CRRT and Acute Kidney Injury: Hemodynamic Consequences and Treatment, Exams of Nursing

Download CRRT and Acute Kidney Injury: Hemodynamic Consequences and Treatment and more Exams Nursing in PDF only on Docsity! CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK .  A nurse is caring for a patient with an acute inferior wall MI, post coronary artery stent deployment. For optimal care of this patient, the nurse should: Select single answer choice. A administer an analgesic for acute back pain.clearYou selected. B apply a pressure dressing to the groin.clearYou did not select. C continuously monitor the patient in lead II. D maintain the patient in a supine position. {{Ans- Answer: C It is best practice to continuously monitor a patient, who is post coronary artery stent deployment, in the lead that was most abnormal during the acute occlusion. Lead II would most likely meet this criterion for a patient with an inferior wall MI. The remaining interventions are NOT indicated for a patientwho is post coronary artery stent deployment.  Which of the following ventilator settings is most likely to decrease the work of breathing? A assist- control B pressure support C tidal volume D CPAP {{Ans- Answer: B Pressure support senses the beginning of the patient's spontaneous inspiration and provides a set pressure to assist the inspiratory effort. The primary purpose of the ventilator settings listed in choices (A), (C), and (D) is not to decrease the work of breathing. CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK .  A patient with aortic regurgitation will have which of the following upon auscultation? Select single answer choice. CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . H2O pressure of PEEP D a patient who is receiving a vecuronium (Norcuron) infusion {{Ans- Answer: B A spontaneous awakening trial should be considered for a patient who is receiving a continuous infusion of a sedating drug and/or an analgesic drug and who meets the hemodynamic criteria. A patient who is receiving a propofol infusion is a potential candidate for a spontaneous awakening trial CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . as long as the hemodynamic criteria are met. A patient who is receiving PRN morphine may be a candidate for a spontaneous breathing trial, but that patient does not require an infusion to be stopped in order to be awakened. The remaining 2 choices do not meet the criteria for performing eithera spontaneous awakening trial or a spontaneous breathing trial. -While the code team is performing resuscitative efforts, many of the patient's family members start to cry and pray, while other family members lie down on the floor in the corner of the room. Which of the following demonstrates the best action forthe nurse to take at this time? Select single answer choice. A Ensure that a member of the code team serves as a family presence facilitator and clearly communicates the treatment strategies to the family. B Call security to escort the family members to the waiting room due to their disruptive behavior. C Encourage the family members to leave the patient care area because they are extremely distressed. D Ask the family members to leave the patient care area because they may suffer anxiety from remaining in the room. {{Ans- Answer: A It is important to offer families the opportunity to witness the efforts of the health care team during a patient's cardiopulmonary resuscitation. Research suggests that allowing family members to stay with a patient during this time may decrease their rates of post-traumatic stress disorder, depression, and anxiety related to the event. If the family interferes with the code team's ability to provide care to the patient, it may be necessary to have security remove the family; however, this scenario does not state that the family members are interfering with the code team's efforts, so choice (B) is incorrect. The remaining 2 choices do not allow the family to grieve in a way that may be natural to them. -Cardiogenic shock secondary to left ventricular failure CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . will generally result in: Select single answer choice. A decreased afterload. B a narrow pulse pressure. C decreased preload. D a widening pulse pressure. {{Ans- Answer: B CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . Select single answer choice. A a decrease in the SaO2 B a decrease in the blood pressure C an increase in the heart rate D a shift of the oxyhemoglobin dissociation curve to the left {{Ans- Answer: D Hypothermia shifts the oxyhemoglobin dissociation curve to the left, which inhibits the release of oxygen from hemoglobin, thereby resulting in a higher SaO2 than usual at the same PaO2. The remaining choices are not related to hypothermia. -It is important for a nurse to identify the signs of respiratory depression during procedural sedation. Which of the following is a LATE sign of respiratory depression? Select single answer choice. A a coug h B SpO2 88% C ETCO2 of 50 mmHg per waveform capnography D sedation {{Ans- Answer: B A pulse oximetry decrease is a late sign of respiratory depression. A cough is not indicative of respiratory depression. An elevated ETCO2 per waveform capnography is an early sign of respiratory depression. Sedation precedes respiratory depression. -The most common cause of acute hepatic failure is: Select single answer CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . choice. A alcohol abuse. B a salicylate overdose. C biliary obstruction. D an acetaminophen overdose. CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . {{Ans- Answer: D Alcohol abuse results in chronic, not acute, hepatic failure. A salicylate overdose results in renal failure. Biliary obstruction may lead to pancreatitis or gallbladder disease. -Which of the following is most likely to lead to cardiopulmonary arrest for a patient with status asthmaticus? Select single answer choice. A bronchosp asm. B thick, tenacious secretions. C hypoxe mia. D air trapping. {{Ans- Answer: D Air trapping, due to the inability to effectively exhale, leads to chest hyperinflation, which in turn leads to decreased venous return and a precipitous drop in cardiac output. The remaining choices are seen with status asthmaticus but are not directcauses of cardiopulmonary arrest. -The ECG demonstrates ST elevation in leads II, III, and aVF. The nurse needs to monitor the patient closely forwhich of the following? Select single answer choice. A tachycardia, lung