Sample Chapter



Critical Care Nursing A Holistic Approach 10th Edition by Patricia Gonce Morton – Test Bank 


1. A nurse is the only one in the ICU who has not achieved certification in critical care nursing. She often will ask her fellow nurses what to do in caring for a patient because she doubts the accuracy of her knowledge and her intuition. She loves her work but wishes she could do it with a greater level of competence. What is the most important effect that obtaining certification would likely have on the nurse’s practice?
A) Recognition by peers
B) Increase in salary and rank
C) More flexibility in seeking employment
D) Increased confidence in making decisions



2. A hospital interviews two different candidates for a position in the ICU. Both candidates have around 10 years of experience working in the ICU. Both have excellent interpersonal skills and highly positive references. One, however, has certification in critical care nursing. Which of the following is the most compelling and accurate reason for the hospital to hire the candidate with certification?
A) The certified nurse will have more knowledge and expertise.
B) The certified nurse will behave more ethically.
C) The certified nurse will be more caring toward patients.
D) The certified nurse will work more collaboratively with other nurses.



3. A nurse is caring for an elderly man recently admitted to the ICU following a stroke. She assesses his cognitive function using a new cognitive assessment test she learned about in a recent article in a nursing journal. She then brings a cup of water and a straw to the patient because she observes that his lips are dry. Later, she has the patient sit in a wheelchair and takes him to have some blood tests performed. He objects at first, saying that he can walk on his own, but the nurse explains that it is hospital policy to use the wheelchair. That evening, she recognizes signs of an imminent stroke in the patient and immediately pages the physician. Which action taken by the nurse is the best example of evidence-based practice?
A) Giving the patient a cup of water
B) Transferring the patient in a wheelchair
C) Using the cognitive assessment test
D) Recognizing signs of imminent stroke and paging the physician



4. A nurse is on a committee that is trying to reduce the occurrence of hospital-acquired infections in the ICU. Her role is to conduct research to find which interventions have been shown to be most effective in reducing these infections. She consults many different sources and finds conflicting information. Which of the following sources should she consider the most authoritative?
A) AACN expert panel report
B) A meta-analysis of randomized controlled trials in the American Journal of Nursing
C) A systematic review of qualitative studies in the Journal of Advanced Nursing
D) A single randomized controlled trial in the American Journal of Critical Care



5. A nurse who has been recently hired to manage the nursing staff of the ICU is concerned at the lack of evidence-based practice she sees among the staff. Which of the following would be the best step for her to take to promote incorporating evidence into clinical practice?
A) Only hire nurses certified in critical care nursing.
B) Leave copies of several different nursing journals in the nurses’ lounge.
C) Demonstrate to the staff the best nursing-related search terms to use in Google or Yahoo!
D) Introduce the staff to the PubMed search engine and assign them topics to research on it.



6. A physician visits a patient in the ICU while the nurse is out. The patient complains that the pain medication is not effective and that he would like to receive an increased dose. The physician has the nurse paged and consults with him in the hallway regarding the patient’s request for stronger pain medication. The nurse explains that patient was started on a morphine drip only 20 minutes ago and that the drug has not had time to take effect yet. The physician agrees and tells the patient to give it just a bit more time. Which component of a healthy work environment is most evident in this scenario?
A) Skilled communication
B) Appropriate staffing
C) True collaboration
D) Meaningful recognition



7. A nurse in the ICU is responding to a patient who has just gone into cardiac arrest. A moment later, the nurse is notified that another patient has just gone into anaphylactic shock due to a drug allergy. She is conflicted as to what to do, as she is the only nurse available at the moment to tend to both patients. Which component of a healthy work environment is lacking in this scenario?
A) Effective decision making
B) Appropriate staffing
C) Authentic leadership
D) Meaningful recognition



8. An ICU nurse has provided excellent care for a 6-year-old girl who had been admitted to the ICU for a head injury. The nurse was attentive not only to the needs of the patient but also went out of her way to care for the needs of the girl’s family. According to research, which of the following forms of recognition would the nurse value the most?
A) A card from the girl’s family
B) A plaque from the ICU physicians naming her as “Nurse of the Year”
C) A letter of commendation from the hospital’s administration
D) A bouquet of flowers from her supervisor



9. A patient in the ICU has recently been diagnosed with diabetes mellitus. Before being discharged, this patient will require detailed instructions on how to manage her diet, how to self-inject insulin, and how to handle future diabetic emergencies. Which nurse competency is most needed in this situation?
A) Clinical judgment
B) Advocacy and moral agency
C) Caring practices
D) Facilitation of learning



