Exam #2

Which finding indicates that rehydration is complete and hypovolemic shock has been successfully treated in a patient? 1. CVP = 8 mm Hg 2. MAP = 45 mm Hg 3. Urinary output of 0.1 mL/kg/hr 4. Hct = 54%

ANS: 1 A CVP reading of 8 mm Hg is within normal range and rehydration has been restored.

What is the most appropriate position for a patient in pulmonary edema with a blood pressure of 194/92? 1. Sitting upright with legs dependent 2. Dorsal recumbent 3. Head of the bed elevated 60 degrees 4. Torso flat, feet elevated

ANS: 1 A patient with a blood pressure of 194/92 is able to sit upright. Sitting upright with legs dependent allows the patient to breathe more comfortably and prevents fluid from accumulating as easily in the lungs.

A patient is being treated for pericarditis. The nurse will plan interventions to prevent the onset of which type of shock? 1. Obstructive 2. Hypovolemic 3. Distributive 4. Cardiogenic

ANS: 1 Acute pericarditis and the development of fluid accumulation in the pericardial space can lead to the development of obstructive shock.

The nurse should explain to a patient in heart failure that an aldosterone antagonist works by: 1. Reducing sodium and water retention 2. Filtering potassium out with the water in the renal tubules 3. Promoting the excretion of the urinary waste products urea and creatinine 4. Retaining calcium to improve the condition of blood vessels in the glomeruli

ANS: 1 An aldosterone antagonist removes water through the excretion of sodium and water through the renal tubules.

Which assessment finding indicates that an infusion of intravenous epinephrine 4 mcg/min is effective in the treatment of a patient with anaphylactic shock? 1. Reduced wheezing 2. Heart rate 55 and regular 3. Blood pressure 98/50 mm Hg 4. Respiratory rate 28

ANS: 1 An expected action for epinephrine is bronchodilation as evidenced by less wheezing.

When providing care to critically ill patients, whether they are responsive or unresponsive, the nurse should: 1. Clearly explain what care is to be done before starting the activity. 2. Perform the activity and then let the patient rest without explaining the care. 3. Make sure the patient always responds and is cooperative before giving care. 4. Explain to the family that the patient will not understand or remember any of the discomfort associated with care.

ANS: 1 By explaining to both the responsive and unresponsive patient, the nurse provides orientation, reassurance, respect, and assessment of the patient's mental status. Seeking permission and apologizing if discomfort is involved will also minimize the stress of the critically ill patient by allowing the patient to hear what is about to occur. Even the unresponsive patient has been known to explain procedures, conversations, and feelings once he or she has awakened.

A patient is diagnosed with cardiac tamponade. When planning care, the nurse will include interventions to address which type of shock? 1. Obstructive 2. Hypovolemic 3. Distributive 4. Cardiogenic

ANS: 1 Cardiac tamponade can lead to obstructive shock.

A patient is demonstrating signs of obstructive shock but the cause has yet to be determined. Which finding indicates the patient is experiencing a pulmonary embolism as the cause for obstructive shock? 1. Chest pain 2. Hypotension term-22 3. Tachycardia 4. Oliguria

ANS: 1 Chest pain is a symptom associated with a massive pulmonary embolus.

Dobutamine is often used in the treatment of sepsis at a moderate or high dose to improve a patient's hemodynamics. The nurse knows that this medication is used because: 1. It decreases systemic vascular resistance and increases perfusion to organs. 2. It has no effect on systemic vascular resistance but improves oxygenation. 3. It decreases the heart rate and increases oxygen delivery to the tissues. 4. It increases systemic vascular resistance and improves hemodynamics.

ANS: 1 Dobutamine is an inotrope that has beta-adrenergic effects. The expected outcome is to increase contractility and to vasodilate, which increases microcirculation or blood flow and organ perfusion.

The nurse is discussing the Dietary Approaches to Stop Hypertension (DASH) program with a patient and spouse. They are overwhelmed and ask if there is one measure recommended by the program that would have the biggest impact so they can start with that measure first. The nurse should suggest: 1. Decreasing sodium intake to less than 1,500 mg/day 2. Losing weight 3. Increasing intake of dairy products 4. Controlling diabetes to an A1C less than 7%

ANS: 1 Dropping sodium intake to 1,500 mg per day results in the largest reduction in BP.

The nurse is evaluating a patient with sepsis for the development of disseminated intravascular coagulation (DIC). What is a sign that the patient may have developed this complication? 1. Ecchymoses of the gums or skin 2. Resistance when flushing a capped port of a central venous catheter 3. A reduction in the D-dimer 4. Increased fibrinogen levels

ANS: 1 Ecchymoses of the gums or skin is a sign that the patient has developed DIC.

The central venous pressure of a patient with heart failure is slowly increasing. What does this finding suggest to the nurse? 1. Right heart function is deteriorating. 2. Left heart function is deteriorating. 3. Fluid is backing up in the lungs. 4. Right heart function is improving.

ANS: 1 Elevations in right filling pressures, such as the central venous pressure, can cause systemic venous pressure elevations leading to peripheral edema and ascites. These are symptoms of right heart failure.

Which action should the nurse implement to help reduce the fever in a patient with sepsis? 1. A cooling blanket is often considered when the patient's temperature reaches 103°F. 2. Shivering should be avoided because it causes a decreased metabolic rate. 3. Prevent shivering by keeping the patient's hands and feet on the cooling blanket. 4. Sedation should be avoided during the use of the cooling blanket because it masks potential shivering.

ANS: 1 Exogenous cooling is recommended when a patient's temperature reaches 103°F.

The nurse is preparing adult smoking cessation material for a patient admitted with heart failure. What criteria did the nurse use to determine that the patient should receive this material? 1. Patient smoked cigarettes any time during the last year prior to hospitalization 2. Patient uses chewing tobacco 3. Patient smokes five cigars a week 4. Patient stopped smoking five years prior to hospitalization

ANS: 1 For the Adult Smoking Cessation Advice/Counseling heart failure core measure, a smoker is defined as someone who has smoked cigarettes anytime during the year prior to hospital arrival.

A patient is experiencing an anaphylactic reaction to a medication. The nurse is concerned that the patient will develop distributive shock because: 1. The release of histamine causes vasodilation with plasma leakage. 2. Sympathetic innervation is interrupted. 3. Microorganisms overwhelm the vascular system. 4. Parasympathetic innervation functions are unopposed.

ANS: 1 In an anaphylactic reaction leading to distributive shock, the release of histamine causes vasodilation with plasma leakage. Vasodilation leads to profound hypotension, hypovolemia from fluid extravasation, reduced reload, and reduced cardiac output.

The nurse, providing patient care in an "open" ICU, would most likely be working with a: 1. Multidisciplinary team with physicians who are also responsible for patients on other units 2. Multidisciplinary team that includes a physician employed by the hospital 3. Physician in charge of patient care who is a specialist in critical care 4. Primary care physician who must consult a critical care specialist

ANS: 1 In an open ICU, nurses, pharmacists, and respiratory therapists are ICU based but the physicians directing patient care may have other obligations. These physicians may or may not choose to consult an intensivist to assist with the management of their ICU patients.

A patient with cardiomyopathy is demonstrating signs of cardiogenic shock. The nurse realizes that this type of shock is due to: 1. Reduced cardiac output 2. Increased stroke volume 3. Reduced blood volume 4. Blood flow blocked in the pulmonary circulation

ANS: 1 In cardiogenic shock, cardiac output is reduced, leading to poor tissue perfusion

A patient scores positive on the Confusion Assessment Method of the Intensive Care Unit (CAM-ICU). Which nursing diagnosis would have the highest priority based on this positive score? 1. Injury, Risk for 2. Family Processes, Altered 3. Social Interaction, Impaired 4. Memory Impaired

ANS: 1 Injury falls into the Safety/Security level, which is the highest priority according to Maslow's hierarchy of needs.

A patient is brought to the emergency department with hypotension, tachycardia, reduced capillary refill, and oliguria. During the assessment, the nurse determines the patient is experiencing cardiogenic shock because of which additional finding? 1. Jugular vein distention 2. Dry mucous membranes 3. Poor skin turgor 4. Thirst

ANS: 1 Jugular vein distention is a manifestation of cardiogenic shock.

Why is the nurse implementing actions to prevent the onset of catheter-related infections in a patient receiving care in the intensive care unit? 1. Statistics report that as many as one in five individuals who develop a catheter-related infection die from it. 2. Nosocomial catheter-related infections prolong hospitalization by an average of 4 days. 3. The increased cost of care due to the development of a blood-borne infection averages between $1,700 and $17,000. 4. Central venous catheters have about the same rate of infection as peripherally inserted catheters.

ANS: 1 Mortality attributable to these infections is between 4% and 20%, so between 500 and 4,000 patients in the United States died annually due to CVC-related bloodstream infections

The nurse, caring for a patient recovering from an acute myocardial infarction, is planning interventions to reduce the risk of which type of shock? 1. Cardiogenic 2. Hypovolemic 3. Distributive 4. Obstructive

ANS: 1 One etiology of cardiogenic shock is a myocardial infarction.

The nurse is assessing a patient for septic shock. Which statement best describes this health problem? 1. Sepsis with hypotension that does not correct itself when a fluid challenge is administered 2. Sepsis with hypotension accompanied by decreased protein C levels and coagulation abnormalities 3. Sepsis with hypotension accompanied by increased creatinine and absent bowel sounds 4. Sepsis with hypotension accompanied by altered mental status and lactic acidosis

ANS: 1 Septic shock is defined by the presence of sepsis plus refractory hypotension.

A patient with heart failure is experiencing increased fatigue and has a weight gain of 1 kg. The nurse realizes this patient is demonstrating signs of: 1. Systemic deterioration 2. Pulmonary deterioration 3. Cardiac deterioration 4. Renal deterioration

ANS: 1 Signs of systemic deterioration include weight gain and fatigue.

A nurse has inserted a nasogastric tube and is planning to confirm placement of the tube prior to starting enteral feedings. What is the most accurate method for confirming placement? 1. Obtaining a radiological x-ray of the abdomen 2. Checking gastric aspirate for a pH of less than 7 3. Instilling 30 mL of air while listening with a stethoscope when placed over the fundus of the stomach 4. Determining the presence of carbon dioxide

ANS: 1 The appropriate method for identifying placement of the feeding tube in the stomach is visualizing the tube in the stomach on an abdominal x-ray.

A patient is prescribed vasopressin 0.03 units/minute as treatment for septic shock. What action will the nurse take when providing this medication? 1. Provide the vasopressin infusion in addition to a norepinephrine infusion. 2. Infuse through a peripheral line. 3. Utilize a rapid infuser. 4. Administer with 0.9% normal saline.

ANS: 1 The dose of 0.03 units/min is usually added to a norepinephrine infusion.

A patient is receiving phenylephrine 50 mcg/min as treatment for shock. Which assessment finding indicates this medication is effective? 1. Blood pressure 110/68 mm Hg 2. Heart rate 110 3. Respiratory rate 12 and regular 4. Decreased peripheral pulses

ANS: 1 The expected effect of this medication is an increase in blood pressure.

A nurse is discussing management of hypertension with a patient. Which patient statement indicates that additional teaching about the relationship between hypertension and acute coronary syndrome (ACS) is needed? 1. "My high blood pressure has no relationship to the severity of heart disease or its outcomes." 2. "Because I'm over 80, even a 20 mm Hg drop in my blood pressure can reduce my risk." 3. "High blood pressure will increase my body's need for oxygen and increase my heart's workload." 4. "Controlling my blood pressure will decrease my risk of having a heart attack to some degree."

ANS: 1 The higher the hypertension rates, the greater the severity of ACS. There is a direct correlation between the two.

While caring for an older patient, the nurse is aware that the two most common sources of infection that can lead to sepsis in this patient include: 1. Pneumonia and urinary tract infections 2. Skin infections and diabetes 3. Surgical incisions and abdominal wounds 4. Traumatic wounds and abdominal surgeries

ANS: 1 The most common source of sepsis stems from urinary tract infections and pneumonia. Among older patients, the most common source of infection is the urinary tract. The second most common source, the lungs, accounts for 35% of sepsis cases.

Which nursing diagnosis should receive the highest priority when caring for a patient who is receiving total parenteral nutrition? 1. Infection, Risk for 2. Trauma, Risk for 3. Skin Integrity, Impaired 4. Fluid Volume, Risk for Imbalance

ANS: 1 The risk for infection is the greatest risk for the patient receiving parenteral nutrition due to the high glucose present, the central vein access route, and the declining nutritional status that the patient is in when this therapy is started.

The nurse is assessing a patient for heart failure (HF). Which early findings would indicate decreased cardiac output and a potential for fluid overload from heart failure? 1. Orthopnea, peripheral edema, crackles 2. Dizziness, syncope, palpitations 3. Pallor and/or cyanosis of extremities 4. PAWP of 12 and CVP of 6

ANS: 1 These symptoms reflect decreasing perfusion and accumulation of fluid in the pulmonary system, which is not being effectively circulated by a failing heart.

