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Critical Care Exam 3

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Test sobre Critical Care Exam 3 , creado por Breana C. el 06/12/2018.
Breana C.
Test por Breana C., actualizado hace más de 1 año
Breana C.
Creado por Breana C. hace casi 6 años
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Resumen del Recurso

Pregunta 1

Pregunta
The nurse is caring for a patient with the diagnosis of sepsis. The pt is on a ventilator in the critical care unit and is receiving a proton pump inhibitor (PPI) to reduce the risk of a stress ulcer. In this scenario, a stress ulcer is likely secondary to
Respuesta
  • decreased number of parietal cells
  • ischemia associated with sepsis
  • decreased acetylcholine production
  • infection with Helicobacter pylori bacteria

Pregunta 2

Pregunta
continuous renal replacement therapy (CRRT) differs from conventional intermittent hemodialysis in that
Respuesta
  • a hemofilter is used to facilitate ultrafiltration
  • it provides faster removal of solute and water
  • the process removes solute and water slowly
  • it does not allow diffusion to occur

Pregunta 3

Pregunta
which of the following laboratory values would be found in a patient with syndrome of inappropriate secretion of antidiuretic hormone?
Respuesta
  • serum sodium 152 mEq/L
  • serum potassium 5.8 mEq/L
  • fasting blood glucose 156 mg/dL
  • serum sodium 115 mEq/L

Pregunta 4

Pregunta
the nurse working in a trauma center administers blood products to a severely hemorrhaging trauma patient in a 1:1:1 ratio. Which blood products does the nurse in the transfusion protocol? (select all that apply.)
Respuesta
  • red blood cells
  • plasma
  • whole blood
  • universal donor blood only
  • platelets

Pregunta 5

Pregunta
the pt is admitted with reports of chronic fatigue and shortness of breath. The nurse notices that the pt is tachycardia and has multiple bruises and petechiae on the body and arms. The pt also complains of frequent nosebleeds. The nurse should evaluate the pt's _____
Respuesta
  • blood culture results
  • complete blood count
  • hemoglobin and hematocrit
  • electrolyte values

Pregunta 6

Pregunta
which of the following pts is at greatest risk of developing acute kidney injury? A pt who
Respuesta
  • has been on aminoglycosides for the past 6 days
  • was discharged 2 weeks earlier after amnioglycosides therapy of 2 weeks
  • has a history of fluid overload as result of heart failure
  • has a history of controlled hypertension with a BP of 138/88 mmHg

Pregunta 7

Pregunta
when assessing the pt's bowel sounds, the nurse
Respuesta
  • places a pillow over the pt's knees
  • places the pt in a relaxed prone position
  • listens to the abdomen after palpation is done
  • listens to bowel sounds before palpation

Pregunta 8

Pregunta
your pt is receiving enteral feedings and has just vomited 250 mL of milky green liquid. You hold the tube feeding, which had been infusing at 100 mL/hr. Your next step is to:
Respuesta
  • continue the tube feeding
  • recheck the residual in 2 hours
  • connect the feeding tube to suction
  • decrease the tube feeding

Pregunta 9

Pregunta
the nurse is caring for a pt who has sustained blunt trauma rot the left flank area, and is evaluating the pt's urinalysis results. The nurse should become concerned when
Respuesta
  • red blood cells and albumin are found in the urine
  • urine uric acid levels have the same values as serum levels
  • creatinine levels in the urine are similar to blood levels of creatinine
  • sodium and chloride are found in the urine

Pregunta 10

Pregunta
The nurse is caring for a pt with active GI bleeding. Estimated blood loss is 1,000mL. Which of the following assessments would the nurse expect to find with this amount of blood loss?
Respuesta
  • all vital signs would expect to be normal
  • heart rate 125 bpm
  • systolic BP of 120 mmHg
  • oral temperature of 103

Pregunta 11

Pregunta
A pt who was an unrestrained driver in a high-speed, head-on motor vehicle collision presents with dyspnea, tachycardia, hypotension, jugular venous distention, tracheal deviation to the left, and decreased breath sounds on the right side. What is the most likely diagnosis?
Respuesta
  • cardiac pneumothorax
  • simple pneumothorax
  • tension pneumothorax
  • ruptured diaphragm

Pregunta 12

Pregunta
The pt has a platelet count of 9,000/microliter. The nurse realizes that
Respuesta
  • the patient is at great risk for fatal hemorrhage
  • this a normal platelet level
  • spontaneous bleeding may occur
  • this level is considered slightly low

Pregunta 13

Pregunta
A pt, who has a tube feeding, requires a chest x-ray study for evaluation of a cough. To reduce the risk of aspiration, the nurse:
Respuesta
  • helps the radiology technician to position the pt to avoid dislodging the tube
  • stops feedings 10 to 15 minutes before placing flat to obtain the radiograph
  • slows the rate of the feedings until placement has been verified
  • cuts the infusion rate by half

Pregunta 14

Pregunta
The nurse is assessing a pt with a new arteriovenous fistula, but does not hear a bruit or feel a thrill. Pulses distal to the fistula are not palpable. The nurse should
Respuesta
  • raise the arm above the level of the pt's heart
  • apply warm packs to the fistula site and reassess
  • notify the provider immediately
  • reassess the pt in a hour

