NUR 240: NUR 240 Final Exam: 100 % Verified Questions & Answers: Latest Updated, Exams of Nursing

Download NUR 240: NUR 240 Final Exam: 100 % Verified Questions & Answers: Latest Updated and more Exams Nursing in PDF only on Docsity! NUR 240 Final Exam: Questions & Answers The nurse reviews assessment data on a group of patients. Which patient should the nurse identify as experiencing a critical illness? 1. Chronic airflow limitation with VS: BP 110/72, P 110, R 16 2. Acute bronchospasm with VS: BP 100/60, P 124, R 32 3. Motor vehicle crash with VS: BP 124/74, P 74, R 18 4. Chronic renal failure on hemodialysis with no urine output with VS: BP 98/50, P 108, R 12 (Ans- 2 Which patient should the nurse expect to be transferred to a critical care unit? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Experiences an acetaminophen overdose 2. Diagnosed with an acute mental illness 3. Receiving treatment for chronic renal failure 4. New onset of acute decompensated heart failure 5. Treatment for bacteremia from an infected foot wound (Ans- 1,4,5 The nurse employed in a hospital in a small rural town would expect to provide which level of care in the critical care unit? 1. Level I 2. Level II 3. Level III 4. It is unlikely that the hospital would have a critical care unit. (Ans- 3 With which individuals should the nurse expect to provide patient care in an "open" ICU? 1. Multidisciplinary team with physicians who are also responsible for patients on other units 2. Multidisciplinary team that includes a physician employed by the hospital 3. Physician in charge of patient care who is a specialist in critical care 4. Primary care physician who must consult a critical care specialist (Ans- 1 What should the nurse who provides care to patients in a critical care unit realize the role of technology is on the amount of errors? 1. It relies heavily on human decision making. 2. Devices are programmed to function without double checks. 3. It makes the workload seem overwhelming to health care providers. 4. There is uniform equipment throughout each facility. (Ans- 2 What should the nurse identify as an example of an installed forcing function or a system-level firewall to prevent errors when providing patient care? 1. Prior to administration of insulin, two nurses check the dose. 2. Prior to obtaining a medication, height, weight, and allergies are recorded. 3. All medications are checked by two nurses prior to administration. 4. Undiluted potassium chloride is not available on critical care units. (Ans- 4 The nurse realizes that the increased use of technology in critical care units has resulted in which consequence for patient care? 1. Decreased risk of errors in patient care 2. Decreased therapeutic nurse-patient communication 3. Improved overall patient satisfaction with care 4. Improved patient safety across the entire spectrum (Ans- 2 The nurse collaborates with other members of the health care team to effect optimal outcomes in patient care. Which characteristics of emotional maturity is the nurse using? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Maintaining current skills 2. Being a lifelong learner 3. Actively identifying best practices 4. Overlooking one's own shortcomings 5. Willing to take responsibility for failures (Ans- 1,2,3,5 Which informal power bases should the nurse use in the health care setting? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Expertise 2. Goodwill 3. Information 4. Observation 5. Collaboration (Ans- 1,2,3 Which action ensures that a patient has consented to care? 1. Provide a consent form to sign to receive medications. 2. Ask the patient to sign a consent form to have dressings changed. 3. Discuss a consent form to sign to be turned in bed. 4. Explain how a dressing is to be changed. (Ans- 4 For what can the nurse be held liable if forcibly inserting a nasogastric tube against a patient's wishes? 1. Negligence 2. Malpractice 3. Damages 4. Battery (Ans- 4 For which patient would decision-making capacity likely be impaired? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Being medicated for severe pain 2. Does not understand the medical condition 3. Diagnosed with septic shock 4. Is depressed 5. Asks questions about identified treatments (Ans- 1,2,3,4 Which condition is most likely to occur when a patient is restrained? 1. Pulling out an endotracheal tube 2. Pulling out an intravenous line 3. Disconnecting ventilator tubing 4. Developing a nosocomial infection (Ans- 4 What must the patient demonstrate for a nurse to be found guilty of negligence? 1. Was assaulted 2. Incurred damages 3. Suffered a wrongful death 4. Was not consulted before being touched (Ans- 2 What is associated with moral distress in critical care nurses? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Having no voice in clinical decision making 2. Providing aggressive care to patients who cannot benefit 3. Realizing that nurses maintain power in bedside decision making 4. Knowing the right thing to do but not being able to do it 5. Leaving employment as a critical care nurse (Ans- 1,2,4,5 What might occur when a nurse employs conscientious refusal to participate? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Dismissal from a nursing position 2. Employer sanctions 3. Support from nursing administrators 4. Protection from the state boards of nursing 5. Support by the patient (Ans- 1,2 Which symptoms indicate a nurse is experiencing compassion fatigue? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Difficulty separating work from personal life 2. Excessively high tolerance for frustration 3. Having a completely laissez-faire attitude 4. Decreased functioning in nonprofessional situations 5. Dreads working with certain types of patients (Ans- 1,4,5 The nurse is providing care to patients in a Level II general critical care unit. For which types of patient problems will this nurse most likely provide care? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Exacerbation of heart failure 2. Wound infection 3. Burns over 50% of total body surface 4. Kidney transplant 4. Act 5. Assert (Ans- 1,2,3,4 The critical care nurse is experiencing psychologic symptoms of compassion fatigue. What strategies should the nurse use to enhance psychological well-being? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Make time for recreational activities. 2. Practice yoga for relaxation. 3. Plan to take a walk in the park at least once a week. 4. Monitor food and beverage intake. 5. Darken the room and limit activities before sleep. (Ans- 1,2,3 The nurse manager is planning the staffing budget for the next fiscal year. What action should the manager take to ensure that staffing is adequate? 1. Study the results of the organization's staffing evaluation. 2. Meet with other nurse managers to compare staffing needs. 3. Remember that nurses should not work more than 72 hours each week. 4. Review staff competency needs with the director of human resources. (Ans- 1 The critical care nurse discusses a patient's change in status with the health care provider, pharmacist, and physical therapist. Which QSEN competency is this nurse demonstrating? 1. Patient-centered care 2. Quality improvement 3. Evidence-based practice 4. Teamwork and collaboration (Ans- 4 The nurse plans to question a health care provider's choice of medication for a critically ill patient. Which statement demonstrates assertive communication? 1. "At times I think it would be wise to update the prescribing references that are used." 2. "I learned that this medication might not be effective with this health problem. Would you explain choosing it?" 3. "This patient is getting worse, and it is because someone prescribed an antiquated medication to treat the problem." 4. "I realize I am only a nurse, but I can read and I learned that this medication is a poor choice to treat this medical problem." (Ans- 2 The adult daughter of a client with end-stage kidney disease informs the health care provider that all interventions are to be provided even though the client is heard telling the spouse that "enough is enough." What should be done first when analyzing this situation? 1. Identify significant information. 2. Determine the decision maker for the client. 3. Estimate the resources needed for care. 4. Calculate the expense of providing care to the client (Ans- 1 The nurse manager reviews the standards of self-care for caregivers during a staff meeting. Which staff nurse comment indicates that teaching about the standards has been effective? 1. "I will consider yoga classes." 2. "I will play tennis with my sister at least twice a week." 3. "I do love to read, but at times I review the events of the day and I'm distracted." 4. "Going to the zoo with my nephew might be a good idea if I'm not needed for overtime." (Ans- 2 The nurse identifies a patient in the critical care unit as having "resiliency." What characteristic has the nurse identified in the patient? 1. Motivation to reduce anxiety through positive self-talk 2. Ability to bounce back quickly after an insult 3. Physical strength to endure extreme physical stressors 4. Ability to return to a state of equilibrium (Ans- 2 While caring for a patient in the critical care unit, the nurse realizes that the patient's care needs must be a balance between the patient's long-term prognosis and the family's expectations of recovery. Which AACN Synergy Model characteristic does this situation describe? 1. Complexity 2. Predictability 3. Participation in care 4. Resource availability (Ans- 1 The nurse realizes that which stressor is one of the primary concerns of critically ill patients and should be routinely included during assessments? 1. Inability to control elimination 2. Lack of family support 3. Hunger 4. Altered ability to communicate (Ans- 4 A patient has just completed a preoperative education session prior to undergoing coronary artery bypass surgery. Which patient statements indicate that teaching has been effective? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. "I understand that I will have to blink my eyes to respond after the breathing tube is in my throat." 