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Understanding The Essentials of Critical Care Nursing 2nd Edition, Kathleen Test Bank

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Test Bank For Understanding The Essentials of Critical Care Nursing 2nd Edition, Kathleen. Note: This is not a text book. Description: ISBN-13: 978-0132724159, ISBN-10: 0132724154.

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Test Bank Understanding Essentials Critical Care Nursing 2nd Edition, Kathleen

CHAPTER 1

Question 1

Type: MCSA

Which patient would the nurse identify as experiencing a critical illness? The patient:

  1. With chronic airflow limitation whose VS are BP 110/72, P 110, R 16
  2. With acute bronchospasm and whose VS are BP 100/60, P 124, R 32
  3. Who was involved in a motor vehicle crash whose VS are BP 124/74, P 74, R 18
  4. On hemodialysis for chronic renal failure with no urine output and whose VS are BP 98/50, P 108, R 12

Question 2

Type: MCMA

Of the following patients, which will the nurse expect to be transferred to a critical care unit? The patient:

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. With an acetaminophen overdose
  2. Suffering from acute mental illness
  3. With chronic renal failure
  4. With acute decompensated heart failure
  5. With bacteremia from an infected foot wound

Question 3

Type: MCSA

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.

Question 4

Type: MCSA

The nurse, providing patient care in an “open” ICU, would most likely be working with a:

  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

Question 5

Type: MCSA

The nurse, providing care to patients in a critical care unit, realizes that technology increases the likelihood of errors when:

  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.

Question 6

Type: MCSA

What will the nurse identify as an example of an installed forcing functions 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.

Question 7

Type: MCSA

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

Question 8

Type: MCSA

The nurse in the critical care area is completing a preoperative checklist before sending a patient for surgery. This nurse’s activity is an example of which recommendation issued by the Institute of Medicine?

  1. Utilizing constraints
  2. Simplifying key processes
  3. Avoiding reliance on vigilance
  4. Standardizing key processes

Question 9

Type: MCMA

Which actions should the nurse complete after realizing that an incorrect dose of medication has been administered to a patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Notify the patient and family
  2. Notify the physician
  3. Document the error
  4. Prepare for an analysis of the error
  5. Keep the notification of the error silent

Question 10

Type: MCSA

The nurse working within the AACN Synergy Model realizes that optimal patient outcomes are realized when:

  1. Highly qualified nurses care for patients in highly technical settings.
  2. Nurses agree to work overtime to cover unit staffing needs.
  3. Staff nurse competency is matched with patient needs.
  4. Patient care is delivered within a “closed unit” model.

CHAPTER 2

Question 1

Type: MCSA

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

Question 2

Type: MCSA

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 of the AACN Synergy Model’s characteristics does this situation describe?

  1. Complexity
  2. Predictability
  3. Participation in care
  4. Resource availability

Question 3

Type: MCSA

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

Question 4

Type: MCMA

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?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  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.”

Question 5

Type: MCSA

When providing care to critically ill patients, whether they are responsive or unresponsive, the nurse should:

  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.
  3. Make sure the patient always responds and is cooperative before giving care.
  4. Explain to the family that the patient will not understand or remember any of the discomfort associated with care.

Question 6

Type: MCSA

Which communication strategy is most appropriate for a critical care nurse to use when communicating with a ventilated patient? The nurse should:

  1. Use professional terminology and provide the patient with detailed information.
  2. Use simple language and explain in other terms if the patient does not seem to understand.
  3. Provide minimal information so the patient is not overwhelmed.
  4. Discuss issues primarily with the family because the patient is unlikely to understand the information.

Question 7

Type: MCSA

During an assessment, a ventilated patient begins to frown and wiggle about in bed. Which assessment strategy would be most helpful for the nurse to validate these observations?

  1. Glasgow Scale
  2. Maslow’s hierarchy levels
  3. Critical-Care Pain Observation Tool (CPOT)
  4. Vital signs trends

Question 8

Type: MCMA

Which parameters indicate that a patient in the intensive care unit being mechanically ventilated is ready for an interruption in sedation? The patient:

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Had a MAP of 75 and heart rate of 76
  2. Was sleeping but awakened with verbal stimuli
  3. Frowned when turned but otherwise showed no muscular tension
  4. Activated the ventilator alarms but the alarms stopped spontaneously
  5. Is receiving neuromuscular blocking agents to ensure adequate ventilation

Question 9

Type: MCSA

A patient scores positive on the Confusion Assessment Method of the Intensive Care Unit (CAM-ICU). Which nursing diagnosis would have the highest priority based on this positive score?

  1. Injury, Risk for
  2. Family Processes, Altered
  3. Social Interaction, Impaired
  4. Memory Impaired

Question 10

Type: MCSA

Which nursing actions would be appropriate when a nurse is initiating an infusion of morphine sulfate for a post-operative patient who is experiencing pain?

  1. Anticipate that the patient will begin to experience the effect of the morphine 15 minutes after the start of the infusion.
  2. Provide additional intermittent boluses of morphine sulfate if the patient experiences breakthrough pain.
  3. Complete the Critical-Care Pain Observation Tool scale 5 minutes after increasing the infusion rate each time.
  4. Begin the infusion at the lowest ordered dose and increase the rate every 30 minutes if the patient continues to have pain.

CHAPTER 3

Question 1

Type: MCSA

A patient is diagnosed with type I hypoxemic failure. The nurse realizes that this type of respiratory failure is linked to:

  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

Question 2

Type: MCSA

The nurse is reviewing the health history of a patient diagnosed with an acute lung injury for a cause of 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.

Question 3

Type: MCSA

In caring for a brain-injured patient with damage to the cortex, which changes in respiratory and ventilatory efforts would 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 CO2in blood analysis

Question 4

Type: MCSA

Which arterial blood gas results would indicate the development of acute lung injury?

  1. pH 7.4, PaCO240 mm Hg, PaO2 96, HCO3 24 mEq, SaO2 94%
  2. pH 7.31, PaCO250 mm Hg, PaO2 70 mm Hg, HCO3 20 mEq, SaO2 90%
  3. ph 7.49, PaCO232 mm Hg, PaO2 75 mm Hg, HCO3 22 mEq, SaO2 90%
  4. pH 7.29, PCO228 mm Hg, PaO2 97 mm Hg, HCO3, 16 mEq, SaO2 94%

Question 5

Type: MCMA

When assessing a patient with type I hypoxemic failure, the nurse would evaluate for which contributing health problem?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Acute respiratory distress syndrome
  2. Asthma
  3. Cardiogenic pulmonary edema
  4. Pneumonia
  5. Narcotic overdose

Question 6

Type: MCMA

The nurse is concerned that which patients are at risk for developing type II hypoxemic hypercapneic failure?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  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 post-op 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

Question 7

Type: MCSA

What will the nurse assess in a patient experiencing the fibrotic phase of acute lung injury?

  1. Pulmonary occlusive pressures are less than 18 mm Hg.
  2. Bilateral fluid can be seen on radiographic exams.
  3. Severe bleeding is noted from all body orifices.
  4. Fever and leukocytosis are present.

Question 8

Type: MCSA

What will 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

Question 9

Type: MCSA

Which patient would 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

Question 10

Type: MCMA

When planning care for a patient who is mechanically ventilated, the nurse will include interventions to address which potential complications?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Cardiovascular compromise
  2. Community acquired pneumonia (CAP)
  3. Barotrauma
  4. Volutrauma
  5. Anxiety from lack of synchrony with the ventilator

CHAPTER 4

Question 1

Type: MCSA

A 57-year-old male patient is admitted to the telemetry unit with new onset of weakness and fatigue. The following rhythm is now seen on the monitor and the patient is now complaining of shortness of breath and mild chest discomfort. Which medication would be appropriate for this patient?