Pregunta 15

Pregunta
The nurse is caring for a pt from a rehabilitation center with a preexisting complete cervical spine injury who is complaining of a severe headache. The nurse assesses a BP of 180/90 mmHg, HR 60 bpm, respirations 24 breaths/min and 50 mL of urine via indwelling urinary catheter for the past 4 hours. What is the best action by the nurse?
Respuesta
  • notify the provider of the pt's BP
  • encourage the pt to take slow, deep breaths
  • assess for a kinked urinary catheter and assess for bowel impaction
  • administer acetaminophen as ordered for the headache

Pregunta 16

Pregunta
The pt is admitted to the unit with the diagnosis of rhabdomyolysis. The pt is started on IV fluids and IV mannitol. What action by the nurse is best?
Respuesta
  • give extra doses before giving radiological contrast agents
  • decrease IV fluids once the diuretic has been administered
  • assess the pt's hearing
  • assess the pt's lungs

Pregunta 17

Pregunta
What psychosocial factors may potentially contribute to the development of DKA? (Select all that apply.)
Respuesta
  • lack of financial resources
  • exposure to influenza
  • high levels of stress
  • eating disorder
  • altered sleep/rest patterns

Pregunta 18

Pregunta
The trauma nurse understands which information related to the older trauma pt? (Select all that apply.)
Respuesta
  • hypotension in the elderly can appear as normotension
  • fractures to bones other than hips are uncommon from trauma
  • physiologic capacity is an important predictor of outcome
  • falls are the leading cause of death in the older population
  • chronic diseases do not have much effect on the older trauma pt

Pregunta 19

Pregunta
The best nursing approach to prevent feeding tube obstruction is to
Respuesta
  • pass a stylet daily to keep the tubing clear
  • dilute the feeding to make it flow more easily
  • flush the tube every 4 hours with 20 to 30 mL of tap water
  • use a larger bore tube where possible

Pregunta 20

Pregunta
An 18 y/o pt who sustains multiple traumatic injuries from a motor vehicle crash has a BP of 80/60 mmHg at the scene. This pt should be treated at which level trauma center?
Respuesta
  • Level III
  • Level I
  • Level II
  • Level IV

Pregunta 21

Pregunta
A pt is having complications from abdominal surgery and remains NPO. Because enteral tube feedings are not possible, the decision is to initiate parenteral feedings. What are the major complications for this therapy?
Respuesta
  • Aspiration pneumonia and sepsis
  • Hypoglycemia and renal insufficiency
  • Sepsis and fluid and electrolyte imbalances
  • Fluid overload and pulmonary edema

Pregunta 22

Pregunta
The need for fluid resuscitation can be assessed best in the trauma pt by monitoring and trending which of the following tests?
Respuesta
  • arterial oxygen saturation
  • mean arterial pressure
  • serum lactate levels
  • hourly urine output

Pregunta 23

Pregunta
A client presents to the urgent care center with complaints of abdominal pain and vomits bright red blood. Which of the following is the priority action taken by the nurse?
Respuesta
  • prepare to insert a NG tube and test pH and occult blod
  • obtain a thorough history of the recent health status
  • perform a complete abdominal assessment
  • take the client's vital signs

Pregunta 24

Pregunta
The pt is in a progressive care unit following arteriovenous fistula implantation in his left upper arm and is due to have blood drawn with his next set of vital signs and assessment. When the nurse assesses the pt, the nurse should
Respuesta
  • draw blood from the left arm
  • take blood pressures from the left arm
  • start a new IV line in the left lower arm
  • auscultate the left arm for a bruit and palpate for a thrill

Pregunta 25

Pregunta
Accepted treatments for disseminated intravascular coagulation (DIC) may require (Select all that apply)
Respuesta
  • platelet infusions
  • administration of fresh frozen plasma
  • heparin
  • cryoprecipitate
  • packed RBCs

Pregunta 26

Pregunta
A pt with acute pancreatitis is started on parenteral nutrition. Nursing care for this pt includes all EXCEPT:
Respuesta
  • monitor the blood glucose every 6 hours
  • monitor the fluid and electrolyte balance
  • infuse antibiotics through the IV line
  • change the IV tubing every 25 hours

Pregunta 27

Pregunta
The pt has yellow skin and low hemoglobin and hematocrit levels. The nurse should look for
Respuesta
  • sickled cells
  • low reticulocyte count
  • an elevated bilirubin level
  • low WBC and platelet counts

Pregunta 28

Pregunta
The nurse is caring for a pt with a HR of 140 bpm. The provider orders parasympathetic medications to slow down the heart rate. With this type of medication, the nurse should
Respuesta
  • assess mucous membranes for signs of dryness
  • expect decreased bowel sounds
  • evaluate the pt for symptoms of constipation
  • observe for diarrhea

Pregunta 29

Pregunta
During the treatment and management of the trauma pt, maintaining tissue perfusion, oxygenation and nutritional support are strategies to prevent
Respuesta
  • multisystem organ dysfunction
  • disseminated intravascular coagulation
  • septic shock
  • wound infection

