Exam 1 High Acuity
Why is the risk of pulmonary infections higher in the older client? Increased lung elasticity Increased alveolar surface area Decreased chest anteroposterior (AP) diameter Loss of pulmonary epithelial cell function
D
For a client with hypokalemia, the nurse should monitor the ECG for which changes? (Select all that apply.) Presence of U waves Flattened T waves Peaked T waves Depressed ST segment Extreme bradycardia
a, b, d
What are the most common complaints associated with pulmonary disease? (Select all that apply.) Cough Sputum Cyanosis Dyspnea Chest pain
a, b, d, e
Elevated temperature can cause fluid volume deficit through which process? (Select all that apply.) Diaphoresis Tachypnea Vasoconstriction Diarrhea Increased metabolic rate
a, b, e
What are common causes of hypocalcemia in high-acuity clients? (Select all that apply.) Administration of large amounts of stored blood Hypoparathyroidism Acute pancreatitis Malignancy Sepsis
a, b, e
The use of prn analgesics is appropriate in which situations? (Select all that apply.) When pain is intermittent When pain is consistent When pain is unpredictable When used as a supplement to scheduled doses When the client fears addiction
a, c, d
What are the risk factors for aspiration? (Select all that apply.) Incompetent lower esophageal sphincter Age greater than 65 years Decreased level of consciousness Elevated gastric pressure Male gender
a, c, d
What is the primary reason that airway patency becomes compromised in the mechanically ventilated client? Ineffective cough to clear mucus Oversedation Presence of thin watery secretions Dehydration
a
When an older adult requires pain medication, how should it be administered? Routinely Sparingly On an as-needed (prn) basis Liberally
a
When caring for the older client, which common nursing intervention is most likely to result in skin breakdown? Elevating head of bed 30 degrees Turning every 2 hours Using support surfaces Moisturizing sacral skin
a
Which description correctly applies to acute pain? (Select all that apply.) A short duration Continually changing Rapid onset Little emotional arousal May follow cellular or tissue damage
a, b, c, e
Which factors contribute to medical errors? (Select all that apply.) Staffing ratios Overtime Excessive documentation Specialty certification Responsible management
A, B, C
Which conditions are contraindications to massage therapy? (Select all that apply.) Advanced osteoporosis Bone fractures Burns Deep vein thrombosis Chest pain
A, B, C, D
What are the components of a healthy work environment? (Select all that apply.) True collaboration Appropriate staffing Authentic leadership Individual priorities Skilled communication
A, B, C, E
What is an appropriate nursing intervention for a client experiencing shock and disbelief about his or her diagnosis? Active listening Providing accurate information Exhibiting empathy Acknowledging loss
B
What must be done to ensure client safety before a percutaneous tracheostomy is placed at the bedside? One person should confirm the order. The correct client, site, and procedure should be identified during a time-out. Two people should confirm the order. Visitors should be asked to leave the room.
B
How may complementary and alternative therapies be used? (Select all that apply.) In lieu of standard medical treatment As a complement to standard medical treatment Only with a physician's order In limited situations Only by a certified therapist
A, B
Respiratory compensation involves the excretion or retention of which gas or substance? CO2 HCO3 H2O K+
A
What do the current client safety and healthy work environment cultures in the high-acuity environment promote? An increase in error reporting and systems improvement A decrease in error reporting A culture of blame The failure to publicly disclose medical errors
A
What should the nurse use to validate the technologic data? Nursing assessment data The healthcare provider Other technologic data Another nurse
A
When caring for the older client, which intervention should be a nursing priority for prevention of airway clearance and gas exchange complications? Deep breathing and coughing exercises High fluid intake Monitoring of respiratory rate and depth Assessing for adventitious breath sounds
A
Which condition may cause metabolic acidosis because of a decrease in bicarbonate levels? Diarrhea Uremia Aspirin ingestion Diabetic ketoacidosis
A
Which strategy should the nurse use to reduce transfer anxiety? Introduce the client and family to the receiving nurse before the transfer occurs. Transfer the client during the night while he or she is sleeping. Do not include the family in the transfer until it's over. Inform the client that he or she will not receive as much nursing care in the lower-acuity unit.
A
he nurse recognizes that older clients can have delayed manifestations of intracranial bleeding due to which age-related change? More dead space in the cranium Delays in reflex responses Decreased compensatory mechanisms Altered perceptions of pain
A
When teaching high-acuity clients, what are the initial goals? (Select all that apply.) To reduce stress To promote comfort To increase knowledge To establish a trusting relationship To meet established education outcomes
A, B
Guided imagery may be a useful strategy for clients with which conditions? (Select all that apply.) Anxiety Depression Pain Hypotension Delirium
A, B, C
Why are older adults more likely to present with a common problem in an uncommon way? (Select all that apply.) They take more medications. They have more comorbidities. They are less likely to care for themselves well. They are at greater risk for infection. They are less likely to follow care instructions correctly.