crackles B sinus bradycardia, an acute systolic murmur in the fifth intercostal space, midclavicular C second-degree AV block (Type II), hypotension. D hypoxemia, an acute systolic murmur in the fifth intercostal space, left sternal border. {{Ans- Answer: B CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . B right atrial pressure (RAP) 5 mmHg; pulmonary artery occlusion pressure (PAOP) 7 mmHg; systemic vascular resistance (SVR) 400 dynes/sec/cm-5; cardiac output (CO) 8 L/min. C right atrial pressure (RAP) 5 mmHg; pulmonary artery occlusion pressure (PAOP) 17 mmHg; systemic vascular resistance (SVR) 1,900 dynes/sec/cm-5; cardiacoutput (CO) 2 L/min. D CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . right atrial pressure (RAP) 12 mmHg; pulmonary artery occlusion pressure (PAOP) 7 mmHg; systemic vascular resistance (SVR) 1400 dynes/sec/cm- 5; cardiacoutput (CO) 5 L/min. {{Ans- Answer: B The hemodynamic profile described in choice (B) is typical of septic shock. The patient described in choice (B) would benefit from the interventions described in the question. The hemodynamic profile described in choice (A) is one of hypovolemia. The hemodynamic profile described in choice (C) is one of cardiogenic pulmonary edema. The hemodynamic profile described in choice (D) is one of right ventricular failure. The treatment plan described in the question would not be appropriate for the patients described in choices (A), (C), and (D). -Pulmonary hypertension may result in which of the following? Select single answer choice. A left-sided heart failure. c B right-sided heart failure. C increased lung compliance D arterial hypertension {{Ans- Answer: B The right ventricular wall is normally thinner than the left because the RV generally ejects into a low- pressure pulmonary system with a mean pulmonary artery pressure of approximately 20 mmHg. An increase in the mean pulmonary artery pressure may result in right-sided heart failure. -A patient received a transfusion for upper GI bleeding 4 hours ago. The patient developed acute tachypnea, and the pulse oximeter read 0.88 on room air. After examining the patient and getting a chest radiograph, the physician diagnosed the patient with transfusion-related acute lung injury (TRALI). The nurse anticipates an order for which of the following? Select single answer choice. A CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . furosemide (Lasix). B diphenhydramine (Benadryl). C subcutaneous epinephrine. D aggressive respiratory support. {{Ans- Answer: D CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . Choice (C) is reflective of a patient who has respiratory acidosis with full compensation. Choice (D) is reflectiveof apatient who has uncompensated metabolic acidosis. -A patient has an 18-gauge intravenous catheter in his right wrist. The nurse assessed the insertion site prior to administering an IV medication, and the nurse noticed that there was a red line up the arm above the insertion site, there was no swelling, the catheter blood return was brisk, and the site up the arm with the red line was tender to touch. Which assessment and intervention is appropriate at this time? Select single answer choice. A The patient has an extravasation; apply warm compresses over the insertion site. B The patient has a grade 2 infiltration; restart the IV, and apply cool compresses over the insertion site. C The patient has phlebitis; restart the IV with a 20-gauge catheter in the left arm. D The IV catheter is functional; give the IV medication, and reassess the catheter for blood return in an hour. {{Ans- Answer: C A red line above the insertion site, with tenderness, is a sign that the wall of the vein is inflamed, and the catheter needs to be removed. Reinsertion with a smaller gauge catheter is a strategy that can be used to prevent vein irritation. There is no evidence provided that this patient received a vesicant nor are there signs of an extravasation. Therefore, choice (A) is incorrect. The nurse's findings do not support an infiltration. Therefore, choice (B) is incorrect. The nurse should not administer the IV medication into a vein with phlebitis. Therefore, choice (D) is also incorrect. -Which of the following treatments is appropriate for the corresponding overdose? Select single answer choice. A dialysis for a salicylate overdose B Romazicon for an opiate CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . overdose. C a beta blocker for a cocaine overdose. D warming for a phencyclidine (PCP) overdose. {{Ans- Answer: A Dialysis may be initiated even before abnormal creatinine or GFR develop. The remaining choices are incorrect treatments forthe associated overdoses. CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . -Which of the following would be LEAST likely to cause hypoglycemia for a patient with Type 1 diabetes? Select single answer choice. A late sepsis. B discontinuation of enteral feeding after a morning insulin dose. C a strenuous exercise session. D stress. {{Ans- Answer: D Stress will result in DKA rather than hypoglycemia. The remaining choices may cause hypoglycemia. -A patient with diastolic heart failure develops supraventricular tachycardia, with a heart rate of 220 beats/minute. The most dangerous hemodynamiceffect is a decrease in: Select single answer choice. A myocardial contractility. B coronary artery perfusion. c ejection fraction. D arterial oxygenation. {{Ans- Answer: B Diastolic heart failure results in a problem with left ventricular filling secondary to ventricular thickening, and myocardial contractility and the ejection fraction are maintained in diastolic heart failure. The rapid heart rate will decrease the filling time and worsen the left ventricular filling. Since coronary artery perfusion occurs during diastole, this arrhythmia may be life-threatening. -A 75-year-old patient develops frequent 6- to 10-second episodes of CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . choice. A renal hypoperfusion without tubular basement membrane involvement. B nephrotoxic acute tubular necrosis, intrarenal failure. C ischemic acute tubular necrosis, intrarenal failure. D cortical renal failure with tubular basement membrane involvement. {{Ans- Answer: A CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . A urine sodium less than 20, the renal tubules' ability to concentrate urine, and a BUN/creatinine ratio of ~ 20:1 indicate that the renal tubular basement membrane remains intact. The remaining 3 choices involve an injury to the renal