CCRN Practice Questions with 100% CORRECT ANSWERS BEST GRADED A+, Exams of Nursing

Download CCRN Practice Questions with 100% CORRECT ANSWERS BEST GRADED A+ and more Exams Nursing in PDF only on Docsity! CCRN Practice Questions with 100% CORRECT ANSWERS BEST GRADED A+ A 47-year-old male has been admitted to the CCU from the emergency room with a history of sudden diaphoresis, nausea, vomiting and radiating pain down his left arm. He reports no significant medical history, and has been a two PPD smoker since his early twenties. His admitting diagnosis is UA/NSTEMI and he is being prepped for cardiac catheterization for possible angioplasty with stent placement. What type of medication orders might the nurse see prior to his procedure? a. Clopidogrel and ASA b. Clopidogrel and prasugrel c. Clopidogrel and meperidine d. Prasugrel, ASA, and hyoscyamine - SOLUTION a. Clopidogrel and ASA Agnes is a 65-year-old white female who has a history of pulmonary fibrosis with steroid use for the past two years with concomitant hypertension. She has been on oxygen therapy at 4L per nasal cannula for the past 3 years. Recently, her first great-grandchild was born, and she decided to quit smoking. Three days ago, she experienced nausea and dizziness and was admitted to the CCU with a diagnosis of acute myocardial infarction. During shift change, Agnes' low blood pressure alarm sounds. Upon assessment, she is diaphoretic and has severe dyspnea. What is the most likely cause of her symptoms? a. Exacerbation of pulmonary fibrosis b. Pulmonary embolism c. Recurrent myocardial infarction d. Papillary muscle rupture - SOLUTION d. Papillary muscle rupture Norman is a 65-year-old paraplegic who resides in a nursing home. He presents with a 3-day history of increased temperature, productive cough, and increased weakness. His caregiver states that he had developed a decubitis ulcer, and has not been able to tolerate sitting in his wheelchair, so has been in bed for the past week. Bibasilar crackles are audible on auscultation, with overall diminished breath sounds bilaterally. Obvious respiratory distress is apparent with tachypnea, suprasternal retractions and use of accessory muscles. Vitals: T-100.2F, HR-120, RR-28, BP 104/50, O2 Sat on RA - 88%. An initial chest x-ray reveals the "spine sign" and a normal cardiac silhouette. What is the most likely cause of Norman's condition? a. CAP b. HCAP c. NHAP d. HAP - SOLUTION c. NHAP - Nursing home acquired pneumonia What does the finding of "spine sign" on a chest x-ray indicate? a. Pre-existing spinal injury b. Kyphosis c. Pneumonia d. Scoliosis - SOLUTION c. Pneumonia If a patient is suspected of having an episode of acute hypoglycemia, which of the following is NOT the most appropriate first intervention? a. Draw a STAT blood glucose level. b. Give the patient a ½ glass of orange juice. c. Give the patient IV dextrose or IM glucagon. d. Check the blood glucose with a glucometer. - SOLUTION a. Draw a STAT blood glucose level. Marilyn is a Type I diabetic who has been admitted to the unit after a severe hypoglycemic episode in which she lost consciousness. She states that she has had many episode of hypoglycemia, but just does not seem to know when they are coming on anymore. What is the term for this phenomenon? a. Hypoglycemia tolerance b. Hypoglycemia unawareness c. Hypoglycemia latency d. Hypoglycemia neurosis - SOLUTION b. Hypoglycemia unawareness Of the following, which is included in the etiology of idiopathic thrombocytopenic purpura (ITP)? Ramona is a 21-year-old who has been admitted to the ICU after suffering an anaphylactic reaction during dinner due to peanut sauce in a dish that the host didn't tell her about. She was stabilized in the emergency room with IV epinephrine and IV diphenhydramine. However, 4 hours after being admitted to the ICU she becomes anxious, develops hives and begins to have difficulty breathing. What is the most likely cause for Ramona's symptoms? a. Persistent anaphylaxis b. Biphasic anaphylaxis c. Unresponsive anaphylaxis d. Rebound anaphylaxis - SOLUTION b. Biphasic anaphylaxis Madge is a 91-year-old nursing home resident with a history of dementia and atrial fibrillation who has been admitted to the ICU for treatment of pneumonia. As you are performing her bed bath, you note bruising around her breasts and genital area. What potential issue should be of major concern in Madge's situation? a. Idiopathic thrombocytopenia purpura (ITP) b. Embolic stroke c. Sexual abuse d. Nursing home acquired pneumonia (NHAP) - SOLUTION c. Sexual abuse Jerry is a 55-year-old veteran who has been admitted after a motor vehicle accident with multiple injuries. His friend reported that he had been using synthetic marijuana prior to the accident, and that he also sees a psychiatrist at the VA hospital for an unknown diagnosis. He stated that Jerry sometimes gets "hyper" for no reason, starts "ranting" and becomes violent. Of the following, which general psychiatric disorder is characterized by a pattern of aggression or violence which includes irritability, agitation, and violent behavior during manic or psychotic episodes? a. Schizophrenia b. Post-traumatic stress disorder (PTSD) c. Bipolar disorder d. Delusional disorder - SOLUTION c. Bipolar disorder Emily has been admitted to the ICU after being found unconscious on the street. She was found to be in diabetic ketoacidosis (DKA) with a blood sugar of 785. Emily is homeless, has had multiple admissions for DKA, and could benefit from use of an insulin pump, but says she has been repeatedly told, "Those are for rich people." What ethical principle supports Emily's right to have an insulin pump? a. Beneficence b. Nonmalficence c. Justice d. Autonomy - SOLUTION c. Justice Tonya is a 44-year-old with a history of substance abuse who has been admitted to the ICU status-post left lateral thoracotomy. She has been clean and sober for 14 years, and discussed her status with her physician prior to her surgery. When she arrives from the operating room, she is in a great deal of pain. Post-operative pain management orders are for acetaminophen only. When you ask the surgeon for an opioid for pain management, he states, "She's an addict. She doesn't need anything for pain." What should your first response be? a. Report the doctor to administration b. Discuss the situation with the doctor privately c. Complain to the other nurses d. Ask another doctor to intervene - SOLUTION b. Discuss the situation with the doctor privately What are the benefits of intra-aortic balloon (IAB) therapy for a patient with cardiogenic shock? a. Increase afterload with balloon deflation and decrease diastolic augmentation with balloon inflation b. Decrease afterload with balloon inflation and decrease diastolic augmentation with balloon deflation c. Increase afterload with balloon inflation and decrease diastolic augmentation with balloon deflation d. Decrease afterload with balloon deflation and increase diastolic augmentation with balloon inflation - SOLUTION d. Decrease afterload with balloon deflation and increase diastolic augmentation with balloon inflation Balloon deflation right before left ventricular (LV) ejection (prior to systole) decreases afterload. Balloon inflation after aortic valve closure at the beginning of diastole augments blood flow to the coronary arteries. Which intervention is indicated in the management of chest tubes for a postoperative cardiac surgery patient? a. Clamp the tube during patient transport b. Avoid dependent loops kinking c. Contact provider for bubbling in the suction chamber d. Strip the tubing if clots appear - SOLUTION b. Avoid dependent loops or kinking a - only should be done if provider ordered, when changing the system, or there is a disconnect c - normal d - can greatly increase pressure in system (shouldn't be done) An RN is caring for a patient post-op cardiac surgery and notes that the patient's chest tube output has been greater than 100 mL for two consecutive hours. What will the nurse do next? a. Milk the chest tubes b. Contact the physician c. Administer vasopressors d. Administer vitamin K - SOLUTION b. Contact the physician Which of the following are indicative of cardiac tamponade post-op heart surgery? a. hypotension, flat neck veins, widened pulse pressure b. muffled heart sounds, minimal chest tube output, pulsus paradoxus c. hypertension, distended neck veins, narrow pulse pressure d. crackles, hypoxemia, S3 - SOLUTION b. muffled heart sounds, minimal chest tube output, pulsus paradoxus other signs: neck veins distended, pulse pressure narrow, hypotension d - signs of elevated L heart pressure a. Close monitoring for ventricular arrhythmias b. Administration of diuretics to decrease preload c. Close monitoring for conduction disturbances d. Administration of positive inotropes to increase contractility - SOLUTION c. close monitoring for conduction disturbances The mitral, tricuspid, and aortic valves are near conduction pathways, and the need for temporary pacing needs to be considered The patient is admitted with ripping pain between the scapulae with a dissecting aortic aneurysm seen on the CT scan. In addition to preparation for immediate surgery, which agent is most likely to improve the outcome of the patient? a. nitroglycerin (Tridil) drip b. dopamine (Intropin) drip c. nitroprusside (Nipride) drip d. labetalol (Trandate) drip - SOLUTION d. labetalol (Trandate) drip Aggressive blood pressure and heart rate control are priorities for a patient with aortic dissection The patient has an S3 at the apex of the heart on auscultation. What is most likely a part of the treatment plan? a. Coronary artery reperfusion b. Heart rate control c. Pain management d. Left ventricular preload reduction - SOLUTION d. Left ventricular preload reduction S3 is due to elevated left ventricular pressure and heart failure The patient is having non-sustained runs of torsades de pointes on the cardiac monitor. Which medication will most likely