Final Complex
The physician has ordered Dopamine to be administered @ a rate of 5 mcg/kg/min. The patient weighs 145 pounds and the drug is sent to the unit as Dopamine 400 mg in 250 mL D5W. The nurse will set the infusion pump @ Answer
12
A patient has been admitted to the ICU for alcohol withdrawl and is ordered lorazepam 10 mg/hr. The pharmacy has sent lorazepam 120 mg in 600 mL of D5W. The nurse will infuse the medication on the infusion pump @ the rate of Answer
50
The patient has hypokalemia and is to receive an IV infusion of potassium chloride. The physician orders the KCl to infuse at a rate of 2 mEq/hr. The pharmacy sends KCL 40mEq/L in D5W. The nurse will set the infusion pump @ Answer
50
The physician has ordered nitroglycerin for a patient with chest pain at a rate of 10 mcg/min. The pharmacy provides Nitroglycerin 25 mg in 250 mL of D5W. The nurse will set the infusion pump @ a rate of Answer
6
A clinician is providing education to a patient with a recent diagnosis of a transient ischemic attack (TIA). Which of the statements by the patient indicates that the patient understands the information? Select one: a. "It is important for you to seek medical attention immediately if you experience these symptoms again because they could mean that you are having a stroke." b. "Transient ischemic attacks (TIAs) are often caused by small bleeds in the brain that resolve on their own." c. "Because TIAs don't cause permanent damage, I do not need to worry if I have another one." d. "TIAs are usually caused by large bleeds in the brain that resolve on their own."
a. "It is important for you to seek medical attention immediately if you experience these symptoms again because they could mean that you are having a stroke."
The nurse is caring for a burn-injured patient who weighs 154 pounds, and the burn injury covers 40% of his body surface area. The nurse calculates the fluid needs for the first 24 hours after a burn injury using a standard fluid resuscitation formula of 4 mL/kg/% burn of intravenous (IV) fluid for the first 24 hours. The nurse plans to administer what amount of fluid in the first 24 hours? Select one: a. 11200 ml b. 2800 ml c. 14000 ml d. 7000 ml
a. 11200 ml
Patients who are not able to meet their nutritional needs orally should be started on enteral nutrition within what time frame? Select one: a. 24-48 hours b. 5 days c. 6-12 hours d. 12-24 hours
a. 24-48 hours
A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg. The blood pressure is 144/90 mm Hg, and mean arterial pressure (MAP) is 90 mm Hg. What is the cerebral perfusion pressure (CPP)? Select one: a. 72 mm Hg b. 90 mm Hg c. 54 mm Hg d. 126 mm Hg
a. 72 mm Hg
Which of the following patients is at the highest risk for hyperosmolar hyperglycemic syndrome? Select one: a. An 18-year-old college student with type 2 diabetes who was diagnosed with the flu b. A 45-year-old woman with type 1 diabetes who forgets to take her insulin in the morning c. A 75-year-old man with type 2 diabetes and coronary artery disease who has recently started on insulin injections d. An 83-year-old, long-term care resident with type 1 diabetes and new onset Alzheimer's disease.
a. An 18-year-old college student with type 2 diabetes who was diagnosed with the flu
The nurse is caring for a patient with an arterial monitoring system. The nurse asses the patient's noninvasive cuff blood pressure to be 70/40 mm Hg. The arterial blood pressure measurement via an intra-arterial catheter in the same arm is assessed by the nurse to be 108/70 mm Hg. What is the best action by the nurse? Select one: a. Assess the cuff for proper arm size b. Place the patient in Trendelenburg position c. Administer 0.9% normal saline bolus d. Activate the rapid response system
a. Assess the cuff for proper arm size
A community-based external disaster is initiated after a tornado moved through the city. A nurse from the medical records review department arrives at the emergency department asking how to assist. The best response by a nurse working for the trauma center would be to Select one: a. Assign the nurse administrative duties, such as obtaining patient demographic information. b. Have the nurse assist with transport of patients to procedural areas. c. Assign the nurse to a triage room with another nurse from the emergency department. d. Thank the nurse but inform her to return to her department as her skill set is not a good match for patients' needs.
a. Assign the nurse administrative duties, such as obtaining patient demographic information.
