Critical Care Final Exam Review Questions and Answers., Exams of Nursing

Download Critical Care Final Exam Review Questions and Answers. and more Exams Nursing in PDF only on Docsity! Critical Care Final Exam Review Questions and Answers. The nurse is caring for a patient with petechiaae underneath compression stockings and slight oozing around venipuncture sites. The nurse notices what on the lab results that indicates this patient may be experiencing DIC? A. Increased hemoglobin levels B. Shystocytes on the blood smear C. Decreased lactic acid D. Decreased potassium - Correct Answers B. Shystocytes on blood smear What will the nurse assess in a patient experiencing the fibrotic phase of acute lung injury resulting in hypoventilation, hypoxemia? A. Pulmonary artery pressure of 18/9 mmHg B. Stridor on inspiration C. Bilateral effusion can be seen on radiographic exams D. Decreased volume and lung compliance on the ventilator - Correct Answers D. Decreased volume and lung compliance on the ventilator Which statement made by a new graduate nurse about invasive mechanical ventilation techniques requires additional teaching? A. Assist control mode refers to the patient receiving a set total lung capacity but the rate is maintained by the patient's own rate of breathing B. Total control mode controls both the rate and volume that are preset and delivered without the machine responding to any of the patient' own breaths C. Synchronized intermittent mandatory ventilation (SIMV) refers to the patient setting an independent rate but limited tidal volume based on the patient's own strength. A minimum rate is also used as a backup to prevent hypoventilation D. Continuous positive airway pressure will increase the residual capacity and keep the alveoli open. rate and volume are controlled by the patient. This is one step weaning process - Correct Answers A. Assist control mode refers to the patient receiving a set total lung capacity but the rate is maintained by the patient's own rate of breathing A patient with ARDS is on a mechanical ventilator with a heart rate of 128, SaO2 of 88%, and the ventilator settings are FiO2 50%, PEEP 8 cm, AC 10 with total respiratory rate of 30, and tidal volume 00 mL. There are coarse rhonci audible in all lung fields. The appropriate nursing action would be to: A. Administer the ordered neuromuscular blockade medications B. Increase the PEEP to 10 cm and sedate the patient C. Hyperoxygenate with 100% oxygen and suction the patient D. Increase the FiO2 to 60% and tidal volume to 750 mL for 2 minutes - Correct Answers C. Hyperoxygenate with 100% O2 and suction the patient Which nursing action would best optimize overall oxygenation and ventilation in the patient with ARDS? A. Hyperventilate the patient after suctioning B. Provide adequate rest and recovery time between procedures C. Suction the patient every 30 minutes D. Administer sedation infrequently - Correct Answers B. Provide adequate rest and recovery time between procedures C. D5 1/2 NS D. Dopamine - Correct Answers D. Dopamine A six-year-old pediatric client, who recently underswent a tonsillectomy 27 hours prior, presented to the ED after an episode of severe coughing, resulting in continuous bright red bleeding from back of throat. The patient is hypotensive, pale, and slow to respond. The mother teaches critical care nursing and asks what type of shock her child is in. You respond with _____ shock. A. Distributive B. Hypovolemic C. Septic D. Cardiogenic - Correct Answers B. Hypovolemic A patient with neurogenic shock is demonstrating symptomatic bradycardia. What action will the nurse take at this time? A. Prepare to administer crystalloids B. 0.5 mg atropine C. Limit patient movement D. Administer phenylephrine as prescribed - Correct Answers B. 0.5 mg atropine The nurse identifies that a patient is experiencing ventricular tachycardia. What did the nurse assess on the patient's ECG rhythm strip? Select all that apply A. Six or more PVCs in rapid succession B. Narrow QRS complex C. Unmeasurable PR interval D. Undetectable QRS complexes E. Absent P waves F. HR > 150 bpm - Correct Answers A. Six or more PVCs in rapid succession C. Unmeasurable PR interval E. Absent P waves F. HR > 150 bpm The nurse receives report from the previous shift, and documents the the patient tis in sinus rhythm. The nurse is verifying patient identity and the patient does not respond to verbal or physical stimuli. The monitor still displays an organized rhythm, but the nurse is unable to palpate or auscultate a pulse. Which of the statements is true? A. Do not attempt an emergency response alert B. The patient is in PEA and care should be provided based on code status C. Administer 1 mg of epinephrine over 3 - 5 minutes D. Defibrillate at 300 joules - Correct Answers B. The patient is in PEA and care should be provided based on code status A patient with acute lung injury is being started on enteral nutrition. Which interventions will the nurse provide to ensure optimal nutritional support for this patient? A. Withold the use of NG tube until radiographic placement is confirmed B. Monitor for diarrhea C. Assess for gastric residual D. Keep the HOB elevated at least 30 degrees E. Check gastric residuals with each assessment F. Discard any residual gastric contents during assessments - Correct Answers A. Withold the use of NG tube until radiographic placement is confirmed B. Monitor for diarrhea C. Assess for gastric residual D. Keep the HOB elevated at least 30 degrees E. Check gastric residuals with each assessment During assessment, a ventilated patient has a furrowed brow and begins to move about in bed. Which assessment strategy would be most helpful for the nurse to validate these observations? A. Maslow's hierarchy of needs B. Neurological assessment C. Pain assessment tool D. Glasgow Scale - Correct Answers C. Pain assessment tool A client with a systemic infection from an infected leg wound tells the nurse, "its getting hard to breathe". What does the nurse suspect this client is at risk for developing? A. Anemia B. ARDS C. DVT D. Hypovolemia - Correct Answers B. ARDS A. Can not sustain life without use of beta blockers. B. Requires immediate cardioversion if symptomatic. C. Is a compensatory mechanism for bladder regulation. D. This rhythm may be normal for very active adult patients. - Correct Answers D. This rhythm may be normal for very active adult patients. The nurse is caring for a patient and notices this rhythm on the monitor: The nurse understands that... A. This is ventricular tachycardia. B. Assess patient level of consciousness. C. Can not sustain life without use of beta