A, B, D
The nurse understands that there is an increased risk of neurologic side effects or toxicity from drug therapies in the older client, related to which age-related change? (Select all that apply.) A smaller brain volume A more permeable blood-brain barrier Greater water content in the brain Atherosclerotic vascular changes Dilation of the ventricles
A, B, E
In mechanically ventilated older clients, weaning is often more difficult for which major reason? (Select all that apply.) Weak respiratory muscle function Confused mental state Altered respiratory mechanics Changes in hemodynamics Reduced client coping skills
A, C, D
The nurse is aware that REM sleep has which effects on the client? (Select all that apply.) Facilitates protein anabolism Lowers blood pressure and pulse Promotes healing Restores the immune system Reduces glycogen storage
A, C, D
Which changes can induce anxiety in the high-acuity client? (Select all that apply.) Weaning from mechanical ventilation Increasing pain medication Increasing mobility Changing monitoring Promoting sleep
A, C, D
The term burnout refers to which feelings? (Select all that apply.) Personal and professional frustration Loss of self-esteem Physical and emotional exertion Job dissatisfaction Job insecurity
A, C, D,
Which statements are correct regarding the use of technical devices in high-acuity care? (Select all that apply.) They present mechanical impediments to touching. They are usually well accepted by clients. They may evoke fear in clients. They lead to a feeling of depersonalization. They may increase client anxiety.
A, C, D, E
What are the hazards inherent in the use of technology? (Select all that apply.) Fragmenting clients into subpopulations Increasing the nurse's stress level Allowing more time for client contact Making the client overdependent on monitoring equipment Increasing nurse dependence on machines for decision making
A, D, E
Which nursing interventions would support the client's REM sleep? (Select all that apply.) Dimming lights during normal sleep time Putting up a wall clock in the client's room Reducing environmental noise Providing opioid analgesia at bedtime Limiting visitation during quiet time
A,C, D, E
Which statement is correct regarding the improvement of the death and dying experience? It is a goal of modern medicine. It is the sole responsibility of the high-acuity nurse. It is not a standard of care in high-acuity units. It is the sole responsibility of the palliative care team.
A.
amily presence during CPR contributes to which result? Ability of family to say goodbye Increased difficulty of family members moving through the grieving process Increased fear and anxiety Inability to promote a sense of closure
A.
Which priority level indicates that the client is acutely ill and unstable and requires intensive treatment and monitoring that cannot be provided outside the ICU? A. Priority 1 B. Priority 2 C. Priority 3 D. Priority 4
A. Priority 1
Level III ICU setting
Ability to provide initial stabilization of critically ill pt but are limited in their ability to provide comprehensive care for all pt. They are able to care for ICU pt requiring routine care/monitoring.
Which noise do high-acuity clients report as being most annoying? Ambulance siren Staff's loud voices Television Equipment noise
B
Metabolic compensation involves changes in the renal excretion or resorption of which combination of gases or substances? H+, CO2 HCO3, H+ Glucose, HCO3 CO2, HCO3
B
Which statement best describes the use of humor as therapy? Humor is not a way to relieve stress. Humor is a CAT that can be used with high-acuity clients. Humor is ineffective in reducing pain. Humor interferes with the bond between client and nurse.
B
Which factors can help buffer the negative effects of stress? (Select all that apply.) Environmental uncertainty Positive social climate Managerial support Cohesiveness among staff Ignoring stress as it develops
B, C, D
What is a common characteristic of delirium? (Select all that apply.) Labile blood pressure Inability to attend to environmental stimuli Acute onset Disorganized thinking Agitation
B, C, D, E
The atypical presentation of some older clients experiencing acute myocardial ischemia/infarction may include which manifestations? (Select all that apply.) Hypothermia Falls Flu-like syndromes Higher than usual elevations of creatine kinase Acute confusion
B, C, E
Supportive equipment when a person has an artificial airway in place includes which of the following? (Select all that apply.) At least one oxygen source Suctioning equipment Manual resuscitation bag and mask A backup ventilator in the room Oral pharyngeal airway or bite block
B,C,E
What does the designation of Magnet status indicate? The hospital uses UAP to deliver most nursing care. The hospital uses practice models that promote professional nursing. The hospital has low nurse-client ratios. The hospital is not a desirable place for professional nurses to work.
B.
What should be the focus of care of the high-acuity client? Bedside machines Individual client needs The alarms on the machines The nurse's needs
B.
hen interacting with a client in denial, what is the nurse's best strategy? Reinforce reality Function as a noncritical listener Explain the current treatment plan Help the client recall the injury event
B.