  1. Give epinephrine 1 mg IV.
  2. Give atropine 0.5 mg IV.
  3. Give adenosine 6 mg IV.
  4. Give amiodarone 300 mg IV.

Question 2

Type: MCSA

A 78-year-old patient has the following rhythm. Which assessment finding identifies a need for further treatment?

  1. Short period of asystole followed by conversion to normal sinus rhythm
  2. Warm, dry skin
  3. Heart rate of 88 and BP 124/80
  4. Heart rate of 42 and BP 78/60

Question 3

Type: MCSA

A 67-year-old male patient complaining of “feeling tired” has the following cardiac rhythm. The patient states that he has a history of an irregular heartbeat. His vital signs are BP 134/78; RR 17; SaO2 97% on room air. He denies other complaints at present. The priority action for this patient would be to:

  1. Perform a 12-lead ECG and compare it to previously recorded ECGs.
  2. Prepare the patient for transcutaneous pacing.
  3. Place the patient on 100% via nonrebreather mask.
  4. Give Versed 1 mg IVP.

Question 4

Type: MCSA

CPR is started on a patient who has developed ventricular fibrillation. The patient is defibrillated once with the resulting rhythm. Which intervention should the nurse implement next?

  1. Defibrillate the patient with 360 joules.
  2. Administer atropine 1 mg IV push and repeat every 3 minutes.
  3. Infuse amiodarone 300 mg IV push slowly.
  4. Administer epinephrine 1 mg IV push.

Question 5

Type: MCSA

A patient arrives in the emergency department for chest pain, lightheadedness, and shortness of breath (SOB). The cardiac monitor shows sinus rhythm with the presence of multifocal PVCs. Which order would the nurse question?

  1. Oxygen at 4 L/min via nasal cannula
  2. Morphine sulfate 2 mg IV
  3. Atropine 0.5 mg IV
  4. Amiodarone 300 mg IV

Question 6

Type: MCSA

While assessing a patient in the CCU, the nurse observes the following rhythm on the monitor. The patient is alert and oriented and denies any complaints at present. The nurse should:

  1. Administer a precordial thump.
  2. Check lead placement on the patient.
  3. Begin CPR and call for a defibrillator.
  4. Administer epinephrine 1 mg IV every 3 minutes.

Question 7

Type: MCSA

The patient in pulseless ventricular tachycardia is defibrillated twice and received appropriate meds given per ACLS protocol. The following rhythm is now present. What should the nurse do next?

  1. Continue monitoring and observing the patient for PVCs.
  2. Place the patient on a maintenance lidocaine infusion.
  3. Realize that the patient has been successfully converted to NSR.
  4. Check the patient for a pulse and continue CPR if one is not present.

Question 8

Type: MCSA

Which patient response indicates that the patient has had a favorable response to atropine?

  1. An increase in heart rate to 80 bpm
  2. A complaint of a headache from the patient
  3. A decrease in heart rate to 40 bpm
  4. Conversion to normal sinus rhythm from ventricular tachycardia

Question 9

Type: MCSA

A 58-year-old female is admitted with the following new onset rhythm. With complications related to this rhythm in mind, priority nursing assessment would be to:

  1. Monitor for sudden onset of ventricular tachycardia.
  2. Perform neurologic checks every 4 hours.
  3. Monitor for deterioration to third-degree block.
  4. Assess skin turgor for dehydration.

Question 10

Type: MCMA

A patient in the emergency department is in supraventricular tachycardia. What are appropriate nursing actions for this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Start CPR and defibrillate at 200 joules.
  2. Start oxygen at 2 L/min via nasal cannula.
  3. Give atropine 1 mg IVP.
  4. Give epinephrine 1 mg IVP.
  5. Give adenosine 6 mg IVP.

CHAPTER 5

Question 1

Type: MCSA

A patient has a blood pressure of 134/70 per blood pressure cuff and a blood pressure of 90/50 per arterial line. The nurse should:

  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.

Question 2

Type: MCSA

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. 800–1,400 dynes/sec/cm2

Question 3

Type: MCSA

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)

Question 4

Type: MCSA

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. The nurse should assess the patient for:

  1. Excessive sedation
  2. Position of the PA catheter
  3. Hypothermia
  4. Pain

Question 5

Type: MCSA

Which of the following actions has the highest priority for maintaining safety when caring for a patient with a PA catheter?

  1. Obtain pressures per protocol.
  2. Administer fluids and medications via pump.
  3. Maintain asepsis when providing line care.
  4. Obtain lab values as ordered.

Question 6

Type: MCSA

A patient with a right subclavian triple lumen catheter has a CVP reading of 18 mm Hg. The nurse would further assess the patient for symptoms of:

  1. Peripheral edema and jugular vein distention
  2. Decreased peripheral pulses and cool extremities
  3. Hypovolemia and hypotension
  4. Orbital edema and disorientation

Question 7

Type: MCSA

The nurse is monitoring the PA pressure of a mechanically ventilated patient. In order to accurately measure this pressure, the nurse should obtain the measurement:

  1. Whenever because the timing does not matter
  2. At the last clear waveform before the baseline drops
  3. At the last clear waveform before the baseline rises
  4. With the patient off the ventilator

Question 8

Type: MCSA

A patient with a PA catheter has an SVO2 of 90%. The nurse should assess the patient for:

  1. Fever
  2. Pain
  3. Hypothermia
  4. Anemia

Question 9

Type: MCSA

What should the nurse monitor in response to a change in SVO readings?

  1. Potassium level
  2. Glucose level
  3. Sodium level
  4. Hemoglobin level

Question 10

Type: MCSA

A patient asks the nurse, “What is blood pressure?” The nurse would most appropriately respond:

  1. “A measurement that should always be 120/80 unless complications are present.”
  2. “The amount of pressure exerted on your veins by the blood.”
  3. “A measurement that takes into consideration the amount of blood that your heart is pumping and the size of the vessel diameter the heart must pump against.”
  4. “A complex measurement that should only be discussed with your health care provider.”

CHAPTER 6

Question 1

Type: MCSA

A patient says, “I’ve never heard of an acute coronary syndrome. Please explain what happened to me.” The nurse should respond, “Acute coronary syndrome is:

  1. Another name for a myocardial infarction (MI) or heart attack.”
  2. A group of disorders that result in insufficient oxygen supply to the heart.”
  3. The second leading cause of death in the United States.”
  4. A type of abnormal heart rhythm.”

Question 2

Type: MCSA

The nurse is teaching a patient about acute coronary syndrome. What will 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.

Question 3

Type: MCSA

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.”

Question 4

Type: MCSA

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) that is linked to ACS.
  2. Extra weight can lead to diabetes insipidus that 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.

Question 5

Type: MCSA

When 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,” the pain will most likely be classified as:

  1. Variant or Prinzmetal’s angina
  2. Undifferentiated angina
  3. Unstable angina
  4. Stable angina

Question 6

Type: MCSA

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 would 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

Question 7

Type: MCSA

The nurse is instructing 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. “A heart attack in the anterior wall of the heart can be very serious because a large portion of the heart may not pump as well.”
  4. “Angina always leads first to decreased blood flow to the heart muscle and then to tissue death.”