The nurse notes that the patient's neutrophil count is less than 500 cells/microliter. The nurse realizes that this patient is: Select one: a. At severe risk for infection b. At low risk for infection c. At moderate risk for infection d. At mild risk for infection
a. At severe risk for infection
The nurse is caring for patient who has been struck by lightning. Because of the nature of the injury, the nurse assesses the patient for which of the following? Select one: a. Central nervous system deficits b. Infection c. Contractures d. Stress ulcers
a. Central nervous system deficits
The nurse is caring for a patient who underwent pituitary surgery 12 hours ago. The nurse will give priority to monitoring the patient carefully for which of the following? Select one: a. Diabetes Insipidus b. Infection c. Congestive heart failure d. Volume overload
a. Diabetes Insipidus
When fluid is present in the alveoli: Select one: a. Diffusion of oxygen and carbon dioxide is impaired b. Alveoli collapse and atelectasis occurs c. Hypoventilation occurs d. The patient is in heart failure
a. Diffusion of oxygen and carbon dioxide is impaired
Which of the following statements about mass casualty triage during a disaster is true? Select one: a. Disaster victims with the greatest chances for survival receive priority for treatment. b. Once interventions have been initiated, health care providers cannot stop the treatment of disaster victims. c. Priority treatments and interventions focus primarily on young victims. d. Color-coded systems in which green indicates the patient of greatest need are used during disasters.
a. Disaster victims with the greatest chances for survival receive priority for treatment.
The nurse is caring for a mechanically ventilated patient following insertion of a left subclavian central venous catheter (CVC). Which action by the nurse best protects against the development of a central line- associated bloodstream infection (CLABSI)? Select one: a. Documentation of insertion date b. Appropriate sedation management c. Assessment of weaning readiness d. Elevation of the head of the bed
a. Documentation of insertion date
The nurse is assessing a patient being admitted with fatigue and shortness of breath as well as abdominal tenderness. The nurse notes that the patient is jaundiced; the physical examination reports an enlarged liver. The nurse suspects that the patient has: Select one: a. Hemolytic anemia b. Sickle cell anemia c. Aplastic anemia d. Anemia due to acute blood loss
a. Hemolytic anemia
The nurse is assessing a patient. Which assessment would cue the nurse to the potential of acute respiratory distress syndrome (ARDS)? Select one: a. Increased peak inspiratory pressure on the ventilator b. Normal chest radiograph with enlarged cardiac structures c. Increased oxygen saturation via pulse oximetry d. PaO2/FiO2 ratio > 300PaO2/FiO2 ratio > 300
a. Increased peak inspiratory pressure on the ventilator
Tissue damage from burn injury activates an inflammatory response that increases the patient's risk for Select one: a. Infection b. Acute respiratory distress syndrome. c. Acute kidney injury. d. Stress ulcers
a. Infection
Which of the following interventions would not be appropriate for a patient who is admitted with a suspected basilar skull fracture? Select one: a. Insertion of a nasotracheal tube b. Insertion of an indwelling urinary catheter c. Endotracheal intubation d. Placement of an oral airway
a. Insertion of a nasotracheal tube
The emergency department nurse admits a patient following a motor vehicle collision. Vital signs include blood pressure 70/50 mm Hg, heart rate 140bpm, respiratory rate 36 breaths/min, temperature 101 degrees F, and oxygen saturation (SpO2) 95% on 3L of oxygen per nasal cannula. Laboratory results include hemoglobin 6.0 g/dL, hematocrit 20% and potassium 4.0mEq/L. Based on this assessment, what is most important for the nurse to include in the patient's plan of care? Select one: a. Insertion of an 18 gauge peripheral intravenous line b. Implementation of universal precautions c. Implementation of fall precautions d. Application of cushioned heel protectors
a. Insertion of an 18 gauge peripheral intravenous line
Which intervention is most important in assessing fluid balance in the patient with AKI? Select one: a. Intake and Output b. Daily weight c. estimated gfr d. Serum creatinine
a. Intake and Output
A patient with a 60% burn in the acute phase of treatment develops a tense abdomen, decreasing urine output, hypercapnia, and hypoxemia. Based on this assessment, the nurse anticipates interventions to evaluate and treat the patient for Select one: a. Intra-abdominal hypertension. b. Acute respiratory distress syndrome. c. Acute kidney injury. d. Disseminated intravascular coagulation disorder.
a. Intra-abdominal hypertension.
A 24-year-old unrestrained driver who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. The primary survey of this patient upon arrival to the ED Select one: a. Is done quickly in the first few minutes to get a baseline assessment and establish priorities. b. Is a methodical head-to-toe assessment identifying injuries and treatment priorities. c. Involves turning the patient from side to side to get a look at his back. d. Includes a cervical spine x-ray study to determine the presence of a fracture.
a. Is done quickly in the first few minutes to get a baseline assessment and establish priorities.
