Final 240

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A 20-year-old man presents with upper gastrointestinal bleeding. His health history indicates binge drinking on weekends. The nurse inquires about the patients alcohol use and learns that the patient frequently vomits violently after drinking. Which of the following underlying causes should the nurse suspect for this patients bleeding? A)Mallory-Weiss tears B)Dieulafoys lesions C)Peptic ulcer disease D)Stress-related erosive syndrome

A Nepali man is in the ICU recovering from spinal surgery to remove a malignant tumor. He does not speak English, and struggles to communicate with the nurse by using hand motions. His family is constantly at his bedside, speaking with him in Nepalese. Frequently, he puts on headphones and listens to music on his MP3 player. His wife occasionally massages his feet. Which of the following factors is most likely exacerbating this patients pain? A)Inability to communicate with the nurse B)Constant presence of his family C)Listening to music D)His wife massaging his feet

A critically ill patient experiences stress and anxiety from many factors. Treatment of the patient focuses on reducing stressors and providing supportive care such as nutrition, oxygenation, pain management, control of anxiety, and specific care of the illness or injury. What is the best rationale for these interventions? A)Helps to support the patients immune system B)Part of good nursing care C)Mandated by hospital policy D)Reassures the patient and family

A critically ill patient has arterial blood gas results of pH 7.6, PaCO2 40 mm Hg, and HCO3 30 mEq/L. With what medical situation do these results most clearly correlate? A)Excess nasogastric drainage B)Severe diarrhea C)Diabetic ketoacidosis D)Lobular pneumonia

A critically ill patient has developed multiple organ dysfunction syndrome (MODS). What should the nursing goal for management of the patient with impending MODS center on? A)Early normalization of SvO2 and acidbase balance B)Use of intravenous drotrecogin alfa (Xigris) C)Specific organ system support D)General intensive nursing care

A leading cause of death in critically ill patients is sepsis and septic shock. What nursing intervention is most directed toward preventing this life-threatening complication? A)Strict adherence to hand hygiene protocols B)Prompt initiation of isolation protocols C)Patient and family preventive teaching D)Sterile technique for care of intravenous sites

A nurse sees a group of physicians who are making teaching rounds in the hall of the ICU heading toward the room of one of her patients. The patient, who currently has a visitor, has given approval in the past to have teaching groups visit. What should the nurse do in this situation? A)Explain to the group of physicians that the patient currently has a visitor and ask whether they could come by later. B)Ask the visitor to leave so that the teaching group can discuss the patients case. C)Allow the teaching group to enter the patients room, as he has already given approval for them to visit. D)Instruct the physicians to give clear explanations of the medical jargon they use.

A patient has experienced multiple fractures, including pelvic and long bone fractures. After 72 hours, the patient complains of tachypnea and dyspnea and is found to have cyanosis, tachycardia, confusion, and fever. Laboratory analysis reveals a normal complete blood count except for thrombocytopenia and progressive respiratory insufficiency. What is the nursing care priority? A)Administer oxygen and monitor pulse oximetry. B)Initiate low-molecular-weight heparin therapy. C)Obtain cultures of all body substances. D)Initiate fall and seizure precautions.

A patient in the ICU with a history of smoking is having tests performed to assess his respiratory function. Which test would be best for measuring the oxygenation of this patients blood? A)SaO2' B)Pulse oximetry C)End-tidal carbon dioxide D)pH

A patient in the critical care unit has developed shock. What symptom or symptom group does the nurse expect to assess in any type of shock? A)Tissue hypoxia B)Massive vasodilation C)Extreme blood loss D)Presence of enterotoxins

A patient is admitted to the CCU after experiencing blunt trauma to the chest. Among other injuries, the patient has a flail chest on the left and several extremity fractures. About 12 hours after admission, the patient is tachypneic and complaining of shortness of breath. Breath sounds are present bilaterally with scattered fine crackles. Chest radiograph shows an ill-defined, patchy, ground-glass area of density on the left. If the patient has a pulmonary contusion, what is the nursing priority? A)Monitor pulse oximetry and arterial blood gases closely. B)Place an oral endotracheal tube immediately. C)Increase the amounts of intravenous crystalloid administration. D)Obtain sputum culture and sensitivity and Gram stain

A patient is being evaluated for possible syndrome of inappropriate antidiuretic hormone (SIADH). What laboratory abnormality would the nurse most expect to find? A)Serum hyponatremia B)Serum hypokalemia C)Urine hyponatremia D)Urine hypo-osmolarity

A patient is experiencing a malfunction with his permanent implanted pacemaker, and the nurse is examining his electrocardiogram strip. The patients pacemaker has a ventricular unipolar catheter and is in VVI mode. Which of the following findings should the nurse be most concerned about? A)Pacing spikes absent B)Pacing spike followed by a QRS complex C)Tall pacing spikes D)A narrow QRS

A patient is in the ICU with lesions of the chest, back, and extremities. The physician suspects toxic epidermal necrolysis (TEN). What statement by the patient would alert the nurse to the precipitating factor? A)I started taking an antibiotic for a respiratory infection. B)I was working in the garden planting flowers. C)I have been treated for basal cell carcinoma of my nose. D)I had a flu shot one month ago.

A patient who is in the Emergency Department was attacked in a parking lot and suffered several stab wounds to various areas on the chest and abdomen; BP 100/60, heart rate 108, respiratory rate 20, pulse oximetry 98%. In order to counteract the blood loss and restore circulating volume for this patient, what priority intervention will the nurse perform? A)Start lactated Ringers at 150 mL/hr. B)Start dopamine at 5 mcg/kg/min. C)Start an albumin infusion wide open. D)Start a unit of uncrossmatched blood.

A patient with a brain injury is receiving IV mannitol to reduce cerebral edema and intracranial pressure (ICP) during the early resuscitation phase. The patient is rapidly becoming hypovolemic. What intervention should the nurse make to help correct the hypovolemia? A)Administer crystalloid solution. B)Administer morphine. C)Discontinue mannitol. D)Administer propofol.

A patient with a large thermal burn has been admitted to the burn intensive care unit. Because the leading cause of death in burned patients after the initial care period is infection, what is the nurses priority action? A)Ensure compliance with hand hygiene protocols by all health care team members. B)Limit visits of legal next of kin to very brief periods of time. C)Adhere to clean aseptic principles during wound care and dressing changes. D)Collect environmental cultures and wound cultures as scheduled.

A patient with acute pancreatitis is being cared for in intensive care. After several days of therapy, the patient has worsening hypoxemia that does not respond to oxygen therapy, lung sounds are diminished, and there is a patchy infiltrate on the chest x-ray. The patient also has a fever, abdominal distention, and severe pain despite narcotic therapy. What complication of pancreatitis does the nurse most suspect? A)Acute respiratory distress syndrome (ARDS) B)Nonspecific arterial hypoxemia C)Compression of lung by abdominal fluid D)Hypoventilation secondary to severe pain

A patient with an acute brain injury is receiving IV mannitol, an osmotic diuretic. If this medication is effective, what does the nurse expect? A)Increased cerebral perfusion pressure B)Increased serum osmolarity above 320 mOsm C)Reduction of Glasgow Coma Scale values D)Development of fixed and dilated pupils

A patient with an acute myocardial infarction has received three nitroglycerin tablets, oxygen, and aspirin and is still complaining of severe crushing chest pain. What is the best nursing action? A)Give 5 mg intravenous morphine. B)Assess for drug-seeking behavior. C)Give intravenous benzodiazepine. D)Use anxiety reduction measures.

A patient with asthma is receiving a bronchodilator medication. If this therapy is helpful to the patient, the nurse would expect to find which of the following? A)Increased productiveness of cough B)More intense wheezing C)Persistent tachycardia D)Reduced peak expiratory flow rate

A patient with chronic kidney disease has a serum potassium level of 5 mEq/L and no changes on the ECG. What is the proper nursing intervention? A)Administer sodium polystyrene as an enema. B)Administer IV calcium gluconate. C)Administer IV insulin and dextrose. D)Begin dialysis.

A patient with head trauma requires intracranial pressure (ICP) monitoring. The physician insists that the most accurate monitoring device feasible should be used for this patient. This patient also requires frequent draining of cerebrospinal fluid (CSF) while being monitored. The nurse recognizes that which ICP monitoring device would be best for this patient? A)Intraventricular B)Subarachnoid C)Subdural D)Epidural

A patient with severe thyrotoxicosis has a very high temperature. What medication or treatment is least appropriate to suppress the temperature? A)Acetylsalicylic acid (aspirin) B)Acetaminophen (Tylenol) C)Cooling blanket D)Intravascular cooling system

A tall, thin patient in his mid-twenties presents to the ICU with dyspnea, pleuritic chest pain, and a heart rate of 120 bpm. A chest radiograph shows a contralateral mediastinal shift. Which condition does this patient most likely have? A)Primary spontaneous pneumothorax B)Secondary spontaneous pneumothorax C)Traumatic pneumothorax D)Transudative pleural effusion

After an acute myocardial infarction, the patient is receiving tissue plasminogen activator (tPA) and initially on nitroglycerin for chest pain at 10 on 0/10 scale. The patient has rare premature ventricular contractions (PVCs) and a blood pressure of 82/55 mm Hg. What is the most important nursing action? A)Discontinue the nitroglycerin infusion rate. B)Increase the tPA infusion rate. C)Administer a bolus of amioderone. D)Obtain a 12-lead electrocardiogram.

An elderly patient in the ICU is receiving intravenous opioid analgesia for pain. The nurse observes that the patients respiratory rate has decreased to 8 breaths per minute. Which nursing intervention would be most appropriate? A)Administer naloxone intravenously very slowly . B)Administer diazepam immediately. C)Increase the dose of opioid. D)Massage the patients feet to stimulate her breathing.