Pregunta 30

Pregunta
In a unconscious pt, eye movements are tested by the oculocephalic reflex. Which statements regarding the testing of this reflex are true? (Select all that apply.)
Respuesta
  • doll's eyes absent indicate a disruption in normal brainstem processing
  • eye movement in the opposite direction as the head when turned indicates an intact reflex
  • doll's eyes present indicate brainstem activity
  • eye movement in the same direction as the head when turned indicates an intact reflex
  • presence of cervical injuries is a contraindication to the assessment of this reflex
  • increased ICP is a contraindication to the assessment of this reflex

Pregunta 31

Pregunta
The pt is admitted with acute pancreatitis. The nurse should
Respuesta
  • assess pain level because pancreatic pain is unique in character
  • expect lipase levels to decrease within 24 hours
  • evaluate C-reactive protein as a gauge of severity
  • examine laboratory values for low amylase levels

Pregunta 32

Pregunta
The nurse is caring for a pt who has a temporary percutaneous dialysis catheter in place. In caring for this pt, the nurse should
Respuesta
  • assess the catheter site for redness and/or swelling
  • use the catheter for drawing blood samples to reduce pt discomfort
  • replace the transparent dressing every 10 days to prevent manipulation
  • apply a sterile gauze dressing to maintain sterility

Pregunta 33

Pregunta
A 24 y/o unrestrained driver who sustained multiple traumatic injuries from a motor vehicle crash has a BP of 80/60 mmHg at the scene. The primary survey of this pt upon arrival to the ED
Respuesta
  • is a methodical head-to-toe assessment identifying injuries and treatment priorities
  • includes a cervical spine X-ray study to determine the presence of a fracture
  • involves turning the pt from side to side to get a look at his back
  • is done quickly in the first few minutes to get a baseline assessment and establish priorities

Pregunta 34

Pregunta
The nurse is caring for a pt diagnosed with anemia. This morning's hematocrit level is 24%. Platelet level is 200,000/microliter. The nurse can expect to
Respuesta
  • administer platelets to help control bleeding
  • give fresh frozen plasma to decrease prothrombin time
  • continue monitoring the pt, as this hematocrit is normal
  • provide RBC transfusion because this level is below the normal threshold

Pregunta 35

Pregunta
In addition to residual stomach volume, what other evidence suggests feeding intolerance?
Respuesta
  • active bowel sounds
  • abdominal distension
  • elevated blood glucose by fingerstick
  • absence of tympany on percussion

Pregunta 36

Pregunta
Discharge teaching for a client recovering from an attack of chronic pancreatitis should include which of the following instructions?
Respuesta
  • alcohol should be consumed in moderation
  • avoid caffeine, because it may aggravate symptoms
  • frothy fatty stools indicate that enzyme replacement is working
  • diet should be high in carbohydrates, fats and proteins

Pregunta 37

Pregunta
The nurse is caring for a mechanically ventilated pt with a brain injury. ABG values indicate a PaCO2 of 60 mmHg. The nurse understands this value to have which effect on cerebral blood flow?
Respuesta
  • decreased cerebral blood volume due to vessel constriction
  • increased cerebral blood volume due to vessel dilation
  • altered cerebral spinal fluid production and reabsorption
  • no effect on cerebral blood flow (PaCO2 of 60 mmHg is normal)

Pregunta 38

Pregunta
interpret the following rhythm
Image:
Image (binary/octet-stream)
Respuesta
  • sinus arrhythmia
  • sinus bradycardia
  • normal sinus rhythm
  • sinus tachycardia

Pregunta 39

Pregunta
The pt is complaining of severe joint pain, as well as fatigue and shortness of breath. The nurse notices that the pt's joints are swollen and the legs are edematous. The nurse realized that these are symptoms that
Respuesta
  • sickle cell anemia
  • anemia reflective of low volume
  • hemolytic anemia
  • aplastic anemia

Pregunta 40

Pregunta
An individual with type 2 DM who takes glipzide has begun a formal exercise program at a local gym. While exercising on the treadmill, the individual becomes pale, diaphoretic, shaky and has a headache. This indvidual feels as though she is going to pass out. What is the individual's priority action?
Respuesta
  • drink additional water to prevent dehydration
  • go to the first aid station to have glucose checked
  • eat something with 15g of simple carbohydrates
  • take another dose of the oral agent

Pregunta 41

Pregunta
The pt has been admitted to the hospital with nausea and vomiting that started 5 days earlier. BP is 80/44 mmHg and HR is 122 bpm; the pt has not voided in 8 hours, and the bladder is not distended. The nurse anticipates a prescription for "stat" administration of
Respuesta
  • an antiemetic
  • infusion of an inotropic agent
  • blood transfusion
  • fluid replacement with 0.45% saline

Pregunta 42

Pregunta
A pt is admitted to the oncology unit with a small-cell lung carcinoma. During this admission, the pt is noted to have a significant decrease in urine output accompanied by shortness of breath, edema and mental status changes. The nurse is aware that this clinical presentation is consistent with
Respuesta
  • syndrome of inappropriate secretion of antidiuretic hormone (SIADH)
  • myxedema coma
  • diabetes insipidus
  • adrenal crisis