A nurse is preparing to communicate an issue about patient care to a physician using the SBAR technique. Which phrase is an appropriate initial statement? 1. "I am concerned about..." 2. "The patient's immediate history is..." 3. "I think the problem is..." 4. "I would like you to ..."

ANS: 1 This is an appropriate initial statement using the SBAR technique.

The nurse includes which statement for "A - Assessment" in the SBAR technique for communication? 1. "I think the problem is..." 2. "The patient's vital signs are..." 3. "The patient's treatments are..." 4. "I would like you to..."

ANS: 1 This is an appropriate statement for assessment using the SBAR technique for communication.

While caring for a patient in the critical care unit, the nurse realizes that the patient's care needs must be a balance between the patient's long-term prognosis and the family's expectations of recovery. Which of the AACN Synergy Model's characteristics does this situation describe? 1. Complexity 2. Predictability 3. Participation in care 4. Resource availability

ANS: 1 This situation describes the characteristic of complexity that is the intricate entanglement of two or more systems; for example, a patient's illness with complex family dynamics.

A patient with heart failure is scheduled for an echocardiogram and cardiac catheterization. The nurse would document that these diagnostic tests fulfill which heart failure core measure? 1. Evaluation of LVS 2. Discharge education 3. ACE-I or ARB for LVSD 4. Adult smoking cessation advice/counseling

ANS: 1 To fulfill this measure, the patient will have had left ventricular systolic function evaluated through the use of an echocardiogram or cardiac catheterization before hospitalization, during hospitalization, or is planned for after discharge.

The nurse is providing care to patients in a Level II general critical care unit. For which types of patient problems will this nurse most likely provide care? Standard Text: Select all that apply. 1. Exacerbation of heart failure 2. Wound infection 3. Burns over 50% of total body surface 4. Kidney transplant 5. Reattachment of a traumatic amputation of the left leg

ANS: 1, 2 A Level II critical care area is where comprehensive care for most disorders will be provided. A wound infection would not be considered specialized care.

A patient with sepsis is experiencing an elevated temperature. Which medications would the nurse prepare to administer to this patient? Standard Text: Select all that apply. 1. Acetaminophen 2. Ibuprofen 3. Aspirin 4. Warfarin sodium 5. Heparin

ANS: 1, 2 Rationale 1: Acetaminophen is commonly used to reduce a fever in a patient with sepsis. Rationale 2: Ibuprofen is used to reduce a fever in a patient with sepsis.

While caring for a patient in heart failure, the nurse assesses an elevated blood pressure and significant peripheral edema. These symptoms are caused by the renin-angiotensin-aldosterone system which: Standard Text: Select all that apply. 1. Releases angiotensin II 2. Releases aldosterone 3. Decreases cardiac output 4. Decreases heart rate 5. Causes arteriolar vasodilation

ANS: 1, 2 Rationale 1: Activation of the renin-angiotensin-aldosterone system increases vasoconstriction through the release of angiotensin II, a potent vasoconstrictor. Rationale 2: Activation of the renin-angiotensin-aldosterone system increases water and sodium reabsorption through the release of aldosterone.

The nurse is concerned that a patient is at risk for developing obstructive shock because of which assessment findings? Standard Text: Select all that apply. 1. Age 80 2. History of atrial fibrillation 3. Bacteremia 4. T3 spinal cord injury 5. Latex allergy

ANS: 1, 2 Rationale 1: Advanced age increases the risk for development of pulmonary emboli, which is one cause of obstructive shock. Rationale 2: Atrial fibrillation increases the risk for developing pulmonary emboli, which is one cause of obstructive shock.

A patient has been receiving milrinone (Primacor) for cardiogenic shock from acute decompensated heart failure. What findings indicate that this medication has been effective in the patient? Standard Text: Select all that apply. 1. Increased cardiac output 2. Reduced pulmonary arterial wedge pressure 3. Dropping blood pressure 4. Onset of ventricular dysrhythmias 5. Respiratory rate 28 and regular

ANS: 1, 2 Rationale 1: An expected action of this medication is an increase in cardiac output. Rationale 2: An expected action of this medication is a decrease in pulmonary arterial wedge pressure.

The nurse is preparing an infusion of norepinephrine for a patient in severe septic shock. Why is this medication being used for the patient? Standard Text: Select all that apply. 1. It will increase the patient's MAP. 2. It reverses hypotension when fluid resuscitation was unsuccessful. 3. It increases stroke volume. 4. It increases heart rate. 5. Effects are seen in 5 minutes.

ANS: 1, 2 Rationale 1: Norepinephrine usually results in a significant increase in MAP with little change in heart rate or cardiac output. Rationale 2: It seems to be more effective than dopamine at reversing hypotension in septic shock patients resistant to fluid resuscitation.

When a nurse employs conscientious refusal to participate, the nurse should be aware that: Standard Text: Select all that apply. 1. It may lead to dismissal from a nursing position. 2. Consequences may involve employer sanction. 3. Nursing administrators are largely supportive. 4. State boards of nursing protect the nurse in this situation. 5. The patient will support the nurse's decision.

ANS: 1, 2 Rationale 1: The repercussions for the nurse of employing conscientious refusal may include dismissal from the current nursing position. Rationale 2: The nurse must also consider the amount of support that will be received from the administration of the institution.

The nurse is preparing medications for the patient experiencing acute decompensated heart failure. Which medications will be administered first to improve gas exchange for the patient? Standard Text: Select all that apply. 1. Morphine sulfate 2. Nitroglycerin 3. Nesiritide (Natrecor) 4. Dobutamine (Dobutrex) 5. Milrinone (Primacor)

ANS: 1, 2 Rationale 1: This medication is used to reduce patient anxiety during acute decompensated heart failure. Rationale 2: This medication is used to reduce preload and pulmonary wedge pressure.

A patient in the critical care unit is demonstrating increasing agitation. What can the nurse use to assess this patient's agitation level? Standard Text: Select all that apply. 1. Ramsey Scale 2. Riker Scale 3. Glasgow Scale 4. Reaction Level Scale 5. Ventilator Adjusted Motor Assessment Scoring Scale

ANS: 1, 2 This scale is commonly used to assess for agitation.

A patient is receiving norepinephrine 30 mcg/min for treatment of refractory shock. Which assessment findings suggest the patient is experiencing peripheral vasoconstriction from the medication? Standard Text: Select all that apply. 1. Decreased peripheral pulses 2. Drop in body temperature 3. Onset of paresthesias 4. Drop in blood pressure 5. Increased cardiac output

ANS: 1, 2, 3 Rationale 1: At high doses of norepinephrine, decreased peripheral pulses indicates significant vasoconstriction. Rationale 2: At high doses of norepinephrine, a drop in body temperature indicates significant vasoconstriction. Rationale 3: At high doses of norepinephrine, paresthesias indicate significant vasoconstriction.

A patient is diagnosed with diastolic heart failure. The nurse realizes this type of heart failure is caused by: Standard Text: Select all that apply. 1. Normal sized but hypertrophied left ventricle 2. Blood backing up into the right atrium 3. Loss of ventricular diastolic relaxation 4. Blood backing up into the left atrium 5. Excessive fluid in the lower extremities

ANS: 1, 2, 3 Rationale 1: Diastolic dysfunction occurs when the ventricle is normal sized by hypertrophied. Rationale 2: In diastolic heart failure, blood backs up from the right ventricle to the right atrium. Rationale 3: In diastolic heart failure there is a loss of left ventricular diastolic relaxation.

A patient is experiencing acute respiratory distress after eating an item of a known food allergy. What interventions will the nurse implement when providing emergency care to this patient? Standard Text: Select all that apply. 1. Administer epinephrine 1:1000 intramuscularly. 2. Apply oxygen via face mask as prescribed. 3. Provide diphenhydramine 25 mg intravenous. 4. Administer vasopressin. 5. Prepare to administer antithrombolytic agents as prescribed.

ANS: 1, 2, 3 Rationale 1: Epinephrine produces bronchodilation, improving the respiratory status. The route of administration is initially intramuscular. Rationale 2: Supplemental oxygen is used in the treatment of anaphylactic shock. Rationale 3: Hydrogen ion blockers such as diphenhydramine may be administered to block the histamine effects.

Which informal power bases will the nurse use in the health care setting? Standard Text: Select all that apply. 1. Expertise 2. Goodwill 3. Information 4. Observation 5. Collaboration

ANS: 1, 2, 3 Rationale 1: Expertise is an informal power base. Rationale 2: Goodwill is an informal power base. Rationale 3: Information is an informal power base.

During an assessment the nurse is concerned that a patient is developing cardiogenic shock. What did the nurse assess in this patient? Standard Text: Select all that apply. 1. Systolic blood pressure 82 mm Hg 2. Capillary refill 10 seconds 3. Crackles bilateral lung bases 4. Heart rate 55 and regular 5. Warm dry skin

ANS: 1, 2, 3 Rationale 1: Hypotension is a manifestation of cardiogenic shock. Rationale 2: Delayed capillary refill is a manifestation of cardiogenic shock. Rationale 3: Crackles are a manifestation of cardiogenic shock.

The nurse is caring for a patient recovering from a spinal cord injury sustained during a motor vehicle crash. What assessment findings indicate that the patient is developing neurogenic shock? Standard Text: Select all that apply. 1. Hypotension 2. Bradycardia 3. Warm dry skin 4. Abdominal cramps 5. Palpitations

ANS: 1, 2, 3 Rationale 1: Hypotension is a manifestation of neurogenic shock because of the loss of autonomic reflexes. Rationale 2: Bradycardia occurs because of the loss of sympathetic innervation. Rationale 3: Warm dry skin occurs because of a loss of cutaneous control of sweat glands.

A patient in the intensive care unit has been diagnosed with systemic inflammatory response syndrome (SIRS). What additional findings indicate the patient is becoming septic? Standard Text: Select all that apply. 1. Blood pressure 70/48 mm Hg 2. Urine output 10 mL/hr 3. Blood glucose level 185 mg/dL 4. Heart rate 88 5. Respiratory rate 16

ANS: 1, 2, 3 Rationale 1: Hypotension is an indication of sepsis. Rationale 2: Decreased urine output is an indication of sepsis. Rationale 3: Plasma glucose greater than 120 mg/dL is an indication of sepsis.

A patient is admitted to an "open" intensive care unit. In addition to the nurse, which health care providers will assist in the care of this patient? Standard Text: Select all that apply. 1. Pharmacist 2. Respiratory therapist 3. Attending physician 4. Dietician 5. Social worker

ANS: 1, 2, 3 Rationale 1: In an open ICU, pharmacists are ICU based. Rationale 2: In an open ICU, respiratory therapists are ICU based. Rationale 3: In an open ICU, the physicians directing patient care may have other obligations. These physicians may or may not choose to consult an intensivist to assist with the management of their ICU patients.

Which assessment findings should cause a nurse to be concerned that a patient is developing severe sepsis? Standard Text: Select all that apply. 1. Serum creatinine level 2.0 md/dL 2. Absent bowel sounds 3. Onset of confusion 4. Heart rate 54 5. Blood pressure 148/90 mm Hg

ANS: 1, 2, 3 Rationale 1: In severe sepsis, renal dysfunction is evidenced by an increase in serum creatinine greater than 0.5 mg/dL. Rationale 2: Gastrointestinal effects of severe sepsis are evidenced by absent bowel sounds or ileus. Rationale 3: Neurological dysfunction of severe sepsis is indicated by a sudden change in mental status with possible confusion.

A patient, experiencing vasodilation, is diagnosed with distributive shock. The nurse will assess the patient for which etiologies? Standard Text: Select all that apply. 1. Sepsis 2. Spinal cord injury 3. Anaphylaxis 4. Hemorrhage 5. Pulmonary embolism

ANS: 1, 2, 3 Rationale 1: One etiology of distributive shock is sepsis. Rationale 2: One etiology of distributive shock is spinal cord injury. Rationale 3: One etiology of distributive shock is anaphylaxis.

A patient a history of type 2 diabetes mellitus and heart failure is prescribed carvedilol (Coreg). What will the nurse assess prior to administering this medication to the patient? Standard Text: Select all that apply. 1. Blood pressure 2. Pulse 3. Blood glucose level 4. Lung sounds 5. Potassium level

ANS: 1, 2, 3 Rationale 1: Prior to administering a beta blocker, the nurse should assess the patient's blood pressure to ensure it is adequate. Rationale 2: Prior to administering a beta blocker, the nurse should assess the patient's pulse to ensure it is adequate. Rationale 3: The blood glucose level should be monitored in the patient with diabetes because a beta blocker can worsen glucose control and blunt symptoms of hypoglycemia.

The critical care nurse is experiencing psychologic symptoms of compassion fatigue. What strategies will the nurse use to enhance psychological well-being? Standard Text: Select all that apply. 1. Make time for recreational activities. 2. Practice yoga for relaxation. 3. Plan to take a walk in the park at least once a week. 4. Monitor food and beverage intake. 5. Darken the room and limit activities before sleep.

