test 4

32. 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 bedrest at all times.

ANS: C Bacterial meningitis is an infection of the pia and arachnoid layers of the meninges and the cerebrospinal fluid (CSF) in the subarachnoid space. As such, the patient can experience symptoms associated with cerebral irritation such photophobia and seizures. In addition, the patient is at increased risk for seizures because of a high temperature. The priority nursing action is to implement seizure precautions in an attempt to prevent injury. Elevating the head of the bead, keeping the lights dim, and maintaining bedrest are all appropriate nursing interventions but are not the priorities in this scenario.

16. 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.

ANS: D Early intervention for ischemic stroke is recommended. Thrombolytics must be given within 3 hours of the onset of symptoms. Although assessment of allergies, as well accompanying symptoms such as a headache and general orientation, are a part of a complete neurological assessment and should be performed, time of onset of symptoms is critical to the type of treatment.

9. 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.

ANS: A A GCS score of 3 is indicative of a deep coma. Given the assessed respiratory rate of 10 breaths/min combined with the GSC score of 3, the nurse must focus on maintaining the patient's airway. There is no evidence to support the need for increased supplemental oxygen. A respiratory rate of 10 breaths/min may result in increased CO2 retention, which may further increase ICP through dilatation of cerebral vessels. Elevating the head of the bed and supporting bony prominences are appropriate nursing interventions for a patient in a deep coma; however, airway patency is the immediate priority.

17. Which patient being cared for in the emergency department should the charge nurse evaluate first? a. A patient with a complete spinal injury at the C5 dermatome level b. A patient with a Glasgow Coma Scale score of 15 on 3-L nasal cannula c. An alert patient with a subdural bleed who is complaining of a headache d. An ischemic stroke patient with a blood pressure of 190/100 mm Hg

ANS: A A patient with a C5 complete spinal injury is at risk for ineffective breathing patterns and should be assessed immediately for any airway compromise. A GCS score of 15 indicates a neurologically intact patient. The patient with a subdural bleed is alert and not in danger of any immediate compromise. The goal for ischemic stroke is to keep the systolic BP less than 220 mm Hg and the diastolic blood pressure less than 120 mm Hg.

31. 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 prior to use. d. Dispose of all bloody dressings in biohazard bags.

ANS: A Droplet precautions are maintained for a patient with bacterial meningitis until 24 hours after the initiation of antibiotic therapy to reduce the potential for spread of the infection. Washing hands and scrubbing the hub of injection ports are practices that help reduce the risk of infection, but added precautions are necessary for preventing the spread of bacterial meningitis. Disposing all bloody dressings in biohazard bags is a standard universal precaution and is not specific to bacterial meningitis.

28. The nurse is preparing to administer 100 mg of phenytoin (Dilantin) to a patient in status epilepticus. To prevent patient complications, what is the best action by the nurse? a. Ensure patency of intravenous (IV) line. b. Mix drug with 0.9% normal saline. c. Evaluate serum K+ level. d. Obtain an IV infusion pump.

ANS: A Ensuring a patent IV site prevents complications associated with infiltration of the medication (soft tissue necrosis). Mixing the drug with normal saline prevents crystallization of the medication and would be noticed prior to administration. Evaluating the serum K+ is not required prior to administration. The dose of phenytoin (Dilantin) ordered can be safely administered IV push over 2 minutes and does not require an infusion pump.

1. 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°. 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

ANS: A Nurses complete neurological assessments based on ordered frequency and the severity of the patient's condition. The newly admitted patient has an altered neurological status so frequent neurological assessments are most important to include in the patient's plan of care. Side to side position changes, range of motion exercises, and frequent oral suctioning are nursing actions that may need to be a part of the patient's plan of care but in the setting of increased intracranial pressure should not be regularly performed unless indicated.

21. The nurse receives a patient from the emergency department following a closed head injury. After insertion of an ventriculostomy, the nurse assesses the following vital signs: blood pressure 100/60 mm Hg, heart rate 52 beats/min, respiratory rate 24 breaths/min, oxygen saturation (SpO2) 97% on supplemental oxygen at 45% via Venturi mask, Glasgow Coma Scale score of 4, and intracranial pressure (ICP) of 18 mm Hg. Which physician order should the nurse institute first? a. Mannitol 1 g intravenous b. Portable chest x-ray c. Seizure precautions d. Ancef 1 g intravenous

ANS: A The patient's GCS score is 4 along with an ICP of 18 mm Hg. Although a portable chest x-ray and seizure precautions are appropriate to include in the plan of care, Mannitol 1 g intravenous is the priority intervention to reduce intracranial pressure. Ancef 1 g intravenous is appropriate given the indwelling ICP line; however, antibiotic therapy is not the priority in this scenario.

13. 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.

ANS: A To reduce the risk of further injury, a patient experiencing seizure activity while sitting in a chair should be assisted to the floor with head adequately supported. Routine insertion of a nasogastric tube during seizure activity is not indicated unless there is risk for aspiration. Forceful insertion of a padded tongue blade should not be carried out during tonic-clonic activity; most likely the patient's jaws will be clenched shut. Forceful insertion may lead to further injury. Restraining a patient during seizure activity can be traumatizing and is not standard of care.

2. In an unconscious patient, eye movements are tested by the oculocephalic response. Which statements regarding the testing of this reflex are true? (Select all that apply.) a. Doll's eyes absent indicate a disruption in normal brainstem processing. b. Doll's eyes present indicate brainstem activity. c. Eye movement in the opposite direction as the head when turned indicates an intact reflex. d. Eye movement in the same direction as the head when turned indicates an intact reflex. e. Increased intracranial pressure (ICP) is a contraindication to the assessment of this reflex. f. Presence of cervical injuries is a contraindication to the assessment of this reflex.

ANS: A, B, C, E, F In unconscious patients with stable cervical spine, assess oculocephalic reflex (doll's eye): turn the patient's head quickly from side to side while holding the eyes open. Note movement of eyes. The doll's eye reflex is present if the eyes move bilaterally in the opposite direction of the head movement.

3. 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.

ANS: A, C The goal for ischemic stroke is to keep the systolic blood pressure less than 220 mm Hg and the diastolic blood pressure 120 mm Hg. In hemorrhagic stroke, the goal is a mean arterial pressure less than 130 mm Hg. Neurological assessments are compared with the baseline assessments performed in the ED. The elapsed time of 8 hours since onset of symptoms prohibits thrombolytic therapy. The CO2 should be maintained within normal limits; this value is elevated. The elapsed time of 8 hours since onset of symptoms prohibits thrombolytic therapy. Restraints should be avoided.

18. 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.

ANS: B Alignment of the head and neck may help prevent spinal cord damage in the event of a cervical spine injury. Hyperextension of the neck is contraindicated with a cervical spine injury. Immediate endotracheal intubation is not indicated with a suspected cervical spine injury unless the patient's airway is compromised. The use of assist devices to maintain immobilization of the cervical spine is indicated until injury has been ruled out.

15. 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 physician of the patient's blood pressure.

ANS: B Autonomic dysreflexia, characterized by an exaggerated response of the sympathetic nervous system can be triggered by a variety of stimuli, including a kinked indwelling catheter, which would result in bladder distention. Other causes that should be ruled out prior to pharmacological intervention include fecal impaction. Treating the patient for a headache will not resolve symptoms of autonomic dysreflexia. Treatment must focus on identifying the underlying cause. Slow deep breathes will not correct the underlying problem. Assessing for underlying causes of autonomic dysreflexia should precede contacting the physician.

27. The nurse is to administer 100 mg phenytoin (Dilantin) intravenous (IV). Vital signs assessed by the nurse include blood pressure 90/60 mm Hg, heart rate 52 beats/min, respiratory rate 18 breaths/min, and oxygen saturation (SpO2) 99% on supplemental oxygen at 3 L/min by cannula. To prevent complications, what is the best action by the nurse? a. Administer over 2 minutes. b. Administer over 5 minutes. c. Mix medication with 0.9% normal saline. d. Administer via central line.

ANS: B In the presence of hypotension and bradycardia, administering the medication over 2 minutes is too fast. Mixing medication with 0.9% normal saline prevents precipitation of the medication but will not prevent complications related to this scenario. Administering the medications via central line will not prevent complications related to this scenario.