tubular basement membrane and would not produce the lab results described in the question. -Which of the following statements about the provision of enteral nutrition for a critically ill pati ent is accurate? Select single answer choice. A It is preferred over the parenteral nutrition route. B It should be initiated 48 to 72 hours after the first day of mechanical ventilation. C It should be initiated after the patient has bowel sounds and passing flatus. D Enteral nutrition should be withheld if the gastric residual volume is greater than 100 mL. {{Ans- Answer: A If the gut can be used, that is the preferred nutrition route because it is more natural and has fewer complications than the parenteral nutrition route. The remaining choices are not accurate in regard to enteral nutritional support. -A patient with Type 1 diabetes has been started on metoprolol for heart disease. The nurse needs to inform the patient that the first sign of hypoglycemiamight be which of the following? Select single answer choice. A mental status change. B palpitatio ns. C diaphore sis. D irritability. {{Ans- Answer: A CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . The beta blocker (metoprolol) will mask the early signs of hypoglycemia that are due to sympathetic stimulation (tachycardia, palpitations, irritability, headache, shakiness, and diaphoresis). The presenting signs will be the later signs of hypoglycemia (mental status change, slurred speech, seizure, and coma). -Which of the following are appropriate interventions for the treatment of anaphylaxis? Select single answer choice. CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . Balloon deflation in the descending aortic arch right before systole creates a drop in afterload. When the balloon inflates during diastole, blood is displaced into the coronary arteries, increasing coronary artery perfusion. -Which of the following patient diagnoses has the greatest degree of predictability? Select single answer choice. A an acute inferior wall MI B septic shock. C heart failure. D acute leukemia. {{Ans- Answer: A Of the diagnoses listed, the diagnosis of an acute inferior wall MI has the greatest degree of predictability. Predictability is a patient characteristic that considers the degree to which the patient outcome is expected. The remaining 3 choices are more likely to involve unforeseen complications and are therefore are less predictable. -A patient presents with hypotension refractory to initial treatment, and a pulmonary artery catheter is placed. The hemodynamic profile demonstrates right atrial (RA) pressure 1 mmHg, pulmonary artery pressure (PAP) 19/6 mmHg, pulmonary artery occlusion pressure (PAOP) 4 mmHg, systemic vascular resistance (SVR) 1,500 dynes/sec/cm-5, and SvO255%. What is most likely the cause of this patient's hypotension, and what is the appropriate treatment? Select single answer choice. A hypovolemic shock; fluids B septicshock; vasopressors. C cardiogenic shock; IABP. D CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . anaphylactic shock; epinephrine IM. {{Ans- Answer: A Volume depletion results in decreased preload. A compensatory response to volume depletion results in an increase in the SVR in an attempt to maintain pressure. Fluids will restore the filling pressure (preload), and the SVR will return to normal as compensatory mechanisms will no longer be needed. CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . -A patient has right middle and lower lobe pneumonia. Which of the following is an appropriate intervention forthis patient? Select single answer choice. A Provide fluids and expectorants. B Maintain the patient in a supine position. C Withhold enteral nutrition. D Avoid turning the patient to his right side. {{Ans- Answer: D Gravity will increase perfusion to the dependent lung tissue. The "good" lung in this case is the left side. Turning the patient to his right side may precipitate hypoxemia by increasing perfusion to the side with greaterdisease. -A patient was admitted post motor vehicle accident with hypotension and an INR of 8. Which of the following needs to be administered to this patient? Select single answer choice. A protamine sulfate. B vitamin K. C hepari n. D platelets. {{Ans- Answer: B This patient was most likely taking warfarin (Coumadin) prior to admission, which caused an elevated INR. Warfarin works by inhibiting the effects of vitamin K, thereby preventing the conversion of prothrombin to thrombin. A rapid reversal of warfarin with vitamin K is indicated since this patient is hypotensive post MVA and may have internal bleeding. The remaining choices will not decrease the INR. CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . regular feedback. C Discontinue erythropoietin (EPO) and iron pre-op for patients with known anemia. D Default the number of packed red blood cell units to 2 units on standard order sets. {{Ans- Answer: B The identification of providers who do not adhere to blood conservation practices enables a targeted approach for improvement. The remaining choices are all practices that would hinder, rather than improve, blood conservation. CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . -A patient with oat cell carcinoma has the following clinical findings: low urine output, low serum osmolality, hyponatremia, and elevated urine sodium. The nurse anticipates which of the following as part of the treatment plan? Select single answer choice. A vasopressin, free water B vasopressin, hypertonic saline. C phenytoin (Dilantin), 3% saline. D phenytoin (Dilantin), 0.45 normal saline. {{Ans- Answer: C This patient has signs of SIADH, which results in the production of excessive ADH. Phenytoin (Dilantin) will inhibit ADH secretion, and 3% saline will increase the serum sodium. The remaining choices (vasopressin, free water, 0.45 normal saline) will worsen the problem. -What is an indication for which a patient, who is receiving mechanical ventilation, is placed in the prone position? Select single answer choice. A tachypn ea. B hypoventila tion. C pulmonary hypertension. D refractory hypoxemia. {{Ans- Answer: D The prone position helps alleviate refractory hypoxemia (e.g., ARDS) by allowing for the perfusion of lung units that were not able to be perfused while the patient was in the supine position. P lacing the patient in the prone position is not an intervention that is used for the remaining 3 CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . problems. -Which of the following is NOT