10. An elderly patient is admitted to the ICU with stage IV lung cancer, diabetes mellitus, and congestive heart failure. The health care team assembled to care for her is large and diverse, including an oncologist, a pulmonologist, an endocrinologist, a cardiologist, and others. The patient is not expected to survive more than a few weeks, and her husband is overwhelmed with stress and grief. Which nurse competency or competencies are most needed in this situation? Select all that apply.
A) Clinical judgment
B) Caring practices
C) Collaboration
D) Response to diversity



11. An Ethiopian man with AIDS has recently been admitted to the ICU with a case of pneumonia. The man is new to the U.S. and has no health insurance. He would likely be eligible for the state’s Medicaid coverage, but does not understand how to access this coverage. Which competency or competencies are most needed in this situation? Select all that apply.
A) Clinical judgment
B) Advocacy and moral agency
C) Collaboration
D) Systems thinking
E) Response to diversity
F) Clinical inquiry



12. A nurse decides to seek certification in critical care nursing. What is the most important benefit for the individual nurse in becoming certified in a specialty?
A) It will result in a salary increase.
B) It is required to work in critical care.
C) It demonstrates the nurse’s personal expertise.
D) It is mandated by employers.



13. The American Association of Critical-Care Nurses (AACN) sponsors certification in critical care nursing for several critical care subspecialties. What is the most important benefit of such certification for the profession of nursing?
A) Provides positive publicity for nursing
B) Validates nurses’ expert knowledge and practice
C) Mandated by government regulations
D) Demonstrates basic knowledge in the field



14. A nurse has achieved certification in critical care nursing. What is the most important effect that this certification will have on the nurse’s practice?
A) Recognition by peers
B) Increase in salary and rank
C) More flexibility in seeking employment
D) Increased confidence in critical thinking



15. The nurse cites evidence-based practice as a rationale for a patient care decision. What is the best description of evidence-based practice?
A) Decisions based on expert legal testimony
B) Use of best available research data
C) Evolution of nursing practice over time
D) Individual optimization of patient outcomes



16. The nurse caring for a critically ill patient implements several components of care. What component is an example of the use of evidence-based practice?
A) Use of a protocol for admission of a patient to the unit
B) Application of an insulin sliding scale method from research
C) Checking the patient’s armband before giving a medication
D) Limiting visits to immediate family only for 2 hours a day



17. The nurse wishes to increase the use of evidence-based practice in the critical care unit where he works. What is a significant barrier to the implementation of evidence-based practice?
A) Use of computerized records by the hospital
B) Health Information Privacy and Portability Act (HIPPA)
C) Lack of knowledge about literature searches
D) Strong collaborative relationships in the work setting



18. The nurse has identified an increase in medication errors in the critical care unit over the past several months. What aspect of medication procedures should be evaluated first?
A) Adherence to procedures by nursing staff
B) Clarity of interdisciplinary communication
C) Number of new employees on the unit
D) Changes in administration procedures



19. A critical care unit has decided to implement several measures designed to improve intradisciplinary and interdisciplinary collaboration. In addition to an expected improvement in patient outcomes, what is the most important effect that should result from these measures?
A) Identification of incompetent practitioners
B) Improvement in manners on the unit
C) Increased staff retention
D) Less discussion in front of patients and families



20. A nurse wishes to practice using the Synergy Model developed by the American Association of Critical-Care Nurses (AACN). What nursing behavior best supports use of this model?
A) Attending mandatory hospital-wide in-service programs
B) Self-directed study of best practice for the patients she cares for
C) Gathering demographic data on the patients admitted to the unit
D) Participating in a research study as a data collector



21. As part of the Synergy Model, the nurse has identified a patient characteristic of resiliency. What patient behavior demonstrates resiliency?
A) Dysfunctional grieving behaviors after receiving bad news
B) Developing a list of questions for the physician
C) Denial of any possible negative outcomes for a procedure
D) Assigning blame to others for undesired outcomes of illness



22. A patient is admitted to the critical care unit after receiving a mechanical heart implantation. In making a nursing assignment, the charge nurse best demonstrates application of the Synergy Model by assigning which nurse to care for this patient?
A) A newly hired new graduate nurse, for the experience
B) A nurse with a patient in the next room, for proximity
C) The most senior nurse on the unit, for political reasons
D) The nurse with most experience with this device, for expertise



