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Understanding The Essentials Of Critical Care Nursing By Perrin – Test Bank 

 

 

Chapter 1 What Is Critical Care?
1. Identify who of the following patients suffers from critical illness. A patient:
a. With chronic airflow limitation whose VS are: BP 110/72, P 110, R 16.
b. With acute bronchospasm and whose VS are: BP 100/60, P 124, R 32.
c. Who was involved in a motor vehicle accident whose VS are: BP 124/74, P 74, R 18.
d. On chronic dialysis with no urine output and whose VS are: BP 98/50, P 108, R 12.

2. Of the following patients, who should be cared for in a critical care unit? A patient: (Select all that apply.)
a. With an acetaminophen overdose
b. Suffering from acute mental illness
c. With chronic renal failure
d. With acute decompensated heart failure

3. A hospital in a small rural town would be able to provide which level of care in the critical care unit?
a. Level I
b. Level II
c. Level III
d. It is unlikely that the hospital would have a critical care unit

4. A nurse employed in an ʺopenʺ ICU would most likely be working with a:
a. Multidisciplinary team with physicians who are also responsible for patients on other units.
b. Multidisciplinary team that includes a physician employed by the hospital.
c. Physician in charge of patient care who is a specialist in critical care.
d. Primary care physician who must consult a critical care specialist.

5. According to the Institute of Medicine, technology increases the likelihood of errors in critical care units when:

a. It relies heavily on human decision-making.
b. Devices are programmed to function without double-checks.
c. It makes the workload seem overwhelming to health care providers.
d. There is uniform equipment throughout each facility.

6. Which of the following is a common example of installing forcing functions or system level firewalls in order to prevent errors?
a. Prior to administration of insulin, two nurses check the dose.
b. Prior to obtaining a medication, height, weight and allergies are recorded.
c. All medications are checked by two nurses prior to administration.
d. Undiluted potassium chloride is not available on critical care units.

7. The increased use of technology in critical care units has resulted in which of the following consequences for patient care?
a. Decreased risk of errors in patient care
b. Decreased therapeutic nurse-patient communication
c. Improved overall patient satisfaction with care
d. Improved patient safety across the entire spectrum

8. Completion of a preoperative checklist is an operationalized example of which of the following recommendations issued by the Institute of Medicine?

a. Utilizing constraints
b. Simplifying key processes
c. Avoiding reliance on vigilance
d. Standardizing key processes

9. Which of the following actions should the nurse complete first after realizing that an incorrect dose of medication has been administered to a patient? (Select all that apply.)
a. Documentation of the error
b. Notification of the physician
c. Notification of the patient and family
d. Preparation for a root cause analysis

10. The nurse working within the AACN Synergy Model realizes that optimal patient outcomes are realized when:

a. Highly qualified nurses care for patients in highly technical settings.
b. Nurses agree to work overtime to cover unit staffing needs.
c. Staff nurse competency is matched with patient needs.
d. Patient care is delivered within a ʺclosed unitʺ model.

11. The competent critical care nurse demonstrates an understanding of patient advocacy by taking which of the following actions? (Select all that apply.)
a. Maintaining attendance at the bedside with the patient during a physician visit
b. Assisting and supporting the patient and family as they reveal their needs
c. Alerting the physician to concerns about patient placement after hospitalization
d. Encouraging and supporting a patientʹs spouse in preparing for a family meeting

12. A nurse is preparing to communicate an issue about patient care to a physician using the SBAR technique. Which of the following phrases is an appropriate initial statement?
a. ʺI am concerned about…ʺ
b. ʺThe patientʹs immediate history is…ʺ
c. ʺI think the problem is…ʺ
d. ʺI would like you to …ʺ

13. The nurse would include which statement for ʺA – Assessmentʺ in the SBAR technique for communication?
a. ʺI think the problem is…ʺ
b. The patientʹs vital signs are…ʺ
c. ʺThe patientʹs treatments are…ʺ
d. ʺI would like you to…ʺ

14. To complete an SBAR communication about a patient issue, the nurse should use which of the following statements?
a. ʺThe patientʹs immediate history is…ʺ
b. ʺThe patientʹs physical findings are…ʺ
c. ʺI am requesting that you…ʺ
d. ʺI have assessed the patient personally.ʺ

15. Nurses must be able to collaborate with other members of the health care team in order to effect optimal outcomes in patient care. The nurse understands that characteristics of emotional maturity within the profession include: (Select all that apply.)

a. Being a lifelong learner.
b. Actively identifying best practices.
c. Maintaining current skills.
d. Overlooking oneʹs own shortcomings.

16. A nurse might utilize a variety of informal power bases in the health care setting. These include: (Select all that apply.)
a. Information.
b. Expertise.
c. Goodwill.
d. Observation.

17. When a nurse encourages a patient who has experienced a motor vehicle crash to cough and deep -breathe even the patient does not initially want to, the nurse is placing a priority on which of the following ethical principles?

a. Beneficence
b. Nonmaleficence
c. Respect for persons
d. Justice

18. When a nurse forcibly inserts a nasogastric tube against the patientʹs wishes, the nurse can be held liable for:

a. Assault.
b. Battery.
c. Civil penalties.
d. Malpractice.

19. The nurse is aware that decision-making capacity is likely to be impaired for patients who: (Select all that apply.)
a. Are depressed.
b. Are being medicated for severe pain.
c. Do not understand their medical condition.
d. Have been diagnosed with septic shock.

20. The nurse is aware that restraining a patient is most likely to result in the patient:
a. Pulling out an endotracheal tube.
b. Pulling out an intravenous line.
c. Disconnecting ventilator tubing.
d. Developing a nosocomial infection.

21. For a nurse to be found guilty of negligence, which of the following must be demonstrated? That the patient:

a. Was assaulted.
b. Was not consulted before being touched.
c. Suffered a wrongful death.
d. Incurred damages.

22. Moral distress among critical care nurses is associated with: (Select all that apply.)
a. Providing aggressive care to patients who cannot benefit.
b. Having no voice in clinical decision making.
c. Realizing that nurses maintain power in bedside decision making.
d. Knowing the right thing to do but not being able to do it.

23. When a nurse employs conscientious refusal to participate, the nurse should be aware that: (Select all that apply.)
a. Consequences may involve employer sanction.
b. It may lead to dismissal from a nursing position.
c. Nursing administrators are largely supportive.
d. State boards of nursing protect the nurse in this situation.

24. Which of the following symptoms seen in a nurse would suggest compassion fatigue? (Select all that apply.)

a. Difficulty separating work from personal life
b. Excessive high tolerance for frustration
c. Having a completely laissez-faire attitude
d. Decreased functioning in nonprofessional situations

Chapter 2 Care of the Critically Ill Patient
1. ʺResiliencyʺ in the American Association of Critical-Care Nurses synergy model refers to a personʹs:
a. Motivation to reduce anxiety through positive self-talk.
b. Ability to bounce back quickly after an insult.
c. Physical strength to endure extreme physical stressors.
d. Ability to return to a state of equilibrium.

2. Which of the following is the AACNʹs synergy model patient characteristic described as ʺthe intricate entanglement of two or more systemsʺ?
a. Complexity
b. Predictability
c. Participation in care
d. Resource availability

3. Which of the following stressors is one of the primary concerns of critically ill patients and should therefore be included routinely in patient assessments?
a. Inability to control elimination
b. Lack of family support
c. Hunger
d. Altered ability to communicate

4. A patient has just completed a preoperative education session prior to undergoing coronary artery bypass surgery. Which statement by the patient would indicate that he needs additional teaching by the nurse? (Select all that apply.)

a. ʺI understand that I will have to blink my eyes to respond after the breathing tube is in my throat.ʺ
b. ʺI will be given frequent mouth care to help me when I am thirsty.ʺ
c. ʺI will be able to move about freely in bed and into the chair without help while connected to the electronic equipment for monitoring.ʺ

d. ʺI may need something to help me rest due to the unfamiliar lights and sounds of the ICU unit.ʺ

5. When providing care to critically ill patients, whether they are responsive or unresponsive, the nurse should:
a. Clearly explain what care is to be done before starting the activity.
b. Perform the activity then let the patient rest without explaining the care.
c. Make sure the patient always responds and is cooperative before giving care.
d. Explain to the family that the patient will not understand or remember any of the discomfort associated with care.

6. Which of the following communication strategies is most appropriate for a critical care nurse to use when communicating with a ventilated patient? The nurse should:
a. Use professional terminology and provide the patient with detailed information.
b. Use simple language and explain in other terms if the patient does not seem to understand.
c. Provide minimal information so the patient is not overwhelmed.
d. Discuss issues primarily with the family because the patient is unlikely to understand the information.

7. During an assessment, a ventilated patient begins to frown and wiggle about in bed. Which assessment strategy would be most helpful for the nurse to validate these observations?
a. Glasgow Scale
b. Maslowʹs hierarchy levels
c. Critical-Care Pain Observation Tool (CPOT)
d. Vital signs trends

8. Nurses in many ICUs are required to automatically attempt to wean sedation for their ventilated patients when the patients meet certain parameters. Which of the following parameters would indicate that a patient in ICU is ready for such an interruption in sedation, also sometimes known as a sedation vacation? The patient: (Select all that apply.)

a. Activated the ventilator alarms but the alarms stopped spontaneously.
b. Frowned when turned but otherwise showed no muscular tension.
c. Had a MAP of 75 and heart rate of 76.
d. Was sleeping but awakened with verbal stimuli.

9. (A patient scores positive on the Confusion Assessment Method of the Intensive Care Unit (CAM -ICU). Which of the following nursing diagnoses would have the highest priority based on this positive score?
a. Injury, Risk for
b. Family Processes, Altered
c. Social Interaction, Impaired
d. Memory Impaired

10. A nurse is beginning an intravenous infusion of morphine sulfate on her post-op ventilated patient. When initiating the infusion and for the first few hours, the nurse should do which of the following?
a. Anticipate that the patient will begin to experience the effect of the morphine 5 minutes after the start of the infusion.

b. Begin the infusion at the lowest ordered dose and increase the rate every 5 minutes if the patient continues to have pain.

c. Complete the Critical-Care Pain Observation Tool scale 5 minutes after increasing the infusion rate each time.

d. Provide additional intermittent boluses of morphine sulfate if the patient experiences breakthrough pain.

11. Which of the following strategies should the nurse include in the plan of care when trying to minimize sleep disruptions for a patient in an ICU? (Select all that apply.)
a. Instituting a short course of therapy for sleeping agents
b. Accurate scoring and vigilance in sedation and sedation scoring
c. Managing the environment to reduce lighting, sounds, and so on
d. Minimizing staff interruptions during sleep periods
e. Scheduling treatments only during the day or at least 4 hours apart at night
f.

12. A nurse is confirming the medication orders and schedule for sedative administration to a patient with delirium. Which of the following schedules would maximize the effectiveness of the drugs? Administration of medication:

a. Only in the early morning.
b. Only at bedtime (HS).
c. Around the clock with higher dosages in the evening.
d. Only on an as-needed (PRN) basis.

13. Which of the following patients would be considered at risk for nutritional imbalances? A patient: (Select all that apply.)
a. Who is a stable post-MI.
b. With renal dysfunctions/failure.
c. With slightly elevated liver enzymes.
d. With burns or excessive trauma.
e. Who is intubated and sedated.

14. While members of the multidisciplinary team are reviewing a patientʹs nutritional status, they note the following values. Which of the values would need additional investigation?
a. A serum albumin of more than 3.5 g/dL or 35 g/L
b. A weight increase of 1.5 kg in a day
c. A serum hemoglobin of 11.7 g/dL or 117 mmol/L
d. A serum magnesium of 1.6 mg/dL or 132 mEq/L

15. A nurse has inserted a nasogastric tube and is planning to confirm placement of the tube prior to starting enteral feedings. Which of the following is the most accurate method for confirming placement? By:
a. Obtaining a radiological x-ray of the abdomen.
b. Checking gastric aspirate for a pH of less than 7.
c. Instilling 30 mL of air while listening with a stethoscope when placed over the fundus of the stomach.
d. Determining the presence of carbon dioxide.

16. Which of the following nursing diagnoses should receive the highest priority when caring for a patient who is receiving total parenteral nutrition?
a. Infection, Risk for
b. Trauma, Risk for
c. Skin Integrity, Impaired
d. Fluid Volume, Risk for Imbalance

17. When planning care to meet the needs of family members of a critically ill patient, the nurse should include: (Select all that apply.)
a. Expressing an attitude of hope, honesty, open communication, and caring.
b. Stating specific facts about the patientʹs condition in timely manner.
c. Planning regular times for family visits throughout the day.
d. Limiting the number of visitors to significant others.
e. Communicating to a single family member to cut down time wasted repeating information to all visitors.

18. Which of the following statements describing the needs of family members of critically ill patients has not been validated by research?
a. ʺ ʹNot knowing is the worst partʹ of waiting.ʺ
b. Families in the waiting room have no effect on patient outcomes.
c. ʺHoveringʺ in the proximity phase is characterized by confusion and tension.
d. A unified message from staff minimizes family stressors.

19. Which of the following is not one of the family needs identified in Leskeʹs 1991 research?
a. Proximity
b. Information
c. Assurance
d. Timeliness

20. When planning care for the families of critically ill patients, the nurse would include which of the strategies by Miracle (2006) to meet family needs? (Select all that apply.)
a. Regular family conferences to meet patient goals/progress
b. Frequent verbal communication to clarify the purpose of unit, equipment, procedures, waiting areas, phones, and so on

c. A way to contact family through a specific family member by phone if needed
d. Information about how to contact the primary doctor if needed
e. A consistent nurse and unified staff responses if that nurse is not available

21. A physician suggests that a ventilated patient needing immediate transport to CT scan and having severe pain be given IV fentanyl rather than morphine sulfate for pain management. One reason the physician might recommend the use of fentanyl is:

a. It has a more rapid onset and a shorter duration of action.
b. It is not likely to cause respiratory depression.
c. Rapid administration does not have any hemodynamic consequences.
d. Weaning of a continuous infusion is never needed due to its short half-life.

22. A ventilated patient is receiving midazolam (Versed) for sedation. The nurse would recognize that the patient is receiving an appropriate dose of midazolam when the patient is:
a. Awake with a heart rate of 124 and attempting to pull out the IV.
b. Awake with a respiratory rate of 38 and a heart rate of 132.
c. Asleep but withdrawing to noxious stimuli with a heart rate of 80.
d. Asleep but awakening to light touch with a heart rate of 72.

23. A nurse is caring for a ventilated post-op patient who she suspects is experiencing pain. Which method of assessing if the patient is actually in pain should the nurse try first?
a. Attempting an analgesic trial
b. Asking a family member if she thinks the patient is in pain
c. Observing the patientʹs face for grimacing
d. Asking the patient if he is in pain

24. A nurse is administering haldoperidol (Haldol) IV push to a delirious patient. Which of the following is it most important for the nurse to monitor? The patientʹs:
a. Heart rate.
b. Respiratory rate.
c. PR interval.
d. QT interval.

Chapter 3 Care of the Patient with Respiratory Failure
A potential cause for hypoxemic failure from Type I respiratory failure is linked to:
Failure of the neurological system to stimulate respirations.
Muscular failure to move the air into and out of the lungs.
Skeletal alterations of the thoracic region that limit air movement.
Breakdown of oxygen transport from the alveolus to arterial flow.

Which of the following criteria is correct concerning acute lung injury (ALI)?
ALIʹs direct causes can include biochemical agents outside the pulmonary system.
ALI is a single organ dysfunction syndrome that has a chronic onset.
Symptoms of ALI include presence of little infiltrates on chest radiography.
Right ventricular failure occurs immediately with PAOP > 18 mm Hg.

In caring for a brain injured patient with damage to the cortex, which of the following changes in respiratory and ventilatory efforts would the nurse expect to observe?
Increased rate of breathing per minute
Increased respiratory effort by the use of chest and diaphragm muscles
Decreased voluntary initiation of ventilatory effort
Decrease in CO2 in blood analysis

Which of the following ABG results would indicate the development of ALI?
pH 7.4, PaCO2 40 mm Hg, PaO2 96, HCO3 24 mEq, SaO2 94%
pH 7.31, PaCO2 50 mm Hg, PaO2 70 mm Hg, HCO3 20 mEq, SaO2 90%
ph 7.49, PaCO2 32 mm Hg, PaO2 75 mm Hg, HCO3 22 mEq, SaO2 90%
pH 7.29, PCO2 28 mm Hg, PaO2 97 mm Hg, HCO3, 16 mEq, SaO2 94%

When assessing a patient with Type I hypoxemic failure, the nurse would evaluate for which of the contributing factors/conditions? (Select all that apply.)
Pneumonia
Asthma
Cardiogenic pulmonary edema
Adult respiratory distress syndrome
Narcotic overdose

Which of the following patients is at risk for developing Type II hypoxemic hypercapneic failure? (Select all that apply.)
A 5-year-old male with a 5-year history of muscular dystrophy
A 34-year-old female patient who is 3 days post-op open cholecystectomy
A 24-year-old male newly admitted with possible Guillain-Barré syndrome
A 72-year-old female with kyphosis

Which of the following will the nurse find upon assessment of the patient in the fibrotic phase of ALI?
Pulmonary occlusive pressures are less than 18 mm Hg
Bilateral fluid can be seen on radiographic exams
Fever and leukocytosis are present
Severe bleeding is noted from all body orifices

When respiratory failure and hypoxemia develop, the nurse would expect to find which of the following symptoms?
Exertional dyspnea, circumoral cyanosis, distal cyanosis
Subcutaneous emphysema, absent breath sounds, sharp chest pain
Agitation, disorientation, lethargy, chest pain
Rales, distended neck veins, orthostatic hypotension

Which of the following patients would the nurse anticipate could benefit from the use of noninvasive ventilation (NIV)?
A 55-year-old female with an acute exacerbation of asthma
A 57-year-old male with a history of sleep apnea
A 48-year-old female with an acute myocardial infarction
A 72-year-old male with sepsis

In planning for the prevention of complications for a ventilated patient, which complications should the nurse include in her plan of care? (Select all that apply.)
Community acquired pneumonia (CAP)
Direct lung tissue injury (barotrauma) or volume damage (volutrauma)
Cardiovascular compromise
Stress ulcers
Anxiety from lack of synchrony between patient and ventilator

The nurse was teaching the patient the advantages of noninvasive mechanical ventilation (NIV). Which statement by the patient would reflect a need for additional teaching?
ʺI will not have to have a tube down my throat for it to work.ʺ
ʺI will probably recover faster, so I can get out of the hospital faster.ʺ
ʺI am more likely to have fewer complications such as pneumonia.ʺ
ʺNIV is not uncomfortable and I wonʹt have to be admitted to ICU to use it.ʺ

The nurse is suctioning an intubated, mechanically ventilated patient. Complications that should be observed for include:
Dysrhythmias.
Hyperthermia.
Hematuria.
Decreased urinary output.