2. "I will be given frequent mouth care to help me when I am thirsty." 3. "I will be able to move about freely in bed and into the chair without help while connected to the electronic equipment for monitoring." 4. "I may need something to help me rest due to the unfamiliar lights and sounds of the ICU unit." 5. "I might not behave like my usual self after the surgery, but it will be because of the medications and my illness." (Ans- 1,2,4,5 When providing care to critically ill patients, whether they are responsive or unresponsive, what should the nurse do? 1. Clearly explain what care is to be done before starting the activity. 2. Perform the activity and then let the patient rest without explaining the care. The nurse confirms medication orders and the schedule to administer a sedative to a patient with delirium. Which dosing schedule maximizes the effectiveness of the drugs? 1. Only in the early morning 2. Only at bedtime (HS) 3. Around the clock with higher dosages in the evening 4. Only on an as-needed (PRN) basis (Ans- 3 The charge nurse reviews information about patients received during morning report. Which patient is at risk for nutritional imbalances? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Client recovering from a myocardial infarction 2. Client receiving hemodialysis treatments 3 times a week 3. Client with slightly elevated liver enzymes 4. Client who is intubated for respiratory failure 5. Client recovering from extensive burns (Ans- 1,2,4,5 Members of the multidisciplinary care team review a patient's nutritional status and analyze assessment values. Which value would need additional investigation? 1. A serum albumin of more than 3.5 g/dL or 35 g/L 2. A weight increase of 1.5 kg in a day 3. A serum hemoglobin of 11.7 g/dL or 117 mmol/L 4. A prealbumin level of 35 mg/dL (Ans- 2 The nurse inserts a nasogastric tube and plans to confirm placement of the tube prior to starting enteral feedings. Which is the most accurate method for confirming tube placement? 1. Obtaining a radiological x-ray of the abdomen 2. Checking gastric aspirate for a pH of less than 7 3. Instilling 30 mL of air while listening with a stethoscope when placed over the fundus of the stomach 4. Determining the presence of carbon dioxide (Ans- 1 Which nursing diagnosis should receive the highest priority when caring for a patient who is receiving total parenteral nutrition? 1. Infection, Risk for 2. Trauma, Risk for 3. Skin Integrity, Impaired 4. Fluid Volume, Risk for Imbalance (Ans- 1 What should the nurse do to meet the needs of the critically ill patient's family members? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Express an attitude of hope, honesty, open communication, and caring 2. State specific facts about the patient's condition in a timely manner 3. Plan regular times for family visits throughout the day 4. Limit the number of visitors to significant others 5. Communicate to a single family member to cut down time wasted repeating information to all visitors (Ans- 1,2,3 Which statement describing the needs of family members of critically ill patients has yet to be validated by research? 1. "Not knowing is the worst part" of waiting. 2. Families in the waiting room have no effect on patient outcomes. 3. "Hovering" in the proximity phase is characterized by confusion and tension. 4. A unified message from staff minimizes family stressors. (Ans- 2 The nurse addresses the family needs of a critically ill patient. Which family need was not identified? 1. Proximity 2. Information 3. Assurance 4. Timeliness (Ans- 4 When planning care to meet the needs of families of critically ill patients, the nurse should include which strategies by Miracle (2006)? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Information about how to contact the primary doctor if needed 2. Frequent verbal communication to clarify the purpose of unit, equipment, procedures, waiting areas, phones, and so on 3. Regular family conferences to meet patient goals and progress 4. A consistent nurse, and unified staff responses if that nurse is not available 5. A way to contact family through a specific family member by phone if needed (Ans- 1,3,4 A physician suggests that a patient being mechanically ventilated, needing immediate transport to CT scan, and having severe pain be given IV fentanyl (Sublimaze) rather than morphine sulfate for pain management. Why is fentanyl (Sublimaze) preferred? 1. Rapid administration does not have any hemodynamic consequences. 2. It has a more rapid onset and a shorter duration of action. 3. Weaning of a continuous infusion is never needed due to its short half- life. 4. It is not likely to cause respiratory depression (Ans- 2 A patient being mechanically ventilated receives midazolam (Versed) for sedation. What findings indicate to the nurse that the patient is receiving an appropriate dose of this medication? 1. Awake with a respiratory rate of 38 and a heart rate of 132 2. Asleep but withdrawing from noxious stimuli with a heart rate of 80 3. Awake with a heart rate of 124 and attempting to pull out the IV 4. Asleep but awakening to light touch with a heart rate of 72 (Ans- 4 The nurse cares for a patient recovering from surgery who is being mechanically ventilated and experiencing pain. Which approach should the nurse use first to assess this patient's pain? The nurse plans to use music therapy to help reduce a critically ill patient's level of anxiety. What should the nurse do when using this complementary and alternative therapy? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Ask family members to identify the patient's preferred music. 2. Plan for the music to be played for 30 uninterrupted minutes. 3. Listen to the music in advance to make sure it does not have lyrics. 4. Ensure that the music beats are between 60 to 80 per minute. 5. Play the music from a CD player on the bedside table. (Ans- 1,2,3,4 The nurse assesses the nutritional needs of a patient in the intensive care unit. What information is essential for the nurse to obtain during this assessment? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Patient's current height and weight 2. Food allergies 3. Use of nutritional supplements 4. If the patient can swallow 5. Amount of water consumed each day (Ans- 1,2,3,4 The nurse is a member of a committee that is designing improvements to the critical care waiting areas. What improvements should the nurse suggest to enhance the comfort of family members of critical care patients? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Plan for a large space to be used for the waiting areas. 2. Provide coffee and soft drinks in the waiting area. 3. Place televisions and DVD players in the waiting area. 4. Find space for sleeping rooms. 5. Use dark paint and minimal lighting in the waiting areas. (Ans- 1,2,3,4 The nurse uses the Synergy Model patient characteristics to plan care for a patient in the intensive care area. Which observations indicate that these actions were effective? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Patient extubated two days earlier than expected 2. Patient expresses dissatisfaction with morning care 3. Patient states that he or she is feeling better and is eager to return home 4. Patient thanks the nursing staff for help with basic care needs 5. Patient rests between procedures and medication administration (Ans- 1,3,4,5 A critically ill patient is prescribed enteral feedings to begin after placement of the nasogastric tube is verified. What should the nurse identify as the goal for this method of nutrition? 1. Prevent infection 2. Avoid aspiration pneumonia 3. Enhance respiratory excursion 4. Reduce the need for pain medication (Ans- 1 A newly admitted patient receiving sedation is prescribed parenteral nutrition via a central line. Which action should the nurse take to prevent overfeeding of this patient? 1. Monitor daily weights 2. Use an infusion pump 3. Evaluate albumin levels 4. Question the order to infuse lipids (Ans- 4 Weekly group meetings are scheduled every Wednesday afternoon for the families of current intensive care patients. What should the nurse prepare in anticipation of the next meeting? 1. Visiting hours for the unit 2. Location of the waiting area 3. Equipment and treatments the patients receive 4. The schedule of when to telephone for patient status updates (Ans- 3 A patient has a blood pressure of 134/70 per blood pressure cuff and a blood pressure of 90/50 per arterial line. What action should the nurse take? 1. Discontinue the arterial line immediately. 2. Check the level of the transducer and relevel and rezero the system. 3. Do nothing because this is a normal variation between the two methods of measurement. 4. Begin the infusion of a dopamine drip. (Ans- 2 The nurse is monitoring a patient's pulmonary vascular resistance. Which value is the normal value? 1. 100-250 mm Hg 2. 10-250 dynes/sec/cm2 3. 400-800 mm Hg 4. 900-1,400 dynes/sec/cm2 (Ans- 2 A patient's systemic vascular resistance (SVR) has dangerously decreased. The nurse would expect to administer which medications? 1. Furosemide (Lasix) and dopamine 2. Nitroprusside and furosemide (Lasix) 3. Dopamine and norepinephrine (Levophed) 4. Nitroglycerin and digoxin (Lanoxin) (Ans- 3 A patient has mixed venous oxygen saturation (SVO2) of 52% with the following hemodynamic findings: CO of 4.8 L/min, SaO2 of 95%, and an unchanged hemoglobin level. For what should the nurse assess the patient? 1. Excessive sedation 2. Position of the PA catheter 3. Hypothermia 4. Pain (Ans- 4 Which action has the highest priority for maintaining safety when caring for a patient with a PA catheter? 4. Add the systolic pressure and two diastolic pressures and then divide by 3. (Ans- 4 What should the nurse use to measure the contractility of the left side of a patient's heart? 1. Left atrial pressure 2. Pulmonary artery wedge pressure 3. Systemic vascular resistance 4. Left ventricular stroke work index (Ans- 4 Which nursing intervention ensures an accurate cardiac output reading for a patient? 