23. A Muslim patient has been admitted to the critical care unit with complications after childbirth. Based on the Synergy Model, which nurse would be the most inappropriate to assign to care for this patient?
A) New graduate female nurse
B) Most experienced female nurse
C) New graduate male nurse
D) Female nurse with postpartum experience



24. Today’s critical care nursing environment is constantly changing. What nursing behavior best illustrates awareness of current events affecting critical care nursing?
A) Participating in the hospital’s efforts to recruit new nurses
B) Volunteering to serve on a disaster response planning committee
C) Adhering to content taught in basic nursing program
D) Attending hospital-mandated in-services without other education


1. A patient in the CCU with chronic heart failure is prescribed an ACE inhibitor. What side effects should the nurse mention to him? Select all that apply.
A) Angioderma
B) Cough
C) Rebound tachycardia
D) Hyperkalemia
E) Night sweats
F) Anxiety



2. A CCU nurse who works frequently with cardiac patients is putting together a teaching plan to follow when she instructs these patients on how to live with heart failure. Which points should she include in this plan? Select all that apply.
A) Discontinue medications once you are feeling better, to avoid adverse effects.
B) Take your medications about the same time every day.
C) Avoid pepper and spices.
D) Remove the saltshaker from your table.
E) The best time to weigh yourself is in the afternoon.
F) Try to perform 15 to 20 minutes of continuous activity each day.



3. A patient with chronic cardiac failure in the CCU is on an ACE inhibitor but still has significant pitting edema in his extremities. Which medication, in addition to the ACE inhibitor, is the physician likely to prescribe to this patient?
A) Digoxin
B) A loop diuretic
C) b-blocker
D) Calcium channel blocker



4. A patient presents to the CCU with acute, decompensated heart failure. The nurse observes that this patient has chronic obstructive pulmonary disease and hypotension. She eats a low-sodium diet and drinks alcohol excessively. Which of the following are contributing factors to this patient’s heart failure? Select all that apply.
A) Chronic obstructive pulmonary disease
B) Hypotension
C) Low-sodium diet
D) Excessive alcohol intake



5. A patient is in the CCU with dilated cardiomyopathy and asymptomatic right-sided chronic heart failure. What finding will the nurse most likely discover in her assessment of this patient?
A) Mitral regurgitation murmur
B) Cheyne-Stokes respiratory pattern
C) Unilateral crackles
D) Rales



6. A nurse in the CCU must assess a cardiac patient’s fluid status. Which of the following is the best method for him to use?
A) Having the patient measure and record all liquids taken in and all urine excreted
B) Weighing the patient daily
C) Pulse oximetry
D) Radionuclide ventriculography



7. A patient presents to the CCU with shortness of breath on exertion. Which diagnostic study would be best for ruling out pneumonia or COPD as the cause of the patient’s symptoms?
A) Echocardiography
B) Radionuclide ventriculography
C) Pulse oximetry
D) Chest radiography



8. A patient in the CCU with chronic heart failure experiences shortness of breath even when at rest. When he stands up and walks across the room, his shortness of breath worsens. Which class of heart failure does this patient exhibit, according to the New York Heart Association (NYHA) Functional Classification of Heart Failure?
A) Class I
B) Class II
C) Class III
D) Class IV



9. A patient in the CCU has clear evidence of structural heart failure, as he lacks contractility in his left ventricle and his ejection fraction is only 37%. However, he has never shown any signs or symptoms of heart failure. According to the American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines for Stages of Heart Failure, which stage of heart failure best characterizes this patient’s condition?
A) Stage A
B) Stage B
C) Stage C
D) Stage D



10. A patient presents to the CCU with cardiac heart failure resulting from atrial tachycardia. Which of the following explains how atrial tachycardia can cause heart failure?
A) Premature ventricular beats leading to sudden death
B) Increase in muscle mass in ventricle
C) Pulmonary embolus leading to acute right-sided heart failure
D) Shortened diastole leading to decreased filling and diastolic dysfunction



11. The nurse is caring for a patient who has been admitted with a diagnosis of heart failure. What does the term “heart failure” mean?
A) It is characterized by rales and alveolar edema.
B) It results from damage caused by acute myocardial infarction.
C) It is a general clinical syndrome with many etiologies.
D) All patients have similar symptoms.



