NUR 221 (Critical Care - Test 3) NCLEX Style Practice Questions
A patient is admitted to the emergency department with clinical indications of an acute myocardial infarction. Symptoms began 3 hours ago. The facility does not have the capability for percutaneous coronary intervention. Given this scenario, what is the priority intervention in the treatment and nursing management of this patient? A. Administer thrombolytic therapy unless contraindicated B. Diurese aggressively and monitor daily weight C. Keep oxygen saturation levels to at least 88% D. Maintain heart rate above 100 beats/min **P-13**
A (Administer thrombolytic therapy unless contraindicated)
The nurse is caring for a patient at risk for respiratory failure. Which assessment findings would alert the nurse to potential respiratory failure? A. Anxiety and restlessness B. Cyanosis and hyperventilation C. Dyspnea and nasal flaring D. Hypertension and bradycardia **Evolve - Chapter 15**
A (Anxiety and restlessness)
An unconscious client arrives in the emergency department following a fall that resulted in severe head injury. Which action does the nurse take FIRST? A) Assess the patency of the airway B) Check the client's pupils for size and reaction to light C) Establish the client's level of consciousness D) Evaluate the client's motor response **K**
A (Assess the patency of the airway)
The nurse responds to a high heart rate alarm for a patient in the neurological intensive care unit. The nurse arrives to find the patient sitting in a chair experiencing a tonic-clonic seizure. What is the best nursing action? A. Assist the patient to the floor and provide soft head support B. Insert a nasogastric tube and connect to continuous wall suction C. Open the patient's mouth and insert a padded tongue blade D. Restrain the patient's extremities until the seizure subsides **P-14**
A (Assist the patient to the floor and provide soft head support)
The nurse is caring for a patient with a ruptured cerebral aneurysm. During initial assessment, the nurse notes that the cerebrospinal fluid draining into a ventriculostomy system is blood tinged. What is the best interpretation of this finding by the nurse? A. Cerebral aneurysms commonly rupture in the subarachnoid space B. This assessment finding is indicative of developing cerebral meningitis C. Normal cerebral spinal fluid contains a small amount of visible blood D. Patient movement has resulted in dislodgment of the catheter **Evolve - Chapter 14**
A (Cerebral aneurysms commonly rupture in the subarachnoid space)
The nurse is managing the blood pressure of a patient with a traumatic brain injury. When planning the care of this patient, which statement best represents appropriate blood pressure management? A. Cerebral perfusion pressure (CPP) should be sustained at least 70 mm Hg B. Nitrates are the vasopressors of choice with increased ICP C. Nimodipine reduces blood pressure through its effect on cerebral vessels D. Hypertension greater than 160 mm Hg is necessary to achieve adequate perfusion **Evolve - Chapter 14**
A (Cerebral perfusion pressure (CPP) should be sustained at least 70 mm Hg)
The nurse is caring for a patient admitted with a spinal cord injury. Upon assessment, the nurse notes a complete loss of motor and sensory function below the patient's nipple line. What is the best interpretation of this assessment finding by the nurse? A. Complete cord lesion B. Central cord lesion C. Anterior cord lesion D. Brown-Sequard syndrome **Evolve - Chapter 14**
A (Complete cord lesion)
The patient presents to the ED with severe chest discomfort. A cardiac catheterization and angiography shows an 80% occlusion of the left main coronary artery. Which procedure will be most likely performed on this patient? A. Coronary artery bypass graft surgery B. Intracoronary stent placement C. Percutaneous transluminal coronary angioplasty (PTCA) D. Transmyocardial revascularization **P-13**
A (Coronary artery bypass graft surgery)
The patient with acute respiratory distress syndrome (ARDS) would exhibit which of the following symptoms? A. Decreasing PaO2 levels despite increased FiO2 administration B. Elevated alveolar surfactant levels C. Increased lung compliance with increased FiO2 administration D. Respiratory acidosis associated with hyperventilation **P-15**
A (Decreasing PaO2 levels despite increased FiO2 administration)
A patient presents to the emergency department (ED) with chest pain that he has had for the past 2 hours. The patient is nauseated and diaphoretic, with dusky skin color. The electrocardiogram shows ST elevation in leads II, III, and aVF. Which therapeutic intervention would the nurse question? A. Emergent pacemaker insertion B. Emergent percutaneous coronary intervention C. Emergent thrombolytic therapy D. Immediate coronary artery bypass graft surgery **P-13**
A (Emergent pacemaker insertion)
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? A. Frequent neurological assessments B. Side to side position changes C. Range-of-motion to extremities D. Frequent oropharyngeal suctioning **P-14**
A (Frequent neurological assessments)
A client has a diagnosis of meningitis. The nurse assesses the client. The nurse notes that when the client flexes the head, the client also flexes the hip and knee. Which nursing action is best? A) Immediately report this finding to the health care provider B) Document the finding and continues with the nursing assessment C) Give 10 mg of morphine sulfate for the pain D) Place the client's in high Fowler's position and start oxygen at 2 liters **K**
A (Immediately report this finding to the health care provider)
The nurse has just received a patient from the emergency department with an admitting diagnosis of bacterial meningitis. To prevent the spread of nosocomial infections to other patients, what is the best action by the nurse? A. Implement droplet precautions upon admission B. Wash hands thoroughly before leaving the room C. Scrub the hub of all central line ports before use D. Dispose of all bloody dressings in biohazard bags **P-14**
A (Implement droplet precautions upon admission)
The nurse understands that pain of angina is caused by which mechanism? A) Insufficient oxygen to the heart muscles B) Inflammation of the pericardium C) Ineffective contractions of the heart muscle D) Severe cardiac arrhythmias **K**
A (Insufficient oxygen to the heart muscles)
A patient has been diagnosed with Marfan syndrome. What information does the nurse plan to teach the patient about this condition? A. It is an autosomal dominant inherited disorder of connective tissue B. It is caused by a random genetic mutation and is not familial C. There are no drugs that help control the cardiac symptoms of the disease D. Contact sports are permitted if precautions against concussion are taken **P-13**
A (It is an autosomal dominant inherited disorder of connective tissue)
Which of the following nursing actions is most important for a patient with acute kidney injury? A. Maintain accurate intake, output, and daily weight measurements B. Restrict fluids to 200 mL per day C. Obtain a drug trough level immediately after an antibiotic is administered D. Insert an indwelling urinary catheter **Evolve - Chapter 16**
A (Maintain accurate intake, output, and daily weight measurements)
The nurse is caring for a patient who is being turned prone as part of treatment for acute respiratory distress syndrome. The nurse understands that the priority nursing concern for this patient is which of the following? A. Management and protection of the airway B. Prevention of gastric aspiration C. Prevention of skin breakdown and nerve damage D. Psychological support to patient and family **P-15**
A (Management and protection of the airway)
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? A. Monitor the patient's airway patency B. Elevate the head of the patient's bed C. Increase supplemental oxygen delivery D. Support bony prominences with padding **P-14**
A (Monitor the patient's airway patency)
Which of the following statements is true regarding venous thromboembolism (VTE) and pulmonary embolus (PE)? A. PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk factors for VTE. B. Bradycardia and hyperventilation are classic symptoms of PE C. Dyspnea, chest pain, and hemoptysis occur in nearly all patients with PE D. Most critically ill patients are at low risk for VTE and PE and do not require prophylaxis **P-15**
A (PE should be suspected in any patient who has unexplained cardiorespiratory)
A patient is admitted to the critical care unit with a diagnosis of possible meningitis. Actions the nurse anticipates include all of the following except: A) Placing the patient on contact precautions B) Obtaining blood and urine cultures C) Administering antibiotics as soon as possible D) Preparing the patient for lumbar puncture **Rationale: Text book pg. 605**
A (Placing the patient on contact precautions)
The patient is admitted with a suspected acute myocardial infarction (AMI). In assessing the 12-lead electrocardiogram (ECG) changes, which findings would indicate to the nurse that the patient is in the process of an evolving Q wave myocardial infarction (MI)? A. ST-segment elevation on ECG and elevated CPK-MB or troponin levels B. Depressed ST-segment on ECG and elevated total CPK C. Depressed ST-segment on ECG and normal cardiac enzymes D. Q wave on ECG with normal enzymes and troponin levels **P-13**
A (ST-segment elevation on ECG and elevated CPK-MB or troponin levels)
All of the following are true about the brainstem functions except: A) The brainstem is responsible for temperature control B) Mechanisms that regulate respiratory rhythm are located in the brainstem C) The brainstem connects the cerebellum to the rest of the brain D) Nuclei for most cranial nerves are located in the brainstem **Rationale: Text book pg. 605**
A (The brainstem is responsible for temperature control)
The nurse provides care for a client admitted to the emergency department following an automobile accident. The client reports dizziness, and the health care provider suspects a head injury. The nurse intervenes if which activity is observed? A) The client is placed in the Trendelenburg position B) The client's neck is immobilized prior to being x-rayed C) The nursing staff frequently monitors the client's level of consciousness D) The nursing staff observes for seizures **K**
A (The client is placed in the Trendelenburg position)
The nurse provides care for a client diagnosed with a spinal cord injury (SCI) following an accident. The client was stable immediately after admission. Eight hours later the nurse notices that the client has clear, blood-tinged fluid leaking from the right ear. Which problem is the nurse most concerned about? A) The fluid may be cerebrospinal fluid (CSF) B) The client may be uncomfortable with this discharge C) There may be something in the client's ear canal D) The eardrum may have ruptured and be leaking fluid **K**
A (The fluid may be cerebrospinal fluid (CSF))
The nurse provides care for a client admitted to the medical/surgical unit diagnosed with a stroke. The nurse plans care to prevent the client form experiencing sensory overload. The nurse determines which plan is MOST effective? A) The nurse obtains the vital signs and assists the client with morning care in one visit B) The nurse obtains vital signs, and completes morning care two hours later C) The nurse completes morning care and schedules physical therapy to follow immediately D) The nurse instructs the family to visit the client every other day **K**
A (The nurse obtains the vital signs and assists the client with morning care in one visit)
A patient presents to the ED complaining of severe substernal chest pressure radiating to the left shoulder and back that started about 12 hours ago. The patient delayed coming to the ED, hoping the pain would go away. The patient's 12-lead ECG shows ST-segment depression in the inferior leads. Troponin and CK-MB are both elevated. What does the nurse understand about thrombolysis in this patient? A. The patient is not a candidate for thrombolysis B. The patient's history makes him a good candidate for thrombolysis C. Thrombolysis is appropriate for a candidate having a non-Q wave MI D. Thrombolysis should be started immediately **P-13**
A (The patient is not a candidate for thrombolysis)
The nurse is caring for a patient who has symptoms of an acute myocardial infarction (AMI). Which lab should the nurse prepare to draw in order to detect myocardial necrosis? A. Troponin I B. CK C. Potassium D. CK-MB **Evolve - Chapter 13**
A (Troponin I)
The patient is in need of immediate hemodialysis, but has no vascular access. The nurse prepares the patient for insertion of A. a percutaneous catheter at the bedside B. a percutaneous tunneled catheter at the bedside C. an arteriovenous fistula D. an arteriovenous graft **P-16**
A (a percutaneous catheter at the bedside)
Renin plays a role in blood pressure regulation by A. activating the renin-angiotensin-aldosterone cascade B. suppressing angiotensin production C. decreasing sodium reabsorption D. inhibiting aldosterone release **P-16**
A (activating the renin-angiotensin-aldosterone cascade)
The etiology of noncardiogenic pulmonary edema in acute respiratory distress syndrome (ARDS) is related to damage to the A. alveolar-capillary membrane B. left ventricle C. mainstem bronchus D. trachea **P-15**
A (alveolar-capillary membrane)
During rounds, the provider alerts the team that proning is being considered for a patient with acute respiratory distress syndrome. The nurse understands that proning is A. an optional treatment to improve ventilation B. less of a risk for skin breakdown because the patient is face down C. possible with minimal help from coworkers D. used to provide continuous lateral rotational turning **P-15**
A (an optional treatment to improve ventilation)
The nurse is caring for a patient receiving peritoneal dialysis. The patient suddenly complains of abdominal pain and chills. The patient's temperature is elevated. The nurse should A. assess peritoneal dialysate return B. check the patient's blood sugar C. evaluate the patient's neurological status D. inform the provider of probable visceral perforation **P-16**