A patient presents to the emergency department in acute respiratory failure secondary to community-acquired pneumonia. The patient has a history of chronic obstructive pulmonary disease. The nurse anticipates which treatment to facilitate ventilation? Select one: a. Noninvasive positive-pressure ventilation (NPPV) b. Oxygen at 100% via bag-valve-mask device c. Emergency tracheostomy and mechanical ventilation d. Mechanical ventilation via an endotracheal tube
a. Noninvasive positive-pressure ventilation (NPPV)
A mode of pressure-targeted ventilation that provides positive pressure to decrease the workload of spontaneous breathing through the endotracheal tube is Select one: a. Pressure support ventilation b. Positive end-expiratory pressure c. T-piece adapter d. Continuous positive airway pressure
a. Pressure support ventilation
An autograft is used to optimally treat a partial- or full-thickness wound that Select all that apply Select one or more: a. Requires less than 2 weeks for healing. b. Involves the face, hands, or feet. c. Is infected. d. Involves a joint.
a. Requires less than 2 weeks for healing. b. Involves the face, hands, or feet. d. Involves a joint.
The charge nurse assigns patients based on their acuity and the level of experience of the critical care nurses on duty. This is an example of implementation of: Select one: a. Synergy model b. National patient safety goals c. Healthy work environment d. SBAR communication
a. Synergy model
The nurse is caring for a patient who has a diminished level of consciousness and who is mechanically ventilated. While performing endotracheal suctioning, the patient's hands clench and pull into the chest. What is the best interpretation by the nurse? Select one: a. The patient is exhibiting decorticate posturing. b. The patient is exhibiting flexion posturing. c. The patient is exhibiting extension posturing. d. The patient is exhibiting purposeful movement.
a. The patient is exhibiting decorticate posturing.
Which of the following laboratory values would be found in a patient with syndrome of inappropriate secretion of antidiuretic hormone? Select one: a. Urinary sodium 22 mEq/L b. Fasting blood glucose 156 mg/dL c. Serum sodium 152 mEq/L d. Serum potassium 5.8 mEq/L
a. Urinary sodium 22 mEq/L
The nurse assesses that there is significant disagreement among family members about what course of treatment is best for the patient. What would be the best response by the nurse? Select one: a. "Perhaps you should consult with your pastor or priest." b. "Could we hold a family conference so that we can develop the best plan of care for your loved one?" c. d. " Which one of you is the patient's surrogate to make the decision?" e. "You need to come to a decision quickly and let us know what you want."
b. "Could we hold a family conference so that we can develop the best plan of care for your loved one?"
The healthcare provider is teaching a patient who has been newly diagnosed with second-degree AV block Mobitz type I. The healthcare provider determines teaching has been successful when the patient makes which of the following statements? Select one: a. "Each day I will eat foods that are high in vitamin K" b. "I will take my pulse each day before taking my beta blocker medication" c. "If I have symptoms, I will feel tired or I might have chest pain" d. "I will need to learn to use oxygen therapy at home"
b. "I will take my pulse each day before taking my beta blocker medication"
The nurse is planning care to meet the patient's pain management needs related to burn treatment. The patient is alert, oriented, and follows commands. The pain is worse during the day, when various treatments are scheduled. Which statement to the provider best indicates the nurse's knowledge of pain management for this patient? Select one: a. "The patient's pain is often unrelieved. I suggest that we also add benzodiazepines to the opioids around the clock." b. "The patient's pain varies depending on the treatment given. Can we try patient-controlled analgesia to see if that helps the patient better?" c. "The patient's pain is often unrelieved. It would be best if we can schedule the opioids around the clock." d. "Can we ask the music therapist to come by each morning to see if that will help the patient's pain?"
b. "The patient's pain varies depending on the treatment given. Can we try patient-controlled analgesia to see if that helps the patient better?"
The nurse is caring for a patient admitted to the emergency department in status epilepticus. Vital signs assessed by the nurse include blood pressure 160/100 mm Hg, heart rate 145 beats/min, respiratory rate 36 breaths/min, oxygen saturation (SpO2) 96% on 100% supplemental oxygen by non-rebreather mask. An IV has been established and the patient has been given lorazepam, but the seizures continue. What is the next nursing priority? Select one: a. Obtain stat portable chest x-ray. b. Administer phenytoin. c. Administer 2 nd lorazepam dose. d. Obtain stat serum electrolytes.
b. Administer phenytoin.