Question 8

Type: MCSA

What action would be most helpful to the nurse in determining whether the chest pain of a patient who has just entered the emergency department is cardiac in origin?

  1. Gathering a complete medical history
  2. Performing a 12-lead ECG
  3. Administering NTG to see if the pain goes away
  4. Asking the patient if performing a Valsalva maneuver reduces the pain

Question 9

Type: MCSA

An 80-year-old woman has arrived in the emergency department. The health care provider is questioning whether she has had an MI although she is not displaying the classic chest pain. Which symptoms would more likely occur in this patient than others because of the patient’s gender and age?

  1. Jaw and/or tooth pain
  2. Centralized chest pain
  3. Generalized fatigue accompanied by dyspnea and diaphoresis
  4. Dyspnea accompanied by crackles in all lobes

Question 10

Type: MCSA

Which laboratory value would the nurse review to validate a diagnosis of a myocardial infarction (MI) that was suspected of occurring approximately 3 hours earlier?

  1. CK
  2. Troponin T assay
  3. Myoglobin
  4. PTT

CHAPTER 7

Question 1

Type: MCSA

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? “Remodeling:

  1. Leads to progressive worsening of heart function.”
  2. Can be described as an enlargement of the pumping chamber.”
  3. Occurs with an increase in blood pressure and results in weight gain.”
  4. Develops primarily because the heart is pumping harder.”

Question 2

Type: MCMA

The nurse is reviewing a patient’s medical history. Which factors in the history most likely contributed to the patient’s development of heart failure?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Hypertension
  2. Diabetes mellitus
  3. Drinking one or two alcoholic drinks daily
  4. Being overweight
  5. Ischemic heart disease

Question 3

Type: MCSA

The nurse is assessing 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

Question 4

Type: MCSA

Which assessment finding indicates that a patient’s heart failure (HF) is worsening?

  1. An increase in O2saturation to greater than 90%
  2. A decrease in heart rate to 66 bpm
  3. The onset of atrial fibrillation
  4. Louder S1and S2 heart sounds

Question 5

Type: MCSA

A patient is very short of breath. Which finding should cause the nurse to be concerned that the shortness of breath might be due to heart failure?

  1. An echocardiogram that reflected 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

Question 6

Type: MCSA

Which finding would support the diagnosis of heart failure (HF)?

  1. RA/CVP of 8 mm Hg
  2. PAWP of 20 mm Hg
  3. Cardiac index of 3
  4. Peripheral vasodilation reflected by normalizing capillary refill times

Question 7

Type: MCSA

After teaching a patient with heart failure about beta blocking agents, the nurse recognizes that additional teaching is needed when the patient states, “While taking the medication, I will:

  1. Weigh myself every day.”
  2. Check my blood sugar regularly.”
  3. Notify my health care provider if I become increasingly short of breath.”
  4. Monitor myself daily for an increased heart rate and blood pressure.”

Question 8

Type: MCSA

The nurse should explain to a patient in heart failure that an aldosterone antagonist works by:

  1. Reducing sodium and water retention
  2. Filtering potassium out with the water in the renal tubules
  3. Promoting the excretion of the urinary waste products urea and creatinine
  4. Retaining calcium to improve the condition of blood vessels in the glomeruli

Question 9

Type: MCSA

What would the nurse not expect to find in a patient who was experiencing acute decompensated heart failure with pulmonary edema?

  1. Dyspnea at rest, peripheral edema
  2. Hypertension, bradycardia
  3. Increased coughing, crackles
  4. Decreased O2saturation, increased PAWP

Question 10

Type: MCSA

A patient in heart failure is to be started on an infusion of dobutamine (Dobutrex). What is most important for the nurse to assess before starting the infusion? The patient’s:

  1. Breath sounds
  2. Blood pressure
  3. Level of consciousness
  4. Urine output

CHAPTER 8

Question 1

Type: MCMA

What will the nurse identify as symptoms of hypovolemic shock in a patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Temperature of 97.6°F (36.4°C)
  2. Restlessness
  3. Decrease in blood pressure of 20 mm Hg when the patient sits up
  4. Capillary refill time greater than 3 seconds
  5. Sinus bradycardia of 55 beats per minute

Question 2

Type: MCSA

Which laboratory finding should cause the nurse to suspect that a patient is developing hypovolemic shock?

  1. Serum sodium of 130 mEq/L (130 mmol/L)
  2. Metabolic acidosis validated by arterial blood gases
  3. Serum lactate of 3 mmol/L
  4. SvO2greater than 80%

Question 3

Type: MCSA

The nurse recognizes that which patient would be most likely to develop hypovolemic shock? A patient with:

  1. Decreased cardiac output
  2. Severe constipation, causing watery diarrhea
  3. Ascites
  4. Syndrome of inappropriate ADH (SIADH)

Question 4

Type: MCSA

Which finding indicates that a patient is experiencing increased peripheral resistance and vasoconstriction?

  1. Strong bounding pulse with deep red coloring
  2. Pale, cool extremities with decreased pulses
  3. Increased venous engorgement with strong pulses
  4. Faster than normal capillary refill time

Question 5

Type: MCSA

Which solution would be the most appropriate initial volume replacement for a patient with severe GI bleeding?

  1. 200 mL of normal saline (NS) per hour for 5 hours
  2. A liter of Ringer’s lactate (RL) over 15 minutes
  3. Two liters of D5W over half an hour
  4. 500 mL of 0.45% normal saline (1/2 NS) over half an hour

Question 6

Type: MCMA

Which life-threatening complications would the nurse anticipate developing in the patient being treated for hypovolemic shock?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Fluid volume overload
  2. Renal insufficiency
  3. Cerebral ischemia
  4. Gastric stress ulcer
  5. Pulmonary edema

Question 7

Type: MCSA

The nurse, caring for a patient in hypovolemic shock, will not utilize a hypotonic solution for fluid resuscitation because hypotonic solutions:

  1. Move quickly into the interstitial spaces and can cause third spacing
  2. Stay longer to expand the intravascular space but deplete intracellular fluid levels
  3. Do not stay in the intravascular space long enough to expand the circulating blood volume
  4. Need a smaller bore needle to run at a slower rate to keep the intravascular space low

Question 8

Type: MCSA

The nurse should warm intravenous fluids when a rapid infuser is being utilized to prevent which complication?

  1. Hemorrhagic shock
  2. Hypothermia
  3. Sepsis
  4. Cardiogenic shock

Question 9

Type: MCSA

Which finding indicates that rehydration is complete and hypovolemic shock has been successfully treated in a patient?

  1. CVP = 8 mm Hg
  2. MAP = 45 mm Hg
  3. Urinary output of 0.1 mL/kg/hr
  4. Hct = 54%

Question 10

Type: MCSA

A patient is demonstrating pulmonary edema, hypotension, and delayed capillary refill. The nurse suspects the patient is experiencing which type of shock?

  1. Hypovolemic
  2. Cardiogenic
  3. Anaphylactic
  4. Obstructive

CHAPTER 9

Question 1

Type: MCSA

A patient arrives in the emergency department with a flail chest after a motor vehicle accident (MVA) in which the patient’s chest hit the steering wheel. The nurse realizes 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

Question 2

Type: MCSA

Which patient sustained an open traumatic injury? A patient with:

  1. A closed hip fracture that was caused by a fall
  2. A gun shot 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

Question 3

Type: MCMA

When performing a quick assessment to identify life-threatening problems in a trauma patient, the nurse would include which assessments under the D–Disability section?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  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

Question 4

Type: MCSA

What activities would the nurse implement under the A section of assessment priorities when admitting a trauma 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

Question 5

Type: MCMA

Which risk factors could lead to the development of airway failure if not recognized while assessing the airway of a trauma patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  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

Question 6

Type: MCSA

Which nursing assessment would have highest priority for early airway management of a trauma patient?