blockers. D. May indicate fluid volume loss with or without alteration to blood pressure. - Correct Answers D. May indicate fluid volume loss with or without alteration to blood pressure. The nurse is administering intravenous nitroglycerin to a patient admitted with hypersensitive crisis. The infusion has been titrated based on the physician titration orders and the guidelines of the facility. During the next assessment the nurse notices that the patient is pale, diaphoretic, lethargic, disoriented and severely hypotensive. Which intervention by the nurse is most appropriate? A. Immediately call the physician to report the current status of the patient and obtain order to decrease infusion. B. Recheck the blood pressure C. Pause or stop the nitro infusion and reassess D. Administer two breaths via bag valve mask ventilation. - Correct Answers C. Pause or stop the nitro infusion and reassess A patient has been diagnosed with septic shock. The patient has received a 3L NS bolus. Hemodynamics are as follows: ABP 78/44, MAP 56, HR 133, O2 90% with FiO2 at 100%. Which intervention would the nurse anticipate next? A. Initiate dopamine infusion at 20 mcg/kg/min B. Begin bolus of an additional liter of NS C. Tirate norepinephrine infusion at 5-20mcg/min D. Increase FiO2 % - Correct Answers C. Tirate norepinephrine infusion at 5-20mcg/min A 70 year old man presents to the emergency department with a 2 day history of fever, chills, cough, and right sided pleuritic chest pain. On the day of admission, the patients family noted that he was more lethargic and dizzy and was frequently falling. The patient's VS are: T 101.5F, HR 120bpm, RR 30, BP 70/35mmHg, and O2 sat by pulse oximetry 80% without supplementation. A chest radiograph shows a right lower lobe infiltrate. Which intervention would the nurse anticipate first? A. Initiate norepinephrine infusion at 30mcg/kg/min B. Antipyretic therapy C. Administer broad spectru, antibiotics D. Assist with airway maintenance and provide supplemental oxygen - Correct Answers D. Assist with airway maintenance and provide supplemental oxygen A 40 year old man with a history of IV drug use presents with cellulitis with multiple abscesses of the right upper extremity. His current weight is 70 kg. He rapidly develops worsening respiratory distress and hypotension and ultimately requires intubation and mechanical ventilation. Blood gas analysis shoes a pH of 7.23, PaCO2 of 68, PaO2 of 80, and an oxygen saturation of 91%. His ventilator setting are assist control mode with a tidal volume of 420mL, RR 16, PEEP of 5cm H2O, and FiO2 of 70%. His end tidal CO2 is 22mmHg. the nurse understand that which setting on the ventilator would have the greatest affect PaCO2 and ETCO2 of this patient? A. Increase PEEP B. Increase FiO2 C. Decrease inspiratory pressure - Correct Answers A. Increase PEEP Match the rhythm with the correct interpretation A. Second Degree Type 1 B. Atrial Flutter with Multifocal PVC C. Third Degree Heart Block D. Second Degree Type 2 E. Bigeminy - Correct Answers C. Third Degree Heart Block Match the rhythm with the correct interpretation A. Second Degree Type 1 B. Atrial Flutter with Multifocal PVC C. Third Degree Heart Block D. Second Degree Type 2 E. Bigeminy - Correct Answers A. Second Degree Type 1 Match the rhythm with the correct interpretation A. Second Degree Type 1 EXAM 1 QUESTION 37 - Correct Answers VENTILLATOR QUESTION The nurse is caring for a patient on the ventilator. Which of the following assessment findings requires immediate response? A. Lactic acid level of 2.9, down from a level of 3.1 B. Emesis coming out around ET tube and OG tube that is attached to low continuous suction C. Bilateral infiltrates on a chest x-ray D. Urine output of 120 mL between 4 hour assessments - Correct Answers B. Emesis coming out around ET tube and OG tube that is attached to low continuous suction The nurse is caring for a patient on the ventilator secondary to acute respiratory distress. The patient is on a continuous infusion of regular insulin. The previous glucose level was 120 and the titration order suggested an increase in the infusion by 1 unit/hour. The nurse titrated the infusion up by 1 unit and the infusion has been running at 12 units/hour for the last 60 minutes. The nurse checks the glucose level again, because the order states to check the blood glucose every hour. The current glucose reading is 42, and resulted as 41 on immediate re-check. Prioritize the interventions. A. Contact the physician B. Initiate hypoglycemic protocol C. Complete a crucial result form D. Stop or pause the infusion - Correct Answers 1. D - Stop or pause the infusion 2. B - Initiate hypoglycemic protocol 3. A - Contact the physician 4. C - Complete a crucial result form The nurse is caring for a patient that was admitted for respiratory distress. The patient has a history of peripheral vascular disease and coronary artery disease. The patient appears cyanotic, dysgenic, has tracheal tug, respiratory rate 38, and O2 saturation reading of 84% on 2L NC. Which action by the nurse is most appropriate for this patient? A. Reposition or apply new oximeter B. Increase the oxygen flow rate or apply a higher flow device C. Call the physician D. Internet message or page respiratory therapy - Correct Answers B. Increase the oxygen flow rate or apply a higher flow device The nurse is administering blood to a patient who was admitted for potential sepsis. The initial vital signs were temp 36.8, pulse 102, BP 101/58, RR 18, SPO2 94% 8L high flow nasal cannula after 15 minutes the patient is complaining of back and flank pain. The 15 minute vital signs are temp 38.8, pulse 122, BP 90/58, RR 28, SPO2 94% 10L high flow nasal cannula. Which action by the nurse is most appropriate given the situation? A. Slow or decrease the rate of the infusion secondary to transfusion associated circulatory overload B. Administer furosemide 80 mg rapid IV push C. Stop the transfusion D. Contact the physician for antipyretic order - Correct Answers C. Stop the transfusion Comparing today's X-ray and yesterday X-ray, the image shows much more consolidation (see picture). What does the nurse anticipate for this patient? A. Administer fluid bolus B. The physician will decrease the antibiotics based on improvement C. Administer diuretics D. WBC level is responding to antibiotic therapy - Correct Answers C. Administer diuretics The nurse is caring for a patient on the ventilator and the ventilator continues to alarm related to low volume during inspiration. The patient's oxygen saturation is 90% and the patient continues to move head back and forth on pillow and raising arms