective for afterload reduction in the setting of severe heart failure. The drug is administered by continuous intravenous infusion, with the dosage titrated to maintain the desired blood pressure and systemic vascular resistance. p. 403|Table 15-19

KEY CONCEPT CH #14 E1 15. Which medication may be administered to the patient with a hypertensive crisis? a.Digitalis c.Verapamil b.Vasopressin d.Sodium nitroprusside Page 352-353

ANS: D-Sodium nitroprusside Sodium nitroprusside is frequently the first drug used to lower blood pressure in a hypertensive emergency. Sodium nitroprusside is useful because of its half-life of seconds. It is not suitable for long-term use because of the development of a metabolite that causes cyanide-like toxicity. Short-acting beta-blockers that are effective are labetalol and esmolol. Beta-blockers are especially effective if aortic dissection is present. Digoxin is frequently prescribed for atrial fibrillation.

KEY CONCEPT E1 CH #14 3. A patient is admitted to the critical care unit with VS: BP 220/110, P 108, RR 24, T 103F, and O2 sat 94% on oxygen 2L/NC. The patient is responsive and denies chest pain. The physician has ordered a workup for CAD. The nurse expects the admitting diagnosis to be which of the following? a. Hypotension b. Prehypertension c. Stage 1 hypertension d. Stage 2 hypertension

ANS: D-Stage 2 hypertension Stage 2 hypertension is defined as a systolic blood pressure of 160 mm Hg or above and diastolic blood pressure of 100 mm Hg or above. p. 348|Table 14-2

KEY CONCEPT E1 10. A patient complains of pain at his incision site. There are four steps to nociception... In what order do the processes occur? a. Transmission, perception, modulation, and transduction b. Perception, modulation, transduction, and transmission c. Modulation, transduction, transmission, and perception d. Transduction, transmission, perception, and modulation

ANS: D-d. Transduction, transmission, perception, and modulation Pages 115-116

E1 9. A patient with ventricular fibrillation (VF) is a. hypertensive. b. bradypnea. c. diaphoretic. d. pulseless. Q2

ANS: D-pulseless. In VF, the patient does not have a pulse, no blood is being pumped forward, and defibrillation is the only definitive therapy. No forward flow of blood or palpable pulse is present in VF. Page-263-without forward flow, no palpable pulse or audio apical heart tones are present

E1 Which professional organization administers critical care certification exams for registered nurses? a.State Board of Registered Nurses b.National Association of Clinical Nurse Specialist c.Society of Critical Care Medicine d.American Association of Critical-Care Nurses

ANS: D.American Association of Critical-Care Nurses American Association of Critical-Care Nurses (AACN) administers certification exams for registered nurses. The State Board of Registered Nurses (SBON) does not administer certification exams. National Association of Clinical Nurse Specialists (NACNS) does not administer certification exams. Society of Critical Care Medicine (SCCM) does not administer nursing certification exams for registered nurses. Page 3

CH 1 E1 What type of practitioner has a broad depth of specialist knowledge and expertise and manages complex clinical and system issues? a.Registered nurses b.Advanced practice nurses c.Clinical nurse leaders d.Intensivists

ANS: b.Advanced practice nurses Advanced practice nurses (APNs) have a broad depth of knowledge and expertise in their specialty area and manage complex clinical and systems issues. Intensivists are medical practitioners who manage the critically ill patient. Registered nurses (RNs) are generally direct care providers. Clinical nurse leaders (CNLs) generally do not manage system issues. Page 2

E1 12. The rationale for giving the patient additional fluids after a cardiac catheterization is that a. fluids help keep the femoral vein from clotting at the puncture site. b. the patient had a nothing-by-mouth order before the procedure. c. the radiopaque contrast acts as an osmotic diuretic. d. fluids increase cardiac output.