needed to calculate the creatinine clearance? Select single answer choice. A serum BUN B CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . ARDS. C pneumo nia. D obstructive pulmonary disease. {{Ans- Answer: D Of the choices available, only obstructive pulmonary disease results in a problem "getting air out," which in turn results in air trapping; the flattening of the diaphragm on the chest X-ray is a sign of air trapping. -What would be expected for a patient with intrarenal failure who requires hemodialysis? Select single answer choice. A low urine osmolality, low urine sodium. B high urine osmolality, low urine sodium. C low urine osmolality, high urine sodium. D high urine osmolality, high urine sodium. {{Ans- Answer: C Low urine osmolality and elevated urine sodium are signs of damage to the renal tubular basement membrane, which indicates intrarenal failure. -PEEP therapy and mechanical ventilation are ordered for a patient with acute respiratory failure. Which of the following is a possible complication? Select single answer choice. A barotrau ma. B atelecta sis. C increased venous return. D decreased lung compliance. {{Ans- Answer: A The addition of positive end-expiratory pressure will increase alveolar CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . recruitment, prevent atelectasis, and improve oxygenation. However, the increase in the intrathoracic pressure may lead to a pneumothorax or subcutaneous emphysema. CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . -A patient's chest X-ray demonstrates a right upper lobe infiltrate. The mean arterial pressure (MAP) is 55 mmHg after fluid resuscitation, and the serum lactate is elevated. At this time, which of the following medications is a priority? Select single answer choice. A dopamine (Intropin) B norepinephrine (Levophed). C hydrocortisone (Solu- Cortef). D dobutamine (Dobutrex). {{Ans- Answer: B This patient has septic shock with organ dysfunction, as evidenced by signs of an infection, hypotension despite fluid resuscitation, and elevated serum lactate. A vasopressor is indicated at this point, and norepinephrine is the vasopressor of choice. There are no indications for the administration of the remaining drugs at this time. -Which of the following clinical findings is typical of compensatory shock? Select single answer choice. A hypotens ion B metabolic acidosis. C blood pressure is maintained. D organ failure. {{Ans- Answer: C During the earliest stage of shock (compensatory shock), the compensatory mechanisms are working to maintain the systemic blood pressure. The remaining 3 choices are seen in the progressive and refractory stages of shock. CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . serum sodium. C serum glucose. D serum osmolality. {{Ans- Answer: D Although both DKA and HHS result in elevated serum glucose, the serum osmolalityof a patient with HHS will be greater than the serum osmolality of a patient with DKA since HHS develops more slowly CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . than DKA, which results in a higher serum glucose. The higher serum glucose of HHS results in a higher serum osmolality. An additional differentiating finding is that a patient with DKA will have positive ketones. -A patient presented with status asthmaticus and required mechanical ventilation. Which of the following findings would be expected shortly after intubation? Select single answer choice. A peak inspiratory pressure 68 cm H2O pressure; plateau pressure 25 cm H2O pressure. B peak inspiratory pressure 68 cm H2O pressure; plateau pressure 40 cm H2O pressure. C peak inspiratory pressure 28 cm H2O pressure; plateau pressure 22 cm H2O pressure. D peak inspiratory pressure 28 cm H2O pressure; plateau pressure 42 cm H2O pressure. {{Ans- Answer: A Due to bronchospasm, the airway pressure will be elevated (elevated peak inspiratory pressure), but the lung pressure itself (plateau pressure) will not be elevated above 30 cm H2O pressure. -A man is admitted with a gunshot wound to the head. The nurse is told by the trauma surgeon that the patient has cranial nerve III involvement. Which of the following is evidence of cranial nerve III involvement? Select single answer choice. A loss of gag reflex. B right pupil is dilated and nonreactive. C decerebrate posturing. D loss of vision in the right visual field bilaterally. {{Ans- Answer: B Cranial nerve III is the oculomotor nerve, which controls the pupillary CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . response. Compression of this nerve on the side of the injury (ipsilateral) results in pupildilation on that side. -Which of the following is a contraindication to noninvasive ventilation? Select single answer choice. A a need for FiO2 of 0.60. CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . C a fever D neuromuscular blocking agents {{Ans- Answer: C A fever increases the metabolic rate and oxygen consumption, which may lead to a drop in the mixed venous oxygen saturation. The remaining choices may increase the SvO2 since they are associated with a decrease in oxygen utilization. -A patient's arterial line waveform on the bedside monitor appears overdamped. The nurse understands that this: Select single answer choice. A may be due to pinpoint air bubbles in the tubing/transducer system. B leads to a false high pressure reading. C may be due to add-on pressure tubing. D leads to a false low pressure reading. {{Ans- Answer: D An overdamped arterial line waveform leads to a false low pressure reading, and the arterial pressure reading from the monitor should not be used to assess and treat the patient until the overdamped waveform is corrected. The remaining 3 choices relate to an underdamped arterial line waveform. -A patient is being treated for status epilepticus, and he requires intubation and mechanical ventilation. Which of the following possible pathophysiological changes might the nurse anticipate? Select single answer choice. A hypokale mia. B CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . decreased PaCO2.. C bradycar dia D elevated creatine kinase (CK). {{Ans- Answer: D The destruction of skeletal muscle cells occurs secondary to seizure activity, which results in the release of creatine kinase (CK) into the serum. If skeletal muscle cell destruction is not controlled, the elevated CKs may lead to rhabdomyolysis and acute kidney injury. Neuromuscular blocking agents may be used to CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . stop the skeletal