19. The nurse is caring for a patient 3 days following a complete cervical spine injury at the C3 level. The patient is in spinal shock. Following emergent intubation and mechanical ventilation, what is the priority nursing action? a. Maintain body temperature. b. Monitor blood pressure. c. Pad all bony prominences. d. Use proper hand washing.

ANS: B Maintaining perfusion to the spinal cord is critical in the management of spinal cord injury. Monitoring blood pressure is a priority.

23. The nurse, caring for a patient following a subarachnoid hemorrhage, begins a nicardipine (Cardene) infusion. Baseline blood pressure assessed by the nurse is 170/100 mm Hg. Five minutes after beginning the infusion at 5 mg/hr, the nurse assesses the patient's blood pressure to be 160/90 mm Hg. What is the best action by the nurse? a. Stop the infusion for 5 minutes. b. Increase the dose by 2.5 mg/hr. c. Notify the physician of the BP. d. Begin weaning the infusion.

ANS: B Medications to control blood pressure are administered to prevent rebleeding before an aneurysm is secured. Following infusion, the patient's blood pressure remains dangerously high, so increasing the dose by 2.5 mg/hr is the best action by the nurse. Stopping the infusion or weaning the infusion is contraindicated before reaching the desired blood pressure. Notifying the physician of the blood pressure is not indicated until the upper limits of the infusion are reached without achieving the desired blood pressure.

26. The physician orders fosphenytoin (Cerebyx), 1.5 g intravenous (IV) loading dose for a 75-kg patient in status epilepticus. What is the most important action by the nurse? a. Contact the admitting physician. b. Administer drug over 10 minutes. c. Mix medication with 0.9% normal saline. d. Administer via central line.

ANS: B The nurse can administer the medication over 10 minutes as ordered (100-150 mg phenytoin equivalent [PE] over 1 full minute). The drug dose ordered is appropriate for the patient's weight. Fosphenytoin (Cerebyx) does not have to be administered with normal saline or via a central line.

25. The nurse is caring for a patient admitted to the emergency department in status epilepticus. Vital signs assessed by the nurse include blood pressure 160/100 mm Hg, heart rate 145 beats/min, respiratory rate 36 breaths/min, oxygen saturation (SpO2) 96% on 100% supplemental oxygen by non-rebreather mask. After establishing an intravenous (IV) line, which order by the physician should the nurse implement first? a. Obtain stat serum electrolytes. b. Administer lorazepam (Ativan). c. Obtain stat portable chest x-ray. d. Administer phenytoin (Dilantin).

ANS: B The nurse should administer lorazepam (Ativan) as ordered; lorazepam (Ativan) is the first-line medication for the treatment of status epilepticus. Phenytoin (Dilantin) is administered only when lorazepam fails to stop seizure activity or if intermittent seizures persist for longer than 20 minutes. Serum electrolytes and chest x-rays are appropriate orders but not the priority in this scenario.

29. The nurse is caring for a patient admitted with a subarachnoid hemorrhage following surgical repair of the aneurysm. Assessment by the nurse notes blood pressure 90/60 mm Hg, heart rate 115 beats/min, respiratory rate 28 breaths/min, oxygen saturation (SpO2) 99% on supplemental oxygen at 3L/min by cannula, a Glasgow Coma Score of 4, and a central venous pressure (CVP) of 2 mm Hg. After reviewing the physician orders, which order is of the highest priority? a. Lasix 20 mg intravenous push as needed b. 500 mL albumin intravenous infusion c. Decadron 10 mg intravenous push d. Dilantin 50 mg intravenous push

ANS: B To ensure adequate cerebral perfusion, for a CVP of 2 mm Hg, blood pressure of 90/60 mm Hg, and heart rate of 115 beats/min, an infusion of 500 mL of albumin is most appropriate. Lasix is contraindicated in low volume states. Although Decadron and Dilantin are appropriate medications, in this scenario, they are not the priority medications.

2. A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg. Her blood pressure is 144/90 mm Hg, and her 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

ANS: C CPP = MAP - ICP. In this case, CPP = 108 mm Hg - 18 mm Hg = 90 mm Hg. All other calculated responses are incorrect.

22. The nurse is caring for a patient 5 days following clipping of an anterior communicating artery aneurysm for a subarachnoid hemorrhage. The nurse assesses the patient to be more lethargic than the previous hour with a blood pressure 95/50 mm Hg, heart rate 110 beats/min, respiratory rate 20 breaths/min, oxygen saturation (SpO2) 95% on 3 L/min oxygen via nasal cannula, and a temperature of 101.5° F. Which physician order should the nurse institute first? a. Blood cultures (2 specimens) for temperature > 101° F b. Acetaminophen (Tylenol) 650 mg per rectum c. 500 mL albumin infusion intravenously d. Decadron 20 mg intravenous push every 4 hours

ANS: C Cerebral vasospasm is a life-threatening complication following subarachnoid hemorrhage. Once an aneurysm has been repaired surgically, blood pressure is allowed to rise to prevent vasospasm. Volume expansion with 500 mL albumin is the priority intervention for a blood pressure of 95/50 mm Hg to prevent vasospasm and ensure cerebral perfusion. Blood cultures, acetaminophen administration, and Decadron are appropriate to include in the plan of care but are not priorities in this scenario.

8. 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)

ANS: C Cerebral vessels dilate when PaCO2 levels increase, increasing cerebral blood volume. Cerebral vessels dilate when CO2 levels increase, increasing cerebral blood volume. To compensate for increased cerebral blood volume, cerebral spinal fluid may be displaced, but the scenario is asking for the effect of hypercarbia (elevated PaCO2) on cerebral blood flow. PaCO2 of 60 mm Hg is elevated, which would cause cerebral vasodilation and increased cerebral blood volume.

5. 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.

ANS: C In the presence of suspected cerebrospinal fluid leak, drainage should be unobstructed and free flowing. Small bandages may be applied to allow for fluid collection and assessment. Patients should be instructed not to blow their nose because that action may further aggravate the dural tear. Suction catheters should be inserted through the mouth rather than the nose to avoid penetrating the brain due to the dural tear.

14. The nurse is caring for a mechanically ventilated patient admitted with a traumatic brain injury. Which arterial blood gas value assessed by the nurse indicates optimal gas exchange for a patient with this type of injury? a. pH 7.38; PaCO2 55 mm Hg; HCO3 22 mEq/L; PaO2 85 mm Hg b. pH 7.38; PaCO2 40 mm Hg; HCO3 24 mEq/L; PaO2 70 mm Hg c. pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg d. pH 7.38; PaCO2 28 mm Hg; HCO3 26 mEq/L; PaO2 65 mm Hg

ANS: C Optimal gas exchange in a patient with increased intracranial pressure includes adequate oxygenation and ventilation of carbon dioxide. A pH of 7.38, PaCO2 of 35 mm Hg, and a PaO2 of 85 mm Hg indicates both. PaCO2 values greater than normal (35-45) can lead to cerebral vasodilatation and further increase cerebral blood volume and ICP. Carbon dioxide levels less than 35 mm Hg can lead to cerebral vessel vasoconstriction and ischemia. Adequate oxygenation of cerebral tissues is achieved by maintaining a PaO2 above 80 mm Hg.

3. 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.

ANS: C The ICP is above the normal level of 15 mm Hg. The CPP is within the normal range. All other listed responses are incorrect.

20. The physician has opted to treat a patient with a complete spinal cord injury with glucocorticoids. The physician orders 30 mg/kg over 15 minutes followed in 45 minutes with an infusion of 5.4 mg/kg/min for 23 hours. What is the total 24-hour dose for the 70-kg patient? a. 2478 mg b. 5000 mg c. 10,794 mg d. 12,750 mg

ANS: C The dosing regimen is initiated with a bolus of 30 mg/kg over 15 minutes, followed in 45 minutes by a continuous intravenous infusion of 5.4 mg/kg/hr for 23 hours. (30 mg ´ 70 kg) + (5.4 mg ´ 70 kg) ´ 23 hours = 10,794 mg.

24. The nurse is preparing to administer a routine dose of phenytoin (Dilantin). The physician orders phenytoin (Dilantin) 500 mg intravenous every 6 hours. What is the best action by the nurse? a. Administer over 2 minutes. b. Administer with 0.9% normal saline intravenous. c. Contact the physician. d. Assess cardiac rhythm.