  1. Ask the patient to state his 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.

Question 7

Type: MCSA

Which assessment finding indicates that a trauma patient 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

Question 8

Type: MCMA

Which will the nurse assess when evaluating breathing in a patient suspected of having a thoracic trauma?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  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

Question 9

Type: MCSA

What will 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)

Question 10

Type: MCMA

Which goals are appropriate for a patient with a traumatic injury and an ineffective breathing pattern?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Provide oxygen 100% therapy through a nonrebreather mask.
  2. Restore the normal breathing pattern.
  3. Maintain a calm environment to decrease oxygen demands.
  4. Prevent sepsis
  5. Maintain balanced hydration

CHAPTER 10

Question 1

Type: MCSA

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.

Question 2

Type: MCSA

A patient who has suffered a traumatic brain injury has his blood pressure increase from 130/60 to 170/65 mm Hg. The nurse should respond to this increase in blood pressure by:

  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

Question 3

Type: MCSA

When providing care to a patient with increased intracranial pressure, the nurse would 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

Question 4

Type: MCSA

A patient’s mean arterial pressure (MAP) decreases to 50 while his ICP is 20. The nurse realizes that this drop in MAP is likely to lead to:

  1. Increased intracranial pressure
  2. Hypoxic cerebral tissue
  3. Increased urine output
  4. Bradycardia

Question 5

Type: MCSA

The nurse is preparing 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

Question 6

Type: MCSA

A patient in the neurologic intensive care unit has an endotracheal tube. When the nurse does the hourly Glasgow Coma Scale assessment, what rating would this patient have for verbal response?

  1. 1
  2. 4
  3. 2
  4. 3

Question 7

Type: MCSA

What would be appropriate for the nurse to do when assessing a patient’s motor function?

  1. Assess all four extremities together.
  2. Assess the right leg and the right arm together.
  3. Assess the arms together and then assess the legs separately.
  4. Assess the left leg and the left arm together.

Question 8

Type: MCSA

The nurse is assessing a patient’s corneal reflex. The cranial nerve that is being assessed with this reflex is:

  1. Oculomotor
  2. Optic
  3. Trigeminal
  4. Vagus

Question 9

Type: MCSA

The nurse is going to assist with the assessment of a patient’s oculovestibular reflex. What should be done before this reflex is assessed?

  1. Ensure that the patient’s spinal cord has been found intact.
  2. Ensure that the patient has an intact gag reflex.
  3. Determine that the patient can tolerate being in the supine position.
  4. Determine that the patient has an intact tympanic membrane.

Question 10

Type: MCSA

The nurse, evaluating the tracing made from a patient’s intracranial pressure monitor, notes the presence of many C waves. This finding would be indicative of:

  1. Decreased cerebral compliance
  2. Pending brain herniation
  3. No evidence of pathology
  4. Impaired cerebral spinal fluid flow

CHAPTER 11

Question 1

Type: MCSA

A patient is recovering from transphenoidal surgery for partial resection of a pituitary adenoma. The nurse should instruct the patient to avoid doing which action(s)?

  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

Question 2

Type: MCSA

A patient is diagnosed with a grade II astrocytoma. The nurse realizes that this patient’s prognosis is:

  1. Excellent
  2. Good as long as the tumor is treated soon
  3. Good because the tumor is well defined
  4. Poor because the tumor cells are irregularly shaped

Question 3

Type: MCSA

The nurse is assessing a patient with a meningioma. The nurse realizes that this patient will have:

  1. A hearing disorder
  2. A life expectancy of about 10 months
  3. An excellent prognosis if the tumor is totally removed
  4. Metastasis to other body organs

Question 4

Type: MCSA

A patient with increased intracranial pressure is diagnosed with a brain tumor. The nurse realizes that this patient most likely has:

  1. An astrocytoma
  2. A meningioma
  3. A tumor less than 1 mm in size
  4. A tumor greater than 1 mm in size

Question 5

Type: MCSA

An older patient is not concerned about having a brain tumor because the only symptom has been a slight increase in forgetfulness and no headaches. The nurse realizes that this patient most likely:

  1. Does not have a brain tumor because brain tumors are rarely present with cognitive changes
  2. Does not have a tumor because forgetfulness is seen in children with a brain tumor
  3. Could have a brain tumor even though a headache is not present
  4. Has the beginnings of Alzheimer’s disease

Question 6

Type: MCSA

A patient tells the nurse about an area on the arm that has been getting numb and “feels funny.” This information is important because it will:

  1. Possibly pinpoint the location of a brain tumor
  2. Determine the type and amount of medication to prescribe
  3. Serve as a minor symptom that is nothing for the patient to worry about
  4. Determine how long the patient has to stay in the hospital

Question 7

Type: MCSA

During an assessment, a patient asks the nurse if “something is burning.” The nurse realizes that this patient could be demonstrating:

  1. Engorged nasal passages
  2. A focal seizure
  3. A way to have the nurse leave to check if something is burning
  4. Increased intracranial pressure

Question 8

Type: MCSA

A patient with a brain tumor is having a diagnostic test to help determine response to therapy. This patient is most likely having a(n):

  1. CT scan
  2. PET scan
  3. Angiogram
  4. MRI

Question 9

Type: MCSA

The nurse is preparing to administer a medication to a patient to decrease the cerebral edema caused by a brain tumor. This medication is most likely a(n):

  1. Antiseizure medication
  2. Pain medication
  3. Glucocorticoid
  4. Antispasmodic

Question 10

Type: MCSA

A patient is recovering from posterior fossa surgery. What should the nurse include in the patient’s plan of care?

  1. Assess vital signs and level of consciousness every hour.
  2. Maintain the patient flat in bed for at least 24 hours.
  3. Maintain the patient’s neck in hyperextension.
  4. Observe the patient for the development of diabetes insipidus.

CHAPTER 12

Question 1

Type: MCSA

The nurse caring for a 46-year-old male who has been drinking heavily for 3 years is aware of the potential for alcohol withdrawal syndrome based on the knowledge that physiologically:

  1. Alcohol is a stimulant that increases gamma-aminobutyric acid (GABA).
  2. The neurotransmitters inhibit impulses on the neurons.
  3. The CNS has become accustomed to the depressant effects of the alcohol and CNS excitability develops when alcohol is no longer present.
  4. The neuroreceptors in the brain can begin to initiate a chemical reaction of normalcy.

Question 2

Type: MCSA

Which finding suggests to the nurse that a patient is experiencing early physiologic clinical manifestations of alcohol withdrawal? The patient:

  1. Is yelling at the nurse and demanding to go home
  2. Has a BP of 160/90, HR of 110, and T of 100
  3. Is a well-known repeat offender and is demanding a drink
  4. Cannot sit up straight or respond appropriately to questions

Question 3

Type: MCSA

A patient with a history of alcohol misuse has been admitted for treatment. The essential components of the nursing assessment include:

  1. The use of addiction standards to assess for drinking patterns
  2. The inclusion of objective and subjective input from the patient including signs of anxiety and patterns of usage
  3. The amount of denial that the patient is exhibiting
  4. The amount of time spent obtaining, using, and recovering from alcohol

Question 4

Type: MCSA

When the CAGE questionnaire is used to guide the assessment of alcohol misuse, the nurse would ask which questions?