muscle seizing and to prevent skeletal muscle damage. (Note that the patient may still be seizing when clinically paralyzed; therefore, continuous EEG monitoring is indicated to determine whether or not the patient is seizing.) Hyperkalemia, elevated PaCO2, and tachycardia are also associated with status epilepticus, which makes the remaining 3 choices incorrect. -A 19-year-old male was admitted with traumatic injuries secondary to a motor vehicle accident. The ECG demonstrates a sinus rhythm with a short PR interval and the presence of a slow rise of the initial upstroke of the QRS. This patient is at risk for developing which of the following? Select single answer choice. A pre-excited atrial fibrillation. B second-degree AV block, Type II. C third-degree AV block. D atrial flutter {{Ans- Answer: A This patient has Wolff-Parkinson-White (WPW) syndrome, as evidenced by a short PR interval with the presence of a delta wave (a slow rise of the initial upstroke of the QRS). The abnormal conduction pathway of WPW may result in a supraventricular tachycardia (SVT) or cause pre-excited atrial fibrillation (an irregular rhythm, rates of 150 beats/minute or greater, and a wide QRS). WPW does not cause the remaining arrhythmias listed in choices (B), (C), and (D). -A patient has a blood pressure of 78/40, a right atrial (RA) pressure of 1 mmHg, a pulmonary artery occlusion pressure (PAOP) of 4 mmHg, a systemic vascular resistance (SVR) of 1,800 dynes/s/cm-5, and a cardiac output (CO) of 3 L/min. Which of the following statements about this patient is correct? Select single answer choice. A The patient has septic shock; provide CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . provide an accurate self- report, is to ask the patient's family member whether the patient's behavior is an indication of pain. The remaining 3 strategies are not effective for pain assessment and management. -A patient was admitted 24 hours ago with ST elevation in leads II, III, and aVF and cardiogenic shock. The patient was stabilized, but she now complains of acute dyspnea. Her PAOP is 22 mmHg with giant V - waves. The nurse anticipates: CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . Select single answer choice. A papillary muscle rupture. B mitral stenosis. C a pulmonary embolism. D reinfarction. {{Ans- Answer: A This clinical picture describes acute cardiogenic pulmonary edema, and giant V-waves are a sign of acute backflow of blood into the left atrium during systole. A patient with an inferior wall MI is more likely to develop acute mitral valve papillary muscle dysfunction or rupture, leading to mitral valve regurgitation. -A patient with right ventricular infarction would most likely have which of the following hemodynamic pressure findings? Select single answer choice. A right atrial (RA) 4 mmHg, pulmonary artery occlusion pressure (PAOP) 18 mmHg. B right atrial (RA) pressure 14 mmHg, pulmonary artery occlusion pressure (PAOP) 5 mmHg. C right atrial (RA) 14 mmHg, pulmonary artery occlusion pressure (PAOP) 18 mmHg. D right atrial (RA) 0 mmHg, pulmonary artery occlusion pressure (PAOP) 5 mmHg. {{Ans- Answer: B Due to decreased RV ejection, the right atrial pressure increases. Failure of the RV results in decreased left ventricular preload (low PAOP). The lungs will be clear, but the cardiac output and the B/P may decrease. -A patient requires fluid resuscitation and 8 units of PRBCs status post traumatic injury. Which of the following interventions is most appropriate? Select single answer CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . choice. A Warm both blood products and crystalloids. B Monitor for hypercalcemia. C Start norepinephrine for a systolic pressure less than 90 mmHg. CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . -A Jehovah's Witness was admitted with a bleeding, perforated gastric ulcer. The patient's hemoglobin and hematocrit have decreased. Which of the following interventions is most appropriate for this patient? Select single answer choice. A Explain the consequences of refusing blood transfusions. B Administer washed PRBCs. C Ask the patient to sign a "No CPR" order. D Administer platelets. {{Ans- Answer: A The health care team would need to explain the consequences of refusing blood transfusions, as well as possible options, and ensure that the patient and her family understand this information. The hospital legal team may need to get involved. Choices (B) and (D) are not acceptable to a Jehovah's Witness. A "No CPR" order may need to be discussed, but that is not the priority intervention at this time. -A patient is 5 days status post subarachnoid hemorrhage, and she develops a change in level of consciousness and hyponatremia. Which of the following orders should the nurse anticipate? Select single answer choice. A Administer furosemide (Lasix). B Infuse 3% saline. C Maintain the cerebral perfusion pressure (CPP) with 0.9 normal saline. D Obtain a CT scan of the brain. {{Ans- Answer: C This patient has signs of vasospasm, and maintaining the CPP (in order to prevent worsening of the vasospasm) is a priority. Administering a diuretic may lead to hypotension and could worsen the vasospasm. 3% saline is generally indicated for extreme hyponatremia or an increased ICP, neither of which are described in this scenario. Diagnosing vasospasm is done with a CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . Transcranial Doppler, not with a CT scan. -To provide appropriate care for a patient who requires mechanical ventilation, the nurse needs to: Select single answer choice. A instill saline during suctioning. B CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . maintain the patient in a supine position. C hyperoxygenate during suctioning. D deflate the ETT cuff every 4 hours. {{Ans- Answer: C The insertion of a suction catheter into a tracheal tube during a suctioning procedure may decrease the SaO2. Although oxygen desaturation may not occur during every suctioning procedure, it may occur unpredictably. Therefore, it is best practice to increase the FiO2to 1.00 prior to beginning the suctioning procedure. Most ventilators provide the FiO2 of 1.00 that is needed for hyperoxygenation for a predetermined amount of time (for example, 2 minutes). -A post-op patient is undergoing negative-pressure wound therapy. What is an appropriate nursing intervention forthis patient? Select single answer choice. A Contact the physician if there is blocked tubing. B Change the dressing daily. C Maintain the