A (assess peritoneal dialysate return)
The critical care nurse is responsible for monitoring the patient receiving continuous renal replacement therapy (CRRT). In doing so, the nurse should A. assess that the blood tubing is warm to the touch B. assess the hemofilter every 6 hours for clotting C. cover the dialysis lines to protect them from light D. use clean technique during vascular access dressing changes **P-16**
A (assess that the blood tubing is warm to the touch)
The nurse is caring for a patient who has undergone major abdominal surgery. The nurse notices that the patient's urine output has been less than 20 mL/hour for the past 2 hours. The patient's blood pressure is 100/60 mm Hg, and the pulse is 110 beats/min. Previously, the pulse was 90 beats/min with a blood pressure of 120/80 mm Hg. The nurse should A. contact the provider and expect a prescription for a normal saline bolus B. wait until the provider makes rounds to report the assessment findings C. continue to evaluate urine output for 2 more hours D. ignore the urine output, as this is most likely postrenal in origin **P-16**
A (contact the provider and expect a prescription for a normal saline bolus)
A patient has been prescribed nitroglycerin (NTG) in the ED for chest pain. In taking the health history, the nurse will be sure to verify whether the patient has taken medications before admission for: A. erectile dysfunction B. prostate enlargement C. asthma D. peripheral vascular disease **P-13**
A (erectile dysfunction)
An adult patient suffered an anterior wall myocardial infarction (MI) 4 days ago. Today the patient is experiencing dyspnea and sitting straight up in bed. The nurse's assessment includes bibasilar crackles, an S3 heart sound with a heart rate of 125 beats/min. The nurse anticipates a diagnosis of: A. heart failure B. pulmonary embolism C. papillary muscle rupture D. pericarditis **Evolve - Chapter 13**
A (heart failure)
The patient presents to the emergency department with severe substernal chest discomfort. Cardiac enzymes are elevated, and his ECG shows ST-segment depression in V2 and V3. The nurse anticipates a diagnosis of: A. non-Q-wave myocardial infarction (MI) B. pulmonary embolism C. right ventricular infarction D. Q-wave myocardial infarction (MI) **Evolve - Chapter 13**
A (non-Q-wave myocardial infarction (MI))
Acute kidney injury from postrenal etiology is caused by A. obstruction of the flow of urine B. conditions that interfere with renal perfusion C. hypovolemia or decreased cardiac output D. conditions that act directly on functioning kidney tissue **P-16**
A (obstruction of the flow of urine)
Continuous venovenous hemofiltration is used to A. remove fluids and solutes through the process of convection B. remove plasma water in cases of volume overload C. remove plasma water and solutes by adding dialysate D. combine ultrafiltration, convection, and dialysis **P-16**
A (remove fluids and solutes through the process of convection)
Slow continuous ultrafiltration is also known as isolated ultrafiltration and is used to A. remove plasma water in cases of volume overload B. remove fluids and solutes through the process of convection C. remove plasma water and solutes by adding dialysate D. combine ultrafiltration, convection, and dialysis **P-16**
A (remove plasma water in cases of volume overload)
The most common cause of acute kidney injury in critically ill patients is A. sepsis B. fluid overload C. medications D. hemodynamic instability **P-16**
A (sepsis)
The patient has a potassium level of 7 mEq/L but is not scheduled for a dialysis treatment for the next 3 days. To reduce plasma and body potassium levels, the nurse prepares to administer: A. sodium polystyrene sulfonate (Kayexalate) B. regular insulin to be given IV C. calcium gluconate by mouth D. sodium polystyrene sulfonate (Kayexalate) and sorbitol rectally **Evolve - Chapter 16**
A (sodium polystyrene sulfonate (Kayexalate))
The patient is receiving continuous renal replacement therapy (CRRT). The nurse should become concerned when: A. the ultrafiltrate is showing a pink tinge B. the patient's temperature drops by one degree C. there are no dark fibers in the hemofilter after 2 hours D. the blood tubing becomes warm to touch **Evolve - Chapter 16**
A (the ultrafiltrate is showing a pink tinge)
The patient presents to the emergency department after having crushing chest pain for the past 5 hours. The ECG and laboratory work confirm suspicions of an acute myocardial infarction (AMI). Which findings would be the most conclusive that the patient is having an AMI? (Select all that apply) A. Elevated CK-MB isoenzymes B. ECG changes with ST-elevation C. Elevated serum troponin levels D. Elevated urinary myoglobin level **Evolve - Chapter 13**
A & B (Elevated CK-MB isoenzymes) (ECG changes with ST-elevation)
Complications common to patients receiving hemodialysis for acute kidney injury include which of the following? (Select all that apply) A. Hypotension B. Dysrhythmias C. Muscle cramps D. Hemolysis E. Air embolism **P-16**
A & B (Hypotension) (Dysrhythmias)
The nurse is assessing a patient for a possible pulmonary embolus. Assessment findings may include which of the following? (Select all that apply) A. Acute onset of chest pain B. Low oxygen saturation level C. Hemoptysis D. Pleural friction rub **Evolve - Chapter 15**
A & C (Acute onset of chest pain) (Hemoptysis)
Identify diagnostic criteria for ARDS (Select all that apply) A. Bilateral infiltrates on chest x-ray study B. Decreased cardiac output C. PaO2/ FiO2 ratio of less than 200 D. Pulmonary artery occlusion pressure (PAOP) of more than 18 mm Hg E. PAOP less than 18 mm Hg **P-15**
A & C (Bilateral infiltrates on chest x-ray study) (PaO2/ FiO2 ratio of less than 200)
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) A. Make frequent neurological assessments B. Maintain CO2 level at 50 mm Hg C. Maintain MAP less than 130 mm Hg D. Prepare for thrombolytic administration E. Restrain affected limb to prevent injury **P-14**
A & C (Make frequent neurological assessments) (Maintain MAP less than 130 mm Hg)
Identify which substances in the glomerular filtrate would indicate a problem with renal function. (Select all that apply) A. Protein B. Sodium C. Creatinine D. Red blood cells E. Uric acid **P-16**
A & D (Protein) (Red blood cells)
The patient tells the nurse, "I didn't think I was having a heart attack because the pain was in my neck and back." The nurse explains: (Select all that apply) A. "Pain can occur anywhere in the chest, neck, arms, or back. Don't hesitate to call the emergency medical services if you think it's a heart attack." B. "For many people chest pain from a heart attack occurs in the center of the chest, behind the breastbone." C. "The sooner the patient can get medical help, the less damage is likely to occur in case of a heart attack." D. "You need to make sure it's a heart attack before you call the emergency response personnel." E. "Often symptoms can be treated with nitroglycerin, so be sure to take several before calling 911." **P-13**
A, B, & C ("Pain can occur anywhere in the chest, neck, arms, or back. Don't hesitate to call the emergency medical services if you think it's a heart attack.") ("For many people chest pain from a heart attack occurs in the center of the chest, behind the breastbone.") ("The sooner the patient can get medical help, the less damage is likely to occur in case of a heart attack.")
Which statements related to the management of unstable angina are true? (Select all that apply) A. Early revascularization (e.g., angioplasty) may be helpful B. Calcium channel blockers help to reduce symptoms C. Aspirin is given at the onset of each chest pain episode D. It is best treated with rest and nitroglycerin **Evolve - Chapter 13**
A, B, & C (Early revascularization (e.g., angioplasty) may be helpful) (Calcium channel blockers help to reduce symptoms) (Aspirin is given at the onset of each chest pain episode)
Select the strategies for preventing deep vein thrombosis (DVT) and pulmonary embolus (PE) (Select all that apply) A. Graduated compression stockings B. Heparin or low-molecular weight heparin for patients at risk C. Sequential compression devices D. Strict bed rest E. Leg massage **P-15**
A, B, & C (Graduated compression stockings) (Heparin or low-molecular weight heparin for patients at risk) (Sequential compression devices)
Noninvasive diagnostic procedures used to determine kidney function include which of the following? (Select all that apply) A. Kidney, ureter, bladder (KUB) x-ray B. Renal ultrasound C. Magnetic resonance imaging (MRI) D. Intravenous pyelography (IVP) E. Renal angiography **P-16**
A, B, & C (Kidney, ureter, bladder (KUB) x-ray) (Renal ultrasound) (Magnetic resonance imaging (MRI))
The nurse is caring for a patient in acute respiratory failure and understands that the patient should be positioned (Select all that apply) A. high Fowler's B. side lying with head of bed elevated C. sitting in a chair D. supine with the bed flat E. Trendelenburg **P-15**
A, B, & C (high Fowler's) (side lying with head of bed elevated) (sitting in a chair)
Identify the priority interventions for managing symptoms of an acute myocardial infarction (AMI) in the ED (Select all that apply) A. Administration of morphine B. Administration of nitroglycerin (NTG) C. Dopamine infusion D. Oxygen therapy E. Transfusion of packed red blood cells **P-13**
A, B, & D (Administration of morphine) (Administration of nitroglycerin (NTG)) (Oxygen therapy)
The nurse is caring for a mechanically ventilated patient. The nurse understands that strategies to prevent ventilator-associated pneumonia include which of the following? (Select all that apply) A. Drain condensate from the ventilator tubing away from the patient B. Elevate the head of the bed 30 to 45 degrees C. Instill normal saline as part of the suctioning procedure D. Perform regular oral care with chlorhexidine E. Awaken the patient daily to determine the need for continued ventilation **P-15**
A, B, & D (Drain condensate from the ventilator tubing away from the patient) (Elevate the head of the bed 30 to 45 degrees) (Perform regular oral care with chlorhexidine)
A client with acute kidney injury has a serum potassium level of 7.0 mEq/L. The nurse should plan which actions as a priority? (Select all that apply) A) Place the client on a cardiac monitor B) Notify the primary health care provider (PHCP) C) Put the client on NPO (nothing by mouth) status except for ice chips D) Review the client's medication to determine whether any contain or retain potassium E) Allow an extra 500 mL of intravenous fluid intake to dilute the electrolyte concentration **Rationale: Review Book pg. 784**
A, B, & D (Place the client on a cardiac monitor) (Notify the primary health care provider (PHCP)) (Review the client's medication to determine whether any contain or retain potassium)
Which clinical manifestations are indicative of right ventricular failure? (Select all that apply) A. Jugular venous distension B. Peripheral edema C. Crackles audible in the lungs D. Weak peripheral pulses E. Hepatomegaly **P-13**
A, B, & E (Jugular venous distention) (Peripheral edema) (Hepatomegaly)
The nurse is caring for a patient with status asthmaticus in the emergency department. The nurse anticipates what therapies to be ordered? (Select all that apply) A. Oxygen administration B. Inhaled rapid-acting beta-2 agonists C. Systemic corticosteroids D. Inhaled anticholinergic agent **Evolve - Chapter 15**
A, B, C & D (Oxygen administration) (Inhaled rapid-acting beta-2 agonists) (Systemic corticosteroids) (Inhaled anticholinergic agent)
A patient is admitted with an acute myocardial infarction (AMI). The nurse monitors for which potential complications? (Select all that apply) A. Cardiac dysrhythmias B. Heart failure C. Pericarditis D. Ventricular rupture E. Chest pain **P-13**
A, B, C, & D (Cardiac dysrhythmias) (Heart failure) (Pericarditis) (Ventricular rupture)
Which of the following are physiological effects of positive end-expiratory pressure (PEEP) used in the treatment of ARDS? (Select all that apply) A. Increases functional residual capacity B. Prevents collapse of unstable alveoli C. Improves arterial oxygenation D. Opens collapsed alveoli E. Improves carbon dioxide retention **P-15**
A, B, C, & D (Increases functional residual capacity) (Prevents collapse of unstable alveoli) (Improves arterial oxygenation) (Opens collapsed alveoli)
Which of the following are components of the Institute for Healthcare Improvement's (IHI's) ventilator bundle? (Select all that apply) A. Interrupt sedation each day to assess readiness to extubate B. Maintain head of bed at least 30 degrees of elevation C. Provide deep vein thrombosis prophylaxis D. Provide prophylaxis for peptic ulcer disease E. Swab the mouth with foam swabs every 2 hours **P-15**
A, B, C, & D (Interrupt sedation each day to assess readiness to extubate) (Maintain head of bed at least 30 degrees of elevation) (Provide deep vein thrombosis prophylaxis) (Provide prophylaxis for peptic ulcer disease)
The nurse is caring for a patient with cystic fibrosis (CF) and understands that treatment consists of which of the following? (Select all that apply) A. Airway clearance therapies B. Antibiotic therapy C. Nutritional support D. Tracheostomy E. Lung transplant **P-15**
A, B, C, & E (Airway clearance therapies) (Antibiotic therapy) (Nutritional support) (Lung transplant)
The nurse is listening to a lecture on the physiological consequences of acute respiratory distress syndrome (ARDS). Which statement indicates that teaching has been effective? A. "ARDS is associated with decreased compliance." B. "ARDS is associated with Pulmonary fibrosis." C. "ARDS is associated with decreased physiological dead space." D. "ARDS is associated with increased resistance." **Evolve - Chapter 15**
A ("ARDS is associated with decreased compliance.")