1. Administer the injectate within 4 seconds. 2. Use 5 cc of iced saline as the injectate. 3. Ensure that there is a difference of 10°C between the injectate temperature and the patient's body temperature. 4. Inject the fluid into the pulmonary artery distal port. (Ans- 1 Which value should the nurse recognize is normal for a patient's cardiac output? 1. 6-9 L/min 2. 4-8 L/min 3. 8-10 L/min 4. 2-4 L/min (Ans- 2 A patient is experiencing reduced afterload. What should the nurse identify as causes for this finding? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Sepsis 2. Mitral stenosis 3. Reduced circulating blood volume 4. Vasodilator medications 5. Myocarditis (Ans- 1,4 A patient has a lactate level of 8 mmol/L. What should this finding indicate to the nurse? 1. Carbon dioxide exchange 2. Underuse of oxygen 3. Glucose metabolism 4. Tissue hypoxia (Ans- 4 A patient with an arterial line has an elevated partial thromboplastin time (PTT) and is not on anticoagulation therapy. What should the nurse do? 1. Take the patient for an immediate V/Q scan. 2. Assess for the presence of a deep vein thrombosis. 3. Change the heparinized saline solution in the pressure bag for the arterial line to a normal saline solution. 4. Ask for an order to begin Lovenox therapy. (Ans- 3 Prior to the insertion of an arterial line in the radial artery, which assessment should the nurse perform? 1. Homan's test 2. Kernig's test 3. Allen's test 4. Leopold's maneuver (Ans- 3 When observing the waveform of an arterial line, the nurse notes the presence of a dicrotic notch. How should the nurse interpret this finding? 1. Pulmonic valve opening 2. Mitral valve closure 3. Aortic valve closure 4. Tricuspid valve closure (Ans- 3 The nurse suspects that a patient is experiencing cardiogenic shock. Which parameter indicates that the nurse's suspicion is correct? 1. Cardiac output of 8.9 L/min 2. Pulmonary artery wedge pressure (PAWP) of 8 mm Hg 3. Central venous pressure (CVP) of 5 mm Hg 4. Cardiac index (CI) of 1.8 L/min/m2 (Ans- 4 A patient's hemodynamic parameters include the following: right atrial pressure (RAP) of 13 mm Hg, pulmonary artery wedge pressure (PAWP) of 8 mm Hg, systemic vascular resistance (SVR) of 1,000 dynes/sec/cm2, cardiac output (CO) of 4.9 L/min, cardiac index (CI) of 3.5 L/min, and pulmonary vascular resistance (PVR) of 280 dynes/sec/cm2. Which heart function should cause the nurse concern? 1. Afterload 2. Left heart contractility 3. Right heart contractility 4. Heart rate (Ans- 3 After assessing a patient's hemodynamic parameters, the nurse determines that preload and afterload are both elevated. These findings are consistent with which health problems? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Pericardial tamponade 2. Constrictive pericarditis 3. Hypovolemia 4. Neurogenic shock 5. Mitral stenosis (Ans- 1,2 The nurse wants to assess the oxygenation status of a patient who has been experiencing a gastrointestinal bleed. How should the nurse complete this assessment? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Use pulse oximetry. 2. Send a blood sample for arterial blood gas analysis. 3. Auscultate lung sounds. 4. Evaluate cardiac rhythm strip. 5. Calculate mean arterial pressure. (Ans- 1,2 A patient is admitted with atrial fibrillation. Why should the nurse identify interventions to address low cardiac output for this patient? 1. Loss of atrial kick 2. Pressure in the ventricles 3. Irregular ventricular rhythm 4. Systemic blood from the left ventricle (Ans- 1 A patient demonstrates signs of elevated pulmonary vascular resistance (PVR). For which health problem should the nurse assess this patient? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Hypoxia 2. Aortic stenosis 3. Pulmonary stenosis 4. Pulmonary embolism 5. Pulmonary hypertension (Ans- 1,3,4,5 A patient has a pressure-monitoring device inserted after an acute myocardial infarction. Which action should the nurse take to minimize the risk of overdampened measurements? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Ensure tubing is without kinks. 2. Add tubing to the flush system. 3. Remove all air from the flush system. 4. Inflate the pressure bag to 300 mm Hg. 5. Maintain adequate normal saline in the flush bag. (Ans- 1,3,4,5 A patient with a PA catheter needs PCWP readings every 4 hours. What technique should the nurse follow when obtaining these pressures? 1. Cap the port after the balloon is inflated. 2. Keep the balloon inflated for 30 seconds. 3. Inflate the balloon until the PA waveform changes. 4. Open the balloon inflation valve after each measurement. (Ans- 3 A patient says, "I've never heard of an acute coronary syndrome. Please explain what happened to me." What should the nurse explain about the health problem? 1. "It is another name for a myocardial infarction (MI) or heart attack." 2. "It is a group of disorders that result in insufficient oxygen supply to the heart." 3. "It is the second leading cause of death in the United States." 4. "It is a type of abnormal heart rhythm." (Ans- 2 The nurse is teaching a patient about acute coronary syndrome. What should the nurse teach that describes the progression of events in this disorder? 1. A thin fibrin layer stabilizes the ruptured plaque and prevents the occlusion of coronary vessels when stable angina is present in ACS. 2. When complete platelet occlusion occurs in a vessel, the ECG changes include nonspecific ST elevation without necrosis occurring in ACS. 3. The growth of platelet-rich thrombi in the smaller vessels creates a blockage and is the cause for unstable angina symptoms in ACS. 4. Sudden plaque buildup in a narrow vessel immediately leads to an acute myocardial infarction when stable angina is present in ACS. (Ans- 3 A nurse is discussing management of hypertension with a patient. Which patient statement indicates that additional teaching about the relationship between hypertension and acute coronary syndrome (ACS) is needed? 1. "My high blood pressure has no relationship to the severity of heart disease or its outcomes." 2. "Because I'm over 80, even a 20 mm Hg drop in my blood pressure can reduce my risk." 3. "High blood pressure will increase my body's need for oxygen and increase my heart's workload." 4. "Controlling my blood pressure will decrease my risk of having a heart attack to some degree." (Ans- 1 Which statement explaining the relationship of body weight to acute coronary syndrome (ACS) should the nurse include when presenting a healthy heart program to a community group? 1. Excessive weight will result in a decrease in low-density lipoproteins (LDL), which is linked to ACS. 2. Extra weight can lead to diabetes insipidus, which will increase the risk for ACS. 3. Losing as little as 5% of one's body weight will significantly lower the risk for ACS. 4. Obesity, a BMI of greater than 30, increases the risk for ACS. (Ans- 4 A patient says, "The chest pain occurs each time I play basketball; it does not occur when I am sleeping; and it improves when I take those pills under my tongue." What health problem is this patient describing? 1. Variant or Prinzmetal's angina 2. Undifferentiated angina 3. Unstable angina 4. Stable angina (Ans- 4 A patient tells a nurse, "My chest pain starts when I am resting, and when I had a cardiac catheterization, the doctor said I was having vasospasms." Which type of medication should the nurse anticipate to be prescribed to treat the patient's angina? 1. A vasodilator, such as nitroglycerin (NTG) 2. A calcium channel blocking agent 3. An antidysrhythmic, such as lidocaine 4. A beta adrenergic blocking agent (Ans- 2 The nurse instructs a patient with a myocardial infarction about the disease process. Which patient statement indicates that additional teaching is needed? 1. "A heart attack is the same as a myocardial infarction (MI)." 2. "A heart attack causes tissue death, and that part of the heart may not pump as well." 3. Peripheral emboli distal to the insertion site 4. Over-anticoagulation (Ans- 4 A nurse is caring for a patient who has just started to bleed from the insertion site following a cardiac catheterization. What should be the nurse's first response? 1. Administer vitamin K (AquaMEPHYTON). 2. Locate and apply a compression clamp. 3. Apply a collagen patch or sheath. 4. Apply manual pressure to the site. (Ans- 4 To increase compliance and reduce postoperative complications, the nurse should include which topics in the preoperative teaching for a patient who is to have a coronary artery bypass graft (CABG)? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Reasons for cooling blankets in postop period 2. Equipment used: IVs, Foley, pacer wires, chest tubes, NG tubes, ECG leads 3. Alternate methods for communicating when intubated 4. Reasons and techniques of turning, coughing, and deep breathing once extubated 5. Drug management: need for sedation when intubated, pain med through PCA (Ans- 2,3,4,5 What should be included in the collaborative management of a patient's pulmonary status following coronary artery bypass graft surgery? 1. Keeping the patient intubated for at least 48 hours to maximize gas exchange 2. Mobilizing the patient as soon as possible to prevent atelectasis and venous stasis 3. Evaluating readiness for extubation based on guidelines: PO2 less than 80 mm Hg with an FiO2 greater than 40% and a PCO2 greater than 45 4. Extubating when the patient is arousable to noxious stimuli and shows increased effort for spontaneous breathing (Ans- 2 Which finding should cause the nurse to suspect that a patient recovering from coronary artery bypass surgery might be developing cardiac tamponade? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Widening pulse pressure 2. Increased jugular vein distension 3. Decreasing central venous pressure (CVP) 4. Muffled heart sounds 5. Lack of pleural (chest) tube drainage (Ans- 2,4,5 Which factors would contribute to the risk of a patient developing stress ulcers after coronary artery bypass graft (CABG) surgery? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Incidence of postoperative hemorrhaging 2. Age less than 70 years 3. Alcohol abuse or excess 4. Need for vasodilators for postoperative hypertension 5. Prolonged use of cardiopulmonary bypass (Ans- 1,3,5 Which is least likely to be a goal of a patient participating in cardiac rehabilitation? 1. Taking control of his life through healthy choices 2. Managing symptoms by monitoring exercise 3. Reducing risks by controlling the modifiable risk factors 4. Stabilizing any severe depression that developed post-MI (Ans- 4 The nurse is discussing the Dietary Approaches to Stop Hypertension (DASH) program with a patient and spouse. They are overwhelmed and ask if there is one measure recommended by the program that would have the biggest impact so they can start with that measure first. What should the nurse suggest? 1. Decreasing sodium intake to less than 1,500 mg/day 2. Losing weight 3. Increasing intake of dairy products 4. Controlling diabetes to an A1C less than 7% (Ans- 1 The nurse teaches a patient with coronary artery disease about prescribed nitroglycerin therapy. Which patient statement indicates further teaching is needed? 1. "If the pain doesn't go away, I can take a second tablet after 5 minutes." 2. "I should not take nitroglycerin if I have taken Viagra." 3. "I should try to sit or lie down when I take the nitroglycerin." 4. "I'll put a couple of tablets in a plastic bag in my pocket so I have them with me all the time." (Ans- 4 A patient being discharged after an MI is prescribed lisinopril (Prinivil) 10 mg daily. Which instruction is most appropriate for the nurse to give to the patient? 1. Avoid crossing your legs. 2. Weigh yourself at least 3 times a week. 3. Cut down on your sodium intake to 1,500 mg/day. 4. Change your position slowly when going from lying to sitting. (Ans- 4 The nurse instructs a patient about acute coronary syndrome. What should be included in these instructions? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Fatty plaques develop in the coronary arteries. 2. Plaques in arteries limit the amount of blood that can flow through the heart vessels. 3. Plaque in coronary arteries can cause stable angina. 4. If a plaque ruptures, it can get into the general circulation. 5. Stable angina rarely progresses to unstable angina. (Ans- 1,2,3,4 3. Instruct the patient that a flushed face can occur within 2 hours after taking. 4. Teach to not take medication with grapefruit juice. 5. Remind to notify the health care provider of any onset of muscle pain. (Ans- 1,2,3 The nurse prepares material highlighting the impact of activity and exercise on preventing heart disease for a group of community members. What other risk factors for heart disease should the nurse emphasize that are positively impacted by exercise? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Obesity 2. Arthritis 3. Diabetes 4. Hypertension 5. Hyperlipidemia (Ans- 1,3,4,5 The nurse reviews orders written for a patient with non-ST-segment elevation myocardial infarction (NSTEMI). Which order should the nurse question before implementing? 1. Bedrest for 48 hours 2. Supplemental oxygen 3. Antiemetic as needed 4. Serial cardiac enzymes (Ans- 3 The nurse prepares discharge instructions for a patient recovering from percutaneous transluminal coronary intervention (PTCI). What medication information should the nurse include with this teaching? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Aspirin 2. Heparin 3. Ibuprofen 4. Clopidogrel 5. Acetaminophen (Ans- 1,4 The nurse cares for a patient recovering from coronary artery bypass grafting (CABG) surgery. Which action should the nurse take to maximize this patient's renal function? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Monitor urine output hourly for 24 hours. 2. Evaluate postoperative serum potassium level. 3. Transition to subcutaneous insulin sliding scale. 4. Keep nasogastric tube to low continuous suction. 5. Request orders for blood urea nitrogen and creatinine levels. (Ans- 1,2,5 When teaching a patient with heart failure about ventricular remodeling, the nurse should recognize that additional teaching is needed if the patient makes which statement about remodeling? 1. "It leads to progressive worsening of heart function." 2. "It can be described as an enlargement of the pumping chamber." 3. "It occurs with an increase in blood pressure and results in weight gain." 4. "It develops primarily because the heart is pumping harder." (Ans- 4 The nurse is reviewing a patient's medical history. Which factor in the history most likely contributed to the patient's development of heart failure? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Hypertension 2. Diabetes mellitus 3. Drinking one or two alcoholic drinks daily 4. Being overweight 5. Ischemic heart disease (Ans- 1,5 The nurse assesses a patient for heart failure (HF). Which early findings would indicate decreased cardiac output and a potential for fluid overload from heart failure? 1. Orthopnea, peripheral edema, crackles 2. Dizziness, syncope, palpitations 3. Pallor and/or cyanosis of extremities 4. PAWP of 12 and CVP of 6 (Ans- 1 Which assessment finding indicates that a patient's heart failure (HF) is worsening? 1. An increase in O2 saturation to greater than 90% 2. A decrease in heart rate to 66 bpm 3. The onset of atrial fibrillation 4. Louder S1 and S2 heart sounds (Ans- 3 A patient is very short of breath. Which finding should cause the nurse to consider that the shortness of breath might be due to heart failure? 1. An echocardiogram that reflects increased right ventricular wall thickening 2. A B-type natriuretic peptide (BNP) of 300 pg/mL 3. A left ventricular ejection fraction (VEF) of 50% 4. A serum sodium of 135 (Ans- 2 Which finding would support the diagnosis of heart failure (HF)? 1. RA/CVP of 8 mm Hg 2. PCWP of 20 mm Hg 3. Cardiac index of 3 4. Peripheral vasodilation reflected by normalizing capillary refill times (Ans- 2 After teaching a patient with heart failure about beta blocking agents, the nurse recognizes that additional teaching is needed when the patient makes which statement? 1. "I should weigh myself every day." 2. "I need to check my blood sugar regularly." A patient with heart failure has a decreasing cardiac output. Why should the nurse expect compensatory mechanisms to be activated? 1. To decrease the heart rate 2. To maintain perfusion to vital organs 3. To cause arteriolar vasodilation in nonessential vascular beds 4. To inhibit the release of aldosterone (Ans- 2 While caring for a patient in heart failure, the nurse assesses an elevated blood pressure and significant peripheral edema. How is the renin- angiotensin-aldosterone system causing these symptoms? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Releases angiotensin II 2. Releases aldosterone 3. Decreases cardiac output 4. Decreases heart rate 5. Causes arteriolar vasodilation (Ans- 1,2 A patient is diagnosed with left-sided heart failure. What should the nurse include when describing the disease process to this patient? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Pumping action of the heart is impaired. 2. Filling action of the heart is impaired. 3. Blood backs up in the left side of the heart. 4. Extra fluid can build up in the lungs. 5. Extra fluid can build up in the lower extremities. (Ans- 1,2,3,4 A patient is diagnosed with diastolic heart failure. What should the nurse realize is the cause of this type of heart failure? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Normal-sized but hypertrophied left ventricle 2. Blood backing up into the right atrium 3. Loss of ventricular diastolic relaxation 4. Blood backing up into the left atrium 5. Excessive fluid in the lower extremities (Ans- 1,2,3 Which finding should cause the nurse to suspect a patient with heart failure is experiencing end organ hypoperfusion? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Confusion 2. Dropping blood pressure 3. Urine output 15 mL per hour 4. Heart rate 124 5. Peripheral edema (Ans- 1,2,3,4 While transferring a patient with heart failure from the bed to a chair, the nurse stops and decides to keep the patient in bed. What patient manifestation indicated to the nurse that this patient's status was deteriorating? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Respiratory rate 30 2. Heart rate 134 on the cardiac monitor 3. Gasping for breath 4. Productive cough 5. Jugular vein distention (Ans- 1,2,3 The central venous pressure of a patient with heart failure is slowly increasing. What should this finding suggest to the nurse? 1. Right heart function is deteriorating. 2. Left heart function is deteriorating. 3. Fluid is backing up in the lungs. 4. Right heart function is improving. (Ans- 1 A patient with heart failure begins to cough pink frothy sputum. Which pressure should the nurse assess to confirm this manifestation? 1. Central venous pressure 2. Pulmonary capillary wedge pressure 3. Arterial pressure 4. Right arterial pressure (Ans- 2 The nurse teaches a patient with heart failure nonpharmacological strategies to improve quality of life. What should be included in these instructions? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Stop smoking. 2. Reduce salt intake to 1 gram per day. 3. Restrict caloric intake to attain recommended body weight. 4. Attend cardiac rehabilitation sessions as prescribed. 5. Ingest no more than three alcoholic drinks per day. (Ans- 1,3 A patient with a history of type 2 diabetes mellitus and heart failure is prescribed carvedilol (Coreg). What should the nurse assess prior to administering this medication to the patient? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Blood pressure 2. Pulse 3. Blood glucose level 4. Lung sounds 5. Potassium level (Ans- 1,2,3 Which findings should the nurse report to the health care provider as evidence that the condition of a patient with heart failure is deteriorating? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. S3 and S4 heart sounds The nurse reviews a new order written for a patient with heart failure. When should invasive hemodynamic monitoring be considered for this patient? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. When the patient is experiencing fatigue 2. When the patient is experiencing severe dyspnea at rest 3. When the patient is experiencing cool, clammy extremities 4. When an inotropic infusion is initiated 5. When doses of pressor therapy are increased (Ans- 2,4,5 A patient with heart failure is prescribed fosinopril (Monopril). For which reason should the nurse question this medication? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Serum creatinine 5 mg/dL 2. Serum potassium 5.9 mmol/L 3. Blood pressure 74/50 mm Hg 4. Respiratory rate 12 per minute 5. Pulse oximetry 92% on room air (Ans- 1,2,3 A patient is admitted for treatment of acute decompensated heart failure (ADHF). Which medication should the nurse prepare to administer first? 1. Diuretic 2. Vasopressor 3. Beta blocker 4. Inotropic agent (Ans- 1 A patient is diagnosed with type I hypoxemic failure. The nurse should realize that this type of respiratory failure is linked to what? 1. Muscular failure to move the air into and out of the lungs 2. Failure of the neurological system to stimulate respirations 3. Skeletal alterations of the thoracic region that limit air movement 4. Breakdown of oxygen transport from the alveolus to arterial flow (Ans- 4 The nurse searches the health history of a patient diagnosed with an acute lung injury for a reason for the disease process. Which statement correctly identifies the cause for this type of lung injury? 1. Acute lung injury can be caused indirectly from sepsis, systemic inflammatory response syndrome, or pancreatitis. 2. Acute lung injury is a single organ dysfunction syndrome that has a chronic onset. 3. Acute lung injury is caused by few infiltrates on chest radiography. 4. Acute lung injury is caused by right ventricular failure. (Ans- 1 When caring for a patient with damage to the cerebral cortex, which change in respiration and ventilation should the nurse expect to observe? 1. Increased rate of breathing per minute 2. Increased respiratory effort by the use of chest and diaphragm muscles 3. Decreased voluntary initiation of ventilatory effort 4. Decrease in CO2 in blood analysis (Ans- 3 Which arterial blood gas result indicates the development of an acute lung injury? 1. pH 7.4, PaCO2 40 mm Hg, PaO2 96, HCO3 24 mEq, SaO2 94% 2. pH 7.31, PaCO2 50 mm Hg, PaO2 70 mm Hg, HCO3 20 mEq, SaO2 90% 3. pH 7.49, PaCO2 32 mm Hg, PaO2 75 mm Hg, HCO3 22 mEq, SaO2 90% 4. pH 7.29, PCO2 28 mm Hg, PaO2 97 mm Hg, HCO3, 16 mEq, SaO2 94% (Ans- 3 When assessing a patient with type I hypoxemic failure, the nurse should evaluate for which contributing health problem? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Acute respiratory distress syndrome 2. Asthma 3. Cardiogenic pulmonary edema 4. Pneumonia 5. Narcotic overdose (Ans- 1,3,4 Which patients should the nurse identify as being at risk for developing type II hypoxemic hypercapneic failure? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. A 5-year-old male with a 5-year history of muscular dystrophy 2. A 34-year-old female patient who is 3 days' postoperative open cholecystectomy 3. A 24-year-old male newly admitted with possible Guillain-Barré syndrome 4. A 72-year-old female with kyphosis 5. An 85-year-old patient admitted with aspiration pneumonia (Ans- 1,3,4 What should the nurse expect to assess in a patient experiencing the fibrotic phase of acute lung injury? 1. Pulmonary occlusive pressures less than 18 mm Hg 2. Bilateral fluid seen on radiographic exams 3. Severe bleeding from all body orifices 4. Fever and leukocytosis (Ans- 4 What should the nurse expect to assess in a patient with respiratory failure and hypoxemia? 1. Exertional dyspnea, circumoral cyanosis, distal cyanosis 2. Subcutaneous emphysema, absent breath sounds, sharp chest pain 3. Agitation, disorientation, lethargy, chest pain 4. Rales, distended neck veins, orthostatic hypotension (Ans- 3 Which patient should the nurse identify as benefiting from the use of noninvasive ventilation (NIV)? 1. A 55-year-old female with an acute exacerbation of asthma 2. A 57-year-old male with a history of sleep apnea 3. A 48-year-old female with an acute myocardial infarction 4. A 72-year-old male with sepsis (Ans- 2 The nurse receives the following ABG result: pH = 7.00 PaCO2 = 50 mm Hg PaO2 = 89 mm Hg SaO2 = 90% Based on the results, what should the nurse do first? 1. Check the last dose of CNS depressant drug. 2. Assess lung sounds and vital signs. 3. Review the history for asthma or emphysema. 4. Apply oxygen per nasal cannula at 2 L/min. (Ans- 2 Which assessment findings should indicate to the nurse that a patient is experiencing respiratory distress? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Tachycardia 2. Use of abdominal muscles 3. Intercostal muscle retractions 4. Bradypnea 5. Jugular vein distention (Ans- 1,2,3 Arterial blood gas (ABG) results of an intubated, mechanically ventilated patient are as follows: pH 7.33; PaO2 50; PaCO 49; bicarbonate 27. What nursing action is a priority for this patient? 1. Increase respiratory rate and FiO2. 2. Increase IV fluids. 3. Add positive end expiratory pressure. 4. Decrease the respiratory rate and FiO2. (Ans- 1 Which nursing action optimizes overall oxygenation and ventilation in the patient with acute respiratory distress syndrome (ARDS)? 1. Provide adequate rest and recovery time between procedures. 2. Hyperventilate the patient before and after suctioning. 3. Administer sedation frequently. 4. Suction the patient as needed. (Ans- 1 A patient with ARDS has PEEP added to the mechanical ventilation therapy. Which assessment finding indicates that the use of PEEP has been effective? 1. PCO2 of 52 mm Hg 2. A PO2 of 92 mm Hg 3. A respiratory rate of 33 4. A urine output of 50 cc/hr (Ans- 2 Which assessment finding indicates that a patient is ready to be weaned off of mechanical ventilation? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Unstable hemodynamics 2. Rapid shallow breathing index of 40 3. A spontaneous tidal volume of 600 cc 4. An SaO2 of 95% 5. A respiratory rate of 18 on CPAP (Ans- 3,4,5 During multidisciplinary rounds, a discussion is held regarding the use of medications in acute respiratory distress syndrome (ARDS). Which statement is most accurate based upon published research findings? 1. Corticosteroids are used for their anti-inflammatory property to manage the cytokine-mediated inflammatory response in ARDS. 2. Exogenous surfactant therapy is more beneficial to adult patients with ARDS than when it is given to neonates. 3. β-agonists reduce pulmonary edema and inflammation. 4. Inhaled nitric oxide promotes blood flow to ventilated areas of the lungs. (Ans- 4 What assessment finding indicates that a patient is in the fibroproliferative phase of acute respiratory distress syndrome? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Crackles on auscultation 2. Agitation 3. Peripheral edema 4. Fever 5. Increased heart rate and drop in blood pressure (Ans- 1,2,3 A patient in the recovery phase of acute respiratory distress syndrome continues to experience difficulty with breathing. What should the nurse recognize as being the characteristics of this phase? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Development of fibrotic tissue in the alveolar capillary membrane resulting in alveolar disfigurement 2. Decreased lung compliance 3. Worsening pulmonary hypertension 4. Increased dead space ventilation 5. Formation of hyaline membranes (Ans- 1,2,3,4 What is important for the nurse to assess in a patient who is beginning noninvasive ventilatory support? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Patient orientation and level of alertness 2. Respiratory pattern and depth 3. Status of skin of the nose 4. Bowel sounds and presence of insufflation 5. Peripheral pulses (Ans- 1,2,3,4 The high-pressure alarm on a patient's mechanical ventilator is sounding. What action should the nurse take? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Assess if the patient needs to be suctioned. 2. Assess if the patient is biting the tube. 3. Assess if the patient has rolled onto the tube. A patient with chronic obstructive pulmonary disease (COPD) experiences shortness of breath. What should the nurse explain to the patient about this symptom? 1. "It is because you have excess fluid in your lungs." 2. "It is caused by excess mucus in your lung membranes." 3. "It's because you have excess carbon dioxide trapped in your lungs." 4. "It is because you have pneumonia that has not been treated correctly." (Ans- 3 A patient is prescribed high-flow oxygen therapy. What action should the nurse take when caring for this patient? 1. Ensure the reservoir bag inflates. 2. Clear condensation from the tubing. 3. Keep the port on the face mask uncovered. 4. Position the fluid collection reservoir above face level. (Ans- 2 A patient with an acute lung injury has lower extremity edema. What should the nurse expect to be prescribed to treat this patient's problem? 1. Fluid restriction 2. Colloid infusions 3. Low-dose furosemide 4. 0.9% normal saline infusion (Ans- 3 A patient arrives in the emergency department with a flail chest after a motor vehicle crash (MVC) in which the patient's chest hit the steering wheel. What should the nurse realize this injury is due to? 1. Blunt trauma from internal forces caused by acceleration 2. Blunt trauma from external forces caused by deceleration 3. Penetrating trauma from external forces caused by deceleration 4. Penetrating trauma from internal forces caused by acceleration (Ans- 2 Which patient assessment data supports an open traumatic injury? 1. A closed hip fracture that was caused by a fall 2. A gunshot wound without penetration of the bullet due to the bullet-proof vest 3. Near-drowning after falling through a frozen lake 4. Burns over 30% of the body from a house fire (Ans- 4 When performing a quick assessment to identify life-threatening problems in a trauma patient, the nurse should include which assessments under the D—Disability section? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Ability to respond to painful stimuli 2. Vital signs 3. Ability to respond to verbal command 4. Level of consciousness or unconsciousness 5. Oxygen saturation levels (Ans- 1,3,4 What activity should the nurse implement under the A section of assessment priorities when admitting a patient with a suspected spinal cord injury? 1. Using a manual ventilation bag 2. Applying heated blankets 3. Using the jaw thrust maneuver 4. Assessing for history of asthma (Ans- 3 Which risk factor could lead to the development of airway failure if not recognized while assessing the airway of a trauma patient? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Chest wall injury 2. Displacement of the trachea (tracheal shift) 3. Aspiration of gastric contents 4. Foreign object occlusion of the throat/mouth 5. Swelling of soft tissue in the throat (Ans- 2,3,4,5 Which nursing assessment should have highest priority for early airway management of a trauma patient? 1. Ask the patient to state his or her name. 2. Assess increasing intracranial pressure (ICP) with facial fractures. 3. Prepare for emergency tracheostomy. 4. Perform a computerized tomography (CT) scan of tissues of the neck. (Ans- 1 Which assessment finding indicates that a patient with a traumatic injury is having problems with breathing rather than difficulty maintaining an airway? 1. Pain with swallowing, coughing, or hemoptysis 2. Chest pain on inspiration 3. Popping sound (crepitus) in the throat when touching the skin by the trachea 4. Hoarseness when talking (Ans- 2 What should the nurse assess when evaluating breathing in a patient suspected of having thoracic trauma? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Jugular vein distention 2. Symmetry of chest movement bilaterally 3. Chest movements that rise and fall with breathing effort 4. Respiratory rate, pattern, and effort 5. Peripheral skin coloring (Ans- 1,2,3,4 What should the nurse expect to assess in a patient with a tension pneumothorax? 1. Tracheal deviation to the unaffected side 2. Bilateral equal chest movement 3. Decreased muscular effort by chest muscles 4. Decreasing central venous pressure (CVP) (Ans- 1 Which goals are appropriate for a patient with a traumatic injury and an ineffective breathing pattern? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Relieve muscle spasm pain. 2. Maintain cervical alignment. 3. Support respiratory effort and prevent atelectasis. 4. Promote hypothermia. (Ans- 3 The mother of a patient just admitted with a spinal cord injury is asking if the patient will be given steroids. How should the nurse explain the role of steroids in treating spinal cord injuries? 1. Steroids will make the patient feel better overall and retain muscle strength due to its "muscle-bulking" effects. 2. Steroids have few side effects and remove all symptoms while healing the problem. 3. Steroids can lead to "road rage and anger outbursts" and therefore are avoided except under extreme emergencies. 4. Steroids have not been used recently because of possible adverse outcomes. (Ans- 4 A patient with a traumatic abdominal injury is prescribed conservative, nonoperative management. Which ongoing assessments should the nurse include in the plan of care? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Hourly vital signs 2. Assessment of the degree and type of guarding or rigidity 3. Hourly CVP readings 4. ECG changes for bradycardia and widening QRS 5. Widening pulse pressure (Ans- 1,2,3 For which situation should the nurse plan to prepare a patient with abdominal trauma for surgery? 1. A suspected splenic injury having received 1 unit of blood 2. A Grade III liver injury with stable vital signs 3. A contusion to the kidney with a stable H & H 4. A pelvic fracture with muscle rigidity of the abdominal wall (Ans- 4 Under the F section of the assessment process, in addition to full vital signs, the family is considered as a part of the treatment process. Which approach to the family would be most appropriate for the nurse to use? 1. The family gets in the way of acute care management, so the nurse should offer no support until the patient is stable. 2. Ethically the family has a right to support the patient by being at the bedside during acute care management, including trauma resuscitation. 3. Depending on the family's awareness of health care management, they have the privilege to watch the care if they do not get in the way of the care. 4. Because the care during trauma management can be too graphic for family to witness, the family should not be allowed at the bedside. (Ans- 2 What should the nurse do to convey comfort to a trauma patient? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Explain and talk to the patient, and do not ignore the patient. 2. Give clear, precise directions to follow. 3. Directly look at the eyes of the patient when talking. 4. Provide human contact, such as a reassuring touch. 5. Give all details to get full cooperation. (Ans- 1,2,3,4 Which activities should the nurse plan to increase comfort for a patient who is intubated? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Speak directly to the patient by looking into the patient's eyes. 2. Keep the patient sedated, and let the patient sleep when giving care. 3. Give additional pain medication whenever restlessness is noted. 4. Establish a communication method that does not require talking. 5. Keep the family at the bedside to interpret the patient's needs. (Ans- 1,4 The nurse plans interventions for a patient with traumatic injuries to prevent the onset of the lethal triad. What should the nurse include in this patient's plan of care Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Monitor temperature. 2. Measure intake and output. 3. Evaluate laboratory data. 4. Assess arterial blood gas values. 5. Measure gastric pH. (Ans- 1,2,3,4 The nurse prepares to complete the secondary survey of a patient admitted with a traumatic chest injury. On what should the nurse focus when conducting this survey? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Full set of vital signs 2. Comfort measures 3. Head-to-toe assessment 4. Assessment of posterior surfaces 5. Exposure (Ans- 1,2,3,4 A patient receives emergency care for maxillofacial injuries from a motor vehicle crash. What assessment finding should indicate to the nurse that the patient sustained laryngeal trauma? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Hoarse speech 2. Pain when swallowing 3. Coughing blood 4. Epistaxis 5. Periorbital edema (Ans- 1,2,3 An unconscious patient is brought to the emergency department. During the primary survey, the patient begins to moan when the left arm is moved. How should the nurse document this finding using the AVPU scale? 1. A 2. P 3. U 4. V (Ans- 2 The nurse assists the health care professional with rapid sequence intubation of a patient with severe traumatic injuries. Which agents should the nurse have available for this procedure? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Repolarizing 2. Depolarizing 3. Anesthetizing 4. Infection control 5. Pain management (Ans- 1,2,3,5 A patient with traumatic injuries has a carotid pulse of 64 bpm. What should this finding indicate to the nurse? 1. The patient is not actively bleeding. 2. The injuries are not as severe as they seem. 3. Blood pressure is at least 60 to 80 mm Hg systolic. 4. Blood pressure is at least 40 to 60 mm Hg diastolic. (Ans- 3 A patient with a C6 spinal cord injury who received several liters of intravenous fluid continues to have a blood pressure of 78/50 mm Hg. What should the nurse anticipate being prescribed for this patient? 1. Steroids 2. Beta blocker 3. Norepinephrine 4. Packed red blood cells (Ans- 3 The nurse assesses a patient with abdominal injuries sustained during a motor vehicle crash. Which finding indicates that the patient may have bleeding from the liver? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Hematuria 2. Left shoulder pain 3. Absent bowel sounds 4. Tender costovertebral angle 5. Bruising around the umbilicus (Ans- 3,5 The charge nurse delegates the completion of a secondary survey of a patient with traumatic injuries to a nurse being oriented to the emergency department. What should the charge nurse remind the new colleague to complete? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. History 2. Vital signs 3. Comfort measures 4. Head-to-toe assessment 5. Nasogastric tube insertion (Ans- 1,2,3,4 A patient with a head injury has a pO2 of 88 and a pCO2 of 58. The nurse realizes that which physiologic process will occur in this patient? 1. Cerebral blood vessels will constrict. 2. Cerebral blood vessels will dilate. 3. Blood flow to the cerebral cortex will slow. 4. Blood will be shunted from the cerebral cortex. (Ans- 2 The blood pressure of a patient with a traumatic brain injury increases from 130/60 to 170/65 mm Hg. How should the nurse respond to this change in blood pressure? 1. Weighing the patient to determine if the patient is fluid overloaded 2. Documenting the blood pressure and completing a neurologic assessment 3. Alerting the physician and preparing to administer an antihypertensive agent 4. Providing the patient with immediate pain and/or antianxiety medication (Ans- 2 When providing care to a patient with increased intracranial pressure, the nurse should be concerned about which clinical finding because it can result in an additional increase in intracranial pressure? 1. Temperature of 99°F (37.2°C) 2. Respiratory rate of 24 3. Serum sodium of 110 mEq/L 4. Blood pressure of 150/65 (Ans- 3 A patient's mean arterial pressure (MAP) decreases to 50 while his ICP is 20. What should the nurse realize that the drop in MAP could lead to? 1. Increased intracranial pressure 2. Hypoxic cerebral tissue 3. Increased urine output 4. Bradycardia (Ans- 2 The nurse prepares to conduct an hourly neurologic assessment on a patient in the intensive care unit. What is included in this assessment? 