An immunocomprised patient presents with the following: chills, tachycardia, tachypnea, and hypotension. The critical care nurse suspects which of the following? A)Early septic shock B)Acute pancreatitis C)AIDS D)HIV

As part of a multiple trauma injury, a patient developed hemorrhagic hypovolemic shock, necessitating fluid resuscitation with massive amounts of intravenous crystalloid fluids and blood products as well as extensive surgical repair under general anesthesia. Twenty-four hours later, the patient develops hypoxia unresponsive to oxygen therapy and diffuse white, ground-glass infiltrates of the lung fields on a chest radiograph. Development of this complication has what effect on the patients recovery? A)Significantly greater chance of death B)No change in outcome expectations C)Outcome depends on treatment. D)Lower chance of death

Hyponatremia without edema or hypovolemia is a sign of water intoxication caused by which of the following? A)Syndrome of inappropriate ADH secretion (SIADH) B)Diabetes insipidus (DI) C)Newly diagnosed type 1 diabetes D)Prerenal kidney failure

In a patient with trauma-induced central diabetes insipidus, what urine specific gravity result does the nurse expect? A)Specific gravity 1.001 to 1.010 B)Specific gravity 1.011 to 1.024 C)Specific gravity 1.025 to 1.030 D)Specific gravity varies diurnally

One of the major goals of therapy for a patient with a head injury is to control rising intracranial pressure (ICP). What assessment data would first cause the nurse to suspect rising ICP? A)Deteriorating level of consciousness B)Brisk pupils with equal reactivity C)Absence of speech secondary to sedative use D)Narrow pulse pressure and hypotension

Regulation of intracranial pressure is explained by the Monro-Kellie doctrine. Based on this doctrine, under normal circumstances, if a patients brain volume increases, what compensatory change does the nurse expect? A)Reduction of cerebral blood volume B)Increased cerebrospinal fluid volume C)Increased cerebrospinal fluid production D)Elevation of systemic blood pressure

Sodium and osmolarity levels of both plasma and urine are helpful in the diagnosis of endocrine disorders. When serum sodium and serum osmolarity values are low while urine sodium and urine osmolarity are high, what is the most likely diagnosis? A)SIADH B)Diabetes insipidus C)Hypoglycemia D)Water intoxication

Teaching patients and families is an important part of critical care nursing. What factor in todays critical care unit is a barrier to this education function? A)Large numbers of inexperienced nurses B)Serious illness of patients C)Increased computer support D)Use of specialty educators

The nurse is caring for a patient from a very different cultural group. In delivering care, how can the nurse best demonstrate cultural sensitivity? A)Ask the family about their cultural beliefs and customs that may apply. B)Assume that the patient and family will adjust to the hospital culture. C)Inform the patient and family that the routines of the hospital take precedence. D)Do a literature search on the patients culture to determine beliefs.

The nurse is caring for a patient who is orally intubated and on a mechanical ventilator. The nurse believes that the patient is experiencing excess anxiety. For this patient, what behavior best indicates anxiety? A)Restlessness B)Verbalization C)Increased respiratory rate D)Glasgow Coma Scale score of 3

The nurse is caring for a patient who was run over by an automobile. The patient has hematuria on admission to the emergency department. What is the most likely cause of the hematuria? A)Kidney trauma B)Kidney stones C)Prostatic disease D)Toxic damage

The nurse is caring for a patient with hypovolemic shock who has had 6 units of packed red blood cells. Which of the following values would alert the nurse to a complication related to the administration of blood? A)Potassium level of 6.0 B)Hemoglobin of 13 C)Sodium level of 134 D)pH 7.37

The nurse is caring for the patient with chest tubes. Which observation by the nurse is a priority concern? A)250 mL/hr of blood in drainage collection system B)Pulse oximetry of 94% C)Blood pressure of 104/62 D)30 mL/hr of urine output

The nurse is examining the skin of a critically ill patient. What technique should the nurse? A)Inspect the appearance of the skin every 12 hours. B)Inspect only the anterior body skin every 12 hours. C)Auscultate for bruits over skin lesions when found. D)Percuss the borders of skin lesions when found.

The nurse is performing a physical examination on a patient with neurologic disease. What finding from the examination is the most indicative of diminished cerebral hemisphere functioning? A)Deteriorating level of consciousness B)Positive Romberg test C)Unequal pupillary response D)Glasgow Coma Scale score of 15

The nurse is teaching a patient newly diagnosed with cardiovascular disease how to reduce risk factors. The nurse begins by explaining why this information is important for the patient. What principle of adult learning is the nurse applying? A)Need to know B)Learners self-concept C)Learners life experience D)Motivation to learn

The nurse understands that which of the following patients in the hospital is at the greatest risk for cardiogenic shock? A)The 76-year-old male patient with a history of diabetes mellitus and previous myocardial infarction (MI) B)The 42-year-old male who has mitral valve prolapse with a left ventricular ejection fraction of 65% C)The 52-year-old female with a recent small anteroseptal wall MI D)The 84-year-old female with hypertension

The patient has developed cardiogenic shock and is decompensating. What pattern of hemodynamic alterations does the nurse expect to find? A)High preload, high afterload, low cardiac index, tachycardia B)Low preload, low afterload, high cardiac index, bradycardia C)Low preload, high afterload, high cardiac index, tachycardia D)High preload, low afterload, high cardiac index, tachycardia

The patient has systemic inflammatory response syndrome (SIRS) and very severe third spacing of fluid. During routine assessment, the nurse finds that the patients skin appears generally swollen, red, and shiny, and the nurse is unable to depress the surface of the skin. What type or degree of edema is present? A)Nonpitting B)2+ C)3+ D)4+

The patient has undergone a percutaneous coronary intervention (PCI) for relief of coronary stenosis secondary to arteriosclerotic heart disease. During discharge teaching, what patient statement most indicates the need for reteaching? A)This procedure means that my heart disease is cured. B)I should continue to take my antilipidemic. C)If I have any chest pain, I will call my doctor. D)I will start a walking program after my doctor agrees.

The patient is being evaluated for acute myocardial infarction. Elevation in what laboratory value would confirm an acute MI? A)Troponin I or T B)CK-MB or CK-MM C)Myoglobin after 12 hours D)Leukocyte count

The patient is being evaluated for oxygen deficit. What laboratory study will be most helpful to the nurse in this evaluation? A)Red blood cell count B)Complete blood count C)Complete blood count differential D)Serum carbon dioxide combining power

The patient is being monitored with an intracranial pressure monitor. What nursing assessment most indicates the development of a complication of intracranial pressure monitoring? A)Purulent drainage around monitor access site B)Intracranial pressure 12 mm Hg at rest C)Intracranial pressure 20 mm Hg during suctioning D)Development of slight respiratory alkalosis

The patient is being supported with mechanical ventilation and is requiring very high levels of inspired oxygen to maintain his arterial blood gases at acceptable levels. In an attempt to reduce the amount of oxygen required, positive end-expiratory pressure (PEEP) at 5 cm H2O is added to the ventilator settings. What is the most important effect of PEEP? A)Increases number of open alveoli B)Increases patient comfort C)Assists in ventilator weaning D)Compensates for tubing resistance

The patient is being well supported with a positive-pressure mechanical ventilator. Because of the mechanism of action of this type of ventilator, what common complication does the nurse watch for? A)Diminished cardiac output B)Increased somnolence C)Deep venous thrombosis D)Reduced patient control

The patient is experiencing respiratory acidosis. What nursing action is most likely to alleviate this condition? A)Suction the endotracheal tube. B)Reduce the respiratory rate on the ventilator. C)Administer intravenous bicarbonate. D)Increase the rate of crystalloid intravenous fluids.

The patient is in hypovolemic shock from traumatic massive blood loss and is tachypneic and tachycardic, with cool, clammy skin and weak and thready pulses. What additional assessment parameter would the nurse be least likely to find during stage one or early compensated shock? A)Hypotension B)Increased urine output C)Estimated blood loss greater than 30% D)Mild altered mental status

The patient is seriously ill and has developed a fever, a cough productive of thick, yellow sputum, and respiratory insufficiency. What changes in the white blood cell differential count does the nurse expect to find? A)Increased neutrophils and bands B)Increased eosinophils and blasts C)Decreased neutrophils with bands D)Decreased lymphocytes and neutrophils

Two patients, a husband and wife, are admitted to the ICU after sustaining traumatic head injuries in a motor vehicle accident. The husband is in a coma but shows no abnormalities on a CT scan. He is 45 years old and has a systolic blood pressure of 85 mm Hg. The wife, 42 years old, is not comatose and has a normal CT scan, but shows signs of brain injury, and has a systolic blood pressure of 80 mm Hg. The nurse recognizes that intracranial pressure monitoring is indicated for which of these patients? A)Both the husband and wife B)Neither the husband nor the wife C)The husband only D)The wife only

When performing a physical examination of a hematological or immunocompromised patient, the critical care nurse focuses on which of the following major areas? A)Skin, liver, spleen, lymph nodes B)Skin, respiratory, cardiac, spleen C)Skin, liver, cardiac, lymph nodes D)Respiratory, kidney function, liver, spleen

Which of the following descriptive words are indicative of myxedema coma? A)Rare, hypothyroid B)Chronic, hypothyroid C)Common, hyperthyroid D)Rare, hyperthyroid

A patient in the CCU is suspected to have had a myocardial infarction. His blood work results have arrived, and the nurse is reviewing them. Which results would indicate myocardial infarction? Select all that apply. A)Elevated troponins B)CK-MB isoenzyme at 10% of total creatine kinase C)C-reactive protein serum value of 6 mg/dL D)Decreased levels of D-dimer

A,B, C

The nurse is administering an intravenous antibiotic infusion over 30 minutes for a patient with cellulitis of the left lower extremity. The patient states, I am itching all over and am having trouble swallowing. What priority interventions by the nurse are necessary for this patient? Select all that apply . A)Stop the antibiotic infusion . B)Administer subcutaneous epinephrine. C)Administer diphenhydramine (Benadryl) IV. D)Switch to amoxicillin by mouth. E)Administer Ativan for the patients anxiety.