The nurse is orienting a new RN in the care of a patient with respiratory distress due to emphysema. The patient is being treated with O2 via a Venturi mask with 35% oxygen. Which statement by the new RN indicates that teaching has been effective, when the nurse questions the new RN about the use of the Venturi mask? A. "Her respiratory center requires low O2 concentration to stimulate breathing." B. "Her alveoli cannot absorb higher levels of O2 because of the emphysema." C. "A nasal cannula will dry the mucous membranes and cause an increased risk of infection." D. "Her alveoli have been damaged and may rupture with higher doses of O2." **Evolve - Chapter 15**
A ("Her respiratory center requires low O2 concentration to stimulate breathing.")
The nurse is providing care to a patient on fibrinolytic therapy. Which statement from the patient warrants further assessment and intervention by the critical care nurse? A. "I have an incredible headache!" B. "There is blood on my toothbrush!" C. "Look at the bruises on my arms!" D. "My arm is bleeding where my IV is!" **P-13**
A ("I have an incredible headache!")
A client is admitted with a diagnosis of acute kidney injury. The nurse understands which explanation is the most accurate description of the client's condition? A) A sudden loss of kidney function due to failure of the renal system circulation or to glomerular or tubular damage B) A progressive deterioration in kidney function that ends fatally when uremia develops C) An inflammation of the kidney pelvis, tubules, and interstitial tissues of one or both kidneys D) An inflammatory process precipitated by chemical changes in the glomeruli of both kidneys **K**
A (A sudden loss of kidney function due to failure of the renal system circulation or to glomerular or tubular damage)
The nurse is caring for a client who begins to experience seizure activity while in bed. Which action should the nurse take? (Select all that apply) A) Loosening restrictive clothing B) Restraining the client's limbs C) Removing the pillow and raising padded side rails D) Positioning the client to the side, if possible, with the head flexed forward E) Keeping the curtain around the client and the room door open so when help arrives they can quickly enter to assist **Rationale: Review Book pg. 851**
A, C, & D (Loosening restrictive clothing) (Removing the pillow and raising padded side rails) (Positioning the client to the side, if possible, with the head flexed forward)
The patient is admitted with acute kidney injury from a postrenal cause. Acceptable treatments for that diagnosis include: (Select all that apply) A. bladder catheterization B. increasing fluid volume intake C. ureteral stenting D. placement of nephrostomy tubes E. increasing cardiac output **P-16**
A, C, & D (bladder catheterization) (ureteral stenting) (placement of nephrostomy tubes)
The patient is in the critical care unit and will receive dialysis this morning. The nurse will (Select all that apply) A. evaluate morning laboratory results and report abnormal results B. administer the patient's antihypertensive medications C. assess the dialysis access site and report abnormalities D. weigh the patient to monitor fluid status E. give all medications except for antihypertensive medications **P-16**
A, C, & D (evaluate morning laboratory results and report abnormal results) (assess the dialysis access site and report abnormalities) (weigh the patient to monitor fluid status)
The most common reasons for initiating dialysis in acute kidney injury include which of the following? (Select all that apply) A. Acidosis B. Hypokalemia C. Volume overload D. Hyperkalemia E. Uremia **P-16**
A, C, D, & E (Acidosis) (Volume overload) (Hyperkalemia) (Uremia)
Which statements are true regarding the symptoms of an AMI? (Select all that apply) A. Dysrhythmias are common occurrences B. Men have more atypical symptoms than women C. Midsternal chest pain is a common presenting symptom D. Some patients are asymptomatic E. Patients may complain of jaw or back pain **P-13**
A, C, D, & E (Dysrhythmias are common occurrences) (Midsternal chest pain is a common presenting symptom) (Some patients are asymptomatic) (Patients may complain of jaw or back pain)
The nurse is educating a new RN on the therapeutic effect of head-of-the-bed elevation and neutral head and neck alignment on a patient with increased intracranial pressure (ICP). Which statement by the new RN indicates that teaching has been effective? A. "Head-of-the-bed elevation lowers ICP by maintaining an open airway." B. "Head-of-the-bed elevation lowers ICP by facilitating venous drainage and decreasing venous obstruction." C. "Head-of-the-bed elevation lowers ICP by reducing the risk of snoring." D. "Head-of-the-bed elevation lowers ICP by allowing for elevations in CO2 to dilate cerebral arteries." **Evolve - Chapter 14**
B ("Head-of-the-bed elevation lowers ICP by facilitating venous drainage and decreasing venous obstruction.")
The nurse teaches a client diagnosed with a spinal cord injury. Which statement best indicates that the client understands the long-term effects of a spinal cord injury? A) "I can't wait to get back on my feet again and repair my bike." B) "I'm going to have to make a lot of adjustments in my life." C) "My friends are expecting me to go camping with them next month." D) "It's weird not to feel things. I'll be glad when that is over." **K**
B ("I'm going to have to make a lot of adjustments in my life.")
A client diagnosed with angina, and the nurse instructs the client about care at home. The nurse determines that teaching is effective if the client makes which statement? A) "If I have chest pain, I should stop my activity and take an aspirin." B) "If I have chest pain, I should stop my activity and take a nitroglycerin tablet." C) "I can take another aspirin if my chest pain doesn't subside in 30 minutes." D) "If I have chest pain, I should rest for 30 minutes and then take a nitroglycerin tablet." **K**
B ("If I have chest pain, I should stop my activity and take a nitroglycerin tablet.")
The nurse is discharging a patient home following treatment for community-acquired pneumonia. As part of the discharge teaching, the nurse instructs, A. "If you get the pneumococcal vaccine, you'll never get pneumonia again." B. "It is important for you to get an annual influenza shot to reduce your risk of pneumonia." C. "Stay away from cold, drafty places because that increases your risk of pneumonia when you get home." D. "Since you have been treated for pneumonia, you now have immunity from getting it in the future." **P-15**
B ("It is important for you to get an annual influenza shot to reduce your risk of pneumonia.")
An older client has been taking sustained-release nitroglycerin for several years. The client asks the nurse if there are any concerns about taking sildenafil on the same day. Which response by the nurse is best? A) "Taking sildenafil at night will decrease any adverse effects of the nitroglycerin." B) "Taking both together can result in hypotension, which could be fatal." C) "Taking the sildenafil at atleast two hours after taking the sustained-release nitroglycerin is advised." D) "Taking both will not cause any harm unless you already have heart problems." **K**
B ("Taking both together can result in hypotension, which could be fatal.") **Sildenafil = erectile dysfunction pill
The patient's spouse is feeling overwhelmed about cooking different dinners for the patient and the rest of the family to satisfy a cholesterol-reducing diet. Which response by the nurse is best? A. "It will be worth it to have a healthy spouse, won't it?" B. "The low-cholesterol diet is one from which everyone can benefit." C. "As long as you change at least a few things in the diet, it will be okay." D. "You can go on the diet with him, and then let the children eat whatever they want." **P-13**
B ("The low-cholesterol diet is one from which everyone can benefit.")
Which comment by the patient indicates a good understanding of a diagnosis of coronary heart disease? A. "I had a heart attack because I work too hard, and it puts too much strain on my heart." B. "The pain in my chest gets worse each time it happens. I think that there is more damage to my heart vessels as time goes on." C. "If I change my diet and exercise more, I should get over this and be healthy." D. "What kind of pills can you give me to get me over this and back to my lifestyle?" **P-13**
B ("The pain in my chest gets worse each time it happens. I think that there is more damage to my heart vessels as time goes on.")
A patient is having a stent and asks why it is necessary after having an angioplasty. Which response by the nurse is best? A. "The angioplasty was a failure, and so this procedure has to be done to fix the heart vessel." B. "The stent is inserted to enhance the results of the angioplasty, by helping to keep the vessel open and prevent it from closing again." C. "This procedure is being done instead of using clot-dissolving medication to help keep the heart vessel open." D. "The stent will remove any clots that are in the vessel and protect the heart muscle from damage." **P-13**
B ("The stent is inserted to enhance the results of the angioplasty, by helping to keep the vessel open and prevent it from closing again.")