up against soft restraints. Given this presentation, what is the most appropriate initial intervention by the nurse? A. Increase sedation infusion based on titration orders B. Assure the patient that everything is going to be okay C. Contact the physician for an order to alter the ventilator settings D. Contact respiratory therapy - Correct Answers A. Increase sedation infusion based on titration orders Order to run Dopamine at 10 msg/kg/min, concentration is Dopamine 400 mg/250 mL. patient weighs 235 pounds. How many mLs per hour will be infusing? - Correct Answers 40 Round the following to the nearest whole number (no decimals). Do not type in unit of measure. Ordered: heparin 25,000 units/500 mL D5W is ordered to begin at 10 units/kg/hr. Patient weighs 176 pounds. How many units per hour will you run this IV? - Correct Answers 800 EXAM 1 QUESTION 46, 47, 48, 49, 50 - Correct Answers 12 LEAD EKGS A client with a head injury is demonstrating signs of increased ICP. Which classifications of medications will the nurse anticipate administering that will decrease symptoms related to IICP? Select all that apply. A. Diuretics B. Antibiotics B.The nurse will administer IM if unable to obtain IV access C.The remainder of the second vial will need to be stored in a refrigerator. D.The nurse will need to administer 10mLs - Correct Answers D.The nurse will need to administer 10mLs The nurse is caring for a patient admitted with thoracic trauma related to blunt injury. The patient has a central line in the right internal jugular, and has several infusions ordered (listed below) as well as an order to monitor central venous pressures (CVP). Utilizing the resources available, which of the following is appropriate? Continuous infusion of dopamine Furosemide IV infusion Fentanyl PCA Normal saline infusion at 10ml/hr Verapamil IV push every 8 hours Lorazepam IV push PRN Potassium chloride IV piggyback every 12 hours over 1 hour Calcium chloride IV piggyback every once daily over 1 hour **Picture shows all meds are compatible** A. Administer Dopamine, fentanyl and furosemide in the medial lumen, infuse saline alone for the IV pushes and piggybacks and transduce CVP on medial lumen B. Transduce CVP on the medial lumen, infuse fentanyl and furosemide together and the dopamine seperate. Ini - Correct Answers D. Transduce CVP on distal lumen, infuse dopamine and fentanyl PCA together in the proximal lumen and infuse the furosemide and NS in the medial lumen as well as administer IV pushes and IV piggybacks through the saline The nurse becomes concerned when a client who sustained a head injury, while playing a virtual reality video game, begins to demonstrate decerebrate posturing. What does this posture suggest to the nurse about the client's brain functioning? A.Developing a seizure disorder B. Corticospinal tract impairment C. Brainstem impairment D. Altered level of consciousness - Correct Answers C. Brainstem impairment The nurse is determining ways to decrease environmental stimuli for a client with increased intracranial pressure. What actions should the nurse take to support this client's care need? Select all that apply. A. Teach family to speak softly and minimize touching. B. Elevate the head of the bed. C. Provide all care quickly at one time D. Limit the client's visitors. E. Keep the room dark and quiet. - Correct Answers A. Teach family to speak softly and minimize touching. D. Limit the client's visitors. E. Keep the room dark and quiet. The nurse is planning the care for a client with a closed head injury sustained from playing a competitive game of "Would You Rather". Which of the following would be appropriate to include in this client's plan of care? A. Maintain client in the supine position. B. Maintain blood pressure above normal. C. Encourage increase in cerebral blood flow. D. Maintain HOB elevated to 30 degrees. - Correct Answers D. Maintain HOB elevated to 30 degrees. Coma stimulation is being implemented for a patient who sustained a traumatic brain injury. Which of the following should be included in this plan for stimulation? A. Provide stimulation during a sleep/rest period. You Answer B. Increase the volume level of speaking and stimulation in the patient's room. C. Stop the family from bringing in personal items of the patient. D. Ensure that only one person at a time is speaking during the period of stimulation. - Correct Answers D. Ensure that only one person at a time is speaking during the period of stimulation. Please match the patients with the correct level of Traumatic Brain Injury. A. Patient received a head injury while skateboarding down a ramp. The patient lost conciousness for about 8 hours and does not remember any events within the last 30 hours. GCS score is a 9. Mild, Moderate, or Severe TBI B. Patient presents with a head injury from flipping upside down on a pole. She has been unconcious for 30 hours and unable to answer any orientation or memory questions. Mild, Moderate, or Severe TBI The nurse is caring for a patient who experienced a traumatic brain injury while recon rolling over the top of the pizza delivery person's car. The patient is unresponsive and withdraws to painful stimuli. The nurse interprets this CT as what type of traumatic brain injury? A. Subdural hematoma B. Intracranial insufficiency C. Epidural hematoma D. Diffuse Axonal Injury - Correct Answers D. Diffuse Axonal Injury The nurse is caring for a patient that was admitted for a traumatic brain injury. The patient is 47 years old and has a history of high impact sports. Upon admission the patient's spouse admits that the patient has been confused and impulsive the past few months. The nurse understands that this CT and the history from the spouse suggest that the patient has what type of brain injury? A. Diffuse Axonal Injury B. Intracerebral hemorrhage C. Subdural hematoma D. Chronic traumatic encephalopathy - Correct Answers D. Chronic traumatic encephalopothy The nurse is caring for a patient that fell off of the top of a lamp post when he decided that would be a good time to text his professor a new meme. The patient presents with shortness of breath, dyspnea, pale, diaphoretic, absent lung sounds on the right and hypoxia. The nurse identifies what on the chest ray? A. atelectisis B. cardiac tamponade C. pulmonary collapse D. hemothorax - Correct Answers D. hemothorax The nurse is caring for a patient that was admitted to the emergency department after sustaining a penetrating injury from a competitive game of breaking a piñata, and he and his friends took turns being the piñatas. The patient currently has a blood pressure of 62/34, heart rate 