be ordered for this patient? a. Magnesium IV b. Potassium drip c. Amiodarone drip d. Synchronized cardioversion - SOLUTION a. Magnesium IV The patient, status post anterior MI, is scheduled for emergent surgery for ventricular septal defect repair. What will the nurse most likely hear on auscultation of this patient's chest? a. Diastolic murmur at the apex of the heart b. Systolic murmur at the left sternal border c. Diastolic murmur at the base of the heart d. Systolic murmur at the apex of the heart - SOLUTION b. Systolic murmur at the left sternal border The patient is status post insertion of a DDD permanent pacemaker. Which of the following indicates normal functioning of the pacemaker? a. A pacer spike after the P-wave, a spike after each QRS, a constant heart rate b. A pacer spike before the P-wave, a spike on the T-wave, an increase in heart rate with activity c. No P-wave, a pacer spike before each QRS, a constant heart rate d. A pacer spike before the P-wave, a spike before the QRS, an increase in heart rate with activity - SOLUTION d. A pacer spike before the P-wave, a spike before the QRS, an increase in heart rate with activity The DDD pacemaker is capable of pacing and sensing both the atria and the ventricles, and the response to sensing may be both inhibition of pacing in the presence of native beats or stimulation to increase the heart rate if there is a physiological need. Which of the following assessment findings would be expected for a patient with pericarditis? a. Pain with deep inspiration, ST elevation in V2-V6 b. Midsternal pain radiating to the back, T-wave inversion in V2-V6 c. Pain with deep inspiration, global ST elevation d. Pain with movement, ST elevation in II, III, and aVF - SOLUTION c. Pain with deep inspiration, global ST elevation Rewarming the post-op surgical heart patient may result in which hemodynamic change? a. Vasoconstriction with decreased blood pressure b. Fever with an increased blood pressure c. Vasodilation with decreased blood pressure d. Narrowing pulse pressures with increased blood pressure - SOLUTION c. Vasodilation with decreased blood pressure Warming results in vasodilation, which decreases both preload and blood pressure The monitor shows sustained ventricular tachycardia (VT). The patient's blood pressure is 112/60. The patient denies having dyspnea, pain, and dizziness. The nurse anticipates that immediate treatment will include: a. Anti-arrhythmic therapy b. Defibrillation c. Cardioversion d. Potassium - SOLUTION a. Anti-arrhythmic therapy The patient presents with acute ST elevation in V1-V4, blood pressure 84/62, atrial fibrillation 112/min, and respiratory rate 26 with crackles to the scapulae. Definitive treatment includes which of the following? a. Coronary artery reperfusion b. Dopamine at 5 mcg/kg/min c. Cardioversion d. furosemide (Lasix) - SOLUTION a. Coronary artery reperfusion The patient has acute anterior STEMI with cardiogenic shock. Coronary artery reperfusion will restore blood flow and improve the outcome. The patient was admitted 6 hours ago with unstable angina and an ECG showing ST depression in leads II, III, and aVF. A nitroglycerin (Tridil) drip at 30 mcg/min is infusing. Chest pain reoccured, a repeat ECG demonstrated ST elevation in leads II, III, and aVF, and a right-sided ECG showed ST elevation in V3R and V4R. The patient's BP is 88/52, the HR is 92/min, and the lungs are clear. What are the priority interventions for this patient? c. bronchodilation d. arterial dilation - SOLUTION b. arterial constriction Vasopressors (phenylephrine) are alpha adrenergic drugs that stimulate alpha receptors in arteries to constrict The patient was admitted with an anterior wall STEMI and recieved a stent in the left anterior descending (LAD) artery. Which lead should the nurse monitor for this patient after the PCI procedure? a. I b. V2 c. II d. V6 - SOLUTION b. V2 The patient develops hypotension, distended neck veins, and distant heart sounds post-op coronary artery bypass surgery. The mediastinal chest tube is noted to have minimal drainage. The nurse anticipates that the patient will need which of the following intervention? a. a return to the OR b. fluid bolus and pressors c. pericardiocentesis d. stripping the mediastinal tubing - SOLUTION a. a return to the OR The patient has signs of cardiac tamponade, and there is evidence that the mediastinal tube is not draining the operative site A 29-year-old female patient has cardiomyopathy and NYHA class IV heart failure. An assessment includes a point of maximal impulse (PMI) shift to the left, an enlarged heart size, and bilateral pulmonary edema on the chest x-ray as well as an ejection fraction (EF) of 18% on her echocardiogram (ECHO). What interventions will the nurse anticipate for this patient's plan of care? a. administering beta blockers to improve diastolic dysfunction b. administering calcium-channel blockers to improve systolic dysfunction c. administering positive inotropes for systolic dysfunction d. administering diuretics for diastolic dysfunction - SOLUTION c. administering positive inotropes for systolic dysfunction The patient has signs of dilated cardiomyopathy, which results in systolic dysfunction and a problem with ejection, not filling. Which intravenous agent is he preferred treatment for a patient with hypertensive crisis and a history of coronary artery disease? a. nitroglycerin (Tridil) b. enalaprilat (Vasotec) c. nitroprusside (Nipride) d. labetalol (Trandate) - SOLUTION d. labetalol (Trandate) Labetolol is a beta blocker that lowers BP by blocking the effects of the adrenergic system on the heart. It also offers protection to the heart in the presence of coronary artery disease. The patient is admitted with acute shortness of breath, chest pain, ST elevation on the ECG, and a loud systolic murmur at the apex of the heart. Which of the following has most likely occured? a. inferior MI with acute mitral valve insufficiency b. anterior MI with acute mitral valve stenosis c. inferior MI with acute ventricular septal defect d. anterior MI with acute aortic valve insufficiency - SOLUTION a. inferior MI with acute mitral valve insufficiency The patient suddenly develops chest pain, dyspnea, hypotension, and sinus bradycardia. An examination reveals jugular venous distention (JVD), lungs clear, S4, and no murmurs. The ECG reveals ST elevation in II, III, and aVF. In addition to preparing for PCI, which interventions should the nurse anticipate? a. nitroglycerin drip, aspirin b. furosemide (Lasix), atropine c. aggressive fluid administration, right-sided ECG d. transcutaneous pacing, morphine - SOLUTION c. aggressive fluid administration, right-sided ECG The patient admitted with acute MI received reperfusion therapy (PCI). What are signs of successful reperfusion? a. ST depression, chest pain relief, drop in troponin b. sinus rhythm, reduction of chest pain, elevated troponin c. troponin returns to baseline, short runs of accelerated idioventricular rhythm (AIVR), chest pain relief d. chest pain relief, ST returns to baseline, short runs of VT - SOLUTION d. chest pain relief, ST returns to baseline, short runs of VT Chest pain relief and the resolution of ST segment deviation are evidence of the return of blood flow. Marked elevation of troponin results from reperfusion stunning of myocardial tissue. Reperfusion arrhythmias (VT, VF, AIVR) are also signs of successful reperfusion. What are signs of development of a ventricular septal defect? a. systolic murmur, loudest at the apex of the heart b. diastolic murmur, seen with a lateral MI c. systolic murmur, loudest at the left sternal border d. diastolic murmur, loudest at the base of the heart - SOLUTION c. systolic murmur, loudest at the left sternal border A cardiologist tells an RN that a patient has a history of a diastolic murmur and atrial fibrillation, What is associated with these signs? a. mitral stenosis b. aortic stenosis c. mitral insufficiency d. ventricular septal defect (VSD) - SOLUTION a. mitral stenosis Diastolic murmurs occur during filling, which would include mitral stenosis, tricuspid stenosis, or aortic or pulmonic insufficiency The patient is status post-PCI for acute high lateral wall MI. Which leads will the nurse continually monitor for ST changes following the procedure? a. II, III, and aVF b. Vi-V4 c. V5 and V6 d. I and aVL - SOLUTION d. I and aVL Clinical signs for SYSTOLIC heart failure: - SOLUTION Dilated left ventricle Problem emptying Clinical signs for DIASTOLIC heart failure - SOLUTION Normal ejection fraction (EF) Left ventricular hypertrophy pattern on the ECG Thickened LV walls or septum Clinical sign(s) of BOTH systolic and diastolic heart failure: - SOLUTION Pulmonary edema The patient complains of a right-sided headache on the day of discharge status post right carotid endarterectomy. The nurse will do which of the following? a. administer an analgesic, and reassess within one hour b. contact the physician; the patient has signs of carotid artery restenosis c. assess the operative site, and provider non-pharmacological intervention d. contact the physician; the patient is at risk for seizure activity - SOLUTION d. contact the physician; the patient is at risk for seizure activity. The patient may be experiencing a complication - hyperperfusion syndrome. This increases the risk of seizure activity and an ICH. The BP and the HR should be assessed prior to notifying the physician. Treatments for SYSTOLIC heart failure: - SOLUTION Positive inotrope Diuretic ACE inhibitor Avoid negative inotrope during acute phase Treatments for DIASTOLIC heart failure: - SOLUTION Diuretic ACE inhibitor Calcium-channel blocker Treatments for BOTH systolic and diastolic heart failure: - SOLUTION Diuretic ACE inhibitor The patient admitted two days ago with an anterior MI develops hypotension, tachycardia, decreasing urine output, cool and clammy skin, a decreasing level of consciousness, and tachypnea. What should be included in