A patient at high risk for pulmonary embolism is receiving enoxaparin. The nurse explains to the patient: A. "I'm going to contact the pharmacist to see if you can take this medication by mouth." B. "This injection is being given to prevent blood clots from forming." C. "This medication will dissolve any blood clots you might get." D. "You should not be receiving this medication. I will contact the provider to get it stopped." **P-15**
B ("This injection is being given to prevent blood clots from forming.")
Which statements best represent optimal fluid administration for the management of increased intracranial pressure? A. Hypotonic solutions are avoided to prevent an increase in cerebral edema B. 0.45% saline solution is acceptable for fluid volume resuscitation C. The goal is to keep serum osmolality greater than 320 mOsm/L D. Normal saline (0.9%) is recommended for fluid volume resuscitation **Evolve - Chapter 14**
B (0.45% saline solution is acceptable for fluid volume resuscitation)
What is a minimally acceptable urine output for a patient weighing 75 kg? A. Less than 30 mL/hour B. 37 mL/hour C. 80 mL/hour D. 150 mL/hour **P-16**
B (37 mL/hour) **Normal urine output is 0.5 to 1 mL/kg of body weight each hour
The patient's serum creatinine level is 0.7 mg/dL. The expected BUN level should be A. 1 to 2 mg/dL B. 7 to 14 mg/dL C. 10 to 20 mg/dL D. 20 to 30 mg/dL **P-16**
B (7 to 14 mg/dL)
A normal glomerular filtration rate is A. less than 80 mL/min B. 80 to 125 mL/min C. 125 to 180 mL/min D. more than 189 mL/min **P-16**
B (80 to 125 mL/min)
The nurse identifies which client is most at risk for developing pneumonia? A) A client with indwelling urinary catheter B) A client with a nasogastric (NG) tube C) A client diagnosed with psoriasis D) A client diagnosed with Paget disease **K**
B (A client with a nasogastric (NG) tube)
A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hr for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily lab result indicate that the blood urea nitrogen level is 45 mg/dL and the serum creatinine level is 2.2 mg/dL. On the basis of these findings, the nurse anticipate that the client is at risk for which problem? A) Hypovolemia B) Acute kidney injury C) Glomerulonephritis D) Urinary tract infection **Rationale: Review Book pg. 733**
B (Acute kidney injury)
The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine injury who is complaining of a severe headache. The nurse assesses a blood pressure of 180/90 mm Hg, heart rate 60 beats/min, respirations 24 breaths/min, and 50 mL of urine via indwelling urinary catheter for the past 4 hours. What is the best action by the nurse? A. Administer acetaminophen as ordered for the headache B. Assess for a kinked urinary catheter and assess for bowel impaction C. Encourage the patient to take slow, deep breaths D. Notify the provider of the patient's blood pressure **P-14**
B (Assess for a kinked urinary catheter and assess for bowel impaction)
The patient is admitted to the unit with the diagnosis of rhabdomyolysis. The patient is started on intravenous (IV) fluids and IV mannitol. What action by the nurse is best? A. Assess the patient's hearing B. Assess the patient's lungs C. Decrease IV fluids once the diuretic has been administered D. Give extra doses before giving radiological contrast agents **P-16**
B (Assess the patient's lungs)
The patient has undergone open chest surgery for coronary artery bypass grafting. One of the nurse's responsibilities is to monitor the patient for which common postoperative dysrhythmia? A. Second-degree heart block B. Atrial fibrillation or flutter C. Ventricular ectopy D. Premature junctional contractions **P-13**
B (Atrial fibrillation or flutter)
The term used to describe an increase in blood urea nitrogen (BUN) and serum creatinine is A. oliguria B. azotemia C. acute kidney injury D. prerenal disease **P-16**
B (Azotemia)
Autonomic dysreflexia is characterized by an exaggerated response of the sympathetic nervous system to a variety of stimuli. Common causes of autonomic dysreflexia include: A. fecal impaction B. bladder distension C. urinary tract infection D. sinus bradycardia **Evolve - Chapter 14**
B (Bladder distention)
The nurse is monitoring a patient's intracranial pressuere (ICP). While the nurse is providing hygiene measures, she observes that the ICP reading is sustained at 18 mm Hg. What is the priority nursing action? A. Lower the head of the bed to 10 degrees B. Cease stimulating the patient C. Continue with hygiene measures D. Open the ICP monitor to continuous drainage **Evolve - Chapter 14**
B (Cease stimulating the patient)
Herniation syndromes can be life-threatening situations. Which syndrome causes the supratentorial contents to shift downward and compress vital centers of the brainstem? A. Cingulate herniation B. Central herniation C. Uncal herniation D. Tonsillar herniation **Evolve - Chapter 14**
B (Central herination)
The nurse is caring for a postoperative patient with chronic obstructive pulmonary disease (COPD). Which assessment would be a cue to the patient developing postoperative pneumonia? A. Bradycardia B. Change in sputum characteristics C. Hypoventilation and respiratory acidosis D. Pursed-lip breathing **P-15**
B (Change in sputum characteristics)
The nurse provides care for a newly admitted client diagnosed with a head injury. The nurse notes the client has clear nasal drainage. Which action does the nurse take FIRST? A) Obtains a specimen of the fluid for culture and sensitivity B) Checks the nasal drainage for glucose C) Obtains the client's temperature D) Instructs the client to blow the nose **K**
B (Checks the nasal drainage for glucose)
The nurse provides care for a client diagnosed with angina. The nurse understands nitroglycerin is used in the treatment of angina pectoris for which reason? A) Prevents attacks precipitated by stressful events B) Decreases preload C) Produces coronary artery dilation in sclerotic vessels D) Corrects medication-induced dysrhythmias **K**
B (Decreases preload)
The nurse reviews information about the relationship of psychological risk factors in persons with coronary artery disease. Which risk factor does the nurse identify? A) Schizophrenia B) Depression C) Sleep disturbance D) Phobias **K**
B (Depression)
Which of the following activities may help decrease increased intracranial pressure? A) Frequent suctioning B) Head elevation to 30 degrees C) Pressure on the abdomen while coughing D) Valsalva maneuver **Rationale: Text book pg. 605**
B (Head elevation to 30 degrees)
The nurse assesses a patient who is admitted for an overdose of sedatives. The nurse expects to find which acid-base alteration? A. Hyperventilation and respiratory acidosis B. Hypoventilation and respiratory acidosis C. Hypoventilation and respiratory alkalosis D. Respiratory acidosis and normal oxygen levels **P-15**
B (Hypoventilation and respiratory acidosis)
The nurse is assessing a patient. Which assessment would cue the nurse to the potential of acute respiratory distress syndrome (ARDS)? A. Increased oxygen saturation via pulse oximetry B. Increased peak inspiratory pressure on the ventilator C. Normal chest radiograph with enlarged cardiac structures D. PaO2/FiO2 ratio >300 **P-15**
B (Increased peak inspiratory pressure on the ventilator)
The nurse is caring for the client with increased intracranial pressure as a result of a head injury. The nurse would note which trend in vital signs if the intracranial pressure is rising? A) Increasing temperature, increasing pulse, increasing respirations, and decreasing blood pressure B) Increasing temperature, decreasing pulse, decreasing respirations, and increasing blood pressure C) Decreasing temperature, decreasing pulse, increasing respirations, and decreasing blood pressure D) Decreasing temperature, increasing pulse, decreasing respirations, and increasing blood pressure **Rationale: Review Book pg. 850**
B (Increasing temperature, decreasing pulse, decreasing respirations, and increasing blood pressure)
An acute exacerbation of asthma is treated with which of the following? A. Corticosteroids and theophylline by mouth B. Inhaled bronchodilators and intravenous corticosteroids C. Prone positioning or continuous lateral rotation D. Sedation and inhaled bronchodilators **P-15**
B (Inhaled bronchodilators and intravenous corticosteroids)
Which of the following treatments is done in conjunction with an angioplasty procedure to facilitate long-term patency of the vessel? A) Coronary artery bypass B) Insertion of a stent C) Thrombectomy D) Thrombolysis **Rationale: Text book pg. 604**
B (Insertion of a stent)
The nurse provides care for a client diagnosed with a closed head injury and increase intracranial pressure. which action by the nurse is BEST? A) Position the client with head of bed flat and client's head in a neutral position B) Instruct the client to exhale when turning or moving in bed C) Encourage the client to cough and deep breath every two hours D) Suction client frequently and hyperoxygenate prior to suctioning **K**
B (Instruct the client to exhale when turning or moving in bed)
A patient was admitted in terminal heart failure and is not eligible for transplant. The family wants everything possible done to maintain life. Which procedure might be offered to the patient for this condition to increase the patient's quality of life? A. Intraaortic balloon pump (IABP) B. Left ventricular assist device (LVAD) C. Nothing, because the patient is in terminal heart failure D. Nothing additional; medical management is the only option **P-13**
B (Left ventricular assist device (LVAD))
Lung-protective strategies for mechanical ventilation to treat acute respiratory distress syndrome while also preventing complications include which of the following? A. Positive end-expiratory pressure (PEEP) 25 cm H20 or higher B. Low tidal volume of 6 mL/kg ideal body weight C. High levels of sedation D. Oxygen levels (FIO2) 0.80-1.00 **Evolve - Chapter 15**
B (Low tidal volume of 6 mL/kg ideal body weight)
The nurse admits a patient to the emergency department (ED) with a suspected cervical spine injury. What is the priority nursing action? A. Keep the neck in the hyperextended position B. Maintain proper head and neck alignment C. Prepare for immediate endotracheal intubation D. Remove cervical collar upon arrival to the ED **P-14**
B (Maintain proper head and neck alignment)
The patient is admitted with an acute myocardial infarction (AMI). Three days later the nurse is concerned that the patient may have a papillary muscle rupture. Which assessment data may indicate a papillary muscle rupture? A. Gallop rhythm B. New murmur C. S1 heart sound D. S3 heart sound **P-13**
B (New murmur)
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? A. Apply warming devices as needed B. Perform hourly incentive spirometry C. Assist with passive range-of-motion D. Give small, frequent feedings **Evolve - Chapter 14**
B (Perform hourly incentive spirometry)
Which of the following types of angina is associated with ST-segment elevation? A) Exercised-induced B) Prinzmetal's C) Smoking-induced D) Stable **Rationale: Text book pg. 604**
B (Prinzmetal's)
The nurse provides care for a client diagnosed with right-sided hemiplegia due to a stroke. The nurse observes the client has an inability to eat without total assistance. Which intervention is MOST appropriate to improve the client's nutrition? A) Assist the client to eat with the left hand B) Provide a pureed diet C) Stroke the client's throat D) Provide a wide variety of food choice on the meal tray **K**
B (Provide a pureed diet)
The left atrium receives oxygenated blood from which vessel? A. Pulmonary artery B. Pulmonary vein C. Right ventricle D. Superior Vena Cava **Rationale: Text book pg. 604**
B (Pulmonary vein)
A client diagnosed with a cervical spinal cord injury reports a pounding headache and blurred vision. The nurse assesses the client and notes the blood pressure is 210/110, heart rate is 50, the client's face and chest are flushed, and the urinary catheter is kinked. Which action does the nurse take first? A) Flush the indwelling urinary catheter with sterile saline B) Raise the head of the bed 45 to 60 degrees C) Check the blood pressure on the opposite arm D) Provide reassurance and attempt to calm the client **K**