144, and peritoneal bleeding on the abdominal ultrasound: *Image shows blood in spaces between organs* The nurse interprets these findings as what score for massive transfusion protocol? A. Level 4, 100% need for transfusion B. Level 3, 45% need for transfusion C. Level 1, minimal need for transfusion D. Level 2, 36% need for transfusion - Correct Answers A. Level 4, 100% need for transfusion The nurse is assisting the neurologist during a cold caloric stimulation test on a 25 year old male patient who sustained a traumatic brain injury from: *weird pic of kid on trampoline* A. The patient's brain stem function is compromised B. This patient will have cognitive impairment or slowed response, but will regain higher motor function skills with therapy. C. The patient will recover cognitively but will have decreased nerve stimulation of lower extremities. D. This patient will gain most function with aggressive physical and occupational therapy. - Correct Answers A. The patient's brain stem function is compromised The nurse is caring for a nine-month-old who just returned from the PACU after a shunt placement for hydrocephalus. Which of the physician's orders would the nurse question? A. Daily head circumference B. Small, frequent formula feedings C. Elevate head of bed D. Vital signs and neuro checks hourly - Correct Answers C. Elevate head of bed Which of the following is the best indicator of brain function in a child with a moderate brain injury? A. Level of consciousness B. Vital signs C. Papillary response D. Gross motor strength - Correct Answers A. Level of consciousness The health care provider has ordered mannitol (Osmitrol) for a child with a head injury. The best indicator that this medication has been effective is: A. Increased urine output B. Decreased intracranial pressure C. Improved level of consciousness D. Decreased facial swelling - Correct Answers B. Decreased intercranial pressure Upon assessment, you are concerned that the patient is experiencing herniation. Which of the following would be expected findings of Cushing's triad? A. Wide pulse pressure, tachycardia, increased systolic pressure C. Pain rating of 7 out of 10 D. Decreased mobility of the affected extremity - Correct Answers A. Loss of sensation in the affected extremity The nurse is caring for a patient that sustained a traumatic injury after thinking that it would be a good idea to ingest Tide Pods. The nurse is concerned that the patient is experiencing signs of abdominal compartment syndrome. The nurse is measuring abdominal girth. Which of the following would be necessary for the accuracy of the measurements? Select all that apply. A. Measure from the top of pubic bone to top of uterus. B. Use a marker to line the points of measurement. C. Measure across the umbilicus D. Measure from iliac crest to iliac crest E. Measure the anterior and multiply by 2 for the posterior - Correct Answers B. Use a marker to line the points of measurement. C. Measure across the umbilicus D. Measure from iliac crest to iliac crest The nurse is caring for a patient that experienced a traumatic brain injury while performing at a concert. When the nurse asks the patient his name, he responds with: "Back to the rhythm of the funky jam, DJ Kool is who I am." When the nurse asks the patient where he is at, he responds with: "Rockin' to the beat in the place to be" When the nurse asks the patient what year it is, he responds with: "Check out the flavor of the rhythm I wrote! While I got a chance here, let me clear my throat!" What will the nurse document as the orientation status for this patient? A. Now all the way live from New York City Mister Biz-mark, grab the mic and get busy B. Alert and oriented to person, place and time. C. Patient is alert, but is not orientated to place and time, as well as a narrative note describing the current orientation questions and answers. D. Patient is not alert or oriented to person, place or time. - Correct Answers C. Patient is alert, but is not orientated to place and time, as well as a narrative note describing the current orientation questions and answers. The nurse is assessing a patient admitted with a spinal cord injury that occurred while tailgating. During the assessment the nurse discovers that the patient has only visible contraction from the hip down. The patient has no sensation of light touch or pin prick from hip and down. The patient has also been incontinent of stool and did not have any pressure or sensation during incontinent episode. After completing the assessment the nurse suspects the patient has what type of spinal cord injury? A. Complete L5 injury B. Incomplete T2 injury C. Complete L2 injury D. Complete C7 injury - Correct Answers C. Complete L2 injury The nurse in the Emergency Department is preparing to administer methylprednisolone to a client with a spinal cord injury. What effect will this medication have on the client? A. Improve the level of consciousness B. Prevent cord damage from ischemia and edema C. Improve circulation to the area of injury D. Improve the ability to be adequately ventilated - Correct Answers B. Prevent cord damage from ischemia and edema Which actions should the nurse complete after realizing that an incorrect dose of medication has been administered to a patient? A. Notify the patient and family B. Mark the medication as not given in the chart C. Call a code error D. Keep the incident silent - Correct Answers A. Notify the patient and family The nurse is caring for a patient with a spinal cord injury. During the assessment the patient is able to extend and flex at the elbows and no contraction from hip flexors down. The patient has no sensation or muscle contraction from T2 down, the patient is incontinent of bowel and bladder, does not have anal sensation. Use the ASIA protocol to determine the type of spinal cord injury for this patient. A. Incomplete T2 B. Complete T1 C. Incomplete T3 D. Complete T2 - Correct Answers D. Complete T2 The nurse is planning care for a client admitted with a high thoracic spinal cord injury. Which immediate interventions would be most appropriate for emergent treatment of autonomic dysreflexia? A. Crede's manuever education B. Instruct the patient to urinate C. Insert foley catheter D. Discuss future care needs after discharged - Correct Answers C. Insert foley catheter When assisting a patient with a cane to transfer or ambulate, what does the nurse instruct the patient to do? A. Use the stronger arm to hold onto the cane C. prone with a sterile saline dressing over sac D. Prone with a pressure dressing over the sac - Correct Answers C. prone with a sterile saline dressing