The nurse is caring for a patient in septic shock. The nurse assess the patient to have a blood pressure of 105/60 mm Hg, heart rate 11o beats/min, respiratory rate 32 breaths/min, oxygen saturation (SpO2) 95% on 45% supplemental oxygen vial Venturi mask, and a temperature of 102 degrees F. The physician orders stat administration of an antibiotic. Which additional physician order should the nurse complete first? Select one: a. Serum electrolytes b. Blood cultures c. Chest x-ray d. Foley insertion
b. Blood cultures
The healthcare provider is caring for a patient on a ventilator with an endotracheal tube in place. What assessment data indicate the tube has migrated too far down the trachea? Select one: a. High pressure alarm sounds b. Decreased breath sounds on the left side of the chest c. Low pressure alarm sounds d. Increased crackles bilaterally
b. Decreased breath sounds on the left side of the chest
An elderly female patient has presented to the emergency department with altered mental status, hypothermia, and clinical signs of heart failure. Myxedema is suspected. Which of the following laboratory findings support this diagnosis? Select one: a. Elevated adrenocorticotropic hormone b. Elevated thyroid-stimulating hormone c. Elevated T 3 and T 4 d. Elevated cortisol levels
b. Elevated thyroid-stimulating hormone
The optimal measurement of intravascular fluid status during the immediate fluid resuscitation phase of burn treatment is Select one: a. Serum potassium b. Hourly intake and urine output c. Blood urea nitrogen. d. Daily weight
b. Hourly intake and urine output
The nurse admits a 35-year-old patient to the emergency department following a 3-day history of nausea and vomiting. Vital signs assessed by the nurse include a BP of 70/50 mm Hg, HR 145 beats/min, RR 36 breaths/min, and SpO 2 of 92% on room air. The nurse recognizes which classification of shock? Select one: a. Anaphylactic b. Hypovolemic c. Cardiogenic d. Obstructive
b. Hypovolemic
The greatest risk of GI bleeding is: Select one: a. Hypovolemia b. Infection c. Increased cardiac output d. Anemia
b. Infection
The nurse has just completed an infusion of a 1000 mL bolus of 0.9% normal saline in a patient with severe sepsis. One hour later, which laboratory result requires immediate nursing action? Select one: a. Potassium 3.8 mEq/L b. Lactate 6 mmol/L c. Sodium 140 mEq/L d. Creatinine 1.0 mg/dL
b. Lactate 6 mmol/L
Which of the following statements are true regarding fluid resuscitation during the care of a trauma patient? Select all that apply Select one or more: a. Lactated Ringer's is recommended for rapid crystalloid infusion. b. Massive transfusions should be avoided to improve patient outcomes. c. IV fluids may need to be warmed to prevent hypothermia. d. Only fully crossmatched blood products are administered
b. Massive transfusions should be avoided to improve patient outcomes.
Which liver transplant patient being cared for in the ICU is exhibiting signs of acute rejection? Select one: a. Patient with temp of 99.0° F and thirst b. Patient with postoperative pain 6/10 c. Patient with dark urine and jaundice d. Patient with a CVP of 6 mm Hg
b. Patient with postoperative pain 6/10
A patient is admitted to the critical care unit with a diagnosis of diabetic ketoacidosis. Following aggressive fluid resuscitation and intravenous (IV) insulin administration, the blood glucose begins to normalize. In addition to glucose monitoring, which of the following electrolytes requires close monitoring? Select one: a. Sodium b. Potassium c. Calcium d. Chloride
b. Potassium
Which of the following interventions is a strategy to prevent fat embolism syndrome? Select one: a. Provide prophylaxis with low-molecular weight heparin. b. Stabilize extremity fractures early. c. Intubate the patient early after the injury to provide mechanical ventilation. d. Administer lipid-lowering statin medications.
b. Stabilize extremity fractures early.
When assessing the patient for hypoxemia, the nurse recognizes that an early sign of the effect of hypoxemia on the cardiovascular system is Select one: a. Restlessness b. Tachycardia c. Tachypnea d. Heart block
b. Tachycardia
The patient has a platelet count of 9,000/microliter. The nurse realizes that: Select one: a. Spontaneous bleeding may occur b. The patient is a great risk for fatal hemorrhage c. This is a normal platelet level d. This level is considered slightly low
b. The patient is a great risk for fatal hemorrhage
Positive end-expiratory pressure (PEEP) is a mode of ventilator assistance that produces the following condition: Select one: a. Each time the patient initiates a breath, the ventilator delivers a full present tidal volume b. There is pressure remaining in the lungs at the end of expiration that is measured in cm H2O c. For each spontaneous breath taken by the patient, the tidal volume is determined by the patient's ability to generate negative pressure d. The patient must have a respiratory drive, or no breaths will be delivered
b. There is pressure remaining in the lungs at the end of expiration that is measured in cm H2O
A patient with disseminated intravascular coagulation is receiving I.V. albumin, which Select one: a. increases intersitital volume b. increases intravascular volume c. is isotonic d. decreases intravascular volume
b. increases intravascular volume
The nurse is discharging a patient home following treatment for community-acquired pneumonia. As part of the discharge teaching, the nurse should instruct the patient: Select one: a. "Since you have been treated for pneumonia, you now have immunity from getting it in the future" b. "If you get the pneumococcal vaccine, you'll never get pneumonia again" c. "It is important for you to get an annual influenza shot to reduce your risk of pneumonia" d. "Stay away from cold, drafty places because that increases your risk of pneumonia when you get home"
c. "It is important for you to get an annual influenza shot to reduce your risk of pneumonia"
The nurse is caring for a patient who has circumferential full-thickness burns of his forearm. A priority in the plan of care is Select one: a. To prepare for an escharotomy as a prophylactic measure. b. To keep the extremity in a dependent position. c. Active or passive range-of-motion exercises every hour. d. To splint the forearm.