The nurse is explaining the purpose of the tracheostomy tube for mechanical ventilation. Which statement by the patient would indicate the need for additional teaching? ʺThe tracheostomy tube is:
Used for long-term management, usually more than 2 or 3 weeks.ʺ
Helpful in allowing the respiratory muscles to be strengthened by increasing resistance to airflow.ʺ
Easier to use when there are increased secretions that need to be removed by suctioning.ʺ
Generally a method that allows oral nutrition to be resumed.ʺ

Which of the following settings on a ventilator would require a nursing intervention for improving patient outcomes for a 60-kg patient with acute lung injury (ALI)?
FiO2 = 0.30 or 30%
Tidal volume (VT) = 900 mL
Respiratory rate = 15 per minute, when the CO2 levels are elevated
Inspiratory:Expiratory ratio (I:E) = 1:2

Which of the following statements made by a new graduate nurse about invasive mechanical ventilation techniques is incorrect and requires additional teaching?
ʺAssist control mode refers to the patient receiving a set total lung capacity (TLC) but the rate can be modified by the patientʹs own rate of breathing.ʺ

ʺTotal control mode controls both the rate and volume that are preset and delivered without the machine responding to any of the patientʹs own breaths.ʺ

ʺSynchronized intermittent mandatory ventilation (SIMV) refers to the patient setting an independent rate but limited tidal volume based on the patientʹs own strength. A minimum rate is also used as a backup to prevent hypoventilation.ʺ

ʺContinuous positive airway pressure will increase the residual capacity and keep the alveoli open. Rate and volume are controlled by the patient. This is one step in the weaning process.ʺ

A patient with ARDS is on a mechanical ventilator and is becoming increasingly restless with a heart rate of
128. The SaO2 is 88% and the ventilator settings are FiO2 50%; PEEP 8 cm; AC 10 with a total respiratory rate of
30; and a tidal volume of 700 mL. There are coarse rhonchi audible in all lung fields. The appropriate nursing action would be to:
Hyperoxygenate with 100% oxygen and suction the patient.

Administer the ordered neuromuscular blockade medications.
Increase the FiO2 to 60% and tidal volume to 750 mL for 2 minutes.
Increase the PEEP to 10 cm and sedate the patient.

The nurse receives the following ABG result. pH = 7.00
PaCO2 = 50 mm Hg PaO2 = 89 mm Hg SaO2 = 90%
Based on the results, what would the nurse expect to do first?
Check the last dose of CNS depressant drug
Assess lung sounds and vital signs
Review the history for asthma or emphysema
Apply oxygen per nasal cannula at 2 L/min

When interpreting arterial blood gases (ABGs), what is the correct order of the following steps? (Rank in order)
Consider the pH. Is it alkaline, acidic, or normal?
Consider the HCO3. Is it alkaline, acidic, or normal?
Consider the PaCO2. Is it alkaline, acidic, or normal?
Consider oxygenation by PaO2 and SaO2.

When assessing the patient in respiratory distress, the nurse would expect to find which of the following? (Select all that apply.)
Intercostal muscle retractions
Use of abdominal muscles
Tachycardia
Bradypnea

Arterial blood gas (ABG) results of an intubated, mechanically ventilated patient are: pH 7.33; PaO 2 50; PaCO2 49; Bicarbonate 27.The nurse would anticipate the priority action would be to:

Increase respiratory rate and FiO2.
Increase IV fluids.
Administer Diamox 250 mg IV.
Decrease the respiratory rate and FiO2.

Which of the following nursing interventions would best optimize overall oxygenation and ventilation in the patient with acute respiratory distress syndrome (ARDS)?
Provide adequate rest and recovery time between procedures
Hyperventilate the patient before and after suctioning.
Administer sedation frequently
Suction the patient as needed

A patient with ARDS has PEEP added to the mechanical ventilation therapy. Which of the following assessments would indicate that the use of PEEP has been effective?
PCO2 of 52 mm Hg
A PO2 of 92 mm Hg
A respiratory rate of 33
A urine output of 50 cc/hr

Which of the following assessment findings would indicate a readiness to wean the patient off the mechanical ventilation? (Select all that apply.)
Unstable hemodynamics
A heart rate of 125 bpm
A respiratory rate of 18 on CPAP
An SaO2 of 95%
A spontaneous tidal volume of 600 cc

During multidisciplinary rounds, a discussion develops concerning the rationale for use of medications in Acute Respiratory Distress Syndrome (ARDS). Which of the following statements is most accurate based upon published research findings?

Corticosteroids are used for their anti-inflammatory property to manage the cytokine-mediated inflammatory response in ARDS.

Exogenous surfactant therapy is more beneficial to adult patients with ARDS than when it is given to neonates.

Cytokine inhibitors (a xanthine derivative; e.g., lisofylline), which inhibit the release of cell-mediated free fatty acids that convert into proinflammatory mediators, were shown to decrease mortality rates.

Inhaled nitrous oxide (through vasodilation) relaxes vascular smooth muscle and decreases pulmonary artery pressures to increase oxygenation without hypotension.

Chapter 4 Interpretation and Management of Basic Dysrhythmias
A 57-year-old male patient is admitted to the telemetry unit with new onset of weakness and fatigue. The following rhythm is now seen on the monitor and the patient is now complaining of shortness of breath and mild chest discomfort. Which of the following medications would be appropriate for this patient?.

Give epinephrine 1 mg IV.
Give atropine 0.5 mg IV.
Give adenosine 6 mg IV.
Give amiodarone 300 mg IV.

A 78-year-old patient arrives in the emergency department with the following rhythm. Which of the assessment findings identifies a need for further treatment?

23 Short period of asystole followed by conversion to normal sinus rhythm
24 Warm, dry skin
25 Heart rate of 88 and BP 124/80
26 Heart rate of 42 and BP 78/60

23 A 67-year-old male patient comes to the emergency department complaining of ʺfeeling tired.ʺ He is placed on a cardiac monitor and the following rhythm is observed. The patient states that he has a history of an irregular heartbeat. Vital signs are: BP 134/78; RR 17; SaO 2 97% on room air. He denies other complaints at present. The priority action for this patient would be to:

23 Perform a 12-lead ECG and compare it to previously recorded ECGs.
24 Prepare the patient for transcutaneous pacing.
25 Place the patient on 100% via nonrebreather mask.
26 Give Versed 1 mg IVP.

23 CPR is begun on a patient who has developed ventricular fibrillation. The patient is defibrillated once with the resulting rhythm. Which of the following interventions should the nurse implement next?

0 Defibrillate the patient with 360 joules.
1 Administer atropine 1 mg IV push and repeat every 3 minutes.
2 Infuse amiodarone 300 mg IV push slowly.
3 Administer epinephrine 1 mg IV push.

0 A patient arrives in the emergency department for chest pain, lightheadedness, and shortness of breath (SOB). The cardiac monitor shows sinus rhythm with the presence of multifocal PVCs. Which of the following orders would the nurse question?

23 Oxygen at 4 L/min via nasal cannula
24 Morphine sulfate 2 mg IV
25 Atropine 0.5 mg IV
26 Amiodarone 300 mg IV

0 While assessing a patient in the CCU, the nurse observes the following rhythm on the monitor. The patient is alert and oriented and denies any complaints at present. The nurse should:

23 Administer a precordial thump.
24 Check lead placement on the patient.
25 Begin CPR and call for a defibrillator.
26 Administer epinephrine 1 mg IV every 3 minutes.

23 The patient in pulseless ventricular tachycardia is defibrillated twice and received appropriate meds given per ACLS protocol. The following rhythm is now present. The nurse should now:

0 Continue monitoring and observing the patient for PVCs.
1 Place the patient on a maintenance lidocaine infusion.
2 Realize that the patient has been successfully converted to NSR.
3 Check the patient for a pulse and continue CPR if one is not present.

23 Which of the following patient responses is an indication that the patient has had a favorable response to atropine?
23 The patient experiences an increase in heart rate to 80 bpm.
24 The patient complains of a headache.
25 The patient experiences a decrease in heart rate to 40 bpm.
26 The patient converts to normal sinus rhythm from ventricular tachycardia.

0 A 58-year-old female is admitted with the following new onset rhythm. With complications related to this rhythm in mind, priority nursing assessment would be to:

23 Monitor for sudden onset of ventricular tachycardia.
24 Perform neuro checks every 4 hours.
25 Monitor for deterioration to third-degree block.
26 Assess skin turgor for dehydration.

23 A patient in the emergency department is in supraventricular tachycardia. What are appropriate nursing actions for this patient? (Select all that apply.)
23 Start CPR and defibrillate at 200 joules
24 Start oxygen at 2 L/min via nasal cannula
25 Give atropine 1 mg IVP
26 Give epinephrine 1 mg IVP
27 Give adenosine 6 mg IVP

0 A patient is experiencing chest pain and shortness of breath and is lethargic. The patientʹs vital signs are: BP 88/58, HR 40, RR 20. Which nursing action is priority for this patient?
23 Nitroglycerin 1 tab sublingual
24 Aspirin 325 mg PO
25 Morphine 2 mg IVP
26 Atropine 1 mg IVP

23 The nurse receives the following ECG strip at shift report. Which of the following actions is most appropriate for this patient?

0 Place the patient on oxygen at 2 L/min via nasal cannula.
1 Give atropine 1 mg IVP per protocol.
2 Start a second IV for normal saline bolus per protocol.
3 Assess the patient.

23 Second-degree heart block (Wenkebach [type I]) is characterized by:
23 Progressive lengthening of the PR interval until a QRS is dropped.
24 Prolonged PR interval greater than 0.22.
25 Complete disassociation of the atria and ventricles.
26 Consistent PR interval with occasional dropped QRS complexes.

23 Which of the following is an indication that the patient has had a favorable response to adenosine? The patient:

23 Is complaining of a headache.
24 Experiences a decrease in heart rate to 80.
25 Converts to sustained asystole.
26 Experiences an increase in heart rate to 64.

23 A patientʹs cardiac monitor shows a rate of 89 with a PR interval of 0.2 second and a QRS of 0.16 second. What is the most important nursing action?
23 Start the patient on O2 at 4 L/min via nasal cannula.
24 Get a 12-lead ECG stat.
25 Report these abnormal findings to the physician.
26 Continue to monitor the patientʹs cardiac status.

23 A patientʹs monitor strip shows an irregular rhythm. Which method of estimating the rate would be best for the nurse to use? The nurse should count the number of:
23 Small blocks between two consecutive R waves and divide by 1500.
24 Large blocks between two consecutive R waves and divide by 300.
25 QRS complexes in 6 seconds and multiply by 10.
26 Large blocks in 3 seconds and multiply by 20.

23 In practicing how to assess rhythms, the nurse would assess which correct sequencing process for effectively interpreting an ECG rhythm strip? (Rank in order).
23 Heart rhythm.
24 QRS width
25 P wave.
26 Heart rate.
27 P to QRS ratio.
28 PR interval.

0 The nurse is analyzing a 6-second ECG rhythm strip with the following findings: P to QRS ratio is 1:1; four regular R waves were present; QRS width was 0.10 second; PR interval was 0.18 second. The nurse documents this rhythm as:

23 Atrioventricular (AV) block with 2:1 ratio.
24 Sinus tachycardia noted with AV junctional rhythm.
25 AV complete heart block noted.
26 Sinus bradycardia with normal sinus rhythm (NSR).

23 The nurse is interpreting an ECG strip. Which of the following would be appropriate when describing paroxysmal supraventricular tachycardia (PSVT)? (Select all that apply.)
23 QRS width is 0.18 second.
24 Heart rate is between 150 and 250 beats per minute.
25 The increased rate can start abruptly and cease quickly when viewing a cardiac monitor to validate its presence.

26 The P wave is hidden in the preceding T wave; therefore, the PR interval cannot be measured.

23 When teaching a class of new nursing graduates, the nurse would expect the students to describe atrial fibrillation on an ECG strip as having:
23 No P wave but waves that can be described similar to a picket fence or saw-tooth pattern that are regularly spaced between normal QRS waves.

24 No consistent P waves are noted, only an erratic and wavy baseline is noted between normally configured QRS waves.

25 A progressive deterioration of the wavy baseline with irregular R to R spacing that leads to ventricular tachycardia and a cardiac arrest situation.

26 A QRS width greater than 0.12 second and lasting about 30 seconds before ventricular fibrillation occurs.

23 Which outcome would the nurse expect to be included in the plan of care for a patient with atrial fibrillation? (Select all that apply.)
23 To monitor neurological status every 4 hours
24 To administer beta blockers (atenolol) and calcium channel blockers (diltiazem) to lower heart rate in order to maximize cardiac output

25 To prepare the patient for defibrillation to assist in conversion to normal sinus rhythm
26 To administer anticoagulants as ordered to minimize risk for an embolic event
27 To use vagal stimulation to control heart rate

5888 When the nurse assesses for atrial fibrillation on the ECG strip, which of the following criteria is correct?
5888 Ventricular rate is usually regular in R to R distancing
5889 Atrial rate runs 300 to 500 with an unequal ratio of P to QRS
5890 P waves are regular and vary in ratio to QRS
5891 QRS width is wide due to a conductivity delay

23 When evaluating the history for a patient with a complete heart block, which of the following would be considered as a potential cause for this condition? (Select all that apply.)
23 Digitalis toxicity
24 Degenerative heart disease
25 Severe aortic stenosis
26 Myocarditis

23 In order to correctly manage ventricular dysrhythmias, the nurse should expect to implement which of the following treatments?
Magnesium sulfate to terminate ventricular tachycardia pattern called torsades de pointes that was noted on the ECG strip

Potassium chloride (KCl) replacement for a potassium level of 4 mEq/ mL
Procainamide for coarse ventricular fibrillation that is developing
Synchronized cardioversion after atropine is given for ventricular tachycardia

23 What action is appropriate for the nurse to implement when monitoring the ECG of a patient with a transvenous ventricular demand pacemaker? The ECG strip shows QRS complexes without a pacer spikes.
Plan for immediate removal of pacer lead wires.
Continue to observe the patient and the ECG rhythm.
Call the physician and explain that capture has been lost.
Call a code for ventricular fibrillation.

Chapter 5 Cardiodynamics and Hemodynamics Regulation
23 A patient has a blood pressure of 134/70 per blood pressure cuff and a blood pressure of 90/50 per arterial line. The nurse should:

Discontinue the arterial line immediately.
Check the level of the transducer and relevel and rezero the system.
Do nothing because this is a normal variation between the two methods of measurement.
Begin the infusion of a dopamine drip.

23 The nurse is monitoring a patientʹs pulmonary vascular resistance. Which value is the normal value?
100-250 mm Hg
10 -250 dynes/sec/cm2
400-800 mm Hg
800-1400 dynes/sec/cm2
23 A patientʹs systemic vascular resistance (SVR) has dangerously decreased. The nurse would expect to administer which medications?
Dopamine and furosemide (Lasix)
Nitroprusside and furosemide (Lasix)
Dopamine and norepinephrine (Levophed)
Nitroglycerin and digoxin (Lanoxin)

23 A patient has mixed venous oxygen saturation (SVO2) of 52% with the following hemodynamic findings: CO of 4.8 L/min, SaO2 of 95%, and an unchanged hemoglobin level. The nurse should assess the patient for:

Excessive sedation.
Position of the PA catheter.
Hypothermia.
Pain.

23 Which of the following actions has the highest priority for maintaining safety when caring for a patient with a PA catheter?
Obtain pressures per protocol.
Obtain lab values as ordered.
Maintain asepsis when providing line care.
Administer fluids and medications via pump.

23 A patient with a right subclavian triple lumen catheter has a CVP reading of 18 mm Hg. The nurse would further assess the patient for symptoms of:
Hypovolemia, hypertension.
Orbital edema, disorientation.
Decreased peripheral pulses and cool extremities.
Peripheral edema, JVD.

23 The nurse is monitoring the PA pressure of a mechanically ventilated patient. In order to accurately measure this pressure, the nurse should obtain the measurement:
At the last clear waveform before the baseline rises.
At the last clear waveform before the baseline drops.
With the patient off the ventilator.
Whenever because the timing does not matter.

23 A patient with a PA catheter has an SVO2 of 90%. The nurse should assess the patient for:
Fever.
Hypothermia.
Anemia.
Pain.