over sac A patient is admitted with Diabetic Ketoacidosis. The physician orders intravenous fluids of 0.9% Normal Saline and 10 units of intravenous regular insulin IV bolus and then to start an insulin drip per protocol. The patient's labs are the following: pH 7.25, Glucose 455, potassium 2.5. Which of the following is the most appropriate nursing intervention to perform next? A. Hold IV fluids and administer insulin as ordered B. Start the IV fluids and administer the insulin bolus and drip as ordered C. Hold the insulin and notify the doctor of the potassium level of 2.5 D. Recheck the glucose level - Correct Answers C. Hold the insulin and notify the doctor of the potassium level of 2.5 A patient diagnosed with diabetes mellitus is being discharged home and you are teaching them about preventing DKA. What statement by the patient demonstrates they understood your teaching about this condition? A. It is important I check my blood glucose every 3-4 hours when I'm sick and consume liquids B. If I am sick and unable to eat or drink, I should still check my blood glucose level but not adminster myself any insulin until I start eating and drinking again. C. I can continue my keto diet to help maintain a carb count of less than 10 per day. D. Join a social media blog for diabetics, because that is a way to have support and learn from other diabetics as well. E. I should not call my doctor until my blood glucose level is greater than 400 for at least 3 consecutive checks over 12 hours. - Correct Answers A. It is important I check my blood glucose every 3-4 hours when I'm sick and consume liquids It is halloween and a school nurse has one student with type 1 diabetes. If the students eats all of the candy in the classroom, what should the school nurse be ready to do? A. Have the child pinky swear that they will not eat any candy B. Make sure that the student has testing supplies and humolog on site C. Remove the child from the class party so that they are not tempted to eat the candy D. Send a note home to the parents that the child ate candy - Correct Answers B. Make sure that the student has testing supplies and humolog on site A client with DM demonstrates acute anxiety (Links to an external site.)Links to an external site. when first admitted for the treatment of hyperglycemia. The most appropriate intervention to decrease the client's anxiety would be to: A. Ignore the signs and symptoms of anxiety so that they will soon disappear B. Convey empathy, trust, and respect toward the client. C. Make sure the client knows all the correct medical terms to understand what is happening. D. Administer a sedative - Correct Answers B. Convey empathy, trust, and respect toward the client. True or False, we want critically ill patients to have a higher than normal CVP? - Correct Answers True What type of IV fluid is used with a pressure bag system when monitoring CVP, ABP or PA pressures? A. 1000mL 0.45% Saline B.Dextrose 5% C. Any available fluid D. 500mL Normal Saline - Correct Answers D. 500mL Normal Saline True or False, Oral care must be completed on intubated and or BiPAP/CPAP at least every four hours including antiseptic cleanser, mouth moisturizer and suctioning? - Correct Answers True True or False, A filter needle is needed when drawing medications from a glass ampule to help filter out particulate glass? - Correct Answers True Which type of oxygen device requires a humidifier prior to placing on patient? A. Oxi Mask B. Venti Mask C. Non-Rebreather D. nasal cannula with flow greater than 4L - Correct Answers D. nasal cannula with flow greater than 4L Which of the following steps are used to interpret basic cardiac rhythms? A. Count the total number of QRS complexes in a 60 second strip and multiply by ten B. Count the total number of QRS complexes in a 10 second strip C. Count the total number of QRS complexes in a 15 second strip D. Count the total number of QRS complexes in a 6 second strip and multiply by ten - Correct Answers D. Count the total number of QRS complexes in a 6 second strip and multiply by ten F. Prepare for synchronized cardioversion - Correct Answers B. Apply O2 via nasal cannula or mask D. Vagal maneuvers E. Establish IV access F. Prepare for synchronized cardioversion A nurse caring for a client in the ICU notes that the client's cardiac rhythm indicates a ventricular tachycardia. What action should the nurse implement? A. Check the patient's pulse and LOC. B. Place the patient on a nasal cannula. C. Immediately begin chest compressions. D. Replace the electrodes that may have become dry - Correct Answers A. Check the patient's pulse and LOC. A nurse working in the Emergency Department is participating in the resuscitation of a client experiencing sudden cardiac death. After 5 cycles of CPR, the nurse evaluates the client's cardiac rhythm as asystole. What is the next action by the nurse? A. Resume chest compressions B. Prepare for defibrillation C. Administer 1 mg of atropine D. Assess the blood pressure - Correct Answers A. Resume chest compressions The ACLS certified nurse is caring for a patient in the ICU and just contacted the physician about the patient's status and she will be there within 15-20 minutes. The patient is in symptomatic ventricular tachycardia with blood pressure of 60/20, diaphoretic and unresponsive. The priority intervention for this patient is? A. Atropine 0.5mg B. Synchronized cardioversion C. Resume chest compressions D. Early defibrillation - Correct Answers B. Synchronized cardioversion After successful return of spontaneous circulation post cardiac arrest, the patient has a blood pressure of 70/40 mgHg and is moaning incoherently. What is the next priority intervention for this patient? A. Obtain health history B. Call for immediate transport to cardiac cath lab C. Initiate Target Temperature Management D. Administer fluid bolus of up to 2liters - Correct Answers D. Administer fluid bolus of up to 2liters A graduate nurse entered the patient's room and finds the patient unresponsive, not breathing, and without a carotid pulse. The graduate nurse is aware that the patient had mentioned he does not wish to be resuscitated, but there is no DNR order on the patient's chart. What is the nurse's best action? A. Initiate a slow code to allow time for physician to sign DNR order B. Contact the next of kin to alert of patient passing C. Initiate chest compressions D. Call the MD about the status change of the patient - Correct Answers C. Initiate chest compressions The graduate nurse, on day two of orientation, is providing care to a patient in the ICU that has been made a terminal wean. The patient care tech comes