12. A patient has been diagnosed with left ventricular heart failure. What physical findings would the nurse expect?
A) Enlarged liver
B) Peripheral edema
C) Pulmonary rales
D) Enlarged spleen



13. An elderly patient with uncontrolled hypertension and atrial fibrillation with rapid ventricular response is admitted with a diagnosis of heart failure. He has crepitant pulmonary rales and his chest x-ray shows pulmonary congestion. The patient probably has what type of heart failure?
A) Left ventricular systolic failure
B) Left ventricular diastolic failure
C) Right ventricular failure
D) Combination heart failure



14. A patient has been admitted with acute left systolic heart failure secondary to acute myocardial infarction. The patient has dyspnea and orthopnea and a cardiac rhythm of sinus tachycardia. The physiologic dysfunction for this type of heart failure is what?
A) Impaired contractility of the left ventricle
B) Impaired compliance of the left ventricle
C) Cardiac valve disease
D) Acute myocardial infarction



15. A patient has been admitted with right heart failure. The physiologic basis of right heart failure is what?
A) Left heart failure
B) Impaired right cardiac output
C) Pulmonary hypertension
D) Acute pulmonary embolus



16. A patient has been diagnosed with acute left heart failure secondary to acute myocardial infarction and increased afterload. What changes in assessment findings does the nurse expect to find?
A) Elevated pulmonary capillary wedge pressure
B) Normal or low blood pressure
C) Enlarged liver and spleen
D) Lungs clear to auscultation



17. A patient with heart failure is being monitored with a pulmonary artery catheter to assess cardiac output and its components. What pattern of results would indicate a need for immediate intervention?
A) Heart rate, preload, contractility, and afterload are balanced and cardiac output is normal.
B) Heart rate is rapid, preload is reduced, contractility and afterload are normal, and cardiac output is reduced.
C) Heart rate is rapid, preload is high, contractility is high, afterload is low, and cardiac output is normal.
D) Heart rate is low, preload is high, contractility is high, afterload is low, and cardiac output is normal.



18. A patient has been diagnosed with chronic heart failure, compensated. What symptoms would the nurse expect to find?
A) Frothy sputum progressing to pink frothy sputum
B) Severe hypotension when supine
C) Mild dyspnea on exertion or when supine
D) 4+ pitting edema of the lower extremities when dependent



19. A patient with long-standing hypertension has a viral upper respiratory illness and is self-medicating with over-the-counter medications. The patient complains of severe dyspnea with activity and has new-onset crepitant rales and pitting edema of the lower extremities. In evaluating the patient’s medications, what medication should the nurse look for in particular?
A) Furosemide (Lasix)
B) Nonsteroidal anti-inflammatory medications (NSAIDs)
C) Hydrochlorothiazide diuretic (HCTZ)
D) Angiotensin-converting enzyme (ACE) inhibitor



20. A patient with heart failure is being discharged. What discharge instruction should the nurse emphasize most?
A) Date and time of next medical appointment
B) Dietary alterations to reduce sodium intake
C) Structured exercise program
D) Maintaining weight within 1 to 2 pounds



21. For a patient with heart failure, maintenance of a steady weight is an important goal. The nurse should teach the patient that which of the following is the most accurate method for monitoring fluid volume changes?
A) Intake and output, with 24-hour totals and trends
B) Daily weight at the same time every day
C) Daily assessment of peripheral edema
D) Periodic assessment of serum electrolyte values



22. A patient with heart failure has been started on an ACE inhibitor. What lab value related to the ACE inhibitor would concern the nurse?
A) Elevated serum potassium
B) Elevated CK-MB
C) Diminished sodium
D) Increased prothrombin time



23. A patient receiving an ACE inhibitor has a blood pressure of 85/50 mm Hg. The patient is asymptomatic otherwise. What is the best nursing action?
A) Hold the medication because the blood pressure is too low.
B) Recheck the blood pressure in 1 hour.
C) Administer the medication because the patient is asymptomatic.
D) Reschedule time of medication administration to hour of sleep.



24. The patient is prescribed hydralazine and a nitrate for management of heart failure. The patient tells the nurse he has trouble taking medications that must be taken several times a day. What intervention will be the most helpful to the patient?
A) Stress the importance of taking medications as prescribed.
B) Ask the physician to change his therapy to long-acting medications that can be taken less often.
C) Ask the physician to change his therapy to other drug classes at the same frequencies.
D) Inform the physician that the patient is not taking his prescribed medications.