B (Raise the head of the bed 45 to 60 degrees)
The nurse understands that hematocrit measures which data about the blood? A) Oxygen-carrying capacity of the blood B) Ratio of red blood cells to fluid volume C) Number of red blood cells in 100 mL of blood D) Ratio of red blood cell to white blood cells **K**
B (Ratio of red blood cells to fluid volume)
The nurse provides care for a client diagnosed with a stroke resulting in right hemiplegia. Which is the CORRECT technique for the nurse to use when transferring the client from the bed to a chair? A) Assist the client from a sitting to a standing position by pulling up no the affected side B) Support the standing client for a minute before pivoting towards the chair C) Ask the client to roll to the right side of the bed and assist the client form the right side D) Instruct the client to place arms around the nurse's neck to move from a standing position to the chair **K**
B (Support the standing client for a minute before pivoting towards the chair)
Which should the nurse include in the plan of care for a client diagnosed with increased intracranial pressure (ICP)? A) Frequently suction the airway B) Teach the client to avoid the Valsalva maneuver C) Position the client supine in a dark room D) Withhold sedatives when the ICP is greater than 20 mmHg **K**
B (Teach the client to avoid the Valsalva maneuver)
Which of the following cardiac diagnostic tests would include monitoring the gag reflex before giving the patient anything to eat or drink? A. Barium swallow B. Transesophageal echocardiogram C. MUGA scan D. Stress test **P-13**
B (Transesophageal echocardiogram)
Lung protective ventilation strategies include: A) Tidal volume (Vt) calculated according to current patient weight B) Vt at 4 to 8 mL/kg predicted ideal body weight C) Consistent use of 100% fraction of inspired oxygen (FiO2) D) Positive end-expiratory pressure (PEEP) levels of 30 cm H2O for 8 hours each day **Rationale: Text book pg. 605**
B (Vt at 4 to 8 mL/kg predicted ideal body weight)
A client is being prepared for peritoneal dialysis. Which nursing action is taken first? A) Assess for bruit B) Warm the dialysate C) Position the client on the left side D) Insert an indwelling urinary catheter **K**
B (Warm the dialysate)
The nurse provides care for a school-age client with traumatic brain injury. Which symptoms BEST indicate increased intracranial pressure? A) Headache, crying, sensitivity to loud noises and bright lights B) Widening pulse pressure, slow respirations, and bradycardia C) Hypotension, cyanosis, and tachycardia D) Increased temperature, increased respirations, and shaking **K**
B (Widening pulse pressure, slow respirations, and bradycardia)
The nurse is caring for an elderly patient who was admitted with renal insufficiency. An expected laboratory finding for this patient may be A. an increased glomerular filtration rate (GFR) B. a normal serum creatinine level C. increased ability to excrete drugs D. hypokalemia **P-16**
B (a normal serum creatinine level)
The nurse is examining the patient's urinalysis and notices the presence of red blood cells and albumin as well as nitrogenous waste products and sodium. The nurse interprets this assessment finding as: A. abnormal; urinary sodium levels should be higher than serum levels B. abnormal; albumin is an abnormal finding in urine C. normal; red blood cells are normally found in urine D. abnormal; nitrogenous waste products in urine indicate kidney disease **Evolve - Chapter 16**
B (abnormal; albumin is an abnormal finding in urine)
The patient has elevated blood urea nitrogen (BUN) and serum creatinine levels with a normal BUN/creatinine ratio. These levels most likely indicate A. increased nitrogen intake B. acute kidney injury, such as acute tubular necrosis (ATN) C. hypovolemia D. fluid resuscitation **P-16**
B (acute kidney injury, such as acute tubular necrosis (ATN))
The critical care nurse knows that in critically ill patients, renal dysfunction A. is a very rare problem B. affects nearly two thirds of patients C. has a low mortality rate once renal replacement therapy has been initiated D. has little effect on morbidity, mortality, or quality of life **P-16**
B (affects nearly two thirds of patients)
An essential aspect of teaching that may prevent recurrence of heart failure is A. notifying the provider if a 2-lb weight gain occurs in 24 hours B. compliance with diuretic therapy C. taking nitroglycerin if chest pain occurs D. assessment of an apical pulse **P-13**
B (compliance with diuretic therapy)
The nurse is caring for a patient with a diagnosis of pulmonary embolism. The nurse understands that the most common cause of a pulmonary embolus is A. amniotic fluid embolus B. deep vein thrombosis from lower extremities C. fat embolus from a long bone fracture D. vegetation that dislodges from an infected central venous catheter **P-15**
B (deep vein thrombosis from lower extremities)
When fluid is present in the alveoli, A. alveoli collapse, and atelectasis occurs B. diffusion of oxygen and carbon dioxide is impaired C. hypoventilation occurs D. the patient is in heart failure **P-15**
B (diffusion of oxygen and carbon dioxide is impaired)
The patient has a temporary percutaneous catheter in place for treatment of acute kidney injury. The catheter has been in place for 5 days. The nurse should A. prepare to assist with a routine dialysis catheter change B. evaluate the patient for signs and symptoms of infection C. teach the patient that the catheter is designed for long-term use D. use one of the three lumens for fluid administration **P-16**
B (evaluate the patient for signs and symptoms of infection)
The patient undergoes a cardiac catheterization that requires the use of contrast dyes during the procedure. To detect signs of contrast-induced kidney injury, the nurse should A. not be concerned unless urine output decreases B. evaluate the patient's serum creatinine for up to 72 hours after the procedure C. obtain an order for a renal ultrasound D. evaluate the patient's postvoid residual volume to detect intrarenal injury **P-16**
B (evaluate the patient's serum creatinine for up to 72 hours after the procedure)
The patient has been admitted to the hospital with nausea and vomiting that started 5 days earlier. Blood pressure is 80/44 mm Hg and heart rate is 122 beats/min; the patient has not voided in 8 hours, and the bladder is not distended. The nurse anticipates a prescription for "stat" administration of A. a blood transfusion B. fluid replacement with 0.45% saline C. infusion of an inotropic agent D. an antiemetic **P-16**
B (fluid replacement with 0.45% saline)
The nurse is caring for a patient who weighs 70 kg. For this patient, the nurse interprets oliguria is defined as urine output that is _________________ mL per hour A. less than 100 B. less than 35 C. less than 50 D. greater than 35 **Evolve - Chapter 16**
B (less than 35)
The patient is complaining of severe flank pain when he tries to urinate. His urinalysis shows sediment and crystals along with a few bacteria. Using this information along with the clinical picture, the nurse realizes that the patient's condition is A. prerenal B. postrenal C. intrarenal D. not renal related **P-16**
B (postrenal)
Peritoneal dialysis is different from hemodialysis in that peritoneal dialysis A. is more frequently used for acute kidney injury B. uses the patient's own semipermeable membrane (peritoneal membrane) C. is not useful in cases of drug overdose or electrolyte imbalance D. is not indicated in cases of water intoxication **P-16**
B (uses the patient's own semipermeable membrane (peritoneal membrane))
Which nursing interventions would be appropriate after angioplasty? (Select all that apply) A. Elevate the head of the bed by 45 degrees for 6 hours B. Assess pedal pulses on the involved limb every 15 minutes for 1 to 2 hours C. Monitor the vascular hemostatic device for signs of bleeding D. Instruct the patient to bend his or her knee every 15 minutes while the sheath is in place E. Maintain NPO status for 12 hours **P-13**
B & C (Assess pedal pulses on the involved limb every 15 minutes for 1 to 2 hours) (Monitor the vascular hemostatic device for signs of bleeding)
The nurse cares for a client with increased intracranial pressure (ICP). Which activities contribute to increased intracranial pressure (ICP)? (Select all that apply) A) A quiet environment B) Hand restraints C) Having a bowel movement D) Listening to soft music E) Watching television **K**
B & C (Hand restraints) (Having a bowel movement)
Which of the following statements is true regarding oral care for the prevention of ventilator-associated pneumonia (VAP)? (Select all that apply) A. Tooth brushing is performed every 2 hours for the greatest effect B. Implementing a comprehensive oral care program is an intervention for preventing VAP C. Oral care protocols should include oral suctioning and brushing teeth D. Protocols that include chlorhexidine gluconate have been effective in preventing E. Using oral swabs or toothettes are just as effective as brushing the teeth **P-15**
B, C, & D (Implementing a comprehensive oral care program is an intervention for preventing VAP) (Oral care protocols should include oral suctioning and brushing teeth) (Protocols that include chlorhexidine gluconate have been effective in preventing)
The nurse is monitoring a client with heart failure who is taking digoxin. Which findings are characteristics of digoxin toxicity? (Select all that apply) A) Tremors B) Diarrhea C) Irritability D) Blurred vision E) Nausea and vomiting **Rationale: Review Book pg. 753**
B, D, & E (Diarrhea) (Blurred vision) (Nausea and vomiting)
The nurse explains to the new RN that angiotensin-converting enzyme inhibitors (ACE inhibitors) should be started within 24 hours of acute myocardial infarction (AMI). Which statement by the new RN indicates that teaching has been effective? A. "ACE inhibitors are started within 24 hours to prevent tachycardia." B. "ACE inhibitors are started within 24 hours to prevent myocardial stunning." C. "ACE inhibitors are started within 24 hours to prevent myocardial remodeling." D. "ACE inhibitors are started within 24 hours to prevent hibernating myocardium." **Evolve - Chapter 13**
C ("ACE inhibitors are started within 24 hours to prevent myocardial remodeling.")
The nurse is listening to a lecture on the impact of decreased blood flow through the kidneys. Which statement by the nurse indicates that teaching has been effective? A. "Decreased kidney blood flow can lead to peripheral vasodilation." B. "Decreased kidney blood flow can lead to decreased systolic blood pressure." C. "Decreased kidney blood flow can lead to release of renin from the kidney." D. "Decreased kidney blood flow can lead to increased excretion of sodium and water." **Evolve - Chapter 16**
C ("Decreased kidney blood flow can lead to release of renin from the kidney.")
The nurse provides care for a client diagnosed with coronary artery disease. Which client statement indicates to the nurse an understanding of the disease process? A) "I will notify my health care provider if I have to take any sublingual nitroglycerin." B) "I will massage the area around my nitroglycerin patch." C) "I will go to the hospital if pain persist after I have taken my medication and rested." D) "I will work out for 2 hours every day." **K**
C ("I will go to the hospital if pain persist after I have taken my medication and rested.")
The patient has just returned from having an arteriovenous fistula placed. The patient asks, "When will they be able to use this and take this other catheter out?" The nurse should reply, A. "It can be used immediately, so the catheter can come out anytime." B. "It will take 2 to 4 weeks to heal before it can be used." C. "The fistula will be usable in about 4 to 6 weeks." D. "The fistula was made using graft material, so it depends on the manufacturer." **P-16**
C ("The fistula will be usable in about 4 to 6 weeks.")