ANS: C The ordered dose is an inappropriate maintenance dose. The nurse should contact the physician. Administering the dose over 2 minutes, administering with normal saline, and assessing the cardiac rhythm for bradycardia are normal administration guidelines for normal dose parameters.

10. The nurse is caring for a patient who has a diminished level of consciousness and who is mechanically ventilated. While performing endotracheal suctioning, the patient reaches up in an attempt to grab the suction catheter. What is the best interpretation by the nurse? a. The patient is exhibiting extension posturing. b. The patient is exhibiting flexion posturing. c. The patient is exhibiting purposeful movement. d. The patient is withdrawing to stimulation.

ANS: C This is a good example of purposeful movement that is sometimes seen in patients with reduced consciousness. Flexion posturing is characterized by rigid flexion and extension of the arms, wrist flexion, and clenched fists. Extension posturing is characterized by rigid extension of arms and legs with plantar extension of the feet. Withdrawing occurs when a patient moves an extremity away from a painful source of stimulation.

1. The nurse is preparing to monitor intracranial pressure (ICP) with a fluid-filled monitoring system. The nurse understands which principles and/or components to be essential when implementing ICP monitoring? (Select all that apply.) a. Use of a heparin flush solution b. Manually flushing the device "prn" c. Recording ICP as a "mean" value d. Use of a pressurized flush system e. Zero referencing the transducer system

ANS: C, E Neither heparin nor pressure bags nor pressurized flush systems are used for ICP monitoring setups. ICP is recorded as a mean value with the transducer system zero referenced at the level of the foramen of Munro. Manually flushing the device may result in an increase in ICP.

12. 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.

ANS: D In this scenario, the patient's temperature is elevated, which increases metabolic demands. Increases in metabolic demands increase cerebral blood flow and contribute to increased intracranial pressure (ICP). Cooling measures should be implemented. Insertion of an oral airway in an alert patient is contraindicated. While maintaining neutral head position and ensuring adequate periods of rest between nursing interventions are appropriate actions for patients with elevated ICP, treatment of the fever is of higher priority.

7. The nurse is caring for a patient with an ICP of 18 mm Hg and a GCS score of 3. Following the administration of mannitol (Osmitrol), which assessment finding by the nurse requires further action? a. ICP of 10 mm Hg b. CPP of 70 mm Hg c. GCS score of 5 d. CVP of 2 mm Hg

ANS: D Osmotic diuretics draw water from normal brain cells, decreasing ICP and increasing CPP and urine output. An ICP of 10 mm Hg and CPP of 70 mm Hg are within normal limits. A GCS score of 5, while not optimum indicates a slight improvement. A CVP of 2 mm Hg indicates hypovolemia. To ensure adequate cerebral perfusion, further action on the part of the nurse is necessary.

11. The nurse is caring for a patient admitted to the ED 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 nare. 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.

ANS: D Patient assessment findings are indicative of a skull fracture. The presence of straw-colored nasal draining may be indicative of a CSF leak. Drainage should be monitored and allowed to flow freely. Application of a nasal drip pad is the most appropriate action. Monitoring airway patency and maintaining the head in a neutral position are not priorities in a patient who is awake and alert. Insertion of bilateral ear plugs is not standard of care.

4. 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.

ANS: D Sustained increases in ICP lasting longer than 5 minutes should be avoided. This is accomplished by spacing nursing care activities to allow for rest between activities. All other nursing actions are a part of the patient's plan of care; however, spacing out interventions is the priority.

30. After receiving the hand-off 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

ANS: D The charge nurse should assess the patient with an ICP of 20 mm Hg and a temperature of 104° F as this is an abnormal finding and should be investigated further. A patient with a GCS of 6 being mechanically ventilated has a secure airway and there is no indication of distress. Photophobia is an expected finding with meningitis and droplet precautions are appropriate for a patient with bacterial meningitis.

6. 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 (ED) 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 physician immediately.

ANS: D These are classic symptoms of epidural and acute subdural hematomas: injury, lucid period, and progressive deterioration. The physician must be notified of this neurological emergency so appropriate interventions can be implemented. Although elevating the head of the bed, continuously monitoring the patient and applying stimulation as necessary to assess neurological response are appropriate interventions, notification of the physician is a priority given the severity in change of neurological status.

A patient with ascites is recovering from a paracentesis where 8 liters of fluid have been removed. What will the nurse monitor in order to detect a common complication after this procedure? 1. Blood pressure at least every half hour until the patient is stable 2. Serum ammonia every 4 hours for the next 24 hours. 3. Chest film for evidence of a pneumothorax 4. Temperature every 2 hours to detect bacterial peritonitis

Correct Answer: 1 Rationale 1: Post-procedure responsibilities include monitoring hemodynamic status to detect the potential complications of hypovolemic shock. Rationale 2: A paracentesis does not change serum ammonia levels. Rationale 3: A post-procedure chest film is not indicated following a paracentesis. Rationale 4: The patients temperature should be routinely monitored every 4, not 2, hours.

An adolescent patient is admitted after ingesting 20 500 mg acetaminophen (Tylenol) tablets as a suicide attempt. The patient is currently nauseated, vomiting, and diaphoretic with a BP of 96/52. What will be the priority in this patients care? 1. Have a serum acetaminophen level drawn. 2. Observe for possible urticaria and bronchospasms. 3. Provide the first oral dose of acetylcysteine (Mucomyst) in orange juice. 4. Start an intravenous access line for rehydration.

Correct Answer: 1 Rationale 1: The predicted risk of toxicity from a single acute overdose relies on the time of ingestion and serum acetaminophen level. Whether a level is toxic or nontoxic can only be interpreted when the time of ingestion is accurately accounted for. The Rumack-Matthew nomogram can be used to predict hepatic toxicity between 4 and 24 hours after an acute ingestion. Rationale 2: These symptoms are side effects of intravenous administration of acetylcysteine NAC (Mucomyst). Rationale 3: This medication is administered after the initial acetaminophen level is drawn. It must be administered within 424 hours after acetaminophen. Rationale 4: This will depend upon the patients status.

A patient in the intensive care unit is reported to be in the oliguric phase of intrinsic renal failure, which is reflected by: 1. Urine output of less then 400 mL/day 2. BUN and creatinine that may begin to increase slightly 3. Urinary output of up to 5 liters of urine each day 4. Abnormal laboratory values that can last from 6 months to a year in duration

Correct Answer: 1 Rationale 1: The oliguric phase may last 10 to 14 days during which the patient excretes less then 400 mL of urine/day. Rationale 2: The onset phase immediately follows the renal injury and lasts 2-4 days. The urine output is reduced by 20% and the BUN and creatinine may begin to increase slightly. Rationale 3: As a patient begins to regain renal function, the diuretic phase of intrinsic renal failure begins and urine output often increases up to 5 liters of urine each day. Rationale 4: The final phase of intrinsic renal failure is the recovery phase that typically lasts from 6 months to a year. During this phase, most patients' renal function and lab values slowly return to normal.

The nurse monitors the patient undergoing intermittent hemodialysis (IHD) for the most common complication of the procedure, which is: 1. Hypotension 2. Infection 3. Hyperglycemia 4. Hypokalemia

Correct Answer: 1 Rationale 1: Up to 30% of patients with acute kidney injury who undergo IHD experience rapid shifts in plasma volume that can result in hypotension, which is the most common complication. Rationale 2: The nurse should also continuously monitor for the complications of infection as the hemodialysis is an invasive procedure. However, it is not the most common complication. Rationale 3: Hyperglycemia would be the expected complication with peritoneal dialysis related to glucose in the dialysate. Rationale 4: Hypokalemia is not a common complication associated with IHD as the dialysate bath contains potassium. If the patient's potassium is 5.5, then the dialysate bath would be 3.0. This would lower the patient's potassium level to 4.0 via diffusion.

What will the nurse most likely find on assessment of a patient with acute liver failure? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Jaundice 2. Sudden severe nose bleed 3. Ascites 4. Peripheral edema 5. Asterixis

Correct Answer: 1,2 Rationale 1: Severe acute liver injury can lead to impaired elimination of bilirubin leading to jaundice, which may appear immediately before or soon after presentation. Rationale 2: Acute bleeding is an indication of coagulopathy, which is seen in acute liver failure. Rationale 3: Ascites is a manifestation of chronic liver failure. Rationale 4: Peripheral edema is a manifestation of chronic liver failure. Rationale 5: Asterixis is a manifestation of chronic liver failure.