ANS: 1, 2, 3 Rationale 1: Sustaining a balance between work and play enhances psychological well-being. Rationale 2: Developing an effective relaxation method enhances psychological well-being. Rationale 3: Maintaining contact with nature enhances psychological well-being.

While transferring a patient with heart failure from the bed to a chair the nurse stops and decides to keep the patient in bed. What patient manifestations indicated to the nurse this patient's status was deteriorating? Standard Text: Select all that apply. 1. Respiratory rate 30 2. Heart rate 134 on the cardiac monitor 3. Gasping for breath 4. Productive cough 5. Jugular vein distention

ANS: 1, 2, 3 Rationale 1: Tachypnea is an indication of worsening heart failure. Rationale 2: Tachycardia is an indication of worsening heart failure. Rationale 3: Dyspnea is an indication of worsening heart failure.

The critical care nurse is identifying patients at risk for safety and medical errors. Which patients would the nurse identify as being at risk for these issues? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Patient in isolation with MRSA 2. Patient who does not understand English 3. Patient with end stage renal disease and a respiratory rate of 8 per minute 4. Patient recovering from pacemaker insertion 5. Patient with pulmonary edema

ANS: 1, 2, 3 Rationale 1: The most vulnerable of unstable ICU patients who are at highest risk for medical error include patients in isolation. Rationale 2: The most vulnerable of unstable ICU patients who are at highest risk for medical error include patients with limited English proficiency. Rationale 3: The most vulnerable of unstable ICU patients who are at highest risk for medical error include patients at end of life.

A patient being treated for cardiogenic shock is being hemodynamically monitored. Which findings are consistent with the patient's diagnosis? Standard Text: Select all that apply. 1. Elevated pulmonary arterial wedge pressure 2. Elevated central venous pressure 3. Elevated systemic vascular resistance index 4. Elevated mean arterial pressure 5. Elevated stroke volume

ANS: 1, 2, 3 Rationale 1: This finding is consistent with pulmonary vascular congestion. Rationale 2: This finding is consistent with fluid volume overload. Rationale 3: This finding is consistent with pulmonary vascular congestion.

A patient in the emergency department is demonstrating signs of sepsis. Which interventions will the nurse implement as part of the sepsis resuscitation bundle? Standard Text: Select all that apply. 1. Draw blood for a serum lactate level. 2. Obtain blood cultures. 3. Provide a broad spectrum antibiotic. 4. Administer low dose steroids. 5. Provide insulin for blood glucose level 200 mg/dL.

ANS: 1, 2, 3 Rationale 1: This is the first element of the sepsis resuscitation bundle. Rationale 2: This is the second element of the sepsis resuscitation bundle. Rationale 3: This is the third element of the sepsis resuscitation bundle.

A patient with type 2 diabetes mellitus is prescribed nicotinic acid (Nicobid) as adjunctive therapy for hypercholesterolemia. What will the nurse instruct the patient about this medication? Standard Text: Select all that apply. 1. Instruct to check blood glucose level frequently for elevations. 2. Teach that this medication may cause the patient to feel warm. 3. Instruct the patient that a flushed face can occur within 2 hours after taking. 4. Teach to not take medication with grapefruit juice. 5. Remind to notify the health care provider with any onset of muscle pain.

ANS: 1, 2, 3 Rationale 1: This medication can increase the blood glucose level. Rationale 2: Feeling warm is an expected response to this medication. Rationale 3: A flushed face can occur within 2 hours after ingesting this medication.

When planning care to meet the needs of family members of a critically ill patient, the nurse should include: Standard Text: Select all that apply. 1. Expressing an attitude of hope, honesty, open communication, and caring 2. Stating specific facts about the patient's condition in timely manner 3. Planning regular times for family visits throughout the day 4. Limiting the number of visitors to significant others 5. Communicating to a single family member to cut down time wasted repeating information to all visitors

ANS: 1, 2, 3 This is an appropriate approach when meeting the family needs of the critically ill patient.

The nurse, providing care to an unresponsive ventilated patient, is using unintentional distractions. What is the nurse doing when providing care? Standard Text: Select all that apply. 1. Singing 2. Humming 3. Joking 4. Talking to a colleague 5. Apologizing for causing pain

ANS: 1, 2, 3 This is an unintentional distraction.

The nurse is a member of a committee that is designing improvements to the critical care waiting areas. What improvements will the nurse suggest to enhance the comfort of family members of critical care patients? Standard Text: Select all that apply. 1. Plan for a large space to be used for the waiting areas. 2. Provide coffee and soft drinks in the waiting area. 3. Place televisions and videocassette players in the waiting area. 4. Find space for sleeping rooms. 5. Use dark paint and minimal lighting in the waiting areas.

ANS: 1, 2, 3, 4 Rationale 1: A larger area that is less cramped would enhance the comfort of families of critical care patients. Rationale 2: Providing coffee and soft drinks in the waiting area would enhance the comfort of families of critical care patients. Rationale 3: Placing television and videocassette players in the waiting areas would enhance the comfort of families of critical care patients. Rationale 4: Finding space for sleeping rooms would enhance the comfort of families of critical care patients.

The nurse manager, concerned that several staff nurses are experiencing moral distress, is planning to implement the 4 A's to Rise Above Moral Distress. What are the steps in this tool? Standard Text: Select all that apply. 1. Ask 2. Affirm 3. Assess 4. Act 5. Assert

ANS: 1, 2, 3, 4 Rationale 1: Ask is a step in the 4 A's to Rise Above Moral Distress tool. Rationale 2: Affirm is a step in the 4 A's to Rise Above Moral Distress tool. Rationale 3: Assess is a step in the 4 A's to Rise Above Moral Distress tool. Rationale 4: Act is a step in the 4 A's to Rise Above Moral Distress tool.

Which finding would cause the nurse to suspect a patient with heart failure was experiencing end organ hypoperfusion? Standard Text: Select all that apply. 1. Confusion 2. Dropping blood pressure 3. Urine output 15 mL per hour 4. Heart rate 124 5. Peripheral edema

ANS: 1, 2, 3, 4 Rationale 1: Confusion is a manifestation of end organ hypoperfusion. Rationale 2: Hypotension is a manifestation of end organ hypoperfusion. Rationale 3: Decreased urinary output is a manifestation of end organ hypoperfusion. Rationale 4: Tachycardia is a manifestation of end organ hypoperfusion.

Which parameters indicate that a patient in the intensive care unit being mechanically ventilated is ready for an interruption in sedation? The patient: Standard Text: Select all that apply. 1. Had a MAP of 75 and heart rate of 76 2. Was sleeping but awakened with verbal stimuli 3. Frowned when turned but otherwise showed no muscular tension 4. Activated the ventilator alarms but the alarms stopped spontaneously 5. Is receiving neuromuscular blocking agents to ensure adequate ventilation

ANS: 1, 2, 3, 4 Rationale 1: Hemodynamic stability is one criterion that indicates daily weaning of sedatives should be automatically attempted. Rationale 2: Awakening with verbal stimuli indicates that daily weaning of sedatives should be attempted. Rationale 3: Control of pain is an indication that daily weaning of sedatives should be attempted. Rationale 4: Patient-ventilator synchrony is an indication that daily weaning of sedatives should be attempted.

What would be appropriate reasons for an Intensive Care Unit intensivist to call a huddle? Standard Text: Select all that apply. 1. Make care providers aware of a change in a patient's situation. 2. Communicate a critical issue about a patient. 3. Make an assignment change. 4. Discuss concerns about a patient's status or care. 5. Plan care for the shift.

ANS: 1, 2, 3, 4 Rationale 1: Huddles are used so that team members may regain situation awareness. Rationale 2: Huddles are used so that team members may discuss critical issues. Rationale 3: Huddles are used so that team members may assign resources. Rationale 4: Huddles are used so that team members may express concerns.

A patient recovering from coronary artery bypass grafting is experiencing dysrhythmias. What will the nurse assess as the reasons for the dysrhythmias? Standard Text: Select all that apply. 1. Patient's body temperature 2. Potassium level 3. Calcium level 4. Arterial blood gases 5. Pupil size and reactivity to light

ANS: 1, 2, 3, 4 Rationale 1: Hypothermia can cause dysrhythmias after this type of surgery. Rationale 2: Hypokalemia can cause dysrhythmias after this type of surgery. Rationale 3: Hypo- and hypercalcemia can cause dysrhythmias after this type of surgery. Rationale 4: Metabolic acidosis can cause dysrhythmias after this type of surgery.

Which actions should the nurse complete after realizing that an incorrect dose of medication has been administered to a patient? Standard Text: Select all that apply. 1. Notify the patient and family 2. Notify the physician 3. Document the error 4. Prepare for an analysis of the error 5. Keep the notification of the error silent

ANS: 1, 2, 3, 4 Rationale 1: In a critical care unit that has embraced a culture of safety, practitioners have a responsibility to their patients to make their errors known, have them corrected, and share them with the patient and family. Rationale 2: In a critical care unit that has embraced a culture of safety, practitioners have a responsibility to their patients to make their errors known, have them corrected, and share them with other practitioners. Rationale 3: In a critical care unit that has embraced a culture of safety and practice, improvement is a goal rather than punishment. The reporting of errors results in the examination of the factors that contributed to the error and changes practice patterns. Rationale 4: In a critical care unit that has embraced a culture of safety and practice, improvement is a goal rather than punishment. The reporting of errors results in the examination of the factors that contributed to the error and changes practice patterns.

A patient is diagnosed with left-sided heart failure. When describing this disease process to the patient, the nurse will include: Standard Text: Select all that apply. 1. Pumping action of the heart is impaired. 2. Filling action of the heart is impaired. 3. Blood backs up in the left side of the heart. 4. Extra fluid can build up in the lungs. 5. Extra fluid can build up in the lower extremities.

ANS: 1, 2, 3, 4 Rationale 1: In left-sided heart failure, the pumping action or systolic action of the left ventricle is impaired. Rationale 2: In left-sided heart failure, the ability of the left ventricle to fill or diastolic action of the left ventricle is impaired. Rationale 3: In left-sided heart failure, blood backs up from the left ventricle to the left atrium. Rationale 4: In left-sided heart failure, fluid eventually builds up in the lungs.

While caring for a patient with sepsis, the nurse suspects that disseminated intravascular coagulation is developing. What did the nurse assess in the patient? Standard Text: Select all that apply. 1. Cyanosis of the fingers 2. Patient complains of finger pain 3. Diminished pulses 4. New onset of confusion 5. Urine output 60 mL/hr

ANS: 1, 2, 3, 4 Rationale 1: Occlusion of blood vessels may be seen as cyanosis and/or gangrene, especially of the digits. There may actually be a demarcation line between the viable and necrotic tissue visible on the fingers or toes, and the patient may complain of pain in the digits. Rationale 2: Occlusion of blood vessels may be seen as cyanosis and the patient may complain of pain in the digits. Rationale 3: Diminished pulses are an indication of disseminated intravascular coagulation. Rationale 4: Inadequate perfusion of the brain may present as an altered level of consciousness, especially confusion.

The nurse instructs a patient on the procedure for percutaneous coronary intervention (PCI) with stent placement. Which patient statements indicate that teaching has been effective? Standard Text: Select all that apply. 1. "This procedure is done on an artery that is about 70% smaller than it should be." 2. "The artery in my heart is reached by going through an artery in my leg." 3. "After the fatty clot is smashed against the artery wall, a mesh stent remains in the artery to keep it open." 4. "I will need to take aspirin and another blood thinner for up to 6 months after the procedure." 5. "I will have my blood sugar level measured many times after the procedure."

ANS: 1, 2, 3, 4 Rationale 1: PCI is indicated in coronary arteries that have at least 70% narrowing. Rationale 2: A catheter with a balloon is inserted into the femoral artery and guided to the desired site. Rationale 3: The balloon is inflated, expanding the stent which squeezes the atherosclerotic plaque against the vessel wall and widens the arterial lumen. After the stent is in place, the balloon is deflated and removed. The stent remains in place holding the plaque against the arterial wall providing structural support. Rationale 4: Patients with stent placement usually require antiplatelet therapy with aspirin and clopidogrel for up to 6 months after stenting to reduce the risk of vessel thrombosis.

The nurse is preparing discharge instructions for a patient admitted with heart failure. What will the nurse include in this teaching? Standard Text: Select all that apply. 1. Permitted activity level 2. Diet 3. Prescribed medications 4. Importance of daily weight monitoring 5. Stress reduction strategies

ANS: 1, 2, 3, 4 Rationale 1: Permitted activity level should be included in discharge education for the patient with heart failure. Rationale 2: Diet should be included in discharge education for the patient with heart failure. Rationale 3: Medications should be included in discharge education for the patient with heart failure. Rationale 4: Weight monitoring should be included in discharge education for the patient with heart failure.