  1. Have you ever crashed overnight in an unfamiliar area, arrived late for work, given up family and friends, or escaped arrest by the law?
  2. Have you ever felt the need to cut down on drinking, felt annoyed by criticism of your drinking, ever had guilty feelings about your drinking, or ever had an eye opener first thing in the morning to get rid of a hangover?
  3. Have you ever had a big crisis that led to arrest and grief from your family and friends and tried to explain away your actions?
  4. Have you called off or were absent from work because you had too much to drink and needed to sleep it off?

Question 5

Type: MCSA

A patient who misuses alcohol finished drinking at noon. At 6 p.m. which autonomic manifestations of alcohol withdrawal would the nurse assess in the patient?

  1. Nausea and abdominal cramps
  2. Diaphoresis and tremors
  3. Anorexia and diarrhea
  4. Auditory-visual hallucinations and global confusion

Question 6

Type: MCMA

In anticipation of a patient’s alcohol withdrawal symptoms, the nurse will perform which actions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Recognize that hallucinations are common and reorient the patient.
  2. Prepare for seizures that might occur within the first 12 hours of admission.
  3. Frequently assess vital signs.
  4. Have a sitter present to monitor any attempt by the patient to escape.
  5. Prevent, recognize, and treat symptoms while providing a safe environment.

Question 7

Type: MCSA

The nurse is planning to use the Clinical Institute Withdrawal Assessment (CIWA-Ar) scale with a patient who has been recently admitted with pancreatitis. When using this measurement tool, the nurse must realize that:

  1. The lower the score, the greater the patient’s risk for severe withdrawal symptoms.
  2. The higher the score, the lower the patient’s risk for severe withdrawal symptoms.
  3. Pharmacologic therapy is matched with the score to direct the level of care required.
  4. Sixteen specific areas are scored and assessed with this tool.

Question 8

Type: MCSA

When using the Clinical Institute Withdrawal Assessment for Alcohol scale, the nurse realizes that the use of medication for clinically significant symptoms is based on:

  1. The temperature, pulse oximetry, and urine output
  2. The response to treatment
  3. A designated threshold of severity
  4. The amount of one-to-one attention needed

Question 9

Type: MCSA

The nurse suspects that a patient is dependent on alcohol rather than abusing alcohol when what is assessed?

  1. Alcohol is taken in larger amounts than planned and there is proof of tolerance.
  2. Recurrent legal problems related to substance abuse are present.
  3. Despite social and interpersonal problems, the person continues to use alcohol.
  4. The person uses alcohol in physically hazardous situations.

Question 10

Type: MCSA

A patient with a myocardial infarction is withdrawing from alcohol. The patient is nauseated and having tremors despite receiving medications for withdrawal. The nurse suspects the patient is experiencing which electrolyte imbalance?

  1. Serum magnesium 2.5 mEq/dL
  2. Serum phosphate 2.7 mEq/dL
  3. Serum potassium 3.1 mEq/dL
  4. Total calcium 9.0 mg/dL

CHAPTER 13

Question 1

Type: MCSA

A patient arrives in the emergency department with clinical manifestations consistent with a lower gastrointestinal bleed. What should the nurse assess to determine the patient’s stability?

  1. Hemoglobin
  2. Hematocrit
  3. Vital signs
  4. Abdominal rigidity to determine the amount of blood being lost

Question 2

Type: MCSA

A patient being treated for a lower gastrointestinal bleed has a capillary refill of 3 seconds, a urinary output of 20 mL/hour, a heart rate of 88, and reports “feeling tired.” Which finding should the nurse report to the physician?

  1. Capillary refill of 3 seconds
  2. Urinary output of 20 mL/hour
  3. Heart rate of 88 bpm
  4. Reports of fatigue

Question 3

Type: MCSA

A patient with a serious gastrointestinal bleed arrives in the emergency department and the physician intends to initiate aggressive intravenous therapy. Which solution would the nurse anticipate being used to manage this patient’s condition?

  1. D5and NS
  2. D5W
  3. 0.9% NS
  4. 0.45% NS

Question 4

Type: MCMA

A patient, being treated for a gastrointestinal bleed, has the following assessment findings: temperature 97.2°F, blood pressure 99/70 mm Hg, heart rate 74 bpm, capillary refill of 3 seconds, and oxygen saturation 94%. Four hours later the nurse identifies changes in the patient’s condition. Which changes are associated with complications from management of the condition?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Temperature 98.2°F
  2. Heart rate 98 bpm
  3. Oxygen saturation 85%
  4. Capillary refill of 2 seconds
  5. Rales auscultated bilateral bases

Question 5

Type: MCSA

A patient with an active lower gastrointestinal bleed has the following vital signs: temperature 97.0 F, HR 68, RR 20, and BP 82/60 mm Hg. The nurse would place the patient in which position?

  1. Prone
  2. Supine with the legs bent at the knees
  3. Supine with the legs raised
  4. Side lying with the head of the bed elevated to 30 degrees

Question 6

Type: MCSA

The nurse has been assigned to provide care for several patients on the medical-surgical unit. After reviewing the data exchanged during the shift report, which patient should the nurse plan to assess first? The patient with:

  1. An elevated temperature of 99.2°F and complaints of nausea
  2. Complaints of feelings of fullness and no bowel movement for 2 days
  3. A heart rate of 82 bpm, complaints of fatigue, and an episode of coffee ground emesis 4 hours ago
  4. Two episodes of melena diarrhea within the past 2 hours

Question 7

Type: MCSA

A patient being prepared for an endoscopy to diagnose an upper gastrointestinal bleed asks why a nasogastric tube has to be inserted. What would the nurse respond to this patient?

  1. “You need this to assist with placement of the ostomy tube.”
  2. “The nasogastric tube will assist in the removal of blood clots that may limit the physician in seeing your esophagus.”
  3. “Your physician has left orders for placement of the tube.”
  4. “The tube will reduce the likelihood of you vomiting during the procedure.”

Question 8

Type: MCSA

A patient recovering from a colonoscopy reports abdominal pain of 4 on a 5 point scale. The patient’s abdomen is rigid and vital signs are T 99.2, HR 94, R 28, and BP 98/69. What initial action by the nurse is indicated?

  1. Assist the patient to turn to aid in relieving the flatus buildup.
  2. Continue to observe the patient for additional changes in 15 minutes.
  3. Notify the physician.
  4. Medicate the patient for discomfort.

Question 9

Type: MCSA

A patient prescribed pantoprazole (Protonix) asks the purpose of the medication. Which response by the nurse is most appropriate?

  1. “The medication will stop the stomach bleeding.”
  2. “The medication will provide a protective coating to your gastrointestinal system.”
  3. “The medication is used to reduce the acid in your gastric secretions and stabilize the clot to prevent further bleeding.”
  4. “The medication will eliminate any potential gastrointestinal infection you may have.”

Question 10

Type: MCSA

A patient being admitted to determine the presence of an upper gastrointestinal bleed does not believe the diagnosis because of the absence of pain. How would the nurse respond to this patient?

  1. “Some patients have a high pain tolerance and are able to handle the condition better than others.”
  2. “Pain is not a typical symptom of this condition.”
  3. “You should share this with your physician next time you see him.”
  4. “You must be in the early stages of the disease because pain does not occur until later.”