c. Active or passive range-of-motion exercises every hour.
A patient presents to the emergency department with the following clinical signs: Pulse: 132 beats/min, Blood pressure: 88/50 mm Hg, Respiratory rate: 32 breaths/min, Blood sugar of 60, fatigue, dizziness and darkening of skin. These signs are consistent with which disorder? Select one: a. Thyroid Storm b. Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) c. Adrenal Crisis d. Myxedema coma
c. Adrenal Crisis
The patient is admitted with anemia and active bleeding. The nurse suspects intravascular disseminated coagulation (DIC). Definitive diagnosis is made by Select one: a. A decrease in fibrin degradation products b. Thrombocytopenia c. An increase in D-dimer level d. Low fibrinogen levels
c. An increase in D-dimer level
Which of the following statements is true about the medical management of diabetic ketoacidosis? Select all that apply Select one or more: a. Sodium bicarbonate is used to correct severe acidosis. b. The degree of acidosis is assessed through continuous pulse oximetry. c. Blood glucose levels are used to guide insulin administration. d. Volume replacement and insulin infusion often correct the acidosis.
c. Blood glucose levels are used to guide insulin administration
Intrapulmonary shunting refers to: Select one: a. Blood that is shunted from the right side of the heart to the left without oxygenation b. Alveoli that are not perfused c. Blood that is shunted from the left side of the heart to the right and causes heart failure d. Shunting of blood supply to only one lung
c. Blood that is shunted from the left side of the heart to the right and causes heart failure
Interpret these ABGs; patient has a history of COPD: pH 7.37, PaCO 2 50 mm Hg, bicarbonate 30 mEq/L; SpO 2 93% Select one: a. Partly compensated respiratory alkalosis b. Combined metabolic and respiratory acidosis c. Compensated respiratory acidosis d. Compensated metabolic alkalosis
c. Compensated respiratory acidosis
A 36-year-old driver was pulled from a car after it collided with a tree and the gas tank exploded. What assessment data suggest the patient suffered tissue damage consistent with a blast injury? Select one: a. Blood pressure 82/60 mm Hg, heart rate 122 beats/min, respiratory rate 28 breaths/min b. Responsive only to painful stimuli c. Crackles (rales) on auscultation of bilateral lung fields d. Irregular heart rate and rhythm
c. Crackles (rales) on auscultation of bilateral lung fields
The patient with acute respiratory distress syndrome (ARDS) would exhibit which of the following symptoms? Select one: a. Elevated alveolar surfactant levels b. Respiratory acidosis associated with hyperventilation c. Decreasing PaO2 levels despite increased FiO2 administration d. Increased lung compliance with increased FiO2 administration
c. Decreasing PaO2 levels despite increased FiO2 administration
When paramedics notice singed hairs in the nose of a burn patient, it is recommended that the patient be intubated. What is the reasoning for the immediate intubation? Select one: a. Carbon monoxide poisoning always occurs when soot is visible. b. The patient will have a copious amount of mucus that will need to be suctioned. c. Inhalation injury above the glottis may cause significant edema that obstructs the airway. d. The singed hairs and soot in the nostrils will cause dysfunction of cilia in the airways.
c. Inhalation injury above the glottis may cause significant edema that obstructs the airway.
The nurse is caring for a patient admitted with new onset of slurred speech, facial droop, and left-sided weakness 8 hours ago. Diagnostic computed tomography scan rules out the presence of an intracranial bleed. Which actions are most important to include in the patient's plan of care? Select all that apply Select one or more: a. Maintain MAP greater than 130 mm Hg. b. Maintain CO 2 level at 35-45 mm Hg. c. Make frequent neurological assessments. d. Prepare for thrombolytic administration.
c. Make frequent neurological assessments.