the patient's plan of care? a. positive inotropic agents, diuretics, vasodilators b. ACE inhibitors, adenosine, beta blockers c. beta blockers, diuretics, calcium-channel blockers d. negative inotropic medications, digoxin, antiarrhythmics - SOLUTION a. positive inotropic agents, diuretics, vasodilators What is indicative of a massive pulmonary embolism? a. fever, purulent sputum, hypoxemia b. hypoxemia, hypotension, increased alveolar dead space c. hypoxemia, shunt, decreased surfactant production d. hypoventilation, wheezing, air trapping - SOLUTION b. hypoxemia, hypotension, increased alveolar dead space a- pneumonia c- ALI/ARDS d- asthma The patient develops agitation with respiratory distress, distended neck veins, hypotension, and diminished breath sounds on the right with tracheal deviation to the left. Which treatment is a priority for this patient? a. fluid bolus b. needle aspiration of the chest c. chest tube insertion d. intubation - SOLUTION b. needle aspiration of the chest pt is showing signs of a tension pneumothorax A 75 kg female patient with ARDS is receiving mechanical ventilation with the following settings: assist control mode, rate 16/minute; FiO2 80%; Vt 350 mL; PEEP 10 cm H2O. ABGs are obtained and reveal the following: pH 7.32, PCO2 55, pO2 45, HCO3 25. Which intervention should the nurse anticipate? a. increase the Vt b. increase the breath rate c. increase the FiO2 d. increase PEEP - SOLUTION d. increase PEEP The PEEP setting of 10 cm H20 is often not high enough to correct the hypoxemia for a patient with ARDS; higher PEEP is required. What would indicate worsening of condition and the possible need for intubation for a patient with status asthmaticus? a. anxiety b. bilateral wheezing c. pulsus paradoxus d. SaO2 92% - SOLUTION c. pulsus paradoxus PP, a variation of systolic pressure > 15 mmHg with inspiration and expiration, is a sign of significant air trapping that may decrease venous return and B/P. The patient is receiving mechanical ventilation and enteral tube feeding. There is a sudden increase in the peak inspiratory pressure. The ventilator high-pressure alarm is sounding. There is development of a right lung infiltrate of the chest film. What most likely caused these finding? a. aspiration b. pneumothorax c. bronchospasm d. acute respiratory distress syndrome (ARDS) - SOLUTION a. aspiration Due to the shorter, wider, less angled right mainstem bronchus as compared to the left mainstem bronchus, most incidents of of aspiration involve the right lung What will shift the oxyhemoglobin dissociation curve to the right, increasing the release of oxygen to tissues? a. hypothermia b. fever c. alkalosis experiencing increased work of breathing, and SpO2 is 0.95. What intervention will most likely decrease the patient's work of breathing? a. increasing the tidal volume b. increasing the CPAP c. increasing the FiO2 d. increasing the pressure support - SOLUTION d. increasing the pressure support The patient receiving mechanical ventilation is scheduled for a spontaneous breathing trial (SBT). The patient's chest XR is improving. The LOC has decreased, and he now responds to shaking rather than voice. The FiO2 is 40%, the resting minute ventilation is 8L/min, and the RSBI is 108 breaths/min/L. What intervention is indicated at this time? a. continue with the SBT as planned b. hold the SBT because of the patient's minute volume c. hold the SBT because of the FiO2 requirements d. hold the SBT because of the change in the LOC ad because of the RSBI - SOLUTION d. Hold the SBT because of the change in the LOC ad because of the RSBI RSBI should ideally be less than 105 breaths/min/L, and the patient's change in LOC needs to be discussed with the provider before beginning an SBT The patient was admitted with acute pancreatitis and has developed tachypnea, bilateral crackles, and SpO2 of 84% despite an increase of FiO2 to 1.00 per non-rebreather mask. A CXR shows bilateral "ground glass" appearance. The nurse anticipates which priority intervention? a. initiation of non-invasive ventilation b. mechanical ventilation with PEEP c. initiation of a fibrinolytic for a massive pulmonary embolism d. administration of diuretics for a pulmonary edema - SOLUTION b. mechanical ventilation with PEEP The patient has signs of ARDS as evidenced by refractory hypoxemia, the CXR, and the clinical presentation. Non-invasive ventilation cannot provide the PEEP and full ventilatory support that is required for the treatment of ARDS. Which of the following ABGs is characteristic of acute respiratory failure? a. pH 7.34; pCO2 34; HCO3 23; pO2 65 on room air b. pH 7.33; pCO2 31; HCO3 22; pO2 79 on 2L/nc c. pH 7.34; pCO2 55; HCO3 35; pO2 62 on RA d. pH 7.33; pCO2 31; HCO3 22; pO2 62 on 50% 02 per mask - SOLUTION d. pH 7.33; pCO2 31; HCO3 22; pO2 62 on 50% 02 per mask A 60kg patient with status asthmaticus required intubation and mechanical ventilation. The patient is sedated, and the ventilator setting include the following: mode - assist control FiO2 - 0.40 BR - 20/minute Vt - 500 mL PEEP - 0 cm H20 Which of these setting should the nurse question? a. breath rate b. tidal volume c. mode d. PEEP - SOLUTION a. breath rate The breath rate needs to be lowered to allow for a longer expiratory time. A patient with asthma requires a longer expiratory time to prevent air trapping. What physiologic factors of ARDS lead to refractory hypoxemia? a. increased left heart pressure resulting in a pulmonary edema b. damage to type II alveolar cells with increased surfactant production c. alveolar collapse and decreased functional residual capacity (FRC) d. increased compliance caused by decreased surfactant production - SOLUTION c. alveolar collapse and decreased functional residual capacity (FRC) The arterial blood gases (ABG) results o the post-op patient with diabetes are reported as follows: pH 7.30, PaCO2 51, PaO2 61, HCO3 25. Which interventions would address this patient's acid-base status? a. assess the electrolytes b. increase the FiO2 c. administer naloxone (Narcan) d. check the patient's blood sugar - SOLUTION c. administer naloxone (Narcan) The post-op patient who is receiving mechanical ventilation has a right- sided chest tube. Which assessment would be necessitate notifying the provider? a. peak airway pressure of 20 cm H20 b. development of bubbling in the water seal chamber c. drainage of 40 mL over eight hours d. tidaling with deep inspiration in the water seal chamber - SOLUTION b. development of bubbling in the water seal chamber The patient who is receiving mechanical ventilation developed agitation, tachypnea, unequal chest excursion, and diminished breath sounds on the right. The ventilatory high pressure alarm is frequently sounding. The BP is elevated. What is the priority treatment for this patient? a. right lung chest tube insertion b. increase in FiO2 c. right lung needle aspiration d. sedation - SOLUTION a. right lung chest tube insertion The patient has signs of a right-sided pneumothorax, and emergent placement of a chest tube is needed PEEP therapy is essential for a patient with ARDS. Which nursing intervention is appropriate for a patient receiving PEEP therapy for the treatment of ARDS? a. monitor for possible barotrauma b. decrease PEEP if hypotension develops c. initiate non-invasive ventilation (NIV) d. re-evaluate antibiotic therapy - SOLUTION c. initiate non-invasive ventilation (NIV) In addition to administering beta-2-agonists for bronchospasm, what additional therapies are needed for a patient with an asthma excerbation? a. PEEP for alveolar recruitment b. diuretics to decrease secretions c. sedation to decrease oxygen demands d. fluids administration to prevent thickened secretions and mucous plugs - SOLUTION d. fluids administration to prevent thickened secretions and mucous plugs Thickened secretions are expected during as asthma exacerbation, along with bronchospasm and bronchial mucosal inflammation and edema. The patient presented with signs and symptoms of a pulmonary embolism. Diagnostic testing has been ordered to confirm the diagnosis prior to initiating anticoagulation. Which diagnostic test will confirm the diagnosis? a. ventilation/perfusion (V/Q) lung scan b. high-speed CT scan of the chest c. d-dimer d. pulmonary angiogram - SOLUTION d. pulmonary angiogram Pulmonary angiography is the gold standard for confirming PEs. Which of the following patients would most likely meet the criteria for ARDS? a. a patient, with a PaO2 of 95 mmHG, recieving 1.00 FiO2 b. a patient with right lung pulmonary edema and patchy infiltrates c. a patient who has acute systolic heart failure d. a patient on room air with a PaO2 of 62 mmHG - SOLUTION a. a patient, with a PaO2 of 95 mmHG, recieving 1.00 FiO2 The patient described in choice (a) has a PaO2/FiO2 relationship that meets the criteria for ARDS (<200 mmHG). The other three criteria (acute onset, bilateral infiltrates, and left heart pressure <18 mmHG) would also need to be met. The patient required emergent intubation and mechanical ventilation for acute respiratory failure with severe hypoxemia and paraoxical breathing pattern secondary to bacterial pneumonia. Shortly after the initiation of mechanical ventilation, the patient's blood pressure decreased to 82/42. The breath sounds are unchanged. What intervention is indicated at this time? a. decrease the ventilator breath rate b. start a fluid bolus c. suction the patient to assess for a mucus plug d. assess the plateau pressure - SOLUTION b. start a fluid bolus when positive pressure ventilation is initiated, there may be an increase in the intrathoracic pressure with a reduction in preload Pharmacologic therapy, used for the treatment of pulmonary hypertension, requires close monitoring for which of the following complications? a. infection b. left ventricular failure c. hypotension d. pedal edema - SOLUTION c. hypotension Pulmonary hypertension is treated with dilators. These agents not only decrease pulmonary pressure, but