Evidence suggests that which of the following factors reduces mortality and life-threatening complications in the hospitalized client? A. A nurse-client ratio of 1:2 B. Constant surveillance of clients by nurses C. High-technology ICUs D. IMCs
B. Constant surveillance of clients by nurses
A hospital with an ICU that has the capability of providing comprehensive care to most critically ill clients but not to trauma clients meets the criteria for which level ICU? A. I B. II C. III D. IV
B. II
The nurse expects which age-related change when checking the pupils in the older client? Increased response to light Larger pupils Decreased response to light No pupil size change
C
What is the effect of unrestricted visiting hours on some clients? Fatigue Depression Fewer hallucinations Increased anxiety
C
What is the proper procedure to ensure client safety when the nurse is preparing a medication that will be administered to the client by another person? (Select all that apply.) This should never be done. Confirm the order with the healthcare provider (HCP). Labels should be verbally verified by the two healthcare providers. Labels should be visually verified by the two healthcare providers. Document in the medication administration record prior to giving the medication.
C, D
Critical incident stress debriefings (CISDs) can be used for which purposes? (Select all that apply.) Assess high-acuity clients Help families cope with stress Address staff symptoms of stress Provide staff with a sense of closure Assess the need for follow-up
C, D, E
Which statement is accurate concerning unlicensed assistive personnel (UAP)? UAP may not work in high-acuity environments. UAP may work independently as long as they notify the RN at the end of their shifts. UAP perform only those tasks delegated to them by a professional nurse. UAP are not governed by state boards of nursing.
C.
Which statement about intermediate care units is correct? A. They are outdated and should not be used. B. They are labor intensive and are not cost effective. C. They provide an efficient distribution of resources. C. They are reserved for clients with life-threatening illnesses.
C. They provide an efficient distribution of resources.
Level II ICU Setting
Capability of providing comprehensive care to most critically ill pt but not specific pt populations (i.e. neurosurgical, cardiothoracic, trauma).
A client was involved in a motor vehicle crash and sustained multiple lower-extremity fractures. He will need additional surgery and prolonged physical therapy. The nurse finds the client drawing plans for remodeling his porch to accommodate a wheelchair. This behavior reflects which stage of illness? Denial Anger Depression Acceptance
D
Client situations associated with respiratory alkalosis include which condition? Sedation Neuromuscular blockade Pulmonary edema Anxiety
D
The nurse understands that, in the older client, the diminished rate of neurotransmitter synthesis leads to which condition? Hypertension More rapid respiratory rate Increased cardiac response to stressors Decreased sympathetic nervous system response
D
What is the normal BUN-to-Cr ratio? 1:1 1:5 5:1 10:1
D
According to some, ICU resources should be used for which clients? Those with cancer Those of advanced age Those with DNR orders Those who have the greatest possibility of benefiting
D.
Level I ICU Setting
Hospitals with ICU's that provide comprehensive care for patients with a wide range of disorders. Sophisticated equipment is available. Units are staffed with specialized nurses and healthcare providers with critical care training. Comprehensive support services are available to include pharmacy, respiratory therapy, nutritional support, social services, pastoral care. May be in an academic teaching hospital or may be community based.
The World Health Organization (WHO) Analgesic Ladder provides the clinician with what information? General pain management choices based on level of pain Nonpharmacologic interventions based on level of pain Specific pain management choices based on severity of pain Pharmacologic and nonpharmacologic pain-management choices
a
The older client is more susceptible to skin breakdown for which reasons? (Select all that apply.) Thinning of the skin Increased subcutaneous tissue Lower body fat content Thickening of capillary beds
a
The older client may not develop a fever as an early sign of infection due to which factor? Lower basal temperature Hyperthyroidism Elevated humoral immune function Increased circulating T-lymphocytes
a
What is a major weakness of multidimensional tools? The client must comprehend the vocabulary. They measure only pain intensity. The nurse performs the assessment. They are unable to measure degree of anxiety.
a
What does an increasing PIP most commonly indicate? Increasing airway resistance and/or decreasing lung compliance Decreasing airway resistance and/or decreasing lung compliance Increasing airway resistance and increasing lung compliance Decreasing airway resistance and decreasing lung compliance
a
Permissive hypercapnia is contraindicated in which client population? Those with unstable intracranial pressure Those requiring mechanical ventilation Those whose ARDS is related to traumatic injury Those who are over age 45 years
a
What is a common side effect of the administration of potassium in a peripheral IV catheter? Burning pain Dysrhythmia Diarrhea Tissue necrosis
a
Positive pressure ventilation (PPV) alters the relationship of ventilation to perfusion in what way? Ventilation increases in nondependent lung areas. Ventilation increases in the small airways. Perfusion increases in the nondependent lung areas. Perfusion increases near the large airways.