The nurse is caring for a mechanically ventilated patient and notes the high pressure alarm sounding. The nurse cannot quickly identify the cause of the alarm and notes the patient's oxygen saturation is decreasing and heart rate and respiratory rate are increasing. The nurse's priority action is to Select one: a. Call the rapid response team to assess the patient b. Ask the respiratory therapist to get anew ventilator c. Manually ventilate the patient while calling for a respiratory therapist d. Continue to find the cause of the alarm and fix it
c. Manually ventilate the patient while calling for a respiratory therapist
The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at the scene briefly but is now conscious upon arrival at the emergency department with a GCS score of 15. One hour later, the nurse assesses a GCS score of 3. What is the priority nursing action? Select one: a. Elevate the head of the bed. b. Continue to monitor the patient. c. Notify the provider immediately. d. stimulate the patient hourly.
c. Notify the provider immediately.
The nurse is preparing to admit a patient from the ED who has sustained a complete spinal cord lesion at the C5 level. When planning the patient's care, which nursing intervention is most important? Select one: a. Apply warming devices as needed. b. Give small, frequent feedings. c. Perform hourly incentive spirometry. d. Assist with passive range-of-motion.
c. Perform hourly incentive spirometry.
The nurse has admitted a patient to the ED following a fall from a first-floor hotel balcony. The patient smells of alcohol and begins to vomit in the ED. Which of the following interventions is most appropriate? Select one: a. Send a specimen of the emesis to the laboratory for analysis of blood alcohol content. b. Offer the patient an emesis basin so that you can measure the amount of emesis. c. Prepare to suction the oropharynx while maintaining cervical spine immobilization. d. Insert an oral airway to prevent aspiration and to protect the airway.
c. Prepare to suction the oropharynx while maintaining cervical spine immobilization.
The nurse asks a patient with chest pain if it travels to the neck or shoulders. This is an assessment of: Select one: a. Severity b. Quality c. Radiation d. Postion
c. Radiation
The nurse is managing the pain of a patient with burns. The provider has prescribed opiates to be given intramuscularly. The nurse contacts the provider to change the prescription to intravenous administration because Select one: a. Burn pain is so severe it requires relief by the fastest route available. b. Intramuscular injections cause additional skin disruption. c. Tissue edema may interfere with drug absorption of injectable routes. d. Hypermetabolism limits effectiveness of medications administered intramuscularly.
c. Tissue edema may interfere with drug absorption of injectable routes.
A 63-year-old patient is admitted with new-onset fever; flulike symptoms; blisters over the arms, chest, and neck; and red, painful oral mucous membranes. The patient should be further evaluated for which possible non-burn-injured skin disorder? Select one: a. Graft-versus-host disease b. Staphylococcal scalded skin syndrome c. Toxic epidermal necrolysis d. Necrotizing soft tissue infection
c. Toxic epidermal necrolysis
Nursing management of the patient with angina is directed toward: Select one: a. administration of prophylactic lidocaine for ventricular ectopy b. assessment of history of previous anginal episodes c. assessment and documentation of chest pain episodes d. Immediate administration of nitrates
c. assessment and documentation of chest pain episodes
The nurse is caring for a mechanically ventilated patient. The providers are considering performing a tracheostomy because the patient is having difficulty weaning from mechanical ventilation. Related to tracheostomy, the nurse understands which of the following? Select one: a. Procedures performed in the operating room are associated with fewer complications b. Percutaneous tracheostomy can be done safely at the beside by the respiratory therapist c. the greatest risk after a percutaneous tracheostomy is accidental decannulation d. Patient outcomes are better if the tracheostomy is done within a week of intubation
c. the greatest risk after a percutaneous tracheostomy is accidental decannulation
The nurse recognizes which statement as a potential ethical issue? Select one: a. "My mother has designated my brother to make decisions." b. "Can I assist with some of my mother's care?" c. . "The physician explained my mother's poor prognosis." d. "If the breathing machine is helping my mother, why is the doctor asking me about removing the breathing tube?"
d. "If the breathing machine is helping my mother, why is the doctor asking me about removing the breathing tube?"