What findings identified by the nurse on an assessment of a patient being treated for heart failure would cause the nurse to notify the patient's health care provider that the patient's status was deteriorating? Standard Text: Select all that apply. 1. S3 and S4 heart sounds 2. Oxygen saturation 80% on 4 liters oxygen nasal cannula 3. Urine output 10 mL over the last hour 4. Onset of production cough 5. Weight loss of 3 lbs from previous weight

ANS: 1, 2, 3, 4 Rationale 1: S3 and S4 heart sounds indicate the patient's cardiac status is deteriorating. Rationale 2: Reduced oxygen saturation is an indication that the patient's pulmonary status is deteriorating. Rationale 3: Poor urine output is an indication that the patient's systemic status is deteriorating. Rationale 4: Worsening cough is an indication that the patient's pulmonary status is deteriorating.

An 82-year-old patient is readmitted for heart failure (HF) 1 week after being discharged for the same diagnosis. Which findings most likely contributed to the patient's readmission? Standard Text: Select all that apply. 1. Not knowing how or when to take medications 2. Not prescribed appropriate medications, including ACE inhibitors and beta blockers 3. No record of body weight since discharge 4. Not filling prescribed medications 5. Received the pneumococcal immunization during the last hospitalization

ANS: 1, 2, 3, 4 Rationale 1: Some studies indicate that older patients with heart failure have poor knowledge of appropriate medication management. Rationale 2: There is evidence that a significant number of older adults with heart failure do not receive evidence-based, AHA-recommended care including angiotensin-converting enzymes (ACE) inhibitors and beta blockers. Rationale 3: Patient records indicate that daily weights are not consistently obtained. Rationale 4: Pharmacy records indicate that prescriptions are not promptly refilled.

The competent critical care nurse demonstrates an understanding of patient advocacy by taking which actions? Standard Text: Select all that apply. 1. Maintaining attendance at the bedside with the patient during a physician visit 2. Assisting and supporting the patient and family as they reveal their needs 3. Alerting the physician to concerns about client placement after hospitalization 4. Encouraging and supporting a patient's spouse in preparing for a family meeting 5. Seeing the big picture when planning patient care

ANS: 1, 2, 3, 4 Rationale 1: The nurse realizes that the patient may be vulnerable and need support to obtain what is needed from the health care system. Rationale 2: The nurse realizes that the patient may be vulnerable and need support to obtain what is needed from the health care system. Rationale 3: The nurse realizes that the patient may be vulnerable and need support to obtain what is needed from the health care system. Rationale 4: The nurse realizes that the patient may be vulnerable and need support to obtain what is needed from the health care system.

The nurse is aware that decision-making capacity is likely to be impaired for a patient who: Standard Text: Select all that apply. 1. Is being medicated for severe pain 2. Does not understand the medical condition 3. Has been diagnosed with septic shock 4. Is depressed 5. Asks questions about identified treatments

ANS: 1, 2, 3, 4 Rationale 1: The patient must be capable of rational thought and be able to recognize what the prospective treatment involves. Rationale 2: Understanding the health condition is one component of informed consent. Rationale 3: It is common for health care providers and family members to question the decision-making ability of critically ill patients. Many critically ill patients lack the capacity to give informed consent. Rationale 4: Patients who are depressed may not be capable of thinking clearly.

The nurse is planning to use music therapy to help reduce a critically ill patient's level of anxiety. What will the nurse do when using this complementary and alternative therapy? Standard Text: Select all that apply. 1. Ask family members to identify the patient's preferred music. 2. Plan for the music to be played for 30 uninterrupted minutes. 3. Listen to the music in advance to make sure it does not have lyrics. 4. Ensure that the music beats are between 60 to 80 per minute. 5. Play the music from a tape recorder on the bedside table.

ANS: 1, 2, 3, 4 Rationale 1: The patient's preferred music should be used. Rationale 2: Evidence based music therapy calls for a critically ill patient to listen to at least 30 minutes of music. Rationale 3: It is most beneficial if the music is without words. Rationale 4: It is most beneficial if the music is approximately 60 to 80 beats per minute

While completing a self-evaluation, the critical care nurse compares personal practice to the competencies identified by the AACN Synergy Model. Which behaviors are consistent with those in the Synergy Model? Standard Text: Select all that apply. 1. Seeks out research studies to update protocols 2. Approaches patient care by looking at the "big picture" 3. Ensures family members are comfortable when visiting critical care patients 4. Encourages patient families to discuss issues with the physician 5. Telling the next shift that a patient needs help with understanding instructions

ANS: 1, 2, 3, 4 Rationale 1: This behavior demonstrates the competency of clinical inquiry. Rationale 2: This behavior demonstrates the competency of clinical judgment. Rationale 3: This behavior demonstrates the competency of caring. Rationale 4: This behavior demonstrates the competency of advocacy.

What interventions will the nurse include when planning care for a patient recovering from PCI with stent placement? Standard Text: Select all that apply. 1. Monitor for reperfusion dysrhythmias. 2. Monitor for bleeding from the catheter site. 3. Assess for pulses at the ankle and knee. 4. Maintain the patient on bedrest with the cannulated extremity straight for 4 to 6 hours. 5. Administer blood products for low blood pressure as prescribed.

ANS: 1, 2, 3, 4 Rationale 1: This is an appropriate intervention for a patient recovering from PCI with stent placement. Rationale 2: This is an appropriate intervention for a patient recovering from PCI with stent placement. Rationale 3: This is an appropriate intervention for a patient recovering from PCI with stent placement. The nurse should monitor the extremity below the insertion site for pulses. Rationale 4: This is an appropriate intervention for a patient recovering from PCI with stent placement.

A patient with chest pain is prescribed to have a troponin level drawn. What purpose does this diagnostic test serve in the care of a patient with chest pain? Standard Text: Select all that apply. 1. It appears in the bloodstream 4 to 12 hours after the onset of cardiac injury. 2. The peak level of troponin appears in 12 hours. 3. If a cardiac injury has occurred, the troponin level will stay elevated for 7 to 10 days. 4. The troponin level may be a predictor of myocardial infarction size. 5. A negative result does not need to be retested.

ANS: 1, 2, 3, 4 Rationale 1: This marker appears in the bloodstream 4 to 12 hours after the onset of injury. Rationale 2: This marker peaks in 12 hours. Rationale 3: This marker remains elevated for 7 to 10 days after cardiac injury. Rationale 4: After an acute myocardial infarction, it may be a predictor of size.

The nurse manager of a critical care unit is explaining the AACN Synergy Model to the critical care nurses. What will the manager include as basic parts of this model? Standard Text: Select all that apply. 1. Based on the patients' characteristics 2. Based on the competencies of the nurses 3. Patient outcomes will be measured 4. The nurses' assessment of patient outcomes will be measured 5. Reduction of cost to provide critical care services to patients

ANS: 1, 2, 3, 4 Rationale 1: This model is based on the patients' characteristics. Rationale 2: This model is based on the nurses' competencies. Rationale 3: This model is based on outcomes derived from the patient. Rationale 4: This model is based on outcomes derived from the nurse.

The nurse is instructing a patient about acute coronary syndrome. What will be included in these instructions? Standard Text: Select all that apply. 1. Fatty plaques develop in the coronary arteries. 2. Plaques in arteries limit the amount of blood that can flow through the heart vessels. 3. Plaque in coronary arteries can cause stable angina. 4. If a plaque ruptures, it can get into the general circulation. 5. Stable angina rarely progresses to unstable angina.

ANS: 1, 2, 3, 4 Rationale 1: This would be included when teaching about acute coronary syndrome. Rationale 2: The growth of the atherosclerotic plaques narrows the vasculature, which then limits the blood flow and delivery of oxygen to the coronary muscle. This would be included when teaching about acute coronary syndrome. Rationale 3: This buildup of plaque in the coronary arteries results in a less serious condition known as stable angina. This would be included when teaching about acute coronary syndrome. Rationale 4: Rupture of a thin fibrous cap exposes the thrombogenic contents of the plaque into a patient's circulation. This would be included when teaching about acute coronary syndrome.

A patient is brought to the emergency department with manifestations of anaphylactic shock. What will the nurse assess as possible causes for this disorder? Standard Text: Select all that apply. 1. Recent bee sting 2. Ingestion of drugs 3. History of latex allergy 4. Recent diagnostic imaging tests 5. Recent myocardial infarction

ANS: 1, 2, 3, 4 Rationale 1: Venoms such as bee stings can trigger anaphylactic shock. Rationale 2: Drugs can trigger anaphylactic shock. Rationale 3: Latex can trigger anaphylactic shock. Rationale 4: Contrast media for diagnostic tests can trigger anaphylactic shock.

The nurse is assessing a critically ill patient's nutritional needs. What information is essential for the nurse to obtain during this assessment? Standard Text: Select all that apply. 1. Patient's current height and weight 2. Food allergies 3. Use of nutritional supplements 4. If the patient can swallow 5. Amount of water consumed each day

ANS: 1, 2, 3, 4 This information is essential for the nurse to obtain.

The nurse is assessing a critically ill patient utilizing the AACN Synergy Model's characteristics. Which characteristics are identified as impacting the outcome of a critically ill patient? Standard Text: Select all that apply. 1. Participation in care 2. Resource availability 3. Stability 4. Complexity 5. Level of consciousness

ANS: 1, 2, 3, 4 This is a characteristic identified by the Synergy Model.

During a health history the nurse suspects a patient has been experiencing stable angina. What did the patient most likely describe to the nurse? Standard Text: Select all that apply. 1. Chest pain that lasts between 5 to 10 minutes 2. Chest pain that occurs during stress 3. Chest pain that occurs when out of doors on very cold days 4. Chest pain that stops with rest 5. Chest pain that occurs at rest

ANS: 1, 2, 3, 4 This is a manifestation of stable angina.

Which strategies should the nurse include in the plan of care when trying to minimize sleep disruptions for a patient in an ICU? Standard Text: Select all that apply. 1. Instituting a short course of therapy for sleeping agents 2. Accurate scoring and vigilance in sedation and sedation scoring 3. Managing the environment to reduce lighting, sounds, and so on 4. Minimizing staff interruptions during sleep periods 5. Scheduling treatments only during the day or at least 4 hours apart at night

ANS: 1, 2, 3, 4 This is a strategy to minimize interruptions of sleep and to maximize the rest benefits that will shorten the duration of care based on research findings.

The nurse is planning care for a patient in the critical care area. What will the nurse include to address major areas of concern for the patient? Standard Text: Select all that apply. 1. Explain the purpose of the tube in the nose. 2. Explain the purpose of the tube in the mouth. 3. Determine a method of communication. 4. Explain the purpose of the intravenous tubes. 5. Ensure that the room lights will be turned off and alarms set to low volume.

ANS: 1, 2, 3, 4 This is considered a stressor for the patient in intensive care and should be addressed by the nurse.

What strategies would the nurse utilize to optimize communication with an older adult who is intubated and mechanically ventilated? Standard Text: Select all that apply. 1. Make sure the patient is wearing eyeglasses. 2. Speak slowly. 3. Decide on which gestures mean "yes" and "no." 4. Have questions and possible answers ready so the patient can point to the response. 5. Ask several questions at a time to limit interruptions in rest periods.

ANS: 1, 2, 3, 4 This will maximize communication with the older patient.

The nurse is beginning emergency care of a patient with a myocardial infarction. Place in order the medication interventions that the nurse will provide to this patient. Standard Text: Click and drag the options below to move them up or down. Choice 1. Administer four baby strength aspirins. Choice 2. Administer nitroglycerin. Choice 3. Apply oxygen. Choice 4. Administer morphine 2 to 5 mg intravenous every 5 to 30 minutes as needed. Choice 5. Administer a beta blocker.

ANS: 1, 2, 3, 4, 5 Rationale 1: This is the first medication intervention that the nurse will provide. It is used to prevent platelet aggregation and the formation of blood clots in the coronary vasculature. Rationale 2: This is the second medication intervention that the nurse will provide. It is used to reduce coronary pain and improve coronary blood flow. Rationale 3: This is the third medication intervention that the nurse will provide. It is used to ensure adequate oxygenation of coronary tissues. Rationale 4: This is the fourth medication intervention that the nurse will provide. Morphine is used for both pain management and as an anti-anxiety medication. Rationale 5: This is the fifth medication intervention that the nurse will provide. Beta blockers should be promptly instituted because they decrease heart rate, and blood pressure levels. These drugs will also decrease left ventricular contractility, thereby reducing myocardial oxygen demand.

The nurse is explaining the mechanism of a pulmonary embolism to the family of a patient diagnosed with the disorder. Place in order the steps the nurse will use to instruct the family about this disease process. Standard Text: Click and drag the options below to move them up or down. Choice 1. Blood clot causes backup of blood in the right ventricle. Choice 2. Blood clot blocks blood to the left ventricle. Choice 3. Left ventricle does not get enough blood to pump through the body. Choice 4. Amount of blood the heart has to pump to the body drops. Choice 5. Blood pressure drops. Choice 6. Amount of blood going to the body drops.