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 108 mm Hg. What is the cerebral perfusion pressure (CPP)? A. 54 mm Hg B. 72 mm Hg C. 90 mm Hg D. 126 mm Hg **P-14**
C (90 mm Hg) **CPP = MAP - ICP
The nurse provides discharge teaching in a client with a diagnosis of angina. It is most important for the client to report which occurrence? A) Chest pain following sexual activity B) A headache after taking nitroglycerin C) A change in the character of the pain D) Chest pain after eating a large meal **K**
C (A change in the character of the pain)
Which state BEST describes the events leading to death of neurons after an ischemic stroke? A) Increased metabolic activity in the neurons surrounding the affected area B) Movement of potassium ions into the cells from the extracellular area C) Accumulation of sodium and water inside the neurons in the affected area D) Increased formation of adenosine (ATP) in the neurons in the affected area **K**
C (Accumulation of sodium and water inside the neurons in the affected area)
The provider prescribes a pharmacological stress test for a patient with activity intolerance. The nurse would anticipate that the drug of choice would be A. dopamine B. dobutamine C. adenosine D. atropine **P-13**
C (Adenosine)
Which of the following assessment findings indicate that the patient with an acute cervical spinal cord injury is experiencing neurogenic shock? A) Heart rate of 112 and temperature of 38.7 B) Absence of deep tendon reflexes in the lower extremities C) Blood pressure of 84/56 mmHg and heart rate of 41 bpm D) Inability to sense pain in the lower extremities **Rationale: Text book pg. 605**
C (Blood pressure of 84/56 mmHg and heart rate of 41 bpm)
The nurse identifies that respiratory paralysis may occur if a client experiences a spinal cord injury above which level? A) C6 B) C5 C) C4 D) T1 **K**
C (C4)
The nurse provides care for a client diagnosed with increased intracranial pressure (ICP). Which is the MOST important short-term goal for this client? A) Encourage coughing and deep breathing B) Maintain client in supine position with limited movement C) Control agitation and restlessness D) Avoid bright lights **K**
C (Control agitation and restlessness)
While instructing a patient on what occurs with a myocardial infarction, the nurse plans to explain which process? A. Coronary artery spasm B. Decreased blood flow (ischemia) C. Death of cardiac muscle from lack of oxygen (tissue necrosis) D. Sporadic decrease in oxygen to the heart (transient oxygen imbalance) **P-13**
C (Death of cardiac muscle from lack of oxygen (tissue necrosis))
A client diagnosed with angina and receives nitroglycerin. The nurse informs the client that which of the following are common adverse effects of nitroglycerin? A) Palpitations, hypertension, and tachycardia B) Flushing, bradycardia, and muscle weakness C) Dizziness, headache, and hypotension D) Flushing, vertigo, and motor seizures **K**
C (Dizziness, headache, and hypotension)
The nurse is assessing a patient with left-sided heart failure. Which symptom would the nurse expect to find? A. Dependent edema B. Distended neck veins C. Dyspnea and crackles D. Nausea and vomiting **P-13**
C (Dyspnea and crackles)
A patient is having a cardiac evaluation to assess for possible valvular disease. Which study best identifies valvular function and measures the size of the cardiac chambers? A. 12-lead electrocardiogram B. Cardiac catheterization C. Echocardiogram D. Electrophysiology study **P-13**
C (Echocardiogram)
What does HFrEF refer to? A) Heart failure that is compensated B) Heart failure with preserved ejection fraction C) Heart failure with reduced ejection fraction D) Heart failure with refractory ejection fraction **Rationale: Text book pg. 605**
C (Heart failure with reduced ejection fraction)
The nurse is caring for a patient with a head injury. If autoregulation is lost, what should the nurse be most concerned for? A. Shunting of cerebrospinal fluid (CSF) blockage B. Occurrence of central venous engorgement C. Hypertension increasing cerebral blood flow D. Unchanged cerebral blood flow **Evolve - Chapter 14**
C (Hypertension increasing cerebral blood flow)
While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mm Hg and a CPP of 85 mm Hg. What is the best interpretation by the nurse? A. Both pressures are high B. Both pressures are low C. ICP is high; CPP is normal D. ICP is high; CPP is low **P-14**
C (ICP is high; CPP is normal)
The nurse is caring for a patient admitted with bacterial meningitis. Vital signs assessed by the nurse include blood pressure 110/70 mm Hg, heart rate 110 beats/min, respiratory rate 30 breaths/min, oxygen saturation (SpO2) 95% on supplemental oxygen at 3 L/min, and a temperature 103.5 F. What is the priority nursing action? A. Elevate the head of the bed 30 degrees B. Keep lights dim at all times C. Implement seizure precautions D. Maintain bed rest at all times **P-14**
C (Implement seizure precautions)
The nurse is caring for a mechanically ventilated patient with a brain injury. Arterial blood gas values indicate a PaCO2 of 60 mm Hg. The nurse understands this value to have which effect on cerebral blood flow? A. Altered cerebral spinal fluid production and reabsorption B. Decreased cerebral blood volume due to vessel constriction C. Increased cerebral blood volume due to vessel dilation D. No effect on cerebral blood flow (PaCO2 of 60 mm Hg is normal) **P-14**
C (Increased cerebral blood volume due to vessel dilation)
Which of the following are nursing interventions to prevent ventilator-associated pneumonia (VAP)? A. Intubate the patient with an endotracheal tube with continuous subglottic aspiration of secretions. B. Elevate the head of bed to at least 30 degrees. C. Maintain a deep level of sedation. D. Provide regular oral care, including the use of chlorhexidine **Evolve - Chapter 15**
C (Maintain a deep level of sedation)
A patient is admitted with an acute myocardial infarction (AMI). The nurse knows that an angiotensin-converting enzyme (ACE) inhibitor should be started within 24 hours to reduce the incidence of which process? A. Myocardial stunning B. Hibernating myocardium C. Myocardial remodeling D. Tachycardia **P-13**
C (Myocardial remodeling)
The patient, who is being treated for hypercholesterolemia, complains of hot flashes and a metallic taste in the mouth. The nurse educates the patient that this is a side effect of: A. bile acid resins B. statins C. nicotinic acid D. clopidogrel **Evolve - Chapter 13**
C (Nicotinic acid)
A patient is admitted with angina. The nurse anticipates which drug regimen to be initiated? A. ACE inhibitors and diuretics B. Morphine sulfate and oxygen C. Nitroglycerin, oxygen, and beta blockers D. Statins, bile acid, and nicotinic acid **P-13**
C (Nitroglycerin, oxygen, and beta blockers)
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? A. Emergency tracheostomy and mechanical ventilation B. Mechanical ventilation via an endotracheal tube C. Noninvasive positive-pressure ventilation (NPPV) D. Oxygen at 100% via bag-valve-mask device **P-15**
C (Noninvasive positive-pressure ventilation (NPPV))
The nurse is drawing labs on a patient with COPD in the critical care unit. Which baseline arterial blood gases (ABGs) should the nurse expect for this patient? A. PaO2 50 mm Hg and PaCO2 35 mm Hg B. PaO2 80 mm Hg and PaCO2 50 mm Hg C. PaO2 55 mm Hg and PaCO2 55 mm Hg D. PaO2 75 mm Hg and PaCO2 40 mm Hg **Evolve - Chapter 15**
C (PaO2 55 mm Hg and PaCO2 55 mm Hg)
A patient is admitted with the diagnosis of unstable angina. The nurse knows that the physiological mechanism present is most likely which of the following? A. Complete occlusion of a coronary artery B. Fatty streak within the intima of a coronary artery C. Partial occlusion of a coronary artery with a thrombus D. Vasospasm of a coronary artery **P-13**
C (Partial occlusion of a coronary artery with a thrombus)
The nurse provides care for a client diagnosed with a stroke resulting in right hemiplegia, sensory loss, and cognitive dysfunction. During the client's first 72 hours of hospitalization, which is the priority nursing action? A) Teach the client how to transfer from bed to chair B) Use a picture board to help the client communicate C) Perform neurological assessments every 2 hours D) Assist the client to comb hair and brush teeth **K**
C (Perform neurological assessments every 2 hours)
The nurse is caring for a patient getting peritoneal dialysis. The patient complains of abdominal pain, chills, and nausea. The dialysate return is cloudy. The nurse notifies the provider that the patient is exhibiting symptoms of: A. catheter blockage B. intolerance of peritoneal fluid volume C. peritonitis D. mechanical dysfunction of the dialysate **Evolve - Chapter 16**
C (Peritonitis)
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? A. Have the patient blow the nose until clear B. Insert bilateral cotton nasal packing C. Place a nasal drip pad under the nose D. Suction the left nares until the drainage clears **P-14**
C (Place a nasal drip pad under the nose)
The patient is admitted for general malaise and low urine output. The patient is alert and oriented and states that he has lost 5 pounds over the past few days. His heart rate is 124 beats/min. His blood pressure is 88/40 mm Hg. His mouth is dry and he has flat neck veins and poor skin turgor. The nurse interprets that his low urine output is due to: A. uremia B. intrarenal causes C. prerenal causes D. fluid overload **Evolve - Chapter 16**
C (Prerenal causes)
The patient is admitted with recurrent supraventricular tachycardia that the cardiologist believes to be related to an accessory conduction pathway or a reentry pathway. The nurse anticipates which procedure to be planned for this patient? A. Implantable cardioverter-defibrillator placement B. Permanent pacemaker insertion C. Radiofrequency catheter ablation D. Temporary transvenous pacemaker placement **P-13**
C (Radiofrequency catheter ablation)
Evidence-based interventions for the prevention of ventilator-associated pneumonia (VAP) include: A) Head of bed (HOB) flat with patient supine B) Readiness-to-wean trails every other day C) Regular antiseptic oral care D) Deep vein thrombosis (DVT) prophylaxis on select patients **Rationale: Text book pg. 605**
C (Regular antiseptic oral care)
Which of the following acid-base disturbances commonly occurs with the hyperventilation and impaired gas exchange seen in severe exacerbation of asthma? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis **P-15**
C (Respiratory acidosis)