For patients with major burns, when should you start enteral feedings? Select one: a. A few hours after the injury has occurred b. After the emergent phase of the injury c. Not until bowel sounds have returned d. 2 to 3 days after the injury
d. 2 to 3 days after the injury
After receiving the handoff report from the day shift charge nurse, which patient should the evening charge nurse assess first? Select one: a. Mechanically ventilated patient with a GCS of 6 b. Patient with meningitis complaining of photophobia c. A patient with bacterial meningitis on droplet precautions d. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104°F
d. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104°F
A reduction in the number of circulating RBCs or hemoglobin, which leads to inadequate oxygenation of tissues, is known as: Select one: a. Iron Deficiency b. Polycythemia c. An Increase in hemoglobin d. Anemia
d. Anemia
A patient presents to the emergency department with suspected thyroid storm. The nurse should be alert to which of the following cardiac rhythms while providing care to this patient? Select one: a. Sinus bradycardia b. Idioventricular rhythm c. Junctional rhythm d. Atrial fibrillation
d. Atrial fibrillation
A college student was admitted to the emergency department after being found unconscious by a roommate. The roommate informs emergency medical personnel that the student has diabetes and has been experiencing flulike symptoms, including vomiting, since yesterday. The patient had been up all night studying for exams. The patient used the last diabetes testing supplies 3 days ago and has not had time to go to the pharmacy to refill prescription supplies. Based upon the history, which laboratory findings would be anticipated in this client? Select all that apply: Select one or more: a. Blood glucose: 43 mg/dL b. pH: 7.40 c. HCO 3 — : 10 mEq/L d. Blood glucose: 524 mg/dL
d. Blood glucose: 524 mg/dL
After falling from a 10-foot ladder, a patient is brought to the emergency department. The patient is alert, reports back pain, and difficulty moving the lower extremities. Which additional observation is an indication the patient may be experiencing neurogenic shock? Select one: a. Cool and pale skin b. Poor skin turgor c. Increased systolic blood pressure d. Bradycardia
d. Bradycardia
Which of the following would be seen in a patient with myxedema coma? Select one: a. Tachycardia b. Hyperthermia c. Hyperventilation d. Decreased reflexes
d. Decreased reflexes
While caring for a patient who is experiencing a postoperative hemorrhage, the healthcare provider notes the rhythm observed on the electrocardiogram (EKG) does not produce a pulse. Which actions should the healthcare provider initiate first? Select one: a. Administer epinephrine b. Cardiopulmonary resuscitation (CPR) c. Syncronized cardioversion d. Defibrillation
d. Defibrillation
An individual with type 2 diabetes who takes glipizide has begun a formal exercise program at a local gym. While exercising on the treadmill, the individual becomes pale, diaphoretic, shaky, and has a headache. The individual feels as though she is going to pass out. What is the individual's priority action? Select one: a. Drink additional water to prevent dehydration b. Go to the first-aid station to have glucose checked c. Take another dose of the glipizide d. Eat an apple
d. Eat an apple
A patient suddenly becomes unresponsive as you're speaking to him and develops generalized tonic-clonic seizures. Your priority is to: Select one: a. Notify the primary care provider immediately. b. Perform a rapid neurologic exam. c. Administer intravenous diazepam. d. Establish an airway.
d. Establish an airway.
The nurse admits a patient to the critical care unit following a motorcycle crash. Assessment findings by the nurse include blood pressure 100/50 mm Hg, heart rate 58 beats/min, respiratory rate 30 breaths/min, and temperature of 100.5°F. The patient is lethargic, responds to voice but falls asleep readily when not stimulated. Which nursing action is most important to include in this patient's plan of care? Select one: a. Side to side position changes b. Range-of-motion to extremities c. Frequent oropharyngeal suctioning d. Frequent neurological assessments
d. Frequent neurological assessments
Arterial blood gas alterations in pneumonia include which of the following? Select one: a. Normal oxygen and respiratory acidosis b. Normal values c. Hypoxemia and metabolic acidosis d. Hypoxemia and respiratory alkalosis
d. Hypoxemia and respiratory alkalosis
While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mm Hg and a CPP of 55 mm Hg. What is the best interpretation by the nurse? Select one: a. Both pressures are low. b. ICP is high; CPP is normal. c. Both pressures are high. d. ICP is high; CPP is low.
d. ICP is high; CPP is low.
In patients with extensive burns, edema occurs in both burned and unburned areas because of Select one: a. Catecholamine-induced vasoconstriction. b. Loss of integument barrier. c. Decreased glomerular filtration. d. Increased capillary permeability.
d. Increased capillary permeability.