ANS: 1, 2, 3, 4, 5 , 6 Rationale 1: The obstruction caused by the pulmonary embolism increases the afterload of the right ventricle, causing right ventricular failure. Rationale 2: The embolus prevents adequate blood flow from the pulmonary circulation to the left ventricle. Rationale 3: Because blood flow from the pulmonary circulation is blocked, left ventricular preload drops. Rationale 4: Because left ventricular preload is decreased, there is not enough blood in the heart to pump, causing decreased cardiac output. Rationale 5: A lack of blood circulating will lead to hypotension. Rationale 6: When the blood is backed up and is not being pumped into the general circulation, tissue perfusion is reduced.

The nurse is preparing medications for a patient being treated for cardiogenic shock. Which medications will the nurse most likely provide to this patient?Standard Text: Select all that apply. 1. Dopamine 2. Norepinephrine 3. Dobutamine 4. Epinephrine 5. Phenylephrine

ANS: 1, 2, 3, 5 Rationale 1: Dopamine is commonly used in the treatment of cardiogenic shock. Rationale 2: Norepinephrine is commonly used in the treatment of cardiogenic shock. Rationale 3: Dobutamine may be used in the patient with cardiogenic shock who has an adequate blood pressure. Rationale 5: Phenylephrine is a vasopressor and may be used in the patient with cardiogenic shock who is receiving dobutamine.

In order to collaborate with other members of the health care team to effect optimal outcomes in patient care, the nurse utilizes the characteristics of emotional maturity which include: Standard Text: Select all that apply. 1. Maintaining current skills 2. Being a lifelong learner 3. Actively identifying best practices 4. Overlooking one's own shortcomings 5. Willing to take responsibility for failures

ANS: 1, 2, 3, 5 Rationale 1: This is an attribute of emotional maturity in nursing. Rationale 2: This is an attribute of emotional maturity in nursing. Rationale 3: This is an attribute of emotional maturity in nursing. Rationale 5: This is an attribute of emotional maturity in nursing.

The nurse is preparing a patient for surgery to repair an abdominal aortic aneurysm. Which interventions would reduce the patient's risk of developing a surgical site infection? Standard Text: Select all that apply. 1. Administer prescribed antibiotic 1 hour before the surgery begins. 2. Discontinue intravenous antibiotics 24 hours after the surgery. 3. Shave abdominal region before the surgery. 4. Remove excess hair from abdominal area with an electric clipper. 5. Apply antiembolism stocking prior to surgery.

ANS: 1, 2, 4 Rationale 1: Providing an appropriate antibiotic no more than 1 hour prior to the surgical incision results in fewer surgical site infections. Rationale 2: Discontinuing antibiotics 24 hours after surgery results in fewer surgical site infections. Rationale 4: If hair removal is necessary, it should be removed with the use of an electric clipper.

The multidisciplinary team would identify which goals for initial collaborative management of a patient with an acute coronary event (ACS)? Standard Text: Select all that apply. 1. Limit the size of infarction by decreasing oxygen demands. 2. Maximize coronary artery blood flow. 3. Strengthen the heart by increasing activity as soon as possible. 4. Balance oxygen demand with supply. 5. Prevent dysrhythmias with prophylactic antidysrhythmic medications.

ANS: 1, 2, 4 Rationale 1: The symptoms are caused by decreased oxygen or increased demand for oxygen in the myocardium. If the nurse increases the oxygen supply and decreases the level of activity (decreasing metabolic rates) to decrease the demands, ischemic tissue can recover or limit additional tissue death. Prolonged continually, hypoxia will eventually cause tissue necrosis (death). Rationale 2: In a collaborative environment, maximization of coronary artery blood flow would be achieved through medication therapy, procedural intervention, and rest. Rationale 4: The symptoms are caused by decreased oxygen or increased demand for oxygen in the myocardium. If the nurse increases the oxygen supply and decreases the level of activity (decreasing metabolic rates) to decrease the demands, ischemic tissue can recover or limit additional tissue death.

A patient has just completed a preoperative education session prior to undergoing coronary artery bypass surgery. Which patient statements indicate that teaching has been effective? Standard Text: Select all that apply. 1. "I understand that I will have to blink my eyes to respond after the breathing tube is in my throat." 2. "I will be given frequent mouth care to help me when I am thirsty." 3. "I will be able to move about freely in bed and into the chair without help while connected to the electronic equipment for monitoring." 4. "I may need something to help me rest due to the unfamiliar lights and sounds of the ICU unit." 5. "I might not behave like my usual self after the surgery but it will be because of the medications and my illness."

ANS: 1, 2, 4, 5 Rationale 1: An alternate method of communication discussed in advance of tube placement will assist in better communication after the tube is inserted to aid the breathing process. Rationale 2: While intubated, oral hygiene is needed to prevent mucosal drying due to the inability of the patient to take oral fluids. Rationale 4: Due to environmental lights, sounds, and difference in sleeping environment, additional aids, such as drug management, may be needed to assist the patient to rest at night. Rationale 5: A patient concern in the critical care area is the inability to control self. This statement indicates the patient's understanding of the teaching.

Moral distress among critical care nurses is associated with: Standard Text: Select all that apply. 1. Having no voice in clinical decision making 2. Providing aggressive care to patients who cannot benefit 3. Realizing that nurses maintain power in bedside decision making 4. Knowing the right thing to do but not being able to do it 5. Leaving employment as a critical care nurse

ANS: 1, 2, 4, 5 Rationale 1: Nurses consistently state that when they do not have a voice in the decision making, they feel powerless, which contributes to moral distress. Rationale 2: Nurses consistently state that when they cannot find meaning in the patients' or families' suffering this contributes to moral distress. Rationale 4: Moral distress is when a nurse knows the right thing to do, yet institutional constraints such as lack of resources or personal authority would prevent the nurse from doing it. Rationale 5: As many as half of critical care nurses may have left a unit due to moral distress.

Which patients would be at risk for nutritional imbalances? The patient: Standard Text: Select all that apply. 1. Who is a stable, post-myocardial infarction 2. With renal failure 3. With slightly elevated liver enzymes 4. Who is intubated and sedated 5. With burns or excessive trauma

ANS: 1, 2, 4, 5 These patients are at risk for nutritional imbalances.

The physician has prescribed the sepsis management bundle to be implemented in a patient with severe sepsis. The nurse will prepare to administer which interventions? Standard Text: Select all that apply. 1. Administer steroids as prescribed. 2. Administer human recombinant activated protein C. 3. Administer insulin coverage for blood glucose greater than 150 mg/dL. 4. Administer a fluid challenge. 5. Assist with the insertion of a central line.

ANS: 1, 3 Rationale 1: Steroids are a part of the sepsis management bundle. Rationale 3: The treatment of elevated blood glucose levels is a part of the sepsis management bundle.

The nurse is teaching a patient with heart failure nonpharmacological strategies to improve quality of life. What will be included in these instructions? Standard Text: Select all that apply. 1. Importance of smoking cessation 2. Reduce salt intake to 1 gram per day 3. Restrict caloric intake to attain recommended body weight 4. Attend cardiac rehabilitation sessions as prescribed 5. Ingest no more than three alcoholic drinks per day

ANS: 1, 3, 4 Rationale 1: One nonpharmacological strategy to improve the quality of life in a patient with heart failure is to stop smoking. Rationale 3: Weight reduction in obese patients is a nonpharmacological strategy to improve the quality of life in the patient with heart failure. Rationale 4: One nonpharmacological strategy to improve the quality of life in the patient with heart failure is to attend cardiac rehabilitation.

When planning care to meet the needs of families of critically ill patients, the nurse would include which strategies by Miracle (2006)? Standard Text: Select all that apply. 1. Information about how to contact the primary doctor if needed 2. Frequent verbal communication to clarify the purpose of unit, equipment, procedures, waiting areas, phones, and so on 3. Regular family conferences to meet patient goals and progress 4. A consistent nurse, and unified staff responses if that nurse is not available 5. A way to contact family through a specific family member by phone if needed

ANS: 1, 3, 4 This is a strategy to minimize stress and maximize communication to meet the family needs of the critically ill patient.

Which factors would contribute to the risk of a patient developing stress ulcers after coronary artery bypass graft (CABG) surgery? Standard Text: Select all that apply. 1. Incidence of postoperative hemorrhaging 2. Age less than 70 years 3. Alcohol abuse or excess 4. Need for vasodilators for post-operative hypertension 5. Prolonged use of cardiopulmonary bypass

ANS: 1, 3, 5 Rationale 1: Bleeding disorders increases the risk for stress ulcers in the post-operative period. Rationale 3: History of alcohol abuse or excess increases the risk for stress ulcer formation in the patient recovering from this type of surgery. Rationale 5: Prolonged use of cardiopulmonary bypass increases the risk for stress ulcer formation in the patient recovering from this type of surgery.

Of the following patients, which will the nurse expect to be transferred to a critical care unit? The patient: Standard Text: Select all that apply. 1. With an acetaminophen overdose 2. Suffering from acute mental illness 3. With chronic renal failure 4. With acute decompensated heart failure 5. With bacteremia from an infected foot wound

ANS: 1, 4, 5 Rationale 1: Critical care units are cost-efficient units for caring for patients with specific organ system failure. Patients with acetaminophen overdose often suffer liver failure as a consequence. Rationale 4: The patient with acute decompensated heart failure would receive care in a critical care unit. This patient has a specific organ that has failed. Rationale 5: Bacteremia can affect many organs and lead to multisystem organ failure. This patient would receive care in a critical care unit.

Which symptoms seen in a nurse would suggest compassion fatigue? Standard Text: Select all that apply. 1. Difficulty separating work from personal life 2. Excessive high tolerance for frustration 3. Having a completely laissez-faire attitude 4. Decreased functioning in nonprofessional situations 5. Dreads working with certain types of patients

ANS: 1, 4, 5 Rationale 1: This is a symptom of compassion fatigue. Rationale 4: This is a symptom of compassion fatigue. Rationale 5: This is a symptom of compassion fatigue.

The nurse is reviewing a patient's medical history. Which factors in the history most likely contributed to the patient's development of heart failure? Standard Text: Select all that apply. 1. Hypertension 2. Diabetes mellitus 3. Drinking one or two alcoholic drinks daily 4. Being overweight 5. Ischemic heart disease

ANS: 1, 5 Rationale 1: Hypertension is identified as an etiology of heart failure. Rationale 5: Ischemia to the heart is a known cause of heart failure.

What action would be most helpful to the nurse in determining whether the chest pain of a patient who has just entered the emergency department is cardiac in origin? 1. Gathering a complete medical history 2. Performing a 12-lead ECG 3. Administering NTG to see if the pain goes away 4. Asking the patient if performing a Valsalva maneuver reduces the pain

ANS: 2 A 12-lead ECG is performed immediately if the symptoms are suggestive of pain that is cardiac in origin.

A patient is very short of breath. Which finding should cause the nurse to be concerned that the shortness of breath might be due to heart failure? 1. An echocardiogram that reflected increased right ventricular wall thickening 2. A B-type natriuretic peptide (BNP) of 300 pg/mL 3. A left ventricular ejection fraction (VEF) of 50% 4. A serum sodium of 135

ANS: 2 A BNP greater than 100 pg/mL suggests heart failure as a cause of dyspnea.

Which nursing actions would be appropriate when a nurse is initiating an infusion of morphine sulfate for a post-operative patient who is experiencing pain? 1. Anticipate that the patient will begin to experience the effect of the morphine 15 minutes after the start of the infusion. 2. Provide additional intermittent boluses of morphine sulfate if the patient experiences breakthrough pain. 3. Complete the Critical-Care Pain Observation Tool scale 5 minutes after increasing the infusion rate each time. 4. Begin the infusion at the lowest ordered dose and increase the rate every 30 minutes if the patient continues to have pain.

ANS: 2 A critically ill patient often will receive an IV bolus of an analgesic followed by an ongoing infusion of the pain medication with intermittent boluses and increases in infusion until the drug attains steady state and the patient experiences pain relief.

Members of the multidisciplinary care team are reviewing a patient's nutritional status and analyzing assessment values. Which value would need additional investigation? 1. A serum albumin of more than 3.5 g/dL or 35 g/L 2. A weight increase of 1.5 kg in a day 3. A serum hemoglobin of 11.7 g/dL or 117 mmol/L 4. A prealbumin level of 35 mg/dL

ANS: 2 A weight change of 1.5 kg (approximately 3.3 lb) reflects approximately 1.5 liters of fluid. Additional assessment needs to be done to evaluate the cause and risks.

Which patient would the nurse identify as experiencing a critical illness? The patient: 1. With chronic airflow limitation whose VS are BP 110/72, P 110, R 16 2. With acute bronchospasm and whose VS are BP 100/60, P 124, R 32 3. Who was involved in a motor vehicle crash whose VS are BP 124/74, P 74, R 18 4. On hemodialysis for chronic renal failure with no urine output and whose VS are BP 98/50, P 108, R 12

ANS: 2 Acute bronchospasm can present a life-threatening situation, which can jeopardize a patient's survival. The patient's pulse and respiratory rate are elevated, which could indicate a critical illness.