23 Which of the following would the nurse monitor in response to a change in SVO 2 readings?
Hemoglobin level
Sodium level
Potassium level
Glucose level

23 A patient asks the nurse, ʺWhat is blood pressure?ʺ The nurse would most appropriately respond:
ʺThe amount of pressure exerted on your veins by the blood.ʺ
ʺA complex measurement that should only be discussed with your health care provider.ʺ
ʺA measurement that takes into consideration the amount of blood that your heart is pumping and the size of the vessel diameter the heart must pump against.ʺ

ʺA measurement that should always be 120/80 unless complications are present.ʺ

23 The physician is preparing to insert a PA catheter. The nurse should ensure that:
The patient is in the Trendelenburg position to prevent air embolism.
The site has been cleaned with soap and water.
The patient has received a dose of IV lidocaine.
A tourniquet has been applied to the neck.

23 In order to correctly calculate cardiac output, the nurse should:
Take three to five measurements and take the average of the three readings of the ones within 10% of one another.

Only take two measurements and then average the two readings.
Obtain five measurements and record the highest reading.
Take one measurement to prevent fluid volume overload.

23 Pulsus paradoxus may be seen on arterial pressure waveform monitoring when:
There is a decrease of more than 10 mm Hg in the arterial waveform before inhalation.
There is a single, nonperfused beat.
The waveform has tall, tented waves.
The pulse pressure is above 20 mm Hg on exhalation.

23 The mean arterial pressure is calculated by:
Averaging three of the patientʹs blood pressures over a 6-hour period.
Dividing the systolic pressure by the diastolic pressure.
Adding the systolic pressure and two diastolic pressures then dividing by 3.
Dividing the diastolic pressure by the pulse pressure.

23 Contractility of the left side of the heart is measured by:
Pulmonary artery wedge pressure.
Left atrial pressure.
Systemic vascular resistance.
Left ventricular stroke work index.

Which of the following interventions should be followed to ensure accurate cardiac output readings?
Use 5 cc of iced saline as the injectate.
Inject the fluid into the pulmonary artery distal port.
Ensure that there is a difference of 10°C between the injectate temperature and the patientʹs body temperature.

Administer the injectate within 4 seconds.

The normal cardiac output is:
2-4 L/min.
4-8 L/min.
6-9 L/min.
8-10 L/min.

Causes of reduced preload include which of the following? (Select all that apply.)
Vasodilator medications
Reduced circulating blood volume
Sepsis
Mitral stenosis

A lactate level of 8 mmol/L is a reliable indicator of:
Glucose metabolism.
Tissue hypoxia.
Carbon dioxide exchange.
Underuse of oxygen.

The nurse notices that a patient with an arterial line has an elevated PTT and is not on anticoagulation therapy. The nurse should:
Change the heparinized saline solution in the pressure bag for the arterial line to a normal saline solution.

Ask for an order to begin Lovenox therapy.
Assess for the presence of a DVT.
Take the patient for a STAT V/Q scan.

Prior to the insertion of an arterial line in the radial artery, which assessment needs to be performed?
Homanʹs test
Allenʹs test
Kernigʹs test
Leopoldʹs maneuver

When observing the waveform of an arterial line, the nurse notes the presence of a dicrotic notch. The nurse knows this due to:
Mitral valve closure.
Tricuspid valve closure.
Aortic valve closure.
Pulmonic valve opening.

The nurse suspects that a patient is experiencing cardiogenic shock. Which parameter indicates that the nurseʹs suspicion is correct?
Cardiac output of 8.9 L/min
Pulmonary artery wedge pressure (PAWP) of 8 mm Hg
Cardiac index (CI) of 1.8 L/min/m2
Central venous pressure (CVP) of 5 mm Hg

A patientʹs hemodynamic parameters include the following: right atrial pressure (RAP) of 13 mm Hg, pulmonary artery wedge pressure (PAWP) of 8 mm Hg, systemic vascular resistance (SVR) of 1000 dynes/sec/cm2, cardiac output (CO) of 4.9 L/min, cardiac index (CI) of 3.5 L/min, and pulmonary vascular resistance (PVR) of 280 dynes/sec/cm2. Which heart function should cause the nurse concern?

Afterload
Left heart contractility
Right heart contractility
Heart rate

Chapter 6 Care of the Patient Experiencing Shock or Heart Failure

Which of the following should the nurse identify as symptoms of hypovolemic shock? (Select all that apply.)
A temperature of 97.6°F (36.4°C)
A decrease in blood pressure of 20 mm Hg when the patient sits up
Capillary refill time greater than 3 seconds
Restlessness
Sinus bradycardia of 55 beats per minute

Which of the following lab findings should cause the nurse to suspect that a patient was developing hypovolemic shock?
Serum sodium of 130 mEq/L (130 mmol/L)
Metabolic alkalosis validated by arterial blood gases
Serum lactate of 5 mmol/L
SvO2 greater than 80%

The nurse should recognize that which of the following patients would be most likely to develop hypovolemic shock? A patient with:
Decreased cardiac output.
Severe constipation, causing watery diarrhea.
Ascites.
Syndrome of inappropriate ADH (SIADH).

Which of the following findings would indicate that a patientʹs peripheral vascular resistance was increased?
Strong bounding pulse with deep red coloring
Pale, cool extremities with decreased pulses
Increased venous engorgement with strong pulses
Faster than normal capillary refill time

Which of the following solutions would be the most appropriate initial volume replacement for a patient with severe GI bleeding?
200 mL of normal saline (NS) per hour for 5 hours
A liter of Ringerʹs lactate (RL) over 15 minutes
Two liters of D5W over half an hour
500 mL of 0.45% normal saline (1/2 NS) over half an hour

Which life-threatening complications would the nurse anticipate might develop in the patient who is being treated for hypovolemic shock? (Select all that apply.)
Renal insufficiency (RI)/renal failure (RF)
Cerebral ischemia
Irreversible shock
Gastric stress ulcer

Which of the following reasons best explains why hypotonic solutions are not used in hypovolemic shock? Hypotonic solutions:
Move quickly into the interstitial spaces and can cause third spacing.
Stay longer to expand the intravascular space but deplete intracellular fluid levels.
Do not stay in the intravascular space long enough to expand the circulating blood volume.
Need a smaller bore needle to run at a slower rate to keep the intravascular space low.

The nurse should warm intravenous fluids when a rapid infuser is being utilized in order to prevent which of the following complications?
Hemorrhagic shock
Hypothermia
Sepsis
Cardiogenic shock

Which of the following findings would indicate that rehydration is complete and hypovolemic shock has been successfully treated in a patient?
CVP = 7 mm Hg
MAP = 45 mm Hg
Urinary output of 0.1 mL/kg/hr
Hct = 54%

When teaching a patient with heart failure about ventricular remodeling, the nurse should recognize that the patient needs additional teaching if the patient made which of the following statements? ʺRemodeling:
Leads to progressive worsening of heart function.ʺ
Can be described as an enlargement of the pumping chamber.ʺ
Occurs with an increase in blood pressure and results in weight gain.ʺ
Develops primarily because the heart is pumping harder.ʺ

The nurse is reviewing a patientʹs medical history. Which of the following factors in the history are most likely to have contributed to the patientʹs development of heart failure? (Select all that apply.)
Hypertension
Diabetes mellitus
Drinking one or two alcoholic drinks daily
Being overweight
Persistent atrial fibrillation

The nurse is assessing a patient for heart failure (HF). Which early findings would reflect a decreased cardiac output and a potential for fluid overload from heart failure?
Orthopnea, peripheral edema, crackles
Dizziness, syncope, palpitations
Pallor and/or cyanosis of extremities
PAWP of 12 and CVP of 6

Which of the following findings would indicate that a patientʹs heart failure (HF) was worsening?
An increase in O2 saturation to greater than 90%
A decrease in heart rate to 66 bpm
The onset of atrial fibrillation
Louder S1 and S2 heart sounds

A patient is very short of breath. Which of the following findings should cause the nurse to be concerned that the shortness of breath might be due to heart failure?
An echocardiogram that reflected increased right ventricular wall thickening
A B-type natriuretic peptide (BNP) of 300 pg/mL
A left ventricular ejection fraction (VEF) of 50%
A serum sodium of 135

Which of the following findings would support the diagnosis of heart failure (HF)?
CVP/RA of 8 mm Hg
PAWP of 20 mm Hg
Cardiac index of 3
Peripheral vasodilation reflected by normalizing capillary refill times

After teaching a patient in heart failure about beta blocking agents, the nurse would understand that the patient required additional teaching if he said, ʺWhile taking the medication, I will:
Weigh myself every day.ʺ
Check my blood sugar regularly.ʺ
Notify my health care provider if I become increasingly short of breath.ʺ
Monitor myself daily for an increased heart rate and blood pressure.ʺ

The nurse should explain to a patient in heart failure that an aldactone antagonist works by:
Reducing sodium and water retention.
Filtering potassium out with the water in the renal tubules.
Promoting the excretion of the urinary waste products urea and creatinine.
Retaining calcium to improve the condition of blood vessels in the glomeruli.

Which of the following would the nurse not expect to find in a patient who was experiencing acute decompensated heart failure with pulmonary edema?
Dyspnea at rest, peripheral edema
Hypertension, bradycardia
Increased coughing, crackles
Decreased O2 saturation, increased PAWP

A patient in heart failure is to be started on an infusion of dobutamine (Dobutrex). Which of the following is most important for the nurse to assess before starting the infusion? The patientʹs:
Blood pressure.
Level of consciousness.
Breath sounds.
Urine output.

A patient in heart failure is being given a first dose of lisinopril 10 mg PO. Which of the following findings would cause the nurse to question the administration of the first dose?
Blood pressure 100/72
Heart rate 92 beats per minute
Potassium 5.7 mEq/dL
Urine output 35 mL/hr

An 82-year-old man is readmitted for heart failure (HF) 1 week after being discharged for the same diagnosis. Which of the following is likely to have contributed to his readmission? (Select all that apply.) He may:
Be depressed.
Not have been prescribed appropriate medications, including ACE inhibitors and beta blockers.
Not have filled his prescribed medications.
Not have known how or when to take his medications.
Not have weighed himself since discharge.

The nurse is caring for a patient with acute decompensated heart failure (HF) receiving BiPaP. While caring for this patient, the nurse should:
Assess the patient for the development of gastric distention, nausea, and vomiting.
Ensure that the mask does not fit too tightly on the patientʹs face to prevent skin breakdown.
Monitor the expiratory time to be sure that it always exceeds the inspiratory time.
Prepare for endotracheal intubation because BiPap is used primarily to buy time for intubation.

What is the most appropriate position for a patient in pulmonary edema with a blood pressure of 194/92?

Dorsal recumbent
Head of the bed elevated 60 degrees
Sitting upright with legs dependent
Torso flat, feet elevated

The nurse notes that the QRS duration of a patient with a biventricular pacemaker is widening? What does this most likely indicate?
Battery failure
Loss of ventricular capture
Loss of ventricular synchronization
Worsening of the patientʹs underlying cardiomyopathy

Chapter 7 Care of the Patient with Acute Coronary Syndrome
A patient says to his nurse, ʺIʹve never heard of an acute coronary syndrome. Please explain what happened to me.ʺ The nurse should respond, ʺAcute coronary syndrome is:

Another name for a myocardial infarction (MI) or heart attack.ʺ
A group of disorders that result in insufficient oxygen supply to the heart.ʺ
The second leading cause of death in the United States.ʺ
A type of abnormal heart rhythm.ʺ

Which of the following is an accurate description of the progression of events in an acute coronary syndrome (ACS)?
A thin fibrin layer stabilizes the ruptured plaque and prevents the occlusion of coronary vessels when stable angina is present in ACS.

When complete platelet occlusion occurs in a vessel, the ECG changes include nonspecific ST elevation without necrosis occurring in ACS.

The growth of platelet-rich thrombi in the smaller vessels creates a blockage and is the cause for unstable angina symptoms in ACS.

Sudden plaque buildup in a narrow vessel immediately leads to an acute myocardial infarction when stable angina is present in ACS.

A nurse is discussing management of hypertension with a patient. Which of the following statements by the patient would indicate that the patient needs additional teaching about the relationship between hypertension and acute coronary syndrome (ACS)?

ʺMy high blood pressure has no relationship to the severity of heart disease or its outcomes.ʺ
ʺBecause Iʹm over 80, even a 20 mm Hg drop in my blood pressure can reduce my risk.ʺ
ʺHigh blood pressure will increase my bodyʹs need for oxygen and increase my heartʹs workload.ʺ
ʺControlling my blood pressure will decrease my risk of having a heart attack to some degree.ʺ

Which of the following explanations of the relationship of being overweight to acute coronary syndrome (ACS) should the nurse include when presenting a healthy heart program to a community group?
Excessive weight will result in a decrease in low-density lipoproteins (LDL) that is linked to ACS.
Extra weight can lead to diabetes insipidus that will increase the risk for ACS.
Losing as little as 5% of oneʹs body weight will significantly lower the risk for ACS.
Obesity, a BMI of greater than 30, increases the risk for ACS at a greater rate than just being overweight.

When a patient says, ʺThe chest pain occurs each time I play basketball; it does not occur when I am sleeping; and it improves when I take those pills under my tongue,ʺ the pain will most likely be classified as:
Variant or Prinzmetalʹs angina.
Undifferentiated angina.
Unstable angina.
Stable angina.

A patient tells a nurse, ʺMy chest pain starts when I am resting and when I had a cardiac catheterization, the doctor said I was having vasospasms.ʺ Which of the following types of medications would the nurse anticipate would be utilized to treat the patientʹs angina?

A vasodilator such as nitroglycerin (NTG)
A calcium channel blocking agent
An antidysrhythmic such as lidocaine
A beta adrenergic blocking agent

A nurse is evaluating a patientʹs understanding after he was diagnosed with a myocardial infarction. Which of the following would indicate that the patient did not understand important information and needs additional teaching?

A heart attack is the same as a myocardial infarction (MI).
A heart attack causes tissue death and that part of the heart may not pump as well.
A heart attack in the anterior wall of the heart can be very serious because a large portion of the heart may not pump as well.

Angina always leads first to decreased blood flow to the heart muscle and then to tissue death.

Which of the following would be most helpful to the nurse in determining whether the chest pain of a patient who has just entered the emergency department is cardiac in origin?
Gathering a complete medical history
Performing a 12-lead ECG
Administering NTG to see if the pain goes away
Asking the patient if performing a Valsalva maneuver reduces the pain

An 80-year-old woman has arrived in the ED. The ED physician is questioning whether she has had an MI although she is not displaying the classic chest pain. Which of the following symptoms might cause him to suspect that she was experiencing an MI?

Jaw and/or tooth pain
Confusion accompanied by hypotension
Generalized fatigue accompanied by dyspnea and diaphoresis
Dyspnea accompanied by crackles in all lobes

Which of the following lab findings would the nurse review to validate a diagnosis of a myocardial infarction (MI) that was suspected of occurring approximately 3 hours earlier?
CK
Troponin T assay
Myoglobin
PTT

The multidisciplinary team would identify which of the following goals for initial collaborative management of a patient with an acute coronary event (ACS)? (Select all that apply.)
Maximize coronary artery blood flow.
Limit the size of infarction by decreasing oxygen demands.
Strengthen the heart by increasing activity as soon as possible.
Balance oxygen demand with supply.
Prevent dysrhythmias with prophylactic antidysrhythmic medications.

A patient is admitted with chest discomfort and a possible UA/NSTEMI. Which of the following would be a contraindication to administration of GP-IIb-IIIA inhibitors to the patient? The patient had:
A platelet count greater than 150,000 mm3.
Major surgery in the last 6 months.
A stroke within the past month.
A creatinine level of 1.4 mg/dL.

The ECG of a patient receiving tPA for a myocardial infarction shows that the ST segment has returned to baseline. How should the nurse interpret this finding?
The myocardial injury is evolving.
The blocked artery has been reperfused.
The patient has become more relaxed.
The spasm in the coronary artery has resolved.

A nurse is preparing to administer the first 5-mg dose of metoprolol to a patient who is 12 hours post MI. For which of the following findings should the nurse withhold administration of the medication?
Blood pressure of 110/65
PR interval 0.12 second
Serum potassium 3.9 mEq/L
Sinus bradycardia 52 beats per minute

Following angioplasty, a patient develops the following: hematuria,hypotension, tachycardia, a drop in hemoglobin and Hematocrit, and a decrease in oxygen saturation. Which of the following is most likely to be responsible for the symptoms?

Reaction to vasovagal stimulation
Myocardial ischemia
Peripheral emboli distal to the insertion site
Overanticoagulation

A nurse is caring for a patient who has just started to bleed from her insertion site following a cardiac catheterization. What should be the nurseʹs first response? The nurse should:

Apply manual pressure to the site.
Locate and apply a compression clamp.
Apply a collagen patch or sheath.
Administer vitamin K (AquaMEPHYTON).

To increase patient compliance and reduce postoperative complications, the nurse should include which of the following topics in the preoperative teaching for a patient who is to have a coronary artery bypass graft (CABG)? (Select all that apply.)