An 18-year-old unrestrained passenger who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. This patient should be treated at which level trauma center? Select one: a. Level IV b. Level III c. Level II d. Level 1
d. Level 1
diabetic ketoacidosis, the laboratory results are similar to those of hyperosmolar hyperglycemic syndrome, with three major exceptions. What differences would you expect to see in patients with diabetic ketoacidosis? Select one: a. Lower serum glucose, lower osmolality, and no ketosis b. Higher serum glucose, higher osmolality, and higher ketosis c. Higher serum glucose, higher osmolality, and no ketosis d. Lower serum glucose, lower osmolality, and higher ketosis
d. Lower serum glucose, lower osmolality, and higher ketosis
The nurse admits a patient to the emergency department (ED) with a suspected cervical spine injury. What is the priority nursing action? Select one: a. Keep the neck in the hyperextended position. b. Prepare for immediate endotracheal intubation. c. Remove cervical collar upon arrival to the ED. d. Maintain proper head and neck alignment.
d. Maintain proper head and neck alignment.
The nurse is assessing a patient being admitted for anemia. The nurse sees no overt signs of bleeding. The nurse understands that: Select one: a. Mucous membranes have a high threshold for bleeding b. Capillaries in mucous membranes lie deep in the membrane. c. All patients with bleeding disorders demonstrate active bleeding d. Many patients have bleeding that is not obvious
d. Many patients have bleeding that is not obvious
The nurse assesses a patient with a skull fracture to have a Glasgow Coma Scale score of 3. Additional vital signs assessed by the nurse include blood pressure 100/70 mm Hg, heart rate 55 beats/min, respiratory rate 10 breaths/min, oxygen saturation (SpO2) 94% on oxygen at 3 L per nasal cannula. What is the priority nursing action? Select one: a. Increase supplemental oxygen delivery. b. Elevate the head of the patient's bed. c. Support bony prominences with padding. d. Monitor the patient's airway patency.
d. Monitor the patient's airway patency.
During the treatment and management of the trauma patient, maintaining tissue perfusion, oxygenation, and nutritional support are strategies to prevent Select one: a. Septic shock. b. Wound infection c. Disseminated intravascular coagulation. d. Multisystem organ dysfunction.
d. Multisystem organ dysfunction.
Oxygen saturation (SaO2) represents Select one: a. Total oxygen consumption b. Alveolar oxygen tension c. Oxygen that is physically dissolved in plasma d. Oxygen that is chemically combined with hemoglobin
d. Oxygen that is chemically combined with hemoglobin
Which patient would benefit the most from central venous/right atrial pressure monitoring? Select one: a. Patient receiving two units of blood b. Patient admitted in cardiogenic shock c. Patient taking routine doses of furosemide d. Patient admitted with a bowel obstruction
d. Patient admitted with a bowel obstruction
While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the patient's left naris. What is the best nursing action? Select one: a. Have the patient blow the nose until clear. b. Suction the left nares until the drainage clears. c. Insert bilateral cotton nasal packing. d. Place a nasal drip pad under the nose.
d. Place a nasal drip pad under the nose.
A patient has a vitamin K deficiency. Which of the following lab results would be expected for a patient with this deficiency? Select one: a. Normal prothrombin time (PT) b. Low platelets c. Prolonged activated partial thromboplastin time (aPTT) d. Prolonged international normalized ration (INR)
d. Prolonged international normalized ration (INR)
The nurse is caring for a patient diagnosed with anemia. This morning's hematocrit level is 24%. Platelet level is 200,000/microliter. The nurse can expect to: Select one: a. Continue monitoring the patient, as this hematocrit is normal b. Administer platelets to help control bleeding c. Give fresh frozen plasma to decrease prothrombin time d. Provide RBC transfusion because this level is below the normal threshold
d. Provide RBC transfusion because this level is below the normal threshold
The nurse is caring for a patient being treated with therapeutic hypothermia post-CPR. Which order should the nurse question? Select one: a. Measure blood glucose every 2 hours b. Draw serum electrolytes stat c. Continuously monitor EEG and ECG d. Record tympanic temperature every hour
d. Record tympanic temperature every hour
While caring for a patient with a closed head injury, the nurse assesses the patient to be alert with a blood pressure 130/90 mm Hg, heart rate 60 beats/min, respirations 18 breaths/min, and a temperature of 102°F. To reduce the risk of increased intracranial pressure (ICP) in this patient, what is (are) the priority nursing action(s)? Select one: a. Maintain neutral head alignment and avoid extreme hip flexion. b. Ensure adequate periods of rest between nursing interventions. c. Insert an oral airway and monitor respiratory rate and depth. d. Reduce ambient room temperature and administer antipyretics.
d. Reduce ambient room temperature and administer antipyretics.
One of the early signs of hypoxemia on the nervous system is Select one: a. Cyanosis b. tachypnea c. Agitation d. Restlessness
d. Restlessness
Being present during a code can assist family members in: Select one: a. Taking a photo of the family member b. Documenting care that was provided c. Determining the need for a lawsuit d. Witnessing that everything has been done
d. Witnessing that everything has been done