a
Pressure-cycled ventilation uses which of the following as a constant? Pressure Time Volume Flow rate
a
A client has developed left lower lobe pneumonia; however, the remaining lung fields are clear. It is time to reposition the client in bed. Of the following positions, which is most likely to optimize the ventilation-perfusion relationship? Lying on the right side Supine Lying on the left side Horizontal in the bed
a
A client who is mechanically ventilated is not sleeping well. What nursing action would address this problem? Cluster activities Administer sedatives Administer neuromuscular blocking agents Space activities evenly throughout the 24-hour day
a
A client who typically has normal ABG values is found to have a PaO2 of 73 mmHg. Which classification of hypoxia exists? Mild No hypoxia is present Moderate Severe
a
During expiration, the intrapulmonary pressure causes air to flow out of the lungs for which reason? Because the intrapulmonary pressure is higher than atmospheric pressure Because the intrapulmonary pressure is equal to perfusion pressure Because the intrapulmonary pressure is lower than atmospheric pressure Because the intrapulmonary pressure is equal to alveolar pressure
a
How is the chest pain typical of pleuritic pain best characterized? Sharp Pressurelike Radiating Dull
a
Hyperkalemia can be caused by which condition? Renal failure Potassium-wasting diuretics Metabolic alkalosis Severe diarrhea
a
Hypokalemia and hyponatremia have which neurologic effects? Confusion and lethargy Irritability and coma Disorientation and seizures Hallucinations and tetany
a
In an emergency situation, what is the most common entry route for airway access? Oral intubation Nasal intubation Tracheostomy Oropharyngeal airway
a
Oxygen binds loosely and reversibly to hemoglobin. Hemoglobin is attracted to oxygen molecules. The affinity of hemoglobin to oxygen is constant. The relationship is expressed in mmHg (pressure).
a
Oxygen therapy is most effective in treating which condition? Shuntlike effect Anatomic shunt Capillary shunt Absolute shunt
a
What is the most common predisposing factor for development of thromboembolism? Immobility Postsurgery status Malignancy Coronary artery disease
a
When the stress response becomes too great, it is associated with which physiologic changes? (Select all that apply.) Organ hypoperfusion Enhanced hormone function Increased vascular shunting Elevated endogenous opioid peptide levels Decreased oxygen demand
a
When the titration approach to pain management is used, the emphasis is on what? The client's analgesic response Total milligrams per day Physical dependence Psychological dependence
a
Which IV solution is commonly used for clients who have intravascular dehydration? Lactated Ringer's 0.45% normal saline 2.5% dextrose 3% normal saline
a
Which age-related change in urinary system function should the nurse anticipate in the older adult? Decreased glomerular filtration rate Increased size of nephrons Decreased ureter lumen size Increased creatinine clearance
a
Which drug inhibits resorption of sodium and chloride in the loop of Henle? Furosemide Spironolactone Hydrochlorothiazide No drugs work in this area.
a
Which pulmonary disorder is considered a restrictive disease? Pneumonia Asthma Emphysema Chronic bronchitis
a
Which statement best reflects nasal CPAP? It is used as a treatment of obstructive sleep apnea. It requires a positive pressure mechanical ventilator. The pressure level cannot be adjusted once it has been set. It allows manipulation of inspiratory and expiratory pressures.
a
Which statement is correct regarding hypoactive delirium in the older adult? It is sometimes misdiagnosed as depression. It is easy for the nurse to identify. It is usually associated with global hypoxia. It is generally irreversible even with early treatment.
a
Which statement is true regarding the relationship of ventilation to perfusion in an upright person? It varies throughout the lung. Ventilation is best in the apices. Perfusion is best in peripheral lung areas. It maintains a 1:1 relationship.
a
Which statement reflects the relationship between pain and stress? Increased levels of stress worsen pain. Increased levels of stress worsen pain, only if anxiety is also present. Increased levels of stress worsen chronic pain but not acute pain. There is no significant relationship between pain and stress.