The nurse is planning care for a patient with an acute kidney injury. Which interventions would prevent further injury to the patient's kidneys? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Use strict aseptic technique when providing care. 2. Discuss the need for acetylcysteine with the health care provider prior to testing that uses contrast dye. 3. Measure urine output every 8 hours. 4. Prepare a fluid challenge with Dextrose 5% and water. 5. Calculate fluid restriction.

Correct Answer: 1,2 Rationale 1: The nurse is scrupulous in his use of aseptic technique to prevent the development of an infection because removal of the by-products of infection and excretion of antibiotics may impose additional burdens on the damaged kidneys. Rationale 2: If contrast dye must be administered, it is given sparingly or the physician may prescribe it; the nurse administers acetylcysteine for its renal protective effects. Rationale 3: The patient's urine output should be measured as frequently as necessary to assess renal function. However, every 8 hours would be an excessive amount of time to make this assessment. Rationale 4: Dextrose 5% and water is not the solution used for a fluid challenge. Rationale 5: This might need to be done for the patient who is fluid volume overloaded. However, this intervention would not specifically prevent any further kidney injury.

A patient comes into the emergency department after ingesting 50 650 mg tablets of arthritis-strength acetaminophen (Tylenol) 2 hours ago. What interventions will the nurse prepare to implement at this time? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Provide medication to induce vomiting. 2. Prepare to insert a nasogastric tube for gastric lavage. 3. Contact the pharmacy for activated charcoal. 4. Draw a serum acetaminophen level. 5. Administer N-acetylcysteine (NAC) (Mucomyst).

Correct Answer: 1,2,3 Rationale 1: If the time of ingestion was less than 4 hours, induction of emesis may be considered. Rationale 2: If the time of ingestion was less than 4 hours gastric lavage of pill fragments may be considered for treatment. Rationale 3: If the time of ingestion was less than 4 hours, administration of activated charcoal to reduce absorption may be considered. Rationale 4: If the time of ingestion is greater than 4 hours but less than 24, a serum acetaminophen level should be immediately drawn. Rationale 5: This medication is used if the patient is at risk for hepatotoxicity.

What complications might a patient develop in response to portal hypertension? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Hepatomegaly 2. Splenomegaly 3. Ascites and variceal hemorrhage 4. Atherosclerotic plaques 5. Portal system pressure 5 to 10 mm Hg.

Correct Answer: 1,2,3 Rationale 1: In the early stages of portal hypertension, blood collects in the sinusoids of the liver to compensate for the elevated pressure. As the pressure remains elevated, the liver enlarges. Rationale 2: The spleen is a part of the portal system and as pressure increases, blood will back up in the system and also collect in the spleen. Rationale 3: Ascites is a marker for severe progression of liver disease. The high pressure frequently causes the esophageal and/or gastric varices to rupture and bleed. The most common site for a variceal bleed is the submucosa of the distal end of the esophagus. Rationale 4: The cardiovascular consequences related to portal hypertension and hepatic failure include hypotension, peripheral edema, arrhythmias, and heart failure. Rationale 5: This is a normal range of portal pressure. Portal hypertension is defined as portal pressure 20 mm Hg

A patient with a history of taking acetaminophen (Tylenol) for osteoarthritis pain is surprised to learn the diagnosis of liver failure. What will the nurse explain to the patient about this diagnosis? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Liver damage can occur when the maximum daily dose of acetaminophen is taken repeatedly. 2. If your body cannot remove the toxins from acetaminophen then liver damage occurs. 3. Liver damage from acetaminophen can occur from taking as little as 4 grams of the medication a day. 4. Liver damage from acetaminophen only occurs when taking 10 grams or more of the medication per dose. 5. Liver damage from acetaminophen only occurs when it is taken with alcoholic beverages.

Correct Answer: 1,2,3 Rationale 1: When the maximum daily dose is repeatedly exceeded, the normal pathways of metabolism become saturated and more of the toxic metabolite is produced. Rationale 2: When hepatic glutathione stores are depleted, the toxic substances accumulate causing hepatic injury. Rationale 3: The minimal dose that produces liver injury varies between 4 to 10 grams. Rationale 4: The minimal dose that produces liver injury varies between 4 to 10 grams per day. Rationale 5: Liver damage from acetaminophen occurs with or without the ingestion of alcohol.

A patient with acute kidney injury is prescribed intermittent hemodialysis three times a week for 4 hours each session. The nurse will plan interventions to address what problems that can occur between sessions? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Fluid overload 2. Waste accumulation 3. Electrolyte imbalances 4. Hypotension 5. Infection

Correct Answer: 1,2,3 Rationale 1: A disadvantage of intermittent hemodialysis is that fluid overload can develop between sessions. Rationale 2: A disadvantage of intermittent hemodialysis is that waste accumulation can develop between sessions. Rationale 3: A disadvantage of intermittent hemodialysis is that electrolyte imbalances can develop between sessions. Rationale 4: Hypotension can occur after a session and not usually between sessions. Rationale 5: The risk for infection is not higher between sessions

The nurse suspects that a patient with acute kidney injury will not be prescribed peritoneal dialysis because: Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Peritoneal dialysis takes too much time to remove body wastes. 2. The excess fluid in the peritoneum can negatively impact the patient's breathing. 3. There are poorer outcomes from using peritoneal dialysis. 4. The patient has hypertension. 5. The patient has a potassium level of 5.5 mEq/L

Correct Answer: 1,2,3 Rationale 1: Peritoneal dialysis is often not speedy or efficient enough to adequately remove the midsized wastes such as urea, which accumulate rapidly in catabolic acute kidney injury patients. Rationale 2: The volume of fluid that is placed in the peritoneum during peritoneal dialysis tends to have a negative impact on respiratory function. Rationale 3: Several studies have demonstrated poorer outcomes for patients who received peritoneal dialysis rather than other modalities of treatment for acute kidney injury. Rationale 4: Hypertension is not a reason why peritoneal dialysis would not be indicated for this patient. Rationale 5: This potassium level is not a contraindication for the use of peritoneal dialysis

The nurse is caring for a patient during continuous renal replacement therapy. What interventions would the nurse perform at this time? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Monitor vital signs every half hour. 2. Administer replacement fluid as determined by the hourly fluid balance goal. 3. Assess partial thromboplastin time every 1 to 2 hours. 4. Warm the dialysate to body temperature. 5. Inspect the dialysate return.

Correct Answer: 1,2,3 Rationale 1: The nurse will monitor the patient's vital signs and hemodynamic and fluid balance status every half hour. Rationale 2: The nurse will administer replacement fluid as determined by the hourly fluid balance goal set by the nephrologist. Rationale 3: The nurse will review partial thromboplastin times as often as every 1 to 2 hours. Rationale 4: This intervention would be done if the patient were receiving peritoneal dialysis. Rationale 5: This intervention would be done if the patient were receiving peritoneal dialysis

A critically ill patient is being evaluated for acute kidney injury. The nurse expects that which laboratory tests will be prescribed for this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Urinalysis 2. Blood-urea-nitrogen level 3. Serum creatinine 4. Arterial blood gases 5. Hemoglobin and hematocrit levels

Correct Answer: 1,2,3 Rationale 1: This laboratory test will be used to differentiate prerenal failure from intrinsic renal failure. Rationale 2: This blood test measures the amount of urea that is being filtered out of the blood by the kidneys. Rationale 3: This blood test assesses kidney function and is more accurate than the blood-urea-nitrogen level. Rationale 4: This blood test is not specific for renal function. Rationale 5: These levels are not specific for renal function.

A patient with an acute kidney injury is prescribed intravenous calcium for a potassium level of 6.8 mEq/L. What actions will the nurse make when providing this medication? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Administer the medication IV push over 2 minutes. 2. Observe for electrocardiogram rhythm changes in 1 to 3 minutes after administering the medication. 3. Monitor for ongoing effects to last 30 to 60 minutes. 4. Discontinue the medication if tachycardia occurs. 5. Observe for a urine output increase within 10 minutes after administering this medication.