Pregunta 43

Pregunta
interpret this strip
Image:
Image (binary/octet-stream)
Respuesta
  • atrial fibrillation
  • ventricular fibrillation
  • atrial flutter
  • sinus arrhythmia

Pregunta 44

Pregunta
The nurse is caring for a pt with severe ascites due to chronic liver failure. The pt is lying supine in bed and complaining of difficulty breathing. The nurse's first action should be to
Respuesta
  • administer diuretics
  • prepare the pt for emergent paracentesis
  • position the pt in a semi-Fowler's position
  • measure the abdominal girth to determine the amount of fluid accumulation

Pregunta 45

Pregunta
A community-based external disaster is initiated after a tornado moved through the city. A nurse from the medical records review department arrives at the ED asking to assist. The best response by a nurse working for the trauma center would be to
Respuesta
  • assign the nurse to a triage room with another nurse from the ED
  • thank the nurse but inform her to return to her department as her skill set is not a good match for a pts needs
  • assign the nurse administrative duties, such as obtaining pt demographic info
  • have the nurse assist with transport of pts to procedural areas

Pregunta 46

Pregunta
Acute kidney injury from postrenal etiology is caused by
Respuesta
  • obstruction of the flow of urine
  • conditions that interfere with renal perfusion
  • conditions that act directly on functioning kidney failure
  • hypovolemia or decreased cardiac output

Pregunta 47

Pregunta
Secondary immunodeficiency involves the loss of a previously functional immune defense system, which can be caused by (select all that apply.)
Respuesta
  • AIDS
  • aging
  • immunosuppressive therapies
  • nutritional deficiencies
  • single gene defect

Pregunta 48

Pregunta
The most common cause of acute kidney injury in critically ill pts is
Respuesta
  • medications
  • hemodynamic instability
  • fluid overload
  • sepsis

Pregunta 49

Pregunta
The nurse is caring for a pt admitted to the ED following a fall from a 10-foot ladder. Upon admission, the nurse assesses the pt to be awake, alert and moving all 4 extremities. The nurse also notes bruising behind the left ear and straw colored drainage from the left saris. What is the most appropriate nursing action?
Respuesta
  • apply a small nasal drip
  • monitor airway patency
  • insert bilateral ear plugs
  • maintain neutral head position

Pregunta 50

Pregunta
The pt is diagonosed with hepatitis. In caring for this pt, the nurse should
Respuesta
  • administer anti-inflammatory medications
  • instruct the pt to take OTC anti-inflammatory medications at home
  • provide rest, nutrition and antiemetics if needed
  • provide antianxiety medications freely to decrease agitation

Pregunta 51

Pregunta
The nurse notices sinus bradycardia on the pt's cardiac monitor. The nurse should
Respuesta
  • start a dopamine infusion to stimulate heart function
  • begin transcutaneous pacing for the pt
  • give atropine to increase heart rate
  • assess for hemodynamic instability

Pregunta 52

Pregunta
The nurse assesses a pt with a skull fracture to have a Glasgow Coma Scale score of 3. Additional vital signs assessed by the nurse include BP 100/70 mmHg, HR 55 bpm, respiratory rate 10 breaths/min, oxygen saturation 94% on oxygen at 3L per nasal cannula. What is the priority nursing action?
Respuesta
  • increase supplemental oxygen delivery
  • elevate the head of the pt's bed
  • support bony prominences with padding
  • monitor the pt's airway patency

Pregunta 53

Pregunta
The nurse is caring for a mechanically ventilated pt admitted with a traumatic brain injury. Which ABG value assessed by the nurse indicated optimal gas exchange for a pt with this type of injury?
Respuesta
  • pH 7.38; PaCO2 28 mmHg; HCO3 26 mEq/L; PaO2 65 mmHg
  • pH 7.38; PaCO2 35 mmHg; HCO3 24 mEq/L; PaO2 85 mmHg
  • pH 7.38; PaCO2 40 mmHg; HCO3 24 mEq/L; PaO2 70 mmHg
  • pH 7.38; PaCO2 55 mmHg; HCO3 22 mEq/L; PaCO2 85 mmHg

Pregunta 54

Pregunta
In assessing the pt complaining of abdominal pain, it is more important for the nurse to understand that
Respuesta
  • pain receptors in the abdomen are more likely to be localized
  • increasing intensity of pain is always significant
  • pain of a peptic ulcer is easily distinguished from that of heart attack
  • visceral pain often leads to tachycardia and hypertension

Pregunta 55

Pregunta
Which of the following injuries would result in a greater likelihood of internal organ damage and risk for infection?
Respuesta
  • a motor vehicle crash in which the driver hits the steering wheel
  • a knife wound to the right chest
  • a fall from a 6-foot ladder onto the grass
  • a shotgun wound to the abdomen

Pregunta 56

Pregunta
Which of the following interventions is a strategy to prevent fat embolism syndrome?
Respuesta
  • provide prophylaxis with low-molecular weight heparin
  • stabilize extremity fractures early
  • intubate the pt early after the injury to provide mechanical ventilation
  • administer lipid-lowering statin medications