a
he presence of a nasotracheal tube can affect the ears because it can do what? Occlude the eustachian tubes Exert direct pressure on the inner ears Cause inner ear ischemia Directly damage the eustachian tubes
a
what is the best tool for assessing delirium in the high-acuity older adult? CAM-ICU CAM GDS Mini-Cog
a
What are some risk factors for the development of sepsis in older clients? (Select all that apply.) Institutionalization Pressure ulcers Altered mental status Indwelling urinary catheters Female gender
a, b, c, d
Which client outcome would be appropriate for a client who is experiencing fluid volume excess? (Select all that apply.) CVP within normal range for client Weight gain of 2%-3% Balanced intake and output BUN within acceptable limits Pulse rate below 60 bpm
a, c, d
Age-related changes may affect which factors of pharmacodynamics? (Select all that apply.) Absorption Swallowing Metabolism Excretion Distribution
a, c, d, e
Older adult clients are predisposed to develop fluid volume deficit for which reasons? (Select all that apply.) Decreased muscle mass Decreased fat stores Alterations in nutrition Alterations in thirst Diminished renal function
a, c, d, e
Internal-origin problems that may require chest tube insertion include which types of injury? (Select all that apply.) Barotrauma Penetrating chest trauma Procedural rupture of visceral pleura Chest contusion Bleb rupture
a, c, e
Treatment for fluid volume excess may include restricting which intake? (Select all that apply.) Fluids Protein Carbohydrates Sodium Fats
a, d
Pneumothorax is characterized by which common clinical findings? (Select all that apply.) Tachypnea Bradycardia Respiratory acidosis Shortness of breath Decreased PaO2
a, d, e
The guidelines for choosing appropriate nonpharmacologic interventions include which of the following? (Select all that apply.) Skill of clinician Effectiveness for client Pain problem identification Type of opioid being used Type of nonopioid being used
a,b,c
Hypercalcemia increases the client's risk of complications from which factors? (Select all that apply.) Pathological fractures Falls Decreased mental status Cardiac dysrhythmias Seizures
a,b,c,d
Common complications of noninvasive methods of ventilatory support include what conditions? (Select all that apply.) Conjunctivitis Nasal congestion Hypoventilation Otitis media Aspiration
a,b,c,e
The atypical presentation of urinary tract infection often seen in the older adult client includes which symptoms? (Select all that apply.) Abdominal pain Incontinence Nausea and vomiting High fever Confusion
a,b,c,e
Magnesium plays an active part in which physiologic functions? (Select all that apply.) Sodium transport Nerve cell conduction Fluid regulation Transference of energy Potassium transport
a,b,e
Hypercalcemia can be caused by which factors? (Select all that apply.) Bone metastasis Hyperactivity Hypothyroidism Thiazide diuretics Hyperparathyroidism
a,d,e
Which description of Alzheimer disease is most accurate? It is an acute problem with memory and thinking. It is the most common cause of progressive dementia. It is the result of brain inflammation. It is part of Lewy body disease.
b
A client with chest trauma has sustained a hemothorax, and preparations are made for chest tube placement. The chest tube will be inserted at which location? Anteriorly at level of second intercostal space Midaxillary at the fifth or sixth intercostal space Posterior-laterally at the second intercostal space Anteriorly at the fifth or sixth intercostal space
b
A common physiologic consequence of chronic opioid use that results in a person's requiring an increasing dose of opioids to maintain the same level of analgesia defines which term? Pseudoaddiction Tolerance Psychological dependence Physical dependence
b
A low V/Q exists when what occurs? Ventilation is in excess of perfusion. Perfusion is in excess of ventilation. Blood is shunted away from the alveoli. There is an obstruction in the pulmonary capillaries.
b
An increase in bicarbonate would have which effect on the pH? More acidic More alkaline More neutral No change
b
Barotrauma is associated with which ventilator setting? Assist control mode High tidal volumes Low FiO2 Rapid respiratory rates
b
Beta agonist agents such as albuterol are given to relieve which acute airway problem? Airway edema Bronchoconstriction Airway inflammation Pulmonary hypertension
b
During a physical assessment, it is noted that the client has pitting edema around the ankles, with 4 mm indentation that disappears within 10 seconds. How should this be documented? 1+ pitting edema 2+ pitting edema 3+ pitting edema 4+ pitting edema
b
How is angiotensin II best characterized? Diuretic Vasoconstrictor Thirst trigger Sodium waster
b
Hypermagnesemia is associated with which symptom? Tetany Lethargy Tremors Positive Chvostek sign
b
If a client is mildly confused, the nurse should initially try to assess pain using which method? Vital signs Self-report Facial expression Body posturing
b
Loeser and Cousins's multifaceted model of pain includes which combination of facets? Nociception, perception, modulation, and remission Nociception, pain, suffering, and pain behaviors Transduction, transmission, modulation, and perception Perception, anxiety, remorse, and fear
b
PPV affects the cardiovascular system by doing what? Increasing cardiac output Decreasing venous return to the heart Increasing arterial blood pressure Increasing venous return to the heart
b
Pressure gradient affects the diffusion of gases in which way? The more rapid the ventilatory rate, the greater the gradient The greater the difference, the more rapid the gas flow The less rapid the ventilatory rate, the greater the gradient The smaller the difference, the more rapid the gas flow
b
The term cycle as it applies to mechanical ventilation refers to the mechanism by which what occurs? The ventilator turns on and off. Inspiration ceases and expiration starts. The concentration of oxygen is controlled. The rate of airflow is maintained.
b
The term pulmonary shunt refers to what condition? Movement of air directly from one alveolus to another Normal pulmonary capillary perfusion, reduced alveolar ventilation An opening between the pulmonary artery and the heart Normal alveolar ventilation, reduced pulmonary capillary perfusion
b
Urinary sodium is helpful in assessing which condition? Chronic pancreatitis Acute renal failure Alcohol intoxication Gastrointestinal bleeding
b
Use of continuous SpO2 and EtCO2 monitoring for early recognition of impending respiratory depression has which major advantage? They monitor oxygenation status. They monitor oxygenation and ventilation status. They monitor ventilation status. They monitor sedation and ventilation status.