Reasons for cooling blankets in post-op period
Equipment used: IVs, Foley, pacer wires, chest tubes, NG tubes, ECG leads
Drug management: need for sedation when intubated, pain med through PCA
Alternate methods for communicating when intubated
Reasons and techniques of turning, coughing, and deep -breathing once extubated

Which of the following is appropriate in collaborative management of a patientʹs pulmonary status following coronary artery bypass graft surgery?
Keeping the patient intubated for at least 48 hours to maximize gas exchange
Mobilizing the patient as soon as possible to prevent atelectasis and venous stasis
Evaluating readiness for extubation based on guidelines: PO2 less than 80 mm Hg with an FiO2 greater than 40% and a PCO2 greater than 45
Extubating when the patient is arousible to noxious stimuli and shows increased effort for spontaneous breathing

Which of the following findings should cause the nurse to suspect that a post coronary artery bypass patient might be developing cardiac tamponade? (Select all that apply.)
Widening pulse pressure
Increased jugular vein distension
Decreasing central venous pressure (CVP)
Lack of pleural (chest) tube drainage
Muffled heart sounds

When assessing the risk for stress ulcers after a coronary artery bypass graft (CABG) surgery, which factors would contribute to this risk? (Select all that apply.)
Alcohol abuse or excess
Age less than 70 years
Incidence of postoperative hemorrhaging
Need for vasodilators for postoperative hypertension
Prolonged use of CRB

A patient starting cardiac rehabilitation will work with the rehabilitation team to meet all of the following goals except:
Taking control of his life through healthy choices.
Managing his symptoms by monitoring his exercise.
Reducing risks by controlling the modifiable risk factors.
Stabilizing any severe depression that developed post MI.

The nurse is discussing the Dietary Approaches to Stop Hypertension (DASH) program with a patient and his spouse. They are overwhelmed and ask if there is one measure recommended by the program that would have the biggest impact so they can start with that measure first. The nurse should suggest:

Controlling diabetes to an A1C less than 7%.
Decreasing their sodium intake to less than 1,500 mg/day.
Increasing their intake of dairy products.
Losing weight.

A nurse is teaching a patient with coronary artery disease about his prescribed nitroglycerin therapy. Which of the following statements, if made by the patient, would indicate that he needs further teaching?
ʺI should not take nitroglycerin if I have taken Viagra.ʺ
ʺIʹll put a couple of tablets in a plastic bag in my pocket so I have them with me all the time.ʺ
ʺIf the pain doesnʹt go away I can take a second tablet after 5 minutes.ʺ
ʺI should try to sit or lie down when I take the nitroglycerin.ʺ

A patient is being discharged after an MI taking lisinopril 10 mg daily. Which of the following instructions is most appropriate for the nurse to give to the patient?
Avoid crossing your legs
Change your position slowly when going from lying to sitting
Cut down on your sodium intake to 1,500 mg/day
Weigh yourself at least three times a week

Chapter 8 Care of the Patient Following a Traumatic Injury

A patient arrives in the emergency department with a flail chest after a motor vehicle accident (MVA) in which the patientʹs chest hit the steering wheel. This injury is due to which of the following?
Blunt trauma from internal forces caused by acceleration
Blunt trauma from external forces caused by deceleration
Penetrating trauma from external forces caused by deceleration
Penetrating trauma from internal forces caused by acceleration

Which of the following patients is an example of an open traumatic injury? A patient with:
A closed hip fracture that was caused by a fall
A gun shot wound without penetration of the bullet due to the bullet -proof vest
Near-drowning after falling through a frozen lake
Burns over 30% of the body from a house fire

When performing a quick assessment to identify life-threatening problems, the nurse would include which assessments under the D–Disability section? (Select all that apply.)
Level of consciousness or unconsciousness
Vital signs
Ability to respond to verbal command
Ability to respond to painful stimuli
Oxygen saturation levels

The nurse would implement which activities under the ʺAʺ section of assessment priorities when admitting a trauma patient with a suspected spinal cord injury?
Using a manual ventilation bag
Applying heated blankets
Using the jaw thrust maneuver
Assessing for history of asthma

Which of the following risk factors could lead to the development of failure to maintain the airway if not recognized in the assessment process? (Select all that apply.)
Chest wall injury
Aspiration of gastric contents
Foreign object occlusion of the throat/mouth
Swelling of soft tissue in the throat
Displacement of the trachea (tracheal shift)

Which nursing assessments would have highest priority for early airway management?
Ask the patient to state his name.
Assess increasing intracranial pressure (ICP) with facial fractures.
Prepare for emergency tracheostomy.
Perform a computerized tomography (CT) scan of tissues of the neck.

Which of the following findings by the nurse would be more likely to indicate that a trauma patient was having problems with breathing rather than difficulty maintaining an airway?
Pain with swallowing, coughing, or hemoptysis
Chest pain on inspiration
Popping sound (crepitus) in the throat when touching the skin by the trachea
Hoarseness when talking

Which activity by the nurse should be included in breathing assessment for a patient suspected of having a thoracic trauma? (Select all that apply.)
Jugular vein distention
Chest movements that rise and fall with breathing effort
Symmetry of chest movement bilaterally
Respiratory rate, pattern, and effort
Peripheral skin coloring

The nurse would expect to find which assessment finding for a patient with a tension pneumothorax?
Tracheal deviation to the unaffected side
Bilateral equal chest movement
Decreased muscular effort by chest muscles
Decreasing central venous pressure (CVP)

Which of the following goals are appropriate for a patient with a traumatic injury and an ineffective breathing pattern? (Select all that apply.)
Restore the normal breathing pattern
Provide oxygen 100% therapy through a nonrebreather mask
Maintain a calm environment to decrease oxygen demands
Prevent sepsis
Maintain balanced hydration

When a thoracic trauma occurs, which complications should the nurse identify as potential problems? (Select all that apply.)
kSubcutaneous emphysema
Tracheal shift
Pleural effusion
Vertebral column injury
Bladder rupture

Immediate intervention for a sucking chest wound would include which of the following? (Select all that apply.)
Prepare the patient for chest tube insertion.
Administer pain medication.
Prepare for emergency intubation.
Apply a dressing that is taped on three sides.
Continue to monitor pulse oximetry and respiratory characteristics.

When discussing hemorrhagic shock to a nursing class, which statement by the student would indicate to the nurse educator that the student needs additional teaching?
Blood loss into the abdominal cavity can lead to hypovolemic shock.
Septic shock is more common than hemorrhagic shock due to nosocomial infections.
When fluids shift into the interstitial spaces, the loss of vascular fluids can lead to hypovolemic shock.
Hemorrhagic shock symptoms include tachycardia, dyspnea, and hypotension.

When managing shock, which statement would be incorrect when comparing the level or classification of shock to the drug treatment?
Class I–treated with colloid fluid resuscitation
Class II–treated with crystalloid fluid resuscitation
Class III–treated with colloid and blood products
Class IV–treated with blood and crystalloid products

During assessment of a patient with a suspected cardiac tamponade, the nurse should monitor for the development of which of the following? (Select all that apply.)
Hypotension
Muffled heart sounds
Pulsus paradoxus
Flat jugular veins

The nurse would understand that the patient is at risk for the development of reoccurring cardiac tamponade when:
Fluid or blood continues to accumulate in the pericardial sac.
The cause of the tamponade was persistent hypertension.
Treatment by needle aspiration of the fluid in the sac is performed.
A pericardial window is surgically created.

A nurse notes that a patient with a traumatic brain injury is having a rapid decline in level of consciousness. If the nurse suspects, cerebral herniation, the most appropriate intervention would be to:
Briefly hyperventilate the patient.
Take measures to increase intracranial pressures by Trendelenburg positioning.
Prepare for emergency surgical repair.
Contact the family to come say their last words with the patient.

Which of the following goals would receive highest priority for the patient with a cervical spine injury?
Relieve muscle spasm pain
Maintain cervical alignment
Support respiratory effort and prevent atelectasis
Promote hypothermia

The mother of a patient just admitted with a spinal cord injury is asking if her son will be given steroids. Which of the following would be an accurate way for the nurse to explain the role of steroids in treating spinal cord injuries?

Steroids will make the patient feel better overall and retain muscle strength due to its ʺmuscle -bulkingʺ effects.

Steroids have few side effects and remove all symptoms while healing the problem.
Steroids can lead to ʺroad-rage and anger outburstsʺ and therefore are avoided except under extreme emergencies.

Steroids limit spinal cord edema and ischemia if initiated within 3 hours of the trauma and given for 48 hours.

The nurse is caring for a patient with traumatic injury to the abdomen who is receiving conservative, nonoperative management. Which ongoing assessments should the nurse expect to include in the plan of care? (Select all that apply.)

Hourly vital signs
Hourly CVP readings
Assessment of the degree and type of guarding or rigidity
ECG changes for bradycardia and widening QRS
Widening pulse pressure

Under what circumstance would the nurse expect to prepare the patient for surgery when abdominal trauma has occurred? A patient with:
A suspected splenic injury and who has received 1 unit of blood.
A Grade III liver injury with stable vital signs.
A contusion to the kidney with a stable H & H.
A pelvic fracture who has muscle rigidity of the abdominal wall.

Under the F section of the assessment process, in addition to full vital signs, the family is considered as a part of the treatment process. Which approach to the family would be most appropriate for the nurse to use?
The family gets in the way of acute care management so the nurse should offer no support until the patient is stable.

Ethically the family has a right to support the patient by being at the bedside during acute care management, including trauma resuscitation.

Depending on the familyʹs awareness of health care management, they have the privilege to watch the care if they do not get in the way of the care.

Because the care during trauma management can be too graphic for family to witness, the family should not be allowed at the bedside.

According to Morse (1998), the nurse can plan to convey comfort to a trauma patient by providing which of the following activities? (Select all that apply.)
Human contact such as a reassuring touch
Directly looking at the eyes of the patient when talking
Explaining and talking to the patient, not ignoring the patient
Giving clear precise directions to follow
Giving all details to get full cooperation

The nurse should include what activities in the plan of care to increase comfort for the intubated patient? (Select all that apply.)
Speak directly to the patient by looking into the patientʹs eyes.
Keep the patient sedated and let the patient sleep when giving care.
Give additional pain medication whenever restlessness is noted.
Establish a communication method that does not require talking.
Keep the family at the bedside to interpret the patientʹs needs.

Chapter 9 Care of the Patient Experiencing an Intracranial Dysfunction
A patient with a head injury has a pO2 of 88 and a pCO2 of 58. The nurse realizes that which of the following will occur?

Cerebral blood vessels will dilate
Cerebral blood vessels will constrict
Blood will be shunted from the cerebral cortex
Blood flow to the cerebral cortex will slow

A patient who has suffered a traumatic brain injury has a blood pressure increase from 130/60 to 170/65 mm Hg. The nurse should respond to this increase in blood pressure by:
Alerting the physician and preparing to administer an antihypertensive agent.
Documenting the blood pressure and completing a neurological assessment.
Providing the patient with immediate pain and/or antianxiety medication.
Weighing the patient to determine if the patient is fluid overloaded.

When providing care to a patient who has increased intracranial pressure, the nurse should be concerned about which of the following patient findings because it is likely to result in an additional increase in intracranial pressure?

Blood pressure of 150/65
Respiratory rate of 24
Temperature of 99°F (37.2°C)
Serum sodium of 110 mEq/L

A patientʹs mean arterial pressure (MAP) decreases to 50 while his ICP is 20. The nurse realizes that this drop in MAP is likely to lead to:
Increased intracranial pressure.
Bradycardia.
Increased urine output.
Hypoxic cerebral tissue.

The nurse is preparing to conduct an hourly neurological assessment on a patient in the intensive care unit. Which of the following would be included in this assessment?
ECG
Brainstem functioning
Level of consciousness
Reflexes

A patient in the neurological intensive care unit has an endotracheal tube. When the nurse does the hourly Glasgow Coma Scale assessment, what rating would this patient have for verbal response?
4
3
2
1

The nurse is planning to assess a patientʹs motor functioning. Which of the following should the nurse do?
Assess all four extremities together
Assess the right leg and the right arm together
Assess the left leg and the left arm together
Assess the arms together then assess the legs separately

The nurse is assessing a patientʹs corneal reflex. The cranial nerve that is being assessed with this reflex are:
Optic.
Trigeminal.
Oculomotor.
Vagus.
The nurse is going to assist with the assessment of a patientʹs oculovestibular reflex. Which of the following should be done before this reflex is assessed?
Ensure that the patientʹs spinal cord has been found intact
Determine that the patient can tolerate being in the supine position
Ensure that the patient has an intact gag reflex
Determine that the patient has an intact tympanic membrane

The nurse, evaluating the tracing made from a patientʹs intracranial pressure monitor, notes the presence of many C waves. This finding would be indicative of:
Pending brain herniation.
Impaired cerebral spinal fluid flow.
Decreased cerebral compliance.
No evidence of pathology.

The nurse is providing care to a patient with an intracranial pressure monitoring device. Which of the following should be a priority when providing care to this patient?
Use clean technique when working with the system.
Use strict aseptic technique when working with the system.
Perform neurological assessment checks every 2 hours.
Monitor intracranial pressure every 4 hours.

A patient is being admitted after sustaining a head injury from an acceleration/deceleration motor vehicle accident. The type of injury that this patient most likely sustained would be:
Coup–countercoup.
Skull fracture.
Concussion.
Penetrating.

A patient is admitted with a fracture to the base of his skull. Which of the following might the nurse assess in this patient?
Cerebral spinal fluid leak from the nose
Ecchymoses of the neck
Increased intracranial pressure
Depressed respiratory rate

A patient with a skull fracture was admitted unconscious, became conscious, and has since moved into unconsciousness again. This patient is demonstrating findings indicative of:
A subdural hematoma.
A subarachnoid hemorrhage.
An epidural hematoma.
A cerebral spinal fluid leak.

A patient with a severe head injury has a pO2 of 88 and a pCO2 of 48. Which of the following should be done to support this patient?
Assess oxygen saturation and plan for intubation if saturation is below 86%.
Provide 100% oxygen via face mask.
Plan for a routine intubation.
Plan for a rapid sequence intubation.

A ventilated patient with a head injury needs to be suctioned. Which of the following should the nurse do to limit problems related to suctioning?
Limit the duration of each suctioning pass to less than 20 seconds.
Reduce the flow of oxygen prior to suctioning.
Preoxygenate before suctioning.
Medicate with opiates after suctioning.

A patient with a traumatic brain injury is showing signs of having pain. Which of the following would be the medication of choice for this patient?
Fentanyl
Meperidine
Morphine sulfate
Propofol

A patient with a penetrating traumatic head injury has a Glasgow Coma Scale of 9. The nurse realizes that which of the following will most likely be implemented for this patient?
Intubation
Prophylactic anticonvulsant therapy
Prophylactic hypothermia treatment
High-dose barbiturate therapy

The nurse is planning care for a patient with increased intracranial pressure. Which of the following interventions would be appropriate for this patient?
Cluster care activities.
Maintain head of bed at a 15-degree angle with knee elevation.
Assess for daily bowel movement and provide intervention as appropriate.
Encourage family and physician to discuss patientʹs care and prognosis in the patientʹs room.

A patient comes into the emergency department with a fever, stiff neck, and change in mental status. On assessment it is learned that this patient also has a positive Kernigʹs sign. These findings suggest the patient:
Has meningeal irritation.
Needs to be intubated.
Should receive 100% oxygen via face mask.
Needs surgery to reduce intracranial pressure.

A patient with acute meningitis is receiving antibiotic therapy. The nurse realizes that another medication is used as adjuvant therapy. This medication is:
An anticonvulsant.
A barbiturate.
A pain medication.
A steroid.

The nurse is caring for a patient with status epilepticus. The first goal of care for this patient would be to:
Maintain an airway.
Identify the cause of the seizure.
Determine the patientʹs medical history.
Obtain an EEG.

The nurse is providing medication to a patient with status epilepticus. The medication of choice for this patient would be:
A steroid.
A barbiturate.
A benzodiazepine.
An opioid.

When administering mannitol (Osmitrol) to a patient with increased intracranial pressure (ICP), the nurse should:
Assess the patient carefully for the development of hypertension.
Expect that any reduction in ICP will begin approximately an hour after the dose is administered.
Monitor the osmolality of the blood every 4 to 6 hours if repeated doses are administered.
Review lab data to identify the presence of hypernatremia and hyperkalemia.

When administering hypertonic saline to the patient with increased intracranial pressure (ICP), the nurse should: (Select all that apply.)
Administer any concentrations greater than 2% through a central line.
Expect the patientʹs neurological status and ICP will begin to improve within 15 minutes following administration.

Monitor serum sodium levels frequently during administration.
Monitor the patient for renal failure and pulmonary edema.

Which of the following might the patient develop if IV phenytoin was administered faster than 50 mg/minute?

A pronounced increase in heart rate
Hypotension
Hematologic abnormalities such as agranulocytosis
A severe rash

Chapter 10 Care of the Patient with a Cerebral or Cerebrovascular Disorder

A patient is recovering from transphenoidal surgery for partial resection of a pituitary adenoma. The nurse should caution the patient NOT to do which of the following?
Blow his nose or sneeze
Deep breathe
Drink more than 2 liters of fluid a day
Sit up in bed higher than 30 degrees

A patient is diagnosed with a grade II astrocytoma. The nurse realizes that this patientʹs prognosis is:
Excellent.
Good as long as the tumor is treated soon.
Good because the tumor is well defined.
Poor because the tumor cells are irregularly shaped.

The nurse is assessing a patient with a meningioma. The nurse realizes that this patient will have:
A hearing disorder.
A life expectancy of about 10 months.
An excellent prognosis if the tumor is totally removed.
Metastasis to other body organs.

A patient with increased intracranial pressure is diagnosed with a brain tumor. The nurse realizes that this patient most likely has:
An astrocytoma.
A meningioma.
A tumor less than 1 mm in size.
A tumor greater than 1 mm in size.

An elderly patient is not concerned that he has a brain tumor because he has not had any headaches, only a slight increase in forgetfulness. The nurse realizes that this patient most likely:
Does not have a brain tumor because brain tumors rarely present with cognitive changes.
Does not have a tumor because forgetfulness is seen in children with a brain tumor.
Could have a brain tumor even though he does not have a headache.
Has the beginnings of Alzheimerʹs disease.

