Unit 3 Critical Care Study Guide Part 2

Autonomic dysreflexia is a medial emergency. What is the best position for the patient if this occurs? A. Side lying B. Trendelenburg C. Upright at 90 degrees D. Low Fowler's

C. Upright at 90 degrees

A nurse is an emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the following actions should the nurse take first? A. Auscultate for wheezing B. Assess the client's level of consciousness C. Administer epinephrine D. Monitor for hypotension

A. Auscultate for wheezing

Autonomic dysreflexia is characterized by exaggerated response of the sympathetic stimuli. Common causes of autonomic dysreflexia include: (Select all that apply) A. Bladder distension B. Fecal impaction C. Hyperglycemia D. Low body temperature E. Breakdown of skin

A. Bladder distension B. Fecal impaction E. Breakdown of skin

A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse perform first? A. Clean and dress the wound B. Administer IV fluids C. Administer pain medication D. Administer a tetanus booster

B. Administer IV fluids

A nurse is caring for a client who has infective endocarditis. Which of the following manifestations is the priority for the nurse to monitor for? A. Anorexia B. Dyspnea C. Fever D. Malaise

B. Dyspnea

A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take? A. Insert an indwelling urinary catheter B. Inspect the mouth for signs of inhalation injuries C. Administer IV pain medications D. Draw blood for a complete blood cell (CBC) count

B. Inspect the mouth for signs of inhalation injuries

A nurse is preparing to administer medications to four clients. The nurse should administer medications to which of the following clients first? A. A client who has pneumonia, a WBC count of 11,500/mm3, and is prescribed piperacillin B. A client who has anemia, hemoglobin of 11g/dL, and is prescribed epoetin alfa C. A client who has renal failure, a serum potassium of 5.8/mEq/L, and is prescribed sodium polystyrene sulfonate D. A client who is post coronary artery bypass graft (CABG), has total cholesterol of 318mg/dL, and is prescribed atorvastatin

C. A client who has renal failure, a serum potassium of 5.8/mEq/L, and is prescribed sodium polystyrene sulfonate

A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing? A. Anuria B. Decreased level of consciousness C. Hypotension D. Increased respiratory rate

C. Hypotension

Neurogenic shock is classified which which of the following findings? A. Sudden drop in Blood pressure B. Occurs within 30 minutes of the injury C. Common with a spinal cord injury at T5 or above D. All of these

D. All of these

A nurse is caring for a client who has esophageal varices and is hypotensive after Vomiting 500 ml of blood. Which of the following actions is the nurse's priority? A. Elevate the client's feet B. Initiate a dopamine IV infusion C. Administer broad spectrum antibiotics D. Increase the client's IV fluid rate

D. Increase the client's IV fluid rate

Which data collected are most important in alerting the nurse to a diagnosis of sepsis and systemic inflammatory response syndrome (SIRS)? Select all that apply A. Hematuria B. Atrial fibrillation C. Temperature D. Apical pulse rate E. Respiratory rate F. Blood glucose level

A. Hematuria C. Temperature D. Apical pulse rate E. Respiratory rate

A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns? A. Location of the burn B. Age of the client C. Associated medical history D. Cause of the burn

A. Location of the burn

A nurse is caring for a client who experience a femur fracture 8 hours ago and now reports sudden onset dyspnea and severe chest pain. Which of the following actions should the nurse take first? A. Provide high flow oxygen B. Check the client for positive Chvostek's sign C. Administer an IV vasopressor medication D. Monitor the client for headache

A. Provide high flow oxygen

A patient is brought to the ED by ambulance with a suspected spinal cord injury. To understand how the patient might be injured, which question should the nurse ask the EMTs who transported the patient from the accident site? A. How old is the patient? B. What position did you find the patient? C. Were there any witnesses? D. Did you have any lunch today?

B. What position did you find the patient?

An nurse in an emergency department is caring for a client who is bleeding from a deep laceration on his left lower forearm. After observing standard precautions, which of the following actions should the nurse perform first? A. Apply a tourniquet just below the elbow B. Clean the wound C. direct pressure over the wound D. Elevate the limb and apply ice

C. direct pressure over the wound

The nurse is caring for a patient with possible distributive shock. Which should the nurse look for on assessment? A. Blood loss and actual hypovolemia B. Decreased cardiac output C. Third spacing of fluids into peritoneal space D. Widespread vasodilation and relative hypovolemia

D. Widespread vasodilation and relative hypovolemia