A patient says, "I've never heard of an acute coronary syndrome. Please explain what happened to me." The nurse should respond, "Acute coronary syndrome is: 1. Another name for a myocardial infarction (MI) or heart attack." 2. A group of disorders that result in insufficient oxygen supply to the heart." 3. The second leading cause of death in the United States." 4. A type of abnormal heart rhythm."

ANS: 2 Acute coronary syndrome (ACS) is an inclusive term for conditions that cause chest pain due to insufficient blood supply to the heart muscle.

A patient with heart failure has a decreasing cardiac output. The nurse will expect compensatory mechanisms to be activated in order to: 1. Decrease the heart rate 2. Maintain perfusion to vital organs 3. Cause arteriolar vasodilation in nonessential vascular beds 4. Inhibit the release of aldosterone

ANS: 2 As the heart function fails and cardiac output decreases, compensatory mechanisms are activated to maintain perfusion to the vital organs.

What will the nurse do when administering antibiotics to a patient with sepsis? 1. Antibiotics should be administered as soon as the patient has received a fluid bolus. 2. Antibiotics should always be administered after blood cultures are obtained. 3. Administer the antibiotic with the shortest administration time first so that all antibiotics are administered quickly. 4. Wait for the results of liver and renal function tests before beginning antibiotic therapy.

ANS: 2 Blood cultures must be obtained prior to the administration of antibiotics in order to isolate the infecting organism successfully.

A patient tells a nurse, "My chest pain starts when I am resting, and when I had a cardiac catheterization, the doctor said I was having vasospasms." Which type of medication would the nurse anticipate to be prescribed to treat the patient's angina? 1. A vasodilator such as nitroglycerin (NTG) 2. A calcium channel blocking agent 3. An antidysrhythmic such as lidocaine 4. A beta adrenergic blocking agent

ANS: 2 Calcium channel blocking agents would be the drug of choice to stop the spasms of the coronary arteries that are causing the hypoxic pain in the myocardium from Prinzmetal's angina

Which statement best describes the pathophysiology of multiple organ dysfunction syndrome (MODS) in a patient with sepsis? 1. The primary cause of MODS is decreased blood pressure. 2. Endothelial dysfunction is a primary cause of MODS. 3. Increased microvascular bleeding causes MODS. 4. Circulating pathogens cause destruction of organs, resulting in MODS.

ANS: 2 Endothelial dysfunction is a primary cause of MODS.

A physician suggests that a ventilated patient needing immediate transport to CT scan and having severe pain be given IV fentanyl (Sublimaze) rather than morphine sulfate for pain management. One reason the physician might recommend the use of fentanyl (Sublimaze) is: 1. Rapid administration does not have any hemodynamic consequences. 2. It has a more rapid onset and a shorter duration of action. 3. Weaning of a continuous infusion is never needed due to its short half-life. 4. It is not likely to cause respiratory depression.

ANS: 2 Fentanyl is 100 times more potent than morphine. It has a faster onset of action than morphine and a shorter duration of action.

What would the nurse not expect to find in a patient who was experiencing acute decompensated heart failure with pulmonary edema? 1. Dyspnea at rest, peripheral edema 2. Hypertension, bradycardia 3. Increased coughing, crackles 4. Decreased O2 saturation, increased PAWP

ANS: 2 Hypertension and bradycardia are not symptoms of pulmonary edema.

The nurse should warm intravenous fluids when a rapid infuser is being utilized to prevent which complication? 1. Hemorrhagic shock 2. Hypothermia 3. Sepsis 4. Cardiogenic shock

ANS: 2 Hypothermia can result when providing room temperature fluids at a faster pace than the body can warm them.

A nurse is caring for a ventilated post-operative patient who might be experiencing pain. Which method of assessing the patient's pain level should the nurse try first? 1. Attempting an analgesic trial 2. Asking the patient if he is in pain 3. Observing the patient's face for grimacing 4. Asking a family member if the patient is in pain

ANS: 2 If the patient is responsive, the nurse should ask the patient about presence of pain.

A patient is demonstrating pulmonary edema, hypotension, and delayed capillary refill. The nurse suspects the patient is experiencing which type of shock? 1. Hypovolemic 2. Cardiogenic 3. Anaphylactic 4. Obstructive

ANS: 2 In cardiogenic shock, there is a low cardiac output, hypotension, and pulmonary edema.

For a nurse to be found guilty of negligence, it must be demonstrated that the patient: 1. Was assaulted 2. Incurred damages 3. Suffered a wrongful death 4. Was not consulted before being touched

ANS: 2 In order to prove negligence, damages must have occurred to the patient.

Which finding indicates that a patient is experiencing increased peripheral resistance and vasoconstriction? 1. Strong bounding pulse with deep red coloring 2. Pale, cool extremities with decreased pulses 3. Increased venous engorgement with strong pulses 4. Faster than normal capillary refill time

ANS: 2 Increased peripheral resistance causes the blood supply to decrease and results in decreased blood to the tissues, which causes pallor and decreased skin temperatures. The pulses would decrease in intensity with a decreased blood supply.

Which laboratory finding should cause the nurse to suspect that a patient is developing hypovolemic shock? 1. Serum sodium of 130 mEq/L (130 mmol/L) 2. Metabolic acidosis validated by arterial blood gases 3. Serum lactate of 3 mmol/L 4. SvO2 greater than 80%

ANS: 2 Metabolic acidosis is present due to an accumulation of carbonic acid, leaving a bicarbonate deficit from decreased tissue perfusion.

Which evidence based intervention would the nurse use to prevent pneumonia in the patient receiving mechanical ventilation? 1. Aseptic technique when performing oral hygiene 2. Administration of an H2 antagonist to prevent peptic ulcers 3. Elevation of the head of the bed to 15 degrees to prevent aspiration 4. Changing the ventilator circuit daily

ANS: 2 One of the evidence based practices used to prevent ventilator-associated pneumonia includes the use of an H2 antagonist to prevent peptic ulcers.

A patient in heart failure is to be started on an infusion of dobutamine (Dobutrex). What is most important for the nurse to assess before starting the infusion? The patient's: 1. Breath sounds 2. Blood pressure 3. Level of consciousness 4. Urine output

ANS: 2 Prior to initiation, before each titration, and at the peak action of dobutamine, the nurse must assess blood pressure, heart rate, respiratory rate, and oxygen saturation. Frequent assessment of these parameters should continue throughout the infusion period.

What would be included in the collaborative management of a patient's pulmonary status following coronary artery bypass graft surgery? 1. Keeping the patient intubated for at least 48 hours to maximize gas exchange 2. Mobilizing the patient as soon as possible to prevent atelectasis and venous stasis 3. Evaluating readiness for extubation based on guidelines: PO2 less than 80 mm Hg with an FiO2 greater than 40% and a PCO2 greater than 45 4. Extubating when the patient is arousable to noxious stimuli and shows increased effort for spontaneous breathing

ANS: 2 Pulmonary functions decline with immobility. Gravitational pull on secretions to posterior areas and inadequate inflation cause atelectasis. Activity and position changes will increase mobility of secretions. Even if the patient is intubated, extra movement by changing of positions will minimize respiratory complications or congestion in the lungs, both of which will increase the work effort of the heart and decrease perfusion and ventilation if not corrected.

Which communication strategy is most appropriate for a critical care nurse to use when communicating with a ventilated patient? The nurse should: 1. Use professional terminology and provide the patient with detailed information. 2. Use simple language and explain in other terms if the patient does not seem to understand. 3. Provide minimal information so the patient is not overwhelmed. 4. Discuss issues primarily with the family because the patient is unlikely to understand the information.

ANS: 2 Simple layman's language of information is better understood and repeating or rephrasing gives the patient a better understanding when in a stressful situation.

The nurse, providing care to patients in a critical care unit, realizes that technology increases the likelihood of errors when: 1. It relies heavily on human decision making. 2. Devices are programmed to function without double checks. 3. It makes the workload seem overwhelming to health care providers. 4. There is uniform equipment throughout each facility.

ANS: 2 Technology changes the tasks people do by shifting the workload and eliminating human decision making.

What will the nurse include in the management plan for a patient with sepsis? 1. Use high tidal volumes on the ventilator to prevent adult respiratory distress syndrome (ARDS). 2. Assess capillary blood glucose and prevent hyperglycemia. 3. Stabilize and debride an infected wound after administering antibiotics for 24 hours. 4. Avoid CT and MRI scans until the patient is stable.

ANS: 2 The blood glucose should be maintained between 80 and 150 mg/dL.

The nurse identifies a patient in the critical care unit as having "resiliency." What characteristic has the nurse identified in the patient? 1. Motivation to reduce anxiety through positive self-talk 2. Ability to bounce back quickly after an insult 3. Physical strength to endure extreme physical stressors 4. Ability to return to a state of equilibrium

ANS: 2 The correct definition of "resiliency" is the ability to bounce back quickly after an insult. The degree of resiliency is placed along a continuum between being unable to mount a response to having strong reserves.

The nurse is evaluating a patient for the presence of systemic inflammatory response syndrome (SIRS). Which assessment data indicates the presence of SIRS? 1. Temperature 36.4°C, respiratory rate 22, pulse rate 112, and PaCO2 34 2. Temperature 38.4°C, respiratory rate 23, pulse rate 92, and PaCO2 31 3. Temperature 37.2°C, respiratory rate 24, pulse rate 102, and PaCO2 44 4. Temperature 38.8°C, respiratory rate 25, pulse rate 88, and PaCO2 48

ANS: 2 The definition of SIRS includes temperature 38 degrees centigrade, pulse greater than 90 beats per minute, respiratory rate greater than 20 breaths per minute with a PaCO2 less than 32 torr.

A nurse is administering haldoperidol (Haldol) via IV push to a delirious patient. What is most important for the nurse to monitor in this patient? 1. Heart rate 2. QT interval 3. PR interval 4. Respiratory rate

ANS: 2 The patient needs to be monitored for such adverse effects as QT prolongation and dysrhythmias (torsades de pointes), which can result in sudden death, especially if the drug is administered via IV push.

Which solution would be the most appropriate initial volume replacement for a patient with severe GI bleeding? 1. 200 mL of normal saline (NS) per hour for 5 hours 2. A liter of Ringer's lactate (RL) over 15 minutes 3. Two liters of D5W over half an hour 4. 500 mL of 0.45% normal saline (1/2 NS) over half an hour

ANS: 2 The patient requires immediate infusion of an adequate amount of fluid. Fluid resuscitation begins with 500 to 1,000 mL of an isotonic solution.

A patient with heart failure begins to cough pink frothy sputum. Which pressure would the nurse assess to confirm this manifestation? 1. Central venous pressure 2. Pulmonary capillary wedge pressure 3. Arterial pressure 4. Right arterial pressure

ANS: 2 The pulmonary capillary wedge pressure would be elevated in pulmonary edema. This is the pressure that the nurse would assess to confirm the patient's symptom.

The nurse, implementing the sepsis management bundle for a patient in the intensive care unit, is aware of which information about this bundle? 1. When all elements of the sepsis management bundle are used, survival is prolonged. 2. The sepsis management bundle has not received uniform support. 3. The purpose of the sepsis management bundle is to improve the patient's hemodynamics within 4 hours. 4. The Surviving Sepsis Campaign recommends universal use of each of the elements of the sepsis management bundle to decrease mortality.

ANS: 2 The sepsis management bundle has not received uniform support because the elements have not been shown to increase survival or to decrease mortality.

Steroids may be prescribed to a patient in septic shock. For what additional interventions would the nurse plan when providing this medication? 1. There is a slower reversal of sepsis when steroids are given. 2. There is a risk of superinfection when steroids are given. 3. Vasopressor therapy can often be reduced when steroids are given. 4. Immunosuppression is reduced when steroids are given.

ANS: 2 The use of steroids in the treatment of sepsis can lead to more problems with superinfection.

The nurse realizes that the increased use of technology in critical care units has resulted in which consequence for patient care? 1. Decreased risk of errors in patient care 2. Decreased therapeutic nurse-patient communication 3. Improved overall patient satisfaction with care 4. Improved patient safety across the entire spectrum

ANS: 2 This has been demonstrated as an outcome resulting from an increased use of technology in critical care units.

Which statement describing the needs of family members of critically ill patients has not been validated by research? 1. "Not knowing is the worst part" of waiting. 2. Families in the waiting room have no effect on patient outcomes. 3. "Hovering" in the proximity phase is characterized by confusion and tension. 4. A unified message from staff minimizes family stressors.

ANS: 2 This is an incorrect statement that is not supported by research. In fact the family support has been proven to clinical outcomes.

Which finding would support the diagnosis of heart failure (HF)? 1. RA/CVP of 8 mm Hg 2. PAWP of 20 mm Hg 3. Cardiac index of 3 4. Peripheral vasodilation reflected by normalizing capillary refill times

ANS: 2 With heart failure the backup of fluid from inadequate pumping results in increased PAWP because the heart has to pump harder to push through the rising capillary pressures on the venous side from peripheral edema and ascites.