A patient tells the nurse that the doctor asked him repeatedly about an area on his arm that has been getting numb and ʺfeels funny.ʺ This information is important because it will:
Possibly pinpoint the location of a brain tumor.
Determine the type and amount of medication to prescribe.
Serve as a minor symptom that is nothing for the patient to worry about.
Determine how long the patient has to stay in the hospital.

During an assessment, the patient asks the nurse if she smells ʺsomething burning.ʺ The nurse realizes that this patient could be demonstrating:
Engorged nasal passages.
A focal seizure.
A way to have the nurse leave to check if something is burning.
Increased intracranial pressure.

A patient with a brain tumor is having a diagnostic test to help with his response to therapy. This patient is most likely having a(n):
CT scan.
PET scan.
Angiogram.
MRI.

The nurse is preparing to administer a medication to help decrease the cerebral edema around a patientʹs brain tumor. This medication is most likely a(n):
Antiseizure medication.
Pain medication.
Glucocorticoid.
Antispasmodic.

A patient is recovering from posterior fossa surgery. Which of the following should the nurse include in the plan of care?
Assess the patientʹs vital signs and level of consciousness every hour.
Maintain the patient flat in bed for at least 24 hours.
Maintain the patientʹs neck in hyperextension.
Observe the patient for the development of diabetes insipidus.

A patient with a brain tumor is going to have an ablative procedure to treat the mass. A potential reason for this procedure would be:
To preserve eloquent areas of the brain.
The tumor is in an easy-to-reach area of the brain.
The tumor is too large to resect.
The tumor is small and is in a hard-to-reach area of the brain.

The nurse is planning the care for a patient who had a supratentoral craniotomy. Which of the following should be included in this plan of care?
Apply a soft cervical collar.
Keep the head of the bed elevated at a 30-degree angle.
Keep the head of the bed flat.
Position the patient on the side of the tumor.

The nurse is applying pneumatic compression boots on a postoperative craniotomy patient. The reason for this device is to reduce the risk of developing:
Meningitis.
A deep vein thromboembolism.
A cerebrospinal fluid leak.
Seizures.

A patient recovering from a craniotomy is complaining of a headache with the head of the bed elevated. The nurse also sees a damp mark on the patientʹs pillow. The nurse should: (Select all that apply.)
Alert the physician.
Check the drainage for the presence of glucose.
Elevate the head of the patientʹs bed to 45 degrees.
Plan for insertion of an external ventricular drain.
Apply an occlusive dressing to stop the leak.

A patient with a brain tumor is prescribed an antiseizure medication. The nurse realizes that the patient will have to take this medication for:
The rest of his life.
At least 5 years.
A week if he is seizure free.
The next 6 months if he is seizure free.

A patient recovering from a glioma has concluded radiation therapy. The nurse realizes that the next step of treatment for this patient will most likely be:
Chemotherapy.
An additional 6 weeks of radiation.
Nothing, unless there is evidence the tumor has returned.
Antiseizure medication.

A patient is diagnosed with an intracerebral hemorrhage. Which of the following is the most common cause of this disorder?
Hypertension
Atrial fibrillation
Atherosclerosis
Hyperinsulinemia

A patient tells the nurse that he is experiencing the ʺworst headacheʺ he has ever had. The nurse realizes that this description is often seen in:
Intracranial hemorrhage.
Ischemic stroke.
Subarachnoid hemorrhage.
A brain tumor.

A patient with an embolic stroke is demonstrating urinary incontinence, contralateral weakness, and altered mental status. This location of the embolism is most likely the:
Middle cerebral artery.
Anterior cerebral artery.
Posterior cerebral artery.
Vertebrobasilar artery.

A patient is diagnosed with an ischemic stroke with the onset of symptoms within the last 2 hours. The best course of treatment for this patient would be to:
Admit the patient to a neurosurgical unit for a surgery consultation.
Consider the administration of intravenous thrombolysis (rtPA).
Observe for continuing symptoms.
Provide intravenous fluids.

A patient is admitted to an intensive care unit with an ischemic stroke. Currently the patientʹs oxygen saturation is 88%. What should be done to help this patient?
Position the patient on one side.
Elevate the head of the bed.
Provide low-dose oxygen.
Provide high-dose oxygen.

A patient being treated with Coumadin experiences an intracerebral hemorrhage. Which of the following should be considered to aid in the care of this patient?
Prepare the patient for surgery.
Prepare the patient for a ventriculostomy.
Prepare to administer Vitamin K.
Prepare to administer protamine sulfate.

A patient with a ruptured cerebral aneurysm is demonstrating drowsiness and confusion. On the Hunt and Hess scale, this patient would be rated as being a:
Grade 1.
Grade 2.
Grade 3.
Grade 4.

A patient develops cerebral vasospasm after a ruptured cerebral aneurysm. Collaborative treatment should be focused on:
Reducing blood pressure.
Dehydrating the patient.
Concentrating red blood cells.
Volume expansion.

While providing fluids to swallow morning medication to a patient recovering from a stroke, the nurse notices that the patient coughs repeatedly and has difficulty clearing the throat. Which of the following should the nurse do?

Change the patientʹs diet to full liquid.
Change the patientʹs diet to soft.
Request a physical therapy consult.
Request a swallowing evaluation by speech therapy.

Chapter 11 Care of the Critically Ill Patient Experiencing Alcohol Withdrawal and/or Liver

The nurse in the ICU is caring for a 46-year-old male who has been drinking heavily for 3 years. She is aware of the potential for alcohol withdrawal syndrome based on the knowledge that physiologically:
Alcohol is a stimulant that increases gamma-aminobutyric acid (GABA).
The neurotransmitters inhibit impulses on the neurons.
The CNS has become accustomed to the depressant effects of the alcohol and CNS excitability develops when alcohol is no longer present.

The neuroreceptors in the brain can begin to initiate a chemical reaction of normalcy.

Which of the following findings might suggest to the nurse that a patient was experiencing early physiological clinical manifestations of alcohol withdrawal? The patient:
Is yelling at the nurse and demanding to go home.
Has a BP of 160/90, HR of 110, and T of 100.
Is a well-known repeat offender and is demanding a drink.
Cannot sit up straight or respond appropriately to questions.

Mrs. Jones brings her son, who has a history of alcohol misuse, for treatment. The essential components of the nursing assessment include:
The use of addiction standards to assess for drinking patterns.
The inclusion of objective and subjective input from the patient and/or family, including signs of anxiety and patterns of usage.

The amount of denial that the patient is exhibiting.
The amount of denial that Mrs. Jones has regarding her sonʹs drinking.

When the CAGE questionnaire is utilized to guide the assessment of alcohol misuse, the nurse should ask which of the following questions?
Have you ever crashed overnight in an unfamiliar area, arrived late for work, given up family and friends or escaped arrest by the law?

Have you ever felt the need to cut down on drinking, felt annoyed by criticism of your drinking, ever had guilty feelings about your drinking, or ever had an eye opener first thing in the morning to get rid of a hangover?

Have you ever had a big crisis that led to arrest and grief from your family and friends and tried to explain away your actions?

There is no such thing as a CAGE assessment.

A patient had his last alcoholic drink at noon. At 6 p.m. he could be showing which of the following autonomic manifestations of alcohol withdrawal?
Nausea and abdominal cramps
Diaphoresis and tremors
Anorexia and diarrhea
Auditory-visual hallucinations and global confusion

In anticipation of a patientʹs alcohol withdrawal symptoms, the nurse should plan to implement which of the following interventions? (Select all that apply.)
Take frequent vital signs
Anticipate seizures occurring within the first 12 hours of admission.
Recognize that hallucinations are common and reorient the patient.
Have a sitter present to monitor any attempt by the patient to escape.
Prevent, recognize, and treat symptoms while providing a safe environment.

The nurse is planning to use the Clinical Institute Withdrawal Assessment (CIWA -Ar) Scale with a patient who has been recently admitted with pancreatitis. When using this measurement tool, the nurse must realize that:
The lower the score, the greater the patientʹs risk for severe withdrawal symptoms.
The higher the score, the lower the patientʹs risk for severe withdrawal symptoms.
Pharmacological therapy is matched with the score to direct the level of care required.
16 specific areas are scored and assessed with this tool.

When using the Clinical Institute Withdrawal Assessment for Alcohol Scale, the use of medication for clinically significant symptoms is based on:
The temperature, pulse oximetry, and urine output.
The response to treatment.
A designated threshold of severity.
The amount of one-to-one attention needed.

Alcohol dependency differs from alcohol abuse in that with dependency:
Alcohol is taken in larger amounts than planned and there is proof of tolerance.
Recurrent legal problems related to substance abuse are present.
Despite social and interpersonal problems, the person continues to use alcohol.
The person uses alcohol in physically hazardous situations.

A patient with a myocardial infarction has been withdrawing from alcohol. He is nauseated and having tremors despite receiving medications for withdrawal and is unable to take anything orally. Which of the following electrolyte imbalances is he most likely to be experiencing?

Serum magnesium 2.5 mEq/dL
Serum phosphate 2.7 mEq/dL
Serum potassium 3.1 mEq/dL
Total calcium 9.0 mg/dL

A 15-year-old patient is being admitted after a suicide attempt. She ingested a number of medications including at least 20 500-mg acetaminophen tablets. Her parents last saw her 8 hours ago when she was unhappy and said she was going to bed. Now she is nauseated, vomiting, and diaphoretic with a BP of 96/52. Which of the following should be the priority in her care?

Having a serum acetaminophen level drawn
Observing her for possible urticaria and bronchospasms
Providing the first oral dose of acetylcysteine (Mucomyst) in orange juice
Starting an IV for rehydration

A patient who admits to drinking several alcoholic beverages each day had knee surgery. Following the surgery, he took 1,000 mg of acetaminophen six times a day and occasionally Percocet for more than a week while continuing to drink alcohol. He is currently complaining of nausea with right upper quadrant pain. His AST is 60 units/L and ALT is 45 units/L. Which of the following additional laboratory studies would be most helpful to the nurse when assessing his condition? (Select all that apply.)

Serum acetaminophen level plotted on a Rumack-Matthew nomogram.
Serum potassium to evaluate kidney function.
Toxicology screen to identify other substances ingested.
Prothrombin time and INR to identify coagulation abnormalities.
Urine screen for myoglobin to detect tissue damage.

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:
Liver transplantation is the only feasible treatment.
Abstinence from alcohol may decrease further liver cell injury and improve portal hypertension.
The liver is the only organ affected so that the patient and family need not worry about other body systems.

If the patient does not have any variceal hemorrhages he will probably live for years.

Which of the following are complications that a patient might develop in response to portal hypertension? (Select all that apply.)
Hepatomegaly
Slpenomegaly
Ascites and variceal hemorrhage
Atherosclerotic plaques
Portal system pressure 5 to 10 mm Hg

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

A physician has just performed a paracentesis, withdrawing 8 liters of fluid from a patient with ascites. Which of the following should the nurse do to monitor for development of the most common complication?
Monitor blood pressure at least every half hour until the patient is stable.
Review serum ammonia every 4 hours for the next 24 hours.
Review the chest film for evidence of a pneumothorax.
Take the patientʹs temperature every 2 hours to detect bacterial peritonitis.

Which of the following findings would be the most accurate way to assess the fluid status of a patient with ascites?
Abdominal percussion
Daily weights
Measurement of abdominal girths
Presence of peripheral edema

A patient with portal hypertension with hepatic encephalopathy has been started on a protein restricted diet. The patient asks why he is only being allowed a certain amount of meat. The nurse should explain that a reduced protein diet will:

Help to restore his liver function.
Help decrease the amount of ammonia in his blood.
Give his liver a chance to rest.
Prevent fluid from leaking into his abdomen.

A patient with esophageal varices is being treated with an esophageal tamponade (Blakemore) tube. Which of the following should receive the highest priority by the nurse taking care of the patient?
Ensuring that the gastric balloon remains inflated
Keeping a pair of scissors at the bedside at all times.
Keeping the patient sedated and quiet
Maintaining the esophageal balloon pressure between 15 and 20 mm Hg

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

Which of the following clinical manifestations experienced by a patient undergoing vasopressin (Pitressin) therapy for bleeding esophageal varices would indicate a serious adverse effect of the medication?
A pounding frontal headache
Midsternal chest pain
Abdominal cramping
Vertigo

A patient with esophageal varices has received an octreotide 100 microgram bolus and the nurse is preparing to start a continuous infusion of octreotide. The drug is diluted 500 micrograms in 250 mL NS. It is to be administered at 50 mcg/hour. How many milliliters per hour should a volume pump be set to provide the correct dose?

12.5 mL
25 mL
50 mL
100 mL

A nurse is caring for a patient during a transjugular intrahepatic portosystemic shunt (TIPS) procedure. Which of the following complications is most important for the nurse to assess during the procedure?
Alcohol withdrawal symptoms because minimal sedation should be used
Dysrhythmias as the catheter moves through the heart
Hypotension as the liver is decompressed
Vagal responses as the catheter is inserted

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 should:
Anticipate that the medication will stop the bleeding immediately in all patients.
Notify the physician if the patient has cardiac disease because the medication is contraindicated.
Recognize that doses of 100 mcg/hour and higher are associated with better outcomes.
Review serial hematocrits to determine if the patient is continuing to bleed.

Chapter 12 Care of the Patient with an Acute Gastrointestinal Bleed or Pancreatitis
A patient arrives in the emergency department with clinical manifestations consistent with a lower gastrointestinal bleed. Which of the following should the nurse assess to determine the patientʹs stability? The patientʹs:

Hemoglobin.
Hematocrit.
Vital signs.
Abdominal rigidity to determine the amount of blood being lost.

A nurse has completed a shift assessment on a patient who has been hospitalized for treatment of a lower gastrointestinal bleed. During the assessment the nurse notes that the patient has a capillary refill of 3 seconds, urinary output of 20 mL/hour, heart rate 88, and reports ʺfeeling tired.ʺ Which of these findings should the nurse report to the physician?

Capillary refill of 3 seconds
Urinary output of 20 mL/hour
Heart rate of 88 bpm
Reports of fatigue

An ED nurse is advised that a patient with a serious gastrointestinal bleed is en route via ambulance and the physician intends to initiate aggressive intravenous therapy. Which of the following solutions should the nurse anticipate would be utilized to manage this patientʹs condition?

Lactated Ringerʹs
D5W
0.9% NS
0.45% NS

A patient has been transferred to the nursing unit after stabilization in the emergency department for a gastrointestinal bleed. During the initial assessment, the nurse documents the following: Temperature 97.2°F, blood pressure 99/70 mm Hg, heart rate 74 bpm, capillary refill of 3 seconds, and oxygen saturation 94%. Four hours after admission to the unit, the nurse performs a second assessment and notes changes in the patientʹs condition. Which of the following changes is associated with complications from management of the condition? (Select all that apply.)

Temperature 98.2°F
Heart rate 98 bpm
Oxygen saturation 85%
Capillary refill of 2 seconds

The nurse caring for a patient with an active lower gastrointestinal bleed has taken the patientʹs vital signs. The findings are 97.0°F, HR 68, RR 30, and blood pressure 82/61 mm Hg. What positioning by the nurse will initially be most therapeutic?

Prone
Supine with the legs bent at the knees
Supine with the legs raised
Side lying with the head of the bed elevated to 30 degrees

The nurse has been assigned to provide care for a series of patients on the medical surgical unit. After reviewing the data exchanged during the shift report, which of the following patients should the nurse plan to assess first? The patient with:

An elevated temperature of 99.2°F and is complaining of nausea.
Complaints of feelings of fullness and has not had a bowel movement for 2 days.
A heart rate of 82 bpm, has complaints of fatigue, and had an episode of coffee ground emesis 4 hours ago.

Two episodes of melena diarrhea within the past 2 hours.

A patient is being prepared for an endoscopy to evaluate/diagnose an upper gastrointestinal bleed. In preparation the physician has ordered a nasogastric tube to be inserted. The patient questions why this is being done. What information should the nurse provide to the patient?

ʺYou need this to assist with placement of the ostomy tube.ʺ
ʺThe nasogastric tube will assist in the removal of blood clots that may limit the physician in seeing your esophagus.ʺ

ʺYour physician has left orders for placement of the tube.ʺ
ʺThe tube will reduce the likelihood of your vomiting during the procedure.ʺ

A nurse is assigned to provide care for a patient in the intensive care unit who had a colonoscopy 3 hours prior. The patient reports abdominal pain of 4 on a 5 point scale. During an assessment, the nurse notes that the patientʹs abdomen is rigid. Vital signs are: T 99.2, HR 94, R 28, and BP 98/69. What initial action by the nurse is indicated?
Assist the patient to turn to aid in relieving the flatus buildup.
Continue to observe the patient for additional changes in 15 minutes.
Notify the physician.
Medicate the patient for discomfort.

The nurse is preparing to administer pantoprazole (Protonix) to the patient. The patient asks the nurse for an explanation about the medication. Which of the following responses by the nurse is most appropriate?
ʺThe medication will reduce the pH of your gastric secretions.ʺ
ʺThe medication will provide a protective coating to your gastrointestinal system.ʺ
ʺThe medication is used to reduce the acid in your gastric secretions and reduce the chance of an ulcer.ʺ
ʺThe medication will eliminate any potential gastrointestinal infection you may have.ʺ

The nurse is completing the admission assessment on a patient being admitted for suspicion of an upper gastrointestinal bleed. During the interaction, the patient remarks that he does not believe he has a bleed because he does not have any significant pain. Which of the following would be the most appropriate way for the nurse to respond?