25. A patient with heart failure is taking an ACE inhibitor and a diuretic as prescribed but continues to be symptomatic. What patient behavior would explain lack of achievement of therapeutic goals?
A) Exercises regularly (walking and water aerobics)
B) Diet of mostly canned food and soda pop
C) Does not drink any alcoholic beverages
D) Takes medications as prescribed



26. A patient with heart failure comes to the clinic for a routine monitoring visit. What findings would indicate achievement of therapeutic goals?
A) Lungs have crepitant rales.
B) Complains of dyspnea on exertion
C) Has pitting edema of lower extremities
D) Weight is within 2 pounds of ideal weight.



1. A patient is recovering in the CCU following carotid endarterectomy. What intervention should the nurse make to ensure that a hematoma is not forming in the patient’s neck?
A) Assess neck size by comparing operative side with nonoperative side.
B) Monitor pupil reactivity.
C) Assess hand grip.
D) Monitor blood pressure.



2. A patient who recently underwent carotid endarterectomy is exhibiting signs of stroke. Which intervention or interventions should the nurse take to assess this patient’s neurological function? Select all that apply.
A) Measure chest tube output.
B) Assess eye movement.
C) Monitor level of consciousness.
D) Assess urine output.



3. A patient with left main coronary artery disease (CAD) experiences persistent angina. She would like to exercise more, but is limited by shortness of breath and angina. Her physician believes that she is a good candidate for coronary artery bypass graft. The nurse recognizes that which of the following are indications for coronary artery bypass graft (CABG) surgery in this situation?
A) Having left main CAD
B) Being a good candidate for angioplasty and stenting
C) Having persistent angina
D) Availability of new effective CAD medication
E) Limited exercise tolerance
F) The patient’s spouse was successfully treated with CABG



4. A patient in the CCU is recovering from coronary artery bypass graft (CABG) surgery. He has had multiple graft surgeries in the past. For this latest surgery, the patient’s radial artery was used in the graft. What complication should the nurse most expect to observe in this patient?
A) Occlusion
B) Infection
C) Arterial spasm
D) Internal hemorrhaging



5. A patient is recovering in the CCU following off-pump coronary artery bypass graft (OPCABG) surgery involving the internal mammary artery graft. What nursing intervention is most important for the first 48 hours following surgery for this patient?
A) Administration of anticoagulant therapy
B) Administration of calcium channel blockers
C) Monitoring of fluid status
D) Assessment for hematoma



6. A patient with moderate mitral stenosis with minimal calcification and regurgitation is preparing to have surgery. Which procedure would be most appropriate to restore normal function to this patient?
A) Annuloplasty
B) Valve replacement with biological valve
C) Valve replacement with caged ball valve
D) Commissurotomy



7. A patient recovering from cardiopulmonary bypass surgery is shivering. For what reason should the nurse be concerned about the shivering?
A) Shivering is a sign of cardiogenic shock
B) Shivering is a sign that the patient has a fever
C) Shivering increases myocardial workload
D) Shivering can cause sutures to rupture



8. A patient recovering in the CCU following coronary artery bypass graft (CABG) surgery complains of pain in his chest. The patient underwent a sternotomy incision during the surgery. Which of the following types of pain would indicate angina—which may indicate graft failure—as opposed to typical pain resulting from the sternotomy?
A) Radiates to arms
B) Is worse with deep breathing
C) Is worse with movement
D) Is sharp



9. A patient in the CCU is experiencing premature atrial contractions following coronary artery bypass graft surgery. Which of the following would be the most appropriate nursing intervention?
A) Administration of anticoagulants
B) Administration of potassium and magnesium
C) Administration of dopamine
D) Administration of epinephrine



10. A patient who underwent carotid endarterectomy is being discharged from the CCU. Which of the following instructions should the nurse give to the patient?
A) Avoid rotating your head.
B) Bruising and discoloration of the neck are not normal and should be reported immediately.
C) Eat a low-fat diet.
D) Avoid washing the incision site.



11. A patient with severe coronary artery disease is scheduled for coronary artery bypass graft surgery. As part of the preoperative teaching, the nurse explains the surgery. Which of the following statements about this procedure is true?
A) The diseased artery will be removed and replaced with a graft from another artery.
B) A piece of the saphenous vein will be used to go around the diseased part of the artery.
C) After removal of the diseased artery, the remaining ends will be anastomosed.
D) The wall of the heart will be incised to create a new pathway for blood flow.