1. ECG 2. Brainstem functioning 3. Reflexes 4. Level of consciousness (Ans- 4 A patient in the neurologic intensive care unit has an endotracheal tube. When the nurse does the hourly Glasgow Coma Scale assessment, what rating should this patient have for verbal response? 1. 1 2. 4 3. 2 A patient with a head injury who is being mechanically ventilated needs to be suctioned. What should the nurse do to limit problems related to suctioning? 1. Limit the duration of each suctioning pass to less than 20 seconds. 2. Medicate with opiates after suctioning. 3. Reduce the flow of oxygen prior to suctioning. 4. Preoxygenate before suctioning. (Ans- 4 A patient with a traumatic brain injury is showing signs of having pain. What would be the medication of choice for this patient? 1. Propofol 2. Meperidine 3. Morphine sulfate 4. Fentanyl (Ans- 3 A patient with a penetrating traumatic head injury has a Glasgow Coma Scale of 9. Which of the following will the nurse realize is most likely to be implemented for this patient? 1. Prophylactic hypothermia treatment 2. High-dose barbiturate therapy 3. Intubation 4. Prophylactic anticonvulsant therapy (Ans- 4 The nurse plans care for a patient with increased intracranial pressure. Which intervention would be appropriate for this patient? 1. Encourage family and physician to discuss patient's care and prognosis in the patient's room. 2. Assess for daily bowel movement and provide intervention as appropriate. 3. Maintain head of bed at a 15-degree angle with knee elevation. 4. Cluster care activities. (Ans- 2 A patient experiencing a fever, stiff neck, and change in mental status has a positive Kernig's sign. What should these findings suggest to the nurse? 1. The patient needs surgery to reduce intracranial pressure. 2. The patient needs to be intubated. 3. The patient should receive 100% oxygen via face mask. 4. The patient has meningeal irritation. (Ans- 4 A patient with acute meningitis receives antibiotic therapy. The nurse notes that another medication is used as adjuvant therapy. Which medication is being used as an adjuvant for this patient? 1. An anticonvulsant 2. A steroid 3. A barbiturate 4. A pain medication (Ans- 2 The nurse cares for a patient with status epilepticus. What should be the first goal of care for this patient? 1. Determine the patient's medical history. 2. Obtain an EEG. 3. Maintain an airway. 4. Identify the cause of the seizure. (Ans- 3 The nurse prepares medications for a patient with status epilepticus. What should the nurse identify as the medication of choice for this patient? 1. A barbiturate 2. A steroid 3. An opioid 4. A benzodiazepine (Ans- 4 When administering mannitol (Osmitrol) to a patient with increased intracranial pressure (ICP), what action should the nurse take? 1. Expect that any reduction in ICP will begin approximately an hour after the dose is administered. 2. Assess the patient carefully for the development of hypertension. 3. Review lab data to identify the presence of hypernatremia and hyperkalemia. 4. Monitor the osmolality of the blood every 4 to 6 hours if repeated doses are administered. (Ans- 4 What action should the nurse take when administering hypertonic saline to a patient with increased intracranial pressure (ICP)? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Monitor the patient for renal failure and pulmonary edema. 2. Administer any concentrations greater than 2% through a central line. 3. Monitor serum sodium levels frequently during administration. 4. Expect the patient's neurologic status and ICP will begin to improve within 15 minutes following administration. 5. Monitor the patient's serum osmolarity every 24 hours. (Ans- 1,2,3,4 What might a patient develop if intravenous phenytoin (Dilantin) is administered faster than 50 mg/minute? 1. A severe rash 2. Hypotension 3. Hematologic abnormalities, such as agranulocytosis 4. A pronounced increase in heart rate (Ans- 2 A patient diagnosed with a subdural hematoma has an intracranial pressure of 14 mm Hg. What body effect should the nurse expect if this pressure increases? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Displacing cerebrospinal fluid into the lumbar cistern 2. Reabsorbing more cerebrospinal fluid 3. Shunting blood out of venous sinuses 4. Raising the body temperature 5. Increasing the carbon dioxide level (Ans- 1,2,3 A patient demonstrates neurologic changes consistent with increasing intracranial pressure. For which primary cause of this pressure increase should the nurse assess at this time? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 5. Insert an intravenous access line. (Ans- 1,2,3,4 The nurse identifies interventions to address the potential problem of increasing intracranial pressure for a victim of a house fire. For which secondary causes is the nurse planning care for this patient? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Stroke 2. Hypoxia 3. Hypercarbia 4. Hyperthermia 5. Spinal cord injury (Ans- 2,3,4 During an assessment, the nurse notes that the left pupil of a patient with a traumatic brain injury is larger than the right pupil. What action should the nurse take at this time? 1. Ask the patient to cough. 2. Assist the patient into a side-lying position. 3. Increase the head of the bed to a 30-degree angle. 4. Coach the client to bear down against a closed glottis (Ans- 3 A patient with a traumatic brain injury being mechanically ventilated is prescribed propofol. What should the nurse identify as an advantage of using this medication? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Decreases ICP 2. Reverses cerebral edema 3. Ensures stable electrolyte levels 4. Less need to use benzodiazepines 5. Dose can be lowered to assess neurologic status (Ans- 1,4,5 A patient with meningitis develops hypotension and tachycardia. What action should the nurse take? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Notify the health care provider. 2. Complete a neurological assessment. 3. Ensure intravenous fluids are available. 4. Place intubation equipment at the bedside. 5. Prepare to administer adrenal corticosteroids. (Ans- 1,3,5 A patient is recovering from transphenoidal surgery for partial resection of a pituitary adenoma. Which action should the nurse counsel the patient to avoid performing? 1. Blowing the nose or sneezing 2. Deep breathing 3. Drinking more than 2 liters of fluid a day 4. Sitting up in bed higher than 30 degrees (Ans- 1 A patient is diagnosed with a Grade II astrocytoma. What does the nurse realize is this patient's prognosis? 1. The prognosis is excellent. 2. The prognosis is good as long as the tumor is treated soon. 3. The prognosis is good because the tumor is well defined. 4. The prognosis is poor because the tumor cells are irregularly shaped. (Ans- 2 The nurse is assessing a patient with a meningioma. What should the nurse keep in mind when planning this patient's care? 1. A hearing disorder will occur. 2. A life expectancy of about 10 months is the prognosis. 3. The patient has an excellent prognosis if the tumor is totally removed. 4. Expect metastasis to other body organs (Ans- 3 A patient with increased intracranial pressure is diagnosed with a brain tumor. What should the nurse suspect that this patient is experiencing? 1. An astrocytoma 2. A meningioma 3. A tumor less than 1 mm in size 4. A tumor greater than 1 mm in size (Ans- 4 An older patient is not concerned about having a brain tumor because the only symptom has been a slight increase in forgetfulness, and he has had no headaches. What explanation should the nurse consider about this patient's symptoms? 1. The patient does not have a brain tumor because brain tumors are rarely present with cognitive changes. 2. The patient does not have a tumor because forgetfulness is seen in children with a brain tumor. 3. The patient could have a brain tumor even though a headache is not present. 4. The patient has the beginnings of Alzheimer's disease. (Ans- 3 A patient reports an area on the arm that has been getting numb and "feels funny." Why should the nurse consider this information as being important? 1. It pinpoints the location of a brain tumor. 2. It determines the type and amount of medication to prescribe. 3. It serves as a minor symptom that is nothing for the patient to worry about. 4. It determines how long the patient has to stay in the hospital. (Ans- 1 During an assessment, an older patient asks if "something is burning." What should the nurse suspect is occurring with this patient? 1. Engorged nasal passages 2. A focal seizure 3. A good sense of smell 4. Increased intracranial pressure (Ans- 2 A patient with a brain tumor is scheduled for a diagnostic test to help determine response to therapy. Which test is this patient most likely going to have? 1. CT scan 2. PET scan 3. Atherosclerosis 4. Hyperinsulinemia (Ans- 1 A patient complains of having the "worst headache" ever. What health problem should the nurse suspect is occurring in this patient? 1. Intracranial hemorrhage 2. Ischemic stroke 3. Subarachnoid hemorrhage 4. A brain tumor (Ans- 3 A patient with an embolic stroke is demonstrating urinary incontinence, contralateral weakness, and altered mental status. Where should the nurse suspect the embolism is located? 1. Middle cerebral artery 2. Anterior cerebral artery 3. Posterior cerebral artery 4. Vertebrobasilar artery (Ans- 2 A patient diagnosed with an ischemic stroke developed symptoms within the last 2 hours. What should the nurse anticipate being prescribed for this patient? 1. Surgery 2. Administration of intravenous recombinant tissue-type plasminogen activator (rt-PA or alteplase) 3. Observation 4. Intravenous fluids (Ans- 2 A patient with an ischemic stroke has an oxygen saturation of 88%. What should be done to help this patient? 1. Position the patient on one side. 2. Elevate the head of the bed. 3. Provide low-dose oxygen. 4. Provide high-dose oxygen (Ans- 4 A patient being treated with warfarin experiences an intracerebral hemorrhage. What should the nurse anticipate being prescribed for this patient? 