A 72-year-old woman is brought to the ED by her family. The family states that she's "just not herself." Her respirations are slightly labored, and her heart monitor shows sinus tachycardia (rate 110 beats/min) with frequent premature ventricular contractions (PVCs). She denies any chest pain, jaw pain, back discomfort, or nausea. Her troponin levels are elevated, and her 12-lead electrocardiogram (ECG) shows elevated ST segments in leads II, III, and aVF. The nurse knows that these symptoms are most likely associated with which diagnosis? A. Hypokalemia B. Non-Q wave MI C. Silent myocardial infarction D. Unstable angina **P-13**
C (Silent myocardial infarction)
A patient presents to the emergency department in acute respiratory distress. She has a long-standing history of COPD. Which of the following positions should the nurse place this patient in for optimal tissue perfusion? A. In a recliner, leaning back as far as it will go B. Side-lying with head of bed at 15 degrees C. Stretcher with head of bed as high as it will go D. Prone on a stretcher **Evolve - Chapter 15**
C (Stretcher with head of bed as high as it will go)
The nurse is caring for a patient with an assessed Glasgow Coma Scale score of 3. What is the best interpretation of this finding? A. Damage to the patient's corpus callosum has led to a comatose state B. A Glasgow Coma Scale score of less than 3 indicates a semicomatose state C. There is impairment of the reticular activating system (RAS), resulting in coma D. Coma scale score is a direct result of dysfunction of the cerebellum **Evolve - Chapter 14**
C (There is impairment of the reticular activating system (RAS), resulting in coma)
Conditions that produce acute kidney injury by directly acting on functioning kidney tissue are classified as intrarenal. The most common intrarenal condition is A. prolonged ischemia B. exposure to nephrotoxic substances C. acute tubular necrosis (ATN) D. hypotension for several hours **P-16**
C (acute tubular necrosis (ATN))
The patient has an elevated blood urea nitrogen (BUN) level and an elevated creatinine level but a normal BUN/creatinine ratio. The nurse interprets this as: A. normal kidney function B. problems other than kidney failure C. acute tubular necrosis (ATN) D. prerenal conditions **Evolve - Chapter 16**
C (acute tubular necrosis (ATN))
The patient is diagnosed with acute kidney injury and has been getting dialysis 3 days per week. The patient complains of general malaise and is tachypneic. An arterial blood gas shows that the patient's pH is 7.19, with a PCO2 of 30 mm Hg and a bicarbonate level of 13 mEq/L. The nurse prepares to A. administer morphine to slow the respiratory rate B. prepare for intubation and mechanical ventilation C. administer intravenous sodium bicarbonate D. cancel tomorrow's dialysis session **P-16**
C (administer intravenous sodium bicarbonate)
The nurse is caring for a patient who has a temporary percutaneous dialysis catheter in place. In caring for this patient, the nurse should A. apply a sterile gauze dressing to maintain sterility B. replace the transparent dressing every 10 days to prevent manipulation C. assess the catheter site for redness and/or swelling D. use the catheter for drawing blood samples to reduce patient discomfort **P-16**
C (assess the catheter site for redness and/or swelling)
The patient is on intake and output (I&O), as well as daily weights. The nurse notes that output is considerably less than intake over the last shift, and daily weight is 1 kg more than yesterday. The nurse should A. draw a trough level after the next dose of antibiotic B. obtain an order to place the patient on fluid restriction C. assess the patient's lungs D. insert an indwelling catheter **P-16**
C (assess the patient's lungs)
Intrapulmonary shunting refers to A. alveoli that are not perfused B. blood that is shunted from the left side of the heart to the right and causes heart failure C. blood that is shunted from the right side of the heart to the left without oxygenation D. shunting of blood supply to only one lung **P-15**
C (blood that is shunted from the right side of the heart to the left without oxygenation)
The patient presents to the ED with sudden, severe sharp chest discomfort, radiating to the back and down both arms, as well as numbness in the left arm. While taking the patient's vital signs, the nurse notices a 30-point discrepancy in systolic blood pressure between the right and left arm. Based on these findings, the nurse should: A. contact the physician and report the cardiac enzyme results B. contact the physician and prepare the patient for thrombolytic therapy C. contact the physician immediately and begin prepping the patient for surgery D. give the patient aspirin and heparin **P-13**
C (contact the physician immediately and begin prepping the patient for surgery)
The etiology of pulmonary edema in acute respiratory distress syndrome is related to: A. tension pneumothorax B. decreased cardiac output C. damage to the alveolar-capillary membrane D. volutrauma and hypoxemia **Evolve - Chapter 15**
C (damage to the alveolar-capillary membrane)
The basic underlying pathophysiology of acute respiratory distress syndrome results in A. a decrease in the number of white blood cells available B. damage to the right mainstem bronchus C. damage to the type II pneumocytes, which produce surfactant D. decreased capillary permeability **P-15**
C (damage to the type II pneumocytes, which produce surfactant)
The patient is getting hemodialysis for the second time when he complains of a headache and nausea and, a little later, of becoming confused. The nurse realizes these are symptoms of A. dialyzer membrane incompatibility B. a shift in potassium levels C. dialysis disequilibrium syndrome D. hypothermia **P-16**
C (dialysis disequilibrium syndrome)
A strategy for preventing pulmonary embolism in patients at risk who cannot take anticoagulants is A. administration of two aspirin tablets every 4 hours B. infusion of thrombolytics C. insertion of a vena cava filter D. subcutaneous heparin administration every 12 hours **P-15**
C (insertion of a vena cava filter)
The patient is admitted with complaints of general malaise and fatigue, along with a decreased urinary output. The patient's urinalysis shows coarse, muddy brown granular casts and hematuria. The nurse determines that the patient has: A. acute kidney injury from a prerenal condition B. acute kidney injury from postrenal obstruction C. intrarenal disease, probably acute tubular necrosis D. a urinary tract infection **P-16**
C (intrarenal disease, probably acute tubular necrosis)
The nurse is caring for a patient with acute respiratory distress syndrome who is hypoxemic despite mechanical ventilation. The provider prescribes a nontraditional ventilator mode as part of treatment. Despite sedation and analgesia, the patient remains restless and appears to be in discomfort. The nurse informs the provider of this assessment and anticipates an order for A. continuous lateral rotation therapy B. guided imagery C. neuromuscular blockade D. prone positioning **P-15**
C (neuromuscular blockade)
The nurse is assessing a patient with a new arteriovenous fistula, but does not hear a bruit or feel a thrill. Pulses distal to the fistula are not palpable. The nurse should A. reassess the patient in an hour B. raise the arm above the level of the patient's heart C. notify the provider immediately D. apply warm packs to the fistula site and reassess **P-16**
C (notify the provider immediately)
A definitive diagnosis of pulmonary embolism can be made by A. arterial blood gas (ABG) analysis B. chest x-ray examination C. pulmonary angiogram D. ventilation-perfusion scanning **P-15**
C (pulmonary angiogram)
Continuous venovenous hemodialysis is used to A. remove fluids and solutes through the process of convection B. remove plasma water in cases of volume overload C. remove plasma water and solutes by adding dialysate D. combine ultrafiltration, convection and dialysis **P-16**
C (remove plasma water and solutes by adding dialysate)
The nurse is caring for a patient who is 90 years old. The patient's creatinine level is within normal limits. The nurse interprets the reason for the normal value is: A. the number of glomeruli increases with collateral circulation B. peritubular density increases as glomeruli decrease in number C. serum creatinine levels may remain the same in the elderly D. renal blood flow remains constant throughout life **Evolve - Chapter 16**
C (serum creatinine levels may remain the same in the elderly)
The nurse is discharging a patient with asthma. As part of the discharge instruction, the nurse instructs the patient to prevent exacerbation by: A. obtaining an appointment for follow-up pulmonary function studies 1 week after discharge B. limiting activity until the patient is able to climb two flights of stairs C. taking all asthma medications as prescribed D. taking medications on a "prn" basis according to symptoms **P-15**
C (taking all asthma medications as prescribed)
Which of the following patients is at the greatest risk of developing acute kidney injury? A patient who A. has been on aminoglycosides for the past 6 days B. has a history of controlled hypertension with a blood pressure of 138/88 mm Hg C. was discharged 2 weeks earlier after aminoglycoside therapy of 2 weeks D. has a history of fluid overload as a result of heart failure **P-16**
C (was discharged 2 weeks earlier after aminoglycoside therapy of 2 weeks)
Acute myocardial infarction (AMI) can be classified as which of the following? (Select all that apply) A. Angina B. Nonischemic C. Non-Q wave D. Q wave E. Frequent PVCs **P-13**
C & D (Non-Q wave) (Q wave)
A client with variant angina is scheduled to receive an oral calcium channel blocker twice a daily. Which statement by the client indicates the need for further teaching? A) "I should notify my cardiologist if my feet or legs start to swell." B) "I am supposed to report to my cardiologist if my pulse rate decreases below 60." C) "Avoiding grapefruit juice will definitely be challenge for me, since I drink it every morning with breakfast." D) "My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning." **Rationale: Review Book pg. 736**
D ("My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning.")
The nurse is caring for a patient with acute kidney injury who is being treated with hemodialysis. The patient asks if he will need dialysis for the rest of his life. Which of the following would be the best response? A. "Unfortunately, kidney injury is not reversible; it is permanent." B. "Kidney function usually returns within 2 weeks." C. "You will know for sure if you start urinating a lot all at once." D. "Recovery is possible, but it may take several months." **P-16**
D ("Recovery is possible, but it may take several months.")