Correct Answer: 1,2,3 Rationale 1: This medication should be administered IV push over 2 minutes. Rationale 2: The effects of this medication occur 1 to 3 minutes after administering. Rationale 3: The effects of this medication last 30 to 60 minutes. Rationale 4: This medication should be discontinued if bradycardia occurs. Rationale 5: This medication does not affect urine output.

What will the nurse include when planning care for a patient experiencing pruritis associated with decompensated liver disease? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Provide cholestyramine as prescribed. 2. Provide colestipol as prescribed. 3. Provide diphenhydramine at hour of sleep. 4. Encourage the patient to keep the nails short. 5. Restrict fluids.

Correct Answer: 1,2,3,4 Rationale 1: Cholestyramine binds and prevents the accumulation of bile acids under the skin, reducing pruritis. Rationale 2: Colestipol binds and prevents the accumulation of bile acids under the skin, reducing pruritis. Rationale 3: Diphenhydramine relieves symptoms of pruritis and has a mild sedative effect. Rationale 4: Keeping the nails short will reduce the injury caused when scratching the skin because of pruritis. Rationale 5: Restricting fluids will not help reduce pruritis caused by decompensated liver disease.

A patient is experiencing prerenal failure secondary to hypovolemia. The nurse reviewing the patient's laboratory work and vascular pressures would expect to see which results? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Creatinine clearance of 50 mL/min/1.73m2 2. Low CVP or PAWP pressures 3. BUN of 65 mg/dL 4. Serum creatinine of 3 mg/dL 5. Urine with granular casts and sediment

Correct Answer: 1,2,3,4 Rationale 1: Creatinine clearance provides the most accurate estimate of glomerulo-filtration rate. Normal values range between 85 and 125 mL/min/1.73m2 for adult men and 75 to 115 mL/min/1.73m2 for adult women. Values below normal indicate at least a 50% reduction in the number of functioning nephrons. Rationale 2: With prerenal dysfunction, the nurse assesses the patient for manifestations of hypovolemia, including low CVP or PAWP values. Rationale 3: When the urine flow rate is reduced, more urea is absorbed. Thus, in prerenal failure, the rise in BUN may be out of proportion to the renal dysfunction. Rationale 4: A doubling of serum creatinine normally indicates a 50% reduction in glomerular filtration rates. Normal levels in adults are 0.5 to 1.5 mg/dL. Rationale 5: There are rarely more then a few casts and/or a little sediment present in the urine. The urine appears dark and concentrated but it is clear.

To assist with the common complication of hypotension for the patient undergoing continuous renal replacement therapies, the nurse could implement which actions? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Infuse 0.9% sodium chloride boluses. 2. Administer mannitol. 3. Decrease the rate of ultrafiltration on the dialyzer. 4. Administer albumin. 5. Place the patient in a high-Fowler's position.

Correct Answer: 1,2,3,4 Rationale 1: The nurse might manage hypotension by administering normal saline boluses. Rationale 2: The nurse might manage hypotension by providing volume expanders such as mannitol. Rationale 3: The nurse might manage hypotension by decreasing the rate of ultrafiltration on the dialyzer. Rationale 4: The nurse might manage hypotension by providing volume expanders such as albumin. Rationale 5: Raising the head of the bed would lower the blood pressure even further. Lowering the head of the bed would, instead, raise the blood pressure.

The nurse is preparing an infusion of norepinephrine for a patient with acute kidney injury. What are the nurse's responsibilities when providing this medication? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Monitor the blood pressure every 2 to 5 minutes. 2. Monitor changes in MAP. 3. Monitor heart rate and pattern. 4. Infuse through the central line. 5. Infuse through a hand vein.

Correct Answer: 1,2,3,4 Rationale 1: The nurse monitors the BP every 2 to 5 minutes after beginning a continuous infusion. Rationale 2: The medication will be titrated up or down depending upon the patient's mean arterial pressure. The goal MAP of 80 should be achieved with the lowest possible dose of medication. Rationale 3: The nurse will continuously monitor the patient's heart rate and rhythm pattern while administering this medication. Rationale 4: Norepinephrine should be administered through a central venous catheter. Rationale 5: The veins in the hands, arms, ankles, and legs should be avoided.

While reviewing a patient's medication record, the critical care nurse would be concerned about which drugs that have been implicated in the development of renal failure? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Cyclosporine 2. Contrast media 3. Aminoglycosides 4. Antiseizure medications 5. Nonsteroidal anti-inflammatory drugs (NSAIDs)

Correct Answer: 1,2,3,5 Rationale 1: Cyclosporine has been implicated in the development of renal failure. Rationale 2: Contrast media been implicated in the development of renal failure. Rationale 3: Aminoglycosides have been implicated in the development of renal failure. Rationale 4: Antiseizure medications are not nephrotoxic. Rationale 5: NSAIDs have been implicated in the development of renal failure.

The nurse will review a critically ill patient's history for which causes of intrinsic renal failure? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Contrast media given intravenously during diagnostic imaging 2. Prescribed levothyroxine (Synthroid) following thyroidectomy 3. Acyclovir (Zovorax) prescribed for treatment of genital herpes 4. Receiving prophylactic chemotherapy after surgery for cancer 5. History of using high-dose NSAIDs for rheumatoid arthritis

Correct Answer: 1,3,5 Rationale 1: Drugs that have been implicated in the development of renal failure include contrast media. Rationale 2: Levothyroxine (Synthroid) does not have any nephrotoxic side effects. Rationale 3: Drugs that have been implicated in the development of renal failure include acyclovir. Rationale 4: Chemotherapeutic agents have other systemic side effects such as bone marrow suppression and alopecia. Rationale 5: Drugs that have been implicated in the development of renal failure include nonsteroidal anti-inflammatory drugs (NSAIDs).

The nurse is calculating the distribution restricted fluids for a patient with acute kidney injury. The patient had a urine output of 200 mL the previous day. What amount of fluid is the patient permitted during the night? Standard Text: Record your answer rounding to the nearest whole number.

Correct Answer: 100 Rationale : To calculate the distribution of fluid in a fluid restriction, add the previous day's urine output total to 400 mL as insensible fluid loss. One half of the total is to be allotted to days. One third of the total allotted to evening and one sixth of the total allotted to night. For this patient, 200 mL of the previous day urine output + 400 mL insensible loss = 600 mL. One sixth of 600 mL is 100 mL.

Which manifestation experienced by a patient having vasopressin (Pitressin) therapy for bleeding esophageal varices indicates a serious adverse effect of the medication? 1. A pounding frontal headache 2. Midsternal chest pain 3. Abdominal cramping 4. Vertigo

Correct Answer: 2 Rationale 1: A headache is not a side effect of this medication. Rationale 2: Vasopressin can cause vasoconstriction, resulting in myocardial ischemia. At times it is administered with nitroglycerin to prevent this adverse effect. Rationale 3: Abdominal cramping is not a side effect of this medication. Rationale 4: Vertigo is not a side effect of this medication.

What will the nurse use to accurately assess the fluid status of a patient with ascites? 1. Abdominal percussion 2. Daily weights 3. Measurement of abdominal girth 4. Presence of peripheral edema

Correct Answer: 2 Rationale 1: Abdominal percussion may be difficult and inaccurate in obese patients. Rationale 2: Daily weights are accurate and objective indicators of fluid gain and loss and are directly related to sodium balance. A weight gain of 1 kg is equivalent to the retention of 1 liter of fluid. Rationale 3: The measurement of abdominal girth is subjective and often inaccurate. Rationale 4: The presence of peripheral edema is subjective and often inaccurate.

A patient with portal hypertension and hepatic encephalopathy asks why meat is being restricted in the diet. The nurse explains that a reduced protein diet will: 1. Help to restore his liver function 2. Help decrease the amount of ammonia in his blood 3. Give the liver a chance to rest 4. Prevent fluid from leaking into the abdomen

Correct Answer: 2 Rationale 1: Dietary restriction does not restore liver function but instead lower the production of ammonia. Rationale 2: The goal of treatment is to reduce ammonia production and/or increasing its removal and lower elevated ammonia levels. This may occur by a variety of methods. One method is limiting the amount of protein in the diet. Rationale 3: Restricting protein in the diet does not rest the liver. Rationale 4: Ascites can be controlled with sodium and fluid restriction, the use of diuretics, and intermittent administration of salt-poor albumin.

