Critical Care Exam 3

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

continuous renal replacement therapy (CRRT) differs from conventional intermittent hemodialysis in that

which of the following laboratory values would be found in a patient with syndrome of inappropriate secretion of antidiuretic hormone?

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 _____

which of the following pts is at greatest risk of developing acute kidney injury? A pt who

when assessing the pt's bowel sounds, the nurse

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:

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

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?

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?

The pt has a platelet count of 9,000/microliter. The nurse realizes that

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:

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

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?

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?

The best nursing approach to prevent feeding tube obstruction is to

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?

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?

The need for fluid resuscitation can be assessed best in the trauma pt by monitoring and trending which of the following tests?

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?

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

A pt with acute pancreatitis is started on parenteral nutrition. Nursing care for this pt includes all EXCEPT:

The pt has yellow skin and low hemoglobin and hematocrit levels. The nurse should look for

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

During the treatment and management of the trauma pt, maintaining tissue perfusion, oxygenation and nutritional support are strategies to prevent

The pt is admitted with acute pancreatitis. The nurse should

The nurse is caring for a pt who has a temporary percutaneous dialysis catheter in place. In caring for this pt, the nurse should

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

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

In addition to residual stomach volume, what other evidence suggests feeding intolerance?

Discharge teaching for a client recovering from an attack of chronic pancreatitis should include which of the following instructions?

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?

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

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?

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

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

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

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

Acute kidney injury from postrenal etiology is caused by

The most common cause of acute kidney injury in critically ill pts is

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?

The pt is diagonosed with hepatitis. In caring for this pt, the nurse should

The nurse notices sinus bradycardia on the pt's cardiac monitor. The nurse should

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?

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?

In assessing the pt complaining of abdominal pain, it is more important for the nurse to understand that

Which of the following injuries would result in a greater likelihood of internal organ damage and risk for infection?

Which of the following interventions is a strategy to prevent fat embolism syndrome?

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?

Acute adrenal crisis is caused by

The nurse is caring for a pt with acute pancreatitis. To provide adequate pain control, the nurse

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?

During cardiac resuscitation for ventricular fibrillation, which drug would a nurse most likely prepare first?

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?

signs and symptoms associated with flail chest include

Infection by Helicobacter pylori bacteria is a major cause of

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?

Range of motion exercises, early ambulation, and adequate hydration are interventions to prevent

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

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

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:

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?

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

Which of the following will cause a nurse to suspect that pt's pulmonary contusion is worsening?

After receiving the handoff report from the day shift charge nurse, which pt should be evening charge nurse assess first?

The term used to describe an increase in BUN and serum creatinine is

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

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?

A nurse is field-triaging clients after an industrial accident. Which client condition should the nurse triage with a red tag?

The pt has a total WBC of 600 cells/microliter. The differential shows a normal neutrophil level of 70% with 5% bands. The pt

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

Which of the following interventions would not be appropriate for a pt who is admitted with a suspected basilar skull fracture?

Conditions that produce acute kidney injury by directly acting on functioning kidney tissue are classified as infrarenal. The most common intrarenal condition is

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?

The liver detoxifies the blood by

Which of the following statements about mass casualty triage during a disaster is true?

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

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

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?

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?

A pt has been admitted to the ED with a massive hemothorax. What action by the nurse takes priority?

In trauma pts, enteral nutrition via NG tube feedings into the small bowel is initiated within ___ the onset of injury.

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

Pts experiencing severe physiological stress increase their nutritional requirements to

Pts with muscuoloskeletal injury are at increased risk for compartment syndrome. What is an initial symptom of a suspected compartment syndrome?

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?

A critically ill pt has a nonhealing wound and malnutrition. Which component of nutritional supplementation is most important for this pt to receive?

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?

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

The normal rate for the SA node when the pt is at rest is

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?

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?