CHAPTER 14

Question 1

Type: MCSA

A patient is admitted with diabetic ketoacidosis. The nurse realizes that which problem caused the cascade to diabetic ketoacidosis (DKA) to occur?

  1. Ketosis
  2. Insulin deficiency
  3. Hypoglycemia
  4. Dehydration

Question 2

Type: MCSA

The nurse is explaining the pathophysiology of hyperglycemic hyperosmolar nonketotic syndrome (HHNS). Which statement will the nurse include when teaching? HHNS:

  1. Is accompanied by severe metabolic acidosis
  2. Results in cellular overhydration and interstitial space dehydration
  3. Causes severe dehydration from very high osmolarity
  4. Causes a severe decline in glucose production, resulting in increased metabolic rates to burn fat for energy

Question 3

Type: MCSA

The nurse is comparing diabetic ketoacidosis (DKA) to hyperglycemic hyperosmolar nonketotic syndrome (HHNS). What does the nurse identify as the main difference between the two disorders?

  1. DKA and HHNS are caused by too much insulin in the body.
  2. No insulin is present in DKA, whereas some insulin is present in HHNS.
  3. DKA results in metabolic acidosis; HHNS results in metabolic alkalosis.
  4. Dehydration is greater or more severe in DKA than in HHNS.

Question 4

Type: MCSA

The nurse is caring for a patient with hyperglycemic hyperosmolar nonketotic syndrome (HHNS). The nurse realizes that this health problem could develop because of:

  1. Certain antibiotics that can induce HHNS in those with type 2 diabetes
  2. Poor compliance to medical therapy
  3. Skipping meals, especially during illness
  4. Taking too much insulin during illness

Question 5

Type: MCSA

The nurse is determining if a patient is experiencing DKA or HHNS. Which information would help the nurse in making this determination?

  1. Patients with DKA exhibit Kussmaul’s respirations to blow off CO2and reduce pH levels.
  2. Patients with HHNS have lower arterial pH levels than those with DKA.
  3. Patients with DKA have more visual disturbances than patients with HHNS.
  4. Patients with HHNS have moderate hyperglycemia, whereas patients with DKA have more severe hyperglycemia.

Question 6

Type: MCSA

A patient with diabetes has a serum osmolarity level of 325 mmol/L. What is the correct interpretation and action for the nurse to take based on this result?

  1. The result is somewhat high but no immediate action is necessary.
  2. The result is very low and the physician should be notified of the result.
  3. The result is somewhat low but no immediate action is necessary.
  4. The result is very high and the physician should be notified of the result.

Question 7

Type: MCMA

When planning care for a patient in diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar nonketotic syndrome (HHNS), which goals would be included in the plan of care?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Stabilize blood glucose levels to within normal limits.
  2. Increase understanding of self-management to prevent future episodes.
  3. Reestablish fluid balance through rehydration.
  4. Restore A1C blood levels to at or above 8%.
  5. Effectively treat the precipitating cause for DKA or HHNS.

Question 8

Type: MCSA

Which nursing diagnosis would not be applicable when planning care for a patient with diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar nonketotic syndrome (HHNS)?

  1. Excessive fluid volume related to (RT) fluid shifts from hyperosmolarity
  2. Imbalanced nutrition, less than body requirements RT inability to utilize glucose
  3. Ineffective tissue perfusion RT hypovolemia and decreased peripheral blood flow
  4. Risk for infection RT increased blood glucose and decreased peripheral blood flow

Question 9

Type: MCSA

The nurse is caring for a patient in DKA with serum sodium of 130 and serum glucose of 600. After calculating the corrected serum sodium (CSS) [CSS = Serum Na+ + {[(Serum glucose (mg/dL) – 100)/100] × 1.6}], which intravenous fluid would the nurse plan to provide this patient?

  1. D5 ½ NS
  2. 0.45 NS
  3. 0.9 NS
  4. Lactated Ringer’s (LR)

Question 10

Type: MCSA

What would the nurse assess before beginning insulin therapy in a patient with hyperglycemic hyperosmolar nonketotic syndrome (HHNS)?

  1. Sodium level (Na+)
  2. Previous history of cardiac dysrhythmias
  3. Potassium level (K+)
  4. Arterial blood gas results

CHAPTER 15

Question 1

Type: MCSA

Of the following patients in an intensive care unit, the nurse identifies which patient as being at highest risk for the development of acute kidney injury with a prerenal cause? A patient who is:

  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. Post-operative from a ruptured abdominal aortic aneurysm

Question 2

Type: MCMA

While reviewing a patient’s medication record, the critical care nurse would be concerned about which drugs that have been implicated in the development of renal failure?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Cyclosporine
  2. Contrast media
  3. Aminoglycosides
  4. Antiseizure medications
  5. Nonsteroidal anti-inflammatory drugs (NSAIDs)

Question 3

Type: MCMA

The nurse will review a critically ill patient’s history for which causes of intrinsic renal failure?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  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

Question 4

Type: MCSA

A patient in the intensive care unit is reported to be in the oliguric phase of intrinsic renal failure, which is reflected by:

  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

Question 5

Type: MCSA

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

Question 6

Type: MCMA

A patient is experiencing prerenal failure secondary to hypovolemia. The nurse reviewing the patient’s laboratory work and vascular pressures would expect to see which results?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  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
  5. Urine with granular casts and sediment

Question 7

Type: MCSA

A nurse plans to administer to a patient a fluid challenge for the purpose of establishing normal renal perfusion. What does this treatment involve?

  1. Infusing 250 mL of 0.9% sodium chloride over 1 hour
  2. Administering albumin intravenously, followed by furosemide
  3. Infusing 500 mL of normal saline over a 30-minute period
  4. Giving twice the amount of IV fluid each hour compared to urinary output

Question 8

Type: MCSA

What would the critical care nurse expect to find if administering a fluid challenge to an 80-year-old patient had the intended effect?

  1. A systolic blood pressure of 120 mm Hg or less
  2. Heart rate remaining steady at 60 to 70 beats per minute
  3. Skin turgor showing improvement within 24 hours
  4. A MAP of 70 mm Hg or higher

Question 9

Type: MCSA

For which order would the nurse seek clarification regarding a patient with decreased renal perfusion and lowered glomerular filtration rate?

  1. Administer acetylcysteine prior to an intravenous pyelogram procedure.
  2. Infuse vancomycin 1,500 mg IV every 12 hours.
  3. Check a peak and trough level with every third dose of IV clindamycin.
  4. Give furosemide 10 mg by mouth daily.

Question 10

Type: MCSA

A patient has been placed on a 1,000-mL fluid restriction over 24 hours. Choose the plan that reflects how the critical care nurse would divide this amount of fluid.

  1. 350 mL for dayshift, 325 mL for evening shift, and 325 mL for nightshift
  2. 400 mL for dayshift, 400 mL for evening shift, and 200 mL for nightshift
  3. 500 mL for dayshift, 325 mL for evening shift, and 125 mL for nightshift
  4. 600 mL for dayshift, 200 mL for evening shift, and 200 mL for nightshift

CHAPTER 16

Question 1

Type: MCSA

A nurse recognizes that advocating for organ donation is important because:

  1. The supply of donor organs meets the demand of potential recipients.
  2. Organ recipients are not expected to have a long life span because of complications associated with the transplant.
  3. The organ recipient usually enjoys a better quality of life at less cost to the health care system.
  4. The organ recipient is often confined by frequent health care visits in order to maintain health.