ʺSome patients have a high pain tolerance and are able to handle the condition better than others.ʺ
ʺPain is not a typical symptom of this condition.ʺ
ʺYou should share this with your physician next time you see him.ʺ
ʺYou must be in the early stages of the disease because pain does not occur until later.ʺ

A nurse is preparing a presentation for new graduates about pancreatitis. After attending the seminar, which of the following statements by a graduate nurse indicates the need for additional instruction? (Select all that apply.)

ʺPancreatitis is typically idiopathic.ʺ
ʺThere is only one single test finding that will diagnose pancreatitis.ʺ
ʺAn indication of pancreatitis is an elevation in serum amylase during the first 3 to 5 days.ʺ
ʺNecrotizing pancreatitis is a commonly occurring complication.ʺ
The risk of hypovolemic shock is very high with this disorder.

A patient presents to the physicianʹs office with complaints consistent with pancreatitis. During the history and physical, the patient indicates feeling ill for the past week. Which of the following tests will likely provide the most definitive diagnosis of pancreatitis?

Erythrocyte sedimentation rate
Serum lipase
Serum amylase
Complete blood count

The nurse is providing care for a patient with severe pancreatitis. Which of the following intravenous fluids should the nurse anticipate will be administered?
D5W
Lactated Ringerʹs
D51/2NS
0.9% NS

The patient with severe acute pancreatitis has had aggressive fluid replacement therapy. Which of the following assessment findings is indicative of successful management?
Oxygen desaturation
Elevated heart rate
Decreasing hematocrit
Reduced blood pressure

A patient with a blood pressure of 84/53 mm Hg and a heart rate of 61 bpm has been diagnosed with severe acute pancreatitis. Which of the following medications should the nurse anticipate will be ordered to manage this development?

Dopamine
Lasix
Hydrodiuril
Vitamin K injections

A patient with acute pancreatitis voices concerns that she will become addicted to the morphine prescribed for pain management. What response by the nurse is appropriate?
ʺYou must only take the medication when the pain is intolerable.ʺ
ʺYou may want to consider Demerol to manage your pain because it is less strong.ʺ
ʺAddiction during this period of acute pain is not likely.ʺ
ʺAddiction is a very real concern and should be considered when requesting medication.ʺ

A patient just diagnosed with acute pancreatitis asks when the physician will allow him to begin eating again. Which of the following responses by the nurse is most appropriate?
ʺYour physician will likely allow you to eat when the vomiting has subsided.ʺ
ʺYou will be able to have a soft diet within the next day or two.ʺ
ʺOnce your pain is in control and if your bowels are functioning normally, you will likely be able to begin a liquid diet.ʺ

ʺDuring this time, you will have to get your nutrition from tube feedings.ʺ

After being on a liquid diet for 3 days, the patient with acute pancreatitis has been advanced to a soft diet. The physician and nurse have provided education to the patient concerning the necessary dietary intake. Which of the following statements by the patient indicates understanding?

ʺI am going to have to increase the protein in my diet to at least 75% of my intake.ʺ
ʺThe largest component in my diet will be carbohydrates.ʺ
ʺIt is important that fiber account for 40% of my diet during this acute period.ʺ
ʺI am going to need to cut fats totally out of my diet to protect my pancreas during my recovery.ʺ

The nurse is assembling the equipment needed to begin caring for a patient with a gastrointestinal bleed who is hemodynamically unstable. What size of intravenous catheter would the nurse choose?
22-gauge 2-inch angiocath
18-gauge 1-inch angiocath
22-gauge butterfly
20-gauge 2-inch angiocath

The ICU nurse is caring for a patient with an active gastrointestinal bleed. The patientʹs vitals are BP 80/50 mm Hg, heart rate of 102 bpm, respiratory rate of 24, and oxygen saturation of 80%. The patient is currently receiving a large bolus of normal saline. The physician states that the patient is to receive a transfusion. What component of blood does the nurse anticipate the physician to order?

Whole blood
Packed red blood cells
Platelets
Fresh frozen plasma

The ICU nurse is reviewing the labs of a patient newly diagnosed with acute pancreatitis. Which lab values would the nurse expect to be elevated?
Amylase and lipase
Hemoglobin
Platelets
PT

The critical care nurse is admitting a patient with the diagnosis of acute pancreatitis. The nurse would expect to find the patient has a history of:
Alcohol abuse.
CHF.
Diabetes.
Asthma.

The nurse in the emergency department is assisting in the care of a patient with acute gastrointestinal bleeding. The patient has two large-bore IVs in place and is receiving 0.9% normal saline at 200 mL/hour in both IVs. What assessment findings would the nurse need to report to the physician immediately?

Crackles in both lung bases
Urinary output of 50 mL in 1 hour
Capillary refill of less than 2 seconds
Approximately 200 mL of coffee ground emesis

While preparing a patient for surgery, the patient asked the nurse, ʺWhy are they removing my gallbladder? I thought I had pancreatitis.ʺ What is the best response by the nurse?
ʺOnly the surgeon can answer that question.ʺ
ʺYou donʹt need to worry about the surgery. The surgeons know what they are doing.ʺ
ʺOne common cause of acute pancreatitis is stones in your gallbladder.ʺ
ʺYou said that you had gallbladder problems when you were admitted. The two are not connected.ʺ

The ICU nurse is assessing a patient with acute pancreatitis who is receiving morphine sulfate via a PCA pump. Besides the patientʹs verbal response to the pain scale, what objective assessment findings would the nurse expect if the patientʹs pain level is decreasing? (Select all that apply.)

Blood pressure increase
Pulse decrease
Blood pressure decrease
Facial grimacing
Slow, easy respirations

A client is admitted to the ICU with a diagnosis of acute pancreatitis. The ICU nurse understands that pain management is a priority for patients with this diagnosis. In preparing to educate the client and family regarding the proper use of a PCA pump, the nurse must include which information?

The client should only use the PCA pump when he is in severe pain.
The family may help the patient by ʺpushing the buttonʺ when they feel the patient is in pain.
The PCA allows the patient to administer smaller amounts of pain medication more frequently, which helps to get more effective pain relief.

The PCA delivers pain medication every time the button is pushed.

Chapter 13 Care of the Patient with Endocrine Disorders
The patient has an admitting diagnosis of diabetic ketoacidosis. Which of the following problems causes the cascade to diabetic ketoacidosis (DKA)?

Ketosis
Insulin deficiency
Hypoglycemia
Dehydration

The nurse is explaining the pathophysiology of hyperglycemic hyperosmolar nonketotic syndrome (HHNS). Which statement is most accurate? HHNS:
Is accompanied by severe metabolic acidosis.
Results in cellular overhydration and interstitial space dehydration.
Causes severe dehydration from very high osmolarity.
Causes a severe decline in glucose production, resulting in increased metabolic rates to burn fat for energy.

When comparing diabetic ketoacidosis (DKA) to hyperglycemic hyperosmolar nonketotic syndrome (HHNS), which statement is accurate?
DKA and HHNS are caused by too much insulin in the body.
No insulin is present in DKA, whereas some insulin is present in HHNS.
DKA results in metabolic acidosis; HHNS results in metabolic alkalosis.
Dehydration is greater or more severe in DKA than in HHNS.

Which statement is true regarding causes of hyperglycemic hyperosmolar nonketotic syndrome (HHNS)?
Certain antibiotics can induce HHNS in the person with type 2 diabetes.
Taking too much insulin during illness can induce HHNS.
HHNS can develop from missing meals, especially during illness.
HHNS can develop slowly from poor compliance to medical therapy.
When differentiating between diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar nonketotic syndrome (HHNS), which evaluation would be accurate?
Clients with DKA exhibit Kussmaulʹs respirations to blow off CO2 and reduce pH levels.
Clients with HHNS have lower arterial pH levels than those with DKA.
Clients with DKA have more visual disturbances than clients with HHNS.
Clients with HHNS have moderate hyperglycemia, whereas clients with DKA have more severe hyperglycemia.

The nurse has just received a serum osmolarity result of 325 mmol/L. Which of the following is the correct interpretation and action based on this result?
The result is somewhat high but no immediate action is necessary.
The result is very low and the physician should be notified of the result.
The result is somewhat low but no immediate action is necessary.
The result is very high and the physician should be notified of the result.

When planning care for the patient with diabetes in diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar nonketotic syndrome (HHNS), which goals would be included in the plan of care? (Select all that apply.)

To reestablish fluid balance through rehydration
To effectively treat the precipitating cause for DKA or HHNS
To stabilize blood glucose levels to within normal limits
To restore A1C blood levels to at or above 8%
To increase understanding of self-management to prevent future episodes

Which of the following nursing diagnoses would the nurse NOT use for the plan of care of a patient with diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar nonketotic syndrome (HHNS)?
Excessive fluid volume related to (RT) fluid shifts from hyperosmolarity
Imbalanced nutrition, less than body requirements RT inability to utilize glucose
Ineffective tissue perfusion RT hypovolemia and decreased peripheral blood flow
Risk for infection RT increased blood glucose and decreased peripheral blood flow

The nurse is caring for a newly admitted patient in DKA with serum sodium of 130 and serum glucose of 600. Calculate the corrected serum sodium (CSS). CSS = Serum Na+ + {[(Serum glucose (mg/dL) – 100)/100] × 1.6}. What IV fluid would the nurse expect to administer based on the findings?

D5 ½ NS
0.9 NS
0.45 NS
Lactated Ringerʹs (LR)

What should the nurse assess before beginning insulin therapy in a newly admitted patient with diabetes with hyperglycemic hyperosmolar nonketotic syndrome (HHNS)?
Sodium level (Na+)
Previous history of cardiac dysrhythmias
Potassium level (K+)
Arterial blood gas results

Which type of insulin would the nurse give for IV bolus or continuous IV infusion to regulate blood glucose levels?
Lantus
Lente
NPH
Regular

The nurse is caring for a newly admitted 80-kg patient with DKA. The nurse is preparing to administer the initial dose of insulin. Which dose and route of insulin would be expected?
8 units IV
12 units IV
8 units subcutaneous
12 units subcutaneous

When calculating the initial rate of an insulin infusion for a newly admitted 80-kg patient with DKA, the nurse would expect to administer IV insulin at what rate?
8 units per hour
12 units per hour
80 units per hour
120 units per hour

What is the rationale for decreasing serum glucose levels gradually (50-70 mg/dL/hour) in the presence of DKA/HHNS?
When blood glucose drops rapidly fluids shift out of the cell, which increases dehydration, causing severe hypovolemic shock.

When blood glucose drops rapidly severe damage to the brain results from metabolic alkalosis.
A rapid drop in blood glucose can result in hypokalemia, causing life-threatening arrhythmias.
A rapid drop in blood glucose can result in formation of thromboses as a result of dehydration.

Which of the following drugs contribute to hyperglycemia in the patient with diabetes? (Select all that apply.)

Inotropes such as digoxin
Sympathomimetics such as dopamine
Calcium channel blockers such as nifedipine
Thiazide diuretics such as hydrochlorothiazide/HCTZ
Glucocorticoids such as dexamethasone

A nurse caring for a patient with diabetic ketoacidosis (DKA) would evaluate the patient carefully for what potential complications? (Select all that apply.)
Acute respiratory distress syndrome
Cerebral edema
Pulmonary embolism
Myocardial infarction
Hyperchloremic metabolic acidosis

Which of the following statements explains the reason for seizure precautions in a patient with diabetic ketoacidosis (DKA)? The patient may be at risk for seizures because:

Potassium shifts may cause cerebral ischemia.
Intracellular fluid shifts may cause cerebral edema.
High blood glucose levels overstimulate brain cells.
Drugs used to treat the DKA have a side effect of seizures.

A newly admitted client with HHNK has serum glucose of 850 mg/dL and a potassium level of 3.9 mEq/L. An important nursing consideration that should precede replacement of potassium includes:
Assessment of urine output.
Assessment of lung sounds.
Assessment of dehydration.
Calculation of serum osmolarity.

A patient with type 1 diabetes who is ill is seeking advice from the nurse. The nurse would highly encourage the client to seek medical attention if the patient states: (Select all that apply.)
ʺI have had diarrhea for more than a day.ʺ
ʺI have been vomiting all night.ʺ
ʺI have had ketones in my urine for more than 4 hours.ʺ
ʺI have had a fever of 99 degrees all day.ʺ
ʺMy mouth feels very dry from the flu.ʺ

A nondiabetic client is admitted to the hospital with acute myocardial infarction and has a blood sugar of 180 mg/dL. What is the best explanation for a high glucose in a patient without diabetes? (Select all that apply.)
The physiological stress of a large meal plus a myocardial infarction causes hyperglycemia.
Myocardial infarction causes a physiological stress response that causes the body to enter a hypermetabolic state.

Insulin resistance is caused by beta blockers and nitroglycerin, which are commonly used to treat myocardial infarction.

Glucagon, cortisol, and epinephrine cause hyperglycemia.
Insulin resistance is caused by proinflammatory factors.

Which of the following is true about metabolic syndrome?
It is also called prediabetes
Fasting blood sugars are over 140 mg/dL
It has average A1C levels between 2% and 5%
It affects about 10% of the U.S. population

Which of the following is present in metabolic syndrome and is a risk factor for the development of diabetes?
Central obesity
Decreased triglycerides
Low LDL levels
Low insulin levels

An older client has been admitted to the hospital with pneumonia. He has signs of metabolic syndrome but denies the presence of diabetes. Serum glucose is 220 mg/dL and the hemoglobin A 1C is 5%. Which of the following can be induced from these findings?

The nurse should anticipate discharge teaching related to insulin to manage blood sugars at home.
The nurse anticipates that the doctor will diagnose the patient with type 2 diabetes.
The nurse anticipates that the doctor will diagnose the patient with type 1 diabetes.
The nurse would anticipate treatment with sliding scale insulin even though diabetes is not yet evident.

The certified diabetes educator (CDE) has encouraged a patient with metabolic syndrome who experienced hyperglycemia during hospitalization to attend outpatient diabetes education classes. The patient is questioning why he would attend these classes when he does not have diabetes. What is the nurseʹs best response?

ʺYou will learn about healthy diet, weight management, and exercise. This knowledge can delay the onset of type 2 diabetes.ʺ

ʺThe certified diabetes educator (CDE) saw that you had high blood sugars while in the ICU. I will let her know that you are not diabetic.ʺ

ʺIf you maintain a healthy diet, correct weight, and exercise you can delay the onset of type 2 diabetes.ʺ
ʺThe class is only for those with diabetes. If you become diabetic you may attend the class.ʺ

A patient is admitted with cellulitis. On admission the hemoglobin A1C revealed that the patientʹs average blood sugars prior to admission were 300 mg/dL. The client has been started on insulin in addition to oral diabetes medications. Which teaching point is essential for this client to understand before discharge? ʺIt will be important for you to:

Decrease your weight in order to decrease your hemoglobin A1C.ʺ
Eat for 60 minutes each morning after taking your insulin.ʺ
Change the types of carbohydrates you eat to complex carbohydrates.ʺ
Use the glucose meter to check your blood sugars before you take your insulin.ʺ

Chapter 14 Care of the Patient with Acute Renal Failure

Of the following clients in an intensive care unit, who would be at highest risk for the development of acute renal failure with a prerenal cause? A client who is:
Experiencing acute status asthmaticus.
Being treated for hypertension following a cerebral vascular accident.
In skeletal traction following a motor vehicle accident.
Postoperative from a ruptured abdominal aortic aneurysm.

The critical care nurse is aware that the drugs that have been implicated in the development of renal failure include: (Select all that apply.)
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Aminoglycosides
Contrast media
Antiseizure medications
ACE inhibitors
Cyclosporine

The nurse is aware that intrarenal, or intrinsic renal, failure can be caused by which of the following? (Select all that apply.)
A client with rheumatoid arthritis using high-dose NSAIDs
The individual on levothyroxine (Synthroid) following thyroidectomy
Long-term vancomycin for treatment of osteomyelitis
A young adult undergoing chemotherapy for testicular cancer
Contrast media given intravenously during diagnostic imaging
Acyclovir (Zovorax) prescribed for treatment of genital herpes

A patient in the ICU is reported to be in the oliguric phase of intrinsic renal failure, which is reflected by:
The patient excreting less then 400 mL of urine/day.
BUN and creatinine that may begin to increase slightly.
Urinary output increase, producing up to 5 liters of urine each day.
Abnormal lab values lasting from 6 months to a year in duration.

The expected lab value for a client with prerenal dysfunction, in contrast to intrarenal, would be which of the following?
Urine osmolality of 200 mOsm/L
Urine osmolality of 550 mOsm/L
Urine sodium greater than 40 mmol/L
Presence of granular casts and sediment

A client is experiencing prerenal failure secondary to hypovolemia. The nurse reviewing the clientʹs lab work and vascular pressures would expect to see which of the following results? (Select all that apply.)
Low CVP or PAWP pressures
BUN of 65 mg/dL
Serum creatinine of 3 mg/dL
Creatinine clearance of 50 mL/min/1.73m2

BUN-creatinine ratio greater than 20:1
Urine with granular casts and sediment

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

To evaluate the intended effect of administering a fluid challenge to an 80-year-old patient in critical care, the nurse would expect which of the following clinical signs to be present?
A systolic blood pressure of 120 mm Hg or less
Heart rate remaining steady at 60 to 70 beats per minute
Skin turgor showing improvement within 24 hours
A MAP of 100 mm Hg

Which of the following orders would the nurse seek clarification for regarding the patient with decreased renal perfusion and lowered glomerulo-filtration rate?
Administer acetylcysteine prior to an intravenous pylogram procedure
Infuse vancomycin 1500 mg IV every 12 hours
Check a peak and trough level with every third dose of IV clindamycin
Give furosemide 10 mg po daily

A patient has been placed on a 1000-mL fluid restriction over 24 hours. Choose the plan that reflects how the critical care nurse would typically divide this amount.
350 mL for dayshift, 325 mL for evening shift, and 325 mL for nightshift
400 mL for dayshift, 400 mL for evening shift, and 200 mL for nightshift
500 mL for dayshift, 325 mL for evening shift, and 125 mL for nightshift
600 mL for dayshift, 200 mL for evening shift, and 200 mL for nightshift

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

To test for a positive Trousseauʹs sign indicating hypocalcemia, the nurse would need which piece of equipment?
Percussion hammer
Penlight
Blood pressure cuff
Doppler

The typical dietary plan for a patient with ARF would focus on provision of:
High fat, low protein.
High carbohydrate, low protein.
High protein, low sodium.
High calorie, low carbohydrate.