continuous negative pressure at -150 mmHg. D Discontinue negative-pressure wound therapy during the night. {{Ans- Answer: A The physician needs to be notified if it is suspected that the tubing is blocked (as evidenced by an alarm and/or a lack of drainage). The physician will order flushing of the tubing or discontinuation of the therapy and the application of a wet-to-damp dressing until therapy can be resumed. The remaining interventions are not appropriate during negative-pressure wound therapy. -Which of the following arrhythmias typically manifests itself before a person is 30 years old? Select single answer choice. A Wolff-Parkinson-White (WPW) CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . -A patient presents with a rigid abdomen, rebound tenderness, and free air in the peritoneum, as seen on a KUB X-ray. Which of the following describes the condition that the nurse should anticipate and the appropriate interventions? Select single answer choice. A CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . acute pancreatitis; provide gastric decompression and analgesia. B bowel perforation; provide fluids, prepare for surgery. C small bowel obstruction; provide fluids and gastric decompression D large bowel obstruction; provide antibiotics, prepare for surgery. {{Ans- Answer: B The clinical signs are those of bowel perforation. These clinical signs are not typical of the problems listed in the remaining 3 choices. -A patient with acute ST elevation myocardial infarction received fibrinolytic therapy. Which of the following is a sign of successful coronary artery reperfusion? Select single answer choice. A increased blood pressure. B return of the ST segment to baseline. C resolution of the S4 heart sound. D improved oxygenation. {{Ans- Answer: B Since ST segment elevation is a result of a myocardial infarction (MI) secondary to a lack of perfusion, the return of the ST segment to baseline is a sign of a return of perfusion. The remaining 3 choices are not signs of successful coronary artery reperfusion. -Which of the following is a priority treatment for a patient with DKA who presents with hyperglycemia, ketosis, and normal serum potassium? Select single answer choice. A Reduce serum glucose by 100 to 150 mg/dL/hr. B Administer potassium. C CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . Administer sodium bicarbonate. D Infuse hypertonic saline. {{Ans- Answer: B A patient with DKA will have a low pH and metabolic acidosis. In a state of metabolic acidosis, hydrogen ions (H+) move into the intracellular space. In exchange, potassium leaves the intracellular space. The movement of K+ into the extracellular space results in hyperkalemia (although the total body K+ has not increased). Since this patient presented with acidosis and a normal serum potassium, the total body K+ CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . A a calcium channel blocker and anticoagulation. B cardioversion and a beta blocker. C digoxin and aspirin. D amiodarone and oxygen. {{Ans- Answer: A The patient history seems to be one of intermittent atrial fibrillation over the past week. Controlling the heart rate (with a calcium channel blocker) and addressing potential left atrial clot formation (with anticoagulation) are the priority treatments. Cardioversion is reserved for an unstable patient. Digoxin may be used to control the heart rate (although the onset of that effect is slow), and aspirin is not an anticoagulant. Amiodarone may result in a conversion to sinus rhythm, but the administration of this drug should not be attempted until the patient has been anticoagulated. -A patient with hypoparathyroidism demonstrates a positive Chvostek sign and a positive Trousseau sign. What electrolyte imbalance (that is associated with hypoparathyroidism) is the most likely cause of these signs, and for what other potential sign (related to this electrolyte imbalance) does this patient need to be monitored for? Select single answer choice. A hypokalemia; arrhythmias. B hypercalcemia; kidney stones. C hypophosphatemia; hypoventilation. D hypocalcemia; laryngospasm. {{Ans- Answer: D Hypocalcemia is an electrolyte imbalance that is associated with hypoparathyroidism, and a positive Chvostek sign and/or a positive Trousseau sign are manifestations of hypocalcemia. Laryngospasm is another sign caused by hypocalcemia; therefore, this patient needs to be monitored for this sign as well. The remaining electrolyte imbalances are not associated with a diagnosis of hypoparathyroidism. CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . -Which of the following are the best indicators for a diagnosis of septic shock? Select single answer choice. A an infection and SIRS. B an infection and a fever. C CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . an infection and serum lactate 8. D an infection and a positive blood culture. {{Ans- Answer: C Elevated lactate is evidence of anaerobic metabolism, and it is the best indicator of septic shock of the choices listed. The remaining choices (SIRS, a fever, and a positive blood culture) may be present in sepsis, but they are not specific to a shock state. Additionally, septic shock may be present without signs of a fever ora positive blood culture. -A patient is receiving positive inotropes, vasodilators, and diuretics. This patient most likely has which of the following problems? Select single answer choice. A right ventricular failure. B left ventricular systolic heart failure C papillary muscle rupture. D hypertrophic cardiomyopathy. {{Ans- Answer: B Positive inotropes increase contractility, vasodilators decrease afterload, and diuretics decrease preload. Since a patient with systolic heart failure has decreased contractilityand increased afterload and preload, these agents will be useful forthe treatment of this problem. -A ventricular septal defect is most likely to have which of the following clinical findings? Select single answer choice. A diastolic murmur at the apex of the heart B systolic murmur at the fifth intercostal space, midclavicular C diastolic murmur at the base of the heart D systolic murmur at the fifth intercostal space, left sternal border {{Ans- CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . Select single answer choice. A hypovolemic shock; fluids B septic shock; vasopressors C cardiogenic shock; IABP CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . D anaphylactic shock; epinephrine IM{{Ans- Answer: B The massive vasodilation, loss of vascular tone, and