A patient is in the late stages of liver failure with cirrhosis and progressive, irreversible damage. Knowing this, the nurse explains to the family that: 1. Liver transplantation is the only feasible treatment. 2. Abstinence from alcohol may decrease further liver cell injury and improve portal hypertension. 3. The liver is the only organ affected so that the patient and family need not worry about other body systems. 4. If the patient does not have any variceal hemorrhages he will probably live for years.

Correct Answer: 2 Rationale 1: Evaluation for a liver transplant needs to be done during the early stages of liver failure in order for this therapy to be successful. Rationale 2: In alcoholic cirrhosis, abstinence from alcohol may decrease liver cell injury and improve portal hypertension. Rationale 3: All body systems are affected with hepatic dysfunction. It is a multisystem dysfunctionfluid and electrolyte, renal, integument, hematologic, cardiac, pulmonary, and gastrointestinal. Rationale 4: Late stage liver dysfunction may develop varices as a result of portal hypertension. Even if this patient does not develop varices, this patient will not survive for years.

A patient with esophageal varices is being treated with an esophageal tamponade (Sengstaken-Blakemore) tube. What should be the nurses priority when caring for this patient? 1. Ensuring that the gastric balloon remains inflated 2. Keeping a pair of scissors at the bedside at all times 3. Keeping the patient sedated and quiet 4. Maintaining the esophageal balloon pressure between 15 and 20 mm Hg

Correct Answer: 2 Rationale 1: This is important but airway always takes priority. Rationale 2: Accidental migration of the tube can result in airway obstruction. This requires immediate intervention by cutting all the lumens of the tube to rapidly deflate them and removing the tube. Maintenance of the airway is the priority. Rationale 3: Although this is important to keep the patient from pulling out the tube, airway takes priority. Rationale 4: Although it is important to maintain this pressure against the varices to prevent bleeding, maintaining the airway is the priority.

The typical dietary plan for a patient with acute kidney injury would focus on provision of: 1. High fat, low protein 2. High carbohydrate, low protein 3. High protein, low sodium 4. High calorie, low carbohydrate

Correct Answer: 2 Rationale 1: A high-fat diet is not healthy for any patient population. A low-protein diet is not appropriate as this would cause the body to break down lean muscle mass for metabolic function. Rationale 2: Goals for nutritional intervention in the patient with acute kidney injury include preserving lean body mass, preventing metabolic alterations, and enhancing renal recovery by limiting uremic toxicity. Protein is allowed but limited because its catabolism may result in accumulation of toxic waste products (urea, phosphate, and potassium). Protein requirements can be calculated roughly based on the rise in the patient's BUN in 24 hours, and the amount of protein in the patient's diet can be based on this calculation. The remainder of the calories the patient requires is supplied as carbohydrates or lipids. Rationale 3: A high-protein diet is not appropriate as this would cause a lethal amount of toxic waste to accumulate in a renal failure patient. A low-sodium diet would be appropriate as this would aid in reducing fluid retention. Rationale 4: A high-caloric diet is not appropriate for this would contribute to unnecessary weight gain. Carbohydrates are needed for energy so restriction would be detrimental.

The intensive care nurse is reviewing a patient's chart to find the most accurate indicator of fluid volume status, which is: 1. Intake and output 2. Daily weights 3. Hematocrit level 4. Systolic blood pressure

Correct Answer: 2 Rationale 1: Although intake and output are carefully measured in most critically ill patients, they have been shown to be inaccurate. Still, the nurse attempts to maintain as accurate a record as possible. Rationale 2: Weight is a more accurate indicator of fluid volume status than many of the other assessment parameters. The patient should be weighed daily at the same time on the same properly calibrated scale with the same amount of clothing or bed linens. Rationale 3: Laboratory values can be used to identify hemodilution from fluid volume excess. It may be evident as a decrease in hemoglobin, hematocrit, and serum sodium values. Rationale 4: Multiple factors can affect systolic blood pressure readings in addition to fluid excess.

The nurse would identify which nursing diagnosis for the patient experiencing dialysis disequilibrium syndrome? 1. Infection 2. Altered thought processes 3. Fluid volume deficit 4. Anxiety

Correct Answer: 2 Rationale 1: Disequilibrium syndrome affects the brain and is not related to exposure to pathogens. Rationale 2: Dialysis disequilibrium syndrome is especially common in patients undergoing their first or second dialysis treatment who experience sudden, large decreases in their BUN. The most likely explanation for this syndrome is that the levels of urea do not drop as rapidly in the brain as the plasma because of the blood-brain barrier. The higher levels of urea in the brain result in an osmotic concentration gradient between the brain cells and the plasma. Fluid enters the brain cells by osmosis until the concentration levels equal that of the extracellular fluid, resulting in cerebral edema and the dialysis disequilibrium syndrome. Manifestations of the syndrome include headache and mental impairment that may progress to confusion, agitation, seizures, and nausea and vomiting. Rationale 3: Fluid volume deficit would be manifested by physiologic signs such as hypotension and tachycardia. Rationale 4: Anxiety is a manifestation of hypoxia and fluid volume overload.

The critical care nurse is providing a training session on the principles of renal replacement therapies. When discussing how solutes move across a semipermeable membrane from a higher to lower concentration, the nurse is describing: 1. Ultrafiltration 2. Diffusion 3. Active transport 4. Osmosis

Correct Answer: 2 Rationale 1: Ultrafiltration (convection) involves a pressure gradient being created between the sides of the semipermeable membrane. Solutes are carried in solution across the semipermeable membrane in response to the pressure gradient, producing an ultrafiltrate. Rationale 2: Diffusion involves the movement of solutes across a semipermeable membrane from a solution where they are in a higher concentration (the plasma) to a solution where they are in a lower concentration (the dialysate). Rationale 3: Active transport (sometimes called active intake because of the absorbing movement of particles) is an energy-requiring process that moves material across a cell membrane and up the concentration gradient. Rationale 4: Osmosis occurs when solution (water) moves from an area of low-solute concentration (the plasma) to an area of higher solute concentration (the dialysate).

For which order would the nurse seek clarification regarding a patient with decreased renal perfusion and lowered glomerular filtration rate? 1. Administer acetylcysteine prior to an intravenous pyelogram procedure. 2. Infuse vancomycin 1,500 mg IV every 12 hours. 3. Check a peak and trough level with every third dose of IV clindamycin. 4. Give furosemide 10 mg by mouth daily.

Correct Answer: 2 Rationale 1: If contrast dye must be administered, it is given sparingly, or the physician may prescribe acetylcysteine for its renal protective effects. Rationale 2: This order should be questioned. During the period of decreased renal perfusion and lowered glomerular filtration rate that occurs in prerenal failure, the kidneys are vulnerable to insults from other sources such as medications, contrast dyes, and toxins. The nurse should avoid administering nephrotoxic agents if possible. Rationale 3: This is an appropriate order. The nurse monitors the peak and trough blood levels of medications that are known to be damaging to the kidney such as clindamycin. Rationale 4: This is an appropriate order. Drugs that are known to be excreted by the kidneys and that are potentially harmful to the kidneys are given in reduced doses based on the patient's creatinine clearance. Furosemide (Lasix) 10 mg is a reduced dose and is appropriate for this patient.

What will the nurse do when caring for a patient with an atrioventricular fistula in the forearm for hemodialysis? 1. Percuss the fistula for presence of a bruit each shift 2. Take the blood pressure in the unaffected arm 3. Position the patient so there is pressure on the access area 4. Flush the fistula with heparin every shift

Correct Answer: 2 Rationale 1: It is recommended to palpate for the thrill and auscultate, not percuss, the bruit over the access every 8 hours to assess for patency. Rationale 2: This is the appropriate nursing care. Taking the blood pressure in the arm with fistula is contraindicated. When caring for a patient with an AV fistula or graft, the nurse assesses and maintains the patency of the access by avoiding any obstruction of blood flow in that extremity, such as blood pressure measurement, IV placement, phlebotomy, or positioning the patient so there is pressure on the access. Rationale 3: No pressure should be placed on the arm with the fistula as this could cause the fistula to become clotted. Rationale 4: Around-the-clock heparin flushes would not be utilized because the fistula is not an IV access but is part of the general circulation. Flushing would also increase the potential for infection. Access needs to be limited by HD personnel only.