Which life-threatening complications would the nurse anticipate developing in the patient being treated for hypovolemic shock? Standard Text: Select all that apply. 1. Fluid volume overload 2. Renal insufficiency 3. Cerebral ischemia 4. Gastric stress ulcer 5. Pulmonary edema

ANS: 2, 3 Rationale 2: Renal insufficiency is a serious complication because of the prerenal etiology of hypovolemia. Rationale 3: Early identification and correction of the fluid volume deficit in hypovolemic shock is necessary to prevent cerebral ischemia.

What will the nurse identify as symptoms of hypovolemic shock in a patient? Standard Text: Select all that apply. 1. Temperature of 97.6°F (36.4°C) 2. Restlessness 3. Decrease in blood pressure of 20 mm Hg when the patient sits up 4. Capillary refill time greater than 3 seconds 5. Sinus bradycardia of 55 beats per minute

ANS: 2, 3, 4 Rationale 2: Due to decreased blood flow to the brain and peripheral areas when blood is shunted to maintain the vital organs, cerebral hypoxia occurs, leading to a change in mental status. Rationale 3: Orthostatic hypotension is a manifestation of hypovolemic shock. Rationale 4: Due to decreased blood flow to the brain and peripheral areas when blood is shunted to maintain the vital organs, capillary refill time will be reduced.

To increase compliance and reduce postoperative complications, the nurse should include which topics in the preoperative teaching for a patient who is to have a coronary artery bypass graft (CABG)? Standard Text: Select all that apply. 1. Reasons for cooling blankets in post-op period 2. Equipment used: IVs, Foley, pacer wires, chest tubes, NG tubes, ECG leads 3. Alternate methods for communicating when intubated 4. Reasons and techniques of turning, coughing, and deep breathing once extubated 5. Drug management: need for sedation when intubated, pain med through PCA

ANS: 2, 3, 4, 5 This should be included in the teaching.

Which findings would cause the nurse to suspect that a post-coronary artery bypass patient might be developing cardiac tamponade? Standard Text: Select all that apply. 1. Widening pulse pressure 2. Increased jugular vein distension 3. Decreasing central venous pressure (CVP) 4. Muffled heart sounds 5. Lack of pleural (chest) tube drainage

ANS: 2, 4, 5 Rationale 2: As the heart is compressed within its own pericardial sac from fluid accumulation, the ability to expand is limited because fluid accumulates outside the heart to the point in which contraction cannot occur. The pressures back up and create increased pressure as seen with engorging jugular veins. Rationale 4: As the heart is compressed within its own pericardial sac from fluid accumulation, the ability to expand is limited because fluid accumulates outside the heart to the point in which contraction cannot occur. The fluid surrounding the heart muffles the heart sounds. Rationale 5: Fluid ceases to drain from the pericardial tubes into the pleural (chest) tubes. As the heart is compressed within its own pericardial sac from fluid accumulation, the ability to expand is limited because fluid accumulates outside the heart to the point in which contraction cannot occur

A patient in heart failure is being given a first dose of lisinopril (Prinivil) 10 mg PO. Which finding would cause the nurse to question the administration of the first dose? 1. Heart rate 92 beats per minute 2. Blood pressure 100/72 3. Potassium 5.7 mEq/dL 4. Urine output 35 mL/hr

ANS: 3 Ace inhibitors increase the serum potassium and a further increase from 5.7 could be problematic so the nurse should question the administration of this medication.

Which assessment finding indicates that a patient's heart failure (HF) is worsening? 1. An increase in O2 saturation to greater than 90% 2. A decrease in heart rate to 66 bpm 3. The onset of atrial fibrillation 4. Louder S1 and S2 heart sounds

ANS: 3 As heart failure continues to progress, less oxygenation occurs all over the body, especially the myocardium, which is sensitive to the hypoxia and will result in dysrhythmias such as ventricular ectopy or atrial fibrillation.

The nurse in the critical care area is completing a preoperative checklist before sending a patient for surgery. This nurse's activity is an example of which recommendation issued by the Institute of Medicine? 1. Utilizing constraints 2. Simplifying key processes 3. Avoiding reliance on vigilance 4. Standardizing key processes

ANS: 3 Completing a preoperative checklist is an example of avoiding reliance on vigilance.

An 80-year-old woman has arrived in the emergency department. The health care provider is questioning whether she has had an MI although she is not displaying the classic chest pain. Which symptoms would more likely occur in this patient than others because of the patient's gender and age? 1. Jaw and/or tooth pain 2. Centralized chest pain 3. Generalized fatigue accompanied by dyspnea and diaphoresis 4. Dyspnea accompanied by crackles in all lobes

ANS: 3 Coronary symptoms in women include fatigue, diaphoresis, and nonspecific pain that is different than that identified by men.

The nurse, caring for a patient in hypovolemic shock, will not utilize a hypotonic solution for fluid resuscitation because hypotonic solutions: 1. Move quickly into the interstitial spaces and can cause third spacing 2. Stay longer to expand the intravascular space but deplete intracellular fluid levels 3. Do not stay in the intravascular space long enough to expand the circulating blood volume 4. Need a smaller bore needle to run at a slower rate to keep the intravascular space low

ANS: 3 Hypotonic solutions do not stay in the intravascular space long enough to expand the circulating blood volume.

Which statement will the nurse use to explain why serum lactate is elevated in a patient with sepsis? It is caused by: 1. Increased systemic inflammation 2. The endogenous by-products of bacterial contamination 3. Anaerobic cellular metabolism 4. Greatly accelerated coagulation

ANS: 3 Lactic acid is produced as a by-product of anaerobic cellular metabolism.

The nurse, employed in a hospital in a small rural town, would expect to provide which level of care in the critical care unit? 1. Level I 2. Level II 3. Level III 4. It is unlikely that the hospital would have a critical care unit.

ANS: 3 Level III facilities provide initial stabilization of critically ill patients but limited ability to provide comprehensive critical care. A limited number of patients who require routine care may remain in the facility but written policies should be in place determining which patients require transfer and where they ought to be transferred. This level of care is most likely provided in a small rural facility.

Which statement accurately describes the purpose of sedation vacation for a patient to prevent ventilator-associated pneumonia? 1. The vacation from sedation relieves stress, which decreases the chance of infection. 2. During sedation vacation the patient has a chance to take deep breaths and improve ventilation while more awake. 3. The patient's own tidal volume and respiratory rate can be evaluated during sedation vacation. 4. New data show that sedation vacation is no longer recommended because there is concern about the safety of interrupting sedation.

ANS: 3 Mechanical ventilation is discontinued sooner when close attention is given to measuring tidal volume and respiratory rate, which occurs during a sedation vacation. Evidence indicates that appropriate use of daily interruption of sedation to determine readiness to wean decreases the patient's time on a ventilator.

Which laboratory value would the nurse review to validate a diagnosis of a myocardial infarction (MI) that was suspected of occurring approximately 3 hours earlier? 1. CK 2. Troponin T assay 3. Myoglobin 4. PTT

ANS: 3 Myoglobin will peak between 1 and 4 hours after the hypoxic/necrotic event and return to normal in 24 hours. Therefore, it is the first to rise when tissue damage has occurred.

Which hemodynamic parameters would the nurse expect to see in the patient with septic shock? 1. Central venous pressure (CVP) 4 mm Hg, pulmonary artery pressure (PAP) 30/15 mm Hg, and systemic vascular resistance (SVR) 1,200 dynes/sec/cm-5 2. Central venous pressure (CVP) 8 mm Hg, pulmonary artery pressure (PAP) 26/10 mm Hg, and systemic vascular resistance (SVR) 1,000 dynes/sec/cm-5 3. Central venous pressure (CVP) 2 mm Hg, pulmonary artery pressure (PAP) 20/8 mm Hg, and systemic vascular resistance (SVR) 800 dynes/sec/cm-5 4. Central venous pressure (CVP) 6 mm Hg, pulmonary artery pressure (PAP) 40/20 mm Hg, and systemic vascular resistance (SVR) 700 dynes/sec/cm-5

ANS: 3 Septic shock is a form of distributive shock. Central venous pressure would be low, pulmonary artery pressure would be low, and systemic vascular resistance would be low.

During an assessment, a ventilated patient begins to frown and wiggle about in bed. Which assessment strategy would be most helpful for the nurse to validate these observations? 1. Glasgow Scale 2. Maslow's hierarchy levels 3. Critical-Care Pain Observation Tool (CPOT) 4. Vital signs trends

ANS: 3 The CPOT pain scale will identify if pain is present and the degree of effectiveness of drug management in a patient who cannot speak due to intubation.

Why will the nurse monitor the SVO2 in a patient with septic shock? 1. A SvO2 of 65% shows that the oxygen demand of tissues exceeds the oxygen supply. 2. A SvO2 of 95% or above shows normal oxygen supply and demand. 3. A SvO2 of 70% is adequate to deliver oxygen to body organs and tissues. 4. A decrease in the SvO2 shows that more oxygen is returning to the lungs before being metabolized.

ANS: 3 The SvO2 is a measure of systemic oxygen utilization and an indirect measure of perfusion. The normal SvO2 is 60% to 80%. A SvO2 of 70% is normal, indicating adequate oxygen delivery to body organs and tissues.

The nurse is assessing a patient for severe sepsis. Which finding indicates the patient is developing this health problem? 1. Decreased capillary filling and mottling 2. Fever and decreased urine output 3. Hypotension and lactic acidosis 4. Increased glomerular filtration rate and increased D-dimer levels

ANS: 3 The best description of severe sepsis is hypotension and lactic acidosis. These signs also represent altered cellular metabolism, which results in organ dysfunction.

The best description of the overall goal of providing fluid resuscitation and vasopressors to a patient in septic shock is to: 1. Increase the systolic arterial pressure. 2. Provide adequate vasoconstriction. 3. Increase tissue perfusion. 4. Increase the metabolic rate.

ANS: 3 The overall goal of providing fluid resuscitation and vasopressors to the patient in septic shock is to increase tissue perfusion. Vasopressors are used if the initial fluid bolus fails to bring the mean arterial pressure over 80 mm Hg.

A patient is admitted with chest discomfort and a possible UA/NSTEMI. What would be a contraindication to administration of GP-IIb-IIIA inhibitors to the patient? The patient had: 1. Major surgery in the last 6 months 2. A creatinine level of 1.4 mg/dL 3. A stroke within the past month 4. A platelet count greater than 150,000 mm3

ANS: 3 The purpose of this drug is to prevent platelet aggregation by keeping fibrinogen from binding to the GP IIb-IIIA receptors on the platelet surfaces. This condition is a contraindication for giving this drug group because increased bleeding episodes might follow its administration.

The nurse working within the AACN Synergy Model realizes that optimal patient outcomes are realized when: 1. Highly qualified nurses care for patients in highly technical settings. 2. Nurses agree to work overtime to cover unit staffing needs. 3. Staff nurse competency is matched with patient needs. 4. Patient care is delivered within a "closed unit" model.

ANS: 3 The underlying assumption of the Synergy Model is that optimal patient outcomes occur when the needs of the patient and family are matched with the competencies of the nurse.

The nurse recognizes that which patient would be most likely to develop hypovolemic shock? A patient with: 1. Decreased cardiac output 2. Severe constipation, causing watery diarrhea 3. Ascites 4. Syndrome of inappropriate ADH (SIADH)

ANS: 3 Third spacing shifts move the fluids from the intravascular space into the interstitial space, causing a drop in the circulating blood volume. Therefore, third spacing is a risk factor for the development of hypovolemic shock.

When concluding SBAR communication about a patient issue, the nurse will use which statement? 1. "The patient's immediate history is..." 2. "The patient's physical findings are..." 3. "I am requesting that you..." 4. "I have assessed the patient personally."

ANS: 3 This statement would be used when concluding SBAR communication.

A nurse is confirming the medication orders and schedule for sedative administration to a patient with delirium. Which schedule would maximize the effectiveness of the drugs? Administration of medication: 1. Only in the early morning 2. Only at bedtime (HS) 3. Around the clock with higher dosages in the evening 4. Only on an as-needed (PRN) basis

ANS: 3 Timing medication given around the clock with a greater dosage in the evening will match the symptom of sundowning, when the symptoms appear the greatest later in the day.

The nurse is teaching a patient about acute coronary syndrome. What will the nurse teach that describes the progression of events in this disorder? 1. A thin fibrin layer stabilizes the ruptured plaque and prevents the occlusion of coronary vessels when stable angina is present in ACS. 2. When complete platelet occlusion occurs in a vessel, the ECG changes include nonspecific ST elevation without necrosis occurring in ACS. 3. The growth of platelet-rich thrombi in the smaller vessels creates a blockage and is the cause for unstable angina symptoms in ACS. 4. Sudden plaque buildup in a narrow vessel immediately leads to an acute myocardial infarction when stable angina is present in ACS.

ANS: 3 Unstable angina occurs when a blockage from platelet-rich thrombi in smaller vessels occurs, causing myocardial ischemia. Because ischemic pattern of pain varies, it is unpredictable and can occur with exertion and rest.