1. Surgery 2. Ventriculostomy 3. Vitamin K 4. Protamine sulfate (Ans- 3 A patient with a ruptured cerebral aneurysm is demonstrating drowsiness and confusion. Using the Hunt and Hess scale, how should the nurse rate this patient? 1. Grade 1 2. Grade 2 3. Grade 3 4. Grade 4 (Ans- 3 A patient develops cerebral vasospasm after a ruptured cerebral aneurysm. On what should collaborative treatment focus? 1. Reducing blood pressure 2. Dehydrating the patient 3. Concentrating red blood cells 4. Volume expansion (Ans- 4 While providing oral medications to a patient recovering from a stroke, the nurse notices that the patient coughs repeatedly and has difficulty clearing the throat. What should the nurse do? 1. Change the diet to full liquid. 2. Change the diet to soft. 3. Request a physical therapy consult. 4. Request a swallowing evaluation by speech therapy. (Ans- 4 While conducting a health history, the nurse suspects a patient with headaches is demonstrating signs of a brain tumor. How did the patient most likely describe the headaches to the nurse? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Worse in the morning 2. Worse when coughing 3. Becomes severe when bending to tie shoes 4. Worse in the evening 5. Relieved by over-the-counter pain medication (Ans- 1,2,3 The nurse provides intravenous dexamethasone (Decadron) 10 mg to a patient with a metastatic brain tumor. What patient outcome indicates that the medication is effective? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Neurologic symptoms improve within 12 hours 2. Reduced intracranial pressure 3. Neurologic symptoms improve immediately 4. Reduced respiratory rate 5. Increased heart rate and blood pressure (Ans- 1,2 The nurse is concerned that a patient recovering from a craniotomy for a malignant brain tumor is at risk for developing a deep vein thrombosis. Which interventions would be appropriate for the patient at this time? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Apply graduated compression stockings as indicated. 2. Administer subcutaneous low-molecular-weight heparin (LMWH) 5,000 units twice a day as prescribed. 3. Administer enoxaparin 40 mg each day. 4. Position with the legs of the bed elevated. 5. Perform bedside passive range of motion exercises every 8 hours. (Ans- 1,2,3 A patient is recovering from supratentorial surgery to remove a primary brain tumor. Which intervention should the nurse include in this patient's plan of care? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Determine pupillary response. 2. Instruct to avoid flexion of the neck. 3. Assess using the Glasgow Coma Scale. 4. Monitor strength, movement, and sensory status of all extremities. 5. Encourage fluids to prevent dry mucous membranes and coughing. (Ans- 1,3,4 A patient is brought to the emergency department demonstrating signs of a stroke. What should the nurse assess when using the National Institutes of Health stroke scale? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Gaze 2. Walking gait 3. Arm function 4. Facial muscles 5. Level of consciousness (Ans- 1,3,4,5 A patient experiencing an ischemic stroke is being considered for thrombolytic therapy. Which finding needs to be addressed before preparing the patient for this treatment? 1. Pulse 108 bpm 2. Temperature 99°F 3. Respiratory rate 20 4. Blood pressure 198/120 mm Hg (Ans- 4 A patient recovering from a ruptured cerebral aneurysm is demonstrating signs of hydrocephalus. What should the nurse anticipate being prescribed for this patient? 1. Glucocorticoid therapy 2. External ventricular drain 3. Ventriculoperitoneal shunt 4. Fluid and sodium restriction (Ans- 2 A patient with dysphagia after a stroke has dry oral mucous membranes and poor skin turgor. What should the nurse anticipate being prescribed for this patient? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Nasogastric tube feedings 2. Intralipid infusions several times a day 3. High-volume intravenous fluid infusions 4. Total parenteral nutrition via a central line 5. Placement of a percutaneous endoscopic gastrostomy tube (Ans- 1,5 Of the following patients in an intensive care unit, which patient should the nurse identify as being at highest risk for the development of acute kidney injury with a prerenal cause? 1. Experiencing acute status asthmaticus 2. Being treated for hypertension following a cerebral vascular accident 3. In skeletal traction following a motor vehicle accident 4. Postoperative from a ruptured abdominal aortic aneurysm (Ans- 4 While reviewing a patient's medication record, the critical care nurse should be concerned about which drugs that have been implicated in the development of renal failure? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Cyclosporine 2. Contrast media 3. Aminoglycosides 4. Antiseizure medications 5. Nonsteroidal anti-inflammatory drugs (NSAIDs) (Ans- 1,2,3,5 The nurse reviews a critically ill patient's history for which cause of intrinsic renal failure? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Contrast media given intravenously during diagnostic imaging 2. Prescribed levothyroxine (Synthroid) following thyroidectomy 3. Acyclovir (Zovorax) prescribed for treatment of genital herpes 4. Receiving prophylactic chemotherapy after surgery for cancer 5. History of using high-dose NSAIDs for rheumatoid arthritis (Ans- 1,3,5 A patient in the intensive care unit is reported to be in the oliguric phase of intrinsic renal failure. What assessment finding supports this clinical determination? 1. Urine output of less then 400 mL/day 2. BUN and creatinine that may begin to increase slightly 3. Urinary output of up to 5 liters of urine each day 4. Abnormal laboratory values that can last from 6 months to a year in duration (Ans- 1 The nurse believes a patient is experiencing prerenal dysfunction and not intrinsic renal failure because of which laboratory finding? 1. Urine osmolality of 200 mOsm/L 2. Urine osmolality of 550 mOsm/L 3. Urine sodium greater than 40 mmol/L 4. Presence of granular casts and sediment (Ans- 2 A patient is experiencing prerenal failure secondary to hypovolemia. The nurse reviewing the patient's laboratory work and vascular pressures should expect to see which results? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Creatinine clearance of 50 mL/min/1.73m2 2. Low CVP or PAWP pressures 3. BUN of 65 mg/dL 4. Serum creatinine of 3 mg/dL Which patient situation would increase the risk for developing dialysis disequilibrium syndrome? 1. Peritoneal dialysis provided in a home environment 2. Patient who received an ACE inhibitor prior to hemodialysis 3. A known history of long-term substance abuse 4. Patient undergoing first hemodialysis treatment (Ans- 4 What should the nurse do when caring for a patient with an arteriovenous (AV) fistula in the forearm for hemodialysis? 1. Percuss the fistula for presence of a bruit each shift 2. Take the blood pressure in the unaffected arm 3. Position the patient so there is pressure on the access area 4. Flush the fistula with heparin every shift (Ans- 2 What is the most common complication that the nurse should assess in a patient undergoing intermittent hemodialysis (IHD)? 1. Hypotension 2. Infection 3. Hyperglycemia 4. Hypokalemia (Ans- 1 What should the nurse identify as the most accurate indicator of fluid volume status? 1. Intake and output 2. Daily weights 3. Hematocrit level 4. Systolic blood pressure (Ans- 2 Using evidence-based practice interventions for a patient with acute kidney injury, what should the nurse identify as being the best approach for fluid volume excess management? 1. A sodium-restricted diet 2. Diuretics 3. Fluid restriction 4. Plasmapheresis (Ans- 3 The nurse preparing to administer peritoneal dialysis would have which responsibility in contrast to hemodialysis? 1. Knowing the patient's dry weight prior to beginning 2. Monitoring for changes in vital signs 3. Inspecting the tunneled catheter for infection 4. Suggesting a low-Fowler's position for comfort (Ans- 3 To assist with the common complication of hypotension for the patient undergoing continuous renal replacement therapy, the nurse should implement which action? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Infuse 0.9% sodium chloride boluses. 2. Administer mannitol. 3. Decrease the rate of ultrafiltration on the dialyzer. 4. Administer albumin. 5. Place the patient in a high-Fowler's position. (Ans- 1,2,3,4 The nurse should identify which nursing diagnosis for the patient experiencing dialysis disequilibrium syndrome? 1. Infection 2. Altered thought processes 3. Fluid volume deficit 4. Anxiety (Ans- 2 The critical care nurse provides a training session on the principles of renal replacement therapies. When discussing how solutes move across a semipermeable membrane from a higher to lower concentration, what is the nurse describing? 1. Ultrafiltration 2. Diffusion 3. Active transport 4. Osmosis (Ans- 2 A critically ill patient is being evaluated for acute kidney injury. The nurse should expect which laboratory test to be prescribed for this patient? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Urinalysis 2. Blood-urea-nitrogen level 3. Serum creatinine 4. Arterial blood gases 5. Hemoglobin and hematocrit levels (Ans- 1,2,3 The nurse prepares an infusion of norepinephrine for a patient with acute kidney injury. What are the nurse's responsibilities when providing this medication? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Monitor the blood pressure every 2 to 5 minutes. 2. Monitor changes in MAP. 3. Monitor heart rate and pattern. 4. Infuse through the central line. 5. Infuse through a hand vein. (Ans- 1,2,3,4 The nurse plans care for a patient with an acute kidney injury. Which intervention should prevent further injury to the patient's kidneys? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Use strict aseptic technique when providing care. 2. Discuss the need for acetylcysteine with the health care provider prior to testing that uses contrast dye. 3. Measure urine output every 8 hours. 4. Prepare a fluid challenge with dextrose 5% and water. 5. Calculate fluid restriction. (Ans- 1,2