Question 2

Type: MCSA

The nurse is teaching a patient about the antigen-antibody response. Which statement best describes an antigen?

  1. Antigens are recognized by the body as foreign or non-self.
  2. The presence of HLA antigens means that the recipient cannot receive an organ.
  3. A recipient may have antihuman antigens that would react with a donated organ.
  4. An organ can only be transplanted if the potential donor and recipient antigens completely match.

Question 3

Type: MCSA

The nurse is reviewing the tissue requirements for organ recipients and donors. Which statement correctly describes which recipients can receive an organ from which donor?

  1. Recipients with blood type O are universal recipients.
  2. Recipients with blood type A can receive donations from donors with blood types A, AB, and O.
  3. Recipients with blood type B can receive donations from donors with blood types A, B, and O.
  4. Recipients with blood type AB can receive an organ from any donor blood type.

Question 4

Type: MCSA

A patient is placed on an organ transplant list for a living or deceased kidney donor. What percentage of organ donors are living organ donors?

  1. 20%
  2. 30%
  3. 40%
  4. 50%

Question 5

Type: MCSA

The critical care nurse is reviewing patients who would be good candidates for organ donation. Which patient would be appropriate for this process?

  1. A 25-year-old who is 28 weeks pregnant and has a severe traumatic head injury
  2. A 30-year-old who was healthy before overdosing with barbiturates
  3. A 45-year-old with a small primary lung carcinoma
  4. A 55-year-old with intracranial pressure from a primary intracranial tumor

Question 6

Type: MCSA

Which finding by the nurse assessing a potential organ donor would indicate that the patient did not meet the criteria for donation based on brain death?

  1. Apnea
  2. Decorticate posturing
  3. Unresponsiveness
  4. Absence of brainstem reflexes

Question 7

Type: MCSA

The nurse is caring for a patient who is approaching death. When must the nurse notify the organ bank? When:

  1. Death is imminent in all cases.
  2. Death is imminent and an organ donation card or the back of the driver’s license indicates that the person wanted to donate his organs.
  3. Death is imminent and the family consents to organ donation.
  4. The nurse assesses that the family can be approached about organ donation.

Question 8

Type: MCSA

A patient in a critical care area has passed away. Who is the best person to approach the family about organ donation?

  1. The nurse
  2. The organ procurement specialist
  3. The doctor
  4. A member of the clergy

Question 9

Type: MCSA

What best describes the role of the critical care nurse in the organ donation process?

  1. Talk about the benefits of organ donation to the family.
  2. Reinforce the explanation of brain death after the doctor has talked to the family.
  3. Answer questions about financial concerns related to organ donation.
  4. Let the organ procurement nurse take over the care of the patient and family.

Question 10

Type: MCSA

A patient’s urine output is greater than 200 mL/hour and hemodynamic stability cannot be achieved by using fluids and vasoactive medications. The nurse anticipates that which medication may be prescribed?

  1. Beta blocker such as Lopressor
  2. Diuretic such as furosemide
  3. Concentrated sugar such as 50% dextrose
  4. Hormone such as vasopressin

CHAPTER 17

Question 1

Type: MCMA

The nurse providing an overview of burns to a community group is teaching the causes for thermal burns. These causes include:

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Contact with steam
  2. Exposure to hot liquids
  3. Being splashed with drain cleaner
  4. Stepping on hot charcoal
  5. Friction injuries

Question 2

Type: MCSA

The nurse is explaining to the granddaughter of an 85-year-old patient that older persons are at greater risk for scalding by hot water due to:

  1. This age group’s adversity to taking showers
  2. An inclination to test the water’s temperature
  3. Overall slower reaction time
  4. Loss of elasticity of skin tissue

Question 3

Type: MCSA

A patient rescued from a small house fire is brought to the emergency department. There is no burn injury to the skin, however laboratory results show a CO level of 22%. Which intervention would the nurse expect to implement?

  1. Administer high-flow nebulizer treatment.
  2. Infuse a fluid bolus of lactated Ringer’s solution.
  3. Begin a sodium bicarbonate drip.
  4. Give 100% oxygen by mask.

Question 4

Type: MCMA

The critical care nurse is aware that the depth of burn injury is determined by the depth of tissue destruction and which other factors?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Duration of the burn exposure
  2. Additional chronic medical conditions
  3. Skin thickness
  4. The cause of the burn
  5. Body part of the burn injury

Question 5

Type: MCSA

Which assessment finding by the nurse would be suggestive of a minor burn?

  1. The involved skin is deep reddish-brown in color and edematous.
  2. Blisters begin to form on the skin within the first hour of exposure.
  3. The skin remains intact because only the epidermal layer is involved.
  4. Scarring will be evident on the edges of the burn in a matter of hours.

Question 6

Type: MCSA

When assessing zone of coagulation of a third-degree burn injury, the nurse would be alert for:

  1. The presence of pain
  2. Brisk capillary refill
  3. Surface of the wound that is dry and firm
  4. A bright red wound color

Question 7

Type: MCSA

A patient comes to the emergency department with thermal burns to the left arm and shoulder. Which finding requires immediate attention by the nurse?

  1. Complaint of excessive thirst
  2. Loss of range of motion to the affected side
  3. Pain rating of 8 on a 1 to 10 scale
  4. Presence of coughing and hoarseness

Question 8

Type: MCSA

Which patient situation would present the greatest risk for an inhalation injury? The patient:

  1. With a second-degree electrical burn of the hand
  2. Trapped on an elevator during a fire in a building
  3. With asthma who has extensive first-degree sunburn
  4. With a scalding injury from liquid splashed on the legs

Question 9

Type: MCSA

A patient in ICU with a burn circling the left upper leg suddenly experiences excruciating pain, pallor in the lower extremity, and loss of pedal pulse. The nurse would immediately notify the physician because this patient might be developing:

  1. Compartment syndrome
  2. Inability to perform ADLs
  3. Nosocomial infection
  4. A deep vein thrombosis

Question 10

Type: MCSA

What would the nurse teach a patient with a burn injury about skin changes that occur following a large burn?

  1. Regulating body temperature returns with healing.
  2. Healed burn areas are more susceptible to mechanical injury.
  3. Sensory perception never returns once healing of a burn is complete.
  4. Vitamin D from sun exposure facilitates the healing process.

CHAPTER 18

Question 1

Type: MCSA

The nurse is identifying interventions to prevent the development of sepsis in an older patient because:

  1. Mortality rates from sepsis are 70% worldwide.
  2. If managed early and aggressively, the majority of patients with sepsis may be managed outside of the ICU environment.
  3. The guidelines provided by the Surviving Sepsis Campaign are expected to decrease the incidence of sepsis.
  4. Sepsis rates rise sharply with age.

Question 2

Type: MCSA

While caring for an older patient, the nurse is aware that the two most common sources of infection that can lead to sepsis in this patient include:

  1. Pneumonia and urinary tract infections
  2. Skin infections and diabetes
  3. Surgical incisions and abdominal wounds
  4. Traumatic wounds and abdominal surgeries

Question 3

Type: MCSA

Which evidence based intervention would the nurse use to prevent pneumonia in the patient receiving mechanical ventilation?