ANS: the radiopaque contrast acts as an osmotic diuretic. Fluid is given for rehydration because the radiopaque contrast acts as an osmotic diuretic. The fluid is also used to prevent contrast-induced nephropathy or damage to the kidney from the contrast dye used to visualize the heart structures. Page 275-276

In pulsus paradoxus: A) the rhythm is irregular; every other beat is premature. B) there is a deficiency of arterial blood to a body part. C) the rhythm is regular, but the force of the pulse varies with alternating beats. D) beats have weaker amplitude with respiratory inspiration and stronger amplitude with expiration. https://www.bing.com/videos/search?q=pulsus+paradoxus&view=detail&mid=9F5DA61884F55F3484949F5DA61884F55F348494&FORM=VIRE#

D) beats have weaker amplitude with respiratory inspiration and stronger amplitude with expiration. Pulsus paradoxus, also paradoxic pulse or paradoxical pulse, is an abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less than 10 mmHg.When the drop is more than 10 mmHg, it is referred to as pulsus paradoxus. Pulsus paradoxus is not related to pulse rate or heart rate and it is not a paradoxical rise in systolic pressure. The normal variation of blood pressure during breathing/respiration is a decline in blood pressure during inhalation and an increase during exhalation. Pulsus paradoxus is a sign that is indicative of several conditions, including cardiac tamponade, chronic sleep apnea, croup, and obstructive lung disease.

E1 7. A patient underwent a thoracotomy 12 hours ago and has continuous epidural analgesia with morphine. In addition to respiratory depression, the patient should be monitored for which complications? a. Urinary retention, undue somnolence, itching, nausea, and vomiting b. Urinary incontinence, photophobia, headache, and skin rash c. Apprehension, anxiety, restlessness, sadness, anger, and myoclonus d. Gastric bleeding, nasal discharge, cerebrospinal fluid leak, and calf pain

E1 8. A patient underwent a thoracotomy 12 hours ago and has continuous epidural analgesia with morphine. In addition to closely monitoring the patient for side effects and complications, Which intervention might enhance the patient's pain control? a. Maintain her flat in bed during the infusion. b. Position her on her right side to encourage the flow of the medication across the dura. c. Limit visitors and remove any distractions such as television and music. d. Consider the administration of adjunct medication such as a nonsteroidal anti-inflammatory agent.

MULTIPLE RESPONSE E1 According to the American Association of Critical-Care Nurses, what are the responsibilities of a critical care nurse? (Select all that apply.) a. Respecting the values, beliefs, and rights of the patient b. Intervening when the best interest of the patient is in question c. Helping the patient obtain necessary care d. Making decisions for the patient and patient's family e. Monitoring and safeguarding the quality of care the patient receives f.Acting as a gatekeeper for the patient, the patient's family, and other health care professionals

KEY CONCEPT E1 What is the stepwise decision-making flowchart for a specific care process named? a.Algorithm b.Practice guideline c.Protocol d.Order set

KEY CONCEPT E1 What are the causes of delirium in critically ill patients? (Select all that apply.) a. Hyperglycemia b. Meningitis c. Cardiomegaly d. Pulmonary embolism e. Alcohol withdrawal syndrome f. Hyperthyroidism Page 141

b. Meningitis e. Alcohol withdrawal syndrome f. Hyperthyroidism The causes of delirium in critically ill patients include metabolic causes (acid-base disturbance, electrolyte imbalance, hypoglycemia) Intracranial causes (epidural or subdural hematoma, intracranial hemorrhage, meningitis, encephalitis, cerebral abscess, tumor), endocrine causes (hyperthyroidism or hypothyroidism Addison disease, hyperparathyroidism Cushing syndrome (A disorder resulting from abnormally high levels of the hormone cortisol) Organ failure (liver encephalopathy, kidney encephalopathy, septic shock) Respiratory causes (hypoxemia, hypercarbia) Medication-related causes (alcohol withdrawal syndrome, benzodiazepines, heavy metal poisoning).