Pregunta 57

Pregunta
A pt is admitted to the ICU for observation of his grade II splenic laceration. Which of the following signs and symptoms would suggest that he has had a delayed rupture of his splenic capsule and is now in hemorrhagic shock?
Respuesta
  • BP 100/60 mmHg; 100 bpm; Hct 35 mg/dL; UO 30 mL/hr; pale, cool, dry skin; alert and oriented
  • BP 110/60 mmHg; HR 118 bpm; Hct 38 mg/dL; UO 60 mL/hr; flushed, warm, diaphoretic skin; agitated and confused
  • BP 110/70 mmHg; HR 120 bpm; Hct 42 mg/dL; UO 40 mL/hr; skin that is pink, warm and dry with capillary refill of 3 seconds
  • BP 90/70; HR 140 bpm; Hct 21 mg/dL; UO 10 mL/hr; pale, cool, clammy skin; confused

Pregunta 58

Pregunta
The nurse has been assigned the following pts. Which pts require assessment of blood glucose control as the nursing priority? (Select all that apply.)
Respuesta
  • a 43 y/o male with acute pancreatitis who is receiving total parenteral nutrition (TPN)
  • 72 y/o female who is receiving IV steroids for an exacerbation of chronic obstruction pulmonary disease (COPD)
  • 18 y/o male who has undergone surgical correction of a fractured femur
  • 62 y/o morbidly obese female who underwent a hysterectomy for ovarian cancer
  • 29 y/o female who is undergoing evaluation for pheochromocytoma

Pregunta 59

Pregunta
Acute adrenal crisis is caused by
Respuesta
  • overdose of testosterone
  • deficiency of corticosteroids
  • high doses of corticosteroids
  • acute renal failure

Pregunta 60

Pregunta
Interpret the rhythm
Image:
Image (binary/octet-stream)
Respuesta
  • ventricular pacing
  • dual chamber pacing
  • atrial pacing
  • transcutaneous pacing

Pregunta 61

Pregunta
The nurse is caring for a pt with acute pancreatitis. To provide adequate pain control, the nurse
Respuesta
  • removes any nasogastric tubes
  • provides oral pain mediation on an "as needed" (PRN) basis
  • should suggest that the pt receive epidural analgesia
  • administers pain medication on a routine schedule

Pregunta 62

Pregunta
A pt with newly diagnosed type 1 diabetes is being transitioned from an infusion of IV regular insulin to an intensive insulin therapy regimen of glargine and insulin aspart. How should the nurse manage this transition in insulin therapy?
Respuesta
  • discontinue the IV infusion and administer the insulin aspart with the next meal
  • administer the insulin glargine and discontinue the IV infusion in several hours
  • discontinue the IV infusion and administer the Lantus insulin at bedtime
  • administer the insulin glargine and continue the IV insulin infusion for 24 hours

Pregunta 63

Pregunta
During cardiac resuscitation for ventricular fibrillation, which drug would a nurse most likely prepare first?
Respuesta
  • amiodarone
  • lidocaine
  • epinephrine
  • atropine

Pregunta 64

Pregunta
A pt has been admitted to the critical care unit after a stroke. After "failing" a swallow study, the pt is placed on enteral feedings. Following placement of a nasogastric tube for tube feeding, what is the next critical step?
Respuesta
  • obtain a chest radiograph
  • administer medications
  • start the tube feeding
  • cap off and wait 24 hours before staring feedings

Pregunta 65

Pregunta
Factors associated with the development of nephrogenic diabetes insipidus include which of the following? (Select all that apply.)
Respuesta
  • sickle cell anemia
  • meningitis
  • heredity
  • medications
  • pituitary tumors

Pregunta 66

Pregunta
signs and symptoms associated with flail chest include
Respuesta
  • paradoxical respiratory movement
  • respiratory alkalosis
  • tracheal deviation toward the unaffected side
  • jugular vein distention

Pregunta 67

Pregunta
Infection by Helicobacter pylori bacteria is a major cause of
Respuesta
  • curling's ulcers
  • cushing's ulcers
  • stress ulcers
  • duodenal ulcers

Pregunta 68

Pregunta
The nurse responds to a high heart rate alarm for a pt in the neurological intensive care unit. The nurse arrives to find the pt sitting in a chair experiencing a tonic-clonic seizure. What is the best nursing action?
Respuesta
  • assist the pt to the floor and provide soft head support
  • restrain the pt's extremities until the seizure subsides
  • open the pt's mouth and insert a padded tongue blade
  • insert a NG tube and connect to continuous wall suction

Pregunta 69

Pregunta
Range of motion exercises, early ambulation, and adequate hydration are interventions to prevent
Respuesta
  • venous thromboembolism
  • fat embolism
  • nosocomial pneumonia
  • catheter-associated infection

Pregunta 70

Pregunta
A 24 y/o unrestrained driver who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mmHg at the scene. The primary survey of this pt upon arrival to the ED
Respuesta
  • involves turning the pt from side to side to get a look at his back
  • is done quickly in the first few minutes to get a baseline assessment and establish priorities
  • is a methodical head-to-toe assessment identifying injuries and treatment priorities
  • includes a cervical xray study to determine the presence of a fracture