they also have a systemic effect and reduce arterial blood pressure. There are complications that result from the pulmonary stabilization strategies that are needed to treat a patient with ARDS. A nurse is required to closely monitor for these potential complications. Which of the following is an example of a complication that the nurse might encounter when caring for a patient who requires pulmonary stabilization strategies? a. barotrauma b. hypertension c. hypocapnia d. cardiac arrhymia - SOLUTION a. barotrauma the high PEEP requirement may result in barotrauma The patient is receiving non-invasive ventilation for acute respiratory failure secondary to pneumonia and has a history of COPD. The patient has increased secretions, is agitated, and keeps removing the face mask, resulting in oxygen desaturation below 90%. Which intervention is now indicated for this patient? a. provide sedation b. initiate intubation and mechanical ventilation c. increase the FiO2 d. apply restraints - SOLUTION b. initiate intubation and mechanical ventilation non-invasive ventilation is contraindicated for a patient with copious secretions or a patient who is unable to cooperate by leaving the mask in place A 90 kg patient was admitted with upper GI bleeding secondary to esophageal varices. The patient required fluid resuscitation and developed ARDS, which necessitated mechanical ventilation. The current ventilator settings include: BR 12/min, TV 900mL, FiO2 1.00, and PEEP 20. The SpO2 is 0.91, the plateau pressure is 38 cmH20 and the VS are stable. Which intervention is needed for this patient's treatment plan? a. decrease in tidal volume b. increase breath rate c. decrease PEEP d. decrease FiO2 - SOLUTION a. decrease in tidal volume The patient's plateau pressure is elevated, and the patient requires a decrease in the tidal volume to prevent volutrauma The patient was admitted with a crush injury to the left leg and developed dyspnea, tachypnea, a fever, and a cough. The lungs are clear, and a petechial rash is noted on the back and chest. SpO2 on the room air is decreased to 0.91. The patient is at risk for which complication? a. air trapping c. address the patient's airway, breathing, and circulation d. initiate a gastric lavage - SOLUTION c. address the patient's airway, breathing, and circulation The elderly patient was admitted with a history of having had diarrhea and progressive shock for the past three days. Based on this history, the patient's assessment would most likely include which of the following? a. MAP 60 mmHg, narrowing pulse pressure, elevated serum Na+ b. MAP 66 mmHG, widening pulse pressure, elevated serum lactate c. MAP 55 mmHG, narrowing pulse pressure, urine output 1 mL/kg/hr d. MAP 70 mmHg, widening pulse pressure, normal serum lactate - SOLUTION a. MAP 60 mmHg, narrowing pulse pressure, elevated serum Na+ The patient was admitted with severe sepsis/septic shock 90 minutes ago with the following conditions; BP 78/42; MAP 52 mmHg; HR 112/min; RR 22/min and lungs clear bilaterally; lactate 5 mmol/L; and urine output 0.1 mL/hr/hr. The patient was given 30 mL/kg of 0.9 NS. The latest assessment reveals the following conditions: BP 98/46; MAP 63 mmHg; HR 98/min; RR 20/min and lungs clear; lactate 6 mmol/L; UOP 0.5 mL/kg/hr. Which of the following interventions will best address the patient's current status? a. reduce normal saline to 150 mL/hr b. discontinue NS, and begin LR at 125 mL/hr c. continue the infusion of NS at 30 mL/kg d. initiate a norepinephrine (Levophed) infusion - SOLUTION c. continue the infusion of NS at 30 mL/kg The patient sustained a traumatic injury while driving. Prior to arrival, the patient's spine was stabilized with a cervical collar. He was also receiving bag/mask ventilation via an advanced airway, and two large bore IVs were in place. What is a priority assessment at this time? a. assess the patient's vital signs b. perform a neuro assessment c. auscultate the patient's breath sounds bilaterally d. remove the patient's clothes - SOLUTION b. perform a neuro assessment Important interventions for the treatment of severe sepsis/septic shock include administering 30 mL/kg of isotonic fluid and initiating a vasopressor if the patient is not responsive to fluids. What is the pathology of sepsis that is addressed by administering fluids and initiating a vasopressor? a. pulmonary dysfunction and impaired oxygen utilization b. myocardial dysfunction and maldistribution of blood flow c. impaired carbon dioxide elimination and hypoxemia d. vasodilation and increased capillary leak - SOLUTION d. vasodilation and increased capillary leak fluids address the vasodilation and the increased capillary leak by restoring volume The patient required transfusion of 12U of PRBCs over 24-hour period. The nurse will need to monitor the patient for which of the following complications related to multiple transfusions of PRBCs? a. coagulopathy b. deep vein thrombosis c. alkalosis d. hyperthermia - SOLUTION a. coagulopathy The patient is transferred to the ICU with hypotension, tachycardia, oliguria, and a pressure injury with foul smelling drainage on her coccyx. Fluids are started at 30 mL/kg, blood cultures are drawn, ad a broad-spectrum antibiotic is administered. What additional evidence-based intervention for the treatment of this patient's problem is inicated as soon as possible for this patient? a. measure the electrolytes b. measure the serum lactate c. administer oxygen d. begin a norepinephrine (Levophed) infusion - SOLUTION b. measure the serum lactate What are the priority nursing interventions for a patient with an acetaminophen overdose? a. administer N-acetylcysteine, and monitor hepatic function b. administer activated charcoal, and perform cooling for hyperthermia c. administer activated charcoal, and perform cooling for hyperthermia d. administer flumazenil (Romazicon), and support the patient's airway - SOLUTION a. administer N-acetylcysteine, and monitor hepatic function The patient is receiving epidural analgesia status post thoracotomy for a lung tumor. The patient's blood pressure is 124/78, his heart rate is 72/min, and his RR is 10/min, snoring in quality. When asked about his pain, the patient arouses to a loud voice and to touch, but he does not answer the question. What is the priority intervention for the patient at this time? a. continue current plan of care b. decrease the epidural analgesia c. administer naloxone (Narcan) d. call a code - SOLUTION c. administer naloxone (Narcan) The patient is agitated. He is attempting to pull at his enteral feeding tube and IV line. Which of the following nursing interventions is indicated in this situation? a. attempt to verbally calm the patient b. administer a sedation agent c. administer an analgesic d. assess for hemodynamic instability - SOLUTION d. assess for hemodynamic instability The SIRS criteria assess for a systemic inflammatory response, and the qSOFA score is a bedside assessment for possible organ dysfunction. A qSOFA score of 2 or 3 positive criteria indicates suspicion of organ dysfunction. Which of the following criteria is NOT an element of the qSOFA score? a. altered mentation as evidenced by a GCS < 15 b. temperature > 38 C or < 36 C c. low blood pressure as evidenced by a systolic pressure < 100 mmHg d. high respiratory rate as evidenced by a RR ? 22 breaths per min - SOLUTION b. temperature > 38 C or < 36 C alteration of temperature is a criteria of the SIRS criteria BP: 78/50 PAOP: 30 mmHg CO: 2.9 L/min CI: 1.4L/min/m2 SVR: 1,600 dynes/sec/cm-5 The nurse should expect the patient's immediate treatment to include which of the following? a. vasodilators and positive inotropic agents b. vasodilators and beta blockers c. vasopressors and fluids d. positive inotropic agents and fibrinolytic therapy - SOLUTION a. vasodilators and positive inotropic agents The patient admitted with acute chest pain and an acute inferior MI. The patient's blood pressure is 78/54, and the following pressure readings were obtained from the pulmonary artery (PA) catheter: RA: 15 mmHg PA: 19/4 mmHg PAOP: 5 mmHg CI: 1.9L/min/m2 SVR: 1,650 dynes/sec/cm-5 Based on these values, what is the initial treatment indicated for this part? a. norepinephrine (Levophed) b. IABP therapy c. nitroglycerin (Tridil) d. fluids - SOLUTION d. fluids The patient with an acute inferior MI and a pulmonary artery (PA) catheter develops acute respiratory distress and a loud systolic murmur at the apex of his heart. The nurse suspects that the clinical change in the patient's condition is due to acute mitral valve regurgitation. Which of the following hemodynamic findings would support the fact that the clinical change in the patient's condition is due to acute mitral valve regurgitation? a. the CO increases b. the PAOP increases c. the SVR increases d. the PA pressure decreases - SOLUTION b. the PAOP increases Which of the following hemodynamic findings would be expected for a patient with left heart failure with a blood pressure of 128/68? a. PAOP 20 mmHg b. CO 7 L/min c. RA pressure 1 mmHg d. SVR 600 dynes/sec/cm-5 - SOLUTION a. PAOP 20 mmHg The patient has a sustained SvO2 of 0.55. Which clinical abnormality may be the cause of this SvO2? a. hypothermia b. a cardiac index of 5 L/min/m2 c. hypoxemia d. therapeutic paralysis - SOLUTION c. hypoxemia Which clinical and hemodynamic findings are expected if the patient has hypotension with acute inferior STEMI and a right ventricular infarction? a. an elevated PAOP and a systolic murmur at the base of the heart b. a decrease RA pressure and flat neck veins c. an elevated PA pressure and lung crackles d. an elevated RA pressure and distended neck veins - SOLUTION d. an elevated RA pressure and distended neck veins The patient who was admitted with a gunshot wound to the abdomen has hemorrhagic shock. Which of the following hemodynamic profiles would reflect a patient in this situation? a. PAOP 10 mmHg; SVR 1,100 dynes/sec/m-5; CO 5 L/min b. PAOP 3 