b
Viral pneumonia typically presents in which way? Productive cough with thick, purulent sputum Progressive dyspnea and persistent fever Pleuritis and copious sputum Night sweats and harsh dry cough
b
What is a sign or symptom of hypernatremia? Diarrhea Muscle twitching Stomach cramps Decreased muscle tone
b
What is the most common route used for PCA? Intramuscular Intravenous Subcutaneous Epidural
b
When gathering a nursing history on an older client, what information from the client would indicate an increased risk for peptic ulcer disease? "I have been under intense stress lately." "I take nonsteroidal anti-inflammatory drugs daily." "I stopped taking my calcium supplement because it was difficult to swallow." "I drink about four cups of coffee each day."
b
Where are third-spaced fluids most commonly located? Joints A serous cavity The cranial vault Interstitial fluid
b
Which disease process would increase the thickness of the alveolar-capillary membrane? Pneumothorax Pneumonia Lung tumor Pneumonectomy
b
Which statement is correct regarding MRSA pneumonia in high-acuity clients? It causes a chronic, low-level infection. It increases the risk for death and septic shock. It has a low mortality risk. About 50% of cases require hospitalization.
b
Which statement is correct regarding low serum osmolality? It reflects fluid volume deficit. It reflects fluid volume excess. It is associated with dehydration. It is associated with hypernatremia.
b
Which statement is correct regarding the use of the physical assessment in diagnosing electrolyte abnormalities? Physical assessment findings can point to a specific electrolyte problem. Physical assessment provides important clues to the presence of a general electrolyte problem. Most signs and symptoms of electrolyte problems are highly specific to each electrolyte. There is little correlation between physical signs and symptoms and electrolyte levels.
b
Which measures are useful in fall prevention? (Select all that apply.) Use of restraints Rounds to address toileting needs Assessment of fall risk Identification of orthostatic hypotension Administration of prn pain medication
b, c, d
Hypernatremia can be caused by which conditions? (Select all that apply.) Hyperthyroidism Profuse diuresis Cushing syndrome Diabetes insipidus Fever
b, c, d, e
Which atypical signs of infection may be present in older clients? (Select all that apply.) Metabolic alkalosis Functional decline Altered mental status Recent history of falls Unexplained hypo- or hyperglycemia
b, c, d, e
Which assessments are consistent with fluid volume excess? (Select all that apply.) Weight loss Elevated central venous pressure Elevated blood pressure Sinus bradycardia Decreased hematocrit
b, c, e
Why are medications not absorbed as well in the older adult? (Select all that apply.) Increased gastric motility Decreased splanchnic blood flow GERD Altered gastric pH Increased fat content
b, d
The conducting airways serve which major functions? (Select all that apply.) Gas exchange Filtering Immune protection Humidifying Warming
b,d,e
Which vital signs are most important to monitor in clients with potential or actual electrolyte abnormalities? (Select all that apply.) Temperature Blood pressure Respiratory rate Heart rate Heart rhythm
b,d,e
An increased anion gap reflects which condition? Increased serum osmolality Increased renal excretion of sodium Decreased excretion or increased production of acids Inability of the kidneys to concentrate urine
c
Changes in cardiac output resulting from positive pressure ventilation are associated with which manifestation? Increased arterial blood pressure Increased urinary output Decreased arterial blood pressure Decreased pulse rate
c
Clients with severe hyponatremia may require IV fluids. Which type of IV fluid would the nurse expect to be ordered to treat severe hyponatremia? Isotonic Hypotonic Hypertonic Lactated Ringer's
c
Clients with tracheostomy tubes with overinflation of the cuff are at risk to develop what condition? High blood pressure Gastrointestinal bleeding Tracheomalacia Ventilator-associated pneumonia
c
Dehydration and hyponatremia in the older adult are often associated with which physiologic alteration in the kidneys? Altered neural controls Changes in the urethral sphincter Declining renal tubule function Increased concentration of urine
c
Hyponatremia is associated with which symptom? Edema Hyperreflexia Lethargy Restlessness
c
Negative pressure ventilators adjust the tidal volume by doing what? Adjusting the amount of negative airflow Adjusting the amount of positive airflow Altering the amount of negative pressure applied Altering the amount of positive pressure applied
c
Normal blood flow past completely unventilated alveoli is the definition of which term? Physiologic shunt Anatomic shunt Capillary shunt Venous admixture
c
Normal values for arterial blood gases include which value? pH 7.5 PaCO2 20 mmHg HCO3 26 mmHg SaO2 75 mmHg
c
On the oxyhemoglobin dissociation curve, at a PaO2 less than 60 mmHg, any change in PaO2 yields how much of a change in SaO2? No change A small change A large change An unpredictable change