The nurse would develop which of the following as the best nutritional goal for the patient with ARF?
Weight will increase by 3 pounds in a month.
Patient eats over 50% of all meals.
Albumin level will rise from 2.6 g/dL.
Total protein level will increase to 10 g/dL.

The intensive care nurse has explained to a patient with ARF why the physician has chosen hemodialysis rather than peritoneal dialysis, which the patient strongly prefers. Further teaching is necessary when the patient makes which statement regarding the disadvantages of peritoneal dialysis?

ʺItʹs not speedy enough to remove the wastes.ʺ
ʺIt may worsen my breathing problems.ʺ
ʺIt cannot be used for elderly patients like me.ʺ
ʺItʹs not nearly as efficient as hemodialysis.ʺ

Which of the following patient situations results in the highest risk for development of dialysis disequilibrium syndrome?
Peritoneal dialysis provided in a home environment
Patient who received an ACE inhibitor prior to hemodialysis
A known history of long-term substance abuse
Patient undergoing first hemodialysis treatment

For the patient with an AV fistula in the forearm for hemodialysis, appropriate nursing care includes which of the following measures?
Percussing the fistula for presence of a bruit each shift
Taking the blood pressure in the unaffected arm
Positioning the patient so there is pressure on the access
Flushing the fistula with heparin every shift

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

The intensive care nurse is reviewing a patientʹs chart with a new graduate and emphasizes that the most accurate indicator of fluid volume status is:
Intake and output.
Daily weights.
Hematocrit level.
Systolic blood pressure.

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

The nurse preparing to administer peritoneal dialysis would have which responsibility in contrast to hemodialysis?
Knowing the patientʹs dry weight prior to beginning
Monitoring for changes in vital signs
Inspecting the tunneled catheter for infection
Suggesting a low-Fowlerʹs position for comfort

To assist with the common complication of hypotension for the patient undergoing continuous renal replacement therapies, the nurse could implement which of the following? (Select all that apply.)
Infuse 0.9% sodium chloride boluses.
Administer albumin.
Decrease the rate of ultrafiltration on the dialyzer.
Administer mannitol.
Place the patient in a High Fowlerʹs position.
Discontinue the dialysis for several days.

The primary nursing diagnosis associated with dialysis disequilibrium syndrome would be:
Infection.
Altered thought processes.
Fluid volume deficit.
Anxiety.

The critical care nurse is providing an in-service 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:

Ultrafiltration.
Diffusion.
Active transport.
Osmosis.

Chapter 15 Care of the Organ Donor and Transplant Recipient
A nurse recognizes that he may need to advocate for organ donation because:
The supply of donor organs meets the demand of potential recipients.
Organ recipients are not expected to have a long life span because of complications associated with the transplant.

The organ recipient usually enjoys a better quality of life at less cost to the health care system.
The organ recipient is often confined by frequent health care visits in order to maintain health.

Which of the following is the best description of an antigen?
Antigens are recognized by the body as foreign or nonself.
The presence of HLA antigens means that the recipient cannot receive an organ.
A recipient may have antihuman antigens that would react with a donated organ.
An organ can only be transplanted if the potential donor and recipient antigens completely match.

Which of the following correctly describes which recipients can receive an organ from which donors?
Recipients with blood type O are universal recipients.
Recipients with blood type A can receive donations from donors with blood types A, AB, and O.
Recipients with blood type B can receive donations from donors with blood types A, B, and O.
Recipients with blood type AB can receive an organ from any donor blood type.

What percentage of organ donors are living organ donors?
20%
30%
40%
50%

Which of the following patients would potentially be a good candidate for an organ donation?
A 25-year-old who is 28 weeks pregnant and has a severe traumatic head injury
A 30-year-old who was healthy before overdosing with barbiturates
A 45-year-old with a small primary lung carcinoma
A 55-year-old with intracranial pressure from a primary intracranial tumor

When assessing a patient, the nurse knows that which of the following is NOT a cardinal sign of brain death?
Apnea
Decorticate posturing
Unresponsiveness
Absence of brainstem reflexes

The nurse must notify the organ bank when:
Death is imminent in all cases.
Death is imminent and an organ donation card or the back of the driverʹs license indicates that the person wanted to donate his organs.

Death is imminent and the family consents to organ donation.
The nurse assesses that the family can be approached about organ donation.

Who is the best person to approach a family about organ donation?
The doctor
The nurse
The organ procurement specialist
A member of the clergy

Which of the following would best describe the role of the critical care nurse in the organ donation process? To:

Talk about the benefits of organ donation to the family.
Reinforce the explanation of brain death after the doctor has talked to the family.
Answer questions about financial concerns related to organ donation.
Let the organ procurement nurse take over the care of the patient and family.

If the patientʹs urine output is greater than 200 mL/hour and hemodynamic stability cannot be achieved by using fluids and vasoactive medications, the nurse anticipates that the following drug may be helpful. A:
Beta blocker such as Lopressor.
Diuretic such as furosemide.
Concentrated sugar such as 50% dextrose.
Hormone such as vasopressin.

A patient is a candidate for organ donation. A pulmonary artery catheter has been inserted to help maintain hemodynamic stability. Which of the following findings shows that the patient has adequate hemodynamic stability?

CVP 5 and PCWP 12
CVP 6 and PCWP 10
CVP 4 and PCWP 14
CVP 3 and PCWP 8

A candidate for organ donation has developed diabetes insipidus. Which of the following assessment findings should the nurse expect in this situation?
Large urine output and low urine specific gravity
Low urine output and high serum sodium
High urine specific gravity and high serum glucose
Large urine output and low serum sodium

Which of the following collaborative interventions is important when the nurse is caring for a potential lung donor in order to ensure that the lungs remain suitable for transplant?
Maintaining the FiO2 at 98% to 99%
Avoiding excess fluid replacement
Avoiding frequent suctioning of the donorʹs endotracheal tube
Maintaining the donorʹs oxygen saturation at 80%

A patient wants to donate organs after cardiac death. One hour after the withdrawal of life support the patient continues to breathe shallowly and has a slow heartbeat. What is the nurseʹs most appropriate response?
Call the patientʹs doctor to reintubate the patient.
Update the organ retrieval team that death is imminent.
Maintain hemodynamic stability to perfuse the donorʹs organs.
Allow death to occur naturally without organ donation.

A patient has become a candidate to donate organs in Town A. Based on the UNOS priority system, which potential recipient would be the best candidate to receive a kidney transplant?
A patient on dialysis who lives in Town A and has been on the transplant list for 3 years
A patient with acute renal failure, the same blood type, and all matching antigens who lives in Town A
A patient on dialysis with compatible blood type and six matching antigens who lives in Town B (60 miles away)

A patient on dialysis who lives in Town B (60 miles away) and has been on the transplant list for 4 years

Potential liver recipients are assigned a MELD score to determine the priority to receive a liver transplant. The MELD score is based on which of the following criteria?
Time on the transplant list, INR, and bilirubin
Serum creatinine level, INR, and bilirubin
Quality of antigen match, AST, and ALT
Severity of illness, AST, ALT, and bilirubin

A patient presented to the transplant clinic with signs of organ rejection 3 months following a kidney transplant. This would best be classified as what type of rejection?
Acute rejection
Accelerated rejection
Hyperacute rejection
Chronic rejection

A patient developed signs of rejection to a liver transplant within the first week of receiving the organ. The patient is asking about the possibility of organ failure. What is the nurseʹs most appropriate response to this patient?

ʺYou are receiving medications to prevent the rejection. We will continue to do everything to treat the rejection and keep you informed of what is happening.ʺ

ʺAs long as you continue to take your medications to prevent the rejection, everything should be OK with your new liver. I will call the chaplain to visit with you.ʺ

ʺAlthough you are receiving medications to prevent the rejection, most people in your situation end up losing their new liver.ʺ

ʺPlease donʹt worry about rejection right now. You have a new liver and we will give you the medications that you need to treat the rejection.ʺ

Mr. S received a kidney transplant and is taking daclizumab (Zenapex). He has developed a fever and chills with joint pain. What action should the nurse take?
Call the doctor immediately and expect orders for Benadryl to treat the drug allergy.
Communicate the reaction to the doctor, and expect to hold the medication for 24 hours and then resume it.

Continue to give the medication as scheduled and communicate the reaction to the doctor.
Call the pharmacy for a suggestion regarding another medication that the patient could take.

A nurse should include which of the following when providing discharge instructions for a patient post kidney transplant?
ʺYour diet should be high in protein and low in carbohydrates.ʺ
ʺWeigh yourself once a week and notify your physician of any weight gain.ʺ
ʺYou should avoid exercise such as walking for the first week post-op.ʺ
ʺContact the transplant center if your cardiologist changes your heart medications.ʺ

Which of the following are early signs of chronic rejection of a transplanted kidney?
Protein in the urine and decreased urine output
Protein in the urine and high blood pressure
Decreased urine output and increased glomerular filtration rate (GFR)
High blood pressure and ketonuria

How is rejection of a heart transplant usually assessed?
Repeated heart biopsies to assess for myocyte damage or necrosis
Signs of chest pain or pain, numbness, or tingling in the left arm
2D echo to assess heart function and left ventricular ejection fraction
Signs of heart failure such as sudden weight gain, shortness of breath, and rales on auscultation of the lungs

Which of the following interventions is most important to include in the multidisciplinary plan to prevent infection during the early post-transplant period?
Continuing the administration of antibiotics 10 to 14 days post -op
Encouraging the patient to ambulate and use an incentive spirometer
Keeping the patient on contact precautions for at least 1 week
Providing vaccination against the flu virus

A patient comes to the clinic 3 months post transplant with a sore mouth and throat and trouble eating. Upon assessment the nurse sees white patches on the mucous membranes. This patient has probably developed what opportunistic infection?

Cytomegalovirus (CMV)
Epstein-Barr virus
Candidiasis
Staphylococcal pneumonia

A patient has started taking corticosteroids for immune suppression following transplantation. Which of the following are important nursing instructions to the patient? (Select all that apply.)
Take this medication one hour before, or 2 hours after eating.
Increased thirst and urination may occur, but should be reported immediately.
Mood swings are common when taking this medication.
You may have a deceased appetite and loose weight while on this medication.
Your face may have a full or round appearance after taking this medication.

Chapter 16 Care of the Acutely Ill Burn Patient

The nurse providing an overview of burns to a community group would teach the causes for thermal burns. These causes would include: (Select all that apply.)

Exposure to hot liquids.
Friction injuries.
Being splashed with drain cleaner.
Stepping on hot charcoal.
Contact with steam.
Low-voltage household current.

The nurse is explaining to the granddaughter of an 85 -year-old woman that elderly persons are at greater risk for scalding by hot water due to:
This age groupʹs adversity to taking showers.
An inclination to test the waterʹs temperature.
Overall slower reaction time.
Loss of elasticity of skin tissue.

A patient rescued from a small house fire is brought to the emergency department. There is no burn injury to the patientʹs skin. Lab results show the only abnormality as a CO level of 22%. Which intervention would the nurse expect to implement?

Administer high-flow nebulizer treatment.
Infuse a fluid bolus of lactated Ringerʹs solution.
Begin a sodium bicarbonate drip.
Give 100% oxygen by mask.

The critical care nurse is aware that the depth of burn injury is determined by the depth of tissue destruction and what other factors? (Select all that apply.)
The cause of the burn
Additional chronic medical conditions
Temperature of the burning agent
Skin thickness
Body part of the burn injury
Duration of the burn exposure

In assessing a first-degree burn, the nurse would consider which of the following assessments to be accurate?
The involved skin is deep reddish-brown in color and edematous.
Blisters begin to form on the skin within the first hour of exposure.
The skin remains intact because only the epidermal layer is involved.
Scarring can be minimized if treatment is sought immediately after injury.

In assessing zone of coagulation of a third-degree burn injury, the nurse would be alert for:
The presence of pain.
Brisk capillary refill.
Surface of the wound that is dry and firm.
A bright red wound color.

A patient comes to the emergency department with thermal burns to the left arm and shoulder. Which of the following findings requires immediate attention?
Complaint of excessive thirst
Loss of range of motion to the affected side
Pain rating of ʺ8ʺ on a 1 to 10 scale
Presence of coughing and hoarseness

Which of the following would present the greatest risk for an inhalation injury? The patient:
With a second-degree electrical burn of the hand.
Trapped on an elevator during a fire in a building.
With asthma who has extensive first-degree sunburn.
With a scalding injury from liquid splashed on the legs.

A patient in ICU with a burn circling the left upper leg suddenly experiences excruciating pain, pallor in the lower extremity, and loss of pedal pulse. The nurse would immediately notify the physician that this patient has developed which of the following?

A deep vein thrombosis
Inability to perform ADLs
Nosocomial infection
Compartment syndrome

Which of the following statements is accurate in relation to skin changes following a large burn?
Regulating body temperature returns with healing.
Healed burn areas are more susceptible to mechanical injury.
Sensory perception never returns once healing of a burn is complete.
Vitamin D from sun exposure does not facilitate the healing process.

An alert patient at the scene of an explosion has a respiratory rate of 24 breaths per minute, a faint stridor, and soot on his face. His heart rate is 120 beats per minute. Which of the following actions would be most appropriate to implement first?

Administering humidified oxygen
Placing him on a cardiac monitor
Inserting a large-bore angiocath
Prophylactically intubating the patient

Following establishment of an airway, adequate breathing, and circulation, the nurse would focus next on which of the following assessments following a burn injury?
Determining total body surface area of the burn
A quick check of neurological status
Psychological trauma resulting from the incident
Details of how the injury occurred

The burn unit nurse teaches a new orientee of priority nursing actions during the resuscitation phase of burn management. Which statement made by the inexperienced nurse indicates a need for further teaching?
ʺWe should promote an increased oral fluid intake.ʺ
ʺA urinary catheter is usually inserted.ʺ
ʺIʹll get a nasogastric tube and suction equipment ready.ʺ
ʺAll patients should have a large-bore IV access if possible.ʺ

A middle-aged man who weighs 220 pounds incurred burns to 40% of his total body surface area. Using the Parkland formula, calculate his fluid resuscitation needs for the first 24 hours.
1,600 mL
16,000 mL
3,520 mL
35,200 mL

The nurse is aware that the goal for initial burn wound management includes which of the following actions? (Select all that apply.)
Decrease fluid and electrolyte loss
Promote physical/psychological comfort
Prevent infection
Reduce the degree of scarring
Decrease the risk of developing compartment syndrome

A patient is complaining of increased pain to a third-degree burn covering the entire arm. The nurse suspects compartment syndrome. Which of the following treatments should the nurse immediate prepare in treating this?

Transporting the patient to the whirlpool
Applying multiple ace wraps over the current gauze dressing
An escharotomy performed by the physician
Skin grafting performed by the physician

Choose the statement that is accurate related to skin covering procedures for burn patients.
Autografts are permanent skin replacement for burns.
Meshed autografts are used for the face and hands.
Tissue typing is necessary for use of an allograft.
Cultured autologous epithelial cells provide a temporary wound covering.

In preparing a patient for the rehabilitation phase of burn management, which statement reflects understanding of discharge teaching following a 6-month hospitalization?
ʺI need to begin cutting back on calories to avoid weight gain.ʺ
ʺI should have regular osteoporosis screening.ʺ
ʺI will likely not tolerate cold weather anymore.ʺ
ʺI must avoid getting a flu shot this year.ʺ

The nurse has reviewed plans for wound and scar management for the rehabilitation phase following an extensive burn. The nurse explains that the various complications that can occur over time include which of the following? (Select all that apply.)

Contractures
Neuropathies
Heterotopic bone ossification
Hypertrophic scarring
Wound breakdown
Osteomyelitis

An 80-year-old male is admitted for 39% TBSA burns. The nurse would assess for which of the following risk factors that apply to this patient? (Select all that apply.)
Higher sensitivity to pain
Thinner skin
Delay seeking treatment
Impaired vision
Concurrent respiratory problems

Preexisting health conditions influence how the older adult responds to the resuscitative treatment for injury. The priority consideration in caring for the older adult for the nurse would be:
Calculating nutritional needs.
Coordinating physical therapy.
Managing pain.
Fluid resuscitation.

The intensive care nurse is assessing for cardiovascular system changes related to burn injury. Which of the following is associated with burn injury? (Select all that apply.)
Hypertension
Altered capillary refill
Peripheral extremity vascular compromise
Hypovolemic burn shock

A patient is experiencing high levels of anxiety following a house fire. The nurse would administer which of the following medications for assistance?
Fentanyl
Lorazepam
Hydromorphone
Sertraline

A nurse plans a burn prevention program for older persons at a neighborhood association meeting. The visual aid developed by the nurse to emphasize the most common cause of burn injuries in the elderly would be which of the following?

A lit cigarette
A bathtub of hot water
Pots and pans on a stove
Frayed electrical wires

During the acute phase of burn injury, the patient has the risk of developing complications. The nurse would assess for the presence of:
Hypovolemic shock.
Septic shock.
Wound scarring.
Urinary tract infection.