capillary leak caused by endotoxins results in decreased preload and decreased afterload. Endotoxins prevent oxygen utilization, which results in a high SvO2. Vasopressors will restore the vascular tone. None of the remaining choices results in an elevated SvO2. -A patient with right middle lobe pneumonia would be expected to have which of the following assessment findings overthe affected area? Select single answer choice. A inspiratory and expiratory wheezing B expiratory wheezing and fine crackles C bronchial breath sounds and whispered pectoriloquy D absent breath sounds with fremitus {{Ans- Answer: C Over an area of lung consolidation, the breath sounds are louder (bronchial) than over normal lung tissue. Words that are whispered by the patient will be heard clearly through the stethoscope (whispered pectoriloquy) because sound travels faster through liquids or solids than it does through air. -What would increase the risk of developing contrast media nephropathy, and what intervention may prevent it? Select single answer choice. A age less than 18 years old; NSAIDs pre-procedure B edema; using low-osmolar contrast media C calcium channel blockers; diuretics pre-procedure D diabetes; hydration pre-procedure {{Ans- Answer: D CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . Prolonged exposure to elevated serum glucose has an adverse effect on the tubular basement membrane, and exposure to contrast media may trigger renal failure. Pre-procedure hydration causes the release of prostaglandins, which leads to dilation of the efferent arteriole and possible prevention of renal failure. The remaining choices are not known to lead to contrast media nephropathy. CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . C T-wave inversion, elevated troponin D ST depression, unrelenting chest pain {{Ans- Answer: B This type of angina is thought to be due to an arterial spasm at the point of coronary artery plaque, not due to plaque rupture. The ST elevation is transient because the spasm is relieved with nitrates; therefore, infarction does not occur. -The most specific clinical sign for the presence of brain death would include which of the following? Select single answer choice. A absent oculocephalic reflex B negative apnea test C co ma D positive Babinski reflex {{Ans- Answer: A An absent oculocephalic reflex (the eyes remain midline or turn to the side of head rotation) is a sign of cranial nerve VIII damage and possible brain death. The apnea test is positive in the presence of brain death. While a coma is present during brain death, most patients in a coma do not have brain death. A positive Babinski reflex is a sign of uppermotor neuron damage, not brain death. -A patient was admitted to the ICU status post removal of a cancerous skin lesion on the right upper chest. The patient complained of intense pain surrounding the surgical area and the underlying muscle. There was initially minor redness surrounding the surgical area, but now there is an area of necrosis with purplish discoloration over the surrounding area. The initial wound culture was positive for clostridial myonecrosis. The nurse knows that: Select single answer choice. A CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . the patient is at risk for developing anaphylactic shock. B the patient will require treatment for gas gangrene. C hyperbaric oxygen therapy is a priority treatment. D a single surgical debridement intervention will resolve the problem. {{Ans- Answer: B Clostridial myonecrosis is also known as gas gangrene. This patient most likely has necrotizing fasciitis, which may progress to septic shock, not anaphylactic shock, so choice (A) is incorrect. Hyperbaric oxygen therapy is not a priority treatment, but it may be useful for select patients. Since it is not a CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . priority treatment, choice (C) is incorrect. Surgical debridement will be needed, not only initially, but repeatedly until the spread of the necrosis is resolved. -Prerenal failure may be precipitated by which of the following in high-risk patients? Select single answer choice. A acetaminop hen B calcium channel blockers C beta blockers D NSAIDs {{Ans- Answer: D Chronic use of NSAIDs prevents dilation of the efferent renal arteriole, and this dilation may be needed when renal perfusion is stressed by hypovolemiaorother stressors. -A patient has a blood pressure of 78/40, a right atrial (RA) pressure of 13 mmHg, a pulmonary artery occlusion pressure (PAOP) of 5 mmHg, a systemic vascular resistance (SVR) of 1,900 dynes/sec/cm-5, and a cardiac output (CO) of 1.9 L/min. Which of the following statements about this patient is correct? Select single answer choice. A The patient has septic shock; provide vasopressors. B The patient has cardiogenic shock; provide positive inotropes. C The patient has hypovolemic shock; provide fluid resuscitation. D The patient has right ventricular infarct; provide fluids. {{Ans- Answer: D The hemodynamic profile described is that of right ventricular (RV) failure, which may be se condary to acute RV infarct. The elevated SVR is not typical of septic shock, which rules out choice (A). The low PAOP is not seen CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . a prolonged QT interval. C right bundle branch block. D ST elevation in V1 and V2. {{Ans- Answer: B An acute PE will not cause a prolonged QT interval. (However, you will be expected to know what may cause a prolonged QT interval for the Adult CCRN exam.) The remaining choices may occur with an acute PE, especially a PEthat causes elevated right ventricular pressure. CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . -The physician determines that the patient has ARDS. The patient has developed refractory hypoxemia, bilateral infiltrates, and pulmonary edema, as confirmed by a chest X-ray. Which of the following findings would be expected for apatient with this diagnosis? Select single answer choice. A increased lung compliance B PAOP is normal or low C decreased work of breathing D decreased cardiac output {{Ans- Answer: B The pulmonary edema of ARDS is due to lung capillary leak at a normal or even low left heart pressure (PAOP). This is unlike cardiogenic pulmonary edema, which results in pulmonary edema at a higher than normal left heart pressure (a PAOP of 18 mmHg or greater). -A patient has hepatic encephalopathy and elevated serum ammonia (NH3). Which of the following is a clinical sign of elevated NH3? Select single answer