mmHg; SVR 1,500 dynes/sec/m-5; CO 2.5 L/min c. PAOP 18 mmHg; SVR 1,100 dynes/sec/m-5; CO 4 L/min d. PAOP 4 mmHg; SVR 700 dynes/sec/m-5; CO 3L/min - SOLUTION b. PAOP 3 mmHg; SVR 1,500 dynes/sec/m-5; CO 2.5 L/min The patient is receiving fluid resuscitation and a norepinephrine (Levophed) drip for the treatment of septic shock. What are the beneficial effects of these treatments on the patient's hemodynamics? a. the fluids are increasing the preload, and the norepinephrine is decreasing the afterload b. the fluids are increasing the preload, and the norepinephrine is increasing the afterload c. the fluids are decreasing the preload, and the norepinephrine is also decreasing the preload d. the fluids are decreasing the preload, and the norepinephrine is decreasing the afterload - SOLUTION b. the fluids are increasing the preload, and the norepinephrine is increasing the afterload The patient has an SVR of 520 dynes/sec/cm-5. This finding would typically be seen in the event of which of the following problems? a. septic shock and anaphylactic shock b. cardiogenic shock and left ventricular failure c. cardiac tamponade and pulmonary hypertension d. hypovolemic shock and COPD - SOLUTION a. septic shock and anaphylactic shock the endotoxins of septic shock and the histamine release of anaphylactic shock result in massive vasodilation with a resultant in the SVR and left ventricular afterload Which of the following hemodynamic profiles is typical of a patient with cardiac tamponade? a. RAP 1 mmHg; PAP 21/10 mmHg; PAOP 12 mmHg; CO 4.0 L/min b. RAP 3 mmHg; PAP 26/9 mmHg; PAOP 10 mmHg; CO 5.0L/min c. RAP 14 mmHg; PAP 30/15 mmHg; PAOP 14 mmHg; CO 2.0 L/min d. RAP 10 mmHg; PAP 30/15 mmHg; PAOP 8 mmHg; CO 3.0L/min - SOLUTION c. RAP 14 mmHg; PAP 30/15 mmHg; PAOP 14 mmHg; CO 2.0 L/min The patient is status post anterior wall NSTEMI. He experienced acute shortness of breath and a decrease in blood pressure. His blood pressure is 88/66, his heart reate is 102/min, and his respiratory rate us 24/min. A a. negative corneal reflex b. positive oculovestibular reflex c. positive Babinski reflex d. negative gag reflex - SOLUTION c. positive Babinski reflex The patient was admitted with a history of headaches, and he has a fever and Kernig's sign. A lumbar puncture was performed with an opening pressure of 160 cm H2O. His CSF was clear, and he had elevated CSF protein and CSF glucose of 60 mg/dL. Based on this patient's signs and symptoms, what will the plan of care include for this patient? a. Stat CT of the is needed to rule out a SAH b. Stat antibiotics are needed for bacterial meningitis c. Prep the patient for a cerebral angiogram to rule out A-V malformation d. Administer antipyretics and fluids because the patient most likely has viral meningitis - SOLUTION d. Administer antipyretics and fluids because the patient most likely has viral meningitis What are the expected interventions for a patient following surgery for a subarachnoid aneurysm (SAH)? a. administration of labetolol (Normadyne) and mannitol b. administration of nimodipine (Nimotop) and isotonic saline c. administration of diltiazem (Cardizem) and PRBCs d. administration of enealapril (Vasotec) and 0.45 NS - SOLUTION b. administration of nimodipine (Nimotop) and isotonic saline The patient was admitted with a history of a blow to the right temporal area with a baseball bat several hours prior to admission. Upon arrival, the patient was alert, oriented, and responsive to questions. He complained of a headache and vomiting, his right pupil was larger than his left pupil, and a left pronator drift was present. A CT scan of the head was ordered. Following the CT scan, the patient was responsive to shaking. Which of the following is the most likely finding on the CT scan based on the patient's history and his presenting signs and symptoms? a. subdural hematoma b. epidural hematoma c. intracerebral hematoma d. basilar skull fracture - SOLUTION b. epidural hematoma The patient presented with right-sided paralysis, a right Babinski reflex, and eye deviation to the left. Based on this patient's clinical presentation, what is the patient most likely experiencing? a. right brain bleed or infarct b. generalized brain swelling or encephalopathy c. left brain bleed of infarct d. pontine infarct - SOLUTION c. left brain bleed of infarct The patient presented with a generalized seizure. He has a history of a pulmonary embolus. He is currently anticoagulated, and he is taking warfarin (Coumadin). A CT scan demonstrated a brain hemorrhage secondary to an A-V malformation. What is a priority intervention for this patient? a. begin a heparin drip b. administer phenytoin (Dilantin) c. administer vitamin K d. obtain consent for surgery - SOLUTION c. administer vitamin K The patient sustained a head injury and an epidural hematoma. Post- operatively, the patient developed signs of brain herniation. What are signs of brain herniation? a. a decrease in systolic pressure, an increase in heart rate, increase in respirations b. an increase in systolic pressure, a decrease in heart rate, an increase in respirations c. a decrease in systolic pressure, a decrease in heart rate, an increase in respirations d. an increase in systolic pressure, a decrease in heart rate, a decrease in respirations - SOLUTION d. an increase in systolic pressure, a decrease in heart rate, a decrease in respirations Which clinical findings and/or interventions are detrimental to brain perfusion? a. an elevated ICP and hypertension b. a decreased temperature and the administration of isotonic fluids c. an elevated ICP and hypotension d. decreased environmental stimulation and increased FiO2 - SOLUTION c. an elevated ICP and hypotension The patient sustained an ischemic stroke and developed a loss of vision in the left half visual field of each eye (left homonymous hemianopsia). This is a sign that the stroke has affected which cranial nerve? a. olfactory nerve b. optic nerve c. oculomotor nerve d. trochlear nerve - SOLUTION b. optic nerve The patient is days post-op from an aneurysm repair following a subarachnoid hemorrhage (SAH). What is an appropriate nursing intervention that is specific to the care of this patient? a. contact the surgeon if there is a decrease in the serum Na+ b. maintain a systolic BP of 100-110 c. administer diltiazem (Cardizem) d. restrict fluids - SOLUTION a. contact the surgeon if there is a decrease in the serum Na+ The patient presented with a basilar skull fracture after sustaining a blow to the head. The nurse determined that the nasal drainage was spinal fluid because the fluid was positive for glucose, and the drainage from the ear demonstrated the "halo sign". What additional intervention is indicated for the care of this patient? a. provide a tissue to the patient to blow her nose b. assess for cranial nerve I damage c. administer antibiotics, and prep the patient for surgery d. pack sterile gauze into the patient's nose and ear - SOLUTION b. assess for cranial nerve I damage The patient sustained a large right cerebral ischemic stroke. What clinical sign is the patient most likely to exhibit a. right Babinski reflex Kehr's sign is due to a ruptured spleen causing diaphragmatic irritation, which leads to referred pain to the left shoulder During orientation, the nurse is told by the preceptor that the patient with upper GI bleeding needs to be closely monitored for ST segment elevation and chest pain. This monitoring is necessary for which of the following treatments for GI bleeding? a. administration of octreotide b. infusion of blood products c. administration of vasopressin d. infusion of isotonic fluids - SOLUTION c. administration of vasopressin vasopressin prevents upper GI bleeding by constricting the splanchnic arteriolar bed and reducing the portal venous pressure which of the following is NOT a sign of bowel perforation? a. a "board-like" abdomen b. dilated loops of a gas-filled bowel on a KUB XR c. rebound tenderness d. diminished or absent bowel sounds - SOLUTION b. dilated loops of a gas-filled bowel on a KUB XR The patient presents with signs of nausea, vomiting, abdominal pain that increases with knee flexed, and an abdomen that is rigid to palpation with rebound tenderness. What is the most likely cause of this patient's clinical signs? a. appendicitis b. bowel obstruction c. esophageal varies d. peritonitis - SOLUTION d. peritonitis Which of the following is a contraindication for treating a patient who has chronic alcoholism and bleeding esophageal varices? a. administration of lactulose b. banding or sclerosis of varices c. insertion of an esophageal balloon (Sengstaken-Blakemore tube) d. maintenance of the head of the bed in the supine position - SOLUTION d. maintenance of the head of the bed in the supine position Which of the following is an evidence-based nursing intervention for the provision of enteral nutrition? a. confirm tube placement insufflation and auscultation of air over the abdomen b. hold the feeding if there is a gastric residual volume (GRV) of 250 mL c. monitor for feeding tube displacement into the lung during insertion d. do not initiate feeding until bowel sounds are auscultated - SOLUTION c. monitor for feeding tube displacement into the lung during insertion The patient is day 3 status post repair of a ruptured abdominal aortic aneurysm for which he required fluid resuscitation. The patient has now developed hypotension, tachycardia, and tachypnea. After speaking with the physician, the nurse measured the patient's bladder pressure with the transducer leveled at the symphysis pubis and obtained a reading of 18 mmHg. Which of the following interventions are indicated at this time? a. re-level the transducer b. prep the patient for decompression surgery c. transfuse 2 units of PRBCs d. place the bed in revere Trendelenburg position - SOLUTION d. place the bed in revere Trendelenburg position a bladder pressure of 18 mmHg indicates that the patient's clinical signs are related to