12. The patient is scheduled for coronary artery bypass surgery using the off-pump technique. During preoperative teaching, the nurse explains that using the off-pump procedure has what advantage over the on-pump procedure?
A) There is a lower risk of a cerebral embolus.
B) The patient can anticipate a shorter hospital stay.
C) There will be less need for anticoagulation therapy.
D) The procedure will be less painful.



13. A patient with severe coronary artery disease has persistent angina that is refractory to medical management at maximum drug doses and has severe compromise of activities of daily living from the angina. The patient has had several coronary artery bypass surgeries and has been told that he is not a candidate for any further surgeries or percutaneous interventions such as stents. In discussing options for further therapy, what should the nurse include that would offer the patient the most hope?
A) Unless a new medication is invented, there is nothing that can be done.
B) Discussion of hospice and palliative support for end-of-life care
C) Referral to the social worker for financial assistance
D) Referral to the transmyocardial laser revascularization program for evaluation



14. The patient has been diagnosed with severe mitral valve stenosis. What physical changes would the nurse expect to find as a result of the stenosis?
A) Prolonged capillary refill
B) Normal left atrial and ventricular pressures
C) Clear lung sounds
D) Angina pectoris



15. The patient has been diagnosed with mitral valve insufficiency and left ventricular hypertrophy. What effect would the nurse expect from the left ventricular hypertrophy?
A) Improved cardiac output from increased left ventricular contractility
B) No appreciable signs or symptoms or effects until late in the disease process
C) A more obvious and easier-to-auscultate mitral valve regurgitant murmur
D) Early onset of pulmonary edema and right-sided congestive heart failure



16. The patient has been diagnosed with severe aortic valve stenosis. Considering the most common symptoms caused by aortic valve stenosis, what is the most important nursing intervention?
A) Document characteristics of the aortic stenosis murmur.
B) Teach patient to rise slowly from a supine position.
C) Assess peripheral circulation more frequently.
D) Assess for and document pulmonary adventitious sounds.



17. The patient has developed acute aortic valve insufficiency after experiencing blunt chest trauma. What symptom, if found by the nurse, is indicative of a counterproductive compensatory mechanism that should be treated?
A) Low cardiac output
B) Pulmonary edema
C) Elevated blood pressure
D) Aortic insufficiency murmur



18. The patient has had coronary artery bypass surgery involving the cardiopulmonary bypass pump, systemic hypothermia, topical cardiac hypothermia, and cold cardioplegia. As a result of the various hypothermic therapies, numerous postoperative complications may ensue. What collaborative postoperative intervention is specifically directed at ameliorating one or more of these complications?
A) Use of intravenous pain and sedation medications
B) Mechanical ventilation and supplemental oxygen therapy
C) Vital signs every hour until stable or transferred to step-down unit
D) Management of mediastinal chest tube drainage



19. The nurse is caring for a patient who has just had coronary artery bypass grafting. As part of the admission procedure to the critical care unit immediately after surgery, what nursing assessment has the highest priority?
A) Urine output
B) Cardiac index measurement
C) Chest tube drainage measurement
D) Core body temperature



20. After coronary artery bypass surgery, the patient experiences significant fluid volume shifts and losses. What nursing assessment would be most indicative of fluid volume deficit?
A) Low central venous pressure
B) Urine output 40 mL/hr
C) Brisk capillary refill
D) Diminished core body temperature



21. A patient who has just has coronary artery bypass surgery has developed tachycardia, a low-grade fever, and an elevated total white blood cell count. What additional sign or symptom would support the nurse’s suspicion of a postoperative infection?
A) Purulent drainage from the chest incision
B) Chest incision edges are red and swollen.
C) Elevated immature neutrophils or bands
D) Severe incisional pain with cough



22. The nurse is caring for a patient who has just had coronary artery bypass grafting and is experiencing significant hypotension. What nursing assessment would best confirm that the hypotension is related to blood loss?
A) Low hemoglobin and hematocrit, with high central venous pressure
B) Chest tube drainage in excess of 200 mL/hr
C) Urine output 40 to 50 mL/hr
D) Chest tube drainage less than 30 mL/hr



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



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



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



4. A patient with acute kidney injury (AKI) demonstrates oliguria, a urine osmolality of 550 mOsm/kg H2O, increased urine specific gravity, urine sodium of 15 mEq/L, and a BUN:creatinine ratio of 23:1. Which of the following is a cause of AKI that would best fit with these findings?
A) Congestive heart failure
B) Nephrotoxicity due to aminoglycoside antibiotics
C) Hypertension
D) Retroperitoneal tumor