The nurse believes a patient is experiencing prerenal dysfunction and not intrinsic renal failure because of which laboratory finding? 1. Urine osmolality of 200 mOsm/L 2. Urine osmolality of 550 mOsm/L 3. Urine sodium greater than 40 mmol/L 4. Presence of granular casts and sediment

Correct Answer: 2 Rationale 1: This laboratory value indicates intrinsic renal failure because the osmolality is less than 350 mOsm/L. Rationale 2: In prerenal dysfunction, the urinalysis typically shows a concentrated urine with a high osmolality (500 mOsm/L) and a decreased urine sodium (<20 mmol/L). Rationale 3: This laboratory value indicates instrinsic renal failure because the urine sodium is greater than 40 mmol/L. Rationale 4: A fractional excretion of sodium (FENa) greater than 1% with granular casts and sediment is seen in intrinsic renal failure.

A patient is recovering from an endoscopy with banding of esophageal varices. Which intervention would have the highest priority immediately following the procedure and until the patient is fully awake? 1. Determining if the patient is able to swallow 2. Irrigating the NG tube with saline to detect any additional bleeding 3. Maintaining the patient in the left lateral decubitus position 4. Monitoring the patients vital signs every hour

Correct Answer: 3 Rationale 1: During endoscopy, patients may have a topical anesthetic sprayed to the throat area, which may impair swallowing. The nurse waits until the patient is awake to assess swallowing. Rationale 2: Irrigation is done as needed to maintain patency. Rationale 3: If the patient is not intubated, the nurse should position the patient in the left lateral decubitus position to protect the airway until the patient is fully awake. Airway protection is always top priority. Rationale 4: The nurse monitors vital signs, including temperature and oxygen saturation and level of pain and consciousness, until the patient returns to baseline (typically every 10 to 15 minutes for 30 minutes to an hour, then per ICU protocol, or more frequently depending on acuity).

The nurse is preparing to administer the third dose of aldactone (Spironolactone) to a patient with cirrhosis and ascites. What would cause the nurse to question the administration of this medication? 1. Serum creatinine of 1.6 mg/dL 2. Serum sodium of 130 mEq/L 3. Serum potassium of 5.7 mEq/L 4. Weight gain of 0.2 kg

Correct Answer: 3 Rationale 1: The serum creatinine of 1.6 mmol/L is within normal limits. Rationale 2: The serum sodium of 130 mEq/l, even though it is low, does not meet the criteria to hold the medication. Rationale 3: The nurse anticipates this potassium-sparing diuretic may be discontinued if the potassium level is greater than 5.3 mEq/L. This medication needs to be held or discontinued as this patients potassium level is 5.7 mEq/L. Rationale 4: A weight gain of 0.2 kg is not an indication to hold diuretics. The objective of diuretics is to reduce the ascites and peripheral edema.

To test for a positive Trousseau's sign indicating hypocalcemia, the nurse would need which piece of equipment? 1. Percussion hammer 2. Penlight 3. Blood pressure cuff 4. Doppler

Correct Answer: 3 Rationale 1: A percussion hammer is used to elicit deep tendon reflexes. The hyperactive reflexes associated with hypocalcemia need very little stimulation to elicit a response. Rationale 2: Motor reflexes are not stimulated by light. The penlight is used to assess papillary reflex and to illuminate areas for assessment. Rationale 3: Manifestations of hypocalcemia may develop as soon as 48 hours after the onset of the oliguric phase of acute kidney injury because renal tubule disorders often result in excessive loss of calcium. Spasm of the hand and wrist, called Trousseau's sign, may become apparent when a blood pressure cuff placed on an arm is inflated to 20 mm Hg above the systolic pressure for at least 3 minutes. Rationale 4: A Doppler is used to assess arterial flow such as hard-to-feel peripheral pulses.

Using evidence based practice interventions for a patient with acute kidney injury, the nurse is aware that the best approach for fluid volume excess management is: 1. A sodium-restricted diet 2. Diuretics 3. Fluid restriction 4. Plasmapheresis

Correct Answer: 3 Rationale 1: A sodium-restricted diet alone is not enough. The typical diet would also include potassium restriction and a protein intake of 40-80 gms/day. Rationale 2: Diuretics, once a mainstay of treatment, are being reconsidered as therapy because these medications, especially furosemide, are nephrotoxic. Rationale 3: The most effective interventions for fluid volume excess in the patient with acute kidney injury are fluid restriction and renal replacement therapies. Rationale 4: Plasmapheresis is a blood-purification procedure used to treat several autoimmune diseases, and is not used for fluid volume excess generated by acute kidney injury.

The nurse preparing to administer peritoneal dialysis would have which responsibility in contrast to hemodialysis? 1. Knowing the patient's dry weight prior to beginning 2. Monitoring for changes in vital signs 3. Inspecting the tunneled catheter for infection 4. Suggesting a low-Fowler's position for comfort

Correct Answer: 3 Rationale 1: Knowing the patient's weight prior to beginning is appropriate for both procedures. Rationale 2: Monitoring for changes in vital signs before, during, and after is appropriate to both procedures. Rationale 3: Access to the peritoneum is by tunneled catheter. The catheter has several sections: the first outside the body, the next located in the subcutaneous layer and having at least one Dacron cuff or flanged collar to anchor the catheter, and a section in the peritoneal cavity with multiple lumens for rapid delivery of fluid. The nurse maintains aseptic technique when caring for the catheter and assesses the access site at least daily. Rationale 4: Placing the patient in a low-Fowler's position would be appropriate for either type of therapy.

What would the best nutritional goal for the patient with acute kidney injury? 1. Weight will increase by 3 pounds in a month 2. Patient eats over 50% of all meals 3. Albumin level will rise from 2.6 g/dL 4. Total protein level will increase to 10 g/dL

Correct Answer: 3 Rationale 1: Maintenance of body weight (with no evidence of excessive fluid intake or output) is important. The weight gain could be excess fluid, which, therefore, is not desirable. Rationale 2: Eating over 50% of meals does not indicate the specific foods ingested. In order to accomplish nutritional goals, 100% of the diet should be consumed. Rationale 3: The nurse assesses the patient for indications that he is being adequately nourished. These include albumin level of 3.5 to 4.0 g/dL; increase of this level shows improvement. Rationale 4: The protein level is too high. The normal range is 6 to 8 g/dL.

A patient with acute kidney injury is disappointed that hemodialysis, instead of peritoneal dialysis, is planned for treatment. After teaching about the two types of dialysis, the nurse determines that further instruction is needed when the patient makes which statement about the disadvantages of peritoneal dialysis? 1. "It's not speedy enough to remove the wastes." 2. "It may worsen my breathing problems." 3. "It cannot be used for older patients like me." 4. "It's not nearly as efficient as hemodialysis."

Correct Answer: 3 Rationale 1: This is a correct statement that does not require further teaching. Peritoneal dialysis is often not speedy enough to adequately remove the midsized wastes such as urea that accumulate rapidly in catabolic patients with acute kidney injury. Rationale 2: This is a correct statement that does not require further teaching. The volume of fluid that is placed in the peritoneum in PD tends to have a negative impact on respiratory function. Rationale 3: This is not a correct statement. Age is not a primary determining factor in use of peritoneal dialysis. It is rarely used in acute kidney injury because there are a variety of disadvantages; for example, several studies have demonstrated poorer outcomes for patients who received PD rather than other modalities of treatment for acute kidney injury. Rationale 4: This is a correct statement that does not require further teaching. Peritoneal dialysis is not speedy enough to remove wastes and fluid for those patients experiencing acute kidney injury.

A patient has been placed on a 1,000-mL fluid restriction over 24 hours. Choose the plan that reflects how the critical care nurse would divide this amount of fluid. 1. 350 mL for dayshift, 325 mL for evening shift, and 325 mL for nightshift 2. 400 mL for dayshift, 400 mL for evening shift, and 200 mL for nightshift 3. 500 mL for dayshift, 325 mL for evening shift, and 125 mL for nightshift 4. 600 mL for dayshift, 200 mL for evening shift, and 200 mL for nightshift

Correct Answer: 3 Rationale 1: This is a division of 35%, 35%, and 32.5%. Rationale 2: This is a division of 40%, 40%, and 20%. Rationale 3: 500 mL for dayshift, 325 mL for evening shift, and 125 mL for nightshift is correct and demonstrates a common example of dividing a restricted fluid allotment over a 24-hour period. For 1,000 cc, one half (50%) of calculated fluid may be allotted to days (500 mL), one third (33%) for evenings (325 mL), and the balance of one sixth (17%) for night (125 mL). Rationale 4: This is a division of 60%, 20% and 20%.