Pregunta 71

Pregunta
The nurse is caring for a pt with severe pancreatitis who is orally intubated and on mechanical ventilation. The pt's calcium level this morning was 5.5 mg/dL. The nurse notifies the provider and
Respuesta
  • withholds any further calcium treatments
  • expects that the provider will come and remove the endotracheal tube
  • places the pt on seizure precautions
  • places an oral airway at the bedside

Pregunta 72

Pregunta
A pt with a history of type 1 diabetes and an eating disorder is found unconscious. In the emergency department, the following lab values are obtained: Glucose 646 mg/dL pH 6.88 PaCO2: 20 mmHg PaO2: 95 mmHg HCO3: undetectable Anion gap >31 Na+: 127 mEq/L K+: 3.5 mEq/L Creatinine: 1.8 mg/dL After the pt's airway and ventilation have been established, the next priority for this pt is:
Respuesta
  • IV push administration of 1 amp of sodium bicarbonate
  • administration of a 1L normal saline fluid bolus
  • administration of 0.1 unit of regular insulin IV push followed by an insulin infusion
  • administration of 20 mEq KCl in 100mL

Pregunta 73

Pregunta
The nurse is caring for a pt following a subarachnoid hemorrhage, begins a nicardipine infusion. Baseline BP assessed by the nurse is 170/100 mmHg. Five minutes after beginning the infusion at 5 mg/hr, the nurse assesses the pt's BP to be 160/90 mmHg. What is the best action by the nurse?
Respuesta
  • notify the provider of the BP
  • increase the dose by 2.5 mg/hr
  • begin weaning the infusion
  • stop the infusion for 5 minutes

Pregunta 74

Pregunta
A pt was thrown 30 feet from an open-top Jeep and straddled a row of mailboxes before she landed on the ground. She has a pelvic fracture. The nurse admitting the pt into the ICU knows that
Respuesta
  • she will probably not need surgery to stabilize her fracture
  • there is little likelihood of damage to the genitourinary or gastrointestinal tracts
  • the pt will probably be able to walk as soon as she is hemodynamically stable
  • aggressive fluid and blood replacement will probably be needed

Pregunta 75

Pregunta
Which of the following will cause a nurse to suspect that pt's pulmonary contusion is worsening?
Respuesta
  • an increased need for pain medication
  • an ABG value that demonstrates respiratory alkalosis
  • increased peak airway pressures on the ventilator
  • a pulmonary artery catheter showing a central venous pressure of 6 cm H2O and a wedge pressure of 8 mmHg

Pregunta 76

Pregunta
After receiving the handoff report from the day shift charge nurse, which pt should be evening charge nurse assess first?
Respuesta
  • a mechanically ventilated pt with a GCS of 6
  • a pt with meningitis complaining of photophobia
  • a pt with bacterial meningitis on droplet precautions
  • a pt with an intracranial pressure of 20 mmHg and an oral temperature of 104F

Pregunta 77

Pregunta
The term used to describe an increase in BUN and serum creatinine is
Respuesta
  • acute kidney injury
  • azotemia
  • prerenal disease
  • oliguria

Pregunta 78

Pregunta
The nurse is caring for a pt who sustained rib fractures after hitting the steering wheel of the car during a motor vehicle crash. The pt is spontaneously breathing and receiving oxygen via a face mask; the oxygen saturation is 95%. During the nurse's assessment, the oxygen saturation drops to 80%. The pt's BP has dropped from 126/76 mmHg to 84/60 mmHg. The nurse assesses that breath sounds are absent throughout the left lung fields. The nurse notifies the provider and anticipates
Respuesta
  • needle throracostomy and chest tube insertion
  • endotracheal intubation and mechanical ventilation
  • chest X-ray study to determine the etiology of the symptoms
  • administration of lactated ringer's solution (1L) wide open

Pregunta 79

Pregunta
The nurse is caring for a pt admitted with a subarachnoid hemorrhage following surgical repair of the aneurysm. Assessment by the nurse notes BP 90/60 mmHg, HR 115 bpm, RR 28 breaths/min, oxygen saturation 99% on supplemental oxygen at 3L/min by cannula, a Glasgow Coma Score of 4 and a central venous pressure of 2 mmHg. After reviewing the provider prescriptions, which order is of the highest priority?
Respuesta
  • 500mL albumin IV infusion
  • decadron 10 mg IV push
  • dilantin 50 mg IV push
  • lasix 20 mg IV push as needed

Pregunta 80

Pregunta
A nurse is field-triaging clients after an industrial accident. Which client condition should the nurse triage with a red tag?
Respuesta
  • dislocated right hip and an open fracture of the right lower leg
  • closed fracture of the right clavicle and arm numbness
  • large contusion to the forehead and a blood nose
  • multiple fractured ribs and shortness of breath

Pregunta 81

Pregunta
The pt has a total WBC of 600 cells/microliter. The differential shows a normal neutrophil level of 70% with 5% bands. The pt
Respuesta
  • is at low risk for infection
  • is at moderate risk for infection
  • is at mild risk for infection
  • is at severe risk for infection