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



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



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



8. A patient with acute kidney injury (AKI) complains of a headache. He vomits several times and breathes deeply and rapidly. His heart rate is 110 bpm, and his serum potassium level is elevated. The nurse recognizes in this patient which condition commonly associated with AKI?
A) Fluid overload
B) Anemia
C) Metabolic acidosis
D) Pericarditis



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



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



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



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



13. A patient with a history of diabetes mellitus has had a procedure using radiocontrast dye. The patient’s laboratory results include high urine sodium, urine with muddy-brown granular casts and tubular epithelial cells, and increased blood urea nitrogen (BUN) and serum creatinine. Renal ultrasonography is normal. Urine volume is normal. Which treatment does the nurse anticipate?
A) Increased fluids
B) Renal stent placement
C) Irrigation of urinary catheter
D) Diuretic therapy



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



15. A patient has just been diagnosed with type 2 diabetes mellitus. During teaching, what strategy should the nurse emphasize as protective of kidney cells?
A) Monitoring glycosylated hemoglobin every 3 months
B) Strict adherence to prescribed weight-loss diet
C) Restriction of sodium-containing beverages and food
D) Strict control of serum glucose levels with diet and medication



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



17. A patient has been diagnosed with chronic renal failure. What closely associated pathophysiologies should the nurse assess for? Select all that apply.
A) Hypertension
B) Arteriosclerotic disease
C) Traumatic injury
D) Type 2 diabetes mellitus
E) Preeclampsia
F) Type 1 diabetes mellitus



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



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



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



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



1. A teenaged boy jumped from a two-story building and landed on his feet, injuring his spine, and is now in the ICU. The nurse recognizes his injury as which of the following?
A) Rotational injury
B) Axial loading
C) Hyperflexion
D) Hyperextension



2. The nurse is assessing a patient with a spinal cord injury in the ICU. The patient is completely paralyzed from the waist down but has sensation in his shoulders, chest, arms, and hands. He has no control of his bowel or bladder. Which of the following are possible sites for this patient’s injury, given his loss of function? Select all that apply.
A) C4
B) C7
C) T3
D) T7
E) T12
F) L4



3. A patient presents to the ICU with a spinal cord injury at C3 and the following: loss of position sense, light touch, and vibratory sense below the level of the injury. However, the patient has retained all motor function and pain and temperature sensation. The nurse suspects that the injury has occurred on what portion of the spinal cord?
A) Central
B) Lateral
C) Anterior
D) Posterior



4. A patient involved in a snowmobile accident struck a tree and sustained a fractured vertebra at C4. She demonstrates signs of ischemic areas near the injury, along with hypoperfusion, microscopic hemorrhage, and edema. The nurse observes signs of concussion, including loss of consciousness. Which of the following are considered secondary injuries? Select all that apply.
A) Fractured vertebra
B) Cord ischemia
C) Hypoperfusion
D) Microscopic hemorrhage
E) Edema
F) Concussion



5. A patient with a mild spinal cord injury becomes light-headed every time she attempts to rise from her bed. At rest, her heart rate and blood pressure are normal. All of her motor, sensory, reflex, and autonomic functions are intact. The nurse recognizes which condition in this patient?
A) Spinal shock
B) Neurogenic shock
C) Orthostatic hypotension
D) Central cord syndrome



6. A patient with a spinal cord injury has been stabilized in the ICU and now must undergo diagnostic testing. Which test would be most appropriate for detecting a fracture of the vertebra?
A) Magnetic resonance imaging (MRI)
B) Blood urea nitrogen (BUN)
C) Glasgow coma scale (GCS)
D) Computed tomography (CT)



7. A patient is recovering from a lumbar spine injury and requires an immobilization device for this region. Which device would be most appropriate for this patient?
A) Halo vest
B) Aspen collar
C) Minerva brace
D) Jewett brace



8. A nurse is monitoring a patient with spinal cord injury for respiratory complications. Which of the following findings would indicate that the patient should be intubated?
A) Respiratory rate of 20 breaths/minute
B) Vital capacity of 30 mL/kg
C) PaO2 of 90 mm Hg
D) PaCO2 of 60 mm Hg



9. After failing to effectively clear a patient’s airway by having him cough, the nurse is now suctioning his airway. What complication related to suctioning should the nurse be aware of?
A) Bradycardia
B) Tachycardia
C) Hyperglycemia
D) Hypertension