c
Restrictive pulmonary diseases are associated with which condition? Increased lung expansion Increased lung compliance Decreased lung expansion Decreased airflow into lungs
c
The Numeric Rating Scale is most commonly used to measure what part of the pain experience? Affective Evaluative Intensity Coping
c
The clinical findings of hyperkalemia include which set of signs and/or symptoms? Muscle weakness, T wave inversion on ECG Muscle twitching, ST segment depression on ECG Vomiting, peaked T wave on ECG Diarrhea, presence of U wave on ECG
c
The nurse understands that age-related changes in the thyroid gland increase the risk for development of which thyroid-related problem in the older client? Hyperthyroidism Thyrotoxic storm Hypothyroidism Elevated basal metabolic rate
c
Tissue damage triggers the release of which biochemical mediators? A delta and C fibers Enkephalins, beta-endorphins, and dynorphins Prostaglandins and bradykinin Transduction, transmission, perception, and modulation
c
What is a common sign or symptom of PE? Rhonchi Pneumothorax Dyspnea Bradycardia
c
What is the major function of tissue gel in the interstitial compartment? Shift fluid out of capillaries Provide a source of electrolytes Distribute fluid evenly Dispose of cellular waste products
c
What is the term that refers to the activation of pain receptors and the pain pathway by a noxious stimulus strong enough to threaten tissue integrity? Acute pain Suffering Nociception Neuropathy
c
What statement about opioid-induced respiratory depression is accurate? It is not of concern, since it can be immediately reversed with an opioid antagonist such as naloxone. It prevents tachypnea in the anxious client with pain. Prevention is best for the client in order to decrease risk and side effects or complications of reversal. It occurs more frequently during the first 24 hours postoperatively.
c
When the hypothalamus senses a change in serum osmolality, it stimulates the posterior pituitary to release which substance? Renin Testosterone ADH ACTH
c
Which assessment finding is the client with depression most likely to exhibit? Anxiety Confusion Low mood Inattention
c
Which brief and easy test is used to evaluate a high-acuity older client for dementia? Geriatric Depression Scale (GDS) Richmond Agitation and Sedation Scale (RASS) Mini-Cog Mental Status Test Confusion Assessment Method (CAM)
c
Which consideration is most important when assessing for the presence and severity of pain? The documentation of the previous shift The report of the client's family members The client's account of the pain The physician's assessment of the pain
c
Which is the best description of the stress response? An avoidable reaction A maladaptive response to crises A crucial part of self-preservation An unpredictable reaction to pain
c
Which manifestation is an indication for suctioning? Low airway pressure alarm Low respiratory rate Course crackles over the trachea Normal oxygenation
c
Which musculoskeletal condition is most prevalent among older adults? Gout Rheumatoid arthritis Osteoarthritis Fractures
c
Which of the following statements describes NIPPV? It requires a flow generator (blower). It combines negative and positive pressure principles. It uses a positive pressure device. It independently manipulates inspiratory and expiratory pressures.
c
What is the upper limit of safe tracheal cuff pressure? 15 mmHg 20 mmHg 25 mmHg 30 mmHg
d
Which statement is correct regarding opioid use and respiratory depression? Respiratory depression precedes the onset of sedation. Respiratory depression worsens as tolerance develops. Sedation occurs before respiratory depression. Respiratory depression is a common problem in hospitalized clients.
c
Which substance, released by the adrenal cortex, is known as the salt-regulating hormone? ACTH ADH Aldosterone Renin
c
hich IV solution can cause cells to expand and burst, resulting in cellular destruction? 0.9% normal saline D10W 0.45% normal saline Lactated Ringer's
c
How often should the nurse conduct a skin assessment? Daily After changes in condition At least weekly Once per shift
c **seems wrong**
Rapid infusion of IV calcium can result in which manifestations? (Select all that apply.) Tachycardia Hypertension Cardiac arrest Hypotension Fever
c, d
A mechanically ventilated client who is malnourished is at high risk for failure to wean for what reason? Impaired gas exchange Decreased cardiac output Increased airway resistance Respiratory muscle weakness
d
According to the CURB-65 severity-of-CAP criteria, which value is considered a risk factor? BUN of 15 mg/dL Hemoglobin of 9.8 mg/dL Respiratory rate of 28 breaths/min Systolic BP of 85 mmHg
d
Capillary hydrostatic pressure is the pressure exerted by which element? Plasma proteins in the capillaries Fluid in the interstitial spaces Plasma proteins in the interstitial spaces Fluid moving through the capillaries
d
Endotracheal tube cuff pressures can damage the trachea when cuff pressure is: Increased during coughing. Reduced due to a leak. Lower than surrounding capillary pressure. Higher than surrounding capillary pressure.