  1. Aseptic technique when performing oral hygiene
  2. Administration of an H2antagonist to prevent peptic ulcers
  3. Elevation of the head of the bed to 15 degrees to prevent aspiration
  4. Changing the ventilator circuit daily

Question 4

Type: MCSA

Which statement accurately describes the purpose of sedation vacation for a patient to prevent ventilator-associated pneumonia?

  1. The vacation from sedation relieves stress, which decreases the chance of infection.
  2. During sedation vacation the patient has a chance to take deep breaths and improve ventilation while more awake.
  3. The patient’s own tidal volume and respiratory rate can be evaluated during sedation vacation.
  4. New data show that sedation vacation is no longer recommended because there is concern about the safety of interrupting sedation.

Question 5

Type: MCSA

Why is the nurse implementing actions to prevent the onset of catheter-related infections in a patient receiving care in the intensive care unit?

  1. Statistics report that as many as one in five individuals who develop a catheter-related infection die from it.
  2. Nosocomial catheter-related infections prolong hospitalization by an average of 4 days.
  3. The increased cost of care due to the development of a blood-borne infection averages between $1,700 and $17,000.
  4. Central venous catheters have about the same rate of infection as peripherally inserted catheters.

Question 6

Type: MCSA

Which action is a part of the bundle of measures used to prevent nosocomial catheter-related infections?

  1. Chlorhexidine is most effective when swabbed starting at the insertion site and moving outward in a circular motion.
  2. It is recommended that transparent dressings be changed every 72 hours to prevent growth of bacteria on the skin.
  3. Current recommendations support changing IV tubing every 48 hours on patients at risk for catheter-related infections.
  4. During insertion of a central line the doctor should wear a cap and mask, sterile gloves, and a gown, and the patient should have a full body drape.

Question 7

Type: MCSA

The nurse is evaluating a patient for the presence of systemic inflammatory response syndrome (SIRS). Which assessment data indicates the presence of SIRS?

  1. Temperature 36.4°C, respiratory rate 22, pulse rate 112, and PaCO234
  2. Temperature 38.4°C, respiratory rate 23, pulse rate 92, and PaCO231
  3. Temperature 37.2°C, respiratory rate 24, pulse rate 102, and PaCO244
  4. Temperature 38.8°C, respiratory rate 25, pulse rate 88, and PaCO248

Question 8

Type: MCSA

The nurse is assessing a patient for severe sepsis. Which finding indicates the patient is developing this health problem?

  1. Decreased capillary filling and mottling
  2. Fever and decreased urine output
  3. Hypotension and lactic acidosis
  4. Increased glomerular filtration rate and increased D-dimer levels

Question 9

Type: MCSA

Which hemodynamic parameters would the nurse expect to see in the patient with septic shock?

  1. Central venous pressure (CVP) 4 mm Hg, pulmonary artery pressure (PAP) 30/15 mm Hg, and systemic vascular resistance (SVR) 1,200 dynes/sec/cm-5
  2. Central venous pressure (CVP) 8 mm Hg, pulmonary artery pressure (PAP) 26/10 mm Hg, and systemic vascular resistance (SVR) 1,000 dynes/sec/cm-5
  3. Central venous pressure (CVP) 2 mm Hg, pulmonary artery pressure (PAP) 20/8 mm Hg, and systemic vascular resistance (SVR) 800 dynes/sec/cm-5
  4. Central venous pressure (CVP) 6 mm Hg, pulmonary artery pressure (PAP) 40/20 mm Hg, and systemic vascular resistance (SVR) 700 dynes/sec/cm-5

Question 10

Type: MCSA

The nurse is assessing a patient for septic shock. Which statement best describes this health problem?

  1. Sepsis with hypotension that does not correct itself when a fluid challenge is administered
  2. Sepsis with hypotension accompanied by decreased protein C levels and coagulation abnormalities
  3. Sepsis with hypotension accompanied by increased creatinine and absent bowel sounds
  4. Sepsis with hypotension accompanied by altered mental status and lactic acidosis

CHAPTER 19

Question 1

Type: MCSA

The ICU nurse caring for a patient at the end of life understands that “limitation” of care refers to a decision:

  1. To stop all measures, including pain medication
  2. To exclude all but immediate family members from the patient’s room
  3. Not to initiate one or more interventions
  4. To stop one or more therapies after they had been initiated

Question 2

Type: MCSA

The decision has been made to not start needed dialysis on a patient in the intensive care unit. According to Copnell (2005), this decision would fall under which category of ICU deaths?

  1. Failed CPR
  2. Withdrawal
  3. Brain death
  4. Limitation

Question 3

Type: MCMA

A nurse might elect to have a family present during CPR on a critically ill patient because it is likely to have which benefits?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Staff members are reminded of the patient’s personhood.
  2. The family may realize the seriousness of the patient’s illness and understand the gravity of the situation.
  3. Fewer lawsuits occur when the family members see the care given by the health care team.
  4. The family may provide comfort and support to the patient.
  5. The family can understand the expenses needed with the multitude of equipment used in critical care.

Question 4

Type: MCSA

When planning to allow a family to be at the bedside during CPR, the nurse should anticipate which possible outcome based on reports from post-CPR patients?

  1. The family will be unhappy after seeing the pain and suffering caused by CPR.
  2. The patient will feel comforted and supported by his family’s presence.
  3. The family will be overwhelmed by the confusion and busyness of the events.
  4. The patient will be frustrated because of not being able to speak to the family.

Question 5

Type: MCSA

What does the nurse have a legal responsibility to prevent if family members are present while CPR is delivered to a patient?

  1. Post-traumatic stress syndrome of family members from viewing CPR
  2. Breach of confidentiality about the patient’s medical information during CPR
  3. Family vendetta for perceived unskilled or less efficient staff during CPR
  4. Patient’s lack of privacy and physical exposure during CPR

Question 6

Type: MCSA

When using the mnemonic “in-or-out” as a guideline for evaluating family presence during CPR, what would the nurse include during the “R” step?

  1. Identify the relationship to the patient and the family decision maker.
  2. Explain the rationale for health outcomes and management options.
  3. Assess the family’s reason for wanting to be present in the room.
  4. React to data collected during the family discussion.

Question 7

Type: MCSA

When caring for a bereaved family member, the nurse would avoid which inappropriate action?

  1. Offer privacy and a listening ear to the family before speaking.
  2. Avoid technical, hospital, or medical terminology when explaining conditions or treatments.
  3. Offer clichés, such as “she lived a good life,” to make the family feel better.
  4. Use direct eye contact and offer comfort by touching.

Question 8

Type: MCSA

How would the nurse explain “brain death” to a family member? Brain death is:

  1. Damage to the brain so extensive that the brain is no longer functional and function cannot be restored by medical therapies
  2. Brain tissue that is lacking blood supply so it cannot perform some of its normal functions
  3. Electrical malfunction of brain tissue so that it does not control breathing properly
  4. When one lobe of the brain is traumatized or bruised and is trying to repair itself

Question 9

Type: MCSA

A patient in the intensive care unit is being evaluated for brain death. Which finding is an indication of brain death?

  1. Absence of all motor responses to noxious stimuli
  2. No respiratory effort when the patient is off the ventilator for 4 minutes with a pCO2of 49
  3. Absence of a cough reflex with nasotracheal stimulation
  4. Pupils that are 3 mm and respond to light

Question 10

Type: MCMA

Which reflexes will the nurse assess to determine brainstem response in a patient being evaluated for brain death?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. PERLA
  2. Oculovestibular
  3. Corneal
  4. Oculocephalic
  5. Moro

 

AND MUCH MORE