A,B,C

Which of the following are important to assess in the immunocompromised patient? Select all that apply. A)Nutritional status B)Body temperature C)White blood cell count D)Skin assessment

A,B,C

Which of the following are precipitating factors for thyrotoxic crisis? Select all that apply. A)Infection B)Hypothermia C)Steroid therapy D)Long, chronic illness E)Pregnancy

A,B,C,D,E

A nursing assessment of a patient with hypovolemic shock is most likely to reveal what assessment findings? Select all that apply. A)Tachycardia B)Oliguria C)Disoriented to time and place D)Diuresis E)Bradycardia F)Hypotension

A,B,C,F

A patient in the CCU is undergoing arterial pressure monitoring, and the bedside physiological monitor alarm sounds. Which of the following should the nurse do? Select all that apply. A)Check to see whether the catheter is kinked. B)Check to see whether the stopcocks are turned the wrong way. C)Add IV solution through the arterial pressure monitoring system. D)Make sure that there is sufficient pressure in the pressure bag.

A,B,D

A patient is demonstrating increased pulse pressure, decreased pulse, and irregular respiration. The nurse recognizes these symptoms of increased intracranial pressure and understands that the patients autoregulation of cerebral blood flow in the brain has failed. Which of the following findings would be consistent with a failure of autoregulation of blood flow in the brain? Select all that apply. A)Cerebral perfusion pressure of 40 mm Hg B)Mean arterial pressure of 170 mm Hg C)Systolic pressure of 120 mm Hg D)Intracranial pressure of 35 mm Hg

A,B,D

The patient in the ICU is being treated for left lower lobe pneumonia. What assessment findings by the nurse may indicate that the patient is developing systemic inflammatory response syndrome (SIRS)? Select all that apply. A)White blood cell count of 24,000/mm3 B)Respiratory rate of 24 C)Blood pressure of 100/60 D)Heart rate 96 E)Atrial fibrillation

A,B,D

A patient is admitted to the emergency department after he was hit by a car. The car was going about 30 mph and was braking at the time of impact. The patient was struck just above the right knee, fell forward over the hood of the car, striking his anterior chest, and then slipped off the hood of the car and hit the pavement head first. Based on the mechanism of injury and transfer of force, what injuries does the nurse most expect? Select all that apply. A)Fracture of left femur and damage to left knee B)Fractures of thoracic and lumbar spine C)Fractured ribs and cardiac and lung contusion D)Bilateral radial and humerus fractures E)Closed head injury and cervical spine fracture F)Bilateral clavicle and scapular fractures

A,C,E

The nurse places a large-bore nasogastric tube in a patient who has acute upper gastrointestinal bleeding. What is the rationale for this intervention? Select all that apply. A)Aspiration of gastric contents B)Improvement of ventilation C)Decompression D)Enteral feeding E)Lavage of gastric contents F)Control of bleeding

A,C,E

A 15-year-old boy is in the ICU and preparing for an appendectomy. He is clearly anxious and fidgets with his IV constantly. He complains that he doesnt want to be there and he is sick of everyone telling him what to do. What would be the best way for the nurse to address this patients anxiety? A)Use physical restraints to keep him from pulling out his IV. B)Offer him the remote to the television. C)Lower the head of his bed so that he can rest more easily. D)Explain to the patient in detail what the appendectomy will consist of.

A client has been admitted after experiencing multiple trauma and is intubated and sedated. When the five members of the immediate family arrive, they are anxious, angry, and very demanding. They all speak loudly at once and ask for many services and answers. What is the best nursing response? A)Ask the family to leave until visiting hours begin. B)Take them to a private area for initial explanations. C)Page security to have them removed from unit. D)Show them to the clients bedside and leave them alone.

A critically ill patient has an absolute neutrophil count of 1,000 cells/mm3. The nurse assesses a single patient temperature of 101F; subsequent temperatures were normal, and the patient reports no other new symptoms. What is the best nursing action? A)Assume that the elevated temperature was erroneous. B)Evaluate for acute infection. C)Assess vital signs more frequently. D)Document the temperature results as usual.

A critically ill patient has an elevated platelet count. What potential complication does the nurse assess for? A)Dehydration B)Thrombosis C)Hepatic impairment D)Disseminated intravascular coagulation

A critically ill patient has arterial blood gas results of PaO2 60 mm Hg, SaO2 80%, pH 7.35, PaCO2 35 mm Hg, and HCO3 24 mEq/L. How does the nurse interpret these results? A)Hypoxemia and respiratory acidosis B)Hypoxemia and normal acidbase balance C)Normal oxygenation and metabolic acidosis D)Normal oxygenation and acidbase balance

A critically ill patient has developed septic shock. What pattern of hemodynamic values does the nurse expect to find? A)Low preload, high afterload, low cardiac index, tachycardia B)Low preload and afterload, high cardiac index, tachycardia C)High preload and afterload, low cardiac index, tachycardia D)Normal preload, low afterload, normal cardiac index, bradycardia

A critically ill patient has developed shock. What nursing assessment result indicates a normal compensatory mechanism? A)Reduction of respiratory depth B)Increase in systemic vascular resistance (SVR) C)Decrease in circulating catecholamines D)Increased stimulation of baroreceptors

A critically ill patient is at risk for developing disseminated intravascular coagulation (DIC). What presenting symptoms would the nurse expect if this occurs? A)Elevated core temperature and neutrophil count B)Sudden increase in dyspnea and hemoptysis C)Continued need for opioid analgesia after trauma D)Increase in purulent pulmonary secretions and cough

A critically ill patient tells the nurse that he is not afraid to die because he believes in reincarnation. What is the most appropriate nursing response? A)What if reincarnation is not real? B)This belief gives you strength. C)I dont believe in reincarnation. D)You shouldnt base your hopes on such a belie

A critically ill patient who is mechanically ventilated and has developed shock is in need of nutritional support. What route is preferred for this patient? A)Oral B)Enteral C)Parenteral D)Variable

A critically ill patient with a Hispanic and American Indian ethnic background is in hemorrhagic shock. The nurse notices that the patients skin is yellowish brown and the conjunctiva, oral mucosa, and nail beds are ashen gray. What variation in skin color does the nurse document? A)Pallor B)Cyanosis C)Jaundice D)Erythema

A critically ill patient with a severe burn has developed disseminated intravascular coagulation (DIC). What is the precipitating event for this complication? A)Reaction to medication such as heparin or antineoplastic agents B)Heat and direct damage of blood cells and vessels C)Autoimmune disease causing destruction or clumping of platelets D)Blood and fluid loss from the burn causing hemoconcentration

A female patient has just undergone a percutaneous coronary intervention (PCI). What symptom, if found by the nurse, requires immediate intervention? A)Three premature ventricular complexes B)Frank bleeding from the femoral insertion site C)Serum potassium level 4.8 mEq/L D)Hemoglobin 11.7 g/dL

A nurse is monitoring a patient recently admitted to the critical care unit with an acute brain injury. She is aware that intracranial hypertension is a major risk associated with brain injury. Which of the following findings would definitively indicate that the patient has intracranial hypertension? A)Cerebral perfusion pressure (CPP) of 75 mm Hg B)Intracranial pressure (ICP) of 25 mm Hg C)Mean arterial pressure (MAP) of 150 mm Hg D)Systolic pressure of 110 mm Hg

A nurse needs to evaluate a patients understanding of how to administer an IV medication at home. Which of the following would be the best method for evaluation? A)The nurse explaining the procedure to the patient and family using diagrams B)The nurse having the patient and family members demonstrate the procedure themselves C)The nurse explaining the procedure while performing it on the patient D)The nurse referring the patient to a computer-based educational library that has an interactive program

A nurse needs to obtain informed consent from a deaf patient before a spinal tap procedure is performed. Which of the following would be the best method for the nurse to use to ensure effective communication? A)Explain the procedure verbally, speaking slowly so that the patient can read lips . B)Have a trained oral interpreter interpret for the nurse. C)Have the patient carefully read a printed copy of the informed consent document . D)Use diagrams to explain to the patient the details of the procedure.

A patient being mechanically ventilated with positive end-expiratory pressure and pressure support totaling 30 mm Hg has developed unequal chest expansion, absent breath sounds on the right, and tracheal deviation to the right. The patient is increasingly tachycardic, anxious, and agitated, and his pulmonary compliance is rapidly decreasing. What is the most appropriate nursing action? A)Obtain a chest x-ray to rule out pneumothorax. B)Inititate needle thoracotomy or chest tube insertion. C)Sedate the patient and evaluate ventilator settings. D)Obtain arterial blood gases to evaluate gas exchange.

A patient has been admitted to the CCU in severe distress with acute respiratory failure. Initial arterial blood gases are pH 7.33, PaCO2 65, HCO3 30, PaO2 65, SaO2 90. What is the most important nursing action? A)Administer oxygen at 100%. B)Prepare for intubation. C)Obtain arterial blood gases. D)Measure functional expiratory volume.

A patient has been admitted to the emergency department after being in a severe motor vehicle crash. The patient was a passenger and had a lap and seat belt in place. The patient is lethargic and moaning. Initial exposure and head-to-toe examination reveals scattered minor abrasions and contusions and bruising over the upper abdomen. The patient moans more when the abdomen is palpated, and the abdomen is rigid. Heart rate is 110, capillary refill is greater than 4 seconds, and blood pressure is 140/88 mm Hg. What is the nursing priority of care? A)Administer intravenous opioid for pain. B)Increase rate of intravenous crystalloid. C)Obtain CT of the abdomen. D)Prepare for immediate endotracheal intubation.

A patient has been involved in a motor vehicle accident. The patient, who was driving, was unrestrained by a seat belt when hitting the car in front of him. The patient is complaining of midsternal pain, restlessness, and difficulty breathing. What is the priority nursing diagnosis for this patient? A)Anxiety B)Impaired gas exchange C)Impaired circulation D)Pain

A patient has developed diabetes insipidus after suffering severe head trauma. What symptoms does the nurse expect to find? A)Urine output less than 30 mL/hr B)Urine specific gravity 1.001 to 1.005 C)Serum osmolality below 275 mOsm/kg D)Serum sodium less than 135 mEq/L

A patient has recently had a hemorrhagic stroke. The nurse should most strongly suspect which precipitating factor in this patient? A)Myocardial infarction B)Hypertension C)Atrial infarction D)Diabetes

A patient in a critical care unit has increased stress from the constant noise and light levels. What nursing intervention best attenuates these sources of stress? A)Need for constant observation and evaluation B)Dimming lights during the night C)Frequent nursing group rounds for all patients D)Use of tile floors for ease in cleaning

A patient in intensive care with acute tubular necrosis from a toxic ingestion has been started on renal replacement therapy. The family expresses concern that the patient will not be able to afford dialysis after discharge from the hospital. In responding to the family, what should the nurse consider? A)The family is in crisis and unable to respond rationally. B)Toxic acute tubular necrosis has a higher likelihood of complete healing. C)Since the patient is currently oliguric, renal replacement therapy is indicated. D)The patient is unlikely to survive this illness, so the cost of long-term dialysis is not an issue.