intra-abdominal hypertension (compartment syndrome). Placing the bed in reverse Trendelenburg position will help relieve compression on the major vessels and will improve blood return to the right heart. The patient sustained trauma while driving a car on the interstate. The patient is alert and oriented; however, the patient's blood pressure is 88/48 and her heart rate is 114/min. The physician suspects intraperitoneal bleeding and is preparing for a diagnostic peritoneal lavage. Which of the following is a clinical sign that would indicate that the patient has intraperitoneal bleeding? a. Kehr's sign b. asterixis c. Grey Turner's sign d. Cullen's sign - SOLUTION d. Cullen's sign The patient has signs and symptoms of liver failure. Which of the following statements regarding signs and symptoms of liver failure is accurate? a. hypoventilation may be present as a result of lactic acidosis b. jaundice may be present as a result of an elevated BUN c. mental status change may develop as a result of elevated NH3 d. ascites may be present as a result of elevated protein - SOLUTION c. mental status change may develop as a result of elevated NH3 Bariatric surgery is associated with a number of complications. Which of the following is NOT a complication of gastric bypass surgery? a. bowel obstruction b. malabsorption c. kidney stones d. leakage from the anastomosis site - SOLUTION c. kidney stones The pathophysiology of acute pancreatitis leads to specific signs and symptoms. The nurse anticipates that which of the following signs may develop as a result of the pathophysiology of acute pancreatitis? a. hypoxemia may develop as a result of the release if phospholipase A b. hypoglycemia may occur as a result of beta cell injury c. Trousseau's sign may develop as a result of hypercalcemia d. diffuse inflammation will develop, which will require antibiotic therapy - SOLUTION a. hypoxemia may develop as a result of the release if phospholipase A the release of phospholipase A destroys type II alveolar cells, which produce surfactant. reduced surfactant results in alveolar atelectasis and ARDS The patient with alcoholic liver cirrhosis presents with a stuporous mental state, asterixis, hyperventilation, and an abnormal EEG. Based on these signs, how severe is the patient;s hepatic encephalopathy? c. hemodialysis d. transvenous pacemaker - SOLUTION c. hemodialysis The patient with renal failure requires close assessment due to the risk for developing numerous complications. Which of the following would be the most ominous development for the patient with renal failure? a. sepsis b. hyperkalemia c. heart failure d. acidosis - SOLUTION a. sepsis Which treatment will prevent the most common type of hospital acquired acute tubular necrosis (ATN)? a. identifying the patient as at risk for contrast medium nephropathy b. avoid nephrotoxic drugs c. aggressively treat hypertension d. avoid prolonged hypotension of the kidneys - SOLUTION d. avoid prolonged hypotension of the kidneys A nephrologist is consulted for a patient with acute kidney injury, and a number of lab tests are ordered. Which lab result would suggest that this patient has damage to his renal tubular basement membrane? a. BNU: creatinine ration of 20:1 b. urine sodium < 20 mEq/L c. high urine osmolality (>500 mOsm/kg water) d. low urine specific gravity (<1.010) - SOLUTION d. low urine specific gravity (<1.010) The patient with a history of heart failure and diabetes is scheduled for a coronary angiogram. Which of the following treatments would be the most effective for this patient? a. restrict fluids pre-procedure b. decrease the volume of the dye c. administer a diuretic pre-procedure and post-procedure d. administer acetylcysteine after the procedure - SOLUTION b. decrease the volume of the dye The patient has a history of alcoholism and has been receiving TPN. The patient is lethargic with decreased deep tendon reflexes (DTRs), and his PaCO2 is 55 mmHg. Which of the following is indicated in the treatment for this patient? a. administer phosphate b. administer calcium c. administer sodium d. administer magnesium - SOLUTION a. administer phosphate Which of the following is NOT required is an evaluation of a patient's creatinine clearance? a. serum creatinine b. the patient's ideal body weight (IBW) c. BUN d. the patient's age and sex - SOLUTION c. BUN The patient with a history of multiple myeloma presents with lethargy, an altered mental status, nausea, and muscle weakness. The physician orders furosemide ad etidronate. What problem does this patient most likely have? a. hypocalcemia b. hypercalcemia c. hyperphosphatemia d. hyponatremia - SOLUTION b. hypercalcemia The patient was admitted with an inability to void, and an ultrasound of the bladder revealed urine retention of 950 mL. Labs revealed a BUN of 72 mg/dL, a creatinine level if 3.1 mg/dL, a urine sodium level of 15 mEq/L, and a urine specific gravity level of 1.025. The patient's blood pressure is 156/86, her heart rate us 98/min, her respirations are 22/min, and her lungs are clear. What is the patient's most likely problem, and what treatment is indicated? a. this patient has ATN. She needs dialysis b. this patient has prerenal failure. she needs fluids c. this patient has fluids overload. she needs a diuretic d. this patient has obstruction of urine flow. she needs correction of the obstruction - SOLUTION d. this patient has obstruction of urine flow. she needs correction of the obstruction The patient has a BUN of 75 mEq/L, a creatinine level of 3.5 mEq/L, and a urine output of 180 mL over the past 8 hours. The patient's urine sodium is 18 mEq/L, and his urine specific gravity level is 1.028. Which of the following is the least likely cause of this patient's clinical status? a. rhabdomyolysis b. intravascular volume depletion c. impaired cardiac performance d. vasodilation - SOLUTION a. rhabdomyolysis The patient has a serum K+ level of 2.0 mEq/L. What sign(s) would this patient be expected to exhibit with this electrolyte imbalance? a. paralytic ileus or metabolic alkalosis b. bradycardia c. hyperreflexia d. hypermagnesemia - SOLUTION a. paralytic ileus or metabolic alkalosis An elderly patient was admitted after she was found lying on the floor of her home, immobile for approximately 3 days. A clinical exam is significant for low urine output with dark brown urine. Her creatinine kinase (CK) is elevated, and her urine is positive for myoglobin. Which of the following does the nurse anticipate as part of this patient's treatment? a. administration of furosemide (Lasix) b. infusion of 0.45 NS at 300 mL/hr c. bicarbonate infusion to alkalinize the urine d. treatment of hyponatremia - SOLUTION c. bicarbonate infusion to alkalinize the urine Which of the following patients is most likely to develop an elevated serum creatinine level after a 30-min episode of hypotension secondary to hypovolemic shock? a. a 22-year-old patient with diabetes b. a patient with heart failure who is taking an ACE inhibitor a. insulin and IV fluids (0.45 saline) b. insulin and one amp of sodium bicarbonate c. KCl and IV fluids (0.9 saline), followed by insulin d. IV fluids (0.9 saline) and one amp of sodium bicarbonate - SOLUTION c. KCl and IV fluids (0.9 saline), followed by insulin This patient has DKA and relative hypokalemia. Therefore, K+ needs to be given before insulin. In the presence of metabolic acidosis and a pH of 7.20, the serum K+ would be expected to be approx 5.2 mEq/L if the total body potassium was normal, but this patient's serum K+ is 4.0 mEq/L. Which of the following statements is accurate regarding DKA and HHNK? a. DKA results in a greater fluids deficit than does HHNK b. HHNK presents with rapid, shallow respirations, and DKA presents with deep respiratory pattern c. DKA presents with respiratory acidosis, and HHNK presents with metabolic acidosis d. HHNK develops more rapidly than does DKA - SOLUTION b. HHNK presents with rapid, shallow respirations, and DKA presents with deep respiratory pattern The patient with a history of oat cell carcinoma presents with a serum Na+ of 115 mEq/L, a serum osmolality of 250 mOsm/kg, and decreased urine output. Which of the following statements is accurate regarding this patient? a. this patient is at for for seizures b. this patient needs to be administered a thiazide c. this patient is at risk for hypovolemic shock d. this patient is dehydrated - SOLUTION a. this patient is at for for seizures A 72-year-old patient with a history of Type II DM was admitted in a coma and with hypotension. It was determined that she had HHNK. The patient received large volumes of 0.9 saline and an insulin drip. Her BP is now normal, and she is now awake, alert, and responsive. Her serum glucose has decreased by 50-100 mg/dL/hr, and her latest serum glucose is 295 mg/dL. What intervention is indicated at this time? a. increase insulin drip b. change the IV fluid to 0.45 saline c. discontinue the insulin drip d. add dextrose to the IV fluids - SOLUTION d. add dextrose to the IV fluids when the serum glucose gets to ~ 300 mg/dL during treatment for HHNK, dextrose should be added to the IV fluids. A patient is being treated for DKA. She is receiving an insulin infusion and fluids. Her blood glucose at 0800 was 210 mg/dL. Her acid-base evaluation revealed a pH of 7.31, her PaCO2 is 28 mmHg, and her HCO3 is 18 mEq/L. Based on this current clinical data, which of the following interventions is indicated? a. add bicarbonate to the IV fluids b. discontinue the insulin infusion, and being infusing long-acting insulin c. continue the insulin infusion d. discontinue all insulin - SOLUTION c. continue the insulin infusion A patient with a history of Type II diabetes and heart failure was admitted in a coma. His blood glucose was 1,050 mg/dL, and his serum osmolality was 330 mOsm/kg. His blood pressure was 78/48, his heart rate was 112/min, his respiratory rate was 22/min, and his serum ketones were small. Isotonic fluids and an