Pregunta 82

Pregunta
The nurse is caring for pt receiving peritoneal dialysis. The pt suddenly complains of abdominal pain and chills. The pt's temperature is elevated. The nurse should
Respuesta
  • check the pt's blood sugar
  • assess peritoneal dialysate return
  • evaluate the pt's neurological status
  • inform the provider of probable visceral perforation

Pregunta 83

Pregunta
Which of the following interventions would not be appropriate for a pt who is admitted with a suspected basilar skull fracture?
Respuesta
  • placement of an oral airway
  • endotracheal intubation
  • insertion of an indwelling urinary catheter
  • insertion of a nasotracheal tube

Pregunta 84

Pregunta
Conditions that produce acute kidney injury by directly acting on functioning kidney tissue are classified as infrarenal. The most common intrarenal condition is
Respuesta
  • exposure to nephrotoxic substances
  • acute tubular necrosis
  • hypotension for several hours
  • prolonged ischemia

Pregunta 85

Pregunta
A pt is admitted to the critical care unit with a diagnosis of DKA. Following aggressive fluid resuscitation and IV insulin administration, the blood glucose begins to normalize. In addition to glucose monitoring, which of the following electrolytes requires close monitoring?
Respuesta
  • chloride
  • calcium
  • sodium
  • potassium

Pregunta 86

Pregunta
A nurse triages clients arriving at the hospital after a mass casualty. Which clients are correctly classified? (Select all that apply.)
Respuesta
  • a 35 y/o female with severe chest pain: red tag
  • a 55 y/o female with a scalp laceration: black tag
  • an 88 y/o male with shortness of breath and chest bruises: green tag
  • a 60 y/o male with an open fracture with distal pulses: yellow tag
  • a 42 y/o male with full-thickness body burns: green tag

Pregunta 87

Pregunta
The liver detoxifies the blood by
Respuesta
  • converting water-soluble compounds to fat-soluble compounds
  • excreting fat-soluble compounds in feces
  • metabolizing inactive toxic substances to active forms
  • converting fat-soluble compounds to water-soluble compounds

Pregunta 88

Pregunta
Which of the following statements about mass casualty triage during a disaster is true?
Respuesta
  • disaster victims with the greatest chances for survival receive priority for treatment
  • priority treatments and interventions focus primarily on young victims
  • color-coded systems in which green indicates the pt of greatest need are used during disasters
  • once interventions have been initiated, health care providers cannot stop the treatment of disaster victims

Pregunta 89

Pregunta
The nurse is caring for a pt who is being treated for peptic ulcer disease. Suddenly, the pt yells that the pain has become extreme. The nurse notes that the pt's abdomen is rigid. The nurse should
Respuesta
  • give the pt an antacid
  • call the provider immediately
  • remove the NG tube
  • give the pt pain medication

Pregunta 90

Pregunta
The pt undergoes a cardiac cauterization that requires the use of contrast dyes during the procedure. To detect signs of contrast-induced kidney injury, the nurse should
Respuesta
  • evaluate the pt's postpaid residual volume to detect intrarenal injury
  • not be concerned unless urine output decreases
  • evaluate the pt's serum creatinine for up to 72 hours after the procedure
  • obtain an order for a renal ultrasound

Pregunta 91

Pregunta
What psychosocial factors may potentially contribute to the development of DKA? (select all that apply.)
Respuesta
  • eating disorder
  • exposure to influenza
  • lack of financial resources
  • altered sleep/rest patterns
  • high levels of stress

Pregunta 92

Pregunta
The nurse receives a pt from the ED following a closed head injury. After insertion of an ventriculostomy, the nurse assesses the following vital signs: BP 100/60 mmHg, HR 52 bpm, RR 24 breaths/min, SpO2 97% on supplemental oxygen at 45% via Venturi mask, Glasgow Coma Scale score of 4 and ICP of 18 mmHg. Which provider prescription should the nurse institute first?
Respuesta
  • ancef 1g IV
  • portable chest xray
  • mannitol 1g IV
  • seizure precautions

Pregunta 93

Pregunta
During the assessment of a pt after a high-speed motor vehicle crash, which of the following findings would increase the nurse's suspicion of a pulmonary contusion? (select all that apply.)
Respuesta
  • signs of hypoxia on room air
  • chest wall ecchymosis
  • paradoxical chest wall movement
  • diminished or absent breath sounds
  • pink-tinged or blood secretions

Pregunta 94

Pregunta
The nurse is calculating the rate of a regular rhythm. There are 20 small boxes between each P wave and 20 small boxes between each R wave. What is the ventricular rate?
Respuesta
  • 75 bpm
  • 100 bpm
  • 85 bpm
  • 50 bpm

Pregunta 95

Pregunta
A pt has been admitted to the ED with a massive hemothorax. What action by the nurse takes priority?
Respuesta
  • place the pt on a cardiac monitor
  • start 2 large bore IVs
  • prepare for rapid intubation
  • seal the wound with occlusive dressings

Pregunta 96

Pregunta
In trauma pts, enteral nutrition via NG tube feedings into the small bowel is initiated within ___ the onset of injury.
Respuesta
  • 24 hours after
  • 72 hours after
  • 48 hours after
  • 7 days after