A patient in the ICU with acute respiratory failure demonstrates dyspnea, headache, tachypnea, and tachycardia. Which of these symptoms distinguishes this patients condition as acute hypercapnic respiratory failure, as opposed to acute hypoxemic respiratory failure? A)Dyspnea B)Headache C)Tachycardia D)Tachypnea

A patient is in the emergency department being treated for an ischemic stroke. What is the nursing priority of care? A)Refer for rehabilitation care. B)Initiate fibrinolysis within 3 hours. C)Initiate intravenous glucose therapy. D)Administer 100% oxygen by mask

A patient sustained an injury to the right arm after falling off a motorcycle. The patient is complaining of severe pain and is unable to feel the fingers of the right hand. Radial pulse is absent. What is the priority intervention by the nurse? A)Elevate the right arm above the level of the heart. B)Notify the physician. C)Apply ice packs to the affected area. D)Place the patient in Trendelenburg position.

A patient was in a serious motor vehicle crash. At the scene, what is the highest priority of care? A)Extrication from the vehicle B)Cervical spine protection C)Establishing two large-bore intravenous lines D)Collecting information about the crash

A patient who has had an acute ST segment elevation myocardial infarction (STEMI) is started on an angiotensin-converting enzyme (ACE) inhibitor drug. In explaining the action of this drug to the patient, what is the best rationale for the nurse to use? A)Most patients with acute myocardial infarction also have hypertension. B)Reduction of afterload reduces stress on the damaged heart and further damage. C)Use of ACE inhibitors is part of protocol for treatment of a STEMI. D)ACE inhibitor therapy is not effective for other types of heart disease.

A patient who is on an intracranial pressure monitor after an acute head injury has an intracranial pressure of 10 mm Hg at rest. When the patient is being suctioned, the intracranial pressure rises briefly to 20 mm Hg but returns quickly to 10 mm Hg once the suctioning has ceased. What is the most appropriate nursing intervention? A)Administer intravenous sedation B)Suction no longer than 15 seconds each time C)Drain 10 mL cerebrospinal fluid D)Return to supine position

A patient with a massive upper gastrointestinal hemorrhage is exhibiting signs and symptoms of hypovolemic shock. What initial treatment does the nurse anticipate? A)Admission to a general care nursing unit for monitoring B)Initial fluid resuscitation with intravenous crystalloids C)Diet of clear liquids, advanced as tolerated D)Bed rest in semi-Fowlers positio

A patient with chronic kidney disease is receiving an ACE inhibitor. The nurse understands that this medication helps slow the progression of this disease through what process? A)It lowers the level of blood glucose. B)It prevents nephron hyperfiltration. C)It increases the urine output. D)It filters waste from the blood.

A patient with chronic obstructive pulmonary disease has just been started on pressure-controlled ventilation with positive end-expiratory pressure (PEEP) of 18 cm H2O. The fraction of inspired oxygen is set to 50%. Which of the following is a sign of tension pneumothorax that the nurse should watch for? A)An abrupt decrease in peak inspiratory pressure B)Tracheal deviation from the midline C)Syncope D)Bradypnea

A patient with chronic renal disease is involved in a motor vehicle crash and experiences severe hypovolemia. In caring for this patient in the CCU, which of the following is the most important for the nurse to monitor? A)Blood pressure B)Fluid volume recovery C)Urine output D)Cardiac dysrhythmias

A patient with chronic renal failure also has chronic anemia, arteriosclerotic disease, and diabetes mellitus. The patient asks the nurse why the anemia is persisting. In answering the patients question, what should the nurse most consider? A)The patient most likely has preexisting chronic anemia. B)Erythropoietin is primarily produced in the kidney. C)The patient is receiving low-dose aspirin therapy. D)Chronic renal failure results in persistent uremia.

A patient with head trauma is being monitored with an intraventricular catheter device (IVC). The patients intracranial pressure (ICP) had been staying around 20 mm Hg, but moments ago, it spiked up to 55 mm Hg. What complication related to the monitoring device itself would best explain this dramatic increase in ICP? A)Infection at the catheter access site B)Obstruction of the catheter C)Hemorrhage D)Misplacement of catheter

A patient with severe and refractory elevated intracranial pressure (ICP) has been in an induced barbiturate coma for 48 hours. Over the first 24 hours, the patients ICP decreased from 30 to 14 mm Hg and her systolic blood pressure decreased from 130 to 80 mm Hg. These changes were sustained in the second 24 hours. The nurse recognizes that which of the following is the appropriate intervention for this patient? A)Administer IV solution. B)Discontinue barbiturate therapy. C)Initiate hypothermia therapy. D)Administer a sedative.

A patient with stable angina is being treated with a beta-blocker. What assessment finding would most cause the nurse to question the use of this medication?' A)Heart rate 60 at rest, denies dizziness when standing B)Systolic blood pressure 82, complains of chronic fatigue C)Sinus rhythm with rare premature atrial complexes (PACs) D)Diastolic blood pressure 80 with normal pulse pressure

A young man with spontaneous primary pneumothorax is given supplemental oxygen. What is the primary purpose for giving this patient supplemental oxygen? A)Oxygen reverses the formation of excess pleural fluid. B)Oxygen accelerates the rate of air resorption from the pleural space. C)Oxygen counteracts the hypoxemia associated with pneumothorax. D)Oxygen calms the patient.

An elderly male patient in the ICU is diagnosed with acute kidney injury. This patient demonstrates a decreased glomerular filtration rate and lowered urine sodium concentration, as well as increased BUN and serum creatinine levels. The nurse observes that the patient takes several minutes to empty his bladder when he uses the bathroom. His blood pressure and blood glucose levels are normal. What should the nurse suspect as the cause of this patients acute kidney injury? A)Tubular necrosis as a result of accumulation of radiocontrast dye in the renal tubular cells B)Obstruction of the flow of urine due to benign prostatic hypertrophy C)Lack of perfusion due to congestive heart failure D)Hypotension due to systemic inflammatory response to sepsis

As part of a multiple trauma injury, the patient has suffered a closed fracture of the radius. What nursing assessment finding indicates a significant complication warranting immediate treatment? A)Swelling and pain over the fracture B)Loss of pulses distal to the fracture C)Ecchymosis over the fracture D)Deformity of forearm

As part of the care of a mechanically ventilated patient, the nurse provides oral and subglottic suctioning every 2 hours. What is the best rationale for this nursing action? A)Stimulates cough and deep breathing B)Reduces pulmonary microbial colonization C)Maintains oral mucosal moisture D)Part of Universal Precautions protocols

During routine assessment of a critically ill patient, the nurse is able to indent the skin on the dorsal surface of the foot 4 mm, and the skin rebounds in a few seconds. What degree or type of edema is present? A)Nonpitting edema B)2+ pitting edema C)3+ pitting edema D)4+ pitting edema

For a patient in cardiogenic shock, the physician has ordered an intravenous continuous infusion of dobutamine hydrochloride. What nursing assessment result demonstrates achievement of therapeutic goals? A)Blood pressure 120/70 mm Hg B)Urine output 30 to 40 mL/hr C)Arterial oxygen saturation 60% D)Heart rate 110 to 120 bpm

In a patient with acute ischemic tubular necrosis, urine output has increased from below normal to very high. What is the nursing priority of care during this phase of renal failure? A)Restrict fluid intake B)Monitor serum potassium C)De-emphasize dialysis D)Monitor serum creatinine

Intracranial pressure monitoring can be a valuable diagnostic tool but also has significant complications. In what patient with a severe head injury would the nurse question the use of intracranial pressure monitoring? A)Glasgow Coma Scale score of 3 B)Declared brain dead C)Subarachnoid hematoma D)Severe stroke

The nurse cares for critically ill patients in a busy trauma unit. The nurse manager has instituted a program to incorporate principles of palliative care into the care of all patients in the unit. What is the best reason for this inclusion? A)Most of the patients in critical care will die, so palliative care will be necessary. B)Primary palliative care focuses on relief of suffering and improvement of quality of life. C)This action has been mandated by the nurse manager and must be implemented. D)Palliation is another way of managing pain control in critical care.

The nurse is assigned to the care of a patient in the ICU who is in cardiogenic shock. What priority nursing intervention is necessary to conserve myocardial energy and decrease workload of the heart? A)Lactated Ringers at 150 mL/hr B)Morphine sulfate 4 mg IV C)Furosemide (Lasix) 80 mg IV D)Epinephrine 1:1,000, 0.3 mL IV

The nurse is caring for a critically ill patient who can speak. The nurse notices that the patient is demonstrating behaviors indicative of anxiety but is silent. What nursing strategy would give the nurse the most information about the patients feelings? A)Explain procedures to the patient and family. B)Ask the patient to share his or her internal dialogue. C)Encourage the patient to nap before visiting hours. D)Ensure that the patient has adequate pain control

The nurse is caring for a critically ill patient with a very concerned family. Given that the family is under high stress, what nursing intervention will best ameliorate their stress while preserving independence? A)Encourage the family to participate in patient care tasks. B)Teach the family to ask questions of the health care team. C)Ask the family to select a family representative for communication. D)Limit visits to immediate family members for limited times.

The nurse is caring for a critically ill patient. On the previous shift, a nurse documented unable to teach due to critical illness. What is the best nursing action by the current nurse to address the patients teaching and learning needs? A)Realize that the patient is too ill to accept teaching at this time. B)Look for opportunities for teaching, such a procedure explanation. C)Focus all teaching efforts on the family to the exclusion of the patient. D)Alter the plan of care to delay teaching until transfer to step-down unit.