insulin drip were started. After 3 hrs, 6 liters of 0.9 saline were infused and insulin infusion continued. Currently, his blood pressure is 84/50, his heart rate is 102/min, his respiratory rate is 18/min, and his blood glucose is 750 mg/dL. The patient is not awake, but he is responsive to voice and touch. Based on this patient's current status, what intervention is indicated? a. continue IV fluids b. discontinue IV fluids c. start a vasopressor d. increase the insulin infusion - SOLUTION a. continue IV fluids A patient was admitted with DKA, a serum glucose of 510 mg/dL, an acid- base status of pH 7.28, a PaCO2 of 24 mmHg, and a HCO3 of 9 mEq/L. An insulin drip was started at 5 units/hr after a loading dose and 0.9 saline were started. One hour later, the serum glucose is now 490 mg/dL. What intervention is indicated at this time? a. increase the insulin drip b. decrease the insulin drip c. maintain the insulin drip at the same rate d. discontinue the insulin drip - SOLUTION a. increase the insulin drip The nurse is instructing a patient, who was recently diagnosed with Type I diabetes, about the signs and symptoms of hypoglycemia. The nurse explains to the patient that because he is taking metoprolol, he may not experience the early signs and symptoms of hypoglycemia. Since the metoprolol masks these early signs, the first signs and symptoms that the patient will experience will be the later signs of hypoglycemia. Which of the following are the later signs and symptoms of hypoglycemia? a. tachycardia and irritability b. confusion and lethargy c. diaphoresis and restlessness d. palpitations and headaches - SOLUTION b. confusion and lethargy A patient developed lethargy and slurred speech. His blood glucose was checked and was found to be 38 mg/dL. Since the IV was not patent, the nurse administered glucagon 1 mg IM. Which of the following nursing interventions is now indicated for this patient? a. retreat with glucagon until the blood glucose is greater than 60 mg/dL and the patient is responsive b. reassess the patient's blood glucose 30 min after treatment c. evaluation the etiology of the event, and indicate strategies to prevent its reoccurrence d. maintain a blood glucose greater than 180 mg/dL - SOLUTION c. evaluation the etiology of the event, and indicate strategies to prevent its reoccurrence The patient presented with complaints of weakness, a decreased appetite, and a recent history of treatment for breast cancer. An assessment revealed that her temperature was 37C (98.6F), her blood pressure was 92/42, her heart rate was 122/min, and her respiratory rate was 28/min. Her laboratory values showed the following values: a. the nurse should tell the patient that he will ensure solitude and a quiet space to give the patient time to think b. the nurse should encourage the patient to decide what time to participate in physical therapy c. the nurse should inform the patient's family that the patient is upset today and that limited visiting time would be best d. the nurse should take time to sit at the patient's bedside and talk to the patient during the shift - SOLUTION d. the nurse should take time to sit at the patient's bedside and talk to the patient during the shift The patient was just admitted with pneumonia, and he has had a reported history of nightmares, flashbacks, and acute anxiety disorder in the time that he has been home after a four-week hospitalization for septic shock and ARDS. Which of the following actions will the nurse anticipate for this patient's plan of care? a. reassure the patient that this hospitalization stay will not be as traumatic as his previous hospitalization stay b. discuss the continuation of home medications (alpha blockers) with the provider c. request an order for benzodiazepines to address the patient's anxiety d. steer the conversation with the patient away from discussing emotions - SOLUTION b. discuss the continuation of home medications (alpha blockers) with the provider The patient is receiving mechanical ventilation for community acquired pneumonia and has been identified as having mixed delirium. She is agitated at night and hypoactive most of the day. Which of the following is an appropriate evidenced-based strategy to use address this patient's delirium a. control the room lighting, and cluster patient activities b. resume spontaneous breathing trials (SBTs) when the delirium subsides c. increase the midazolam (Versed) infusion dose during the night d. keep the patient on bed rest - SOLUTION a. control the room lighting, and cluster patient activities The patient, who was admitted with a fractured femur and lacerations following a traumatic injury, is demonstrating insomnia, mild agitation, and tremulousness. The nurse noted a history of chronic, heavy alcohol use. Which of the following interventions would be most effective for this patient at this time? a. the administration of haloperidon (Haldol) b. environmental stimulation c. symptom-triggered treatment with benzodiazepines using a valid tool d. a social services consult - SOLUTION c. symptom-triggered treatment with benzodiazepines using a valid tool Delirium and dementia have similarities and differences. Which of the following statements is accurate regarding both delirium and dementia? a. both are irreversible b. both are caused by organic changes in the brain c. both are chronic conditions d. these are known strategies available that prevent both delirium add dementia during a hospitalization - SOLUTION b. both are caused by organic changes in the brain The patient was admitted with a suicide gesture. During the unit orientation, the novice nurse asked the experienced nurse preceptor about the plan of care for this patient. Which of the following is an accurate statement regarding this patient's plan of care? a. a suicide gesture involves contemplation. A psychiatric evaluation will most likely be deferred b. this patient's plan was potentially lethal and will most likely require that the patient be admitted to the in-patient behavioral health unit c. this patient's plan was not well thought out. Therefore, there us no need for a contraband check d. this patient's actions were nonlethal. However, one-on-one observation will be needed until a psychiatric evaluation is completed - SOLUTION d. this patient's actions were nonlethal. However, one-on-one observation will be needed until a psychiatric evaluation is completed The patient's plan of care included the following nursing interventions: provision of care with another nurse, standing at a slight angle to the patient, and maintaining a calm, quiet manner. These interventions are indicated for which of the following patients? a. a patient who has been verbally threatening b. a patient who has a history of depression c. a patient who has attempted suicide d. a patient with mixed delirium - SOLUTION a. a patient who has been verbally threatening Which of the following is correct regarding the use of restraints? a. alternatives to restraints do not need to be tried for a patient exhibiting violent behaviors b. if the patient requires the use of restraints, assess the patient for physiological problems that may be the cause of the behavior that requires before applying restraints c. a provider order is required for the initial application of restraints, but not for ongoing use as ling as the restraints are not removed d. restrains are an effect strategy for helping a patient with hyperactive delirium - SOLUTION b. if the patient requires the use of restraints, assess the patient for physiological problems that may be the cause of the behavior that requires before applying restraints The patient who is receiving negative pressure wound therapy is scheduled for an insertion of a peripherally inserted central catheter (PICC) in the Interventional Radiology department. What is a priority nursing intervention in this situation? a. ensure that the patient returns to his room within 2 hours of leaving the nursing unit b. change the drainage canister prior to leaving the nursing unit c. lower the wound VAC alarm volume during transport d. change the wound VAC dressing - SOLUTION a. ensure that the patient returns to his room within 2 hours of leaving the nursing unit The patient is at high risk for developing a pressure injury, as evidenced by the patient's Braden score. What is an appropriate nursing intervention in this situation? a. use continuous lateral rotation therapy (CLRT) b. use a pull sheet when moving the patient to a cart c. offload bony prominences The patient with Class III heart failure has repeatedly been admitted to the hospital due to fluids overload. She does not adhere to the prescribed diet and medications and does not respond to early warning signs of an exacerbation. She has received verbal and written instructions on how to manage heart failure during previous admissions. Which of the following is the most effective strategy for the nurse to implement for this patient? a. ask the patient what she knows about controlling her heart failure b. explain to the patient why she was short of breath c. ask the patient if she takes her medication as prescribed d. explain the importance of salt restriction to the patient - SOLUTION a. ask the patient what she knows about controlling her heart failure Which of the following patients has minimal vulnerability? a. a patient with depression who is separated from his wife b. a patient who is studying for the bar exam and has a disabled child c. a patient with an eating disorder who is engaged to be married d. a patient who has been married for three years and works out and meditates - SOLUTION d. a patient who has been married for three years and works out and meditates Nursing leadership has requested that the Clinical Informatics team redesign the patient assessment section for the electronic medical record (EMR) to meet new regulatory requirements. The Clinical Informatics team understands the new content that needs to be