into the room and ties a knot into the corner of the sheet and tells the nurse "we do this so the patient doesn't die on our shift". The best action by this very new nurse is? A. Discretely untie the knot. Do not comment to the tech about this unethical behavior, so that the tech does not get mad. B. Untie the knot and explain to the tech that is against the Dying Person's Bill of Rights C. Explain to the family that we have placed a knot to prolong the patient's death until after the current shift, and will untie during shift change report. D. Ask the tech why this is done and then document this under the linen change section of the electronic health record. - Correct Answers B. Untie the knot and explain to the tech that is against the Dying Person's Bill of Rights A critical care nurse is aware of the legislation that surrounds organ donation. When caring for a potential organ donor, the nurse is aware that: A. Non-heart beating patients are not potential organ donors B. Patients must have an organ donor card to donate organs C. Hospitals are mandated to notify transplantation programs of potential donors. D. Nursing focus should be directed at organ donation once it is decided to withdraw life support - Correct Answers C. Hospitals are mandated to notify transplantation programs of potential donors. A patient who has died an unexplained death has numerous cathers and drainage tubes in place and is being prepared for an autopsy. In providing care for the body after the patient has been pronounced dead, how shall the nurse manage the tubes prior to the autopsy? A patient is undergoing target temperature management and is beginning the rewarming phase. The last K+ obtained for this patient was 4.1, during the cooling phase. The previous supplement order listed giving 10 mEq potassium chloride IVPB for K+<4.2. What is the best response by the nurse, knowing that the order states to discontinue all potassium supplements during rewarming? A. Administer potassium at 10mEq IVPB B. Send a STAT magnesium level C. Anticiapte giving additional potassium replacement D. Nothing - Correct Answers D. Nothing Patient is undergoing target temperature management after sudden cardiac arrest. The nurse is assisting in clinical facilitation of a nursing student as well. The nurse knows that the student probably listened in lecture when she hears the student tell the family? A. I am not really sure why we are doing this but it is just something that we sometimes do. B. This therapy is not going to reverse or change any organ damage that occurred during cardiac arrest. C. This type of therapy is used on critically ill patients to reverse the damage by placing the body in a "suspended animation" like state until physicians can fix the cause. D. This is a Train of Four and it is used to make sure that the patient is not over sedated. - Correct Answers B. This therapy is not going to reverse or change any organ damage that occurred during cardiac arrest. The three phases of treatment and recovery for a burn injury are A. primary phase, secondary phase, tertiary phase. B. emergent phase, intermediate phase, rehabilitative phase. C. control phase, resuscitative phase, recovery phase. D. primary phase, intermediate phase, recovery phase. - Correct Answers B. emergent phase, intermediate phase, rehabilitative phase. When a first- or second-degree burn has occurred, the wound will likely heal on its own and go through several stages of healing, which include A. hemolysis B. emergent C. debridement D. recovery - Correct Answers A. hemolysis Opioid medications for patients with significant burns should always be given A. orally B. IM C. IV push D. Subcutaneous - Correct Answers C. IV push A burn patient who is undergoing therapy to promote strength and to regain function is in what phase of recovery and treatment? A. Emergent B. Intermediate C. Rehabilitative D. Recovery - Correct Answers C. Rehabilitative True or False: A petroleum-based solution spread over a wound site with sticky substances over time will help break down the substance to facilitate easier removal. - Correct Answers True True or False: Patient controlled analgesia (PCA) gives the burn victim more control over pain medication administration and fuller participation in their own care. - Correct Answers True Debridement of eschar and dead tissue from a wound bed must be done A. before the wound can heal B. three times a day for the first week C. after the wound has healed D. immediately upon admission - Correct Answers A. before the wound can heal Deep burns typically require a contact layer dressing that is placed on the wound bed to act as A. a permanent artificial skin layer. B. an outer skin layer. C. an artificial skin layer or protectant. D. an aid for exudate production. - Correct Answers C. an artificial skin layer or protectant. Which of the following statements is true when comparing the use of dermal skin to dermal substitutes as a treatment for deep wound burn victims? A. Dermal substitutes provide faster healing B. Dermal skin heals faster than dermal substitutes C. Dermal substitutes cannot be used with permanent skin grafts B. neuropathic pain C. burn shock D. circulatory pain - Correct Answers B. neuropathic pain _____________ antibiotic ointment has been recommended for application to facial wounds. A. Cyclodextrin B. Silver sulfadiazine C. Bacitracin D. All of the above - Correct Answers C. Bacitracin True or False: Evidence supports the fact that burn patients develop addiction to opioid pain medications with repeated administrations needed for pain control when compared to non-burn patients requiring opioid pain medications. - Correct Answers False Name this rhythm - Correct Answers Junctional The nurse is caring for a patient that was admitted to the ED with SOB, chest pain, and diaphoretic. The patient has a history of chronic dialysis but has missed his last two appointments. The nurse has given six doses of atropine, but it did not decrease his symptoms. The nurse is attempting to transcutaneously pace the patient with the HR set at 80 and current set at 20 has. Below is what the nurse sees on the monitor **Pacer spikes consistent, but not always followed by a QRS** Which action by the nurse is most appropriate? A. Continue to increase the electrical output until capture with each impulse B. Administer 1 mg epinephrine IV push C. Initiate dobutatmine infusion of 50 mcg/kg/min D. Transcutaneous pacing is ineffective - Correct Answers A. Continue to increase the electrical output until capture with each impulse Mr. Romanowski is a 55 year old retired professional wrestler. Over his career he has