The nurse is caring for a patient with active acquired immune deficiency syndrome (AIDS) in an intensive care unit. What is the most important component of care for this patient? A)Psychological support B)Infection control measures C)Prophylactic antibiotics D)Neutropenic precautions

The nurse is caring for an otherwise healthy victim of a motor vehicle crash who is experiencing considerable pain. What factor indicates that the patient may be experiencing acute pain? A)It is associated with an acute and severe injury. B)It is expected to resolve as the injury heals. C)It requires treatment with intravenous opioids. D)No chronic illnesses have been diagnosed.

The nurse is developing a policy and procedure for pain management in a critical care unit. Based on national standards, what should the nurse include? A)Pain assessment in critical care must depend on vital sign monitoring as patients are not verbal. B)Continuous intravenous opioids are preferred over as-needed dosing. C)Intravenous sedation of agitated patients takes priority over pain control . D)Pain control is an independent nursing function and responsibility.

The patient has been diagnosed with severely compromised immune function. What nursing intervention is most important? A)Antibiotic therapy B)Adequate protein C)Coughing and deep breathing D)Restricted visits from family

The patient has been in a motor vehicle crash and is in the critical care unit with severe brain injury. She is comatose but when painful stimuli are applied she extends, adducts, and hyperpronates her upper extremities and has plantarflexion of the feet. This action is called what? A)Decorticate posturing B)Decerebrate posturing C)Clonic-tonic activity D)Flacidity

The patient has been on a mechanical ventilator for 2 weeks. Weaning from mechanical ventilation is to start today. Based on the length of time that the patient has been ventilated, what information should the nurse emphasize to the patient and the family? A)Extubation is expected later today, as the patient is relatively young. B)Delays and setbacks are expected before independence is achieved. C)The best method is continuous positive airway pressure (CPAP). D)Elevation of the head of the bed will provide for the most patient comfort.

The patient has just had a transvenous cardiac pacemaker lead inserted into the subclavian vein. What patient symptom, if found by the nurse, would most indicate a possible complication unique to the use of the subclavian vein? A)Persistent hiccups at the same rate as the pacemakers set rate B)Sudden respiratory distress, hypoxia, and hypotension C)Persistent premature ventricular complexes seen on cardiac monitor D)Oversensing, undersensing, or failure to capture

The patient is being supported with a positive-pressure mechanical ventilator set to a synchronized intermittent mandatory ventilation (SIMV) rate of 8 breaths per minute. What situation, if found by the nurse, would indicate a ventilator malfunction? A)SIMV rate 8, patient rate 30, total rate 38 breaths per minute B)SIMV rate 6, patient rate 2, total rate 8 breaths per minute C)SIMV rate 8, patient rate 0, total rate 8 breaths per minute D)SIMV rate 8, patient rate 8, total rate 16 breaths per minute

The patient is complaining of midsternal chest pain that feels like constant severe pressure. The pain is not relieved by rest or three nitroglycerin tablets and is different than the pain the patient has had in the past. What is the priority nursing action? A)Administer another nitroglycerin tablet. B)Obtain a 12-lead electrocardiogram. C)Use anxiety reduction techniques. D)Teach risk reduction strategies.

The patient is in a critical care unit after an acute head injury and has developed respiratory and ventilatory failure and hypotension. What effect will this development have on the patients cerebral perfusion pressure? A)Elevated above 100 mm Hg B)Reduced below 60 mm Hg C)Will make it very labile D)Will have very little effect

The patient is in decompensated shock. What abnormal variation in peripheral skin color does the nurse expect to find? A)Pallor B)Cyanosis C)Erythema D)Jaundice

The patient is in hypovolemic shock, with mean arterial pressures below 90 mm Hg and a very low urine output. An IV drip of norepinephrine is prescribed to keep blood pressure above 90 mm Hg. No other therapy is initiated. What effect on kidney function does the nurse expect? A)Improvement in renal perfusion secondary to improved blood pressure B)Reduction in urine output secondary to constriction of renal arteries C)Augmentation of water reabsorption from distal tubular fluid D)Decrease in urine sodium concentration to critically low levels

The patient is scheduled to undergo a percutaneous cardiac intervention (PCI). What patient history would the nurse least expect to find? A)Poor left ventricular function and ejection fraction B)Coronary artery lesions less than 70% narrowing C)Extreme old age with fragility D)Unstable angina with activity and at rest

What is the underlying pathophysiologic process for pancreatitis? A)Inflammation from bowel endotoxins B)Autodigestion by pancreatic enzymes C)Inability of the pancreas to activate its enzymes D)Destruction of pancreatic tissue by bile

Which of the following patients would be at highest risk for the development of deep vein thrombosis progressing to pulmonary embolus? A)Age 45, exercises daily, underwent elective knee repair surgery, high normal platelets B)Age 85, sedentary, somewhat dehydrated, underwent repair of a pelvic fracture, high normal platelets C)Age 26, athletic, underwent repair of a football injury, normal platelets D)Age 50, on aspirin and beta blockers, underwent open heart surgery, borderline low platelets

While caring for a critically ill patient, the nurse knows that fostering patient control over the environment is a method for stress reduction. What nursing intervention gives the patient the most environmental control while still adhering to best practice principles? A)Ask the patient whether he or she wants to get out of bed. B)Give the patients bath at the same time every day. C)Explain painful procedures only after giving pain medication. D)Choose menu items for the patient to ensure a balanced diet.

The nurse is caring for a critically ill patient with high levels of pain. To potentiate pharmacological pain relief, the nurse uses several nonpharmacological interventions. What nursing strategies will be helpful in this situation? Select all that apply. A)Frequent turning and repositioning B)Earphones with music of the patients choice C)Limiting visits to twice a day D)Using guided imagery and distraction E)Teaching the quieting reflex F)Using therapeutic touch

B, D,E,F

A critically ill patient has been diagnosed with disseminated intravascular coagulation (DIC). What pattern of abnormal laboratory results does the nurse expect? Select all that apply. A)Low absolute neutrophil count and red blood cell count B)High prothrombin time (PT) and partial thromboplastin time (PTT) C)Increased fibrin degradation products and presence of D-dimers D)Decreased fibrinogen and thrombocytes E)Increased fibrinogen and fibrin degradation products F)Decreased total white cell count and hematocrit

B,C,D

A patient has suffered a mild pulmonary contusion from a jet ski accident. What nursing interventions are appropriate for this patient? Select all that apply. A)Maintenance of chest tubes B)Frequent pulse oximetry monitoring C)Assessment of lung sounds every 2 hours D)Continuous epidural analgesia E)Maintainance of ventilatory support

B,C,D

A nurse is assessing the plantar reflex in a patient. Which of the following results would indicate abnormal response and a possible lesion in the pyramidal tract? Select all that apply. A)Plantar flexion of all toes B)Dorsiflexion of the big toe with fanning of the other toes C)No response at all D)Dorsiflexion of the big toe without fanning of the other toes E)Ticklishness

B,D

Which of the following provide information about the health of the skin and may yield information about the patients fluid volume balance? Select all that apply. A)History B)Mobility C)Temperature D)Color E)Turgor F)Moisture

B,E

A critical care patient has been receiving a continuous heparin drip for treatment of possible deep vein thrombosis for 4 days. The patient now has developed symptoms consistent with heparin-induced thrombocytopenia (HIT). What change in therapy does the nurse anticipate? A)None, as the patient needs anticoagulation for deep vein thrombosis B)Change of heparin to subcutaneous low-molecular-weight heparin C)Discontinuation of all heparin and heparin-coated devices D)Replacement of platelets by transfusion and addition of aspirin therapy

A critically ill patient has been diagnosed with heparin-induced thrombocytopenia (HIT). What symptoms would the nurse expect? A)Gastric aspirate with positive guaiac test B)Oozing of blood around intravenous sites C)Sudden severe hypoxia and lateral chest pain D)Red blood cells in urine

A female patient is in intensive care recovering from a severe illness and has these laboratory results: total white blood cells 2,000 cells/mm3, neutrophils 40%, lymphocytes 35%, monocytes 11%, eosinophils 4%, basophils 0%, red blood cell count 4.2 106 cells/mm3, hemoglobin 11.7 g/dL, hematocrit 38%, serum sodium 140 mEq/L, serum potassium 4.0 mEq/L. Based on the laboratory results, what is the highest-priority nursing action? A)Monitor cardiac rhythm closely. B)Measure intake and output carefully. C)Institute protective isolation. D)Obtain an order for antibiotic therapy.

A nurse needs to explain to a patient about the possible side effects the patient may experience related to the pain medication she is now beginning while in the ICU and which she will be continuing upon discharge. Which method would be the most effective way to teach this to the patient? A)In a planned teaching session, in which the nurse covers medication-related side effects, dietary restrictions, and activity restrictions B)Via a brochure that the patient can take with her on discharge C)By briefly explaining the side effects while administering the medication to the patient D)By relating a story about another patient who had a severe adverse reaction to this medication

A patient admitted to critical care is found to have an absolute neutrophil count of 1,235 cells/mm3. What is the most important nursing intervention? A)Institute strict isolation to prevent disease transmission from the patient. B)Evaluate the patient for bone marrow transplantation for replacement. C)Institute reverse isolation to prevent disease transmission to the patient. D)Administer hematopoietic growth factor stimulation medications.

A patient being supported with endotracheal intubation and mechanical ventilation is increasingly agitated. What is the most appropriate nursing intervention? A)Administer neuromuscular blockade medication. B)Administer a benzodiazepine. C)Obtain arterial blood gas measurement. D)Ask a family member to stay with the patient.

A patient has an acute upper gastrointestinal hemorrhage secondary to esophageal varices. What is the underlying pathophysiology of this type of gastrointestinal hemorrhage? A)Helicobacter pylori infection of esophagus, stomach, and duodenum B)Prolonged stress from multiple causes C)Portal hypertension from cirrhosis or other liver disease D)Overwhelming infection of jejunum and ileum

A patient has arterial blood gas results of pH 7.2, PaCO2 55 mm Hg, and HCO3 24 mEq/L. How does the nurse interpret these results? A)Metabolic acidosis B)Metabolic alkalosis C)Respiratory acidosis D)Respiratory alkalosis

A patient has been admitted to critical care for management of exacerbation of a chronic illness. During this admission, the patients condition deteriorates and death is deemed imminent. A Do Not Resuscitate (DNR) order has been written and agreed to by the family. Considering the principles of palliative care, what is the most appropriate nursing action? A)Transfer the patient to the step-down unit since DNR patients are not eligible for critical care. B)Encourage the family to reduce their visits so that they will not have to witness the patients deterioration. C)Assess the patient and family for specific spiritual needs at this phase of life and death. D)Discontinue all supportive care to hasten the inevitable death of the patient and reduce costs.