Pregunta 97

Pregunta
The nurse is providing insulin education for an elderly pt with long-standing diabetes. A prescription has been written for the pt to take 20 units of insulin glargine at 10PM nightly. The nurse should instruct the pt that the peak of the insulin action for this agent is
Respuesta
  • 0400
  • 0200
  • peakless
  • 0800

Pregunta 98

Pregunta
Pts experiencing severe physiological stress increase their nutritional requirements to
Respuesta
  • 35 kcal/kg/day
  • 30 kcal/kg/day
  • 50 kcal/kg/day
  • 20 kcal/kg/day

Pregunta 99

Pregunta
The nurse is caring for a pt admitted with new onset of slurred speech, facial droop, and left-sided weakness 8 hours ago. Diagnostic CT scan rules out the presence of an intracranial bleed. Which actions are most important to include the pt's plan of care? (select all that apply.)
Respuesta
  • prepare for thrombolytic administration
  • restrain affected limb to prevent injury
  • maintain MAP less than 130 mmHg
  • maintain CO2 level at 50 mmHg
  • make frequent neurological assessments

Pregunta 100

Pregunta
Pts with muscuoloskeletal injury are at increased risk for compartment syndrome. What is an initial symptom of a suspected compartment syndrome?
Respuesta
  • absence of pulse in affected extremity
  • severe, throbbing pain in the affected area
  • pallor in the affected area
  • paresthesia in the affected area

Pregunta 101

Pregunta
A pt is being ventilated and has been started on enteral feedings with a NG small-bore feeding tube. What is the primary reason the nurse must frequently assess tube placement?
Respuesta
  • to prevent aspiration of the feedings
  • to monitor for skin breakdown on the nose
  • to maintain the patency of the feeding tubes
  • to assess for paralytic ileus

Pregunta 102

Pregunta
A critically ill pt has a nonhealing wound and malnutrition. Which component of nutritional supplementation is most important for this pt to receive?
Respuesta
  • vitamin A
  • branched-chain amino acids
  • omega-3 fatty acids
  • arginine

Pregunta 103

Pregunta
The nurse has just received a pt from the ED with an admitting diagnosis of bacterial meningitis. To prevent the spread of nosocomial infections to other pts, what is the best action by the nurse?
Respuesta
  • scrub the hub of all central line ports before use
  • implement droplet precautions upon admission
  • wash hands thoroughly before leaving the room
  • dispose of all bloody dressings in biohazard bags

Pregunta 104

Pregunta
The nurse is caring for a pt with a diagnosis of head trauma. The nurse notes that the pt's urine output has increased tremendously over the past 18 hours. The nurse suspects that the pt may be developing
Respuesta
  • syndrome of inappropriate secretion of antidiuretic hormone
  • diabetes insipidus
  • hyperosmolar hyperglycemic syndrome
  • DKA

Pregunta 105

Pregunta
A college student was admitted to the ED after being found unconscious by a roommate. The roommate informs emergency medical personnel that the student has diabetes and has been experiencing flulike symptoms, including vomiting, since yesterday. The pt has been up all night studying for exams. The pt used the last diabetes testing supplies 3 day ago and has not had time to go to the pharmacy to refill prescription supplies. Based upon the history, which laboratory findings would be anticipated in this client? (select all that apply.)
Respuesta
  • HCO3: 10 mEq/L
  • blood glucose: 43 mg/dL
  • pH: 7.23
  • blood glucose: 524 mg/dL
  • PaCO2: 37 mmHg

Pregunta 106

Pregunta
The normal rate for the SA node when the pt is at rest is
Respuesta
  • 40-60 bpm
  • 20-40 bpm
  • more than 100 bpm
  • 60-100 bpm

Pregunta 107

Pregunta
The nurse is caring for a pt who was hit on the head with a hammer. The pt was unconscious at the scene briefly but is now conscious upon arrival at the ED with a GCS score of 15. One hour later, the nurse assesses a GCS score of 3. What is the priority nursing action?
Respuesta
  • continue to monitor the pt
  • elevate the head of the bed
  • notify the provider immediately
  • stimulate the pt hourly

Pregunta 108

Pregunta
Which of the following findings require immediate nursing interventions in a pt with traumatic brain injury? (select all that apply.)
Respuesta
  • mean arterial pressure 48 mmHg
  • RR of 10 breaths/min
  • elevated serum blood alcohol level
  • open skull fracture
  • nonreactive pupils

Pregunta 109

Pregunta
The nurse is caring for a client diagnosed with suspected acute pancreatitis. When reviewing the client's laboratory results, the nurse determines that which of these findings will support the diagnosis?
Respuesta
  • elevated serum lipase level
  • decreased serum amylase level
  • decreased serum trypsin level
  • elevated serum bilirubin level

Pregunta 110

Pregunta
Risks of total parenteral nutrition include: (select all that apply.)
Respuesta
  • volume overload
  • elevated blood sugar
  • diarrhea
  • aspiration
  • infection at the catheter site

Pregunta 111

Pregunta
interpret the rhythm
Image:
Image (binary/octet-stream)
Respuesta
  • torsades de pointes
  • pulseless electrical activity
  • ventricular fibrillation
  • systole
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