d
In the adult, an inflated ET tube cuff is necessary for positive pressure mechanical ventilation primarily because it does what? Prevents stomach contents from getting into the lungs Seals off the nasopharynx from the oropharynx Prevents air from getting into the stomach Seals off the lower airway from the upper airway
d
Magnesium balance is closely related to which other two electrolytes? Potassium and phosphorus Calcium and sodium Sodium and phosphorus Calcium and potassium
d
NIPPV is most useful for a client who Requires only support of tidal volume. Cannot fully support his or her own expiratory effort. Requires only support for nocturnal hypercapnia and hypoxemia. Cannot fully support his or her own ventilatory effort over long periods of time.
d
Obstructive pulmonary diseases are associated with which condition? Decreased lung expansion Decreased lung compliance Decreased airflow into lungs Decreased expiratory airflow
d
PEEP affects the alveoli by doing what? Increasing alveolar fluid Decreasing their relative size Sealing off nonfunctioning units Maintaining them open at end expiration
d
The nurse is aware that in the older-adult high-acuity client, altered gastric pH increases the risk of which complication? Gastric ulcers Hepatitis Gastric cancer Pneumonia
d
The symptoms of hypomagnesemia reflect which alteration? CNS hypoactivity Fluid compartment shifts Cardiac depressant effects Neuromuscular and CNS hyperactivity
d
The term acute ventilatory failure refers to the inability of the lungs to do what? Expand Diffuse gases Exchange oxygen and carbon dioxide Maintain adequate alveolar ventilation
d
Volume-cycled ventilation differs from pressure-cycled ventilation because it does what? Adjusts volume as pulmonary pressure changes Increases airflow as compliance increases Decreases airflow as airway resistance decreases Can adjust pressure to changes in lung compliance
d
What can a low minute ventilation (V/E) cause? Acute metabolic alkalosis Acute respiratory alkalosis Acute metabolic acidosis Acute respiratory acidosis
d
What factor must always be evaluated to place ABGs in the proper context? Laboratory values Supplemental oxygen therapy Mode of ventilation Client status
d
What is the cause of crackles? Secretions in the large airways Inflammation of the pleural linings Air passing through constricted airways Fluid or secretions in the small airways or alveoli
d
What is the major initial treatment for PE? Thrombolytic therapy Surgical embolectomy Oxygen therapy Anticoagulant therapy
d
What is the primary function of type II alveolar cells? Filtration Gas exchange Immune protection Surfactant production
d
What is the primary regulator of water intake? Nervous system Endocrine system Renal system Hypothalamus
d
What is the purpose of surfactant? To decrease lung compliance To increase alveolar surface tension To cleanse the alveoli To decrease alveolar surface tension
d
What is the safest modality for opioid analgesia? Client-controlled analgesia IV bolus Oral Epidural
d
What statements about evaluating client risk for opioid-induced respiratory depression are accurate? It is not necessary until pain becomes severe. It only is important in opioid-naïve clients. It is the responsibility of the physician. It provides essential information to communicate at transitions in care.
d
When a client is admitted in acute respiratory distress, the initial history should focus on which priority? Smoking history Events leading to current admission Nutritional history Events leading to previous admissions
d
Which assessment finding in a client receiving PPV should make the nurse suspect pulmonary barotrauma or volutrauma? Onset of increased lethargy Increase in arterial blood pressure Increase in breath sounds over a lung field Increased cough with high-pressure alarm triggering
d
Which condition is the most common indirect predisposing disorder of ARDS? Gastric aspiration Severe trauma Sepsis Pneumonia
d
Which is a disadvantage of the Critical Care Pain Observation (CPOT) tool? Its validity has not been established. Its reliability has not been established. It cannot be used with nonverbal clients. It does not measure intensity.
d
Which statement correctly describes the primary purpose of CLRT? It prevents pneumonia. It saves manual turning time. It prevents decubitus ulcers. It prevents reduced stasis of fluid and gas.
d
Which statement is correct regarding extracellular FVD? It can lead to transcellular expansion. It can lead to intracellular expansion. It is associated with low serum osmolality. It is associated with high serum osmolality.
d
Which statement is true about securing the artificial airway? The inflated cuff provides sufficient securing. The airway is generally sutured in place. A nasotracheal tube does not require securing. Artificial airways are optimally secured using a commercial tube holder.
d
Which statement regarding nonopioid therapy is correct? Nonopioids have more severe side effects than opioids. Nonopioids are harder to access than opioids. Nonopioids can manage pain as effectively as opioids. Combining opioids and nonopioids enhances analgesia effectiveness.
d
Which type of embolism manifests as dyspnea, tachypnea, neurological symptoms, and petechiae? Venous air Amniotic Thrombus Fat
d
hat is the expected cognitive status of older adults? Loss of memory Confusion Low mood Memory retention
d
he pulmonary edema associated with ARDS is caused by which condition? Capillary microembolism Left ventricular failure Loss of surfactant Injured alveolar-capillary membrane
d