A patient has been brought into the Emergency Department via ambulance with resuscitation efforts being performed. It is unlikely that the patient will survive the severe injuries sustained. Two adult children of the patient are present and are requesting to be with the patient at this time. What is the best response by the nurse? A)I don't think you should see your loved one like this. Wouldn't you rather remember him the way he was? B)Our hospital doesn't allow more than one family member in with a patient. One of you can come in and one of you will have to wait in the waiting area. C)You may come in with your parent and I will have someone stay with you to explain what is happening. D)I have been through this many times and I promise you, it is a sight that you don't want to remember.

A patient has been diagnosed with prerenal acute renal failure. What condition most likely caused this situation? A)Toxic levels of medications B)Poststreptococcal glomerulonephritis C)Severe sepsis and shock D)Benign prostatic hypertrophy

A patient has been diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). What physical symptoms would the nurse expect? A)Tachycardia and hypotension B)History of weight loss C)Edema and hypertension D)Dry skin and mucosa

A patient in intensive care after a severe head injury has developed diabetes insipidus. What nursing assessment is the most important? A)Vital signs B)Cardiac pattern C)Fluid balance D)Level of consciousness

A patient in oliguric renal failure is receiving IV furosemide (Lasix). What nursing assessment has the highest priority? A)Daily weights B)Intake and output C)Serum potassium D)Blood urea nitrogen

A patient in the ICU failed long-term ventilation weaning via CPAP trials. What is the next intervention that should take place? A)The T-piece trial should be performed. B)The patient should be switched to SIMV method. C)The patient should be rested on the ventilator for 24 hours. D)The patient should be switched to the SIMV plus PSV method.

A patient in the ICU is complaining that he is not sleeping well at night because of anxiety. Which of the following would be the most helpful intervention for the nurse to make? A)Provide the patient with a bath immediately following his first 90-minute REM sleep cycle. B)Increase the patients pain medication. C)Provide the patient with 5 minutes of effleurage and then minimize disruptions. D)Monitor the patients brain waves by polysomnography to determine his sleep pattern.

A patient in the ICU is receiving intravenous opioid analgesia following myocardial infarction. Despite receiving continuous infusion of the opioid, the patient is grimacing and asks for an increase in the medication level. Consulting the medical chart, the nurse recognizes that this patient has a history of opioid addiction. What would be the most appropriate intervention? A)Immediately take the patient off of the opioid and give him Tylenol. B)Leave the patient on the opioid at the current dose level. C)Increase the dose of opioid to provide more effective pain relief. D)Reduce the dose of opioid and offer to turn on the television as a distraction from the pain.

A patient is being treated for severe hypovolemic shock. Based on the primary treatment goal, what nursing intervention has the highest priority? A)Frequent measurement of vital signs B)Management of mechanical ventilation C)Rapid intravenous fluid administration D)Insertion of urinary drainage catheter

A patient is concerned about her steadily worsening chronic kidney disease and asks the nurse at what point she will require dialysis or renal transplantation. Which of the following should the nurse mention? A)When your urine albumin-to-creatinine ratio is greater than 25 mg/g B)When your urine output is less than 0.5 mL/kg/h 6 h C)When your glomerular filtration rate (GFR) falls below 15 mL/min/1.73 m2 D)When your urine osmolality is greater than 500 mOsm/kg H2O

A patient is in shock and is exhibiting low blood pressure, low systemic vascular resistance (SVR), peripheral edema, pulmonary wheezing, tachycardia, and nausea and vomiting. What precipitating event does the nurse expect for this group of symptoms? A)Acute myocardial infarction B)Bacterial infectious illness C)Recent seafood meal D)Massive fluid loss

A patient recently admitted to the ICU for head trauma has a Glasgow Coma Scale score of 4 and a hematoma apparent on CT scan of the head. This patient has multiple fractures in her skull and an intracranial pressure (ICP) of 30 mm Hg. Which ICP monitoring device would be contraindicated for this patient? A)Intraventricular B)Intraparenchymal C)Lumbar/subarachnoid D)Subdural

A patient was resuscitated from a cardiopulmonary arrest and is now being managed with mechanical ventilation, an intravenous amiodarone drip, an angiotensin-converting enzyme (ACE) inhibitor, and a beta-adrenergic antagonist. The patient has severe tachycardia, tachypnea, diaphoresis, temperature above 104F, frequent premature ventricular contractions, clear lung fields, normal oxygen status, and agitation and restlessness. What complication and cause does the nurse suspect? A)Septic shock from ventilator-acquired pneumonia B)Hypovolemia from cardiopulmonary arrest C)Thyrotoxic crisis from amiodarone use D)Adverse reaction to ACE inhibitor

A patient with a brain injury is undergoing intracranial pressure (ICP) monitoring and cerebrospinal fluid (CSF) drainage, along with mannitol therapy, to relieve ICP. What other intervention can the nurse make to aid in relieving this patients ICP? A)Extend and rotate the patients head. B)Flex the patients hips to greater than 90 degrees. C)Elevate the head of the patients bed to 20 degrees. D)Perform frequent blood draws.

A patient with a head injury is being monitored with an intracranial pressure monitor. What nursing assessment best indicates intracranial hypertension? A)Intracranial pressure 8 mm Hg B)Glasgow Coma Scale score 3 C)Intracranial pressure 25 mm Hg D)Glasgow Coma Scale score 15

A patient with acute kidney injury (AKI) demonstrates blue mottling of the skin in her fingers. What other finding would tend to indicate that the cause of this condition is intrarenal? A)Distended bladder B)Edema C)Strep throat infection D)Kinked Foley cathete

A patient with acute respiratory distress syndrome (ARDS) requires mechanical ventilation but is at risk for barotrauma due to decreased lung compliance. Which mode of ventilation should the nurse use with this patient? A)Pressure support ventilation mode B)Synchronized intermittent mandatory ventilation mode C)Pressure-controlled ventilation mode D)Assist-control mode

A patient with an acute myocardial infarction has been started on daily enalapril (Vasotec), an ACE inhibitor, to preserve ejection fraction. What is the most important nursing assessment before giving this medication? A)Intake and output B)Daily weight C)Blood pressure D)Pulse oximetry

A patient with chronic renal disease has mild metabolic acidosis with a pH 7.30 and bicarbonate level 16 mEq/L. What treatment does the nurse anticipate? A)IV sodium bicarbonate B)Reduction of respiratory rate C)Sodium citrate and citric acid (Bicitra) D)Massive IV fluids

A patient with hyperthyroidism is being treated with propylthiouracil and potassium iodide. When giving these medications, what precaution should the nurse take? A)Check apical pulse before administration. B)Check serum potassium before administration. C)Administer medications at least 1 hour apart. D)Give medications intravenously.

According to national standards, pain in critically ill patients should be assessed at regular intervals using a variety of methods. What statement about pain assessment is true? A)Absence of physical signs or behaviors is equivalent to absence of pain. B)Many of the factors in critical care combine to invalidate patient self-report of pain. C)Behavioral observation and physiological parameters should be considered along with the patients report. D)The family has a more accurate assessment of pain than the patient.

An elderly patient with several comorbidities has experienced a massive upper GI hemorrhage from esophageal varices. No treatment has been initiated yet. What signs and symptoms does the nurse expect? A)Tachycardia and hypotension B)Alert and oriented times 3 C)Mild anemia without hypoxemia D)Normal peripheral circulation

As part of a major trauma, a patient has suffered a flail chest injury. What hallmark sign of flail chest does the nurse expect to find? A)Flail segment elevation during inhalation B)Evidence of rib fractures on chest radiograph C)Flail segment depression during inhalation D)Hypoxemia evident on arterial blood gases

During a motor vehicle accident, a patient sustained blunt trauma to the head and face, resulting in hairline skull fracture and a LeFort III maxillofacial fracture. The patient also has bruising across the chest and upper abdomen and multiple small superficial bleeding abrasions and lacerations. On admission to the emergency department, what is the nursing care priority? A)Apply direct pressure to bleeding areas. B)Assess neurologic status. C)Perform endotracheal intubation. D)Administer tetanus booster immunization.

In a patient with acute pancreatitis, what elevation in laboratory study results would the nurse expect? A)Serum potassium and calcium B)Arterial ionized calcium C)Serum amylase and lipase D)Arterial partial pressure of oxygen

In developing the discharge plan for a patient who was treated in the hospital for anaphylactic shock related to a nonsteroidal anti-inflammatory (NSAID) allergy, what would be the most important information for the nurse to include? A)Adhere to dietary restrictions. B)Follow up in one month with the physician. C)Check labels of over-the-counter medications prior to taking. D)Have blood pressure checked on a regular basis.

On initial admission of a trauma victim to the emergency department, the nurse completes a primary survey. The patient is awake and tachypneic, is using accessory muscles of respiration, has unequal chest expansion, and is very anxious. There are absent breath sounds on the right and cyanosis on 100% oxygen, and the trachea is deviated to the left. What action takes the highest priority during the primary survey? A)Jaw thrust maneuver B)Suctioning the oral pharynx C)Chest tube insertion D)Assisting ventilation with bag-mask device

One of the strategies shown to reduce perception of stress in critically ill patients and their families is support of spirituality. What nursing action is most clearly supportive of the patients spirituality? A)Referring patients to the Catholic chaplain B)Providing prayer booklets to patients and families C)Asking about beliefs about the universe D)Avoiding discussing religion with those of other faiths

The nurse in the ICU is assigned to care for a patient with septic shock. What nursing interventions are necessary to prevent malnutrition and optimize cellular function in this patient? A)Administration of crystalloid solutions IV B)High calorie, low protein diet C)Enteral feedings D)Administration of multivitamins in the IV fluid

The nurse is assessing learning by a critically ill patient and family. What is the best method of assessment? A)Written test B)Specific questions C)Open-ended questions D)Literacy assessment

The nurse is assigned to a patient in the Emergency Department who exhibits paradoxical chest movement. What intervention by the nurse can help improve oxygenation in this patient? A)Elevate the head of the bed 30 degrees. B)Splint the chest with 3-inch surgical tape. C)Turn the patient with the injured side down. D)Place the patient in the prone position.