A nurse plans to administer to a patient a fluid challenge for the purpose of establishing normal renal perfusion. What does this treatment involve? 1. Infusing 250 mL of 0.9% sodium chloride over 1 hour 2. Administering albumin intravenously, followed by furosemide 3. Infusing 500 mL of normal saline over a 30-minute period 4. Giving twice the amount of IV fluid each hour compared to urinary output

Correct Answer: 3 Rationale 1: This is too slow of a rate and too little volume. Rationale 2: The use of albumin and furosemide are not used as an initial fluid challenge. This therapy is done later to possibly stimulate the nephrons. Rationale 3: A fluid challenge is the infusion of a bolus of 250 to 500 mL of normal saline rapidly. Although definitions of rapid administration vary depending on the circumstances, a fluid challenge of 500 mL may be administered over half an hour. Rationale 4: Basing the amount of IV fluid to give on urinary output would be inappropriate. A fluid challenge is a large bolus that is administered quickly to rapidly hydrate the patient.

A patient with esophageal varices received octreotide (Sandostatin) 100 microgram intravenous bolus and the nurse is preparing to start a continuous infusion of the medication. The drug is diluted 500 micrograms in 250 mL of 0.9% normal saline to be administered at 50 mcg/hour. How many milliliters per hour should the intravenous infusion pump be set to deliver the correct dose? 1. 100 mL 2. 50 mL 3. 12.5 mL 4. 25 mL

Correct Answer: 4 Rationale 1: The rate of 25 L/hr may be correctly calculated by using the formula: Dose divided by concentration equals rate. The dose is 50 mcg/hour divided by the concentration (500 mcg/ 250 mL). This is 50 divided by 2 = 25 mL/hour. Rationale 2: The rate of 25 L/hr may be correctly calculated by using the formula: Dose divided by concentration equals rate. The dose is 50 mcg/hour divided by the concentration (500 mcg/ 250 mL). This is 50 divided by 2 = 25 mL/hour. Rationale 3: The rate of 25 L/hr may be correctly calculated by using the formula: Dose divided by concentration equals rate. The dose is 50 mcg/hour divided by the concentration (500 mcg/ 250 mL). This is 50 divided by 2 = 25 mL/hour. Rationale 4: The rate of 25 L/hr may be correctly calculated by using the formula: Dose divided by concentration equals rate. The dose is 50 mcg/hour divided by the concentration (500 mcg/ 250 mL). This is 50 divided by 2 = 25 mL/hour.

A patient with bleeding esophageal varices is scheduled to receive a bolus followed by a continuous infusion of octreotide (Sandostatin). The nurse preparing the medication would: 1. Anticipate that the medication will stop the bleeding immediately. 2. Notify the physician if the patient has cardiac disease because the medication is contraindicated. 3. Recognize that doses of 100 mcg/hour and higher are associated with better outcomes. 4. Review serial hematocrit levels to determine if the patient is continuing to bleed.

Correct Answer: 4 Rationale 1: This medication is effective in temporarily stopping the bleeding in approximately 80% of patients. Rationale 2: Octreotide (Sandostatin) has an excellent safety margin and is safe for patients with cardiac disease. Rationale 3: Doses greater than 50 mcg/hr may increase systemic venous pressure and do not increase the portal hypotensive effects. Rationale 4: To evaluate response to the octreotide (Sandostatin) infusion, the nurse would continue to monitor the patients hemodynamic status and expect to see the patients vital signs return to normal, urine output increase, and a decrease in overt bleeding: hematemesis, melena, and hematochezia. Serial hematocrit levels should be evaluated.

The intensive care nurse explains to a patient with acute kidney injury that the most effective method for reducing hyperkalemia is the use of: 1. Insulin plus glucose 2. Inhaled beta agonists 3. Sodium bicarbonate 4. Hemodialysis

Correct Answer: 4 Rationale 1: Insulin plus glucose lowers the total body concentration of potassium but temporarily shifts the potassium into the cells, allowing time to institute other interventions that will decrease the total body concentration of potassium. Rationale 2: Inhaled beta agonists lower the total body concentration of potassium, but temporarily shift the potassium into the cells, allowing time to institute other interventions that will decrease the total body concentration of potassium. Rationale 3: Sodium bicarbonate lowers the total body concentration of potassium, but temporarily shifts the potassium into the cells, allowing time to institute other interventions that will decrease the total body concentration of potassium. Rationale 4: Hemodialysis is the most effective method of adequately treating severe hyperkalemia. This method lowers the total body concentration of potassium.

Which patient situation would increase the risk for developing dialysis disequilibrium syndrome? 1. Peritoneal dialysis provided in a home environment 2. Patient who received an ACE inhibitor prior to hemodialysis 3. A known history of long-term substance abuse 4. Patient undergoing first hemodialysis treatment

Correct Answer: 4 Rationale 1: Peritoneal dialysis is a much slower process than HD because the solute and fluid removal is slower. This allows for equilibrium of cells, especially those in the brain, to adjust to the change in fluid and solutes. Rationale 2: The use of an ACE inhibitor before HD is not contraindicated and does not contribute to disequilibrium syndrome. Rationale 3: A history of substance abuse does not contribute to the development of disequilibrium syndrome because this disorder does not affect osmotic or pressure gradients. Rationale 4: Dialysis disequilibrium syndrome is especially common in patients undergoing their first or second dialysis treatment who experience sudden, large decreases in their BUN. The most likely explanation for this syndrome is that the levels of urea do not drop as rapidly in the brain as the plasma because of the blood-brain barrier. The higher levels of urea in the brain result in an osmotic concentration gradient between the brain cells and the plasma. Fluid enters the brain cells by osmosis until the concentration levels equal that of the extracellular fluid, resulting in cerebral edema and the dialysis disequilibrium syndrome.

Of the following patients in an intensive care unit, the nurse identifies which patient as being at highest risk for the development of acute kidney injury with a prerenal cause? A patient who is: 1. Experiencing acute status asthmaticus 2. Being treated for hypertension following a cerebral vascular accident 3. In skeletal traction following a motor vehicle accident 4. Post-operative from a ruptured abdominal aortic aneurysm

Correct Answer: 4 Rationale 1: Status asthmaticus is a severe airway obstruction that results in respiratory acidosis. There is not an associated reduction in cardiac output linked with this problem. Rationale 2: Hypertension is associated with the development of chronic renal failure and end stage renal disease. Rationale 3: Long bone fractures can result in blood loss but the amount of blood lost is less than what would be considered as a prerenal cause for acute kidney injury. Rationale 4: Prerenal failure commonly results from a pronounced reduction in cardiac output due to severe hypotension, hypovolemia, or severe vasoconstriction. The patient who has experienced significant blood loss as in a ruptured aortic aneurysm would be at greatest risk for the development of acute kidney injury with a prerenal cause.

What would the critical care nurse expect to find if administering a fluid challenge to an 80-year-old patient had the intended effect? 1. A systolic blood pressure of 120 mm Hg or less 2. Heart rate remaining steady at 60 to 70 beats per minute 3. Skin turgor showing improvement within 24 hours 4. A MAP of 70 mm Hg or higher

Correct Answer: 4 Rationale 1: The blood pressure would likely be higher following a fluid bolus. With a rapid increase of intravascular volume, an older patient's vascular system would respond with increased resistance so the blood pressure would rise. Rationale 2: As the result of increased volume from the bolus, an older patient's heart would have to pump faster to accommodate for the increase in intravascular volume. Rationale 3: Skin turgor in an older patient is not a reliable clinical sign for improved renal perfusion. Rationale 4: A MAP of 70 mm Hg is correct and the intended outcome for an older adult. Adults over the age of 70 may require a higher MAP, perhaps as high as 100 mm Hg, to maintain adequate renal perfusion.