choice. A jaundi ce B asteri xis C ascit es D hyperglycemia {{Ans- Answer: B Asterixis is a motor disorder that is manifested as a tremor of the hand when the wrist is extended. Elevated serum ammonia results in abnormal functioning of the diencephalic motor centers in the brain, and these motor centers regulate the muscles that are involved in maintaining position. The remaining 3 choices are not clinical signs of elevated serum ammonia. CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . -Which of the following ABG results (which were obtained from patients with status asthmaticus who were receiving oxygen at 3 L/minute via a nasal cannula) most likely indicates an immediate need for intubation and mechanical ventilation? Select single answer choice. A pH 7.40; PaCO2 39; HCO3 24; PaO2 100 CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . -Which of the following clinical findings is indicative of impending brain herniation? Select single answer choice. A a cerebral perfusion pressure of 80 mmHg. B a change in the level of consciousness. C sustained A waves on an ICP tracing. D a Glasgow Coma Scale score of 13. {{Ans- Answer: C A waves are "awful." They are a sign of a sustained increase in the intracranial pressure (ICP), which, if not lowered, will result in brain stem herniation. A cerebral perfusion pressure (CPP) of 80 mmHg is normal. A change in the level of consciousness (LOC) is not normal, but that is not a sign of impending brain herniation. A Glasgow Coma Scale score of 13 is also not normal, but that is not a sign of impending brain herniation. -An orientee's patient experiences cardiac arrest and requires resuscitation. The preceptor, who is orienting the new nurse to the unit, sees that the orientee has placed the patient in the reverse Trendelenburg position. What would be the preceptor's best response at this time? Select single answer choice. A Immediately begin chest compressions. B Explain the problem with the current position to the orientee, and teach the orientee what the correct position should be. C Place the patient in a supine position D Ask the orientee why he put the patient in that position. {{Ans- Answer: C The preceptor needs to do what is best for the patient in this emergency situation. Beginning chest compressions with the head of the bed elevated would not be the best intervention for the patient. For that reason, choice CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . (A) is incorrect. This is not the appropriate time to use the situation to coach the orientee. For that reason, choice (B) is incorrect. Discussing the orientee's rationale for putting the patient in that position would best be done at a later time. For that reason, choice (D) is also incorrect. -The hospital Nursing Practice Committee wants to provide criteria for the maintenance of a central venous catheter in order to decrease the CLABSI rate. Which of the following is a reason to maintain a central venous catheter? Select single answer choice. CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . A The patient requires acute hemodialysis. B The patient requires frequent lab draws. C The patient is receiving mechanical ventilation. D The patient requires peripheral parenteral nutrition. {{Ans- Answer: A A patient who requires emergent hemodialysis (or CRRT) will need a central venous catheter (CVC). Each of the remaining choices alone is not a requirement formaintaining a CVC. -A patient assessment reveals a fever and nuchal rigidity. A lumbar puncture is done, and the cerebrospinal fluid (CSF) results include the following: clear in appearance, glucose 60 mg/dL, mildly elevated protein, mildly elevated WBC count, and opening pressure 150 cm H2O. Treatment for this patient will most likely includewhich of the following? Select single answer choice. A supportive care. B airborne isolation. C antibiotic therapy. D targeted temperature management. {{Ans- Answer: A Treatment for this patient includes supportive care (e.g., fluids, fever management). The clinical signs described indicate that this patient has meningitis, and the results of the lumbar puncture indicate that the meningitis is viral. Antibiotics are indicated for bacterial meningitis, not viral meningitis. Isolation and targeted temperature management are not indicated forviral meningitis. -A patient's bladder pressure has ranged between 15 and 20 mmHg over the past 12 hours. Which of the following interventions is indicated for this patient? Select single answer CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . included in the treatment plan for a patient with cocaine intoxication. -Which of the following patients has a contraindication to increasing her activity to standing and pivoting to a chair? Select single answer choice. A The patient developed atrial fibrillation 3 days ago and is receiving a diltiazem (Cardizem) drip. CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . B The patient is receiving mechanical ventilation, with an SpO2 of 0.94, an FiO2 of 0.40, and a PEEP of 5 cm H2O pressure. C The patient is arousable to vigorous shaking but is not arousable to voice or touch. D The patient is receiving norepinephrine 5 mcg/min and is being weaned off of it. {{Ans- Answer: C The patient described in choice (C) is not ready for weight-bearing if she is not responsive to verbal stimulation. According to the MOVE criteria, the patients described in choices (A), (B), and (D) do not have contraindications to mobility progression. -Which of the following electrolyte abnormalities does NOT result in hyperreflexia? Select single answer choice. A hypocalce mia B hypermagnes emia. C hyperphosphat emia. D hypomagnesemia {{Ans- Answer: B Hypermagnesemia results in decreased deep tendon reflexes (DTRs). The remaining electrolyte abnormalities result in hyperreflexia. -Which of the following patients is NOT at a high risk for a fall? Select single answer choice. A The patient has an indwelling urinary catheter. B The patient requires an antidepressant. C The patient fell at home last month. D CCRN CRITICAL CARE NUR EXAM LATEST QUESTIONS AND 100% CORRECT ANSWERS TEST BANK . The patient is restrained. {{Ans- Answer: B A need for antidepressants has not been shown to increase the risk for falling. The remaining circumstances have been shown to contribute to a patient's risk fora fall. -A patient is status post motor vehicle accident with a large chest bruise. The nurse knows that this patient needs to be assessed for which of the following?