had several injuries and also engaged in the use of anabolic steroids. He presents at the emergency department with shortness of breath, diaphoresis, and syncope. His current vitals are HR 78, BP 88/62, RR 32, and O2 82%. Auscultation reveals an S3 gallop. What would be the next nursing intervention? A. Call respiratory therapy B. Place O2 on the patient C. Complete medication history D. Get a 12 lead EKG - Correct Answers B. Place O2 on the patient A client with cardiomyopathy is receiving diuretic therapy and has a urine output of 40 mL in 8 hours. What should the nurse do next? A. Ambulate the patient B. Notify the physician C. IV bolus of NaCl D. Irregate bladder for obstruction - Correct Answers B. Notify the physician A 14 year old patient is diagnosed with cardiomyopathy and makes the statement "I am too young to have cardiomyopathy, my grandpa has that. I just got overheated playing baseball". The nurse understands that the patient might be diagnosed with what type of cardiomyopathy? A. Dilated B. Arrhythmogenic C. Congested D. Chronic - Correct Answers B. Arrhythmogenic The nurse is instructing an older client about atorvastatin (Lipitor) to treat elevated cholesterol. What common side effect of statins should the nurse advise the client to report to the healthcare provider? A. Chronic cough B. Muscle pain and weakness C. Thinning hair D. Rhinitis - Correct Answers B. Muscle pain and weakness Because a client has mitral stenosis and is a prospective valve recipient, the nurse preoperatively assesses the client's past compliance with medical regimens. Lack of compliance with which of the following regimens would pose the greatest health hazard to this client? A. Prophylactic antivirals after dental procedures B. Activity tolerance C. Diet modifications D. Taking medications as prescribed by the physician - Correct Answers D. Taking medications as prescribed by the physician The nurse is caring for a patient that is complaining of SOB, dizziness and lethargy. Vitals are BP 102/60, HR > 150, RR 22, )2 92% on room air. The nurse notices this on the 12 lead EKG. Which order from the physician would the nurse want to clarify? **EKG shows ventricular tachycardia*** A. Prepare for synchronized cardioversion B. Place 2 - 6 L NC on the patient B. The patient will not need any intervention until geriatric age C. It is common to need prostaglandins after surgery to keep the ductus open D. Balloon valvuloplasty is preferred treatment for this defect - Correct Answers D. Balloon valvuloplasty is preferred treatment for this defect Which of the following EKG changes are abnormal findings that may indicate ischemia or injury to the cardiac muscle found on a 12-lead EKG? Select all that apply. A. T wave inversion B. Lengthening p waves C. tachycardia D. ST segment elevation E. ST segment depression - Correct Answers A. T wave inversion D. ST segment elevation E. ST segment depression After an anterior wall myocardial infarction, which of the following problems is indicated by auscultation of crackles in the lungs? A. Pulmonic valve malfunction B. Right sided heart failure C. Tricuspid valve malfunction D. Left sided heart failure - Correct Answers D. Left sided heart failure The nurse is providing care to a patient that has been admitted with signs and symptoms of stroke starting 1 hour earlier. The CT was negative for any bleeding and will begin TPA therapy. What is the next priority intervention for this patient? A. Begin IV infusion of TPA and then insert foley catheter for strict intake and output. B. Initiate a second IV line and insert foley catheter C. Initiate SCDs D. Prepare to transfer patient to surgery - Correct Answers B. Initiate a second IV line and insert foley catheter The nurse is caring for a patient admitted for an ischemic stroke. The nurse is testing the patient for limb ataxia. The patient is unable to life the right arm off the bes, make any effort against gravity, nor hav any muscle contraction within the limb. On the NIHSS the nurse will score the arm as: A. Partial limb ataxia present B. Limb ataxia present in all extremities C. Weakness/not testable D. Limb ataxia present - Correct Answers C. Weakness/not testable The nurse is caring for a patient that was admitted for an ischemic stroke. The nurse is completing the NIHSS and shows the patient a picture with a women and two children in a kitchen and asks the patient to describe the picture. The nurse understands that this is testing what? A. Tests the patient's visual field B. Level of consciousness C. Testing Broca and Wernicke functioning D. Ataxia - Correct Answers C. Testing Broca and Wernicke functioning The nurse is caring for a patient recently admitted with an ischemic stroke. During the previous shift his NIHSS was charted as a 16 and that the patient was alert and scored a 0 for aphasia and dysarthria. The nurse completes the NIHSS and the patient scores a 38 and is unable to protect his own airway. Which action by the nurse is the most appropriate? A. Call the previous nurse to make sure the results are accurate. B. Elevate head of bed and call next of kin to notify about change C . Provide jaw thrust or insert oropharyngeal airway D. Complete a bedside swallow study to determine most appropriate route of medication administration - Correct Answers C . Provide jaw thrust or insert oropharyngeal airway While providing oral medications to patient recovering from a stroke, the nurse notices that the patient coughs repeatedly and has difficulty clearing the throat. What should the nurse do? A. Change diet to soft. B. Request a speech therapy consult C. Request an occupational therapy consult D. Change the diet to full liquid - Correct Answers B. Request a speech therapy consult While teaching a wellness class on the warning wigns of a stroke, the participant asks the nurse, What's the most important thing for me to remember? What is an appropriate response by the nurse? A. Be alert if you notice a gradual onset of paralysis or confusion B. Know your family history C. Call 911 for sudden weakness or numbness A pregnant client with preeclampsia delivers the baby. What care might the client need within the first 48 hours after delivery? Select all that apply. A. Antihypertensives as prescribed B. Early and frequent ambulation C. VS assessment at least every 4 hours D. Seizure precautions E. Place patient in trendelenburg - Correct Answers A. Antihypertensives as prescribed C. VS assessment at least every 4 hours D. Seizure precautions The nurse identifies assessment findings for a client with preeclampsia. BP is 158/100, urinary output 50mL/hr, lungs clear to auscultation, urine