The nurse is assigned to a patient in the ICU who is on a ventilator for exacerbation of chronic obstructive pulmonary disease. What intervention by the nurse can prevent the development of multiple organ dysfunction syndrome? A)Suctioning the patient every 2 hours B)Enteral feedings C)Oral care every 2 hours D)Administration of total parenteral nutrition

The nurse is caring for a patient with deep vein thrombosis of the left lower extremity. The patient exhibits a decrease in pulse oximetry readings from 98% to 86%, shortness of breath with a respiratory rate of 34, and is now disoriented to place. The nurse recognizes that these findings are caused by what complication? A)Pulmonary edema B)Cardiac tamponade C)Pulmonary embolus D)Tension pneumothorax

The nurse is interpreting a patients complete blood count. What does the CBC give an overall indication of? A)Coagulation cascade B)Cardiac output and index C)Bone marrow health D)Overall immune status

The nurse is teaching a group of patients newly diagnosed with cardiovascular disease. What action demonstrates application of the adult learning principle of learners life experience? A)Beginning with an explanation of why the material is important B)Creating a learning situation that is self-directed and independent C)Using case scenarios and problem-solving exercises D)Applying content to real-life situations and actions

The nurse is teaching a patient and family in the patients critical care room. The critical care unit is busy and noisy. What nursing action will best enhance learning? A)Explain the material simply using simple terms. B)Give all explanations via commercial teaching brochures. C)Close the door to the patients room. D)Ask the family not to interrupt with questions.

The nurse is using presence to reduce the anxiety of a critically ill patient. What nursing behavior demonstrates an effective use of presence? A)Staying in the patients room to complete documentation B)Having a conversation in the patients room that excludes the patient C)Maintaining eye contact with the patient during explanations D)Focusing on specific nursing care tasks while in the patients room

The nurse wishes to enhance sleep cycles in her critically ill patient. Research has shown that which nursing action improves sleep in critically ill patients? A)Repositioning every 2 hours B)Hypnotic medications C)Five-minute back effleurage D)Adequate pain control

The patient has a newly inserted VVI pacemaker set at a demand rate of 70. What cardiac monitor reading, if found by the nurse, most indicates a pacemaker malfunction? A)Patient pulse is 75 with no pacing stimuli seen on cardiac monitor. B)Patient pulse is 70 with pacing stimulus seen before each R wave. C)Patient pulse is 65 with no pacing stimuli seen on cardiac monitor. D)Patient pulse is irregular with pacing stimuli seen before some R waves.

The patient has an intracranial pressure monitor. After the patient returns from a computed tomography (CT) scan of the head, the nurse notices that the patients intracranial pressure is significantly lower than before the scan. What nursing action is most likely to identify a cause of this change? A)Take vital signs. B)Flush monitor tubing toward patient. C)Relevel the transducer. D)Drain cerebrospinal fluid.

The patient has an upper gastrointestinal hemorrhage. What pathological basis does the nurse least expect? A)Peptic ulcer disease B)Helicobacter pylori infection C)Infectious colitis D)Esophageal varices

The patient has consolidation of his right lateral lower lung segments and is receiving chest physiotherapy. What position is best for draining this portion of the lung? A)Semi-Fowlers B)Supine C)Left side-lying D)Right side-lying

The patient has had a stroke or brain attack, believed to be ischemic in nature. The causes of an ischemic stroke are least likely to include which of the following? A)Thrombus of a cerebral artery B)Embolus of a cerebral artery C)Ruptured cerebral aneurysm D)Cerebrovascular obstruction

The patient has received a gunshot wound. To help predict the amount of damage, what information does the nurse collect? A)Location of the shooting B)Information about the shooter C)Type of weapon and caliber of bullet D)Whether the injury involved a felony

The patient is being supported by mechanical ventilation and is not maintaining adequate oxygenation on current settings. Positive end-expiratory pressure (PEEP) has just been increased from 10 to 12 cm H2O. What nursing assessment finding best indicates that the patient is not tolerating this change? A)Increased cardiac output B)Increased blood pressure C)Significant hypotension D)Increased pulmonary compliance

The patient is receiving a positive inotropic drug by intravenous drip. If this therapy is effective, what physical change would the nurse most expect to find? A)New-onset extra heart sound S3 B)Increasing peripheral edema C)Increased urine output per hour D)Basilar pulmonary crackles

The patient is receiving supplemental oxygen therapy. What finding most clearly demonstrates achievement of one of the goals of oxygen therapy? A)Therapy is discontinued after 3 days. B)Increased respiratory rate and depth C)Verbalization of relief of dyspnea D)Reduction of arterial carbon dioxide pressure

The patient is scheduled for a painful procedure. In addition to premedicating the patient with an opioid drug, what other nursing action is most likely to alleviate the pain? A)Give intravenous midazolam (Versed). B)Monitor vital signs during the procedure. C)Give explanations before and during the procedure. D)Ask the family to wait outside during the procedure.

The patient is to undergo chest tube placement. What is the best nursing intervention to prevent a complication of this procedure? A)Facilitate chest tube removal on day 3. B)Use the supine position during chest tube removal. C)Premedicate with an intravenous opioid. D)Keep drainage tubing off the bed.

The patient is undergoing a necessary but painful procedure that is greatly increasing her anxiety. The nurse decides to use guided imagery to help alleviate the patients anxiety. What is a key part of this technique? A)Provide the patient with an external focus point such as a picture. B)Have the patient take slow, shallow breaths while staring at a focus point. C)Have the patient remember tactile sensations of a pleasant experience. D)Encourage the patient to consciously relax all of her muscles.

What laboratory value is most likely to indicate renal failure? A)Elevated blood urea nitrogen (BUN) B)Low hemoglobin and hematocrit C)Elevated serum creatinine D)Normal urine osmolarity

When teaching a patient and family, the nurse wishes to use the affective domain of learning. What nursing action is most likely to involve the affective domain? A)Presenting facts from simple to complex B)Giving clear directions about when to call the physician C)Using a nonthreatening approach D)Using demonstration/redemonstration approach

A patient in the ICU with severe head trauma remains stable for the first 24 hours after admission, with no indication of intracranial hypertension. Suddenly, however, the patient begins showing signs of Cushings triad. The nurse recognizes that this occurrence indicates that the patients compensatory mechanisms have become exhausted. What physiological change occurs as part of this exhaustion of compensatory mechanisms? Select all that apply. A)Decrease in volume of contents of the intracranial compartment B)Decrease in intracranial pressure C)Decrease in cerebral perfusion D)Decrease in compliance within the intracranial compartment

C,D

A Muslim woman is admitted to the ICU after suffering severe burns over most of her body. Which of the following would be the most appropriate measure for the nurse, a woman, to take in respect for the cultural practices of this patient? A)Insist that only a female doctor be assigned to this patient. B)Ensure that no pork products are included in the patients diet. C)Ensure that direct eye contact is not made with the patients husband. D)Ask the patients husband what religious and cultural preferences should be considered in the patients care.

A critically ill patient has arterial blood gas results of pH 7.35, PaCO2 55 mm Hg, and HCO3 28 mEq/L. How does the nurse interpret these results? A)Respiratory acidosis B)Metabolic alkalosis C)Partially compensated metabolic alkalosis D)Fully compensated respiratory acidosis

A critically ill patient who is intubated and agitated is restrained with soft wrist restraints. Based on research findings, what is the best nursing action? A)Maintain the restraints to protect patient safety. B)Remove the restraints periodically to check skin integrity. C)Remove the restraints periodically for range of motion. D)Assess and intervene for causes of agitation.

A patient develops toxic acute tubular necrosis (ATN) as a result of exposure to a radiocontrast dye. Which of the following should the nurse most expect to observe in this patient as this condition progresses beyond the onset phase? A)Normal potassium levels B)Duration of 7 to 14 days C)Normal urine concentrating function D)Normal urine volume

A patient has a large burn injury that occurred in an enclosed space. On initial assessment, the patient is found to have erythema and blistering of the mouth and pharynx, hoarse speech, and tachypnea. What immediate therapy addressing these symptoms does the nurse anticipate? A)Intravenous fluid resuscitation B)Prophylactic antimicrobial therapy C)Application of topical burn medications D)Endotracheal intubation

A patient has arterial blood gas testing performed. Her PaO2 is 95 mm Hg, SaO2 is 90%, pH is 7.4, and HCO3 is 23 mEq/L. Which of these values should the nurse be most concerned about? A)PaO2 B)HCO3 C)pH D)SaO2

A patient has been admitted to the critical care unit in myxedema coma. What patient description does the nurse most expect? A)Young man with abdominal trauma B)Middle-aged man with skeletal trauma C)Middle-aged woman in summer D)Elderly woman during winter

A patient has been diagnosed with Graves disease. What physical symptoms would the nurse most expect to find? A)Bradycardia B)Diminished bowel sounds C)Alert and oriented times 3 D)Exophthalmos

A patient has been diagnosed with septic shock and is receiving intravenous fluid resuscitation along with other therapies. What nursing assessment best indicates improvement in tissue perfusion? A)Mean arterial pressure 65 to 70 mm Hg B)SvO2 80% to 90% C)Skin warm and dry D)Arterial bicarbonate ion 22 to 24 mEq/L

A patient has been found to have expressive, or nonfluent, dysphasia following a stroke and is having difficulty communicating with his family. What would be the appropriate nursing intervention for this patient? A)Explain to the family that the patient is intellectually impaired. B)Explain to the family that the patient is unable to understand the meaning of spoken language. C)Refer the patient to a rehabilitation specialist. D)Give the patient a note pad so that he can write responses to questions posed to him.