included. Which of the following approaches will most likely lead to a successful redesign o the EMR? a. the Clinical Informatics team should meet monthly with nursing leadership to build the redesign b. the Clinical Informatics team should meet weekly with a nursing task force, with representatives from each nursing specialty, to develop the redesign c. the Clinical Informatics team should develop the redesign and then present the redesign to the Nursing Practice Council for approval d. the Clinical Informatics team should meet weekly to work on the redesign and present the final product to the Clinical Development team to plan education - SOLUTION b. the Clinical Informatics team should meet weekly with a nursing task force, with representatives from each nursing specialty, to develop the redesign A patient has been receiving enteral nutrition via a nasal feeding tube, and the attending physician now needs a decision as to whether to place a gastrostomy tube for long-term access. Which of the following situations demonstrates the greatest degree of patient/family/participation in decision making? a. a patient with decisional capacity who prefers not to decide and defers to his wife b. a patient who has lost decisional capacity and has two daughters: one who wants the feeding tube and on who objects to placement of a feeding tube c. a patient who has lost decisional making capacity and has a valid healthcare power of attorney willing to make decisions d. a patient who has lost decisional capacity and does not have a healthcare power odfattorney or known family - SOLUTION c. a patient who has lost decisional making capacity and has a valid healthcare power of attorney willing to make decisions The wife of a patient in critical condition asks the nurse if she can set up a religious symbol and massage the patient's head while other family members stand around the bed and chant. The family believes this will increase their likehood of the patient's recovery. The nurse has never encountered this type of request. Which of the following actions is the optimal response o the wife's request? a. ask the wife to wait until the neurosurgeon is consulted b. tell the wife to wait until the patient's condition improves c. ask the wife to wait until the nursing manager comes to discuss the issue with her d. give the wife permission to perform these actions as long as the number of family members is limited to three people - SOLUTION a. ask the wife to wait until the neurosurgeon is consulted The patient had a traumatic injury that resulted in multiple fractures and required amputation of the left arm about the elbow. His daughter, who attends college out of state, arrives during the night and requests permission to stay the night with the patient. The unit strictly limits visiting during the night, allowing a specific length of time every 2 hours. What would be the nurse's best response in this situation? a. in a comforting manner, tell the daughter that the policy needs to be followed, but she can wait in the lounge b. allow the daughter to stay, but explain that she may be asked to leave if the nursing manager discovers that she is staying longer than allowed c. reassure the daughter that she will be able to stay as long as she wants during the day d. explain the policy requirements to the daughter, but tell her that permission will be requested from the supervisor - SOLUTION d. explain the policy requirements to the daughter, but tell her that permission will be requested from the supervisor The nurses are discussing staffing, comparing their unit's patient/nurse ratio with that of other area hospitals. Which of the following is the least important consideration when determining patient/nurse assignments? a. nurse competence b. a patient's clinical needs c. nurse preference d. a patient's psychosocial needs - SOLUTION c. nurse preference The patient is a newly diagnosed Type II diabetic who requires instruction on disease management. Which of the following strategies best facilitates patient learning? a. provider written information upon discharge when the patient is stronger b. explain the importance of blood glucose monitoring at home to the patient c. discuss recipes and meal preparation with the patient d. ask the patient to restate important concepts about disease management - SOLUTION d. ask the patient to restate important concepts about disease management A patient's wife asked the nurse detailed questions about each oral and intravenous drug administered by all nurses caring for her husband. She also took notes on each nurse's response to the questions. The next day, the wife repeated the same questioning and note-taking. What is the most appropriate response by the nurse in response to the wife's behavior? d. develop education for nursing on safe handling of patients with central lines - SOLUTION c. work with the unit's Shared Governance Council to analyze system processes that may be contributing to the dislodgments A physician entered an order for a new medication that the nurse was not familiar with, and he had not discussed this plan during morning rounds. What is the best way for the nurse to deal with this situation? a. call the pharmacist to get information on the new medications b. contact the physician to discuss the rationale for the use of this new medication c. ask nurse colleagues if they are familiar with the new medication d. administer the medication as ordered by the physician - SOLUTION b. contact the physician to discuss the rationale for the use of this new medication The patient is receiving enteral nutrition via a small-bore feeding tube. During the shift report, the nurse reported that he confirmed tube placement by auscultation of insufflation of air. What is the top priority for the nurse who receives this report to use in the situation? a. continue the report, and confirm tube placement according to evidenced- based practices during her own initial shift assessment b. seek out the Clinical Nurse Specialist after receiving the report, and let her know that nurses are still using auscultation of air to assess feeding tube placement c. ask the nurse if he also assessed the tube marking at the tube exit site and if he knew that assessment of tube placement using insufflation of air is no longer evidenced based practice d. during the shift, discuss with nurse colleagues what method they use to confirm feeding tube placement to determine where this may be a widespread quality is - SOLUTION c. ask the nurse if he also assessed the tube marking at the tube exit site and if he knew that assessment of tube placement using insufflation of air is no longer evidenced based practice Which of the following patient scenarios has high predictability? a. a 28-year-old trauma patient with epidural hematoma b. a 55-year-old post-op coronary artery bypass graft (CABG) patient c. a 32-year-old patient with DKA b. a 61-year-old patient with ARDS secondary to septic shock - SOLUTION c. a 32-year-old patient with DKA The husband and daughter of a patient, who has numerous complications status post bowel perforation, are upset and dissatisfied with nursing and physician care. During the intershift report, the nurse tells her nurse colleague to be prepared to deal with their "difficult behavior". What strategy would be most effective for the nurse colleague to use when caring for this patient? a. at the beginning of the shift, let the family know how the nurse can be reached throughout the shift b. give a detailed account of the patient's condition to the husband and daughter after the initial shift assessment c. answer questions thoroughly as the arise d. ask the family if the have any concerns before they voice concerns, and engage the family as much as possible throughout the shift - SOLUTION d. ask the family if the have any concerns before they voice concerns, and engage the family as much as possible throughout the shift The patient's daughter will be caring fo her father at home after he is discharged. The patient has an abdominal dressing that will need to be changed. What is an abdominal dressing that will need to be changed. What is an effective strategy for the nurse to use when teaching the patient's daughter how to change the dressing? a. utilize a stimulated environment for demonstration and practice, and then teach at the bedside and observe the daughter changing the dressing b. plan for two or three nurses to teach the daughter in order to expose her to a variety of teaching styles c. explain the entire procedure, provider written instructions, and then have the daughter change the dressing d. have the daughter watch a video of an abdominal dressing change, and then observe the daughter changing the dressing - SOLUTION a. utilize a stimulated environment for demonstration and practice, and then teach at the bedside and observe the daughter changing the dressing The patient was admitted with Guillain-Barre syndrome and required 5 days of mechanical ventilation. He has been weaned from the ventilator and is slowly regaining leg strength, but he is still not independent. The patient has been increasingly demanding and gets upset if the bedside table is not set up properly of if personal hygiene is not done the same way each day. Which of the following interventions is most effective approach for addressing this patient's behavior? a. explain to the patient that there is more than one correct way to arrange the bedside table and perform hygiene b. follow the patient's directions, and engage the patient in a discussion of how he feels about this course of illness and the progress of his recovery c. follow the patient's directions without any comments d. point out to the patient that his demands may be an attempt to exert some control over a situation that resulted in a loss of - SOLUTION b. follow the patient's directions, and engage the patient in a discussion of how he feels about this course of illness and the progress of his recovery