Chapter 17 Care of the Patient with Sepsis

Which of the following statements is true about sepsis?
Mortality rates from sepsis approached 70% worldwide in 2001.
If managed early and aggressively, the majority of patients with sepsis may be managed outside of the ICU environment.

The guidelines provided by the Surviving Sepsis Campaign (2004) are expected to decrease the incidence of sepsis by the year 2010.

Sepsis rates rise sharply with age.

Two of the most common sources of infection that lead to sepsis in a patient over the age of 65 include:
Pneumonia and urinary tract infections.
Skin infections and diabetes.
Surgical incisions and abdominal wounds.
Traumatic wounds and abdominal surgeries.

Which evidence-based intervention would the nurse use to prevent pneumonia in the patient receiving mechanical ventilation?
Aseptic technique when performing oral hygiene
Administration of an H2 antagonist to prevent peptic ulcers
Elevation of the head of the bed to 15 degrees to prevent aspiration
Changing the ventilator circuit daily

Which one of the following accurately describes the purpose of sedation vacation in the prevention of ventilator-associated pneumonia?
The vacation from sedation relieves stress, which decreases the chance of infection.
During sedation vacation the patient has a chance to take deep breaths and improve ventilation while more awake.

The patientʹs own tidal volume and respiratory rate can be evaluated during sedation vacation.
New data show that sedation vacation is no longer recommended because there is concern about the safety of interrupting sedation.

Which of the following is accurate about catheter-related infections?
Statistics report that as many as one in five individuals who develop a catheter-related infection die from it.

Nosocomial catheter-related infections prolong hospitalization by an average of 4 days.
The increased cost of care due to the development of a bloodborne infection averages between $1,700 and $17,000.

Central venous catheters have about the same rate of infection as peripherally inserted catheters.

Which of the following is true regarding the bundle of measures used to prevent nosocomial catheter -related infections?
Chlorhexidine is most effective when swabbed starting at the insertion site and moving outward from the site in a circular motion.

It is recommended that transparent dressings be changed every 72 hours to prevent growth of bacteria on the skin.

Current recommendations support changing IV tubing every 48 hours on patients at risk for catheter-related infections.

During insertion of a central line the doctor should wear a cap and mask, sterile gloves, and a gown, and the patient should have a full body drape.

The nurse is evaluating a patient for the presence of systemic inflammatory response syndrome (SIRS). In which of the following do all measurements define SIRS?

Temperature 36.4°C, respiratory rate 22, pulse rate 112, and PaCO 2 34
Temperature 38.4°C, respiratory rate 23, pulse rate 92, and PaCO 2 31
Temperature 37.2°C, respiratory rate 24, pulse rate 102, and PaCO 2 44
Temperature 38.8°C, respiratory rate 25, pulse rate 88, and PaCO 2 48

The nurse is assessing the patient for severe sepsis. Which of the following is the best description of severe sepsis?
Decreased capillary filling and mottling
Fever and decreased urine output
Hypotension and lactic acidosis
Increased glomerular filtration rate and increased D-dimer levels

Which of the following hemodynamic parameters would the nurse expect to see in the patient with septic shock?
Central venous pressure (CVP) 4 mm Hg, pulmonary artery pressure (PAP) 30/15 mm Hg, and systemic vascular resistance (SVR) 1200 dynes/sec/cm-5

Central venous pressure (CVP) 8 mm Hg, pulmonary artery pressure (PAP) 26/10 mm Hg, and systemic vascular resistance (SVR) 1000 dynes/sec/cm-5
Central venous pressure (CVP) 2 mm Hg, pulmonary artery pressure (PAP) 20/8 mm Hg, and systemic vascular resistance (SVR) 800 dynes/sec/cm-5

Central venous pressure (CVP) 6 mm Hg, pulmonary artery pressure (PAP) 40/20 mm Hg, and systemic vascular resistance (SVR) 700 dynes/sec/cm-5
The nurse is assessing the patient for septic shock. Which of the following is the best description of septic shock?
Sepsis with hypotension that does not correct itself when a fluid challenge is administered
Sepsis with hypotension accompanied by decreased protein C levels and coagulation abnormalities
Sepsis with hypotension accompanied by increased creatinine and absent bowel sounds
Sepsis with hypotension accompanied by altered mental status and lactic acidosis

Which of the following statements is true about serum lactate? Serum lactate is elevated in sepsis as a result of:
Increased systemic inflammation.
The endogenous by-products of bacterial contamination.
Anaerobic cellular metabolism.
Greatly accelerated coagulation.

Which of the following is true regarding the administration of antibiotics in a patient with sepsis?
Antibiotics should be administered as soon as the patient has received a fluid bolus.
Antibiotics should always be administered after blood cultures are obtained.
If antibiotics are administered within the first 12 hours of hospital admission, mortality decreases by as much as 8%.

Choices of specific antibiotics are often limited by the patientʹs liver and renal function.

The goal of antibiotic therapy is to narrow the therapy to one narrow-spectrum antibiotic. What is the one rationale behind this statement?
The use of one antibiotic ensures that the prescribed dose will result in serum concentrations that are clinically effective.

The use of one antibiotic has been shown to cause less organ dysfunction.
The use of one antibiotic reduces mortality in patients with sepsis.
The use of one antibiotic limits the cost to the patient.

The best description of the overall goal of providing fluid resuscitation and vasopressors to the patient in septic shock is to:
Increase the systolic arterial pressure.
Provide adequate vasoconstriction.
Increase tissue perfusion.
Increase the metabolic rate.

Which of the following is the best description of SvO2 monitoring in septic shock?
A SvO2 of 65% shows that the oxygen demand of tissues is exceeding the oxygen supply.
A SvO2 of 95% or above shows normal oxygen supply and demand.
A SvO2 of 70% is adequate to deliver oxygen to body organs and tissues.
A decrease is the SvO2 shows that more oxygen is returning to the lungs before being metabolized.

Dobutamine is often used at a moderate or high dose to improve the patientʹs hemodynamics. The nurse knows that this medication is used because:
It decreases systemic vascular resistance and increases perfusion to organs.
It has no effect on systemic vascular resistance but improves oxygenation.
It decreases the heart rate and increases oxygen delivery to the tissues.
It increases systemic vascular resistance and improves hemodynamics.

Which of the following is accurate about the sepsis management bundle?
When all elements of the sepsis management bundle are used survival is prolonged.
The sepsis management bundle has not received uniform support.
The purpose of the sepsis management bundle is to improve the patientʹs hemodynamics within 4 hours.
The Surviving Sepsis Campaign recommends universal use of each of the elements of the sepsis management bundle to decrease mortality.

Steroids may be given by continuous infusion rather than in divided doses. What is the best rationale for this method of administration?
Recurrent septic shock is less common when steroids are given continuously.
Normoglycemia is maintained when steroids are given continuously.
Vasopressor therapy can often be reduced when steroids are given continuously.
Immunosuppression is reduced when steroids are given continuously.

The nurse knows that the use of human recombinant activated protein C is contraindicated when the patient:
Has invasive lines in place.
Has low platelets.
Had a CABG 1 year ago.
Has a history of cerebral aneurysm.

Which of the following is true regarding the use of human recombinant activated protein C?
One study showed decreased mortality of up to 13% in patients who received human recombinant activated protein C.

The use of human recombinant activated protein C significantly improves the risk of bleeding.
Overall mortality rates have been lower than those reported in clinical trials in those who have received human recombinant activated protein C.

The cost of human recombinant activated protein C is too high to support its use.

Management of the patient with sepsis might include which of the following measures?
The patient on the ventilator should have high tidal volumes to prevent adult respiratory distress syndrome (ARDS).

The blood glucose should be less than 150 mg/dL.
An infected wound should be stabilized and debrided after the patient has had antibiotics for 24 hours.
CT and MRI scans should be avoided until the patient is stable.

Which of the following is true regarding the use of a cooling blanket to help reduce fever in a patient with sepsis?
A cooling blanket is often considered when the patientʹs temperature reaches 103°F.
Shivering should be avoided because it causes a decreased metabolic rate.
The nurse can prevent shivering by keeping the patientʹs hands and feet on the cooling blanket.
Sedation should be avoided during the use of the cooling blanket because it masks potential shivering.

In order to meet the patientʹs nutritional needs during a critical illness with sepsis, the nurse knows that:
TPN is the preferable means to administer nutrition to the patient with sepsis.
Nutritional needs are usually addressed after 72 hours in order to conserve the patientʹs energy expenditure.

Enteral feedings are often avoided because hyperglycemia often results from feedings.
Enteral feedings prevents translocation of bacteria from the gastrointestinal tract.

Which of the following is the best description of the pathophysiology of multiple organ dysfunction syndrome (MODS) as it relates to sepsis?
The primary cause of MODS is decreased blood pressure.
Endothelial dysfunction is a primary cause of MODS.
Increased microvascular bleeding causes MODS.
Circulating pathogens cause destruction of organs, resulting in MODS.

The nurse is evaluating the patient with sepsis for the development of disseminated intravascular coagulation (DIC). Which of the following is a sign that the patient may have developed this complication?
Ecchymoses of the gums or skin
Resistance when flushing a capped port of a central venous catheter
A reduction in the D-dimer
Increased fibrinogen levels

Chapter 18 Caring for the ICU Patient at the End of Life
The ICU nurse caring for a patient at the end of life understands that ʺlimitationʺ of care refers to a decision:
To stop all measures, including pain medication.
To exclude all but immediate family members from the patientʹs room.
Not to initiate one or more interventions.
To stop one or more therapies after they had been initiated.

According to Copnell (2005), the decision not to start needed dialysis treatment on a patient in ICU would fall under which category of ICU deaths?
Failed CPR
Withdrawal
Brain death
Limitation

A nurse might elect to have a family present during CPR because it is likely to have which of the following benefits? (Select all that apply.)
The family may realize the seriousness of the patientʹs illness and understand the gravity of the situation.
The family may provide comfort and support to the patient.
Fewer lawsuits occur when the family members see the care given by the health care team.
Staff are reminded of the patientʹs personhood.
The family can understand the expenses needed with the multitude of equipment used in critical care.

When planning to allow a family to be at the bedside during CPR, the nurse should anticipate which of the following possible outcomes based on reports from post-CPR patients?
The family will be unhappy after seeing the pain and suffering caused by CPR.
The patient will feel comforted and supported by his familyʹs presence.
The family will be overwhelmed by the confusion and busyness of the events.
The patient will be frustrated because he cannot speak to his family.

Which of the following does the nurse have a legal responsibility to prevent if family members are present while CPR is delivered to a patient?
Post-traumatic stress syndrome of family members from viewing CPR
Breach of confidentiality about the patientʹs medical information during CPR
Family vendetta for perceived unskilled or less efficient staff during CPR
Patientʹs lack of privacy and physical exposure during CPR

When using the mnemonic ʺin-or-outʺ as a guideline for evaluating family presence during CPR, the nurse would expect what discussion to be performed during the ʺRʺ step?
Identify the relationship to the patient and the family decision maker.
Explain the rationale for health outcomes and management options.
Assess the familyʹs reason for wanting to be present in the room.
React to data collected during the family discussion.

When caring for a bereaved family member, the nurse would understand which of the following actions is inappropriate? The nurse should NOT:
Offer privacy and a listening ear to the family before speaking.
Avoid technical, hospital, or medical terminology when explaining conditions or treatments.
Offer clichés, such as ʺshe lived a good life,ʺ to make the family feel better.
Use direct eye contact and offer comfort by touching.

When explaining ʺbrain deathʺ to a family member, the nurse should say which of the following? Brain death is:
Damage to the brain so extensive that the brain is no longer functional and function cannot be restored by medical therapies.

Brain tissue that is lacking blood supply so it cannot perform some of its normal functions.
Electrical malfunction of brain tissue so that it does not control breathing properly.
When one lobe of the brain is traumatized or bruised and is trying to repair itself.

Which of the following findings would be one of the indications of brain death?
Absence of all motor responses to noxious stimuli
No respiratory effort when the patient is off the ventilator for 4 minutes with a pCO 2 of 49
Cough reflex that is present with nasotracheal stimulation
Pupils that are 3 mm and respond to light

Which reflexes can the nurse assess to determine the lack of brainstem response? (Select all that apply.)
PERLA
Oculocephalic
Oculovestibular
Corneal
Moro

When attempting to establish a relationship and enter a dialogue with the family of a dying patient, the nurse should:
Begin by saying, ʺI know exactly how you must be feeling.ʺ
Demonstrate respect for the family by saying, ʺIʹm impressed with how involved you have been with the patient during his illness.ʺ

Identify with the family when they have concerns by saying, ʺI have questioned how a physician could believe that also. Iʹll argue with her about it.ʺ

Speak more than the family because silence may be difficult for them to tolerate.

Which of the following questions would be most appropriate for the nurse to ask a son who is his fatherʹs health care proxy to help to clarify the fatherʹs end-of-life wishes?
ʺWhen did your father complete his advance directive?ʺ
ʺDid he ever speak to your mother about his wishes?ʺ
ʺWho else was present during the discussion?ʺ
ʺWould you tell me in his own words what he said he wanted done at the end of his life?ʺ

When applying the ʺsubstituted judgmentʺ standard for decision making, the nurse is asking the health care proxy to make decisions based on what the:
Family would like done under these circumstances.
Spouse would like done under these circumstances.
Proxy could imagine the patient wants for him- or herself.
Health care providers feel is appropriate.

When applying both substituted judgment and best interest standards to end-of-life decision making, the nurseʹs primary role remains to:
Tell the proxy what should be done in the best interest of the patient.
Establish trust and confidence with the family.
Be an advocate and decision maker based on hospital interests.
Promote effective communication and decrease conflict.

The nurse should set which of the following goals when planning care for the family of a dying ICU patient? (Select all that apply.)
Establish trust between the family and the members of the health care team
Establish respect for family choices and support their decisions
Encourage family members to talk about their feelings and concerns
Identify and respect the familyʹs cultural and religious beliefs or practices
Establish a sympathetic approach in response to family membersʹ feelings

The nurse would use all of the following approaches when dealing with the families of dying patients EXCEPT:

Repeating information frequently to make sure the information is being understood fully.
Reaffirming the bad news but allowing time to listen to their responses.
Being honest and sincere but sensitive to the familyʹs needs.
Encouraging a quick decision-making process to decrease the amount of time required to get past the painful part of dealing with the death.

According to Morse (2001), what two patterns of behavior may a family use when expressing their feelings or emotions related to the death of their loved one?
Denial and grieving
Enduring and suffering
Hostility and acceptance
Anger and bargaining

According to Morse (2001) the nurse should anticipate family members of dying patients to display which of the following types of behavior before they are ready to move on and face the reality of the situation?
Denial
Anger
Suffering
Enduring

What can the nurse allow the family to do when trying to meet the familyʹs need to be helpful to the dying patient? (Select all that apply.)
Reposition the patient.
Activate the patient-controlled analgesia if the patient grimaces or has pain.
Moisten the patientʹs lips and mouth.
Comfort or soothe the patient through touch or speech.
Talk or read to the patient to show that they are present in the room.

If a dying patient is being provided with IV hydration, the nurse should assess for which of the following likely patient problems? (Select all that apply.)
A decrease in urine output
An increase in nausea and possible vomiting
An increased likelihood of dyspnea
Development of pitting edema in the extremities

Which approach to controlling pain, nausea, and dyspnea should the nurse use for pharmacological management at the end of a patientʹs life?
Administer medication based only on the severity of symptoms that are observed in the patient.
Administer prophylactic medication aggressively as symptoms arise to maintain comfort.
Administer medications only at the familyʹs request as the patientʹs health care proxy.
Withhold all medication when other therapies are withheld.

When caring for a patient at the end of life, the nurse decides which therapies to continue based on whether the intervention will: (Select all that apply.)
Keep the family happy.
Reduce the workload of the staff.
Promote relief of the patientʹs symptoms.
Enhance the patientʹs functional status.
Lessen the patientʹs emotional, psychological, or spiritual distress.

Which of the following is the most appropriate intervention for the nurse attempting to meet the spiritual needs of a patient at the end of life?
Answer questions about the meaning of life, hope, and purpose of life based on the nurseʹs understanding.

Explain the role of suffering as the nurse sees it.
Discuss ethical decision making with the patient to clarify his desires.
Encourage, respect, and participate when comfortable in the patientʹs and familyʹs cultural or spiritual practices.

According to the American Nurses Association and the American Association of Critical -Care Nurses, a nurseʹs primary duty to the patient is to:
Allow a comfortable death.
Do no harm.
Base all care on cost-benefit ratio analysis.
Minimize emotional distress in the family of a dying patient.

When unresolvable conflicts are present among health care team and family members concerning futile treatment of a patient, who has the legal right to decide the management plan?
The patientʹs family or health care proxy determines the outcome.
The empowered nurse specialist coordinates the discussion among family members.
The hospitalʹs ethics board dictates the final resolution.
The physician decides based on the hospitalʹs ethics boardʹs recommendation, the patientʹs desires, and any written advance directives.

When a dying patient is to be terminally weaned or extubated, the nurse should plan to do which of the following?
Initiate medication therapy to control dyspnea but plan to stop it in the event of hypotension.
Observe the patient and adjust medication dosages every hour.
Provide an anticipatory dose of morphine and initiate an ongoing morphine infusion.
Stop all ongoing sedative infusions at least an hour before extubation.

The nurse is evaluating the patient with sepsis for the development of disseminated intravascular coagulation (DIC). Which of the following is a sign that the patient may have developed this complication?
Ecchymoses of the gums or skin
Resistance when flushing a capped port of a central venous catheter
A reduction in the D-dimer
Increased fibrinogen levels