A normal urine output is considered to be A. 80 to 125 mL/min B. 180 L/day C. 80 mL/min D. 1 to 2 L/day **P-16**
D (1 to 2 L/day)
The patient's creatinine level is 1.1 mg/dL. The nurse would expect the patient's blood urea nitrogen (BUN) level to be: A. 5 to 10 mg/dL B. 0.11 to 0.22 mg/dL C. 0.5 to 0.1 mg/dL D. 11 to 22 mg/dL **Evolve - Chapter 16**
D (11 to 22 mg/dL)
Which of the following is considered a normal left ventricular ejection fraction (LVEF)? A) 30% B) 40% C) 50% D) 60% **Rationale: Text book pg. 604**
D (60%)
After receiving the handoff report from the day shift charge nurse, which patient should the evening charge nurse assess first? A. A patient with meningitis complaining of photophobia B. A mechanically ventilated patient with a GCS of 6 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 **P-14**
D (A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104 F)
Possible treatments for acute respiratory failure (ARF) in the patient with chronic obstructive pulmonary disease (COPD) include: A) Noninvasive ventilation B) Bronchodilators C) Corticosteroids D) All of the above **Rationale: Text book pg. 605**
D (All of the above)
The Berlin criteria for acute respiratory distress syndrome (ARDS) include: A) Acute onset within 1 week after clinical insult B) Bilateral pulmonary opacities not explained by other conditions C) Altered partial pressure of arterial oxygen/fraction of inspired oxygen (PaO2/FiO2) ratio D) All of the above **Rationale: Text book pg. 605**
D (All of the above)
The nurse is caring for a patient admitted to the emergency department following a fall from a 10-foot ladder. Upon admission, the nurse assesses the patient to be awake, alert, and moving all four extremities. The nurse also notes bruising behind the left ear and straw-colored drainage from the left naris. What is the most appropriate nursing action? A. Insert bilateral ear plugs B. Monitor airway patency C. Maintain neutral head position D. Apply a small nasal drip pad **P-14**
D (Apply a small nasal drip pad)
The nurse is caring for a patient with a diagnosis of acute myocardial infarction (AMI). Which medication should the nurse anticipate administering to the patient to reduce platelet aggregation? A. Nitroglycerin B. Lidocaine C. Oxygen D. Aspirin **Evolve - Chapter 13**
D (Aspirin)
The nurse provides care for a client admitted from the operating room after coronary artery bypass graft (CABG) surgery. Which is the first action the nurse takes because the client is mechanically ventilated? A) Monitors for signs and symptoms of increased cardiac output B) Drains liquid condensed in the ventilator hoses back into the humidifier C) Auscultates the client's chest to detect signs and symptoms of pneumonia D) Assesses the client's level of consciousness **K**
D (Assesses the client's level of consciousness)
An example of a pathological reflex in an adult is: A) Palpebral reflex B) Corneal reflex C) Cremasteric reflex D) Babinski reflex **Rationale: Text book pg. 605**
D (Babinski reflex)
The nurse admits a patient to the emergency department with new onset of slurred speech and right-sided weakness. What is the priority nursing action? A. Assess for the presence of a headache B. Assess the patient's general orientation C. Determine the patient's drug allergies D. Determine the time of symptom onset **P-14**
D (Determine the time of symptom onset)
During peritoneal dialysis, a client suddenly begins to breathe more rapidly. Which action does the nurse take first? A) Discontinues the dialysis procedure B) Checks the client's vital signs C) Notifies the health care provider D) Elevates the head of the bed **K**
D (Elevates the head of the bed)
A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? A) Blowing the nose B) Isometric exercises C) Coughing vigorously D) Exhaling during repositioning **Rationale: Review Book pg. 850**
D (Exhaling during repositioning)
A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? A) Fluid is clear and tests negative for glucose B) Fluid is grossly bloody in appearance and has a pH of 6 C) Fluid clumps together on the dressing and has a pH of 7 D) Fluid separates into concentric rings and tests positive for glucose **Rationale: Review Book pg. 850**
D (Fluid separates into concentric rings and tests positive for glucose)
The nurse is caring for a patient with an acute ischemic stroke anticipates: A) Holding blood pressure medications to promote cerebral perfusion so that blood pressure can increase to greater than 200 mmHg B) Planning for induced hyperthermia to protect ischemic brain C) Preparing the patient for emergency surgery D) Identifying the precise time of stroke symptom onset when possible **Rationale: Text book pg. 605**
D (Identifying the precise time of stroke symptom onset when possible)
The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which EARLIEST sign of acute respiratory distress syndrome? A) Bilateral wheezing B) Inspiratory crackles C) Intercostal retractions D) Increased respiratory rate **Rational: Review Book pg. 1063**
D (Increased respiratory rate)
Percutaneous coronary intervention is contraindicated for patients with lesions in which coronary artery? A. Right coronary artery B. Left coronary artery C. Circumflex D. Left main coronary artery **P-13**
D (Left main coronary artery)
While bathing the client diagnosed with a basal skull fracture, the nurse notes that drainage from the client's left ear has stained the bed sheet with a halo-type effect. The drainage tests positive for glucose, the nurse recognize the client is at greatest risk for which complication? A) Otitis media B) Herniation of the brainstem C) Increased intracranial pressure D) Meningitis **K**
D (Meningitis)
The nurse anThe nurse anticipates hyperventilation in patients with renal failure as a compensatory mechanism for: A. infection B. uremic toxins C. volume deficits D. metabolic acidosis **Evolve - Chapter 16**
D (Metabolic acidosis)
The nurse provides care for a client diagnosed with coronary artery disease. Which symptom does the nurse expect the client to report? A) Frequent urination and unexplained weight loss B) Severe nausea and vomiting associated with chest pain C) Diaphoresis associated with increased body temperature D) Mild chest discomfort relieved by rest and nitrates **K**
D (Mild chest discomfort relieved by rest and nitrates)
The nurse is concerned that a patient is at increased risk of developing a pulmonary embolus and develops a plan of care for prevention to include which of the following? A. Antiseptic oral care B. Bed rest with head of bed elevated C. Coughing and deep breathing D. Mobility **P-15**
D (Mobility)
A 67-year-old female is admitted to the emergency department complaining of midback pain and shortness of breath for the preceding 2 hours. She also complains of nausea and states that she vomited twice before coming to the hospital. She denies any chest discomfort or arm pain. The nurse prepares to the treat the patient for a diagnosis of: A. anxiety attack B. osteoporosis C. flu symptoms D. myocardial infarction (MI) **Evolve - Chapter 13**
D (Myocardial infarction (MI))
A patient is complaining of midsternal chest discomfort radiating down the right arm. The discomfort has been present for about 5 minutes. The patient is also asthmatic and allergic to calcium channel blockers. The nurse anticipates an order from the health care provider for which medication? A. Isoptin B. Nifedipine C. Metoprolol D. Nitroglycerin sublingual **Evolve - Chapter 13**
D (Nitroglycerin sublingual)
The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the priority nursing action? A) Monitor the client B) Elevate the head of the bed C) Assess the fistula site and dressing D) Notify the primary health care provider (PHCP) **Rationale: Review Book pg. 786**
D (Notify the primary health care provider (PHCP))
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? A. Stimulate the patient hourly B. Continue to monitor the patient C. Elevate the head of the bed D. Notify the provider immediately **P-14**
D (Notify the provider immediately)
Which of the following treatments should the nurse anticipate administering to a hypoxic patient admitted with exacerbation of COPD? A. Continuous positive airway pressure (CPAP) via face mask B. Bag-valve-mask ventilation with oxygen at 15 L/min C. Non-rebreather mask with 80% oxygen D. Oxygen via Venturi mask at 40% oxygen **Evolve - Chapter 15**
D (Oxygen via Venturi mask at 40% oxygen)
A 53-year-old patient has kidney and ureteral stones and is hospitalized for urinary retention and severe flank pain. The nurse interprets the level of kidney injury to be: A. intrarenal B. acute tubular necrosis C. Prerenal D. postrenal **Evolve - Chapter 16**
D (Postrenal)
The nurse is caring for a mechanically ventilated patient with a sustained ICP of 18 mm Hg. The nurse needs to perform an hourly neurological assessment, suction the endotracheal tube, perform oral hygiene care, and reposition the patient to the left side. What is the best action by the nurse? A. Hyperoxygenate during endotracheal suctioning B. Elevate the patient's head of the bed 30 degrees C. Apply bilateral heel protectors after repositioning D. Provide rest periods between nursing interventions **P-14**
D (Provide rest periods between nursing interventions)
When assessing chest pain using the PQRST mnemonic, the P refers to which of the following? A) Place B) Pressure C) Prevention D) Provocation **Rationale: Text book pg. 604**
D (Provocation)
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)? A. Ensure adequate periods of rest between nursing interventions B. Insert an oral airway and monitor respiratory rate and depth C. Maintain neutral head alignment and avoid extreme hip flexion D. Reduce ambient room temperature and administer antipyretics **P-14**
D (Reduce ambient room temperature and administer antipyretics)
In assessing a patient, the nurse understands that an early sign of hypoxemia is A. clubbing of nail beds B. cyanosis C. hypotension D. restlessness **P-15**
D (Restlessness)
A client is about to undergo a lumbar puncture. The nurse describes to the client that which position will be used during the procedure? A) Side-lying with a pillow under the hip B) Prone with a pillow under the hip C) Prone in slight Trendelenburg's position D) Side-lying with the legs pulled up and the head bent down onto the chest **Rationale: Review Book pg. 1075**
D (Side-lying with the legs pulled up and the head bent down onto the chest)
A patient in acute respiratory failure is experiencing carbon dioxide narcosis secondary to increased CO2 retention. What assessment finding should the nurse expect? A. Nasal flaring B. Paradoxical respirations C. Suprasternal muscle retractions D. Somnolence **Evolve - Chapter 15**
D (Somnolence)
A patient has elevated blood lipids. The nurse anticipates which classification of drugs to be prescribed for the patient? A. Bile acid resins B. Nicotinic acid C. Nitroglycerin D. Statins **P-13**
D (Statins)
The nurse performs a home care visit for the child diagnosed with cystic fibrosis. The nurse intervenes if which finding is observed? A) The child eats a high-protein, high-calorie diet B) The child has two to three stools per day C) The child swallows the pancreatic enzyme capsules whole D) The child takes the pancreatic enzymes one hour after eating **K**
D (The child takes the pancreatic enzymes one hour after eating)
Which of the following treatments may be used to dissolve a thrombus that is lodged in the pulmonary artery? A. Aspirin B. Embolectomy C. Heparin D. Thrombolytics **P-15**
D (Thrombolytics)
During the maintenance phase of intrinsic renal failure, which of the following abnormalities should the nurse anticipate? A. Oliguria, azotemia, hyperkalemia B. Infection, hypokalemia, hyponatremia C. Oliguria, hypokalemia, hypernatremia D. Uremia, hyperkalemia, infection **Evolve - Chapter 16**
D (Uremia, hyperkalemia, infection)
In determining the glomerular filtration rate (GFR) or creatinine clearance, a 24-hour urine is obtained. If a reliable 24-hour urine collection is not possible, A. it is not possible to determine the GFR B. the BUN may be used to determine renal function C. an elevated BUN/creatinine ratio can be used D. a standardized formula may be used to calculate GFR **P-16**
D (a standardized formula may be used to calculate GFR)
The patient is in a progressive care unit following arteriovenous fistula implantation in his left upper arm, and is due to have blood drawn with his next set of vital signs and assessment. When the nurse assesses the patient, the nurse should A. draw blood from the left arm B. take blood pressures from the left arm C. start a new intravenous line in the left lower arm D. auscultate the left arm for a bruit and palpate for a thrill **P-16**
D (auscultate the left arm for a bruit and palpate for a thrill)
The patient is admitted with generalized edema and hypertension. The patient states that his urine output has been less than normal. An indwelling urinary catheter is inserted, but very little urine is obtained. The patient has distended neck veins, and his blood pressure is 210/110 mm Hg. The nurse interprets that the patient's fluid retention is due to: A. volume depletion B. uremia C. prerenal causes D. intrarenal causes **Evolve - Chapter 16**
D (infrarenal causes)
The nurse is caring for a patient who has sustained blunt trauma to the left flank area, and is evaluating the patient's urinalysis results. The nurse should become concerned when A. creatinine levels in the urine are similar to blood levels of creatinine B. sodium and chloride are found in the urine C. urine uric acid levels have the same values as serum levels D. red blood cells and albumin are found in the urine **P-16**
D (red blood cells and albumin are found in the urine)
The nurse is caring for a patient with acute respiratory failure and identifies "Risk for Ineffective Airway Clearance" as a nursing diagnosis. A nursing intervention relevant to this diagnosis is to A. elevate the head of the bed to 30 degrees B. obtain an order for venous thromboembolism prophylaxis C. provide adequate sedation D. reposition the patient every 2 hours **P-15**
D (reposition the patient every 2 hours)
An advantage of peritoneal dialysis is that A. peritoneal dialysis is time intensive B. a decreased risk of peritonitis exists C. biochemical disturbances are corrected rapidly D. the danger of hemorrhage is minimal **P-16**
D (the danger of hemorrhage is minimal)
Continuous renal replacement therapy (CRRT) differs from conventional intermittent hemodialysis in that A. a hemofilter is used to facilitate ultrafiltration B. it provides faster removal of solute and water C. it does not allow diffusion to occur D. the process removes solutes and water slowly **P-16**
D (the process removes solutes and water slowly)
The removal of plasma water and some low-molecular weight particles by using a pressure or osmotic gradient is known as A. dialysis B. diffusion C. clearance D. ultrafiltration **P-16**
D (ultrafiltration)
The kidneys help to maintain acid-base equilibrium by (Select all that apply.) A. excreting hydrogen ions in response to alkalosis B. producing new bicarbonate in response to acidosis C. producing ammonia when the patient is acidotic D. excreting bicarbonate in response to acidosis E. reabsorbing filtered bicarbonate in response to acidosis
D & E (excreting bicarbonate in response to acidosis) (reabsorbing filtered bicarbonate in response to acidosis)
Patients at risk for the development of deep vein thrombosis (DVT) may include: A) Those older than 75 years B) Those who are immobile for longer than 3 days C) Pregnant women D) Patient with burn injury E) All of the above **Rationale: Text book pg. 605**
E (All of the above)