10. A patient with a spinal cord injury and who smokes is at risk for developing deep vein thrombosis (DVT). The nurse provides the patient with antiembolism stockings and encourages her to stop smoking, as it contributes to vasoconstriction in the periphery and thus to DVT. What other measure would be appropriate to help prevent DVT in this patient?
A) Administration of atropine sulfate
B) Administration of heparin
C) Administration of reserpine
D) Administration of methyldopa



11. A patient is admitted to the emergency department after a near-drowning accident. The patient dove head-first into shallow water and has a high blood-alcohol level. Cardiopulmonary resuscitation was used at the scene. The patient is awake and alert. Considering the mechanism of injury, what is the highest nursing priority?
A) Check vital signs often.
B) Obtain an order for radiography studies.
C) Monitor pulse oximetry closely.
D) Provide cervical spine stability.



12. A patient is in critical care recovering from a spinal cord injury. As part of shift report, the nurse is told that the patient’s injury is between C1 and C4 and involves the entire cord. The patient is on a mechanical ventilator. What is the best nursing action to provide for patient safety?
A) Be sure all side rails are up at all times.
B) Keep the bed in low position when unattended.
C) Verify that a functioning bag-mask resuscitator is at the bedside.
D) Place the call light in the patient’s hand.



13. A patient was struck in the jaw and had hyperextension of the cervical spine. If the patient has central cord syndrome, what would the nurse most expect?
A) Full loss of motor function below the lesion
B) Ipsilateral increased cutaneous pain at the lesion
C) Arm paralysis with intact motor function in the legs
D) Full motor paralysis and loss of touch sensation below the lesion

14. Patients with spinal cord injury may experience both spinal shock and neurogenic shock, and differentiating between the two is essential. What symptoms are unique to neurogenic shock?
A) Loss of motor and sensory function
B) Flaccid paralysis below the lesion
C) Presence of poikilothermia
D) Hypotension and bradycardia



15. During the initial assessment of patient with a probable spinal cord injury, the nurse performs a digital rectal examination. What is the best rationale for this examination?
A) Part of routine admission physical
B) Checks for fecal impaction
C) Assesses for sensation or movement
D) Preliminary for rectal medications



16. A patient involved in a motor vehicle accident has a high risk of spinal cord injury. At the scene, what is the priority patient assessment?
A) Level of consciousness
B) Respiratory rate
C) Independent mobility
D) Peripheral sensation



17. A patient with a cervical spine fracture has been fitted with a halo vest and is to ambulate for the first time today. What is the priority nursing action?
A) Put rubber corks on the ends of the pins.
B) Pad the edges of the vest to prevent chafing.
C) Have the patient sit on the side of the bed for several minutes.
D) Teach about loss of peripheral vision.



18. A patient has a C7-C8 spinal cord injury. During recovery, what is the nursing priority of care?
A) Encourage the patient to do incentive spirometry exercises.
B) Monitor neurologic status every 4 hours.
C) Collaborate with physical therapy for exercises.
D) Refer to social services for financial assistance.



19. A patient with a spinal cord lesion at C6-C7 has developed pneumonia and is placed on kinetic therapy producing constant lateral rotation to 40 degrees bilaterally. What is a nursing priority of care for this patient relative to the kinetic therapy?
A) Measure intake and output hourly.
B) Provide nutrition with adequate protein.
C) Auscultate bowel sounds every 4 hours.
D) Inspect skin surfaces every 4 hours.



20. The patient has a spinal cord lesion at T1-T2. About an hour after being turned, the patient experiences a sudden throbbing headache accompanied by extreme blood pressure elevation and profound bradycardia. The patient has a very flushed face. What is the nursing priority?
A) Administer pain medication immediately.
B) Give intravenous beta-antagonist medication.
C) Turn on a fan.
D) Check Foley catheter for twisting or kinks.



21. A patient recovering from a partial spinal cord lesion is experiencing muscle spasticity. Relative to this complication, what is the nursing priority?
A) Monitor neurologic status every 4 hours
B) Ensure compliance with exercise program
C) Medicate often for pain and discomfort
D) Emphasize nutritional balance



1. A patient sustained injuries in a motor vehicle accident and is in the Emergency Department. A CT scan of the head and neck have been ordered. What part of the survey is this?
A) Primary
B) Secondary
C) Tertiary
D) Initial



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



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



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



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



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



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



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



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



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



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



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



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



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



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



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



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



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



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



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



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



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