protein 1+, 1+ edema hands, feet, ankles. On the next hourly assessment, which new assessment finding would indicate worsening of the condition? A. Platelet count 150,000 B. Urinary output 2mL/hr C. Blood pressure 158/100 D. Reflexes 2+ - Correct Answers B. Urinary output 2mL/hr The nurse is assessing a client who is in the third trimester of pregnancy. Which finding would require immediate intervention by the nurse? A. Respiratory rate of 24 per minute B. Weight gain of 16 oz per week C. Complaints of blurred vision D. Pulse of 92 beats per minute - Correct Answers C. Complaints of blurred vision The nurse is caring for a patient who is 32 weeks gestation. She presented to the ED with diaphoresis, tachycardia, sudden onset of severe abdominal pain, and severe vaginal bleeding. Upon review of the patient's history and physical assessment, the OB physician determined that the patient was experiencing a grade 3 placental abruption. What nursing interventions should you provide for this patient? Select all that apply. A. Apply firm pressure to the top of the fundus B. Obtain fetal heart tones C. Prepare to administer blood products D. Assure the patient that there are no risks to the unborn baby E. Administer supplemental oxygen - Correct Answers B. Obtain fetal heart tones C. Prepare to administer blood products E. Administer supplemental oxygen The nurse is providing care for a 6 month old that is recovering from surgical intervention and prosthesis for Tetrolgy of Fallow. The nurse anticipates that the patient may need which medication prophylactically for infective endocarditis? A. Prostaglandins B. Digoxin C. Penicillin D. Aspirin - Correct Answers C. Penicillin The nurse is discharging a patient post MI. The patient states that he has never had blood pressure problems and does not understand why he now needs a beta blocker medication that might make him dizzy or have low blood pressure. Which response by the nurse is most appropriate? A. Even though the beta blocker does work on blood pressure, it also has positive effects that allow the arteries of the heart to fill with more blood B. Hypertension is known as the silent killer and there may be times that your blood pressure is elevated and this will stop that from happening C. I am not sure. That is the doctor's order though. D. The lower your blood pressure, the less effort that your heart has to exert during each beat - Correct Answers A. Even though the beta blocker does work on blood pressure, it also has positive effects that allow the arteries of the heart to fill with more blood A 6 month old client with a ventricular septal defect is receiving digoxin elixir for the regulation of his heart rate. Which finding should be reported to the doctor? A. Glucose 180 B. Respiratory rate 38 C. HR of 62 D. BP of 90/60 - Correct Answers C. HR of 62 A client with angina complains that the pain is prolonged and severe and occurs at rest. There are no precipitating factors to the pain. How should the nurse describe this type of angina pain? A. Munchausen angina B. Stable C. Non-anginal pain B. Call the funeral home or mortuary responsible for services C. Send an internet page or email that the patient has ceased D. Text the provider that respirations have ceased - Correct Answers A. Verbally notify the primary care physician that the patient has ceased The nurse is providing care to a patient that experienced cardiac arrest during MI. The patient has been placed on therapeutic hypothermia protocol after receiving a stent to his left anterior descending coronary after. The patient's monitor currently y displays this rhythm. **Sinus Rhythm with Multifocal PVCs** The nurse knows which of the following to be true about this patient? Select all that apply. A. It is common for a patient to have arrhythmia's after MI B. This patient will need dialysis C. Potassium will shift into the cells during the cooling portion the therapeutic hypothermia and will monitor for arrhythmias D. Therapeutic hypothermia wil correct or reverse heart damage from the MI E. The patient tis experiencing hyperkalemia F. The patient will receive a beta blocker to increase coronary artery filling time G. PVCs are common with low K+ - Correct Answers A. It is common for a patient to have arrhythmia's after MI C. Potassium will shift into the cells during the cooling portion the therapeutic hypothermia and will monitor for arrhythmias F. The patient will receive a beta blocker to increase coronary artery filling time G. PVCs are common with low K+ A nurse working in the ED is participating in the resuscitation of a client experiencing sudden cardiac death. After 5 cycles of CPR, the nurse eventuates the client's rhythm as systole. What is the next action by the nurse? A. Resume chest compressions B. Contact the next of kin C. Administer 1 mg of epinephrine D. Prepare for defibrillation - Correct Answers A. Resume chest compressions A nurse is caring for a client who has been successfully resuscitated after an MI. The client has now developed an arrhythmia. The nurse understands that the causes of this arrhythmia are all of the following except: A. Result from the amount of compressions received B. Electrolyte imbalance C. Hypoxia D. Cardiac muscle cell damage - Correct Answers A. Result from the amount of compressions received What is an important teaching point for a patient with a prescription for nitroglycerine tablets? A. Leave the medication in the brown bottle B. Take one every 15 minutes if pain occurs C. Crush the medication and take it with water - Correct Answers A. Leave the medication in the brown bottle The nurse is caring for a patient recovering from the cath lab after presenting to the ED with this EKG. The nurse anticipates the patient will be discharged on which types of medications? **EKG shows sinus rhythm with frequent PVCs, Right BBB, and ST elevation** A. ASA, niacin, statin, beta bloker, diuretic, calcium channel blocker, diuretic, and PPI B. Calcium channel blocker, statin, anti platelet, and diuretic C. Beta blocker, statin, anti platelet, ACE inhibitor, and ASA D. Antiplatelet, beta blocker, and ACE inhibitor - Correct Answers C. Beta blocker, statin, anti platelet, ACE inhibitor, and ASA The nurse is caring for a patient complaining of 10/10 crushing chest pain radiating down his left arm and into his jaw. The nurse interprets what on the EKG? **12 lead shows ST elevation in I, aVL, V2, V3, and V4*** A. Occlusion of the right circumflex B. Occlusion of the LAD C. Right Bundle Branch Block D. Occlusion of RCA - Correct Answers B. Occlusion of the LAD What rhythm is this? A. Atrial Pacing B. Atrial Ventricular Pacing