The nurse notes that the QRS duration of a patient with a biventricular pacemaker is widening? What does this most likely indicate? 1. Worsening of the patient's underlying cardiomyopathy 2. Loss of ventricular capture 3. Loss of ventricular synchronization 4. Battery failure

ANS: 3 Widening of the QRS duration from the baseline may indicate a loss of ventricular synchronization.

The nurse realizes that which stressor is one of the primary concerns of critically ill patients and should be routinely included during assessments? 1. Inability to control elimination 2. Lack of family support 3. Hunger 4. Altered ability to communicate

ANS: 4 Altered ability to communicate is identified as a primary concern of critically ill patients

The nurse is instructing a patient with a myocardial infarction about the disease process. Which patient statement indicates that additional teaching is needed? 1. "A heart attack is the same as a myocardial infarction (MI)." 2. "A heart attack causes tissue death and that part of the heart may not pump as well." 3. "A heart attack in the anterior wall of the heart can be very serious because a large portion of the heart may not pump as well." 4. "Angina always leads first to decreased blood flow to the heart muscle and then to tissue death."

ANS: 4 Angina pectoris is the pain from ischemia, but necrosis of myocardial tissue does not occur with each episode of pain. The pain is from tissue hypoxia; ischemia areas may improve or deteriorate into necrosis due to collateral circulation from other vessels.

The nurse is identifying interventions to prevent the development of sepsis in an older patient because: 1. Mortality rates from sepsis are 70% worldwide. 2. If managed early and aggressively, the majority of patients with sepsis may be managed outside of the ICU environment. 3. The guidelines provided by the Surviving Sepsis Campaign are expected to decrease the incidence of sepsis. 4. Sepsis rates rise sharply with age.

ANS: 4 Because sepsis affects the elderly disproportionately, more than half of all annual costs in the United States—$8.7 billion—were spent on care of septic patients 65 years or older.

A nurse is preparing to administer the first 5 mg dose of metoprolol (Toprol) to a patient who is 12 hours post MI. For which assessment finding should the nurse withhold administration of the medication? 1. Serum potassium 3.9 mEq/L 2. Blood pressure of 110/65 mm Hg 3. PR interval 0.12 second 4. Sinus bradycardia 52 beats per minute

ANS: 4 Beta blocker therapy is contraindicated when the patient has a heart rate less than 60 beats per minute, systolic blood pressure less than 100 mm Hg, moderate or severe left ventricular failure, shock, PR interval on the electrocardiogram greater than 0.24 second, second- and third-degree heart block, and active asthma and/or reactive airway disease.

After teaching a patient with heart failure about beta blocking agents, the nurse recognizes that additional teaching is needed when the patient states, "While taking the medication, I will: 1. Weigh myself every day." 2. Check my blood sugar regularly." 3. Notify my health care provider if I become increasingly short of breath." 4. Monitor myself daily for an increased heart rate and blood pressure."

ANS: 4 Beta blocking agents will decrease the heart rate and blood pressure. This statement indicates that additional teaching is needed.

A patient with neurogenic shock is demonstrating bradycardia. What action will the nurse take at this time? 1. Limit patient movement. 2. Prepare to administer crystalloids. 3. Administer phenylephrine as prescribed. 4. Administer atropine as prescribed.

ANS: 4 Bradycardia in neurogenic shock is corrected by the administration of atropine at the dose of 0.5 to 1.0 mg intravenous every 5 minutes to a total dose of 3 mg.

Which action is a part of the bundle of measures used to prevent nosocomial catheter-related infections? 1. Chlorhexidine is most effective when swabbed starting at the insertion site and moving outward in a circular motion. 2. It is recommended that transparent dressings be changed every 72 hours to prevent growth of bacteria on the skin. 3. Current recommendations support changing IV tubing every 48 hours on patients at risk for catheter-related infections. 4. During insertion of a central line the doctor should wear a cap and mask, sterile gloves, and a gown, and the patient should have a full body drape.

ANS: 4 During insertion of a central line the doctor should wear a cap, a mask, sterile gloves, and a gown. The patient should have a full body drape. These measures prevent catheter-related sepsis.

The electrocardiogram of a patient receiving tPA for a myocardial infarction shows that the ST segment has returned to baseline. How should the nurse interpret this finding? 1. The spasm in the coronary artery has resolved. 2. The myocardial injury is evolving. 3. The patient has become more relaxed. 4. The blocked artery has been reperfused.

ANS: 4 Early reperfusion can resolve coronary ischemia.

In order to meet the patient's nutritional needs during a critical illness with sepsis, the nurse knows that: 1. TPN is the preferable means to administer nutrition. 2. Nutritional needs are usually addressed after 72 hours in order to conserve energy expenditure. 3. Enteral feedings are often avoided because hyperglycemia often results from feedings. 4. Enteral feedings prevent translocation of bacteria from the gastrointestinal tract.

ANS: 4 Enteral feedings are the preferred method of meeting nutritional needs because they prevent translocation of bacteria from the gastrointestinal tract.

The nurse caring for a patient would ensure that the patient has consented to care by providing what to the patient? 1. A consent form to sign to receive medications 2. A consent form to sign to have dressings changed 3. A consent form to sign to be turned in bed 4. An explanation of a dressing to be changed

ANS: 4 If the nurse does not ask the patient for consent, the nurse should explain the procedure.

Which statement explaining the relationship of body weight to acute coronary syndrome (ACS) should the nurse include when presenting a healthy heart program to a community group? 1. Excessive weight will result in a decrease in low-density lipoproteins (LDL) that is linked to ACS. 2. Extra weight can lead to diabetes insipidus that will increase the risk for ACS. 3. Losing as little as 5% of one's body weight will significantly lower the risk for ACS. 4. Obesity, a BMI of greater than 30, increases the risk for ACS.

ANS: 4 Increased weight increases the risk for diabetes mellitus and decreased HDL, which are both risk factors for ACS.

A nurse is teaching a patient with coronary artery disease about prescribed nitroglycerin therapy. Which patient statement indicates further teaching is needed? 1. "If the pain doesn't go away I can take a second tablet after 5 minutes." 2. "I should not take nitroglycerin if I have taken Viagra." 3. "I should try to sit or lie down when I take the nitroglycerin." 4. "I'll put a couple of tablets in a plastic bag in my pocket so I have them with me all the time."

ANS: 4 Nitroglycerin should be kept in a tightly sealed brown bottle.

The goal of antibiotic therapy in a patient with sepsis is to narrow the therapy to one narrow-spectrum antibiotic. What purpose does this goal serve in the patient's care and how does it aid in the prevention of antibiotic resistance? 1. The use of one antibiotic ensures that the prescribed dose will result in serum concentrations that are clinically effective. 2. The use of one antibiotic has been shown to cause less organ dysfunction. 3. The use of one antibiotic reduces mortality in patients with sepsis. 4. The use of one antibiotic limits the cost to the patient.

ANS: 4 One antibiotic can ultimately reduce the patient's costs but that is not the only purpose of this goal.

"The chest pain occurs each time I play basketball; it does not occur when I am sleeping; and it improves when I take those pills under my tongue," the pain will most likely be classified as: 1. Variant or Prinzmetal's angina 2. Undifferentiated angina 3. Unstable angina 4. Stable angina

ANS: 4 Stable angina occurs in a predictable manner, not when resting, and improves with NTG under the tongue.

When teaching a patient with heart failure about ventricular remodeling, the nurse should recognize that additional teaching is needed if the patient makes which statement? "Remodeling: 1. Leads to progressive worsening of heart function." 2. Can be described as an enlargement of the pumping chamber." 3. Occurs with an increase in blood pressure and results in weight gain." 4. Develops primarily because the heart is pumping harder."When teaching a patient with heart failure about ventricular remodeling, the nurse should recognize that additional teaching is needed if the patient makes which statement? "Remodeling: 1. Leads to progressive worsening of heart function." 2. Can be described as an enlargement of the pumping chamber." 3. Occurs with an increase in blood pressure and results in weight gain." 4. Develops primarily because the heart is pumping harder."

ANS: 4 The heart is not pumping harder but rather the contractility or elasticity of the left ventricle is decreased or stiffer in nature. This statement indicates more teaching is required.

A patient starting cardiac rehabilitation will work with the rehabilitation team to meet all of the following goals except: 1. Taking control of his life through healthy choices 2. Managing symptoms by monitoring exercise 3. Reducing risks by controlling the modifiable risk factors 4. Stabilizing any severe depression that developed post-MI

ANS: 4 The need to stabilize emotions, such as depression and anxiety, are addressed but not a major psychiatric disorder, because it would require in-depth individualized counseling. A referral is needed because this is not the goal of the rehabilitation program.

The nurse is caring for a patient with acute decompensated heart failure (HF) receiving BiPAP. While caring for this patient, the nurse's priority will be to: 1. Monitor the expiratory time to be sure that it always exceeds the inspiratory time. 2. Ensure that the mask does not fit too tightly on the patient's face to prevent skin breakdown. 3. Prepare for endotracheal intubation because BiPAP is used primarily to buy time for intubation. 4. Assess the patient for the development of gastric distention, nausea, and vomiting.

ANS: 4 The nurse must assess the patient for complications resulting from this delivery method to include gastric distention, nausea, vomiting, and aspiration.

A nurse is caring for a patient who has just started to bleed from the insertion site following a cardiac catheterization. What should be the nurse's first response? The nurse should: 1. Administer vitamin K (AquaMEPHYTON). 2. Locate and apply a compression clamp. 3. Apply a collagen patch or sheath. 4. Apply manual pressure to the site.

ANS: 4 The nurse should immediately apply manual pressure to the site

Following angioplasty, a patient develops the following: hematuria, hypotension, tachycardia, a drop in hemoglobin and hematocrit, and a decrease in oxygen saturation. What is most likely the cause for these symptoms? 1. Reaction to vasovagal stimulation 2. Myocardial ischemia 3. Peripheral emboli distal to the insertion site 4. Over-anticoagulation

ANS: 4 The symptoms are a result of over-anticoagulation, which results in blood loss through the kidneys and other organs, resulting in a declining hemoglobin/hematocrit (H/H). The decrease of RBCs results in the compensation mechanism for shock by increasing the HR when compensating for the tissue hypoxia present from the lack of RBCs. Decreased perfusion and O2 saturation in the tissues will be present.

A ventilated patient is receiving midazolam (Versed) for sedation. The nurse would recognize that the patient is receiving an appropriate dose of midazolam when the patient is: 1. Awake with a respiratory rate of 38 and a heart rate of 132 2. Asleep but withdrawing to noxious stimuli with a heart rate of 80 3. Awake with a heart rate of 124 and attempting to pull out the IV 4. Asleep but awakening to light touch with a heart rate of 72

ANS: 4 These findings indicate appropriate sedation.

What will the nurse identify as an example of an installed forcing functions or a system level firewall to prevent errors when providing patient care? 1. Prior to administration of insulin, two nurses check the dose. 2. Prior to obtaining a medication, height, weight, and allergies are recorded. 3. All medications are checked by two nurses prior to administration. 4. Undiluted potassium chloride is not available on critical care units.

ANS: 4 This is an example of an installed forcing function or a system level firewall.

The nurse is addressing the family needs of a critically ill patient. Which family need was not identified? 1. Proximity 2. Information 3. Assurance 4. Timeliness

ANS: 4 Timeliness is not a need identified in Leske's research findings.

A patient is being discharged after an MI and is prescribed lisinopril (Prinivil) 10 mg daily. Which instruction is most appropriate for the nurse to give to the patient? 1. Avoid crossing your legs. 2. Weigh yourself at least 3 times a week. 3. Cut down on your sodium intake to 1,500 mg/day. 4. Change your position slowly when going from lying to sitting.

ANS: 4 Watching for postural hypotension when initiating therapy is important.

The nurse is aware that restraining a patient is most likely to result in the patient: 1. Pulling out an endotracheal tube 2. Pulling out an intravenous line 3. Disconnecting ventilator tubing 4. Developing a nosocomial infection

ANS: 4 When people are restrained, they are more likely to develop nosocomial infections.

If a nurse forcibly inserts a nasogastric tube against a patient's wishes, the nurse can be held liable for: 1. Negligence 2. Malpractice 3. Damages 4. Battery

ANS: 4 When the nurse treats or touches a patient without consent, it is battery.

A patient weighing 220 lbs is prescribed 10 mcg/kg/min of dopamine to improve cardiac output from cardiogenic shock. How many milligrams of dopamine will the patient receive in an hour?

ANS: 60 Determine the patient's weight in kg by dividing 220 lbs by 2.2 or 100 kg. Then multiply the number of mcg of medication the patient is to receive per minute by 100 kg or 10 mcg × 100 kg = 1,000 mcg. This is the dosage the patient will receive in 1 minute. To determine the amount of medication in 1 hour, multiply 1,000 mcg × 60 = 60,000 mcg. Using the conversion 1 mg = 1,000 mcg, divide 60,000 mcg by 1,000 mcg to determine that the patient will receive 60 mg of dopamine in 1 hour.