A patient has experienced a cardiopulmonary arrest and is receiving cardiopulmonary resuscitation. As the nurse evaluates the effectiveness of this therapy, what value on arterial blood gases is most indicative of hypoventilation? A)Diminished PaO2 B)Diminished SaO2 C)Elevated HCO3 D)Elevated PaCO2

A patient has recently arrived in the ICU following cardiac arterial bypass graft surgery and has not yet emerged from anesthesia. He requires full ventilatory support. Which ventilation mode should the nurse use for this patient? A)Pressure support ventilation mode B)Synchronized intermittent mandatory ventilation mode C)Pressure-controlled ventilation mode D)Assist-control mode

A patient has suffered severe blunt trauma to the abdomen with bruising, diffuse pain, guarding, and rigidity evident. Damage to which structure is most likely? A)Stomach B)Bladder C)Large intestine D)Liver

A patient in severe congestive heart failure is at risk for the development of acute respiratory failure and is receiving supplemental oxygen therapy. What nursing assessment parameter is most indicative of acute respiratory failure? A)Dependent pitting edema that is worsening B)New onset of systolic gallop C)Conversion to atrial fibrillation D)Arterial PaO2 45 mm Hg

A patient in shock has developed systemic inflammatory response syndrome (SIRS). What is the most likely type of shock resulting in SIRS? A)Hypovolemic B)Septic C)Cardiogenic D)Any shock

A patient is complaining of extreme thirst and is drinking water constantly. He also excretes large volumes of dilute-appearing urine and is being evaluated for psychogenic water drinking versus central diabetes insipidus. If the patient has diabetes insipidus, what pattern of laboratory results would the nurse expect? A)High urine osmolality, low serum osmolality, and high urine specific gravity B)High urine osmolality, normal serum osmolality, and high urine specific gravity C)Low urine osmolality, normal serum osmolality, and low urine specific gravity D)Low urine osmolality, high serum osmolality, and low urine specific gravity

A patient on mechanical ventilation is experiencing severe agitation due to being on the ventilator. Which nursing intervention would be best? A)Performing breathing exercises with the patient B)Offering the patient a patient-controlled analgesic device C)Asking the physician to prescribe an antianxiety medication D)Offering the patient the patients own MP3 player to listen to

A patient with a head injury has developed central diabetes insipidus. What elevated laboratory test result would the nurse expect? A)Serum antidiuretic hormone (ADH) B)Urine osmolality C)Urine sodium level D)Serum osmolality

A patient with esophageal variceal bleeding unresponsive to endoscopic therapy is receiving a balloon tamponade tube. Which of the following is an appropriate nursing intervention related to this procedure? A)Warm the tube before the physician inserts it. B)Lower the head of the bed so that the patients feet are above his heart. C)Encourage the patient to cough. D)Clean and lubricate the patients nostrils.

A patient with prerenal acute kidney injury is oliguric. The nurse is administering an IV bolus to the patient. What should be of primary concern to the nurse while performing this task? A)Restricting the patients protein intake B)Monitoring the patients potassium level C)Evaluating the patient for signs of nephrotoxicity D)Preventing fluid overload

A young couple whose 5-year-old daughter has been admitted to the ICU approaches the nurse with looks of concern on their faces. They express frustration to the nurse that they have not been able to speak with either the physician or the surgeon and are confused as to what the next steps are for their daughters treatment. What would be the best intervention for the nurse to make in this situation? A)Offer to get ice chips for the couple to give to their daughter to empower them . B)Make sure that they have the cell phone numbers of the physician and surgeon. C)Teach the couple about the pathophysiology of the daughters disease. D)Arrange a patient care conference with the couple and the health care team.

In a motor vehicle crash, a patient suffers a skull fracture, possible cervical spine injury, multiple extremity fractures, and a large thermal burn. On initial admission to the emergency department, what is the nursing priority of care? A)Intravenous fluid resuscitation B)Protection from infection C)Assessment of extent of burns D)Protection of airway and cervical spine

In attempting to teach a patient how to clean around the surgical sutures on his abdomen upon discharge to home, the nurse determines that applying the principle of the learners self-concept would be most effective with this patient. Which of the following is the best example of an application of that principle in this situation? A)Relating to the patient a story about another patient who failed to properly clean his sutures and the outcome B)Explaining that failure to properly clean around the suture site could result in serious infection C)Commenting that learning to properly clean his suture site could give the man skills that would better prepare him for a career in health care D)Mentioning to the patient that, if he would prefer, he can watch a video on the hospitals website on how to clean around a suture site

Increased levels of ADH, low serum osmolarity, and increased urine osmolarity are a sign of which of the following? A)Dehydration B)Diabetes mellitus (DM) C)Diabetes insipidus (DI) D)Syndrome of inappropriate ADH secretion (SIADH)

Intravenous vasopressin (Pitressin) has been ordered for a patient with recurrent esophageal varices causing upper gastrointestinal hemorrhage. What is the purpose of this therapy? A)Increases systemic blood pressure in shock B)Increases myocardial oxygen use and demand C)Reduces blood flow to the mesenteric circulation D)Causes constriction of the splanchnic arteries

Seven days after a traumatic head injury, a patient has elevated intracranial pressure that is refractory to sedation, paralysis, cerebrospinal fluid drainage, and osmotic diuretics. The patients arterial blood gas results are pH 7.45, PaCO2 33, and bicarbonate ion 18. What is the best nursing decision? A)Reduce respiratory rate B)Administer intravenous bicarbonate C)Increase intravenous sedation D)Continue with current plan of care

The critical care unit environment is very stressful for patients, families, and staff. What nursing action is directed at reducing environmental stress? A)Constant evaluation of patient status B)Limiting visits to immediate family C)Bathing all patients during hours of sleep D)Maintaining quiet during hours of sleep

The nurse is administering an intravenous opioid to manage a patients pain. What criteria can the nurse use to determine the adequacy of therapy? A)Minute ventilation is somewhat compromised. B)Patient rates pain below 5 on scale of 1 to 10. C)Minute ventilation is minimally compromised. D)Patient rates pain below own predetermined goal.

The nurse is assigned to care for a patient who was admitted 2 days previous after a four-wheeler accident. The patient sustained a closed fracture to the left femur and had an open reduction with internal fixation the same day. What is a priority for the nurse to assess for this patient? A)White blood count B)Urinary output C)Cardiac output D)Pulse oximetry

The nurse is teaching a patient newly diagnosed with diabetes mellitus how to manage a sliding-scale insulin protocol. What portion of this interaction indicates patient learning? A)The sliding scale insulin protocol B)Patients questions to the nurse C)Nurses demonstration of use of the protocol D)Patients verbalization of a flash of insight

The nurse is teaching a patient who is not a native English speaker. As the nurse gives complex explanations, the patient nods and smiles. What is the best nursing intervention to ensure patient understanding? A)Assume that the patients nods indicate understanding. B)Ask a family member to interpret to the patient. C)Use pictures whenever possible in the teaching. D)Ask the patient to restate the information conveyed.

The nurse is teaching a patient with chronic renal failure and diabetes mellitus about nutrition. What should be included? A)Calorie restriction based on ideal body weight is necessary. B)Sodium and potassium should be supplemented while on dialysis. C)Renal diet restrictions take the place of those for diabetes mellitus. D)Moderate protein restriction is recommended while otherwise healthy.

The patient has been diagnosed with hyperthyroidism. What laboratory result would the nurse least expect to be elevated? A)Total thyroxine (T4) B)Free triiodothyronine (T3) C)Free thyroxine (T4) D)Thyroid stimulating hormone (TSH)

The patient has been diagnosed with shock secondary to an antigen antibody reaction. What collaborative intravenous intervention has the highest priority? A)Dobutamine B)Red blood cells C)Antimicrobials D)Epinephrine

The patient has experienced a significant drop in hemoglobin levels and is slightly tachycardic. The pulse oximetry value is 100% and arterial blood gas values are normal. What is the most important adverse physiologic effect that the nurse would expect? A)Polycythemia B)Diminished blood pressure C)Hyperalertness and hyperreflexia D)Diminished tissue oxygenation

The patient has severe pulmonary edema following an acute myocardial infarction and is receiving intravenous diuretics to ease breathing. The nurse understands that this intervention is considered to be what? A)Definitive B)Curative C)Cause-and-effectbased D)Palliative

The patient is in decompensated cardiogenic shock. What collaborative intervention best addresses the central cause of cardiogenic shock? A)Mechanical ventilation B)Hemodynamic monitoring C)Pharmacologic sedation D)Intravenous nitrate infusion

What would the nurse identify as the primary purpose for the administration of intravenous (IV) crystalloid fluids in the patient with hypovolemic shock? A)Decrease myocardial oxygen demand. B)Maximize oxygen-carrying capability. C)Increase capillary permeability. D)Restore circulating volume.

When caring for an HIV-positive patient, what isolation technique should the nurse implement? A)Droplet B)Aerosol C)Contact D)Standard

When describing a patients responsiveness, the nurse uses the term obtunded. What is the most accurate meaning of this term? A)Unable to arouse with any stimulus B)Sedated with intravenous medications C)Having inborn mental retardation D)Arousable but drowsy and slow to respond

While assessing motor function, the nurse applies pressure to a toenail. What patient response is most normal? A)Extension of both feet B)Flexion of knee and ankle C)Extension of one or both arms D)Kicking the nurses hand away

While shopping, a nurses friend experiences sudden unilateral weakness and slurred speech. What is the most important nursing intervention? A)Activate the emergency response system. B)Observe for return of neurologic stability. C)Notify close family members of the victim. D)Stabilize airway and cervical spine.

A young man is recovering from anaphylactic shock caused by a bee sting. The nurse is trying to instruct the patient on how to use an epinephrine autoinjector (EpiPen), but the patient seems uninterested in learning. The nurse then explains how having the EpiPen with him at all times and knowing how to use it could not only save his life someday but also will give him a greater sense of security and safety. Which adult learning principle is the nurse using? Select all that apply. A)The learners self-concept B)The learners life experience C)Readiness to learn D)Motivation to learn E)The need to know

Final 240

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